山下 千鶴

We report a case in which excessive negative pressure may have been applied to the proximal side hole of a drainage cannula during venovenous extracorporeal membrane oxygenation (V-V ECMO), resulting in abnormal stenosis of the drainage cannula. V-V ECMO was introduced in a 71-year-old male patient who was transferred from another hospital for severe respiratory failure associated with varicella pneumonia and acute respiratory distress syndrome. Drainage was performed using a PCKC-V™ 24Fr (MERA, Japan) cannula via the right femoral vein with the tip of the cannula near the level of the diaphragm under fluoroscopy. Reinfusion was performed via the right internal jugular vein. Due to poor systemic oxygenation, the drainage cannula was withdrawn caudally and refixed to reduce the effect of recirculation. Two days later, drainage pressure dropped rapidly, and frequent ECMO flow interruption occurred due to poor drainage. An abdominal X-ray revealed abnormal stenosis of the proximal side hole site of the drainage cannula. We diagnosed that the drainage cannula was damaged, and it was replaced with another, namely a Medtronic Bio-Medicus™ 25 Fr (GETINGE, Sweden) cannula. However, the removed drainage cannula was not damaged, suggesting that the cannula was temporarily stenosed by momentary excessive negative pressure. In a multi-stage drainage cannula, the main drainage site is the proximal side hole, with little negative pressure applied at the apical foramen in a mock experimental ex vivo drainage test in a water tank. Hence, improvement of a multi-stage drainage cannula is recommended, such as adequate reinforcement of the side hole site with a wire.

【目的】胃がん手術後の体重減少は,生活の質の低下など影響をおよぼす重要な課題である.今回,低侵襲胃がん手術後1ヵ月の体組成変化と除脂肪体重減少の要因について検討した.【対象および方法】2021年4月から2022年8月で低侵襲胃がん手術の術前および術後1ヵ月に体組成測定した88例を対象とした.術後1ヵ月の除脂肪体重減少率の中央値(2.4%)以下46例をLow群(以下,L群と略),中央値より大きい42例をHigh群(以下,H群と略)とし比較検討した.また,重回帰分析にて除脂肪体重減少のリスク因子を検討した.【結果】L群,H群の術後1ヵ月の変化は体重-5.4%,-7.1%,体脂肪量-16.3%,-13.9%であった.重回帰分析の結果,術前体脂肪率(p<0.01)が有意な変数として抽出された.【結論】術前体脂肪率低値は,術後1ヵ月の除脂肪体重減少の有意な危険因子であり,術前からの介入を要すると考えられた.(著者抄録)

BACKGROUND: Surgical site infections (SSIs) increase mortality, hospital stays, additional medical treatment, and medical costs. Subcutaneous drains prevent SSIs in gynecological and breast surgeries; however, their clinical impact in abdominal surgery remains unclear. AIM: To investigate whether subcutaneous drains were beneficial in abdominal surgery using a systematic review and meta-analysis. METHODS: The database search used PubMed, MEDLINE, and the Cochrane Library. The following inclusion criteria were set for the systematic review: (1) Randomized controlled trial studies comparing SSIs after abdominal surgery with or without subcutaneous drains; and (2) Studies that described clinical outcomes, such as SSIs, seroma formation, the length of hospital stays, and mortality. RESULTS: Eight studies were included in this meta-analysis. The rate of total SSIs was significantly lower in the drained group (54/771, 7.0%) than in the control group (89/759, 11.7%), particularly in gastrointestinal surgery. Furthermore, the rate of superficial SSIs was slightly lower in the drained group (31/517, 6.0%) than in the control group (49/521, 9.4%). No significant differences were observed in seroma formation between the groups. Hospital stays were shorter in the drained group than in the control group. CONCLUSION: Subcutaneous drains after abdominal surgery prevented SSIs and reduced hospital stays but did not significantly affect seroma formation. The timing of drain removal needs to be reconsidered in future studies.

術前栄養障害やサルコペニア合併患者では術後感染性合併症発生率や死亡率が高く,特に術前栄養療法がこれらの合併症を減少させる。さらに,近年は術前入院期間が短く,外来の果たす役割は大きい。周術期管理センターで管理栄養士を中心に行う外来栄養療法は,多職種専門家集団の特徴を生かした役割であると考える。当院では2015年に周術期管理センターを開設し,2018年より専任管理栄養士が加わった。周術期管理センターは全科の予定手術患者が手術2～4週間前に受診する。事前に受診が終了した入退院センターでの栄養スクリーニングを元に,周術期管理センターで管理栄養士が体組成や握力の測定,栄養摂取状況の聞き取りの上,The Global Leadership Initiative on Malnutrition(GLIM)基準を用いてアセスメントを行う。麻酔科医は低栄養やサルコペニアの患者に栄養療法の役割や重要性について説明を行い,主治医との情報共有のもとに必要に応じて経口栄養補助剤を処方する。管理栄養士は飲用方法の説明や飲み方の工夫などの説明を行う。また,管理栄養士による体組成計測や栄養評価は入院時や術後にも継続し,効果について患者と情報共有し,患者に寄り添うことに力を入れている。さらに,外来での栄養介入の情報はNSTにも情報共有し,入院後迅速な介入の継続を可能にしている。周術期管理センターの管理栄養士を軸とし,シームレスかつ有機的な連携のもとに周術期栄養管理を行うことが,良好なコンプライアンスやアウトカムに繋がっていると考える。(著者抄録)

The perioperative management of patients who are smokers presents anesthesiologists with various challenges related to respiratory, circulatory, and other clinical problems. Regarding 30-day postoperative outcomes, smokers have higher risks of mortality and complications than non-smokers, including death, pneumonia, unplanned tracheal intubation, mechanical ventilation, cardiac arrest, myocardial infarction, and stroke. Given the benefits of smoking cessation and the adverse effects of smoking on perioperative patient management, patients should quit smoking long before surgery. However, anesthesiologists cannot address these issues alone. The Japanese Society of Anesthesiologists established guidelines in 2015 (published in a medical journal in 2017) to enlighten surgical staff members and patients regarding perioperative tobacco cessation. The primary objective of perioperative smoking cessation is to reduce the risks of adverse cardiovascular and respiratory events, wound infection, and other perioperative complications. Perioperative preparations constitute a powerful teachable moment, a "golden opportunity" for smoking cessation to achieve improved primary disease outcomes and prevent the occurrence of tobacco-related conditions. This review updates the aforementioned guidelines as a practical guide to cover the nuts and bolts of perioperative smoking cessation. Its goal is to assist surgeons, anesthesiologists, and other medical professionals and to increase patients' awareness of smoking risks before elective surgery.

Myoglobin, which can cause acute kidney injury, has a relatively high molecular weight and is poorly cleared by diffusion. We compared and examined myoglobin clearance by changing the blood purification membrane and modality in patients with a myoglobin blood concentration ≥ 1000 ng/ml. We retrospectively analyzed three patient groups based on the following three types of continuous hemofiltration (CHF): AN69ST membrane, polymethylmethacrylate (PMMA) membrane, and high-flow hemodiafiltration (HDF) with increased dialysate flow rate using the PMMA membrane. There was no significant difference in clearance in CHF between AN69ST and PMMA membranes. However, the high-flow HDF group showed the highest myoglobin clearance (p = 0.003). In the PMMA membrane, changing the treatment modality to high-flow HDF increased clearance above the theoretical value, possibly due to internal filtration. To remove myoglobin by kidney replacement therapy from patients with hypermyoglobinemia, a modality such as high-flow HDF would be desirable.

Spontaneous abdominal wall hematomas are relatively rare and mainly attributed to anticoagulation and severe cough. Despite the high incidence of anticoagulation-related bleeding complications, there are no reports of spontaneous abdominal wall hematomas during extracorporeal membrane oxygenation (ECMO). We report a case of a spontaneous rectus sheath hematoma caused by alternation of the lateral semi-prone position during ECMO in a 76-year-old female patient with severe acute respiratory distress syndrome. Unfractionated heparin 12,000-14,000 units/day was administered for anticoagulation during ECMO. From Day 6 of ECMO, the patient who was under deep sedation was alternately placed in the left and right lateral semi-prone positions every 4 h, for approximately 20 h per day. On Day 12 of ECMO, the patient developed hypotension with anemia and a palpable mass in the right lower abdomen. Abdominal ultrasonographic imaging revealed a huge echo-free space centered in the right lower abdomen. Emergency contrast-enhanced computed tomography (CT) scanning showed extravasation from the superior and inferior epigastric arteries as well as a rectus sheath hematoma. Despite no apparent contrast leakage, an inferior epigastric artery embolization was undertaken because the patient was on ECMO. On Day 13 after ECMO initiation, ECMO and anticoagulation were discontinued. On CT scanning a week later, the hematoma had reduced. In conclusion, spontaneous abdominal wall hematoma is a rare and important complication that might occur during ECMO. Thus, careful physical examination should be routinely conducted when the patient is semi-prone during ECMO.

日本麻酔科学会の提唱により、周術期管理センター(以下、センター)の導入が広がってきている。今回、センター運用による麻酔科医の業務効率改善や経営的効果について後方視的に検討した。予定全身麻酔患者の約80%がセンターを受診した。麻酔科医の術前診察時間は48%短縮し、年間約1,000万円の増収となった。また、手術直前の延期はセンター受診者で減少した。センターの運用は麻酔科医の業務効率改善および経営的効果を持つ。(著者抄録)

Tumor necrosis factor-alpha inhibitor (TNFi) treatment is effective for ulcerative colitis (UC) and Crohn's disease (CD). Although several meta-analyses have been performed to evaluate the association between TNFi treatment and surgical morbidity, the results are controversial. We conducted a systematic review and meta-analysis of the prevention of surgical site infection (SSI) after surgery for UC and CD in patients on TNFis, based on literature published between January 2000 and May 2019 (registered on PROSPERO, No. CRD42019134156). Overall, 2175 UC patients in 13 observational studies (OBSs) and 7084 CD patients in 16 OBSs were included. The incidences of incisional (INC) SSI and organ/space (O/S) SSI after surgery for UC were 179/1985 (9.0%) and 176/2175 (8.1%), respectively. TNFi use was not associated with the incidences of INC SSI (odds ratio (OR) 1.04, 95% confidence interval (CI) (0.47-2.32) or O/S SSI (OR 1.85, 95% CI (0.82-4.20)) after surgery for UC. The INC SSI and O/S SSI incidences after surgery for CD were 289/3089 (9.4%) and 526/7,084 (7.4%), respectively. Preoperative TNFi use was not associated with INC SSI (OR 0.98, 95% CI (0.52-1.83)) or O/S SSI incidence (OR 1.09, 95% CI (0.78-1.52)) after surgery for CD. We did not find a significant association between preoperative TNFi use and SSI in surgery for UC or CD.

BACKGROUND: The guidelines for the prevention, detection, and management of gastroenterological surgical site infections (SSIs) were published in Japanese by the Japan Society for Surgical Infection in 2018. This is a summary of these guidelines for medical professionals worldwide. METHODS: We conducted a systematic review and comprehensive evaluation of the evidence for diagnosis and treatment of gastroenterological SSIs, based on the concepts of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The strength of recommendations was graded and voted using the Delphi method and the nominal group technique. Modifications were made to the guidelines in response to feedback from the general public and relevant medical societies. RESULTS: There were 44 questions prepared in seven subject areas, for which 51 recommendations were made. The seven subject areas were: definition and etiology, diagnosis, preoperative management, prophylactic antibiotics, intraoperative management, perioperative management, and wound management. According to the GRADE system, we evaluated the body of evidence for each clinical question. Based on the results of the meta-analysis, recommendations were graded using the Delphi method to generate useful information. The final version of the recommendations was published in 2018, in Japanese. CONCLUSIONS: The Japanese Guidelines for the prevention, detection, and management of gastroenterological SSI were published in 2018 to provide useful information for clinicians and improve the clinical outcome of patients.

Patients who undergo renal replacement therapy often exhibit a high plasma linezolid concentration. Linezolid is metabolized via oxidation. Nafamostat mesilate has antioxidant effects and is frequently used as an anticoagulant during renal replacement therapy. We aimed to investigate the effect of nafamostat mesilate on plasma linezolid concentration. We examined whether the co-administration of linezolid and nafamostat had any effect on plasma linezolid concentration. Mice were randomly allocated to two groups (n = 18/group): linezolid (100 mg kg-1 , subcutaneous injection) + nafamostat (30 mg kg-1 , intraperitoneal injection) and linezolid + saline. At 5 hours, the linezolid concentration was significantly higher in the linezolid + nafamostat co-administration group than that in the linezolid + saline group (20.6 ± 9.8 vs 3.6 ± 1.2 μg/mL, respectively P < .001). The antioxidant effects of nafamostat may inhibit linezolid metabolism, resulting in the adverse event of high linezolid concentration if both are administered concurrently during renal replacement therapy.

We aimed to evaluate whether cardiac output assessed by transpulmonary thermodilution during blood purification is affected by the difference between the blood return temperature and core temperature. We applied different blood return temperatures using a thermostat bath during blood purification in four pigs. After the blood return temperature stabilized and blood purification process stopped, the cardiac output assessed by transpulmonary thermodilution was measured. The thermostat bath was set at 35°C, 40°C, 45°C, and 50°C, with the order changed at random; four measurements were made at each temperature. Cardiac function was evaluated by echocardiography when ice-cold saline was administered in a pig. A decrease in the blood return temperature resulted in decreased cardiac output assessed by transpulmonary thermodilution, whereas an increase resulted in increased cardiac output assessed by transpulmonary thermodilution. Echocardiography revealed that the change in the blood return temperature did not affect the left ventricular ejection fraction.

重症感染症患者の救命と耐性菌出現抑制の両立には,想定原因菌を網羅可能な初期抗菌薬の早期投与と,感受性判明後のde-escalationが重要である。de-escalationは安全で死亡率を低下させるが,集中治療領域ではその施行率は高くはない。自施設ICUに敗血症の診断で入室した76名を検討し,外科的感染症では市中感染・消化器が最多であった。初期治療には90%以上で広域抗菌薬が用いられ,外科系感染症では80%が単剤投与であった。初期治療の適正率は約95%であった。広域抗菌薬投与患者の50%でde-escalationが施行可能であった。重症患者では,原因菌不明,病態改善が得られない,重複感染巣,免疫抑制患者など,de-escalationが躊躇されるやむを得ない理由が多岐にわたっていた。集中治療領域での抗菌薬適正使用の推進には,抗菌薬適正使用支援チームや感染対策室,ICU専従薬剤師との協力のもと,重症患者においても感染症診療の基本的ロジックに即して診療を進めること,細菌の迅速診断法の普及などが望まれる。(著者抄録)

【目的】Quality Improvementモデルを用いた多職種での取り組み(QI project)による浅鎮静管理の安全性と人工呼吸期間短縮効果を検証する。【方法】大学病院ICUで48時間以上人工呼吸を要した18歳以上の患者を対象にQI project前後2年間を比較した。QI projectではプロトコルに基づき鎮静を管理した。【結果】Pre-QI period(n=83)とQI period(n=79)で、日中のRichmond Agitation-Sedation Scale(RASS)中央値が-3から-1へ浅くなった(p<0.001)。デバイス計画外抜去数は24名(28.9%)から14名(17.7%)(p=0.099)、人工呼吸器関連事象(ventilator associated events:VAE)発生数は14名(16.9%)から6名(7.6%)(p=0.095)で、患者背景で調整した人工呼吸期間は短縮した(人工呼吸器離脱ハザード比1.86、95%信頼区間1.28～2.70)。【結論】QI projectは浅鎮静管理を安全に実現し、人工呼吸期間を短縮させる可能性が示された。(著者抄録)

OBJECTIVES: Hepatectomy is used to treat several liver diseases, although perioperative mortality and postoperative complication rates remain high. Given the lack of relevant studies to date, the present study aimed to investigate potential predictive factors for postoperative complications in patients undergoing hepatectomies lasting 12 or more hours (termed "extremely long hepatectomies"). METHODS: Adult patients undergoing treatment in the intensive care unit (ICU) after extremely long hepatectomies at Fujita Health University Hospital between 2014 and 2017 were enrolled in the study. Postoperative complications were classified as "major complications" and "non-major complications" according to the Clavien-Dindo Classification grading system. We also divided our study population into "simple hepatectomy" and "non-simple hepatectomy" subgroups for further analysis. Statistical analyses were performed using the Mann-Whitney U test, chi-squared test, and multiple logistic regression analysis. RESULTS: In total, 114 patients (Major Complications Group, n=44; Non-Major Complications Group, n=70) were enrolled. In the Simple Hepatectomy Group, there were no significant variables. In the Non-Simple Hepatectomy Group, female sex (odds ratio [OR], 13.4; 95% confidence interval [CI], 1.00-1.81×102; p=0.04) and lactate levels at ICU admission (OR, 1.6; 95% CI, 0.99-2.59; p=0.05) were independent factors associated with major postoperative complications. CONCLUSIONS: In the Simple Hepatectomy Group, there were no significant variables. In the Non-Simple Hepatectomy Group, female sex and lactate levels at ICU admission of patients who underwent extremely long hepatectomies may be independent factors associated with major postoperative complications.

INTRODUCTION: Renal replacement therapy (RRT) is widely used in the treatment of septic acute kidney injury. However, little is known about how the adsorption properties of hemofilters used in RRT affect antibiotic concentration. Because a cytokine-adsorption membrane is frequently used in RRT, it is important to determine the antibiotic adsorption capacity of this membrane. OBJECTIVE: The present study aimed to investigate the antibiotic adsorption capacity of different hemofilter membranes by in vitro experiments using 2 antibacterial agents (linezolid and doripenem). METHODS: We performed experimental hemofiltration in vitro using polyacrylonitrile (AN69ST), polymethylmethacrylate (PMMA), and polysulfone (PS) hemofilters for 1,440 min. The test solution was a 1,000-mL substitution fluid containing 30 µg/mL linezolid and 120 µg/mL doripenem. We measured drug concentrations at the inlet, outlet, and filtrate ports of the hemofilters for 1,440 min and calculated the sieving coefficient (SC) and adsorption rate (Ra) of the drugs onto the hemofilters. RESULTS: The amount of linezolid adsorbed onto AN69ST, PMMA, and PS membranes was decreased relative to that in the control group at 15 min (p < 0.05). However, no SC for linezolid was obtained thereafter. The Ra of linezolid onto AN69ST, PMMA, and PS membranes was higher than that in the control group (p < 0.05). In contrast, no significant differences were observed in the concentrations and Ra values of doripenem adsorbed onto AN69ST, PMMA, and PS membranes compared with those in the control group. CONCLUSIONS: Doripenem was not adsorbed onto PMMA, PS, and AN69ST membranes. Linezolid was adsorbed onto PMMA, PS, and AN69ST membranes, but only temporarily, and this did not affect drug bioavailability.

敗血症、肺炎等で当院ICUに入室し間歇的高効率血液浄化法(SHEDD-fA)を施行中の患者の理論上のクリアスペース率から推定したバンコマイシン(VCM)の投与方法が、有効血中濃度を維持できるかについて後方視的に検討した。解析対象となった症例は6症例7施行分でありSHEDD-fA施行中に6時間毎にVCM1.0gが投与された症例を検討した結果、SHEDD-fA開始時、6時間後、12時間後のVCMの血中濃度の中央値はそれぞれ20.5μg/mL(13.9～22.6)、18.4μg/mL(17.1～22.3)、19.7μg/mL(16.4～21.4)であった。対象症例には自己腎機能が保たれている症例、血液浄化に依存している症例が含まれており、高効率血液浄化療法中のVCM投与は自己の残腎機能によらず一定の投与量で血中濃度を維持することができる可能性が示唆された。SHEDD-fAと同等の血液浄化量で施行されるHDFやSLEDDの場合でも同じことが言えると考えられる。(著者抄録)

AIM: Endotracheal intubation of critically ill patients increases the risk of aspiration pneumonia, which can be reduced by regular oral care. However, the rinsing of the residual oral contaminants after mechanical cleaning carries the risk of aspirating the residue during the intubation period. Removing the contaminants by wiping with mouth wipes could be an alternative to rinsing with water because of no additional fluid. This study tested: (i) the amount of oral bacteria during endotracheal intubation and after extubation; and (ii) the changes in the bacterial count during oral care procedures. METHODS: Thirty-five mechanically ventilated patients in the intensive care unit were enrolled. The amount of bacteria on the dorsal tongue surface was counted before and following oral care and then after the elimination of contaminants either by rinsing with water and suctioning or by wiping with mouth wipes. The oral bacterial amount was compared statistically between the intubation and extubation status and among set time points during the oral care procedure. RESULTS: The oral bacterial count was significantly decreased after extubation. During the oral care procedure, the oral bacterial amount was significantly lower after eliminating the contaminants either by rinsing or wiping, with no remarkable difference between the elimination techniques. CONCLUSIONS: The findings suggest that the oral bacterial amount is elevated during endotracheal intubation, which could increase the risk of aspiration pneumonia. The significant reduction in the bacterial count by wiping indicates that it might be a suitable alternative to rinsing for mechanically ventilated patients.

OBJECTIVES: Nasal high-flow (NHF) therapy provides continuous positive airway pressure (CPAP), flushes the anatomical dead space, and improves mucociliary clearance. CPAP is usually applied at a flow rate at or above an established threshold value with the mouth closed because it is hard to maintain it with an open mouth. We conducted a prospective study to validate our hypothesis that CPAP can be applied with the mouth open through a surgical face mask. METHODS: We inserted 12-Fr nasogastric tubes through the noses of 18 healthy individuals and fixed each tube within the pharynx to monitor the intrapharyngeal pressure. We monitored the pressure during the following two conditions: NHF oxygen with the mouth open (condition O) and NHF oxygen with the mouth open and wearing a surgical face mask (condition OM). We set the NHF rate at 40 L/min and the oxygen concentration at 21%, under all conditions. We measured the intrapharyngeal pressure five times during each inspiration and expiration, and calculated mean values. RESULTS: The mean expiratory intrapharyngeal pressure (median [interquartile range]) increased significantly from the baseline during conditions O (2.08 [1.58-4.02] cm H2O) and OM (3.35 [2.72-3.79] cm H2O). In addition, there was a significant difference in pressure between conditions O and OM (p=0.0263, Wilcoxon signed-rank test). CONCLUSIONS: In our healthy volunteers, the intrapharyngeal pressures increased during expiration with an open mouth while wearing a surgical face mask.

BACKGROUND: In 2013, the Centers for Disease Control and Prevention (CDC) issued the concept of the ventilator-associated events (VAEs) as a quality indicator (QI) in the intensive care unit (ICU). A number of studies have been conducted in the United States and other Western countries to evaluate its practicality. However, information on VAEs in non-Western countries is scarce. The purpose of this preliminary study was to illuminate the incidence and associated mortality rate of VAEs in Japan, as a first step in the effort to determine its practicality. METHODS: We conducted a multi-center, retrospective review of patient medical record using VAEs surveillance algorithm. We analyzed 785 patients with ≥2 days of mechanical ventilator (MV), admitted to the ICU at seven urban hospital in Japan. The prevalence of VAEs, including its three subtypes, and in-ICU mortality were researched. RESULTS: Forty-nine VAEs were identified, affecting 5.7% of patients requiring MV for ≥2 days and 6.4 per 1,000 MV days. Mortality in those who developed VAEs was 42.9%, significantly higher than the rest of the cohort (vs. 15.4%, P<0.001). The overall equivalent distribution of the three VAEs subtype incidences was evaluated: the incidences of VAC only, IVAC only and PVAP were 2.20, 1.90 and 2.29 per 1,000 MV days respectively (P=0.933). However, VAE etiology and mortality was facility dependent. ICUs with a large proportion of surgical patients and more severe cases tended to have increased VAE incidence, with a converse decrease in closed ICUs. CONCLUSIONS: The prevalence of VAEs appears low in Japanese ICUs. Nonetheless, mortality was substantially higher in patients who developed VAEs. Although some potential indices of VAEs are suggested to serve as QIs, additional studies to elaborate its practicality would further be required.

BACKGROUND: Antimicrobial-coated sutures have recently become well known for preventing surgical site infections (SSIs). However, the evidence and recommendations from some organizations remain controversial. Therefore, we conducted a systematic review and meta-analysis to analyze the efficacy of antimicrobial-coated sutures for preventing SSIs in digestive surgery. METHODS: We performed a systematic review of literature published from 2000 to 2017 (registered on PROSPERO, No. CRD42017076780). We included studies defined as randomized controlled trials (RCTs) and observational studies (OBSs) for the prevention of SSIs and the reduction in hospital stay length associated with digestive surgery. RESULTS: In the 10 RCTs, the incidence rates of incisional SSIs were 160/1798 (8.9%) with coated sutures and 205/1690 (12.1%) with non-coated sutures. Overall, antimicrobial-coated sutures were superior for reducing the incidence of incisional SSI (risk ratio (RR) 0.67, 95% confidence intervals (CI) 0.48-0.94, p = 0.02) in RCTs for digestive surgery with the mixed wound class and surgeries limited to a clean-contaminated wound (RR 0.66, 95% CI 0.44-0.98, p = 0.04). A superior effect of antimicrobial-coated sutures was found in 9 RCTs that involved only colorectal surgeries (RR 0.69, 95% CI 0.49-0.98, p = 0.04). The mean hospital stay length was similar with coated or uncoated sutures in 5 RCTs involving colorectal surgery (mean difference (MD) - 5.00, 95% CI 16.68-6.69, p = 0.4). CONCLUSION: Antimicrobial-coated sutures are significantly more efficacious for preventing SSIs during digestive and colorectal surgery, even when restricted to clean-contaminated wounds. However, the hospital stay length was not affected.

&lt;b&gt;&lt;i&gt;Background:&lt;/i&gt;&lt;/b&gt; Polymyxin B-immobilized fiber (PMX-F) columns are used as therapeutic interventions for septic shock. The clinical efficacy has been reported for 2-h applications, but their ability to adsorb endotoxin over longer treatments has not been fully elucidated. We hypothesized that PMX-F columns are capable of endotoxin removal for more than 2 h. &lt;b&gt;&lt;i&gt;Method:&lt;/i&gt;&lt;/b&gt; We designed closed circuits incorporating either a PMX-F column with an 8.5-mL priming volume (PMX-01R) or a sham-control column, and used inactivated fetal bovine serum as the circulating perfusate. Endotoxin was continuously injected at a fixed rate for 24 h, and perfusate endotoxin concentrations were measured at fixed time points. PMX-01R endotoxin adsorption was calculated from the difference in the endotoxin concentrations. &lt;b&gt;&lt;i&gt;Results:&lt;/i&gt;&lt;/b&gt; PMX-01R endotoxin adsorption increased continuously in a virtually linear manner. &lt;b&gt;&lt;i&gt;Conclusions:&lt;/i&gt;&lt;/b&gt; The PMX-01R column showed sustained endotoxin adsorption for at least 24 h. This indicated that PMX-F columns would be capable of clinical endotoxin removal for 24 h.

敗血症に対する治療は感染巣に対する根治療法のみならず、炎症の増幅・転移の制御のための支持療法も重要である。現在、敗血症に対するエンドトキシン吸着療法(PMX-DHP)の有効性に関して、無作為化比較試験や傾向スコア分析の結果は一定の傾向を示さず、十分なエビデンスは得られていない。しかし、重症患者では生命予後を改善する可能性が示唆される。エンドトキシン吸着カラムはメディエータカスケードの上流に位置するエンドトキシンを吸着する他に、内因性カンナビノイドおよび活性化好中球・単球の吸着や、単球の表面抗原の変化、尿細管細胞におけるアポトーシスの抑制など、さまざまな作用機序を持つ。また、PMX-DHPは2時間以降もエンドトキシン吸着能、循環動態および肺酸素化能改善効果が持続することが報告されている。対象患者や施行時間などを適切に設定することで、PMX-DHPは重症の敗血症患者の生命予後改善効果を示しえると考える。(著者抄録)

腫瘍崩壊症候群(Tumor Lysis Syndrome:TLS)を発症していたが、間歇的高効率血液浄化療法(Sustained high-efficiency daily diafiltration using a mediator adsorbing membrane:SHEDD-fA)を併用し安全に抗腫瘍療法を行えたBurkittリンパ腫の症例を経験した。【症例】60代男性。肺炎とDICを併発しICUに入室。代謝性アシドーシスと高K血症、高尿酸血症、無尿を認めた。ただちにSHEDD-fAを開始し、徐々に全身状態が改善。SHEDD-fAを継続しつつ、第2、3ICU病日にプレドニゾロン1mg/kg/日を投与し、TLSの悪化を認めないことを確認し、CHOP(Cyclophosphamide:シクロフォスファミド、Hydroxydaunorubicin:ダウノルビシン、Vincristine:ビンクリスチン、Predonisolone:プレドニゾロン)療法を開始。TLSによる有害事象は認めなかった。危機的なTLSを伴う症例の抗腫瘍療法であっても、SHEDD-fAにより安全に施行できる可能性が示唆された。(著者抄録)

Abstract Polymyxin B‐immobilized fiber column direct hemoperfusion (PMX‐DHP) therapy is widely used for the treatment of severe sepsis and septic shock, and is generally performed for 2 h. Although previous studies demonstrated the efficacy of PMX‐DHP therapy, it currently remains unclear whether its optimal duration is 2 h. This retrospective study analyzed 37 patients with septic shock who showed a poor clinical response to 2 h of PMX‐DHP, and underwent a longer duration of this therapy. The mean duration of PMX‐DHP therapy was 15.8 ± 7.9 h, and none of the patients developed adverse events, which enabled the therapy to be performed safely. The pressure catecholamine index [CAIP = catecholamine index/mean arterial pressure; catecholamine index = dopamine + dobutamine + (adrenaline + noradrenaline) × 100 μg/kg per min], as an indicator of hemodynamics, improved significantly in the survival group in the period between the start and 24 h after the end of PMX‐DHP therapy (P &lt; 0.01), and between 2 h after the start of and the end of this therapy (P &lt; 0.05). In addition, the P/F ratio improved significantly in the group of surviving patients with acute respiratory distress syndrome (ARDS) in the period between the start and 24 h after the end of PMX‐DHP therapy (P &lt; 0.01), and between 2 h after the start of and the end of this therapy (P &lt; 0.01). These results suggest that a longer duration of PMX‐DHP therapy can be expected to improve the hemodynamics and pulmonary oxygenation capacity of patients with severe sepsis/septic shock. Strict prospective studies are needed in the future.

深在性真菌症は感染兆候に乏しい一方、重症患者においては、一旦発症すると重症化しやすく生命予後に影響を与える。このため、集中治療領域では深在性真菌症の適切な治療が重要課題となっている。今後、抗真菌薬の適正使用を推進していくために、今回、当大学病院集中治療部の真菌分離状況および抗真菌薬感受性を後方視的に検討した。【対象】2009年6月から2011年5月の間に7日間以上ICUに入室していた286症例から検出した真菌164株を対象とした。【結果】164株中159株がCandida属で、その2/3をC.albicansが占めた。non-albicans Candida属の72.7%はC.glabrataであった。感受性検査を実施したC.albicans 13株中2株でアゾール系薬に耐性であり、C.glabrata 3株も高いアゾール系薬耐性率を示した。【考察】集中治療領域における真菌感染ではCandidaが重要である。Candida属ではアゾール系抗真菌薬への耐性化傾向が認められ、経験的治療の選択薬に注意が必要と考えられた。(著者抄録)

集中治療を受けている重症患者では、感染防御能の低下、抗菌薬療法に伴う菌交代現象などにより、深在性真菌症、特にカテーテル感染に起因するカンジダ血症のリスクは高い。しかし、深在性真菌症は感染初期の徴候に乏しく、治療開始の遅れは予後不良につながるため、確定診断を待たずに早期に治療を開始せざるを得ないことも多い。そこで、耐性菌を増加させず、治療成績を向上させるには一定の基準の適用が望まれる。真菌症フォーラムでは、カンジダ感染症の予後改善を目的として、「ACTIONsプロジェクト」を開始し、深在性真菌症の診断・治療の啓発を行っている。2011年からは、「ACTIONs bundle」が示され、リスク因子の評価および早期診断・早期治療、治療開始後の適正治療を呼びかけている。「ACTIONs bundle」の遵守は、カンジダ血症の予後の改善に有用であると考えられ、bundleの遵守率向上を目指すとともに、各施設の実情に合わせたマニュアル作りが望まれる。(著者抄録)

PMX-DHPは2時間を原則として施行されている.われわれは2時間施行で効果の不十分な症例の救命を目的として,安全性に留意しながらPMX-DHPを長時間施行を行ってきた.PMX-DHPを長時間施行した36例の重症度はAPACH II score 28.3±8.1,SOFA score 11.8±3.0であった.1施行あたりの平均施行時間は18.8時間,28日後生存率は66.7%であった.循環動態はPMX-DHP施行2時間で改善したが,重症例では改善が不十分であった.これらの症例においてもPMX-DHPを長時間施行することによって循環動態は改善した.肺酸素化能の改善は2時間後から終了時にのみ認められ,ARDSを離脱するまでPMX-DHPを継続した症例は全例生存した.敗血症患者は病態も治療に対する反応も様々であるため,PMX-DHPは全身のサポート療法として安全の許す限り患者の状態に応じて施行するべきであると考えられた(著者抄録)

腹壁瘢痕ヘルニアの手術の1ヵ月後,B型劇症肝炎で死亡した.死因は,手術前の輸血によると思われる急性肝炎の発症時期に手術侵襲が加わったこと,薬剤性肝障害の合併,アルコール性肝障害の存在,非A非B肝炎との重複感染の可能性が考えられる