Neurological institute was established in the Nippon Medical School Chiba Hokusou Hospital in April, 1999. We established stroke hot-line in a hospital and a clinic neighboring in about 300 places in April, 2000. Using stroke hot-line, 149 patients was hospitalized until April 30, 2005. They corresponded to 3.1% of the number of all inpatients of our institute. The helicopter emergency medical service (HEMS) of Chiba started on October, 2001. The HEMS (we called doctor helicopter) transported 1, 650 patients to our hospital, and 246 patients of them (22.2%) were hospitalized at our stroke care unit until December 31, 2004. The duration from the patient's emergency call to our hospital arrival was 28.4±6.8min (15-57min) using HEMS. The acute thrombolytic therapy was approved for use within 3 hours of the acute cerebral infarction by the Ministry of Health, Labour and Welfare, Japan, and has been available since October 2005 in Japan, yet few patients receive thrombolytics because of delay of patients' emergency call. The time is very important in the acute stroke therapy. Using the advantage of the doctor helicopter (HEMS) and stroke hot-line, we hope that many patients can receive benefit of the acute stroke therapy and that they rehabilitate into society.

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Patients with end-stage renal disease have a poor prognosis. An acute coronary syndrome (ACS) is the most common cause of death in patients on hemodialysis. Acute coronary occlusion, a primary intimal disease characterized by the thrombus due to rupture of a vulnerable atherosclerotic plaques, is the most frequent underlying cause of ACS. In hemodyalysis patients, heavy calcification of the plaques and striking medial thickness of the coronary artery are also characterized as a dominant morphological change. Therefore the effect of reperfusion therapy was inadequate for these patients. The long-term prognosis has been improved by recent new coronary arteries intervention (Rotablator^TM) and operation method (off-pump CABG), but is still poor. The end-stage renal failure has been already considered to have the most serious risk factor of ACS in U. S. A., and elucidation of risk factors and a guideline for prevention were publicized. Data about these conditions should be accumulated immediately, and more aggressive prophylactic procedures must be investigated in our country.

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Contrast medium-induced nephropathy (CIN) is a serious clinical problem despite common use of low-nephrotoxic non-ionized low-osmolar contrast media, because of the increased usage of radiocontrast-media and the growing number of patients with risk factors of CIN, such as renal dysfunction, diabetics, and high age. Therefore, prevention of CIN is a critical matter of concern for clinicians. However, the underlying mechanisms of CIN remain speculative and no definitive method for prevention of CIN has been confirmed except for the partial validity of dose reduction of the contrast media and intraveous infusion of saline for correction of hypovolemia. Furthermore, pre-emptive hemodialysis, though performed worldwide without solid evidence, has been proven invalid. When using iodinated contrast media, especially to the high risk patients, clinicians should be equipped with the current concept of CIN, applying appropriate methods for renal protection.

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This study introduces “theories on needs and the stress-coping theory” in the discipline of psychology, and how these theories are used in nursing. Patients are placed in such a situation that makes them difficult to meet the needs on their own because of various restrictions, and it prevents them from keeping their life as a human being. Nursing focuses on needs of the patients with illness, and provides support that meet their basic needs. This study introduces the Henderson's theory on needs, chosen from various nursing theories focusing on needs, and to state direction for nursing practice based on it. Patients feel various stress resulted from illness. Continuing stress threatens them physically and psychologically, which results not only in delaying recovery from illness, but also in critical condition physically and psychologically. Nursing provides support that help them to cope with stress effectively. This study introduces Lazarus's stress-coping theory and states direction for nursing practice based on it.

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The purpose of this study was to explore the needs and coping patterns among families of ICU patients differing between emergency and elective admission. A qualitative inductive study was conducted using semi-structured interviews with 12 families of patients under emergency admission and 11 families of patients under elective admission. Needs among families of patients under emergency admission were “alleviation of family anxiety” and “the best available treatment”. Coping patterns among families of patients under emergency admission were “praying for the patient's recovery, ” “participating in nursing care”, and “being frozen”. The coping pattern found only among families of patients under elective admission was “being confused”. These results suggested the followings: (1) nurses need to provide easy-to-understand information, relieve family anxiety, and show empathy for families of patients under emergency admission, and (2) nurses need to provide easy-to-understand information on treatment including progress of the surgery and show sufficient consideration to the family for those of patients under elective admission.

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We experienced a case of severe fat embolism syndrome (FES) who was successfully treated by percutaneous cardiopulmonary support (PCPS). An 18-year-old man sustained a fracture of femoral shaft but no chest and head injury after a traffic accident. Upon admission his respiratory condition was normal, but 12 hours later respiratory failure suddenly developed. Seventeen hours after the admission, he was admitted to our ICU for the treatment of acute respiratory failure due to FES. He was immediately intubated and mechanically ventilated. The chest X-ray film on ICU admission demonstrated “snow storm shadow”. However, his pulmonary oxygenation and haemodynamics were not improved at all, then we selected PCPS for his critical situation. After the introduction of PCPS, his oxygenation and haemodynamics were gradually improved, and he was free from PCPS on day 2. In addition, we administered high doses of methylprednisolone (1g·day^-1) for 3 days and sivelestat for 14 days. We observed many high echoic matters streaming through the inferior vena cava for 5 days in ultrasound cardiography. He was weaned from mechanical ventilation on day 10. Magnetic resonance imaging was performed on day 14, which showed high intensity area in corpus callosum. On day 40 he was performed the internal fixation of his fracture, and was finally discharged from the hospital without any neurological deficit on day 129, when high intensity area shown in MRI on day 14 had already disappeared. This case suggested that urgent and transient use of PCPS is a useful tool to rescue for fulminant FES.

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We report a case of human herpes virus-6 (HHV-6) infection complicated by acute necrotizing encephalopathy (ANE). A 1-year and 3-month-old girl presented generalized seizure following high fever. She was intubated and sedated because of prolonged seizure. Her brain CT scan was normal and cerebrospinal fluid showed albuminocytologic dissociation. She admitted to our hospital due to sustained coma and coagulopathy. On the 2nd day after admission, MRI was obtained. Posterior aspect of bilateral basal ganglia, bilateral thalami, posterior limbs of internal capsule, pons and cerebellar white matter showed hyperintensity on T2-weighted images. On the 3rd day, papula was noticed mainly on the body surface. We examined serological tests and blood polymerase chain reaction study was positive for HHV-6. She was diagnosed as having acute necrotizing encephalopathy and was intensively treated with high-dose methylpredonisolone, high-dose gamma-globulin and barbiturate, however she died on the 14th day. ANE was designated on the basis of accumulated clinicopathological data in our country in 1995. Etiology and pathogenesis of ANE remain mostly unknown. Some viral infections cause ANE, and its prognosis is very poor. Neuroradiological findings are important and typical. In our case, the cause of ANE was thought HHV-6 infection. We should treat carefully HHV-6 infection even though the disease is common in childhood.

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We examined changes in the serum cytokine concentration in a patient with refractory Epstein-Barr virus-associated hemophagocytic syndrome. A 30-year-old man was admitted to a hospital with severe infection and disseminated intravascular coagulation. Since his condition progressed to severe acute renal failure, he was transferred to our hospital. He underwent continuous hemodiafiltration for the renal failure, under artificial respiration. He was suspected of having hemophagocytic syndrome (HPS) on the basis of abnormal clinical symptoms and laboratory data obtained on the following day, and diagnosed as having HPS from the result of a bone marrow aspiration. We began steroid pulse therapy and plasma exchange (PE) but did not perform immunochemotherapy because of severe liver dysfunction. High concentration of serum cytokines at the onset of treatment suggested an adverse prognosis. The cytokine balance indicated immunoparalysis with predominance of anti-inflammatory cytokines. Although the cytokine balance was improved after steroid pulse therapy and PE, the clinical symptoms were not improved. The present case suggested that early treatment and effective cytokine modulation were necessary for severe cases of HPS.

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It is well known that serum lactate is an endproduct of anaerobic metabolism in tissues or organs and that it increases in a condition of inappropriate oxygen supply. Moreover, it has been demonstrated that serum lactate level increases when acute mesenteric ischemia occurs. A case of acute mesenteric ischemia that was diagnosed by monitoring of serum lactate level in a patient who had undergone thoraco-abdominal aortic aneurysm repair is described. A 73-year-old female underwent repair of a throraco-abdominal aortic aneurysm. An aorto-superior mesenteric artery and aorto-celiac trunk bypass using an artificial graft and subsequent endoluminal stent-graft repair were carried out. Hemodynamic derangement and hypoxemia did not occur during or after the operation. However, serum lactate level gradually increased from 24mg·dl^-1 to 75mg·dl^-1, and metabolic acidosis developed from -5mEq·l^-1 of base excess to -15mEq·l^-1 over a period of 4 hours after operation, though the patient did not complain of clinical symptoms associated with ischemic enterocolitis. Since acute mesenteric artery ischemia was suspected because of remarkable elevation of serum lactate without shock or hypoxemia, an emergency operation was performed. It was found that the bypass graft from the aorta to the superior mesenteric artery was obstructed by kinking. An additional bypass was performed to prevent recurrence of acute mesenteric artery ischemia. After the second operation, the elevated serum lactate level decreased from 42mg·dl^-1 to 18mg·dl^-1 over a period of 4 hours. Monitoring of serum lactate level is thought to be a useful adjunct for the diagnosis of acute mesenteric ischemia after thoraco-abdominal aortic repair.

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It has been reported that strict control of blood glucose level reduces morbidity and mortality in critically ill patients. However, strict control of blood glucose level requires frequent measurements of blood glucose. Continuous blood glucose monitoring, therefore, may be useful for intensive insulin therapy to avoid frequent measurements. We report our experience of the bed-side artificial endocrine pancreas system “STG^(R)-22” (Nikkiso Co. Ltd., Tokyo) and a comparison of intravenous blood glucose determined by this apparatus with arterial blood glucose level. The blood sampling device was successfully inserted intravenously in only two of six patients from whom informed consent was obtained.
Intravenous glucose level was significantly correlated with arterial blood glucose level (r=0.964). A significant negative correlation between intravenous and arterial glucose levels was found by analysis of a Bland-Altman plot (r=-0.5556). However, the discrepancy between intravenous and arterial blood glucose levels is attributed to physiological conditions, not mechanical characteristics. Some problems such as the large size of the apparatus, limitation of length of the sampling circuit and large volume of blood sampling should be resolved for this apparatus to be used easily and safely for monitoring continuous blood glucose in ICU.

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We report the utilization of a new ear sensor (TOSCA^(R), Linde, Switzerland) that enable both transcutaneous measurement of arterial carbon dioxide tension and pulse oximetry oxygen saturation in an intensive care unit. The subjects were 12 critically ill patients who were admitted to our intensive care unit. The ear sensor was threaded in the right or left ear lobule for serial measurements of transcutaneous carbon dioxide tension (PtcCO₂) and pulse oximetry saturation (SpO₂). Arterial carbon dioxide tension (PaCO₂) and arterial oxygen saturation (SaO₂) were determined by blood gas analysis and were compared with PtcCO₂ and SpO₂, respectively. A significant relationship was found between PtcCO₂ and PaCO₂ (correlation coefficiency: 0.95). However, the difference between PtcCO₂ and PaCO₂ was tended to increase when PaCO₂ was more than 50mmHg. Serious complications associated with utilization of the ear sensor did not occur, and inability of measurement caused by position change of patient was not found. The discrepancy between PtcCO₂ and PaCO₂ increased following norepinephrine administration in a shock case. These results suggested that serial monitoring of PtcCO₂ using the ear sensor (TOSCA^(R)) might be useful during mechanical ventilation in an intensive care unit. However, further evaluation is needed to confirm precise measurements of PtcCO₂ and SpO₂ using the ear sensor (TOSCA^(R)) when patients are in a hypoperfusion state such as hemorrhagic shock.

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The Ethics Committee of the Japanese Society of Intensive Care Medicine announces the results of the questionnaires sent out to 75 trustees. The questionnaire includes important ethical problems on the end of life care in the intensive care unit (ICU), and the results have been fully discussed at the 33rd Annual Congress of the Japanese Society of Intensive Care Medicine being held in Osaka on March 2006. The Ethics Committee believes this announcement has a great significance to all members of the Japanese Society of Intensive Care Medicine.

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