The acute respiratory distress syndrome (ARDS) is characterized by acute inflammation and subsequent permeability edema of the lung. We have been investigating the pathogenesis of ARDS and efficacy of various agents, including inhibitors of inflammatory mediators, to establish a therapeutic modality for ARDS. Since endotoxin (LPS) is a major substance that induces acute lung inflammation and ARDS, we evaluated the effect of blocking LPS-signaling pathway, using a monoclonal antibody against CD14, an LPS receptor on the cell surface. CD14 blockade significantly attenuated LPS-induced lung injury in mice. Attenuation of LPS-induced lung injury was also observed in a mutant mouse of Toll-like receptor 4, a key molecule of LPS-signaling pathway. We showed protective effects of an analog of lipid A, which is a key component of biological activities of LPS. It has been known that circulating neutrophils play important roles in the pathogenesis of ARDS, but we revealed that activated mononuclear phagocytes also contribute by releasing cytokines and other inflammatory mediators. The efficacy of inhibitors for TNF-α converting enzyme (TACE) and neutrophil elastase were revealed in experimental models of acute lung injury. After clinical trials, the neutrophil elastase inhibitor has been launched in Japan as a prescription drug. We think that experimental approaches like ours may contribute to understanding pathogenesis and development of novel therapeutic modalities for ARDS.

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Objective: The clinical records of 60 patients with the acute Stanford type B aortic dissection between January 1992 and December 2001 were retrospectively reviewed to assess the clinical significance of impaired lung oxygenation in acute aortic dissection. Methods: All patients were admitted to Yamagata Prefectural Central Hospital within 24 hours from onset and received medical treatment. Respiratory index (RI) was used as a parameter of oxygenation. The relationships between oxygenation impairment and the following clinical factors were evaluated: DeBakey type 3a/3b; false lumen patency; pleural effusions; compression atelectasis; ischemic complications; white blood cell counts; serum C reactive protein levels. Results: DeBakey type 3a/3b (p=0.004), pleural effusions (p=0.002), compression atelectasis (p=0.001) and ischemic complications (p=0.005) significantly correlated with impaired oxygenation. Maximum white blood cell counts had a weak correlation with impaired oxygenation. Maximum Serum C reactive protein levels significantly correlated with impaired oxygenation. Discussion: This study confirms that impaired oxygenation is one of the most common clinical manifestations in acute type B aortic dissection. Pleural effusions, compression atelectasis, ischemic complications, extensive dissection and inflammatory reactions including leukocytosis may be associated with impaired lung oxygenation.

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The purpose of this study is to extract general needs and to develop an assessment scale of individual needs in critical care patients'family. A 67-item self questionnaire was handed to 127 family members who consented to our research, and 112 responses were analyzed. We examined the responses and deviled them into two groups; that is General Needs and Individual Needs. There were 15 items which all respondents regarded as “(fairly) necessary/important”. An exploratory factor analysis and a confirmatory factor analysis of the Individual Needs revealed 15 items in three subgroups. The subgroups are, 1) Support from staff, 2) Timely information, and 3) Flexibility of visiting. The author made a new assessment scale of individual needs according to this analysis and examined it's reliability and validity. The new scale has acceptable properties and would be a useful tool to measure individual differences of needs.

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Emphysematous pyelonephritis is lethal infectious disease and its treatment is not established. A 40-year-old woman was cured from the disease with the combination of percutaneous drainage and endotoxin absorption. The patient was admitted to our hospital with high fever and nausea. Computed tomography demonstrated gas accumulation in the right kidney. A day after the admission, she was transferred to ICU because of positive blood culture and renal insufficiency. Serum endotoxin level was 110pg·ml^-1 and her systolic blood pressure was below 70mmHg. She underwent percutaneous drainage and two courses of endotoxin absorption. Her general condition was improving with these therapies and left ICU on the 4th ICU day. We infer that quick institution of percutaneous drainage and endotoxin absorption is the key for treatment of emphysematous pyelonephritis.

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Propofol infusion syndrome has been reported as a fatal syndrome described in critically ill patients undergoing longterm propofol infusion at high dose. To date 21 pediatric cases and 15 adult cases have been described, but there has been no report of this syndrome in Japan. The main clinical symptoms of this syndrome are cardiac failure, fatal arrhythmia, rhabdomyolysis, severe metabolic acidosis, hyperkalemia et cetera and they occur suddenly. The pathogenesis of this syndrome is considered mutual action between long-term propofol infusion at high dose, critical illness and the use of catecholamines or steroids. We present a case of an adult patient who was suspected propofol infusion syndrome. A 28-years old man was admitted to the ICU because of refractory status epilepticus. While he received propofol infusion of more than 5.75mg·kg^-1·hr^-1 for 56.5 hours dose for the treatment of status epilepticus, suddenly he developed circulatory failure (cardiac failure), rhabdomyolysis, severe metabolic acidosis, hyperkalemia, fatal arrhythmia (ventricular tachycardia and ventricular fibrillation), which resulted in death.

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We report two cases of fiberoptic bronchoscopy-guided percutaneous dilational tracheostomy (PDT) using a laryngeal mask airway instead of a tracheal tube. Case 1: A 65-year-old woman who had undergone colectomy was admitted to our intensive care unit because of postoperative acute respiratory failure. Impaired pulmonary oxygenation was improved, but PDT was indicated because she could hardly excrete sputum by herself. Case 2: An 87-year-old woman who had been resuscitated from cardiopulmonary arrest with unknown origin was underwent PDT because of remaining in a vegetative state. In either case a laryngeal mask airway #3 was inserted following 30mg of intravenous propofol, which was continuously administered during the procedure as an anesthetic. A bronchofiberscope was inserted through the laryngeal mask airway to show the 2nd tracheal ring. Monitoring inside with a bronchoscope, the trachea was punctured percutaneously by a double-sheath needle and thereafter a guidewire was inserted through it. A Blue Rhino^(R) dilator was inserted to enlarge subcutaneous passage to trachea enough for the tracheostomy tube. Time from the initial needle puncture to the insertion of the tracheostomy tube was 4 minutes and 2.5 minutes respectively. Hypoxia was not recognized during the procedure in neither case so far as inhaling 100% oxygen. No other complication was associated with our PDT procedure. We suggest that a laryngeal mask airway may be a useful option for fiberoptic bronchoscopy-guided PDT.

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We describe a patient who overdosed thyroid hormone to attempt suicide. A 26-year-old woman ingested an aggregate of 3.5mg (70 tablets) of levothyroxine. Gastric lavage followed by activated charcoal and a laxative was done in an ER and the patient was admitted to intensive care unit. She remained asymptomatic except for slight fever and discharged from the hospital on the fourth day. Thyroid function studies were repeated on follow-up until the 19th day after ingestion. The thyroid hormone values on admission were T₄ 39.8μg·dl^-1 (normal range; 5.1-13.5), T₃ 175ng·dl^-1 (85-200) and TSH 5.03μU·ml^-1 (0.27-4.2). The values of serum T₃ and T₄ fell down temporary less than normal on the 4th day and then spouted up over normal range on the 7th day. Thyroid hormone values were normalized on the 19th day. Serious toxicity is uncommon after levothyroxine ingestion, but the onset of symptoms may be delayed because of long half-life and bioactivity of a metabolyte (T₃). Close observation is necessary for a couple of weeks. Non-specific, supportive therapy is more beneficial than antithyroidal therapy because overdosed levothyroxine, as a result of homeostasis mechanism, suppresses thyroid gland and therefore aggressive antithyroidal therapy may cause critical overdepression.

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Bronchoscope assisted percutaneous tracheostomy (PCT) was performed in 11 patients in our intensive care unit without any complications. A bronchoscope was inserted through an endotracheal tube and we could observe the tracheal lumen throughout the procedures of PCT. This technique could confirm the insertion of tracheal tubes and avoid the serious complications in a conventional blind puncture, such as accidental extubations of the endotracheal tubes before insertion, miscanulations in the tracheal lumen, and esophageal injuries. We recommend the bronchoscope assisted PCT as a safer procedure rather than a conventional blind puncture.

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