方山 真朱

症例は66歳男性で、5日前から全身倦怠感ならびに感冒症状を認めた。1日前から呼吸困難感が出現し、SpO2が90%、胸部X線では両側肺野に浸潤陰影、胸部CTでは両側中下肺野にすりガラス陰影を認めた。間質性肺疾患の疑いで入院し、酸素療法と第3世代セフェム投与を開始した。しかし、呼吸困難感は徐々に進行した。翌日、気管挿管・人工呼吸を開始したが、左気胸が出現したため胸腔ドレーン留置後に救急搬送となった。徒手換気下で胸部CTを行ったところ、広範な荷重側無気肺を形成しており気管支牽引像を認めなかった。間質性肺疾患よりも細菌性肺炎による敗血症性ARDSを疑った。画像所見から肺胞リクルートメントが有効と判断し、腹臥位療法とAPRVを併用したopen lung strategyを施行した。レボフロキサシンを開始し、メチルプレドニゾロンを3日間投与した。第8病日に抜管し、第21病日には酸素投与なしで退院した。

Purpose: We aimed to study the clinical characteristics, courses, and outcomes of critically ill patients with septic acute kidney injury (AKI) treated with continuous renal replacement therapy (CRRT) in comparison with nonseptic AKI treated with CRRT. Methods: This is a multicenter retrospective observational study conducted in 14 Japanese intensive care units in 2010. All adult patients with severe AKI treated with CRRT were eligible (n = 343), and information on patient characteristics, variables at CRRT initiation, CRRT settings, and outcomes was collected. Patients were categorized into the septic AKI group and the nonseptic AKI group according to contributing factors to AKI. Results: Approximately half of study patients (48.7%) had sepsis/septic shock as a contributing factor to AKI, and patients with septic AKI treated with CRRT had more serious clinical conditions than patients with nonseptic AKI. However, no significant difference was observed in intensive care unit mortality (48.5% vs 43.8%; P = .44) and hospital mortality (61.1% vs 56.3%; P = .42) between patients with septic and nonseptic AKIs treated with CRRT. Furthermore, sepsis was associated with lower hospital mortality (odds ratio, 0.378; P = .012) in multivariable regression analysis. Conclusion: Sepsis may not be a risk factor for mortality in patientswith AKI whose condition has become severe enough to require CRRT. (C) 2015 Elsevier Inc. All rights reserved.

Background/Aims: Acute kidney injury (AKI) is associated with high mortality. Multiple AKI severity scores have been derived to predict patient outcome. We externally validated new AKI severity scores using the Japanese Society for Physicians and Trainees in Intensive Care (JSEPTIC) database. Methods: New AKI severity scores published in the 21st century (Mehta, Stuivenberg Hospital Acute Renal Failure (SHARF) II, Program to Improve Care in Acute Renal Disease (PICARD), Vellore and Demirjian), Liano, Simplified Acute Physiology Score (SAPS) II and lactate were compared using the JSEPTIC database that collected retrospectively 343 patients with AKI who required continuous renal replacement therapy (CRRT) in 14 intensive care units. Accuracy of the severity scores was assessed by the area under the receiveroperator characteristic curve (AUROC, discrimination) and Hosmer-Lemeshow test (H-L test, calibration). Results: The median age was 69 years and 65.8% were male. The median SAPS II score was 53 and the hospital mortality was 58.6%. The AUROC curves revealed low discrimination ability of the new AKI severity scores (Mehta 0.65, SHARF II 0.64, PICARD 0.64, Vellore 0.64, Demirjian 0.69), similar to Liano 0.67, SAPS II 0.67 and lactate 0.64. The H-L test also demonstrated that all assessed scores except for Liano had significantly low calibration ability. Conclusions: Using a multicenter database of AKI patients requiring CRRT, this study externally validated new AKI severity scores. While the Demirjian's score and Liano's score showed a better performance, further research will be required to confirm these findings. (C) 2015 S. Karger AG, Basel

Objective Fibre-optic bronchoscopy with bronchoalveolar lavage (FOB-BAL) is an important tool for diagnosing and selecting treatment for acutely hypoxaemic patients with diffuse lung infiltrates. However, FOB-BAL carries a risk of significant hypoxaemia and subsequent tracheal intubation during and after the procedure. The application of FOB-BAL using a laryngeal mask airway (LMA) in combination with continuous positive airway pressure (CPAP) may minimize the incidence of hypoxaemia; however, the safety and efficacy of this procedure have not been investigated. Methods A retrospective chart review was performed from April to September 2013. Data regarding the recovered volume of BAL fluid, incidence of tracheal intubation within eight hours after the completion of FOB-BAL, respiratory and haemodynamic parameters and treatment modifications were collected for the evaluation. Results Ten trials of FOB-BAL using an LMA and CPAP were performed in nine patients with severe acute hypoxaemia associated with diffuse lung infiltrates. The BAL fluid recovery rate was 56%, and the procedure was completed without subsequent complications. In addition, the percutaneous arterial oxygen saturation decreased to 95.7%+/- 3.8%, although it was never lower than 90.0% during the procedure, and no patients required intubation. Furthermore, the arterial blood pressure significantly but transiently decreased due to sedation, and the procedure yielded diagnostic information in all nine patients. Conclusion FOB-BAL using LMA and CPAP appears to be safe and effective in patients who develop severe acute hypoxaemia.

症例は79歳女性。切除不能腹膜癌に対し化学療法を施行中,好中球減少症に伴う腸管起源の感染に基づく敗血症性ショック,腹膜播種性転移による腸閉塞を呈していた。人工呼吸管理,昇圧剤使用中,循環動態維持目的の大量輸液(5時間で約12L)中に腹部膨隆・緊満,呼吸・循環動態の悪化を認め,abdominal compartment syndromeの診断に対し,減圧目的で開腹した。拡張した腸管に小孔を開けると便汁が噴水状に流出し,腸管内容の減圧を契機に呼吸・循環動態は著明に改善した。今回われわれは腸閉塞を背景に大量輸液が一因となって発症したabdominal compartment syndromeに対し緊急手術を施行し救命し得た1例を経験したので文献的考察を加えて報告する。(著者抄録)

当ICUにおけるHAMILTON-G5 INTELLiVENT-ASV(Int/ASV)の使用経験について報告した。2013年7月〜2014年1月迄にInt/ASVは頭頸部ならびに腹部予定手術後患者15例で使用され、平均年齢は55歳、男性が50%、APACHE IIは平均4.4であった。人工呼吸期間は平均3日間で、従来の方法と差はみられなかった。人工呼吸器に関連する有害事象は認めなかったが、2例でパルスオキシメーターやカプノグラフからのデータ取得の問題から導入できなかった。今回の結果から術後症例での使用は可能と判断した。Quick Wean機能やSBTは使用したものの効果判定には至らなかったが、問題なく使用できた。一方、一回換気量が小さく呼吸回数が低下しない拘束性肺障害患者や重症呼吸不全患者では、適応や安全性について今後さらなる評価が必要と考えられた。

Introduction: The recommended lower limit of intensity during continuous renal replacement therapy (CRRT) is 20 or 25 mL/kg/h. However, limited information is available to support this threshold. We aimed to evaluate the impact of different intensities of CRRT on the clearance of creatinine and urea in critically ill patients with severe acute kidney injury (AKI). Methods: This is a multicenter retrospective study conducted in 14 Japanese ICUs in 12 centers. All patients older than 18 years and treated with CRRT due to AKI were eligible. We evaluated the effect of CRRT intensity by two different definitions: daily intensity (the mean intensity over each 24-h period) and average intensity (the mean of daily intensity during the period while CRRT was performed). To study the effect of different CRRT intensity on clearance of urea and creatinine, all patients/daily observations were arbitrarily allocated to one of 4 groups based on the average intensity and daily intensity: &lt 10, 10-15, 15-20, and &gt 20 mL/kg/h. Results: Total 316 patients were included and divided into the four groups according to average CRRT intensity. The groups comprised 64 (20.3%), 138 (43.7%), 68 (21.5%), and 46 patients (14.6%), respectively. Decreases in creatinine and urea increased as the average intensity increased over the first 7 days of CRRT. The relative changes of serum creatinine and urea levels remained close to 1 over the 7 days in the "&lt 10" group. Total 1,101 daily observations were included and divided into the four groups according to daily CRRT intensity. The groups comprised 254 (23.1%), 470 (42.7%), 239 (21.7%), and 138 observations (12.5%), respectively. Creatinine and urea increased (negative daily change) only in the "&lt 10" group and decreased with the increasing daily intensity in the other groups. Conclusions: The lower limit of delivered intensity to control uremia during CRRT was approximately between 10 and 15 mL/kg/h in our cohort. A prescribed intensity of approximately 15 mL/kg/h might be adequate to control uremia for patients with severe AKI in the ICU. However, considering the limitations due to the retrospective nature of this study, prospective studies are required to confirm our findings.

Objective: To study the hospital mortality of patients with severe acute kidney injury treated with low-intensity continuous renal replacement therapy. Design: Multicenter retrospective observational study (Japanese Society for Physicians and Trainees in Intensive Care), combined with previously conducted multinational prospective observational study (Beginning and Ending Supportive Therapy). Setting: Fourteen Japanese ICUs in 12 tertiary hospitals (Japanese Society for Physicians and Trainees in Intensive Care) and 54 ICUs in 23 countries (Beginning and Ending Supportive Therapy). Patients: Consecutive adult patients with severe acute kidney injury requiring continuous renal replacement therapy admitted to the participating ICUs in 2010 (Japanese Society for Physicians and Trainees in Intensive Care, n = 343) and 2001 (Beginning and Ending Supportive Therapy Beginning and Ending Supportive Therapy, n = 1,006). Interventions: None. Measurements and Main Results: Patient characteristics, variables at continuous renal replacement therapy initiation, continuous renal replacement therapy settings, and outcomes (ICU and hospital mortality and renal replacement therapy requirement at hospital discharge) were collected. Continuous renal replacement therapy intensity was arbitrarily classified into seven subclasses: less than 10, 10-15, 15-20, 20-25, 25-30, 30-35, and more than 35 mL/kg/hr. Multivariable logistic regression analysis was conducted to investigate risk factors for hospital mortality. The continuous renal replacement therapy dose in the Japanese Society for Physicians and Trainees in Intensive Care database was less than half of the Beginning and Ending Supportive Therapy database (800 mL/hr vs 2,000 mL/hr, p < 0.001). Even after adjusting for the body weight and dilution factor, continuous renal replacement therapy intensity was statistically different (14.3 mL/kg/hr vs 20.4 mL/kg/hr, p < 0.001). Patients in the Japanese Society for Physicians and Trainees in Intensive Care database had a lower ICU mortality (46.1% vs 55.3%, p = 0.003) and hospital mortality (58.6% vs 64.2%, p = 0.070) compared with patients in the Beginning and Ending Supportive Therapy database. In multivariable regression analysis after combining the two databases, no continuous renal replacement therapy intensity subclasses were found to be statistically different from the reference intensity (20-25 mL/kg/hr). Several sensitivity analyses (patients with sepsis, patients from Western countries in the Beginning and Ending Supportive Therapy database) confirmed no intensity-outcome relationship. Conclusions: Continuous renal replacement therapy at a mean intensity of 14.3 mL/kg/hr did not have worse outcome compared with 20-25 mL/kg/hr of continuous renal replacement therapy, currently considered the standard intensity. However, our study is insufficient to support the use of low-intensity continuous renal replacement therapy, and more studies are needed to confirm our findings.

This study aimed to identify factors that may predict early kidney recovery (less than 48 hours) or early death (within 48 hours) after initiating continuous renal replacement therapy (CRRT) in acute kidney injury (AKI) patients. This is a multicenter retrospective observational study of 14 Japanese Intensive care units (ICUs) in 12 tertiary hospitals. Consecutive adult patients with severe AKI requiring CRRT admitted to the participating ICUs in 2010 (n=343) were included. Patient characteristics, variables at CRRT initiation, settings, and outcomes were collected. Patients were grouped into early kidney recovery group (CRRT discontinuation within 48 hours after initiation, n=52), early death group (death within 48 hours after CRRT initiation, n=52), and the rest as the control group (n=239). The mean duration of CRRT in the early kidney recovery group and early death group was 1.3 and 0.9 days, respectively. In multivariable regression analysis, in comparison with the control group, urine output (mL/h) (odds ratio [OR]: 1.02, 95% confidence interval [CI]: 1.01-1.03), duration between ICU admission to CRRT initiation (days) (OR: 0.65, 95% CI: 0.43-0.87), and the sepsis-related organ failure assessment score (OR: 0.87, 95% CI; 0.78-0.96) were related to early kidney recovery. Serum lactate (mmol/L) (OR: 1.19, 95% CI: 1.11-1.28), albumin (g/dL) (OR: 0.52, 95% CI: 0.28-0.92), vasopressor use (OR: 3.68, 95% CI: 1.37-12.16), and neurological disease (OR: 9.64, 96% CI: 1.22-92.95) were related to early death. Identifying AKI patients who do not benefit from CRRT and differentiating such patients from the study cohort may allow previous and future studies to effectively evaluate the indication and role of CRRT.

Glyceol(®) is an intracranial pressure reducing agent composed of 5% fructose and concentrated glycerol. Although rapid administration of fructose is known to cause lactic acidosis, little is known about hyperlactatemia caused by Glyceol(®) administration itself in adults. We observed an adult case of hyperlactatemia occurred after administration of 200 mL of Glyceol(®) over a period of 30 minutes. Since there was no evidence of an underlying liver disease or metabolic abnormality, and no findings of sepsis or impaired tissue perfusion, the cause of this condition was deemed to be the rapid loading of fructose contained as a constituent of Glyceol(®). We then performed a retrospective chart review and found other 9 cases admitted to Jichi Medical University Hospital ICU and administered Glyceol(®) during the past year. Their lactate levels increased in general, peaked approximately 45 minutes after Glyceol(®) administration and returned to pre-administration levels around 3 hours after. Although hyperlactatemia is an important indicator of sepsis and impaired tissue perfusion, caution is required when performing such an assessment in patients being administered Glyceol(®).

ジスチグミン臭化物10 mg/dayを1年間にわたり内服し，3ヶ月以上続く難治性の下痢や嘔吐など消化器症状のため入院したが，ジスチグミン臭化物中毒によるコリン作動性クリーゼを発症し，救命し得なかった一症例を経験した。背景に肝硬変があり，慢性的にコリンエステラーゼ値が低値であったため，ジスチグミン臭化物中毒の診断に時間がかかった。コリンエステラーゼ残存率は約7ヶ月前から異常低値であり，難治性の消化器症状が出現した時期と合わせて慢性中毒と考えた。難治性の消化器症状およびコリンエステラーゼ値が異常低値を示す高齢者では，ジスチグミン臭化物の中毒を疑い，早期から集中治療の対象とするのが望ましい。