To evaluate the influence of renal function on serum levels of cardiac markers (cardiac troponin T, cTnT and human heart-type fatty acid-binding protein, H-FABP), we measured these parameters and renal function tests on admission in critically ill patients who did not have cardiac disease or chronic kidney disease. Seventy patients divided into two groups according to the result of whole blood panel test for rapid detection of H-FABP negative group (patients with whole blood panel test for H-FABP of less than cut-off value, n=30) and positive group (greater than cut-off value, n=40). The cTnT was detected in 3 patients (4%) in H-FABP positive group. The serum levels of BUN and creatinine in positive group were significantly higher than those of negative group (BUN: 32.0±27.1mg·dl^-1 vs. 12.1±4.1mg·dl^-1, P<0.0001; creatinine: 1.7±0.9mg·dl^-1 vs. 0.9±0.2mg·dl^-1, P<0.0001), and creatinine clearance of positive group was lower than that of negative group (48.4±23.5ml·min^-1 vs. 76.7±21.0ml·min^-1, P<0.0001). The value of BUN (r=0.429, P<0.0001), creatinine (r=0.693, P<0.0001) and creatinine clearance (r=-0.426, P<0.0001) correlated with the serum level of H-FABP. These results indicate that impairment of renal function may affect the value of H-FABP in critically ill patients.

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The importance of controlling coagulation/fibrinolysis during severe sepsis has been widely recognized in these days. Regarding antithrombin (AT), it is known to exert positive effects with high dose but can not exert with the low dose. In this study, we tried to get the beneficial effects with low dose (1/4 quantity of maximal effect) of AT in combination with danaparoid sodium (DS). [Method] Sepsis model was made with the injection of sublethal dose of lipopolysaccharide (LPS) into rats. Concomitant use of 125U·kg^-1 of AT was made in AT group. AT and 400U·kg^-1 of DS were simultaneously infused in AT/DS group. The status of mesenteric microcirculation was observed 1, 2, 3hrs after LPS injection under the intravital microscope. Blood samples were drawn after 3hrs and the indicators of coagulation, inflammation and organ dysfunction were measured. [Results] AT activity was decreased to 70% in control group, whereas approximately 100% was maintained in AT group, and 150% was attained in AT/DS group. FDP and fibrinogen levels in AT group were similar to those of control group. These coagulation markers were significantly improved with DS administration. WBC and platelet number showed steep drop reflecting the adhesion to vascular wall, and these changes were significantly alleviated in AT/DS group. Blood velocity in arteriole and venule were maintained in AT/DS group. IL-6 level was decreased in all treated groups, while the increased level of prostaglandin I₂ (PGI₂) was recognized only in AT/DS group. Organ dysfunction was significantly improved in DS treated groups and bleeding event did not increase in these groups. [Conclusion] Even the low dose of AT can improve the septic organ dysfunction through the inhibition of hypercoagulation, suppression in inflammation and maintenance of microcirculation, when administered with DS.

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Purpose: The effect of wearing an isolation-type cap and gown with clean shoes on environmental contamination in an intensive care unit was studied. Method: Two groups were compared: Staffs and visitors who wear a cap, a gown, and clean shoes (group C) and others who wear ordinary shoes and no cap or gown (group N). Microbes on culture plates (colonies formed per plate, CFP) were examined three times daily at 11 sampling spots in the ICU, and in an entrance of the ICU as a reference. Dust and hairs adhering to a dry cloth of a wiper used in three areas were assessed: i. e. in an entrance room (C), an area around three beds (I), and the floor in the nursing station (O). Bacterial colonies (colony-forming unit, CFU) sampled with an impression plate at four sampling spots (e. g. the computer desk or a door knob) were counted twice daily. All examinations were continued over 12 days. Results: Environmental microbes did not differ between the two groups (C, 0.5 to 7; N, 0.5 to 8 CFP, in an average) and both were smaller than the reference (12 to 19 CFP, P<0.01). Dust and hairs in the area C were significantly greater in group C than in group N (dust, 0.2±0 vs 0.1±0g; hairs, 26±8.1 vs 13±4.0, mean ± SD, P<0.05). No difference was apparent between the two groups concerning dust in the area I or O. Bacterial colonies on impression plates did not differ between the two groups. Hairs were fewer in group N than in group C in the areas in the ICU. Discussion: The data indicated that wearing an isolation-type cap and gown, and clean shoes could not prevent microbial contamination and that wearing a cap might make staffs touch their hair more frequently to lose them and contaminate their hands. The increase of bacterial colonies adhered to some monitoring apparatus and devices suggested that staffs' contaminated hands were transfering it. In summary, use of an isolation-type cap and gown, and clean shoes did not prevent environmental contamination in the ICU.

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Lactic acidosis in diabetics on biguanide therapy is rare but associated with poor prognosis. We report here a case of buformin-associated lactic acidosis successfully treated with hemodialysis (HD) and continuous hemodiafiltration (CHDF). A 49-year-old man with diabetes mellitus presented himself to the emergency room complaining of abdominal pain and general fatigue. He had begun taking buformin three days before. Initial investigations revealed severe hyperkalemia (K⁺9.1mmol·l^-1) and lactic acidosis (pH6.84, BE-31.5mmol·l^-1, Lactate 18.2mmol·l^-1). He was transferred to the ICU where he underwent two sessions of HD and CHDF. On the third hospital day the patient's condition stabilized and CHDF was discontinued. He was discharged from the ICU on the 6th hospital day. We suggest that hemopurification is the treatment of choice for buformin-associated lactic acidosis, since it not only corrects acid-base disorders, but also may remove buformin.

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We report a case of reversible myocardial injury and cardiogenic pulmonary edema after ingestion of phenylpropanolamine. The patient is a 19 year old Japanese female without a remarkable past history and family history, whose chief complaint is vomiting two hours after ingestion of 544mg of phenylpropanolamine. Myocardial injury and cardiogenic pulmonary edema were diagnosed by electrocardiogram, chest X-ray, creatine kinase level, echocardiogram, ¹²³I-MIBG scintigraphy and Swan-Ganz profiles. Catecholamine, phosphodiesterase inhibitor, and diuretics were the treatment of choice. The patient was discharged on day 12 without any sequelae. We reviewed nine reported cases of myocardial injury associated with phenylpropanolamine including our case from the literature. Utilizing the similarity of anatomical pattern of reversible myocardial injury, we hypothesized that myocardial injury associated with phenylpropanolamine of this case can be a variant of ampulla cardiomyopathy.

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A case of acetic acid poisoning is reported. A 59-year-old man ingested about 100ml of 30% acetic acid to commit suicide. He, suffering from acute abdominal pain, vomiting and marked hemoglobinuria, was brought to the emergency department of our hospital within a half hour or so and transferred to the ICU on the following day because of anuria, respiratory insufficiency, disseminated intravascular coagulation (DIC), and circulatory shock. We started mechanical ventilation and continuous hemodiafiltration (CHDF) and administered heparin, antithrombin III, gabexate mesilate, fresh frozen plasma, and concentrated platelets for DIC. An endoscopic examination of upper digestive system revealed corrosive injury in esophagus and stomach. The patient gradually restored his organ function and was weaned from CHDF in one month and from mechanical ventilation in two, however, stayed in the ICU for about three months because of prolonged intestinal bleeding. He received a total of 290 units of erythrocytes and 468 units of fresh frozen plasma. Acetic acid ingestion causes not only topical injury in upper digestive tract but also injury in systemic organs including hemolysis, DIC, renal and hepatic dysfunction, shock to culminate a patient in multiple organ failure. A strict monitoring and treatment are essential during the acute phase of acetic acid poisoning.

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A 57-year-old female who developed acute pulmonary thromboembolism (PTE) after a long bus ride fell into cardiopulmonary collapse and recovered with least neurological deficit after three hours resuscitation. She had undergone a hip joint replacement on her left 11 years ago and was scheduled for its revision. She had no history of dyspnea nor difficulty in her activities of daily living (ADL) after the first operation. On arrival at the hospital early in the morning, the patient suffered severe dyspnea followed by circulatory collapse. Closed chest massage was initiated immediately. Echocardiogram did not show apparent PTE. She suddenly recovered her hemodynamics and consciousness in consequence after three hours resuscitative effort in ICU. Brain CT and enhanced thoracoabdominal CT showed no bleeding. Pulmonary angiogram displayed some branches of pulmonary artery obstructed mainly in the left. Some parts of pulmonary thrombi were aspirated and systemic thrombolytic and anticoagulant therapy were started. Blood gas analysis a few hours later revealed significant improvement. Fatal massive bleeding was not observed as a complication of thrombolytic therapy. Chest radiograph showed diffuse bilateral infiltration for several days. Unstable circulation needed much vasopressors and atrial flutter/fibrillation needed several antiarrythmics for a few weeks. The patient was weaned from a respirator after tracheostomy on the 10th ICU day. She had no neurological deficit except a slight, localized tremor in upper limbs and was therefore discharged on foot on the 67th hospital day.

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Perioperative mortality and morbidity of pleuropneumonectomy for malignant mesothelioma is extremely high and it's postoperative management is by no means easy. We report the postoperative management of 6 patients with malignant mesothelioma listed in the table 1. Although there were no perioperative death, serious postoperative complications occurred in two cases. In Case 1, complications were serious heart failure and respiratory failure during the 3rd to 5th postoperative day. In Case 4, complications were heart failure, respiratory failure, and disruption of the bronchial stump which required reoperation. The patient developed heart failure associated with ventricular tachycardia, atrial flutter and atrial fibrillation after the second surgery. He also developed empyema with MRSA and needed prolonged mechanical ventilation. Extended surgical resection to parietal pleura, diaphragm and pericardium causes postoperative bleeding and exudates excessive. A lot of fluid and blood have to be infused to stabilize hemodynamics, while pulmonary vascular beds are reduced. This is the reason why the patients easily develop heart failure during the refilling phase. We think that an appropriate volume loading to keep optimal preload is most important to avoid postoperative heart failure in patients with malignant mesothelioma.

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Most of the swallowing trainings as curative treatments for dyssialophagy are hardly carried out under tracheal intubation. A patient who has swallowing dysfunction is exposed to a risk of relapsing aspiration pneumonia just before and after tracheal extubation. We report successful extubations with 25 or 50mg·day^-1 prophylactic amitriptyline through a gastric tube in order to inhibit sialorrhea in two patients who repetitively had suffered aspiration pneumonia and consequent circulatory disorders. The sialoschesis, one of the side effects of tricyclic antidepressant, would be a benefitial effect on the old dysphagic patients at the time around tracheal extubation.

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Influenza-associated acute encephalopathy (IAE), a rare and fatal complication of influenza, is more common in Japan than in Europe or in the U. S.. We have induced intracranial pressure (ICP) monitoring since 2002 in the management of infants with IAE in our center. This report describes a survival case of a one-year and four-months old boy with IAE whose ICP was narrowly controlled. The patient was pyrexial, convulsive and comatous at the time of admission and antibodies to Influenza A virus was positive. ICP monitoring was started just after admission and we aimed to maintain his ICP lower than 20mmHg or cerebral perfusion pressure (CPP) higher than 45mmHg. The ICP was controlled with whole body hypothermia with barbiturate infusion and osmolar diuretics. His brain had been almost normal in CT scan on the day of admission but swelled within three days to lose cistern and sulci in the scan. The ICP increased to over 50mmHg against all our efforts and we infused norepinephrine to maintain CPP. The ICP was normalized and ICP monitoring was withdrawn on the 10th hospital day. CT scans and MRI's in chronic phase demonstrated hemorrhagic shock and encephalopathy syndrome (HSES) patterns according to our classification of IAE images. The patient has recovered well without major neurological deficit despite critical ICP in acute phase. We dare to say from our experience that it is difficult without ICP monitoring to manage an IAE infant in the most favourable condition or to cure it without significant neurological sequelae. In conclusion, 1) ICP monitoring in patients with IAE is just as important as with severe head injuries to check sudden increase of ICP, 2) maintaining CPP might be important as well as maintaining ICP within normal limits to improve the outcome of IAE patients.

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