Yoshihito Ujike

Suppression of the thyrotropin response to thyrotropin-releasing hormone and its association with severity of critical illness.

Objective: To study whether the suppression of the thyrotropin (thyroid‐stimulating hormone, TSH) response to thyrotropin‐releasing hormone (TRH) correlates with severity of illness and death in patients with nonthyroidal critical illness. Design: Prospective study. Setting: Intensive care unit (ICU) of a university hospital. Patients: Forty‐one critically ill patients without thyroid disease with multiple organ failure who were admitted to the ICU. Measurements and Main Results: The TSH response to TRH was tested within 24 hrs of ICU admission. Blood samples were obtained just before, and at 15, 30, 60, 90, and 120 mins after 500‐&mgr;g injection of synthetic TRH. Triiodothyronine, free‐triiodothyronine, thyroxine, free‐thyroxine and TSH concentrations were measured in the samples obtained just before TRH injection. Acute Physiology and Chronic Health Evaluation (APACHE II) scores and Sepsis scores were calculated based on the data obtained within 24 hrs of ICU admission. Individual variables were compared between survivors and nonsurvivors. The APACHE II scores and Sepsis scores of nonsurvivors were significantly higher than those scores of survivors. The overall occurrence of suppressed TSH response to TRH was 88%. Peak TSH concentration of the TSH response was significantly lower in nonsurvivors than in survivors. Serial measurement of the TSH response showed that nonsurvivors experienced a decrease in peak TSH concentration from 1.55 ± 0.78 to 0.55 ± 0.30 &mgr;IU/mL; in survivors, it increased from 2.10 ± 0.26 to 7.38 ± 1.83 &mgr;IU/mL. Conversely, the basal TSH concentration did not change in either survivors or nonsurvivors. The “severity” of illness of nonsurvivors remained high; their mean APACHE II score varied from 20.0 ± 1.9 to 22.1 ± 1.3 and the mean Sepsis score varied from 20.0 ± 4.3 to 25.4 ± 4.0, while the same scores for survivors decreased significantly ( p < .05): their APACHE II score decreased from 16.2 ± 0.7 to 7.6 ± 2.0 and the Sepsis score went from 14.0 ± 1.9 to 6.0 ± 1.6. Conclusions: In critically ill patients with multiple organ failure, suppression of the TSH response to TRH frequently occurs and correlates with severity of illness and outcome. Our data indicate that measurement of the TSH response is helpful in evaluating the severity of illness and prognosis for critically ill patients. (Crit Care Med 1994; 22:1603–1609)

The earthquake and tsunami - observations by Japanese physicians since the 11 March catastrophe

Japan was struck by a magnitude 9.0 earthquake and a tsunami on 11 March 2011. Although this catastrophe has caused the most devastating damage to Japan since World War II, we believe that our systematic preparation for disasters somewhat alleviated the damage. Learning lessons from the magnitude 7.3 Great Hanshin earthquake in 1995, the government organized approximately 700 medical teams specialized in disaster management. In this earthquake of 2011, hundreds of medical teams were successfully deployed and started operations within the first 72 hours. Furthermore, the internet, which was not commonly used in 1995, made significant contributions in communication among clinicians and enabled them to promptly identify the needs of the affected hospitals. In addition, medical professional societies took leadership in the logistics of transferring victims away from the disaster zone. We also observed that the spectrum of causes of death is distinct between the earthquakes of 1995 and 2011. In 1995, many victims died from trauma, including crash injury, and delays in providing hemodialysis contributed to additional deaths. In 2011, in contrast, many victims died from drowning in the tsunami, and most survivors did not have life-threatening injuries.

Prolongation of tetracaine spinal anesthesia by oral clonidine

The effects of oral clonidine on the duration of isobaric tetracaine spinal anesthesia were studied in 30 patients undergoing urologic procedures. All patients received 15 mg of tetracaine intrathecally in isobaric saline solution. Group 1 (n = 10) received 0.25 mg of oral triazolam; group 2 (n = 10) received 0.15 mg of oral clonidine; and group 3 (n = 10) received 0.25 mg of oral triazolam and 0.75 mg of intrathecal phenylephrine. In group 1, the times for two- and four-segment regression of the level of analgesia to pin-prick were 80 +/- 17 and 123 +/- 22 min, respectively (mean +/- SD). The corresponding values of those measurements were 170 +/- 27 and 273 +/- 48 min in group 2 and 175 +/- 34 and 273 +/- 68 min in group 3. All the regression times in groups 2 and 3 were significantly longer than those in group 1. Regression times were not different between groups 2 and 3. The authors conclude that prolongation of tetracaine sensory analgesia may be produced by premedication with 0.15 mg of oral clonidine. The prolongation is similar to that produced by intrathecal phenylephrine.

Blood oxygenation using microbubble suspensions

Microbubbles have been used in a variety of fields and have unique properties, for example shrinking collapse, long lifetime, efficient gas solubility, a negatively charged surface, and the ability to produce free radicals. In medicine, microbubbles have been used mainly as diagnostic aids to scan various organs of the body, and they have recently been investigated for use in drug and gene delivery. However, there have been no reports of blood oxygenation by use of oxygen microbubble fluids without shell reagents. In this study, we demonstrated that nano or microbubbles can achieve oxygen supersaturation of fluids, and may be sufficiently small and safe for infusion into blood vessels. Although Po2 increases in fluids resulting from use of microbubbles were inhibited by polar solvents, normal saline solution (NSS) was little affected. Thus, NSS is suitable for production of oxygen-rich fluid. In addition, oxygen microbubble NSS effectively improved hypoxic conditions in blood. Thus, use of oxygen microbubble (nanobubble) fluids is a potentially effective novel method for oxygenation of hypoxic tissues, for infection control, and for anticancer treatment.

Extracorporeal membrane oxygenation following pediatric cardiac surgery: development and outcomes from a single-center experience

Extracorporeal membrane oxygenation (ECMO) has emerged as an effective mechanical support following cardiac surgery with respiratory and cardiac failure. However, there are no clear indications for ECMO use after pediatric cardiac surgery. We retrospectively reviewed medical records of 76 pediatric patients [mean age, 10.8 months (0–86); mean weight, 5.16 kg (1.16–16.5)] with congenital heart disease who received ECMO following cardiac surgery between January 1997 and October 2010. Forty-five patients were treated with an aggressive ECMO approach (aggressive ECMO group, April 2005–October 2010) and 31 with a delayed ECMO approach (delayed ECMO group, January 1997–March 2005). Demographics, diagnosis, operative variables, ECMO indication, and duration of survivors and non-survivors were compared. Thirty-four patients (75.5%) were successfully weaned from ECMO in the aggressive ECMO group and 26 (57.7%) were discharged. Conversely, eight patients (25.8%) were successfully weaned from ECMO in the delayed ECMO group and two (6.5%) were discharged. Forty-five patients with shunted single ventricle physiology (aggressive: 29 patients, delayed: 16 patients) received ECMO, but only 15 (33.3%) survived and were discharged. The survival rate of the aggressive ECMO group was significantly better when compared with the delayed ECMO group (p<0.01). Also, ECMO duration was significantly shorter among the aggressive ECMO group survivors (96.5 ± 62.9 h, p<0.01). Thus, the aggressive ECMO approach is a superior strategy compared to the delayed ECMO approach in pediatric cardiac patients. The aggressive ECMO approach improved our outcomes of neonatal and pediatric ECMO.

Effect of the Pulsatile Extracorporeal Membrane Oxygenation on Hemodynamic Energy and Systemic Microcirculation in a Piglet Model of Acute Cardiac Failure.

The objective of this study was to compare the effects of pulsatile and nonpulsatile extracorporeal membrane oxygenation (ECMO) on hemodynamic energy and systemic microcirculation in an acute cardiac failure model in piglets. Fourteen piglets with a mean body weight of 6.08 ± 0.86 kg were divided into pulsatile (N = 7) and nonpulsatile (N = 7) ECMO groups. The experimental ECMO circuit consisted of a centrifugal pump, a membrane oxygenator, and a pneumatic pulsatile flow generator system developed in-house. Nonpulsatile ECMO was initiated at a flow rate of 140 mL/kg/min for the first 30 min with normal heart beating, with rectal temperature maintained at 36°C. Ventricular fibrillation was then induced with a 3.5-V alternating current to generate a cardiac dysfunction model. Using this model, we collected the data on pulsatile and nonpulsatile groups. The piglets were weaned off ECMO at the end of the experiment (180 min after ECMO was initiated). The animals did not receive blood transfusions, inotropic drugs, or vasoactive drugs. Blood samples were collected to measure hemoglobin, methemoglobin, blood gases, electrolytes, and lactic acid levels. Hemodynamic energy was calculated using the Shepards energy equivalent pressure. Near-infrared spectroscopy was used to monitor brain and kidney perfusion. The pulsatile ECMO group had a higher atrial pressure (systolic and mean), and significantly higher regional saturation at the brain level, than the nonpulsatile group (for both, P < 0.05). Additionally, the pulsatile ECMO group had higher methemoglobin levels within the normal range than the nonpulsatile group. Our study demonstrated that pulsatile ECMO produces significantly higher hemodynamic energy and improves systemic microcirculation, compared with nonpulsatile ECMO in acute cardiac failure.

Overheated and melted intracranial pressure transducer as cause of thermal brain injury during magnetic resonance imaging: case report.

Magnetic resonance imaging is used with increasing frequency to provide accurate clinical information in cases of acute brain injury, and it is important to ensure that intracranial pressure (ICP) monitoring devices are both safe and accurate inside the MRI suite. A rare case of thermal brain injury during MRI associated with an overheated ICP transducer is reported. This 20-year-old man had sustained a severe contusion of the right temporal and parietal lobes during a motor vehicle accident. An MR-compatible ICP transducer was placed in the left frontal lobe. The patient was treated with therapeutic hypothermia, barbiturate therapy, partial right temporal lobectomy, and decompressive craniectomy. Immediately after MRI examination on hospital Day 6, the ICP monitor was found to have stopped working, and the transducer was subsequently removed. The patient developed meningitis after this event, and repeat MRI revealed additional brain injury deep in the white matter on the left side, at the location of the ICP transducer. It is suspected that this new injury was caused by heating due to the radiofrequency radiation used in MRI because it was ascertained that the tip of the transducer had been melted and scorched. Scanning conditions--including configuration of the transducer, MRI parameters such as the type of radiofrequency coil, and the specific absorption rate limit--deviated from the manufacturers recommendations. In cooperation with the manufacturer, the authors developed a precautionary tag describing guidelines for safe MR scanning to attach to the display unit of the product. Strict adherence to the manufacturers guidelines is very important for preventing serious complications in patients with ICP monitors undergoing MRI examinations.

The Japanese Respiratory Society Noninvasive Positive Pressure Ventilation (NPPV) Guidelines (second revised edition)

Division of Sleep and Respiratory Medicine, Nihon University School of Medicine Department of Pediatrics, National Hospital Organization Yakumo National Hospital Department of Respiratory Medicine, Osaka Prefectural Medical Center for Respiratory and Allergic Diseases Department of ER/Disaster Medical Care, Tokushima University Hospital Respiratory and Sleep Medicine Center, Osaka Kaisei Hospital Anesthesiology and Intensive Care Medicine of Toho University Omori Medical Center Cardio-Respiratory Sleep Medicine, Department of Cardiovascular Medicine, Juntendo University, Graduate School of

Successful application of venoarterial-venous extracorporeal membrane oxygenation in the reversal of severe cardiorespiratory failure

Typical configurations of extracorporeal membrane oxygenation (ECMO) include venovenous (VV) and venoarterial (VA) configurations; however, other configurations of ECMO may be necessary in certain situations. We performed VA ECMO for a 71-year-old man who experienced refractory hypoxaemia associated with a brief cardiac arrest after resection of the small intestine showing necrosis. As the cardiac function improved, the patient showed a complication of poor oxygenation in the upper body due to insufficient respiratory function. Therefore, we performed VA-venous ECMO, which further improved his cardiac function and allowed him to be converted to VV ECMO. It is very important to consider different configuration strategies of ECMO by adjusting the patients cardiopulmonary conditions appropriately.

Wakefulness during the induction with high-dose fentanyl and oxygen anesthesia

The purpose of this study was to investigate the state of wakefulness during the induction of anesthesia with high-dose fentanyl using the isolated forearm technique. Ten patients scheduled for elective cardiovascular surgery were premedicated with morphine (0.15 mg/kg) and scoploamine (0.3/2-0.4 mg) intramuscularly one hour before induction. The induction of anesthesia was performed by intravenous administration of 100 /gmg/kg of fentanyl in 15 min or over. The pneumatic tourniquet applied on the left upper arm was inflated to 220/2-240 mmHg after 10 /gmg/kg of fentanyl was given and then pancuronium was administered. Verbal commands were given to the patient after 25, 50, 75 and 100 /gmg/kg of fentanyl was administered. Eight patients out of 10 responded to the verbal commands after administration of 25 /gmg/kg of fentanyl. Six patients also responded after administration of 100 /gmg/kg of fentanyl and diazepam 5 mg was given to prevent tachycardia and rigidity during endotracheal intubation. Muscle rigidity and tachycardia were noticed in three and four patients respectively. These complications disappeared by diazepam administration.It was noted that wakefulness frequently occurred during the induction by high-dose fentanyl and oxygen anesthesia. To prevent such wakefulness therefore, it is necessary to use anesthetic supplements which do not cause cardiovascular depression.