Although postoperative neurologic dysfunction occurs in 10∼70% of all patients undergoing cardiac surgery involving cardiopulmonary bypass (CPB), a universally accepted perioperative cerebral management strategy for reducing the risk of neurological injury has yet to be established. This paper reviews perioperative cerebral management before, during and after surgery. Risk factors for adverse neurological and neuropsychological outcomes should be identified, if possible, during the preoperative period, and preoperative physical and pharmacological neuroprotective strategies should be developed for patients found to be ‘at risk’. The detection of mobile atheromatous plaques in the ascending aorta during surgery is the single most important contributing factor to perioperative neurological morbidity. Significant increases in cerebral temperature can aggravate ischemic neuronal injury and accelerate neuronal death. Therefore, the cooling phase during CPB should be adequate, and the rewarming phase must be carefully managed. Postoperative hyperthermia is correlated with a higher degree of cognitive dysfunction after cardiac surgery. Cardiac anesthesiologists and intensive care physicians can reduce the risk of inadvertent hyperthermia, and in some cases, induce the beneficial effects of hypothermia, of which adverse effects are preventable in an intensive care setting, by continuously monitoring body temperature during the postoperative period.

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Purpose: To evaluate the efficacy and safety of the AMP-1311, a newly developed polysulfone hemofilter (Asahi Kasei Medical Co. Ltd.), through the treatment with continuous hemofiltration (CHF) in patients with renal failure. Patients and methods: Sixty-eight patients requirng CHF treatment were enrolled from seven centers and 62 patients fulfilled the study. The efficacy was assesed by the ultrafiltrability and the removability of urea nitrogen and creatinine of the filter. The safety was assesed by the incidence associated with the treatment. Results: The filter demonstrated superb ultrafiltrability and removability. The filter achieved more than 80% of estimated ultrafiltration volume during the treatment. Moreover, it showed high stability as it was used more than 24 hours in most of the patients. The sieving coefficient was 0.99±0.12 (urea nitrogen) and 1.00±0.13 (creatinine). Sixty out of 62 patients revealed no adverse incidents during the treatment. Two patients showed hypotension and leukocytopenia during the treatment. However, these incidents were considered common in the treatment with blood purification. Thus, the filter was considered highly safe for the treament with CHF. Conclusion: The AMP-1311 filter is highly effective, stable and safe in the treatment with CHF.

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It has been reported from overseas that the existence of full-time intensivists in the ICU can improve outcome of critically ill patients. However, there has been no report about this issue in Japan. We have conducted a retrospective study looking at the impact of changing the physician staffing pattern from low to high intensity in the ICU of a Department of Emergency and Critical Care Medicine, Saitama Medical Center, on outcome of trauma patients. The observation period was one year before and after the pattern change. Six hundred and ninety-one patients were included in this study (before: 320, after: 371). There was no difference in demographics, severity and hospital mortality of trauma patients between the two periods. However, in the multi-variable logistic analysis, high intensity period was found to be a predicting factor for better outcome, although not statistically significant (odds ratio: 0.537, P = 0.096). The Japanese emergency system has been developed differently from that in foreign countries. To improve outcome of Japanese trauma patients further, not only improving resource availability and education of trauma surgeons but also disposing full-time intensivists in emergency departments may be important.

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The neonatal intensive care unit (NICU) and pediatric intensive care unit (PICU) subcommittee of the Japanese Society of Critical Care Medicine examined the results of a nationwide questionnaires and concluded that there are only 16 PICUs with separate nursing units in Japan. They also found that the number of PICUs in Japan has not increased for several years. PICUs have become widespread in North America and Europe, ever since it was recognized in the 1970s that pediatric intensive care specialists could decrease the mortality rate of severely sick children. Nevertheless, the efficacy of PICUs has not yet been demonstrated in Japan. To illustrate the efficacy of PICUs in Japan, we compared the total pediatric mortality rates and the injury-induced pediatric mortality rates between Japanese prefectures with PICUs and those without PICUs. Then, the necessary number of PICU beds in Japan was estimated, based on data from North America and Europe. Finally, we estimated the number of 1- to 4-year-old children who could be saved using the newly planned nationwide PICU system in Japan, since the present mortality rate of 1- to 4-year-old children in Japan is significantly higher than that of other developed countries. Although no significant difference in the total pediatric mortality rates, including those for chronic diseases, was observed between prefectures with and prefectures without PICUs, the average injury-induced pediatric mortality rate was significantly lower in the prefectures with PICUs than in those without PICUs. This is the first evidence showing the efficacy of PICUs in Japan. The necessary number of PICU beds has been estimated to be about 500 beds in Japan, since 1 PICU bed is necessary per 40,000 children in Japan-based on data from North America and Europe. By adopting the newly planned nationwide PICU system in Japan, about 500 children between the ages of 1 and 4 years old are expected to be saved annually. The efficacy of PICUs was demonstrated in this study. The nationwide PICU system should be included in the newly planned nationwide pediatric emergency medicine system being developed by the Japanese Society of Pediatrics.

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In order to examine renal function, arterial blood sample was taken at the left elbow joint in a 56-year-old man with pustular psoriasis. Then the left hand from the elbow to the shoulder gradually swelled against strong compression on the puncture site, which developed the compartment syndrome. Emergency removal of the subcutaneous hematoma was performed. There was no clotted blood in the subcutaneous space, but serous blood. Bleeding points were not clear even with close examination along the artery. Since serous bleeding still persisted after the surgery, blood transfusion was continued. The patient exhibited severe hypotension and tachycardia state, and fallen in cardiac arrest on the 1st postoperative day. Acquired hemophilia was diagnosed after the death from the examination of preserved plasma. The blood coagulation factor VIII was less than 1% (normal range; 60∼150%) and the auto-antibody to the factor VIII was 15 Bethesda U · ml ^-1 (normal range; undetectable). Acquired hemophilia is a rare disease which produces the auto-antibody to the factor VIII or IX. Activated partial thromboplastin time (APTT) was recognized to be indispensable for the preoperative examination as well as prothrombin time. In case the APTT was extremely prolonged, we need to suspect acquired hemophilia and to prepare against massive bleeding.

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We successfully managed a case of serious hypovolemic shock with reexpansion pulmonary edema (RPE). A 47-year-old man developed pneumothorax 11 days after a previous injury. A thoracic cavity drain was inserted, but the patient's respiration and circulation became unstable and he experienced intense coughing. Systolic blood pressure dropped from 120 mmHg to 60 mmHg, and pulse rate increased from 80 min^-1 to 120∼140 min^-1. Central venous pressure became 0 mmHg and hematocrit increased from 32% to 45%, strongly suggesting hypovolemic shock. We were able to save him by loading a large quantity of infusion. Respiratory failure with RPE is common, but its association with serious hypovolemic shock has not been previously mentioned. When inserting a thoracic cavity drain, care must be taken to prevent respiratory and circulatory failure.

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We report a case of a neonate with multiple organ failure treated by bicarbonate-buffered peritoneal dialysis (PD). The newborn suffered from respiratory and circulatory failure, and was intubated and ventilated immediately. However, she did not recover from hypoxia and hypotension, and subsequently developed severe lactic acidosis, hepatic dysfunction, acute renal failure, and disseminated intravascular coagulation. She was admitted to ICU for the treatment of PD at two days after birth. PD was performed for twenty hours, but her blood lactate level remained high and circulation was unstable. Therefore, we decided to switch from lactate-buffered solution to bicarbonate-buffered solution. After the switch, the blood lactate level fell to normal, and clinical condition was improved. On the 4th ICU day, urine output increased, and on the 6th day, PD was discontinued. On the 12th day, she was weaned from the ventilator. We believe that the bicarbonate-buffered PD was effective in treating the refractory lactic acidosis and improved the overall general condition.

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We report a case of nonocclusive mesenteric ischemia (NOMI) that could not be diagnosed despite diagnostic laparotomy. A 76-year-old man underwent urgent sigmoidectomy because of panperitonitis caused by perforated sigmoid diverticulitis. On the 2nd ICU day, shock occurred and serum lactate level increased. Necrosis of the intestine was suspected, and a second diagnostic laparotomy was performed. Significant findings of mesenteric ischemic changes were not obtained during laparotomy, but the increase in serum lactate level persisted. On the 4th ICU day, an abdominal enhanced CT scan showed a poorly contrasted intestine but no occlusive thrombus in the superior mesenteric artery and vein or in the portal vein. On the 5th ICU day, the abdominal sutured wound spontaneously unfastened, revealing necrosis of the whole intestine. Despite supportive therapy except for resection of the necrotic intestine, the patient died on the 9th ICU day. The pathogenesis of NOMI is thought to be vasospasm of peripheral mesenteric arteries. Therefore, in cases of acute mesenteric ischemia, a diagnosis of NOMI is difficult even if direct observation of intestine by diagnostic laparotomy is carried out in the early phase. Open abdominal observation using sterilized transparent drape may be a useful option for management of suspected NOMI when diagnostic laparotomy has failed.

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Purpose: The purpose of the present study was to evaluate the efficacy and safety of micafungin (MCFG) in the cases of deep-seated mycosis. Subjects: The subjects were nine patients admitted to this advanced emergency medical center. They had a fever that was resistant to broad-spectrum antimicrobial agents and were suspected of deep-seated mycosis because of inflammatory findings and abnormally increased β-D-glucan levels. Results: The dose of MCFG was either 100 mg · day^-1 or 150 mg · day^-1 and the duration of its administration ranged from 2 to 19 days. The overall clinical efficacy was evaluated by comparing the data obtained before and after MCFG treatment in terms of improvement in the following aspects: clinical symptoms and findings, results of serological tests of fungi, cultivation of fungi, and results of imaging test. Consequently, clinical efficacy was judged in seven patients, while it was judged impossible to evaluate the other two patients. In this result, β-D-glucan levels decreased in all cases, especially 3/7 cases (42.9%) indicated negative point after MCFG treatment. Both of cultivation of fungi and the canditec test were disappeared. Moreover, in all seven patients, body temperature, WBC, CRP, and interleukin-6 (100%) decreased. In addition, chest X-ray resulted in complete response (CR) 2/7 (28.6%), partial response (PR) 5/7 (71.4%). Seven patients were discharged with survivor. No MCFG associated adverse reactions were recognized. Conclusion: Pre-emptive administration of MCFG, which was effective in treating the both albicans and non-albicans Candida infection, to patients diagnosed as β-D-glucan positive led to satisfactory treatment results. MCFG seems to be a first-choice drug for empiric or pre-emptive therapy in the field of emergency or intensive care.

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Objective: To evaluate the effect of genotypic differences and the blood interleukin-1 receptor antagonist (IL-1ra) / interleukin-1β (IL-1β) levels ratio within IL-1 gene cluster polymorphisms on the outcome. Methods: One hundred and ninety consecutive critically ill patients recruited on admission to the ICU, regardless of diagnosis, were studied. Interleukin-6 (IL-6) blood levels were measured daily with chemiluminescent enzyme immunoassay. IL-1β and IL-1ra blood levels at corresponding time when routinely measured IL-6 showed maximal values were measured retrospectively with enzyme amplified sensitivity immunoassay. Single nucleotide polymorphisms at position -511 and +3953 sites of the IL-1β (IL-1β-511^*C/T and IL1β+3953^*C/T) were identified with restriction fragment length polymorphism method. IL-1ra intron 2nd various number of tandem repeat polymorphism (IL-1RN^*1-5) was identified after polymerase chain reaction with gel electrophoresis. Results: IL-1RN^*1.1 homozygotes had significantly higher survival (P = 0.04) and higher blood IL-1ra/IL-1β ratio (P = 0.01) than the other genotypes in IL-1RN^*1-5. However, all those three polymorphisms (IL-1β-511^*C/T, IL-1β+3953^*C/T, and IL-1RN^*1-5) solely affect neither IL-1β nor IL-1ra blood levels in each. Conclusions: Non-IL-1RN^*1 alleles are associated with poor outcome and decrease in IL-1ra/IL-1β ratio causing overproduction of IL-6. Therefore, IL-1ra/IL-1β imbalance is considered to have induced the cytokine network collapse in those genetically high risk patients for hypercytokinemia.

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