The significance of “clinical pathway technique”, a new case management method, and its application to the rehabilitation program after acute myocardial infarction are demonstrated. We successfully reduced the length of hospital stay by the implementation of three risk-stratified clinical pathways in cardiac rehabilitation after myocardial infarction without any adverse effect. It may be possible to improve the quality of providing care through displaying the goals for patients in the clinical pathway and analyzing the variances (patient outcomes that do not meet the expectation of the pathway). Moreover, this system may provide us the opportunities of multidisciplinary intervention and evidence-based medicine. However, without physician support of the pathway, it is unlikely to achieve any of cost-saving or quality goals. Although clinical pathway techniques were first developed in the States because of economical incentives, it must be reconstituted under the current Japanese health care setting.

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We have extensively applied percutaneous cardiopulmonary support system (PCPS) in intensive care setting in these 10 years and.review 71 cases of PCPS in our institute between April 1991 and March 2001 to evaluate its impact on patient's outcome. Forty-four cases were men and 27 cases were women. The mean age was 61.5±10.5 year old. We applied PCPS to 29 cases of out-of-hospital (prehospital) cardiopulmonary arrest and 13 of in-hospital (after arrival at ER) cardiopulmonary arrest in order to resuscitate them. Twenty-nine hospitalized patients were with cardiac failure or pulmonary embolism, and 10 patients were under citical percutaneous transluminal angioplasty or postoperative period of open heart surgery. All of these patients underwent PCPS and forty-six of them (64.8%) were successfully weaned from it. Twenty-seven patients (38.0%) reached hospital discharge and overall mortality rate was 59.2%. Thirty-one patients among the 42 deceased were the arrested patients. PCPS has had less impact on the patients with cardiomyopathy and cardiac surgery patinets who had unstable hemodynamics in addition to postresuscitative ones despite its improvement in hardware and application skills like rapid setup, but seemed to improve the outcome of the patients with arrythmia (ventricular fibrillation), acute pulmonary embolism, and myocardial infarction. The PCPS procedure should be more sophisticated to save the patients who could not survive without it. The indication of PCPS is still controversial and will be in evolution. Further study must be required to establish the clinical indication of PCPS more strictly.

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Background: A pulmonary artery balloon catheter is one of the most useful monitoring for the management of hemodynamics. We evaluated the relationship between right ventricular end diastolic volume index (RVEDVI) and cardiac index (CI) in patients of emergency cardiovascular diseases with hemodynamic instability using the CCO/CEDV thermodilution catheter. Methods: We measured the pressures, volumes, cardiac outputs, heart rates (HR) and oxygen (O₂) saturations in 9 patients meeting inclusion criteria. Factors relevant to CI were assessed by regression analysis. Results: In the 439 points of those parameters measured every 1 hour for 2 days, RVEDVI and O₂ extraction rate (O₂ER) were shown to be the factors associated with CI (R=0.3 P<0.0001, respectively). However, pulmonary artery wedge pressure and central venous pressure were not related to CI. Multiple regression analysis revealed that HR, RVEDVI, ejection fraction and O₂ER were related to CI (R²=0.4, P<0.0001). Conclusions: The monitoring of RVEDVI in patients of emergency cardiovascular diseases with hemodynamic instability is needed for the management of CI.

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This study examined reliability and validity of the prototype of an assessment tool based on the Japan coma scale (JCS) to judge level of consciousness. The tool includes 58 items concerning patient's memory, orientation, behavior and so on. Eleven nurses who had 4 or more years experience in a neurosurgical ward or an emergency/critical care center were subjected. Randomly selected three nurses among the eleven (=raters) used the assessment tool to evaluate 55 patients with various level of consciousness. The raters who were independent of each other choosed appropriate items from the tool to evaluate patient's consciousness level and simultaneously did it with the Glasgaw Coma Scale (GCS). Interrater reliability and concurrent validity with the GCS of this assessment tool were tested. The statistical significance was determinded by kappa coefficient and intraclass correlation coefficient analysis at the level of P<0.05. As a result, the intraclass correlation coefficients of each 58 items of the assesment tool showed significant correlation with the exception of 2 items. The results of three raters were coincident in 30.9% of the cases and the results of the two were coincident in 67.3%, and intraclass correlation coefficient and kappa coefficient were proved to be significant. Comparison between the tool and the GCS in evaluating level of consciousness showed significant inverse correlation (r=-0.914; P<0.001). In conclusion, the value of this prototype was confirmed although it may have some limits.

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We report a rare case of necrotizing fasciitis not by group A but by group B Streptococcus. An 80-year-old man who had medicated diabetes with hypoglycemic drugs complained of painful erythema in lower abdomen when he arrived at our emergency room. His body temperature was 38°C and CRP was 65.7mg·dl^-1. Subcutaneous gases revealed by computed tomography suggested gas gangrene in the lower abdomen. He immediately underwent extensive debridement of necrotic tissues and put on a ventilator postoperatively in ICU. An open wound was irrigated with acid water everyday and prostaglandin E₁ was infused in expectation of improving wound microcirculation. Skin graft surgery on the 12th day successfully covered the wound and the patient was discharged from ICU on the 14th day. Group B Streptococcus was detected in culture of necrotic tissue. Necrotizing fasciitis caused by group B Streptococcus is as catastrophic as that of group A Streptococcus. Early and extensive debridement, wound irrigation, and administration of appropriate antibiotics and prostaglandin E₁ resulted in good recovery.

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A 35-year-old dyspneic woman diagnosed as lymphangioleiomyomatosis (LAM) underwent left single lung transplantation from a cadaveric donor. The patient developed dyspnea on the 53rd postoperative day after TBLB which found obstruction of the left inferior bronchus, and oxygen administration failed to improve the symptoms. Bilevel positive airway pressure (BiPAP) was introduced via a full face mask. The settings of ventilator were, spontaneous and timed mode, EPAP 4cmH₂O, IPAP 10cmH₂O and F_IO₂ 1.0. Despite of successful weaning from noninvasive positive pressure ventilation (NPPV), the patient was transfered to an ICU on the next day for further observation and NPPV was resumed intermittently in coping with the patients signs and symptoms. A metallic stent was placed on the obstruction on the 2nd ICU day and the patients was discharged from the ICU on the 5th day. As far as we observed NPPV was an effective choice for dyspnea of a patient with bronchial obstruction after lung transplantation.

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A 16-year-old female weighing 43kg attempted suicide by taking 2.7g acetaminophen (60mg·kg^-1), and she was transported to the hospital seven hours after ingestion. Laboratory data showed elevated serum liver enzymes and coagulation defects on her admission. She was treated with plasma exchange and continuous hemofiltration in addition to oral administration of the antidote, acetylcysteine. The elevations of serum liver enzymes were maximum five days after ingestion, and the laboratory data became normalized about two weeks after ingestion. In this case, habitual use of other nonsteroidal anti-inflammatory drugs and the compounds such as bromovalerylurea and ethenzamide included in the acetaminophen tablets may exacerbate the liver damage. In the case of low dose acetaminophen poisoning, we should turn our attention to the exacerbation of hepatotoxicity taking account of other ingested drugs.

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The patient was an 18-year-old female. About two months after beginning of illegal self-administration of psychostimulants, she developed fever of 40°C and was treated symptomatically at several institutes. Three months later, severe buttock pain on the left disabled her to stand up but two more months were needed to get diagnosed as pyrogenic sacroiliitis with sepsis. A CT scan detected inflammatory change in the left sacroiliac joint and γ-Streptococcus was cultured from a blood sample. Intravenous piperacillin was started, however, she developed congestive heart failure and transferred to our critical care medical center after all. The patient was in systemic inflammatory response syndrome with congestive heart failure and renal dysfunction upon arrival and echocardiography revealed tricuspid regurgitation (TR). Diagnosed as infective endocarditis (IE), she was administered 24 million units of Penicillin G per day as an initial dose. Her body temperature, white blood cell count, C-reactive protein, and serum creatinine values were gradually normalized within a month and her buttock pain was also disappeared. Valvoplasty was done in the 4th month for TR and she was discharged in 5th month. Although musculoskeletal symptoms appear in 25-44% of IE in previous reports, most of them are low back pain and buttock pain in the present case is extremely rare. IE resulting from drug abuse is increasing in number, therefore, clinicians should pay attention to those who manifest arthralgia and fever of unknown origin.

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We checked through one hundred brand-new infusion pumps (TE-172, Terumo, Tokyo) and one hundred and twenty brand-new syringe pumps (TE-312C, Terumo, Tokyo) before use to avoid unexpected incidents and compared our results with the company's specifications. No abnormality was found in infusion pumps in appearance, self-check function, and the air-in-the-line detecting function. One infusion pump showed its occulusion detecting function out of the limit at high pressure level (0.6-1.4kgf·cm^-1) and was fixed. Ten infusion pumps showed inaccurate flow volumes at low flow level (25ml·hr^-1 for 60 minutes). We adjusted only one of them which had delivered extremely small quantity for its setting. Lifespan of a battery in any one of the infusion pumps was acceptable (231±47min) but a battery alarm of the infusion pump warned earlier (90min) than the standard. As for syringe pumps, there was no abnormality as well in appearance, self check function, and the functions to detect the size of syringes, the emptiness and the occulusion of the line. No abnormality was found in battery alarms and accuracy of flow rates. Although we found more than 3% aberration of flow rates in 8 pumps, it was in acceptable range and no adjustment was necessary. Working time to check all these pumps was 107.5 hours. We recommend that clinical engineers should appraise the functions of new medical equipments before operate them to the patients, even though it takes a great amount of time.

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The authors have developed a fiber-optic, 4-channel EEG instrument for the reduction of electromagnetic interference, in which bioelectric signals were transmitted with being once converted to optical pulses through an electrical-to-optical transducer and were then inversed through an optical-to-electrical transducer immediately before entering the output instrument over a single fiber channel. It was confirmed in surgical patients under general anesthesia that EEG waveforms obtained with the fiber-optic EEG instrument were almost same with those recorded simultaneously with a conventional EEG instrument. EEG recording with the fiber-optic EEG instrument was not disrupted even during the use of electrocautery. Because electrical conductivity was interrupted with an optic fiber interposed between scalp electrodes and the EEG instrument, the fiber-optic EEG instrument seems to be useful for EEG recordings in a surgical center, where it is hard to exclude electromagnetic and electrostatic interferences.

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Blood lactate level is believed to be a good prognostic indicator in critically ill patients. We evaluated the reliability, precision, clinical usefulness of a new portable lactate analyzer, Lactate Pro^TM. We measured lactate levels of 84 samples of critically ill patients in ICU, emergency rooms and operating rooms by Lactate Pro^TM and ABL625^TM. There was a strong correlation of measured data between Lactate Pro^TM and ABL625^TM (R²=0.963, P<0.001) and the level of agreement (described by Bland and Altman) was good between Lactate Pro^TM and ABL625^TM (differential bias was -1.31mg·dl^-1, ± 2SD 17.2mg·dl^-1). The new lactate analyzer, Lactate Pro^TM, is accurate, reliable, and high degree of agreement with a conventional lactate analyzer. This kit will be useful for not only critically ill patients in ICU but also for emergency cases at the field.

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