Extensive research work on reactive oxygens and rapid progress in nitric oxide (NO) chemistry over the last 10 years have led to a change in the general concepts relating to oxidative damage in biological fields. These include the recognition of importance of nitration, nitrosation and nitrosylation reactions in addition to peroxidation-mediated reaction in various diseases. In the concept of cellular or tissue damage, formation of nitrotyrosine in proteins or non-proteins was demonstrated in many pathological conditions such as septic shock, atherosclerosis, and cerebral infarction. The reaction of superoxide and NO was shown to be responsible for its formation, although detailed mechanism and the implication of nitrotyrosine formation remain to be clarified. In parallel with these new concepts, the importance of free radical-induced redox modulation in cellular signal transduction systems has been recognized recently. Therefore the future research in reactive oxygens and NO will be broadened more to cover these concepts.

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In neuro-intensive care, the estimation of cerebral pressure autoregulation predicts the outcome of brain-injured patients and gives us more information to manage cerebral blood flow and metabolism of the patients. Although various methods using transcranial Doppler ultrasonography were developed, almost all methods were impractical in severe brain-injured patients. In this review, I evaluated several methods to estimate the cerebral pressure autoregulation used in a neuro-intensive care unit.

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We investigated retrospectively the prognosis of 40 patients who were admitted to the intensive care unit (ICU) of Tottori University Hospital after successful cardiopulmonary resuscitation (CPR) in the wards from January 1, 1991 to December 31, 1999. Of the patients, twenty patients were discharged alive from ICU and 14 of the twenty patients were discharged from the hospital without sequelae. Percentage of social recovery of the patients was 35%. Survival rates were 100%, 86% and 57%, respectively, at one, two and four years after the discharge from hospital. The following five factors determined their favorable outcome; 1) less than 70 years old of age, 2) shorter duration until spontaneous heart beating was resumed, 3) less dosage of epinephrine during CPR, 4) better Glasgow Coma Scale at admission to ICU, and 5) the lower incidence of complications during the ICU stay. Particularly, age and the faster return of spontaneous circulation were likely to be the key factors to determine the prognosis of the patients undergoing CPR in the University Hospital.

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We investigated emotional and mood variations between two different groups of the nurses in our hospital in June, September, and December of the graduate year and compared them with a control. The profile of mood status (POMS) test was applied to the nurses who were assigned to the intensive care unit (ICU group) and those who were assigned to the general wards (Ward group). A group of healthy female volunteers aged from twenty to twenty-nine were also examined as a control. The ICU group always demonstrated a higher score in “Tension-Anxiety” cathegory than the control group and the Ward group constantly showed higher scores in “Fatigue” and “Confusion” categories than the control. We conclude that newly registered nurses who were assigned to general wards demonstrated more exhaustion than those who were assigned to ICU did.

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A 39-year-old female diagnosed as cerebral sinus thrombosis was hospitalized and treated with urokinase, heparin, and several anticonvulsants. Edematous erythema appeared on the trunk and both the upper and lower limbs along with granulocytopenia after 17 days medication. Corticosteroid therapy failed to prevent the lesions from extending gradually to the entire surface of the body and 80% of the lesion showed necrolysis of epidermis. We suspected it as toxic epidermal necrolysis (TEN) caused by some of anticonvulsants. We started sodium valproate instead of the previous ones and performed three plasma exchanges (PEs) on alternate days. Epithelization was recognized on facial skin on the following day of of the last PE and almost comleted covering whole body surface within the next ten days. Lymphocyte transformation test was done on four anticonvulsants that she had administered and the only phenytoin resulted in positive. Our results suggest that PE should be applied to the patients with drug-induced TEN which is resistant to corticosteroid.

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A 76-year-old male was scheduled for colonectomy on the 36th day after percutaneous transluminal coronary angioplasty for right coronary artery disease. A pulmonary artery catheter was placed for hemodynamic monitoring preoperatively. After the patient came back to the ward, massive hemoptysis was noted. Emergency bronchoscopy and chest X-ray suggested pulmonary artery perforation caused by a pulmonary artery catheter. In the ICU, the patient was treated with blood transfusion and mechanical ventilation with PEEP under heavy sedation. After 9-day controlled ventilation, the patient was extubated without any subsequent events. Systemic atherosclerosis and prolonged coagulation time may contribute to this event. The indication of perioperative pulmonary artery catheterization should be cautious on consideration of risk-benefit balance.

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We experienced a case of involuntary movement following resuscitation from cardiopulmonary arrest (CPA) due to near-drowning. A 14-year-old boy suddenly lost consciousness to fall into the sea when he prepared angling at a harbor. The boy was underwater for about 15 minutes and was in CPA when rescued. The rescue crew immediately started cardiopulmonary resuscitation (CPR), and the boy was brought to our hospital. He was in CPA and his body temperature was as low as 32.9 degrees C. upon arrival, but uninterrupted resuscitation and warming effort recovered spontaneous circulation. The presence of cafe-au-lait spots on the trunk and his family history led us to diagnose him as neurofibromatosis typel (NF 1). Hypothermia therapy was started at 34.0 degrees C. for three days and was followed by warming to 36.5 degrees C. for two days. Intense generalized involuntary movements were observed during the rewarming period. We could not make the etiology of these movements clear whether NF1 or Lance-Adams syndrome (LAS), but could control these movements with various antiepileptic drugs. The patient regained consciousness after 17 days of treatment and was transferred to the pediatric ward on the 27th hospital day. He has now recovered to talk with others naturally and to ride a wheelchair.

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We report a case of Aspergillus myocarditis presenting as myocardial infarction in a patient with acute myeloblastic leukemia. A 49-year-old-man was intubated and mechanically ventilated in the ICU as a result of invasive Aspergillus pneumonia and acute respiratory insufficiency following chemotherapy in combination with corticosteroid. His electrocardiogram on the 12th ICU day revealed sudden complete atrioventricular block, ST-segment elevation, and then cardiac arrest. Although resuscitative efforts with catecholamine and temporary pacemaker could maintain heart rate and blood pressure for a while, the patient got aggravated and passed away on the next day. Postpartum examination revealed multiple organ failure caused by Aspergillus infection and myocardial necrosis along with abscess formation mainly in the epimyocardium. These findings indicate that anomalous electrocardiogram in a patient with Aspergillosis may be a symptom of Aspergillus myocarditis. You should remember that cardiac Aspergillosis does not have any clinically characteristic feature, and therefore diagnosing Aspergillus myocarditis is quite difficult until autopsy and precarious treatment often fails a patient.

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We encountered severe congestive heart failure accompanied by lethal ventricular tachyarrhythmia in a patient suspected of cardiac sarcoidosis. Percutaneous cardiopulmonary support (PCPS) which was applied first dramatically reduced lethal arrhythmia and made defibrillation unnecessary. Bleeding tendency and other complications of PCPS forced us to switch it to biventricular assited device (BiVAD) one week later the initiation of PCPS. BiVAD lessened VT more than before and improved cardiac function significantly. No major complication was found during two week's BiVAD support and the patient was successfully weaned from it. Complications of PCPS include multiple organ failure, lower limb ischemia, consumption of platelets and coagulation factors, and bleeding or circulatory collapse which takes place while changing the circuit. We should carefully observe a patient with PCPS and switch it to ventricular assist device without hesitation before the complications grow serious. So far as we know, one week might be long enough to maintain PCPS but we succeeded in preventing critical complications by replacing it with VAD and saved the patient.

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