Hajime Nakae

Cardiac rupture by penetration of fractured sternum: a rare complication of cardiopulmonary resuscitation

We report an 82-year-old man in whom cardiopulmonary resuscitation (CPR) was unsuccessful. The postmortem examination revealed right atrial ruptures and pericardial sac perforation by a fractured sternal edge. Even though CPR-related cardiac rupture is rare, emergency medical staff should be aware of this complication.

Effectiveness of electrolyzed oxidized water irrigation in a burn-wound infection model.

OBJECTIVEnThe purpose of the study was to determine whether electrolyzed oxidized water (EOW) functions as a bactericide in burn injury with Pseudomonas aeruginosa infection in a rat burn-wound model.nnnMETHODSnAnesthetized Sprague-Dawley rats (n = 31) were subjected to third-degree burns to 30% of total body surface area. Two days after injury, all rats were infected with P. aeruginosa using 1 mL of a suspension containing 1 x 10(8) colony-forming units. Rats were assigned to one of three groups: no irrigation (group I), irrigation with physiologic saline (group II), or irrigation with EOW (group III). Blood culture, endotoxin levels, and survival rates were determined.nnnRESULTSnSurvival rate was significantly higher in group III than in groups I or II (p < 0.0001). Serum endotoxin levels on day 3 after infection in group III were significantly lower than the levels in group I (p < 0.01) and group II (p < 0.01). There were significant differences between the three groups in the culture of P. aeruginosa (p < 0.05).nnnCONCLUSIONnIrrigation and disinfection with EOW may become useful in preventing burn-wound sepsis.

Bound and soluble adhesion molecule and cytokine levels in patients with severe burns

We measured endotoxins, inflammatory cytokines and soluble adhesion molecules in the blood of 17 severe burn patients to determine the involvement of these factors in the pathophysiology of severe burns. All seventeen patients had burns with a total burn surface area of 20% or more and a burn index of 15% or more. Endotoxin was measured by an endotoxin-specific assay and tumor necrosis factor-alpha, interleukin 6 and interleukin 8 and soluble adhesion molecules were measured by enzyme-linked immunosorbent assay. CD11a, CD11b and CD18, measured by flow cytometry, were elevated in the non-surviving group, the septic shock group and the multiple organ dysfunction syndrome group, suggesting a close connection between these adhesion molecules and burns complicated by infection. Soluble adhesion molecules were found to indirectly reflect the level of endothelial cell adhesion molecules, suggesting that inflammatory cytokines may also be involved in their production.

Failure to clear casts and secretions following inhalation injury can be dangerous: report of a case

A 27-year-old man suffered smoke inhalation during a fire. Three days later, he complained of respiratory difficulty and was admitted to our hospital. Bronchoscopy revealed a very large buildup of sputum mixed with soot extending from the left main bronchus to the bifurcation of the upper and lower lobe bronchi and causing both pulmonary atelectasis and pneumonia. The debris was successfully removed the next day with basket forceps via bronchoscopy. The patients airway pressure dropped significantly, enabling extubation almost immediately. Because of the possibility for respiratory failure caused by viscous secretion, it is important to perform initial bronchoscopy in cases of suspected inhalation injury.

Characteristics of self-immolation attempts in Akita Prefecture, Japan

Akita Prefecture has had the highest suicide rate in Japan for the past 9 years. To obtain further information on suicide attempts by self-immolation in Akita, we performed a statistical analysis of patients in this prefecture who attempted to burn themselves. Over the past 6 years, 541 patients suffering from burns were transferred to medical emergency units. Of these, 35 (6.5%) attempted self-immolation, most of whom were between 20 and 60 years of age. Women over 50 years of age outnumbered men in the same age group. All 35 patients sustained flame burns. The total burn surface area (TBSA), burn index (BI), rate of inhalation injury, and mortality rate were all significantly higher in the patients who attempted self-immolation than in those with nonsuicidal burns. Most (68.6%) of the self-immolation attempts were made indoors. Because the Japanese are not generally a very religious people, training to help them cultivate a philosophy of life and educating them in moral science to help them form a personal view of life and death may be necessary to prevent suicides.

Extravascular lung water measured using single transpulmonary thermodilution reflects perioperative pulmonary edema induced by esophagectomy.

Pulmonary edema is the most frequent postoperative complication following esophagectomy for thoracic esophageal cancer. We enrolled 23 patients who underwent esophagectomy with extended lymph node dissection for thoracic esophageal cancer in a prospective observational clinical trial. We used the PiCCO device to measure extravascular lung water with the aim of determining whether it correlates with the respiratory index and whether it is predictive of pulmonary complications. Based on constant criteria, the tracheal tubes of 11 patients were removed on the morning of postoperative day 1 (extubation group), while 12 patients remained intubated (intubation group). These two groups significantly differed in that all patients in the extubation group recovered without any pulmonary complications, whereas 4 patients (33%) in the intubation group developed pulmonary complications. The extravascular lung water measured using PiCCO correlated significantly with the respiratory index. In the intubation group, both extravascular lung water and respiratory index were elevated 12 h after surgery and were even higher 24 h after surgery. The extravascular lung water measured using PiCCO reflects the level of postoperative pulmonary edema and predicts the pulmonary complications induced by esophagectomy with extended lymph node dissection.

Involvement of IL-18 and Soluble Fas in Patients with Postoperative Hepatic Failure

We measured the levels of tumor necrosis factor alpha (TNF-α), interleukins (IL)-6 and -18, and soluble Fas (sFas) in 11 patients with postoperative hepatic failure and assessed whether IL-18-mediated apoptosis is involved in the onset of liver dysfunction. The serum TNF-α, IL-18, and sFas levels were significantly higher in patients with sepsis as a complication than in those without sepsis. The TNF-α and IL-18 levels were significantly higher in nonsurvivors than in survivors. Significant correlations were observed between TNF-α and IL-6, between TNF-α and IL-18, and between TNF-α and sFas levels. These results showed that Fas-mediated hepatocyte apoptosis functions as an important mechanism responsible for the onset of postoperative hepatic failure in humans. They especially suggested that IL-18 and TNF-α function both as apoptosis-promoting factors and as apoptosis-inhibiting factors, depending on the conditions to which hepatocytes are subjected.

Characteristics of burn patients transported by ambulance to treatment facilities in Akita Prefecture, Japan

This study analyzes patient demographics and injury data of 342 patients transported by ambulance to emergency facilities in Akita Prefecture, Japan, between 1996 and 2000. Significant findings include the following. Fire was the most frequent cause of burn injury, and winter was the season with the highest incidence (40.6%) of cases. The suicide rate in Akita Prefecture is high, the percentage of burn patients due to suicide attempts was 7.9%. The mean time from burn injury to hospital arrival was significantly longer for patients who later died (44.6 +/- 35.3 min) than for those survived (33.0 +/- 22.5 min). Severely burned patients were not always transported directly to a core emergency facility and an unacceptable number (5.8%) of patients died at tertiary hospitals. This relatively high death rate is attributable to the limited facilities for treating burns in the tertiary hospitals and the long distance to core facilities, which sometimes precludes transport system for the prefecture will reduce transport time to the regional trauma center and thus enable more patients to undergo specialized treatment at an earlier injury stage. Additionally, tertiary facilities should improve their level of burn care (e.g., creating a burn unit and skin bank).

Pharmacokinetics of Nafamostat Mesilate During Continuous Hemodiafiltration with a Polyacrylonitrile Membrane

Abstract: We studied the pharmacokinetics of nafamostat mesilate (NM) used as an anticoagulant in continuous hemodiafiltration (CHDF) with a polyacrylonitrile (PAN) membrane used as the hemofilter. Six patients undergoing CHDF for multiple organ dysfunction syndrome (MODS) were chosen as subjects. The inlet NM concentration measured 24u2003h after the start of CHDF was significantly greater than that after 1u2003h (Pu2003=u20030.0431). No significant difference was observed between the outlet NM concentration and the ultrafilter concentration at 1u2003h or 24u2003h after the start of CHDF. However, concentrations at 24u2003h differed significantly from concentrations at 1u2003h at all sites. Significant correlation was observed between the dose of NM and the outlet NM concentration (Pu2003=u20030.0475). No statistical correlation was observed between the dose of catecholamines and the outlet NM concentration (Pu2003=u20030.0985). This study is the first to disclose a mild but significant time‐dependent serum NM concentration in patients with MODS.

Multicenter Study of Plasma Diafiltration in Patients With Acute Liver Failure

Plasma diafiltration (PDF) is a blood purification therapy in which simple plasma exchange (PE) is performed using a selective membrane plasma separator while the dialysate flows outside the hollow fibers. A prospective, multicenter study was undertaken to evaluate the changes in bilirubin, IL‐18, and cystatin C, as well as the 28‐day and 90‐day survival rates, with the use of PDF according to the level of severity as measured by the Model for End‐Stage Liver Disease (MELD) score. Twenty‐one patients with liver failure were studied: 10 patients had fulminant hepatitis and PDF therapies were performed 28 times; 11 had acute liver failure with the therapy performed 96 times. Levels of total bilirubin, IL‐18, and cystatin C decreased significantly after treatment. The 28‐day survival rate was 70.0% and that at 90 days was 16.7%. According to the severity of the MELD score, each of the results compared well with the use of Molecular Adsorbent Recirculating System or Prometheus therapy. In conclusion, PDF appears to be one of the most useful blood purification therapies for use in cases of acute liver failure in terms of medical economics and the removal of water‐soluble and albumin‐bound toxins.