Critically ill patients in the intensive care unit are under stress due to pain, anxiety, discomfort by endotracheal intubation. It is not only humane but also leads to reduce the morbidity of post-traumatic stress syndrome to sedate these patients using sedatives and analgesics. In addition sympathetic strain due to pain and anxiety can affect on patients' outcome. Appropriate sedative should be chosen by taking the half-life in the blood, organ function metabolizing the sedative, activity of metabolite, adverse effect of the sedative and cost into account. At present there is no single drug which can cover all the patients including pediatric patients in the intensive care unit. Further studies are required to evaluate new sedatives, scaling system of sedation assessment and bispectral index in the view of patients' outcome.

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A medical accident due to negligence is called a “medical malpractice”. In a medical dispute, the patient goes to court and this is a “medical lawsuit”. Although it is unknown exactly how many medical accidents or disputes have occurred in Japan, we suppose that about 12, 000 cases occur annually. In a medical accident, there is a legal inquiry as to whether or not it is a civil act, and/or a criminal act, and/or whether administrative responsibility is involved. A total of 1, 004 cases of civil acts were filed in 2004. Four hundred and five judgments were passed, and the patients won in 39.5% of the cases. On the other hand, 463 cases were concluded as out-of-court settlements. Since 1999, there have been about 70 criminal judgments for doctors, nurses and co-medical staff because of medical accidents. There is no actual prison sentence for cases found guilty of manslaughter through professional negligence alone, and the charges were fines or imprisonment without labor (with suspension of execution), A doctor sentenced to a fine or imprisonment without labor is also subjected to administrative penalty as an order to suspend professional operations. Nine civil judgments and a criminal judgment concerned with ICU case were found. The purpose of medical risk management is to investigate the cause, build a prevention system, and reduce accidents.

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From July to September 2004, 86 institutions in Japan used similar criteria to record each instance when patients (N=497) were treated with noninvasive positive pressure ventilation. With 16.2% receiving endotracheal intubation (EI), overall mortality was 31.0%. Average duration of NPPV was 9.2±18.7 days. For APACHE II scores, initial ventilator settings, NPPV duration, percentage of patients who did not require EI, mortality or patient condition at EI, no significant differences were found in data from institutions reporting small (<10 cases) and larger (≥10 cases) samples. For postsurgical patients, and those with acute respiratory distress syndrome or with pneumonia, we found significant differences in PaO₂/F_IO₂ ratio and respiratory rate (RR) between those who did not require EI and those who were intubated. Chronic obstructive pulmonary disease patients showed a significant difference only in RR. Sedation during NPPV correlated with significantly greater application of EI. In conclusion, we found no significant cross-institutional differences in circumstances of NPPV application.

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Objectives: Noninvasive positive pressure ventilation (NPPV) is being increasingly used in the treatment of acute respiratory failure. We analyzed the therapeutic efficacy of NPPV in our ICU. Methods: The cases of NPPV treatment from 1992 to 2004 were analyzed to retrospective. We investigated the number of cases, successful rate and ICU mortality from the medical record. Results: The total number of NPPV treatment was 607 examples. The whole NPPV successful rate was 80%, and it was very as high as 84% and 95% especially for latest two years. Most illness to which treatment was carried out by NPPV were acute cardiogenic pulmonary edema. The successful rate of acute lung injury/acute respiratory distress syndrome was significantly lower than that of other diseases. Conclusions: The therapeutic efficacy of NPPV is fully demonstrated by being carried out at the suitable stage for a suitable case.

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Transfusion-related acute lung injury (TRALI) usually occurs within 1-6 hours from the beginning of a blood transfusion. We report a case of TRALI who developed dyspnea 16 hours after transfusion. A 66-year-old man, having hepatocellular carcinoma, was admitted to our hospital because of aggravation of ascites and anemia. On the 4th hospital day he received two units of packed red cells. About 16 hours later, he developed severe dyspnea and was transferred to the ICU. Chest radiograph and CT revealed diffuse bilateral alveolar infiltrates like acute respiratory distress syndrome. Respiratory support with noninvasive positive pressure ventilation was started and sivelestat sodium hydrate and steroids were administered. In spite of the therapy, oxygen exchange was not improved and liver function was gradually aggravated. The patient died from multiple organ failure on 11th ICU day. Human leukocyte class II antibodies in transfused packed red cells were found to be positive. Whenever we transfuse blood we should be aware of TRALI and of the late onset type of this disease.

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We demonstrate deep vein thrombosis (DVT) in three cases suspected by the increase in soluble fibrin monomer complex (SFMC) in plasma. In two cases, only SFMC increased while D-dimer and FDP did not change. Echoangiography of the femoral vein showed hemostasis and microthrombi in all cases. Measurement of SFMC may have greater clinical efficacy as a diagnostic test of early phase DVT than D-dimer in patients with clinical risk of DVT.

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Phosphodiesterase III (PDE III) inhibitors are clinically used in the treatment of acute heart failure and myocardial depression. PDE III inhibitors selectively inhibit cyclic AMP, specifically PDE III in both cardiac and vascular smooth muscle, which can produce vasodilatation. Recently PDE III inhibitors are available in the treatment of cerebral vasospasm after aneurysmal subarachnoid hemorrhage. Olprinone, a newly developed PDE III inhibitor, has recently become available for the same purpose. In this study, we investigated direct free radical scavenging activity of olprinone measured by electron spin resonance with spin trapping method. ESR study has demonstrated that olprinone can scavenge hydroxyl radicals in a dose dependent manner. This result indicates that PDE III inhibitor has a direct free radical scavenging activity.

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