Diagnosis and treatment of acute myocardial infarction have been developed in the past 50 years. Since the 1970's, the concept of unstable angina has been advocated to stratify the high-risk group of impending myocardial infarction. In the 1980's and 1990's, the new concept i. e., “acute coronary syndrome” was proposed. The mechanisms of acute coronary ischemic events have been clarified. In 2000, the definition of acute myocardial infarction was revised, and the new risk stratification was recommended to detect the myocardial damage more rapidly by using several novel markers, e.g., troponin T and troponin I. With regard to the treatment, the main therapeutic goal of acute myocardial infarction in the 1960's was the prevention of life-threating arrhythmias. Selective coronary angiography and coronary bypass graft surgery spread in the 1970's, and the era of thrombolysis was launched in the 1980's. Percutaneous transluminal coronary angioplasty (PTCA) and stenting were established to be safe and cost effective therapies by large randomized studies in the 1990's. New devices, such as directional coronary atherectomy and rotablator were now widely used. On the other hand, several minimally invasive surgical techniques have been established.

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We analyzed the outcomes of the patients with out-of-hospital cardiac arrest in Japan and make proposals for improving the results in the early 21st century by systemizing a so-called “chain of survival” which includes hypothermic brain protection. The 1-year survival rate of witnessed arrest of cardiac etiology out of hospital is as low as 2.6% in Japan and this poor score was attributed to delays in making ambulance calls, a low rate of layrescur's cardiopulmonary resuscitation (CPR), and low success rate of on-site defibrillation done by emergency life-saving technicians (ELST). Interval between the call and defibrillation is proved to be a problem in Japan. Although advanced life support done by doctors in E. R. may increase the temporary survivors, their long-term morbidity and mortality is worse than that of those who are resuscitated before arriving at a hospital. This result also proves the importance of early defibrillation. We usually go on applying cardiopulmonary bypass in combination with intraaortic balloon pumping, coronary reperfusion, and mild hypothermia of 34°C as an advanced cardiopulmonary cerebral resuscitation. Hypothermic brain protection for post-resuscitative state is still controversial but our non-randomized non-controlled study of twenty-three cases resulted in 52% of good recovery. With all these results we propose the followings as a strategy to obtain good recovery.
1. In the field; promotion of immediate ambulance calls from witnesses by using a mobil phone, popularization of chest-compression-only CPR by laypersons, and spread of public access, automated external defibrillator in hands of trained laypersons are needed.
2. In the hospital; advanced post-resuscitation care to stabilize cardiovascular system, to preserve brain function, and to prevent multiple organ dysfunction and serious infection are needed.
The guideline 2000 for CPR which was based on the latent evidence in the 20th century categorized the efficacy of both cardiopulmonary bypass and resuscitative hypothermia as the Class Indeterminate, but we expect from our clinical experience that new randomized controlled trials in the 21st century will be promising.

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We examined the causes of extubation failure in our ICU. Thirty three patients who had been intubated for more than 7 days were prospectively subjected to fiberscopic observation right after extubation to examine the relationship between the findings of the larynx and the intubation period, clinical manifestations, and the outcome of extubation. The clinical symptoms after extubation were classified into upper airway obstruction type and tenacious secretion type. The fiberoptic findings were divided into (1) laryngeal edema, (2) vocal cord injury, and (3) glottic impotency. Results: Average intubation period is 14 days. Patients manifesting airway obstruction have laryngeal edema significantly more than those who are not and reintubation rate is also higher. Non-invasive positive pressure ventilation (NPPV) is effective to some of these obstructed patients. Patients presenting the symptoms of secretion need reintubation or tracheostomy. As is previously reported, repeated intubation may develop laryngeal injury and early tracheostomy is to be appreciated. We could not evaluate the clinical symptoms and fiberoptic findings quantitatively in this study, but we would like to emphasize the importance of differentiating the type of symptoms and laryngeal lesions, and of appropriate treatment for each pathology.

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Subjects and Methods: We retrospectively analyzed 427 brain injured patients (head trauma plus cerebrovascular diseases) using a multiple logistic regression analysis to determine the factors predicting the mortality of these patients. Factors analyzed were age and sex of the patients, vital signs involving Glasgow Coma Scale (GCS), and basic laboratory studies. An optimal discriminant equation was calculated from all these parameters (EQ1) and then the equation was simplified to which only laboratory data were applied (EQ2). The areas under receiver operating characteristics (ROC) curves were compared between any two of the following four prognostic parameters: the scores by EQ1 and by EQ2, GCS score, and APACHE II score.
Result: An optimal discriminant equation (EQ1) was derived as {P=1/(1+e^-x), X=8.67+0.0092(age)-0.00375 (sex;man=0, woman=1)-0.227(GCS)+0.0504(BUN)-0.700(K)-0.0451(PaCO₂)+5.62×10^-5(WBC)-0.0756(BE)}. The score calculated from data on admission by EQ1 was the best discriminant for all patients but was not significantly different from any one of the others. EQ2 was significantly worse predictor in the case of head trauma than any one of the others and, on the other hand, GCS was worse than others in the case of cerebrovascular diseases. Data obtained on the 7th day in ICU (n=233) was more contributory to predict prognosis than data on admission.
Conclusions: GCS was a useful predictor of mortality in patients with head trauma, while basic blood test was proved to be useful for predicting mortality of cerebrovascular diseases.

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Continuous intravenous propofol was chosen as a sedative of a 50-year-old male patient with tetanus following unsuccessful trial for 6 days to control his tetanic symptoms by continuous intravenous midazolam supplemented with intermittent intravenous diazepam. Although propofol showed dramatic effect to control his sweating and spasm, it was discontinued on the 13th day because of the limit of health insurance coverage. Midazolam was restarted and symptoms got worse again. Administration of propofol was repeated and proved to be effective once again. From this case we thought propofol might be a more suitable drug than midazolam in a patient with mild tetanus.

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A 42-year-old man who had suffered from severe acute pancreatitis after heavy alcohol consumption was transferred to our ICU by reason of renal failure. Continuous hemodiafiltration was introduced in order to replace kidney function and to control systemic inflammatory response syndrome by removing causative humoral mediators of pancreatitis. Although his condition was subsequently improved, sudden massive bleeding through a nasogastric tube on the 8th ICU day required urgent endoscopy and was revealed to be from gastric varices. Splenic artery angiogram confirmed occulusion of splenic vein and bleeding gastric veins. Transcatheter embolization of splenic artery, left gastric artery, and right gastric artery was performed and resulted in successful hemostasis. Splenectomy has been thought to be the standard treatment for gastric varices in chronic pancreatitis, but we believe that not laparotomy but transcatheter splenic embolization should be the first choice for acute variceal bleeding in a patient with severe acute pancreatitis who has the high risk of infectious peritonitis.

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An 86-year-old female patient with severe ARDS resulted from near-drowning was admitted to our ICU. The patient's PaO₂ value is 31mmHg with 100% oxygen inhalation and a PEEP of 17cm H₂O when we started mechanical ventilation with pressure support of 15cm H₂O. Since rising a level of PEEP to 20cm H₂O caused little increase of PaO₂ and critical deterioration of hemodynamics, we decided to accept hypoxemia to maintain hemodynamic stability. Peak airway pressure was set at 30cm H₂O to avoid ventilator-induced lung injury. Although the PaO₂ values were less than 40mmHg for 7 hours and less than 50mmHg for 22 hours, we could not point out hypoxic damage in any one of vital organs with intensive monitoring.
The patient has recovered without any residual dysfunction of vital organs and we attribute her recovery in part to lung protective strategy despite long-term hypoxemia.

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