Journal of the Japanese Society of Intensive Care Medicine
Online ISSN : 1882-966X
Print ISSN : 1340-7988
ISSN-L : 1340-7988
Volume 6, Issue 1
Displaying 1-10 of 10 articles from this issue
  • Hideaki Hanaki, Keiichi Hiramatsu
    1999 Volume 6 Issue 1 Pages 3-13
    Published: January 01, 1999
    Released on J-STAGE: March 27, 2009
    JOURNAL FREE ACCESS
    The mechanism of vancomycin resistance in Mu50 expressing vancomycin resistance with MIC of 8mg·ml-1 (VRSA), and Mu3 having heterogeneous vancomycin resistance with MIC of 2mg·ml-1 (hetero-VRSA) were investigated. Mu3 and Mu50 were found to share three features when compared with the vancomycin-susceptible control strains: 1) accelerated uptake of N-acetylglucosamine into the cell, 2) an increased cytoplasmic murein monomer precursor pool, and 3) increased production of PBP2 (and PBP2'). These phenotypes which would be recapitulated into ‘activated cell-wall synthesis’ may be a precursor of vancomycin resistance in the Mu3-Mu50 lineage of S. aureus strains.
    Chromatography of untreated mutanolysin-hydrolyzed peptidoglycan components of Mu50 revealed: 1) an increased proportion of abnormal muropeptide components, and 2) decreased cross-linking as evidenced by an unusual increase in the muropeptide monomer/dimer ratio as compared to Mu3. The cell wall of VRSA strain Mu50 had a distinct structure and increased binding capacity to vancomycin as compared with hetero-VRSA. This, together with increased cell-wall thickness, may account for the difference of the level of vancomycin resistance between VRSA and hetero-VRSA.
    VRSA can be detected by the current methods (MIC, E-test, paper disc), but hetero-VRSA cannot. In contrast to the known fact that combination of vancomycin and β-lactam antibiotics synergistically acts on VSSA (vancomycin-sensitive Staphylococcus aureus), it was found that the drugs antagonize in acting on hetero-VRSA (Mu3). Utilizing this antagonistic phenomenon (induction of vancomycin resistance by β-lactam antibiotics), we developed a method of detecting the Mu3 strain in which a paper disc containing β-lactam antibiotics was placed on an agar plate containing vancomycin at a concentration which does not allow the Mu3 strain to grow, forcing the Mu3 strain to grow only around the paper disc. The growth zone formed a ring around the disc when the concentration of β-lactam antibiotics contained in the paper disc was increased. From these observations we concluded that there is an optimal concentration of β-lactam antibiotics for inducing vancomycin resistance.
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  • Postmortem analysis using 1H and 19F NMR imaging
    Koshi Makita, Tokujiro Uchida, Koichi Nakazawa, Seiji Ishikawa, Keisuk ...
    1999 Volume 6 Issue 1 Pages 15-20
    Published: January 01, 1999
    Released on J-STAGE: March 27, 2009
    JOURNAL FREE ACCESS
    Intratracheal administration of a perfluorocarbon liquid (perfluorooctyl bromide, PFOB) during continuous positive-pressure ventilation (partial liquid ventilation, PLV) improves lung function in animals with lung injury. We attempted to determine whether there is a correlation between improvement of oxygenation and distribution of PFOB in a rabbit lung injury model using 1H and 19F nuclear magnetic resonance imaging.
    Oleic acid was administered intravenously at 0.1ml·kg-1 to induce lung injury in six anesthetized rabbits ventilated at FIO2 1.0. After baseline blood gas analysis, 45ml of PFOB was given intratracheally and the blood gas was analyzed every 30min thereafter. Postmortem 1H and 19F magnetic resonance imaging (MRI) was conducted using a 4.7-T, 33cm horizontal bore Varian NMR (nuclear magnetic resonance) spectroscopy/imaging system. Seven slices of both 1H and 19F lung images were obtained using the FLASH (fast low angle shot) method. Improvement of oxygenation was calculated by subtracting the baseline PaO2 from the PaO2 (mmHg) at 30min after PLV. Distribution of PFOB was calculated by dividing the sum of PFOB areas of seven lung slices using 19F imaging by the sum of the lung areas in the same slices using 1H imaging.
    Fluorothorax developed in one animal and PaO2 did not improve. This animal was therefore excluded from further analysis. PaO2 improved from 66±23mmHg (mean±SD) at the baseline to 159±91mmHg at 30min after PLV. PFOB was distributed in 54±29% of the lung area in five animals. It was distributed mainly in the dependent lung region, probably because of its high specific gravity (1.92 at 25°C). There was no correlation (r2=0.60, P>0.05) between the improvement of oxygenation and the distribution area of PFOB. It was suggested that reexpansion of dependent lung alveoli by PFOB might be one of the beneficial effects of PLV.
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  • Timing of surgery and inhaled nitric oxide
    Keiko Kinouchi, Kazuo Fukumitsu, Seiji Kitamura, Sonoko Nakamichi, Aki ...
    1999 Volume 6 Issue 1 Pages 21-27
    Published: January 01, 1999
    Released on J-STAGE: March 27, 2009
    JOURNAL FREE ACCESS
    We retrospectively reviewed the treatment protocol and outcome of patients delivered at our institution with prenatal diagnosis of congenital diaphragmatic hernia (CDH) from 1988 to 1997. Patients were divided into four chronological groups according to the change of treatment protocol. Group 1: 5 patients born from July 1988 through December 1990, a period when CDH was considered to be a surgical emergency, underwent immediate repair of hernia after birth. Group 2: 6 patients born from 1991 through June 1993 were treated using a management protocol of delayed repair after stabilization except when their postductal PaO2 exceeded 200mmHg. Group 3: 6 patients born from July 1993 through December 1995 were treated with the same protocol as group 2, but nitric oxide inhalation was available. Group 4: 7 patients (1996-1997) underwent early repair of hernia with the aid of inhaled nitric oxide. All the patients but one were delivered by cesarean section. There were no statistical differences in gestational age, birth weight, umbilical arterial blood gases, Apgar scores, hernia side, or herniated viscera among groups. The survival rate was 60% in group 1, 17% in group 2, 33% in group 3 and 100% in group 4, (P<0.05). Two patients each in groups 2 and 3 died during stabilization without undergoing surgical repair. Extracorporeal membrane oxygenation (ECMO) was instituted in 2 patients in group 1, 4 in group 2, 3 in group 3 and none in group 4. Out of 9 patients treated with ECMO, 8 died. Inhaled nitric oxide was applied to 6 patients in group 3 and 5 patients in group 4. Delayed operation after stabilization did not yield a good outcome. Inhaled nitric oxide may be useful in the treatment of CDH.
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  • Takeshi Aiba, Tomonori Itoh, Akira Itoh, Satoshi Daikoku, Shunichi Miy ...
    1999 Volume 6 Issue 1 Pages 29-33
    Published: January 01, 1999
    Released on J-STAGE: March 27, 2009
    JOURNAL FREE ACCESS
    The purpose of this study was to determine the appropriate indications for the use of a percutaneous cardiopulmonary support system (PCPS) for patients with acute circulatory failure. We studied 43 consecutive patients who used PCPs because of acute circulatory failure. We compared clinical characteristics between the two groups (weaning: n=14, and non-weaning: n=29) and examined the factors related to successful weaning from PCPS. We used a shock scoring system (shock score) for evaluating the severity of shock from five clinical factors such as systolic blood pressure, heart rate, hourly urinary output, base excess and mental state before using PCPS. There were no significant differences between the two groups in the basal disease or the time elapsed from the onset of shock to starting PCPS. Shock scores were significantly higher in the non-weaning group than in the weaning group (9.8±2.3 vs. 6.7±2.8; P<0.001). The incidence of cardiac arrest or fatal arrhythmias before using PCPS was significantly higher in the non-weaning group than in the weaning group (72% vs. 36%; P<0.05). All the patients whose shock scores were greater than 11 could not be weaned from PCPS. The patients with mild or moderate acute circulatory failure whose shock scores were less than 10 could be weaned from PCPS. Thus PCPS should be used before the shock state falls into hemodynamic collapse.
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  • Kaneyuki Kawamae, Choichiro Tase, Masahiro Murakawa, Manabu Otsuki, Yu ...
    1999 Volume 6 Issue 1 Pages 35-40
    Published: January 01, 1999
    Released on J-STAGE: March 27, 2009
    JOURNAL FREE ACCESS
    Excessive interleukin-8 (IL-8) plays an important role as a key mediator in neutrophil-dependent inflammatory disease.
    The purpose of this study was to elucidate the time course of IL-8 exudation from the local inflammatory tissue to systemic circulation using a hydrochloric acid (HCl) injured lung model.
    Fifty-six male Spraque-Dawley rats were mechanically ventilated after tracheostomy under ketamine and xylazine anesthesia. 1.5 ml·kg-1 of HCl with pH 1.5 was instilled through the endotracheal tube. The animals were randomly divided into 6 study groups according to the time at which they were sacrificed: before and 30 minutes, 1, 2, 3, and 4 hours after HCl injection. Two of the control groups did not receive HCl. The first control group was ventilated with room air, and the second control group with pure oxygen for 4 hours. IL-8 concentrations in the blood, broncho-alveolar lavage fluid (BALF), and lung tissue were measured by enzyme-linked immuno-sorbent assay (ELISA).
    IL-8 in lung tissue and in BALE significantly increased one hour after HCl instillation, while IL-8 in the blood significantly increased at 4 hours.
    The release of IL-8 into the blood was delayed for a few hours compared to the elevation of IL-8 in lung tissue and in BALF.
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  • Hiroko Kato, Ikuko Miyawaki, Kazuo Yamazaki
    1999 Volume 6 Issue 1 Pages 41-45
    Published: January 01, 1999
    Released on J-STAGE: March 27, 2009
    JOURNAL FREE ACCESS
    We retrospectively studied all obstetric patients admitted to the General Intensive Care Unit (ICU) of Kobe City General Hospital from 1985 to 1996. The aim of the study was to determine the incidence, causes and outcome of these admissions.
    Forty cases were identified; the incidence was 0.17% of the total number of ICU admissions, and 0.3% with respect to the total number of deliveries during the same period. Of 40 cases, 19 (47.5%) were referred from other hospitals or physicians. All but one patient with bronchial asthma were admitted to the ICU postpartum. Obstetric complications accounted for 75% of admissions and preexisting medical problems accounted for the remaining 25%. Preeclampsia/eclampsia was the most frequent cause of obstetric complications, followed by postpartum hemorrhage and severe placental abruption.
    Nineteen patients (47.5%) had one or more complications; pulmonary embolism in 2, pulmonary edema in 2, eclampsia in 4, acute renal failure in 8, HELLP (hemolysis, elevated liver enzyme, low platelet) syndrome in 2, pneumonia in 1 and disseminated intravascular coagulation in 10. Twenty-six of 40 patients (65%) including all the patients with postpartum hemorrhage and 8 with non-obstetric disorders were discharged from the ICU within 24 hours. Four patients stayed in the ICU over one week, and 10 patients stayed for 2 to 4 days. Most were related to preeclampsia/eclampsia. The transferred patients had more severe obstetric complications and stayed in the ICU longer than the inpatients from our facility.
    This study reconfirmed that proper prenatal care is essential for reducing postpartum morbidity and that preeclampsia/eclampsia remains a significant complication with high morbidity.
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  • Youichi Iwasaki, Sukejuro Ohta, Takahide Mizunuma, Hiromichi Terada, T ...
    1999 Volume 6 Issue 1 Pages 47-51
    Published: January 01, 1999
    Released on J-STAGE: March 27, 2009
    JOURNAL FREE ACCESS
    Postresuscitative consciousness disturbance was ameliorated by a two-step procedure of spinal cord stimulation. A 30-yr-old man fell into unconsciousness and apnea, and was transported to our ICU undergoing cardiopulmonary resuscitation (CPR). On admission, he was in coma with predominant theta waves on electroencephalogram (EEG) and with prolonged latencies on auditory brainstem response (ABR), but there were no abnormal findings on the brain CT.
    We commenced therapy for cerebral protection, including mild hypothermia (35°C), reduction of intracranial pressure, and hyperbaric oxygenation for one week. On the 12th day, eye opening to pain and normal ABR findings were observed without improvement of EEG findings. On the 20th day, atrophic changes were observed on brain CT over the entire cerebrum, especially in the left temporal lobe.
    A two-step procedure of spinal cord stimulation was carried out to help improve the patient's level of consciousness. First, a transcutaneous magnetic stimulation was non-invasively achieved using a Magstim 200(R) (the MAGSTIM company Ltd. U. K.) from the 29th to the 64th day. Spontaneous opening of the eyes appeared after the 2nd stimulation, and verbal sounds and swallowing after the 5th stimulation. The next step involved the surgical implantation of epidural electrodes for spinal cord stimulation at the C3-C6 levels, followed by the start of electric stimulation from the 138th day. One month later, alpha waves on EEG and verbal sounds increased. The patient has been undergoing rehabilitation since then.
    A two-step procedure of spinal cord stimulation may be useful in curing disturbance of consciousness after CPR.
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  • Sumiko Sakai, Yoshito Shiraishi, Junichirou Yokoyama, Hiroshi Igarashi ...
    1999 Volume 6 Issue 1 Pages 53-57
    Published: January 01, 1999
    Released on J-STAGE: March 27, 2009
    JOURNAL FREE ACCESS
    We report a case of a female patient with a blood type of A1Bm who had been accidentally transfused with a large amount of group A blood during an emergency operation. This accident happened because the complete results of her blood typing test were not available in time to treat her critical oligemic condition because of the time (midnight) and since urgent crossmatching examination of group A blood was satisfacting. Though the patient developed episodes of hypovolemic shock and hemolytic reaction, she respond excellently to intensive care and recovered without serious sequelae. We believe that weak agglutination by the Bm antigen with anti-B serum helped avoid more serious sequealae from the incompatible blood transfusion. ABO weak variants are characterized by very weak antigen activity on the surface of red cells which react negatively to ordinary blood typing procedures. It has been thought that the type of blood used for transfusion with weak ABO variants does not necessarity have to be identical to that of the variants for satisfying crossmatching examination. However, we experienced a critical situation due to the limitations urgent crossmatching examinations and believe that transfusion of blood containing serum must be avoided in cases where a large amount of blood is transfused into a patient with ABO variants.
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  • Futoshi Kimura, Isao Araki, Akinori Matsui, Toshihito Tsubo, Hironori ...
    1999 Volume 6 Issue 1 Pages 59-63
    Published: January 01, 1999
    Released on J-STAGE: March 27, 2009
    JOURNAL FREE ACCESS
    Hemophagocytic syndrome (HPS) is rare, sometimes fatal disease characterized by hemophagocytosis and multiple organ dysfunction. Underlying pathology includes hypercytokinemia elicited by activated T-lymphocytes and macrophages. Continuous hemodiafiltration (CHDF) has the potential to eliminate cytokines and other cytotoxic factors from the body. This case report was intended to describe whether CHDF has beneficial effects on the treatment of HPS.
    A 5-year-old girl weighing 20kg with HPS was treated with CHDF for 70 hours in the ICU. A polymethylmetacrylate hollow fiber filter was connected to an extracorporeal circuit for CHDF. Its blood flow rate was maintained at 30ml·min-1.
    Renal functions and clinical manifestations were improved markedly. Tumor necrosis factor-α (TNF-α), interleukin (IL)-1β, IL-6, IL-8, kinetics of myeloperoxidase (MPO) and polymorphonuclear leukocyte elastase (PMNE) were measured. Samples were collected from the CHDF circuit before and after the filter, and ultradiafiltrate at 0, 2, 12 and 24 hours after the start of CHDF. Although serum levels of TNF-αand IL-1β were undetectable, serum levels of IL-6, IL-8, MPO and PMNE were high throughout the period of measurement. The reduction ratio of those variables by CHDF ranged between 14 and 35%. Twenty-four hour eliminations were 2352ng for IL-1β, 126ng for IL-6, 4320ng for IL-8, and 1085 μg for PMNE, respectively.
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  • Toshihito Tsubo, Masako Ebina, Noriaki Otomo, Hironori Ishihara, Akito ...
    1999 Volume 6 Issue 1 Pages 65-67
    Published: January 01, 1999
    Released on J-STAGE: March 27, 2009
    JOURNAL FREE ACCESS
    We report a case of papillary muscle rupture that occurred after acute myocardial infarction. A 56 year old man was transferred to our hospital for acute chest pain. Immediate cardiac catheterization found a total occlusion in segment 2 of the right coronary artery. The patient experienced re-infarction on the third hospital day and developed progressively severe heart failure. Transthoracic echocardiography did not show any signs of papillary muscle rupture. Transesophageal echocardiography, however, did find ruptured papillary muscle in the left atrial and ventricular cavities. The patient underwent emergency mitral valve replacement using a prosthetic valve (SJM(R)). Intraoperative findings confirmed total rupture of the posterior papillary muscle. Unfortunately, the patient died of heart failure 3 hours postoperatively. Transesophageal echocardiography was useful for diagnosis of ruptured papillary muscle in acute myocardial infarction.
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