Antimicrobial chemotherapy for bacterial infection falls into two major categories: definitive therapy and empiric therapy. Definitive therapy is performed when bacterial pathogens are unequivocal. Empiric therapy is instituted to save the patient's life before identifying the bacterial pathogens by inferring their nature and resistance to drugs. It is commonly employed when chemotherapy is required in the ICU.
Regardless of which category of chemotherapy is performed, in addition to the patient's pathophysiological and general condition, biological pharmacokinetics and the safety of the antimicrobials, may have to be considered when selecting antimicrobials and deciding how to use them. The patient should be followed thoroughly to identify bacterial pathogens and alternative bacteria, and to clarify the reason the therapy was not effective.

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Reperfusion therapy for patients with acute myocardial infarction (AMI) is aimed at reopening the occluded infarct-related coronary artery and restoring antegrade flow. This results in the reduction of infarct size and improvement in outcomes. Intracoronary injection of fibrinolytic agents used to be the strategy used for reperfusion therapy. However, intravenous thrombolysis is now considered the treatment of choice for the initial management of patients with AMI in Western countries based on numerous megatrials which showed thrombolysis reduced mortality. The most commonly used fibrinolytic agent is tissue-plasminogen activator (t-PA) which has a higher affinity to fibrin than formerly used agents.
Thrombolytic therapy has failed to achieve at Thrombolysis in Myocardial Infarction (TIMI) flow grade 3 in over 50% of the cases. Percutaneous transluminal coronary angioplasty (PTCA) was introduced to obtain prompt and secure restoration of antegrade coronary flow. Several clinical trials have shown it to be more effective than thrombolysis. PTCA was used as a reperfusion tool in Japan in over 50% of the cases in 1994 and 70% in 1997.
New pharmacological and mechanical interventions have been developed recently to achieve earlier and more successful perfusion. Pilot trials have shown a higher complete reperfusion rate (TIMI flow grade 3) with bioengineered second generation t-PA. Pilot studies of intracoronary stent deployment have shown higher success rates and a lower incidence of restenosis. However, large scale randomized trials will be required to confirm the clinical efficacy and safety of these new interventions.

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Transesophageal echocardiography (TEE) has become one of the techniques used routinely in the operating room. We reviewed how we need TEE in the ICU. Hemodynamics in critically ill patients were evaluated with TEE. It was especially useful for the diagnosis of infective endocarditis and papillary muscle rupture. The effects of PEEP on cardiovascular function can be measured, dependent lung disease can be identified and facilitated by the use of TEE. It plays as the insertion of various kinds of catheters can be important role in the ICU.

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Objectives. Magnesium (Mg) physiologically antagonizes calcium (Ca) and inhibits it from flowing into cells. Mg sulfate was given to patients with acute myocardial infarction (AMI) who were receiving coronary reperfusion therapy. The effectiveness of this treatment in inhibiting reperfusion problems was evaluated.
Methods. Twenty-two patients (20 males, 2 females, average age 64 yrs) treated with coronary reperfusion therapy within six hours after the onset of symptomswere randomly allocated to either the magnesium group which received intravenous Mg sulfate 0.27mmol·kg^-1 prior to therapy, or the control (C) group which did not receive Mg. Mg²⁺ and IL-6 blood concentrations were measured with an ion selective electrode and the ELISA method in succession (normal values, Mg²⁺ 0.54±0.05 (SD) mmol·l^-1, IL-6<5pg·ml^-1). Adverse effects of the therapy which occurred within one hour of coronary reperfusion were chest pain aggravation, increased ST elevation a 12-lead electrocardiogram, and reappearance of arrhythmia (3 PVCs, premature ventricular contraction; VT, ventricular tachycardia; Vf, ventricular fibrillation; AIVR, accelerated idioventricular rhythm; IIIAV block, complete atrioventricular block).
Results. The occluded coronary arteries were recanalized in 20 cases (9 in the Mg group and 11 in the C group). The blood concentration of Mg²⁺ in the Mg group was 0.39±0.08mmol·l^-1 before treatment, 1.04±0.10mmol·l^-1 after therapy, and returned to baseline six hours after therapy. The incidence of arrhythmia after reperfusion was 11% (1 case) in the Mg group and 82% (9 cases) in the C group (P=0.002). ST change after reperfusion was 2.4±2.2mm in the Mg group, and 4.6±3.4mm in the C group(P=0.09). No marked difference was noted in the incidence of chest pain aggravation between the two groups. The IL-6 peak value in the blood was 44±27pg·ml^-1 in the Mg group and 102±80pg·ml^-1 in the C group (P=0.04).
Conclusion. Increased blood Mg²⁺ may inhibit the reappearrance of arrhythmia after reperfusion, as well as IL-6 production and myocardial lesions caused by Ca overload in the cells. Treating AMI patients with magnesium sulfate before coronary reperfusion therapy may be effective for preventing reperfusion injury.

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The production and adsorption of inflammatory cytokines were studied during closed loop circulation of whole blood through regenerated cellulose (RC) or polyacrylonitrile (PAN) hemofilters. Blood cell counts, plasma cytokine levels and expression of mRNAs for cytokines in the peripheral blood mononuclear cells (PBMC) were determined before and after circulation. WBC did not change, but PBMC and platelets decreased after circulation through RC and PAN hemofilters. Plasma tumor necrosis factor-α (TNF α) was not detected either before or after circulation through either hemofilter. Plasma interleukin-6 (IL-6) and interleukin-8 (IL-8) levels were significantly elevated through RC, but not PAN hemofilters. Expression of mRNA for TNF α, IL-6 and IL-8 was markedly induced through both RC and PAN hemofilters. We concluded that the production of cytokines was stimulated by circulation through both RC and PAN hemofilters, and suggested that cytokines were adsorped to the membrane by circulation through PAN hemofilters.

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Objective: To improve sterilization methods for preventing stopcock infection in central venous lines.
Design: Prospective, noninterventional study.
Setting: General intensive care unit at a university teaching hospital.
Measurements and Results: Thirty-six stopcocks connected to the central venous line in critically ill patients were studied. Sixteen stopcocks were wiped with cotton wett with 70% ethyl alcohol at the injection port immediately before intravenous medication (wiping group), and twenty stopcocks were sterilized by spraying 70% ethyl alcohol into the injection port (spray group). Microbiological analysis was performed after using the stopcocks for 24 hours. Pathogenetic bacteria were isolated from five stopcocks (31.3%) and fungi were detected from four stopcocks (25.0%) in the wiping group. Pathogenetic bacteria and fungi were isolated from one stopcock (5.0%) and three stopcocks (15.0%), respectively in the spray group.
Conclusion: This study showed that spraying 70% ethylalcohol on stopcocks is significantly more effective (P<0.05) than wiping method for decreasing bacterial infection rates in central cathters.

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We followed a patient with pulmonary alveolar proteinosis who received bronchopulmonary lavages for eleven years (seven times on the left, six times on the right). Massive bronchopulmonary lavage was performed under general anesthesia with ventilation of one lung. A solution of 0.9% NaCl equal in volume to the capacity of the lung was administered by volume limited instillation for each lavage. Symptoms improved after lavage, but the effects attenuated with each lavage. Interstitial shadowing and bullous change, the so-called honey-comb lung, gradually became worse in the bilateral lower lung fields. The patient died of respiratory failure due to pneumonia and bilateral pneumothorax eleven years after the first admission.
Microscopic examination revealed that the alveolar septum was almost normal at the first admission but had become infiltrated with inflammatory cells and had become markedly fibrous by the terminal stage. Arterial oxygen tension remained within the normal range, but carbon monoxide diffusing capacity (DL_CO) decreased as the patient's condition worsened. We believe DL_CO is important for following the disease. Improvement in DL_CO was observed for several months after lavage, but subsequently became worse. Changes in DL_CO may be useful to determine the timing of the next bronchopulmonary lavage in pulmonary alveolar proteinosis.

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The staphylococcal scalded skin syndrome (SSSS) is a febrile, self-limited illness. It generally affects infants and children; however a few adults, particularly those with immunosuppression, have developed a similar condition. In adult cases, mortality is high. Here, we report a very rare case of SSSS in an adult without underlying diseases. A 68-year-old man was admitted to our hospital because of spondylitis and arthritis of the right knee joint.
The clinical findings and bacteriologic examinations as well as the skin biopsy were consistent with the diagnosis of SSSS. The patient was supported by a mechanical ventilator and successfully treated with antibiotics.

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We reported a case of neutropenic enterocolitis (NE) with septic shock during the treatment of acute promyelocytic leukemia (APL). A 42-year-old man, who had been in consolidation therapy for APL, developed fever and right lower abdominal pain. His white blood cell count decreased to 150mm^-3 and he lapsed into septic shock. Under the diagnosis of diffuse peritonitis, emergency laparotomy was done. NE was diagnosed at this time and ileocecal resection was performed. On admission to ICU after the operation he remained septic and critically ill. We performed extracorporeal endotoxin removal (ECER) three times to eliminate endotoxin (ETX) from his bloodstream. His condition improved and ETX concentration was reduced from 81.9pg·ml^-1 to 14.5pg ·ml^-1 after ECER. Severe necrotic inflammation is found on pathological analysis of NE. This is a frequent complication in those who undergo chemotherapy for hematological malignancies. Even now, this disease has a high mortality rate. We conclude that the combination therapy of early removal of the necrotic infectious intestine followed by ECER was effective in preventing septic multiple organ failure.

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