Study objectives and design: With respect to the management of colonic injuries, controversy continues to surround the topic of which operative option (primary repair?, colostomy? or exteriorized repair?) should be pursued. Therefore, to identify the limits to which primary repair of a colonic injury can be safely performed and to clarify which risk factors are most associated with the development of morbidity, a retrospective analysis has been conducted of 49 patients who underwent surgery at our emergency medical center, for a transmural injury of the colon, over the past 18 years. The patients were divided into two groups; 22 cases treated from April 1975 through December 1984 were designated as the early group, and 27 cases treated from January 1985 through August 1993 were designated as the recent group. The mortality and morbidity rates were then compared between the two groups and an analysis was conducted of several risk factors. Main results: 1) The 2 groups were identical in terms of injury severity score (early group: 23.1±11.7; recent group: 23.4±10.1), and injury mechanisms (early group: blunt trauma 11, stabbing 10, gunshot 1; recent group: blunt trauma 13, stabbing 14). 2) In contrast to the early group, a remarkable decrease in the use of colostomy was noted in the recent group, from 55% (12/22) to 15% (4/27). On the other hand, there was a marked increase in the number of primary repairs, from 45% (10/22) in the early group to 81% (22/27) in the recent group. 3) Mortality decreased from 3/22 (14%) in the early group to 2/27 (7.4%) in the recent group and morbidity from 14/22 (64%) to 10/27 (37%), respectively. 4) Among the 22 patients in the recent group who underwent primary repair, there were 6 who manifested shock on admission, 2 with the complication of pancreatic injuries, 7 with left-sided colon injuries, 3 of delayed laparotomy (over 24 hours after sustaining the injury), and 5 requiring massive blood transfusion (over 10 units). Despite the risk factors associated with each of these cases, no patient died or developed serious complications, such as anastomotic leakage. Among these risk factors, the need for transfusion of more than 10 units was the only one significantly associated with the development of morbidity (p<0.01). Conclusion: The primary method for repair of colonic injuries was found to be safely performed, even in cases with the surgical risk factors evaluated above. More liberal use of primary repair for colonic injury is warranted. However, patients requiring massive blood transfusion should be closely observed.

View full abstract

Early decompressive craniectomy has been recommended as treatment for acute subdural hematoma (ASDH) complicated with cerebral contusion. However, it has frequently entailed acute brain swelling and delayed traumatic intracerebral hematoma (DTICH). Therefore, in addition to early decompressive craniectomy, we devised a new protocol consisting of emergency evacuation of the subdural hematoma via a single burr hole, intracranial pressure monitoring with external ventricular drainage and medical treatment (barbiturate therapy, etc). However when intracranial hypertension developed despite the new management, decompressive craniectomy was done. To compare prognostic and hemostatic data between patients treated with early decompressive craniectomy and patients treated with the new protocol, we assigned 23 patients with severe ASDH and cerebral contusion (GCS Score 8 or less) to the group treated with early decompressive craniectomy and craniotomy (group I) or the group treated with the new protocol (group II). The mean GCS score on admission did not differ between group I (4.5±1.3) and group II (4.2±1.2). Nevertheless, the development rate of DTICH was 6 (60%) of 10 patients (group II) compared with 11 (84.6%) of 13 patients (group I). In addition, group II had a better outcome than group I (66.7% favorable outcome, good recovery and moderate disability, in group II). Hemostatic data were comparable in the cerebral contusion patients with and without DTICH, but an α₂ plasmin inhibitor, which is the main inhibitor of the fibrinolytic system, was lower in patients with DTICH than in those without DTICH. These results suggest that our new protocol appears to be safer and more useful for the management of severe ASDH with cerebral contusion than the traditional method.

View full abstract

Most Japanese researchers believe that the survival rate for sudden cardiopulmonary arrest in Japan is markedly inferior to that in other countries presumably due to infrequent application of bystander cardiopulmonary resuscitation and an immature prehospital emergency medical service system. We have, however, speculated that other factors are responsible for the poor results in Japan. The purpose of this study was to test our hypothesis. Data were obtained from 14 Japanese and 23 foreign publications (1983 to 1991) concerning either out-of-hospital cardiopulmonary arrest (OHCPA) or cardiopulmonary arrest on hospital arrival (CPAOA). Sufficient numbers of cases and detailed case descriptions were the criteria for literature selection. We reviewed the literature in terms of the information on hospital discharge, as well as prognostic factors other than the incidence of bystander cardiopulmonary resuscitation and the level of the prehospital emergency medical service system. The data from Japanese and non-Japanese publications were compared. There were 12 Japanese reports on CPAOA, and 20 non-Japanese investigations of OHCPA. All Japanese publications dealt with cardiopulmonary arrest due to unselected causes. In most other literature, the cause of arrest was restricted to heart disease. The age of the patients was younger in Japan. The incidences of witnessed arrest and of ventricular fibrillation on hospital arrival were not different. The average discharge rate in Japan was 4% for OHCPA, 3% for CPAOA. In the non-Japanese literature, these rates were 9% and 1%, respectively. Of the non-Japanese patients discharged alive after OHCPA, 93% had regained spontaneous circulation before hospital arrival. The discharge rate in Japan was 6% if only the heart disease cases were considered. The number of CPAOA cases approximates the number of OHCPA cases minus the number of cases with prehospital return of spontaneous circulation. The latter accounted for most of the discharged cases after OHCPA. Thus, it is not surprising that the outcome of CPAOA tends to be worse. Japanese articles included cardiac arrest after blunt trauma and cerebrovascular accident. Survival is exceptional in these cases. This etiologic characteristic also leads to a deceptively low discharge rate in Japan. The younger age of Japanese patients is probably due to differences in the cause of arrest. This result, however, may not explain the low discharge rate in Japan. In conclusion, the unsatisfactory survival rate for cardiopulmonary arrest in Japan is partly due to the case definition: Japanese publications represent CPAOA from all causes, in contrast to reports from other countries limited to OHCPA from heart disease.

View full abstract

Objective: To investigate the outcome and pathophysiology of systemic inflammatory response syndrome (SIRS) in critically ill patients with the expectation that the concept and the criteria of SIRS are useful in elucidating the pathophysiology of the critically ill and provide us with an early warning of the development of organ failure. Patients and methods: We studied the incidence of SIRS, multiple organ failure complication rate and outcome of 922 critically ill patients treated at the ICU of Chiba University Hospital between 1986 and 1993, and investigated the relationship between the duration of SIRS and the date of the onset of MOF. In addition, we measured resting energy expenditure/basal energy expenditure (EE/BEE), cellular injury score (CIS), serum interleukin 6 (IL 6) and lipid peroxide (LPO) on the first postoperative day in patients who underwent gastrointestinal surgery and compared the results in SIRS patients and non-SIRS patients to investigate the pathophysiology of SIRS. Furthermore, to investigate the mechanism of deterioration of SIRS to organ failure we followed postoperative serial changes in serum IL-6 levels in non-SIRS, SIRS survivors and SIRS non-survivors. Results: SIRS developed in 63.7% of all ICU patients, and MOF developed in 14.3% of the SIRS patients and 1.2% of the non-SIRS patients, respectively. SIRS patient and non-SIRS patient mortality was 13.6% and 1.2%, respectively. Thus the MOF complication rate and mortality rate in the SIRS patients were significantly higher than in the non-SIRS patients. SIRS in non-MOF patients persisted for 4.0 days on average, and the average duration from the onset of SIRS to the onset of MOF was 8.2 days. There was no significant difference between CIS and serum LPO levels in SIRS patients and non-SIRS patients. However EE/BEE and serum IL-6 levels in SIRS patients were higher than in non-SIRS patients. Serial changes in serum IL-6 levels revealed that the levels in non-SIRS patients remained low, and that those in SIRS survivors were highest on the first postoperative day, but decreased the following day. The serial changes also showed that the IL-6 levels of SIRS non-survivors remained elevated and that non-survivors were unable to recover from SIRS. Conclusion: These findings indicate that SIRS is caused by overproduction of humoral mediators and also indicate that SIRS is not severe enough to cause cellular injury but is a condition which can easily deteriorate to organ failure. Furthermore, countermeasures against humoral mediators including cytokines seemed to be important in the prevention of organ failure in patients with persistent SIRS.

View full abstract

Objective: To analyze the clinical picture of patients with acute aortic dissection (<6 hours from the onset) and to evaluate the factors leading to misdiagnosis. Setting: Tertiary care general hospital. Study population and design: A retrospective analysis of 90 consecutive patients: 50 patients with type-A lesions (mean age 67 years, male/female=16/34), 40 with type-B lesions (mean age 62.6 years, male/female=23/17). Results: The most important predisposing factor was hypertension, which was detected in 33 type-A patients (66%) and in 28 type-B patients (70.3%). Sudden onset of pain was the most frequent chief complaint in both types, but the type-A patients had a lower incidence of pain (97.5% in type-B vs 72% in type-A). Sudden collapse was the chief complaint in 17 type-A patients (34%). Initial systolic blood pressure was significantly lower in type-A (93.5±30.1 vs 167±36.1mmHg), and 25 (50%) of the type-A patients were in shock (<90mmHg) at the time of admission. Complications of aortic dissection occurred in 45 type-A patients (90%, tamponade 23, aortic regurgitation 19, peripheral artery occlusion 15, coronary involvement 8, etc.), and 9 type-B patients (peripheral arterys occlusion 5, renal ischemia 3, etc.). Acute ECG changes were seen in 27 type-A patients (55.1%) and 9 type-B patients (22.5%). A definitive diagnosis of dissection could be made either by CT or surface echocardiogram in 90% of type-A patients and 100% of type-B patients. A correct initial diagnosis was not made in 19 type-A patients (39%) and 9 type-B patients (22.4%). These patients were erroneously diagnosed as having myocardial infarction, gastrointestinal diseases, cerebrovascular accidents, respiratory diseases, etc. There were no differences in age, sex, admission systolic blood pressure, incidence of peripheral arterial occlusion, mediastinal widening, ECG changes, heart failure, tamponade, aortic regurgitation, consciousness disturbance and pain in those accurately diagnosed and those who were not. Conclusion: Making a correct diagnosis was sometimes precluded by a wide variety of clinical pictures in acute aortic dissection. The most important key to the diagnosis was awareness of the possibility of dissection by the physician. Once it was suspected, the correct diagnosis could be made either by CT or a surface echogram in the vast majority of the patients.

View full abstract

Acute brain swelling often occurs following external decompression but only rarely following drainage of cerebrospinal fluid (CSF). How can we predict acute brain swelling before external decompression or CSF drainage? It has been suggested that the mechanism of acute brain swelling involves an increase in cerebral blood volume (CBV) but this remains uncertain. A patient with acute brain swelling following head injury in whom intracranial pressure (ICP), jugular venous oxygen saturation (SjO₂), and transcranial Doppler sonography (TCD) were serially monitored is presented, and the mechanism is discussed. A 17-year-old man was admitted to the emergency room following a traffic accident on a motorcycle. He was comatose with a score of 6 on the Glasgow coma scale. Pupils were anisocoric, and brain stem reflexes were absent except for the cough reflex. Computed tomography showed traumatic subarachnoid hemorrhage and acute hydrocephalus. Initial TCD showed that the brain was hyperemic. The ICP had increased to 50mmHg, despite barbiturate therapy. Therefore ventricular drainage was implemented via the anterior lateral ventricle to decrease ICP. Ventricular drainage was opened while ICP, SjO₂, TCD were being serially monitored. At 4 minutes 30 seconds after opening the drainage, ICP suddenly increased, and SjO₂ simultaneously decreased rapidly. There were no changes in TCD waveform during the first 4 minutes, change, indicating the absence of any significant increase in CBV. At that point ICP suddenly increased to 60mmHg, and the TCD waveform changed to systolic flow. Subsequent CT clearly revealed brain swelling. After that the ICP continued at 60∼70mmHg, but the SjO₂ increased from 20% to 80%, and then decreased to 20% again. During the next stage, the SjO₂ continued at 80∼90%. These changes were explained in terms of alternating periods of relative brain ischemia and brain hyperemia. Hyperemia and intracrnial hypertension were suspected prior to drainage, based on serial monitoring of TCD, ICP, and SjO₂ upon admission. Presumably the sudden increase in cerebral perfusion pressure under these conditions caused the acute brain swelling. When brain hyperemia is suspected, it is important to control ICP gradually.

View full abstract

There have been few studies on mental stress caused by natural disasters from a neuroendocrinological viewpoint. In this study we examined five patients with physical injures as a result of the Hokkaido Nansei-oki earthquake and tsunami and evaluated stress over a two-week period after the disaster. Blood cortisol and catecholamines (epinephrine, norepinephrine, and dopamine) were measured as indices of acute stress reaction, and urine 17-OHCS, 17-KS-S and 17-KS-S/17-OHCS ratio, often used to evaluate psychosocial stress, were also measured as indices of “wear and tear”, “repair and recovery”and “distortion of adaptation”, respectively (the former two expressed as creatinine ratio, all three expressed as percentages of the mean values in a healthy 25-year-old group). Serum cortisol was increased in two of the five patients only on the 4th day after the disaster, while plasma catecholamines remained within normal limits. 17-OHCS increased (over 100%), 17-KS-S clearly decreased (below 50%), and the 17-KS-S/17-OHCS ratio markedly decreased (far below 50%) during the observation period in all of the patients, who experienced continuous mental and physical distress throughout the period. This reveals that disasters create intensive mental stress in which long-term care is indispensable to mental and psychological recovery, as well as physical recovery.

View full abstract

A 49-year-old woman with severe shock and metabolic acidosis was transferred to our hospital. She had no cardiac disease. The patient had been treated with salazopirine, steroid and parenteral hyperalimentation at a local hospital for ulcerative colitis for 3 years. One week ago, she experienced bilateral abductor paralysis. When the steroid dosage was decreased 2 days ago, she developed sudden shock and consciousness disturbance. Large-dose steroid therapy was administered, but her hemodynamic state failed to improve. On admission, her hemodynamics and metabolic acidosis deteriorated despite administration of large-dose catecholamines, sodium bicarbonate and fluid resuscitation. The patient showed characteristic clinical signs of shoshin beriberi, such as abductor paralysis, malnutrition and low output syndrome (LOS), and the cause of the shock was suspected to be shosin beriberi due to long-term parenteral hyperalimentation without vitamins. The patient was therefore put on assisted circulation by intra-aortic balloon pumping (IABP) and vitamin B₁ (thiamine) therapy. Immediately after starting IABP, her hemodynamics, metabolic state, oxygenation and level of consciousness improved dramatically. Six hours later, her hemodynamics had stabilized, and administration of adrenaline was discontinued. The next day, she was weaned from IABP, and five days later, the patient was discharged from the ICU without any complications. It is concluded that IABP is useful in patients with catecholamine-resistant LOS such as shoshin beriberi until efficiency of the fundamental therapy.

View full abstract