記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND: Patients with rheumatoid arthritis (RA) have high mortality risk and are frequently treated in intensive care units (ICUs). METHODS: This was a retrospective observational study. This study included 67 patients (20 males, 47 females) with RA who were admitted at the ICU of our institution for ≥48 h between January 2008 and December 2017. We analyzed the 30-day mortality of these patients and the investigated prognostic factors in RA patients admitted to our ICU. RESULTS: Upon admission, the median age was 70 (range, 33-96) years, and RA duration was 10 (range, 0-61) years. The 5-year survival after ICU admission was 47%, and 30-day, 90-day, and 1-year mortality rates were 22, 27, and 37%, respectively. The major reasons for ICU admission were cardiovascular complications (24%) and infection (40%) and the most common ICU treatments were mechanical ventilation (69%), renal replacement (25%), and vasopressor (78%). In the 30-day mortality group, infection led to a fatal outcome in most cases (67%), and nonsurvival was associated with a significantly higher glucocorticoid dose, updated Charlson's comorbidity index (CCI), and acute physiology and chronic health evaluation (APACHE) II score. Laboratory data obtained at ICU admission showed that lower platelet number and total protein and higher creatinine and prothrombin time international normalized ratio (PT-INR) indicated significantly poorer prognosis. The multivariate Cox proportional hazard model revealed that nonuse of csDMARDs, high updated CCI, increased APACHE II score, and prolonged PT-INR were associated with a higher risk of mortality after ICU admission. CONCLUSION: Our study demonstrated that the nonuse of csDMARDs, high updated CCI, elevated APACHE II score, and coagulation abnormalities predicted poorer prognosis in RA patients admitted to the ICU.

DOI： 10.1186/s41927-020-00164-1

記述言語：英語   掲載種別：研究論文（学術雑誌）  

OBJECTIVES: To characterize the real size and morphology of tracheas in childhood for the optimal selection of endotracheal tube. DESIGN: A retrospective cohort study of pediatric patients who received CT scan of the cervical spine from July 2011 to March 2018. Cross-sectional CT images vertical to trachea were reconstructed and the accurate tracheal diameters were measured. The validity of the traditional age-based formula for predicting the endotracheal tube size was assessed for the best fit to trachea. SETTING: Tertiary Emergency and Critical Care Center of Kyushu University Hospital. PATIENTS: Children, who are 1 month to 15 years old, received CT scan of the cervical spine. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We enrolled 86 children with median age of 53 months. The cross-sectional shape of pediatric trachea was circular at the cricoid level and elliptical at the infraglottic level. The narrowest part of pediatric trachea was the transverse diameter at the infraglottic level at any age. Significant positive correlation between age and the narrowest diameter was observed. When compared the transverse diameter at the infraglottic level with the outer diameter of endotracheal tubes, uncuffed endotracheal tubes selection based on the traditional age-based formula ran a significant risk of oversized endotracheal intubation until 10 years old compared with cuffed endotracheal tubes selection (60.0% vs 23.8%; p < 0.05). CONCLUSIONS: These findings indicate the safety and efficacy of cuffed endotracheal tubes in infants and children and the reconsideration for the airway management in pediatric anesthesia and intensive care.

DOI： 10.1097/PCC.0000000000001996

記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND AND PURPOSE: Accurate diagnosis of acute aortic dissection (AAD) is sometimes difficult because of accompanying central nervous system (CNS) symptoms. The purpose of this study was to investigate the clinical characteristics of Type A AAD (TAAAD) with CNS symptoms. METHODS: We retrospectively reviewed the medical records of 8403 patients ambulanced to our emergency and critical care center between April 2009 and May 2014. RESULTS: We identified 59 TAAAD patients for the analysis (mean age, 67.3±10.5years; 37 (62.0%) male). Eleven patients (18.6%) presented CNS symptoms at the onset of TAAAD, and these patients complained less frequently of typical chest and back pain than those without CNS symptoms (p<0.0001). Initial systolic and diastolic blood pressure were lower (p=0.003, and p=0.049, respectively) and involvement of the supra-aortic artery was more frequent in patients with CNS symptoms (p<0.0001). CONCLUSION: Because CNS symptom can mask chest and back pain caused by TAAAD, physicians should always consider the possibility of TAAAD in patients with CNS symptoms in emergency medicine settings.

DOI： 10.1016/j.ajem.2017.06.011

記述言語：英語   掲載種別：研究論文（学術雑誌）  

Patients with pulmonary hypertension associated with congenital heart disease survive longer with preserved right ventricular (RV) function compared with those with primary pulmonary hypertension. The purpose of this study was to test the hypothesis that superior RV performance can be demonstrated, at baseline and when challenged with increased RV afterload, in lambs with chronic left-to-right cardiac shunts compared with control lambs. A shunt was placed between the pulmonary artery and the aorta in fetal lambs (shunt). RV pressure-volume loops were obtained 4 wk after delivery in shunt and control lambs, before and after increased afterload was applied using pulmonary artery banding (PAB). Baseline stroke volume (8.7 ± 1.8 vs. 15.8 ± 2.7 ml, P = 0.04) and cardiac index (73.0 ± 4.0 vs. 159.2 ± 25.1 ml·min(-1)·kg(-1), P = 0.02) were greater in shunts. After PAB, there was no difference in the change in cardiac index (relative to baseline) between groups; however, heart rate (HR) was greater in controls (168 ± 7.3 vs. 138 ± 6.6 beats/min, P = 0.01), and end-systolic elastance (Ees) was greater in shunts (2.63 vs. 1.31 × baseline, P = 0.02). Control lambs showed decreased mechanical efficiency (71% baseline) compared with shunts. With acute afterload challenge, both controls and shunts maintained cardiac output; however, this was via maladaptive responses in controls, while shunts maintained mechanical efficiency and increased contractility via a proposed enhanced Anrep effect-the second, slow inotropic response in the biphasic ventricular response to increased afterload, a novel finding in the RV. The mechanisms related to these physiological differences may have important therapeutic implications.

DOI： 10.1152/ajpheart.01018.2013

記述言語：英語   掲載種別：研究論文（学術雑誌）  

We have previously shown decreased pulmonary lymph flow in our lamb model of chronically increased pulmonary blood flow, created by the in utero placement of an 8-mm aortopulmonary shunt. The purpose of this study was to test the hypothesis that abnormal lymphatic function in shunt lambs is due to impaired lymphatic endothelial nitric oxide (NO)-cGMP signaling resulting in increased lymphatic vascular constriction and/or impaired relaxation. Thoracic duct rings were isolated from 4-wk-old shunt (n = 7) and normal (n = 7) lambs to determine length-tension properties, vascular reactivity, and endothelial NO synthase protein. At baseline, shunt thoracic duct rings had 2.6-fold higher peak to peak tension and a 2-fold increase in the strength of contractions compared with normal rings (P < 0.05). In response to norepinephrine, shunt thoracic duct rings had a 2.4-fold increase in vascular tone compared with normal rings (P < 0.05) and impaired relaxation in response to the endothelium-dependent dilator acetylcholine (63% vs. 13%, P < 0.05). In vivo, inhaled NO (40 ppm) increased pulmonary lymph flow (normalized for resistance) ∼1.5-fold in both normal and shunt lambs (P < 0.05). Inhaled NO exposure increased bioavailable NO [nitrite/nitrate (NOx); ∼2.5-fold in normal lambs and ∼3.4-fold in shunt lambs] and cGMP (∼2.5-fold in both) in the pulmonary lymph effluent (P < 0.05). Chronic exposure to increased pulmonary blood flow is associated with pulmonary lymphatic endothelial injury that disrupts NO-cGMP signaling, leading to increased resting vasoconstriction, increased maximal strength of contraction, and impaired endothelium-dependent relaxation. Inhaled NO increases pulmonary lymph NOx and cGMP levels and pulmonary lymph flow in normal and shunt lambs. Therapies that augment NO-cGMP signaling within the lymphatic system may provide benefits, warranting further study.

DOI： 10.1152/ajpheart.00841.2013

記述言語：日本語  

悪性カタトニアは,昏迷,無動,カタレプシーなどのカタトニアに特徴的な症状に発熱や自律神経症状を伴い,致死的になり得る症候群である。症例は53歳の女性で,統合失調症の治療中に意識障害,筋緊張亢進,発熱を来して救急搬送された。精神科病棟に医療保護入院したが,呼吸不全を呈したため応援を要請された。ICUで治療を開始し,全身管理と並行して悪性症候群や他の身体疾患の除外診断を行った。統合失調症による悪性カタトニアを疑いロラゼパムを静注したところ,意識が回復し筋緊張亢進も軽快した。悪性カタトニアを疑った場合は,全身管理や合併症への対応と並行して身体疾患の除外診断を行い,ベンゾジアゼピンによる診断的治療を行う。ロラゼパムの静注は効果発現が早いため,悪性カタトニアを疑った場合の診断的治療に有用である。(著者抄録)

記述言語：英語  

BACKGROUND: To maximize the therapeutic effect for complicated sternal fracture, we should know advantages and disadvantages of each surgical repositioning technique, and the choice of an appropriate procedure is essential. We report two successful cases for which a combination of two existing techniques, modified Robicsek wire fixation and locked titanium plate fixation, was applied to transverse sternal fracture with flail chest. CASE PRESENTATION: One patient experienced a transverse sternal and rib fracture due to a traffic injury. Flail chest due to a highly displaced transverse sternal fracture made withdrawal of the ventilator impossible. Another patient, who developed fulminant myocarditis, experienced a transverse sternal fracture resulting from chest compression during cardiopulmonary resuscitation. Severe paradoxical respiratory movement was a limiting factor for cardiac and respiratory rehabilitation. In both cases, a transverse sternal fracture was difficult to correct non-invasively and indicated surgical repair. The surgical repositioning and fixation greatly contributed to the improvement of the respiratory movement, and the patients were successfully withdrawn ventilator support. CONCLUSION: The combination of modified Robicsek wire fixation and locked titanium plate fixation for a complicated sternal fracture employs the complementary and comparative advantages of each procedure and effective fixation may be achieved.

DOI： 10.1186/s40792-021-01267-8

記述言語：英語  

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members.As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.

DOI： 10.1186/s40560-021-00555-7

記述言語：英語  

RATIONALE: In coronavirus disease 2019 (COVID-19) patients with acute respiratory distress syndrome refractory to optimal conventional management, we should consider the indication for veno-venous extracorporeal membrane oxygenation (V-V ECMO). Growing evidence indicates that COVID-19 frequently causes coagulopathy, presenting as hypercoagulation and incidental thrombosis. For these reasons, a multifactorial approach with several anticoagulant markers should be considered in the management of anticoagulation using heparin in COVID-19 patients on V-V ECMO. PATIENT CONCERNS: A 48-year-old man was infected with COVID-19 with a worsening condition manifesting as acute respiratory distress syndrome. DIAGNOSES: He was refractory to conventional therapy, thus we decided to introduce V-V ECMO. We used heparin as an anticoagulant therapy for V-V ECMO and adjusted the doses of heparin by careful monitoring of the activated clotting time (ACT) and activated partial thromboplastin time (APTT) to avoid both hemorrhagic and thrombotic complications. We controlled the doses of heparin in the therapeutic ranges of ACT and APTT, but clinical hemorrhaging and profound elevation of coagulant marker became apparent. INTERVENTIONS: Using thromboelastography (TEG; Haemonetics) in addition to ACT and APTT, we were able to clearly detect not only sufficient coagulability of COVID19 on V-V ECMO (citrated rapid thromboelastography-R 0.5 min, angle 75.5°, MA 64.0 mm, citrated functional fibrinogen-MA 20.7 mm) but also an excessive effect of heparin (citrated kaolin -R 42.7 min, citrated kaolin with heparinase 11.7 min). OUTCOMES: Given the TEG findings indicating an excessive heparin effect, the early withdrawal of ECMO was considered. After an evaluation of the patient's respiratory capacity, withdrawal from V-V ECMO was achieved and then anticoagulation was stopped. The hemorrhagic complications and elevated thrombotic marker levels dramatically decreased. LESSONS: TEG monitoring might be a useful option for managing anticoagulation in COVID-19 patients on V-V ECMO frequently showing a hypercoagulative state and requiring massive doses of heparin, to reduce both hemorrhagic and thrombotic complications.

DOI： 10.1097/MD.0000000000026313

記述言語：日本語  

65歳男性。Stanford A型急性大動脈解離に対し緊急に弓部人工血管置換術を行った。人工心肺は問題なく離脱したが、プロタミン緩徐静注開始約8分後(人工心肺離脱約10分後)に血圧が突然低下した。経食道心エコー(TEE)を行い、解離フラップによる急性冠動脈閉塞と診断した。左大伏在静脈を用いた左冠動脈前下行枝の肝動脈バイパス術を行い、再TEEで左冠動脈の血流を確認した。TEEが人工心肺離脱後の急性冠動脈閉塞の診断に有用であった。

記述言語：英語  

DOI： 10.1111/ped.14528

記述言語：英語  

Some patients with intestinal failure, who are dependent on total parenteral nutrition for long periods, suffer from a lack of suitable conventional venous access points, including axillary, external jugular, internal jugular, subclavian, saphenous, and the brachio-cephalic and femoral veins, due to their occlusion. Furthermore, extensive central venous stenosis and/or thrombosis of the superior and inferior vena cava may preclude further catheterization, so uncommon routes must be used, which can be challenging. In such patients, the azygos vein via the intercostal vein is a viable candidate. Thoracotomy-assisted, thoracoscopy-assisted, and cut-down procedures are currently suggested such access. We found that ultrasound-guided percutaneous puncture method was a safe and minimally invasive approach and successfully placed two central venous lines in preparation for small bowel transplantation via two different intercostal veins (ninth and tenth). Although the lung was actually located just below the target veins, an ultrasound provided augmented and clear vision, which contributed to the safe performance of the procedure without the need for invasive surgical intervention, such as thoracotomy, thoracoscopy, or rib resection using the cut-down technique. Furthermore, constant positive-pressure ventilation during vein puncture under general anesthesia also helps avoid venous collapse. Despite carrying a slight risk of light injury to the lung, artery, and nerve along with the vein compared to other procedures, we believe that ultrasound-guided puncture under general anesthesia is feasible as a minimally invasive method.

DOI： 10.1177/1129729820937133

記述言語：日本語  

日本集中治療医学会と日本救急医学会は,合同の特別委員会を組織し,2016年に発表した日本版敗血症診療ガイドライン(J-SSCG)2016の改訂を行った。本ガイドライン(J-SSCG2020)の目的は,J-SSCG2016と同様に,敗血症・敗血症性ショックの診療において,医療従事者が患者の予後改善のために適切な判断を下す支援を行うことである。改訂に際し,一般臨床家だけでなく多職種医療者にも理解しやすく,かつ質の高いガイドラインとすることによって,広い普及を目指した。J-SSCG2016ではSSCG2016にない新しい領域[ICU-acquircd weakness(ICU-AW)とpost-intensive care syndrome(POCS),体温管理など]を取り上げたが,J-SSCG2020では新たに注目すべき4領域(Patient-and Family-Centered Care, sepsis treatment system,神経集中治療,ストレス潰瘍)を追加し,計22領域とした。重要な118の臨床課題(clinical question:CQ)をエビデンスの有無にかかわらず抽出した。これらのCQには,本邦で特に注目されているCQも含まれる。多領域にわたる大規模ガイドラインであることから,委員25名を中心に,多職種(看護師,理学療法士,臨床工学技士,薬剤師)および患者経験者も含めたワーキンググループメンバー,両学会の公募によるシステマティックレビューメンバーによる総勢226名の参加・協力を得た。また,中立的な立場で横断的に活躍するアカデミックガイドライン推進班をJ-SSCG2016に引き続き組織した。将来への橋渡しとなることを企図して,多くの若手医師をシステマティックレビューチーム・ワーキンググループに登用し,学会や施設の垣根を越えたネットワーク構築も進めた。作成工程においては,質の担保と作業過程の透明化を図るために様々な工夫を行い,パブリックコメント募集は計2回行った。推奨作成にはGRADE方式を取り入れ,修正Delphi法を用いて全委員の投票により推奨を決定した。結果,118CQに対する回答として,79個のGRADEによる推奨,5個のGPS(good practice statement),18個のエキスパートコンセンサス,27個のBQ(background question)の解説,および敗血症の定義と診断を示した。新たな試みとして,CQごとに診療フローなど時間軸に沿った視覚的情報を取り入れた。J-SSCG2020は,多職種が関わる国内外の敗血症診療の現場において,ベッドサイドで役立つガイドラインとして広く活用されることが期待される。なお,本ガイドラインは,日本集中治療医学会と日本救急医学会の両機関誌のガイドライン増刊号として同時掲載するものである。(著者抄録)

記述言語：日本語  

日本集中治療医学会と日本救急医学会は,合同の特別委員会を組織し,2016年に発表した日本版敗血症診療ガイドライン(J-SSCG)2016の改訂を行った。本ガイドライン(J-SSCG2020)の目的は,J-SSCG2016と同様に,敗血症・敗血症性ショックの診療において,医療従事者が患者の予後改善のために適切な判断を下す支援を行うことである。改訂に際し,一般臨床家だけでなく多職種医療者にも理解しやすく,かつ質の高いガイドラインとすることによって,広い普及を目指した。J-SSCG2016ではSSCG2016にない新しい領域[ICU-acquircd weakness(ICU-AW)とpost-intensive care syndrome(POCS),体温管理など]を取り上げたが,J-SSCG2020では新たに注目すべき4領域(Patient-and Family-Centered Care, sepsis treatment system,神経集中治療,ストレス潰瘍)を追加し,計22領域とした。重要な118の臨床課題(clinical question:CQ)をエビデンスの有無にかかわらず抽出した。これらのCQには,本邦で特に注目されているCQも含まれる。多領域にわたる大規模ガイドラインであることから,委員25名を中心に,多職種(看護師,理学療法士,臨床工学技士,薬剤師)および患者経験者も含めたワーキンググループメンバー,両学会の公募によるシステマティックレビューメンバーによる総勢226名の参加・協力を得た。また,中立的な立場で横断的に活躍するアカデミックガイドライン推進班をJ-SSCG2016に引き続き組織した。将来への橋渡しとなることを企図して,多くの若手医師をシステマティックレビューチーム・ワーキンググループに登用し,学会や施設の垣根を越えたネットワーク構築も進めた。作成工程においては,質の担保と作業過程の透明化を図るために様々な工夫を行い,パブリックコメント募集は計2回行った。推奨作成にはGRADE方式を取り入れ,修正Delphi法を用いて全委員の投票により推奨を決定した。結果,118CQに対する回答として,79個のGRADEによる推奨,5個のGPS(good practice statement),18個のエキスパートコンセンサス,27個のBQ(background question)の解説,および敗血症の定義と診断を示した。新たな試みとして,CQごとに診療フローなど時間軸に沿った視覚的情報を取り入れた。J-SSCG2020は,多職種が関わる国内外の敗血症診療の現場において,ベッドサイドで役立つガイドラインとして広く活用されることが期待される。なお,本ガイドラインは,日本集中治療医学会と日本救急医学会の両機関誌のガイドライン増刊号として同時掲載するものである。(著者抄録)

記述言語：英語  

The number of people infected with severe acute respiratory syndrome coronavirus 2 is increasing globally, and some patients have a fatal clinical course. In light of this situation, the World Health Organization (WHO) declared coronavirus disease 2019 (COVID-19) a pandemic on March 11, 2020. While clinical studies and basic research on a treatment for COVID-19 are ongoing around the world, no treatment has yet been proven to be effective. Several clinical studies have demonstrated the efficacy of chloroquine phosphate and nafamostat mesylate with COVID-19. Here, we report the case of a Japanese patient with COVID-19 with severe respiratory failure who improved following the administration of hydroxychloroquine and continuous hemodiafiltlation with nafamostat mesylate. Hence, hydroxychloroquine with nafamostat mesylate might be a treatment option for severe COVID-19.

DOI： 10.1016/j.jiac.2020.08.001

記述言語：日本語  

日本集中治療医学会臨床倫理委員会は,日本COVID-19対策ECMOnet(代表竹田晋浩)(日本集中治療医学会,日本呼吸療法医学会,日本救急医学会)ならびに厚生労働科学研究費補助金(新興・再興感染症及び予防接種政策推進研究事業)「新興・再興感染症のリスク評価と危機管理機能の実装のための研究」分担研究班と合同で,新型コロナウイルス感染症(coronavirus disease 2019,COVID-19)流行に際しての医療資源配分の観点からの治療の差し控え・中止の考え方を提言する。提言は,非常事態にあっても臨床倫理の原則を守りつつ,医療資源を公正に配分するために適切な議論を経て行われるべきことを骨子としている。(著者抄録)

記述言語：日本語  

65歳男。胸背部痛と左下肢の脱力感を主訴に救急搬送され、Stanford A型急性大動脈解離の診断で弓部大動脈置換術を施行した。術後1日目に鎮痛薬を中止したが覚醒不良で、2日目に頭部CTを施行したところ右中大脳動脈領域に広範なlow density areaと左への著明なmidline shiftを認めた。緊急開頭減圧術を施行し、その後の経過は良好であった。本例は術中に近赤外線脳酸素モニター(NIRS)を装着していたが、rSO2の大きな変動はみられなかった。術後2日目の頭部CTで右の前頭葉に一部脳梗塞を逃れた領域を認め、この領域は、右内頸動脈解離に伴う右中大脳動脈の低灌流により左前大脳動脈から前交通動脈を介して灌流された可能性がある。この脳特有の血流支配のために、NIRS装着部位直下の血流はある程度保たれていたことで、実際に脳梗塞を起こしていた部分の低灌流を正確にモニタリングできていなかったものと考えられた。

記述言語：日本語  

57歳女。47歳時にEisenmenger症候群と診断されていた。今回、肉眼的血尿に対し、膀胱生検および尿管鏡が予定された。胸部X線写真では、心拡大と肺血管陰影増強を認め、経胸壁心エコーでは、心房中隔に両方向性シャントを伴う21×42mmの欠損孔や三尖弁圧較差の上昇を認めた。心臓カテーテル検査では、酸素および一酸化窒素への反応が不良であった。病状の進行に対し、PDE5阻害薬とエンドセリン受容体拮抗薬の内服に加え、2年前からプロスタグランジンI2誘導体の持続皮下注を受けており、心房細動に対するワルファリン内服は、ヘパリンの持続静注に変更していた。これらの症状および、抗凝固の継続と小手術である点から、声門上器具を用いて全身麻酔を選択した。麻酔導入時は、体血圧とSpO2の変化を見ながら、フェニレフリンの単回投与および少量のノルアドレナリンの持続投与を行った。シャント血流の変化は、SpO2の変化で判断し、導入前のSpO2を持続することに努めた。術後は経過良好で、術後22日目に退院となった。

記述言語：英語  

BACKGROUND: Arginine vasopressin has been used for the management of refractory vasodilatory shock. However, it is still unclear whether arginine vasopressin is useful for hypotension in patients with spinal cord injury. CASE DESCRIPTION: A 78-year-old man with autonomic dysreflexia and paralysis below the level corresponding to Th2 due to spinal cord injury previously underwent cholecystectomy. During the surgery, accidental hemorrhage led him to refractory hemorrhagic shock unresponsive to fluid resuscitation and catecholamine. Lasting hypotension was improved with arginine vasopressin. CONCLUSION: We described a rare case report on the use of arginine vasopressin for management of refractory hemorrhagic shock in a patient with autonomic dysreflexia.

DOI： 10.1186/s40981-018-0216-8

記述言語：日本語  

症例は40歳男性で、統合失調症で向精神薬を内服していた。4階からの墜落による左大腿骨開放骨折の診断で救急搬送された。麻酔は全身麻酔で行い、麻酔導入、挿管に問題はなかった。体位は仰臥位で開脚した状態で行った。術前より血行動態、呼吸状態ともに安定していた。手術開始1時間後、髄内釘を打ち込んでいた際に突然SpO2が100%から88%まで低下し、血圧も120/60mmHgから90/50mmHgまで低下した。明らかな右心負荷所見、観察する限りに肺動脈内血栓を認めなかった。観血的動脈圧を確保後、輸血を行ったところ、酸素化の改善を認め、血圧も安定した。その後、血行動態は安定して経過した。手術終了時に開脚していた足を戻した際に再度SpO2と血圧の低下を認めた。集中治療室(ICU)での挿管管理の方針となった。ICU入室後は、経過観察のみで酸素化は改善した。CT検査で、左肺動脈分枝に造影欠損像を認めた。術直後の出血を考慮し、術後48時間より予防的にヘパリン投与開始した。術後7日よりエドキサバントシル酸塩水和物の内服を開始した。術後5日目のCTでは欠損像は消失し、術後38日目に退院となった。

記述言語：日本語  

57歳、女性。側臥位での開頭腫瘍摘出術が施行された。手術終了後体位変換時に急性肺血栓塞栓症を発症した。当初、呼気終末二酸化炭素分圧(EtCO2)の低下に気がつかずに対応が遅れたが、その後の経食道心エコー(transesophageal echocardiography:TEE)検査で確定診断となり、循環維持のためECMO(extra-corporeal membrane oxygenation)を導入した。しかし、脱血管を大腿静脈から右房に挿入する際に下大静脈内の血栓を同時に右心系に進展させ、循環虚脱となった。また、ECMO開始とともに脱血管内に血栓が観察され、緊急停止せざるを得ないという事態も生じた。最終的にはECMOにより血行動態は安定し救命しえた。これらの過程においてTEEは原因究明および治療方針決定に有用であった。(著者抄録)

記述言語：英語  

Esophageal perforation due to blunt trauma is a rare clinical condition, and the diagnosis is often difficult because patients have few specific symptoms. Delayed diagnosis may result in a fatal clinical course due to mediastinitis and subsequent sepsis. In this article, we describe a 26-year-old man with esophageal perforation due to blunt chest trauma resulting from a motor vehicle accident. Because a severe disturbance of consciousness masked the patient's trauma-induced thoracic symptoms, we required 11h to diagnose the esophageal perforation. Therefore, the patient developed septic shock due to mediastinitis. However, his subsequent clinical course was good because of prompt combined therapy involving surgical repair and medical treatment after the diagnosis.

DOI： 10.1016/j.ajem.2017.08.043

記述言語：英語  

Monitoring regional cerebral oxygen saturation (rSO(2)) by use of near-infrared spectroscopy (NIRS) is a useful method for detecting cerebral ischemia. Tracheo-innominate artery fistula is a rare but life-threatening complication of tracheostomy. The surgical procedures for management of tracheo-innominate artery fistula include direct or patch closure of the fistula, ligation or division of the innominate artery, and anatomical or extra-anatomical reconstruction of the flow of the innominate artery. Division of the innominate artery is the best method to prevent postoperative recurrence of bleeding and infection. However, cutting off the innominate artery flow may cause brain ischemia. We present the case of a patient with tracheo-innominate artery fistula successfully treated by dividing the innominate artery while the rSO(2) was monitored. In this case report, we have shown that NIRS is a useful method for deciding the surgical maneuver for tracheo-innominate artery fistula.

DOI： 10.1007/s10047-011-0565-9

記述言語：日本語  

Goldenhar syndrome is associated with difficult airway due to the characteristic craniofacial anomalies such as hypoplasia of the mandible and molar bones. We present our method of fiberoptic intubation using two tracheal tubes for a girl with Goldenhar syndrome undergoing cochlear implant surgery. She had received general anesthesia for dental treatment one year before, but the treatment had been cancelled because of the failure of tracheal intubation. We induced anesthesia for her with inhalation of sevoflurane and nitrous oxide. After obtaining a stable anesthetic level, we inserted two tracheal tubes from the right and left nostrils, one for a tracheal tube and the other for a nasopharyngeal airway. During the procedure, the fiberscope was advanced through the tracheal tube with a slit connector, and her ventilation was assisted through the nasopharyngeal airway with her mouth closed by a tape to avoid a leak of ventilating gas. Using this two-tube method, we successfully intubated the trachea of a patient Goldenhar syndrome.

種別：大会・シンポジウム等 

参加者数：400