目的:敗血症患者の循環管理に際しては適切な前負荷の確保が必要である。今回の検討は,臨床で汎用されているSwan-Ganzカテーテル(以下SGと略す)で得られた肺動脈楔入圧(PAOP)が,敗血症例の前負荷を正確に反映しているかどうかを確認することを目的として行った。対象と方法:SGを留置した敗血症11例を対象としてPAOPと一回拍出量係数(SVI),および同時に施行した心エコー法から得た左室拡張末期容量係数(EDVI)の関係を検討した。対照値は受傷後5日以内の外傷急性期16例(以下対照群)から求めた。また,それぞれの左室収縮能を検討した。結果:敗血症群のSVIおよびEDVIは対照群と差がなかったが,PAOPは敗血症群で16±7mmHg (mean±SD,以下同様)と対照群9±4mmHgに比べ有意に高値を示した(p<0.05, Student's t-test)。一方,敗血症群,対照群とも左室収縮能は正常かそれ以上に維持され,差を認めなかった。また,EDVIとPAOPの関係では,同等のEDVIにあっても敗血症群のPAOPが対照群より高値をとる傾向が明らかであった。SGの結果のみを元にして解釈した場合,敗血症群は同等の前負荷(PAOP)からより低値のSVIを示し,左室収縮能の低下があるかのごとく判断される。しかし,実際には敗血症群の左室収縮能は正常に保たれており,対照群と差がない。この矛盾は敗血症に陥った場合,PAOPが真の左室前負荷である左室拡張末期容量を反映せずに高値をとってしまうことで説明される。したがって,PAOPのみを指標として敗血症の循環管理を行った場合には前負荷を過大評価した治療となる可能性が示唆された。結語:敗血症時においては,PAOPは左室拡張末期容量を反映せず,左室前負荷の指標としては適切でない。

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We reported an operated case of spontaneous ventral epidural hematoma of the cervical spine. A 55-year-old male was admitted to our hospital because of sudden back pain and subsequent tetraplegia. On admission he was alert, and the laboratory data were normal. Urgent MRI indicated ventral spinal epidural hematoma at C4-C5 levels that was compressing the cord posteriorily. Six hours after onset we performed laminectomy as a posterior decompression to avoid evacuation of the venous hematoma. MR images 3 weeks after the operation revealed only a very thin mass at the ventral side and the compression of the spinal cord was dramatically improved. Postoperative spinal angiogram was performed to investigate the etiology of bleeding, but there were no specific findings such as venous angioma or arteriovenous malformation. About 1 month after the operation he was discharged with a complete neurological recovery except dysesthetic sensation in the right big toe. In the literature, the majority of these lesions were located dorsally and only 7 reported cases were located in the ventral side. Immediate decompressive surgery has been commonly accepted. We concluded that it is not always necessary to evacuate venous hematoma, and that acute staged laminectomy as posterior decompression is important.

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A 22-year-old man was admitted to the emergency center with melena and hemorrhagic shock. Gastroduodenos-copy and total colonoscopy initially failed to reveal the bleeding site, despite the fact that the blood was observed in the colon. Emergency angiography was performed, and proved invaluable in disclosing the jejunal arteriovenous malformation (AVM) as the bleeding source. After angiography, the patient was successfully treated by surgery. During operation, endoscopy was effective to demonstrate the location of the AVM rupture. Jejunal AVMs are rare. If massive bleeding of the alimentary tract prevents endoscopical examination, angiography should be immediately performed. In addition to these preoperative manoeuvers, intraoperative endoscopy should be prepared in order to define the specific site of bleeding.

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