Low cardiac output syndrome (LOS), one of the most serious complications of cardiovascular surgery, is defined as an imbalance of oxygen demand and supply due to a deterioration of cardiac function. Critical oxygen delivery marks the turning point from the dependent to the independent phase in the relationship between oxygen delivery and consumption. It is crucial to maintain oxygen delivery beyond the point of critical oxygen delivery (the independent phase) after cardiovascular surgery or in critically ill patients. Critical oxygen delivery is approximately 400ml·min^-1·m^-2 immediately after cardiovascular surgery under controlled ventilation. To maintain critical oxygen delivery, hemodynamic management requires a CI (l·min^-1·m^-2)>40/CaO₂(vol%). A CaO₂(vol%) of 40/CI(l·min^-1·m^-2) is the critical level when anemia is present. Alternative strategies to control LOS by improving the imbalance of oxygen demand and supply include the inhalation of nitric oxide, which increases oxygen delivery, and the presence of mild hypothermia (a core temperature of approximately 35°C), which reduces critical oxygen delivery.

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We have demonstrated that a new assay system containing B-phycoerythrin and AAPH [2, 2'-azobis (2-amidinopropane) dihydrochloride] is of value in evaluating the antioxidant activities of various compounds. B-phycoerythrin is a fluorescent protein which is sensitively oxidized and reduces its fluorescence depending on the degree of oxidative destruction, and AAPH is an oxidative stress stimulator which continuously generates peroxyl radicals at a very constant rate. Some compounds, which possibly possess antioxidant activity, protect. oxidation of B-phycoerythrin and inhibit the fluorescence decay, depending on their antioxidant activity. The assay system revealed that both calcium channel blockers (nicardipine, verapamil and diltiazem) and steroids (hydrocortisone, methylprednisolone, betamethasone, dexamethasone and prednisolone) had potent antioxidant activities. Since both kinds of drugs are used in ischemia-reperfusion injury or shock, which are closely relate to free radical injury, some pharmacological effects of these drugs may be based on these antioxidant activities.

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We assessed the effectiveness of our intensive care system in improving patient survival by developing a “life-saving score (LS)” derived from the APACHE II-predicted mortality ratio, in 100 consecutive adult ICU patients. Therapeutic intervention was assessed by a modified therapeutic intervention scoring system (TISS) incorporating utilization of equipment, materials, personnel and technical specialty necessary for ICU interventional procedures (IS). We used this information to make a cost-efficiency analysis of intensive care. LS was found to be useful in evaluating the quality of intensive care taking into account the severity of illness. IS was found to make characterization of the pattern of resource utilization possible. The cost-efficiency balance seemed to be the most satisfactory in central nervous system diseases and the least satisfactory in hepatometabolic diseases, but this may be misleading because of under- or over-estimation of mortality as predicted by the APACHE II system in these disease categories. However, the longitudinal application of our method of cost-efficiency analysis seems useful for obtaining quality assurance in individual ICUs.

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In the conventionally supported prone position (C prone), subjects were supported with rolled pads inserted at a right angle to the body axis on the level of the clavicular and iliac prominences. In the lengthwise supported prone position (L prone), rolled pads were inserted parallel to the body axis at both sides of the body. Skin pressure against the pads was measured at three points (shoulder, ilium and patella) 30 minutes after being turned into each position.
The results showed that body weight was more dispersed on L prone than C prone. The pressure on the skin was decreased at the iliac portion, especially in the obese group. In C prone, seven subjects complained of mild pain at the compressed portions and 26 subjects complained of unpleasant pressure on the upper part of the chest. But in L prone only one subject complained of pain at the knee and nine felt instability of their bodies as if they would slip.

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We retrospectively examined complaints and trouble with the apparatus during NIPPV (noninvasive positive pressure ventilation) in 170 patients. There were 381 incidents of complaints or trouble from 141 of the 170 patients (82.9%) whose medical records were examined. Nursing care resolved the problems in 171 incidents (44.9%) while 193 incidents (50.6%) required intervention by a physician. Nursing care was able to resolve such problems as feelings of oppression and discomfort (77 incidents) resulting from the mask, or oral and nasal injury and dryness (43 incidents). Intervention by a physician was needed for such problems as a decrease in SpO₂ (54 incidents), uneasiness (34 incidents), and trouble with the apparatus (17 incidents). The nursing staff contacted the physician immediately in such cases and prepared for endotracheal intubation. Positive pressure ventilation with tracheal intubation was needed in 53 incidents.
Since patients treated with NIPPV are conscious and sensitive to pain, the nursing staff must respond to complaints by the patient more carefully and quickly than to patients treated with invasive ventilatory support. It is crucial for the nursing staff to accurately assess whether the condition of the patient requires endotracheal intubation for resolution.

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We treated six patients with purulent infections caused by the Streptococcus milleri group (S. milleri group). Three patients had head or neck abscesses and three had subcutaneous abscesses following gastrointestinal surgery. In all patients, the S. milleri group was isolated from the abscesses. In four patients, microaerophilous or anaerobic commensal organisms were also isolated in association with the S. milleri group. Two patients with cervical abscesses had a history of several days of sore throat followed by progressive dyspnea due to a remarkable swelling of the cervical tissue. Airway maintenance and a drainage were necessary immediately after hospitalization. In three patients with infections following gastrointestinal surgery, abscesses formed in intra-abdominal and soft tissue sites and developed into sepsis. Patients with S. milleri group septicemia developed multiple organ dysfunction including the lungs, liver and kidneys. Antibiotic therapy was initiated using broad spectrum antibiotics to cover for both aerobic and anaerobic organisms. Incision and drainage were performed in all cases. Rapid swelling and extension of the infected area, mixed infection with other organisms containing anaerobes, and abscess formation were characteristics of infections caused by the S. milleri group. In an immuno-compromised host, S. milleri group infection may result in sepsis followed by multiple organ dysfunction.

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A 6-year-old boy was admitted to our hospital for fever, anemia and hepatosplenomegaly. Laboratory data revealed pancytopenia and hyperferritinemia. A bone marrow smear demonstrated the proliferation of mature histiocytes with hemophagocytosis. The patient was diagnosed as having Epstein-Barr virus associated hemophagocytic syndrome (EBV-AHS). Massive doses of gamma-globulin were administered, but his condition worsened. He was transferred to the ICU because of disseminated intravascular coagulation syndrome and respiratory failure. Exchange transfusion and plasma exchange were performed. Dexamethasone, etoposide and cyclosporin A were administered. Respiratory and coagulative function were improved, but anemia, hepatosplenomegaly, hyperferrtinemia, increased beta2-microglobulin in the urine and mild consciousness disorder (JCS 1∼2) continued. After discharge from the ICU, transfusion intravenous dexamethasone, etoposide and cyclosporin A were necessary. Despite treatment including ACOP (adriamycin-cyclophosphamide-oncovin-prednisolone) therapy, the patient's respiration deteriorated and he died of multiple organ failure.
EBV-AHS is a rare histiocytic proliferative disorder caused by Epstein-Barr viral infection affecting children and young adults. It has a poor prognosis and there is no specific treatment. Since histiocytes can be activated by cytokines, it is said that blood purification, such as exchange transfusion and plasma exchange may reduce serum cytokines. However this case indicated that blood purification is not a reliable treatment.

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We report two cases of Quasimodo syndrome (kyphoscoliosis with respiratory disorder on sleep), who developed respiratory failure and right heart failure. The first case was a 40-year-old woman who developed severe hypoxemia, hypercapnia and congestive heart failure. She was intubated and mechanically ventilated with pressure support ventilation (PSV) for 7 days. The second case was a 44-year-old woman who was intubated to treat CO₂ narcosis and right heart failure. She was mechanically ventilated with PSV for 5 days. Both cases were weaned from PSV and extubated. However, both needed respiratory support during sleep, and were successfully treated with bi-level positive airway pressure (BiPAP^TM) by nasal mask. BiPAP^TM seems to be effective and useful in managing patients with Quasimodo syndrome. However, it is important to detect sleep apnea syndrome or sleep hypopnea syndrome, which are not readily apparent, in the treatment of Quasimodo syndrome.

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