156 日本温泉気候物理医学会雑誌第 80 巻第 3 号 (2017) 歳 ) を対象とした. 下顎硬直の有る 7 例は対象に含めた. 併存疾患は 23 例に認め, 高血圧を含む心疾患 12 例, 脳梗塞などの中枢神経系疾患 9 例, 糖尿病 4 例, 悪性疾患 3 例, 認知症 2 例, 透析中の
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1 日本温泉気候物理医学会雑誌第 80 巻第 3 号 (2017) 155 浴槽内溺死の赤血球に及ぼす影響 山本俊郎 抄録 背景と目的 浴槽内溺水では気管内に侵入した水が肺胞内から毛細血管へ移行して, 低ナトリウム血症と低クロール血症となることが知られている. そこで, 浴槽内心肺停止 (cardiopulmonary arrest: CPA) の病態が赤血球に及ぼす影響を検討した. 対象と方法 2007 年から 2009 年までの 3 年間に浴槽内に水没して本院救命救急センターに搬送された CPA39 例 ( 年齢 :8 ~ 95 歳, 中央値 78 歳 ) を対象とした. 自己心拍は 6 例で再開したが, 全例死亡を確認した. 以下の項目を検討した. 搬入時の血液 生化学検査から, 電解質 (Na,Cl), ヘマトクリット (hematocrit: Ht)/ ヘモグロビン (hemoglobin: Hb) 値, 平均赤血球容積 (mean corpuscular volume: MCV) と平均赤血球ヘモグロビン量 (mean corpuscular hemoglobin: MCH), および浴槽内 CPA2 例の MCV と MCH の経時的変化, 即ち自己心拍再開症例と外来通院中であった症例と浴槽内溺水とは別の水中毒症 2 例の MCV の経時的変化. 結果 血清 Na( 正常値 :135 ~ 148 meq/l) では 18 例が正常下限を下回り,21 例が正常であった. 血清 Cl( 正常値 :98 ~ 108 meq/l) では 22 例が正常下限を下回り,17 例が正常であった.Ht/Hb 値が正常 (2.78 ~ 3.13) であったのは 3 例のみで,36 例は正常上限を上回った.MCH( 正常値 :27.8 ~ 33.5 pg) では 3 例が正常下限を下回り,1 例が正常上限を上回り,35 例が正常であった.MCV( 正常値 :85.3 ~ fl) では 23 例が正常で,16 例が正常上限を上回った. 自己心拍再開例では,MCV は当日の 97.9 fl から第 1 病日には 92.4 fl へと低下し, 以後 92.0 fl 前後で推移した. 外来通院中であった症例では MCV は発症 37 日,12 日前の fl 前後から当日の fl に増加した. 水中毒症例では, MCV は第 1,2 病日には変化が無く, 第 4 病日以降に初日の 87.0 fl から 91.4 fl に,89.1 fl から 96.5 fl 前後にそれぞれ増加した. 結語 水中毒症とは異なり, 浴槽内溺水では電解質と同様に Ht は減少すると予想したが, 風呂水の血中への移行による血漿浸透圧の低下のために赤血球は膨化し, その膨張率が希釈率を上回ったために Ht は低下しなかったものと思われた. キーワード : 浴槽内溺水, 赤血球, 平均赤血球容積 (MCV), 平均赤血球ヘモグロビン量 (MCH), 浸透圧 I はじめに本邦における溺死の特徴は 4 歳以下の小児と高齢者の二峰性のピークが見られることにある 1). 高齢者の溺死では入浴中が多い. また, 浴槽内の溺死は淡水を気道内に吸引するために, 電解質は希釈されて低ナトリウム血症, 低クロール血症となる 2). そこで,Ht も同様な変化をとるどうか調べるために浴槽内溺死の赤血球に及ぼ す影響を検討した. II 対象と方法 2007 年から 2009 年の 3 年間に浴槽内に水没して発見され, 本院救命救急センターに搬送された心肺停止 (cardiopulmonary arrest: CPA) 症例 45 例中複数の死体徴候のあった 5 例と血液検査未実施の 1 例を除いた 39 例 ( 男性 16 例, 女性 23 例 :8 ~ 95 歳, 中央値 78 ( 投稿受付日 :2017 年 5 月 30 日, 掲載決定日 :2017 年 8 月 24 日 ) 独立行政法人国立病院機構横浜医療センター医療管理 神奈川県横浜市戸塚区原宿 TEL: ,FAX:
2 156 日本温泉気候物理医学会雑誌第 80 巻第 3 号 (2017) 歳 ) を対象とした. 下顎硬直の有る 7 例は対象に含めた. 併存疾患は 23 例に認め, 高血圧を含む心疾患 12 例, 脳梗塞などの中枢神経系疾患 9 例, 糖尿病 4 例, 悪性疾患 3 例, 認知症 2 例, 透析中の腎不全 1 例であった. 自己心拍の再開した 6 例を含め全例が死亡を確認された. 筋酵素 CK と CK-MB が正常範囲を上回り, かつ CK-MB/CK > 10% を AMI の診断基準とすると,CPA の原因疾患として AMI 3 例, 縦隔の拡大と左血胸から胸部大動脈損傷 1 例, 自己心拍再開後の ECG より完全房室ブロック 1 例が診断され,1 例に 25 mg/dl の低血糖を認めた. これらを対象に以下の項目を検討した. 尚, 本研究は院内倫理委員会の承認を受けている ( 登録番号 29-9). 1. 血液 生化学検査 1) 電解質 (Na,Cl) 2) ヘマトクリット (hematocrit: Ht)/ ヘモグロビン (hemoglobin: Hb) 値 Ht は赤血球数の影響を強く受ける為に, 赤血球数の影響を補正した Ht/Hb 値を用いた.Ht/Hb 値は平均赤血球ヘモグロビン濃度 (mean corpuscular hemoglobin concentration: MCHC) の逆数として求められるので, MCHC の正常値 32.0 ~ 36.0% から算出した.Ht/Hb の正常値は 2.78 ~ 3.13 となった. 3) 平均赤血球容積 (mean corpuscular volume: MCV) と平均赤血球ヘモグロビン量 (mean corpuscular hemoglobin: MCH) 2. 浴槽内 CPA2 例の MCV と MCH の経時的変化自己心拍が再開した症例と外来に通院中であった症例の MCV と MCH を治療開始時とその前後で比較した. 3. 水中毒症の 2 例の MCV の経時的変化浴槽内 CPA 症例とは別に精神障害が有り, 過量水分摂取に拠り 120 meq/l 以下の低ナトリウム血症をきたし精神科に入院した 2 症例の MCV の変化を経時的に比較した. III 結果 1. 電解質 (Na,Cl) について血清 Na では 135 ~ 148 meq/l の正常上限を超えた症例は無く,18 例が正常下限を下回った. 正常値の 21 例では 7 例が 140 meq/l を超え 144 meq/l が最高値であった. 血清 Cl では 98 ~ 108 meq/l の正常範囲にあったのは 17 例で,22 例は正常下限を下回った (Fig. 1). 2.Ht/Hb 値について Ht/Hb 値が正常であったのは 3 例のみで,36 例は正常上限を上回り, 正常下限を下回ったものは無かった (Fig. 2).Hb 量とは関係なく,Ht/Hb 値は低下しなかった. 3.MCV と MCH について MCH の正常値は 27.8 ~ 33.5 pg で正常上限を 1 例が上回り,3 例が正常下限を下回り,35 例は正常範囲に 在った. また,MCV では,85.3 ~ fl の正常値を 取ったものは 23 例で,16 例は正常上限を超えていた (Fig. 3). 4. 浴槽内 CPA2 症例の MCV と MCH の経時的変化 について 自己心拍が再開した症例 1 の MCV と MCH の推移を みると,MCH は当日から第 6 病日まで 30.0 pg 前後で 推移したが,MCV は当日の 97.9 fl から第 1 病日の 92.4 fl に低下し, その後は 92.0 fl 前後で推移した (Fig. 4A). 同様に, 外来通院中であった症例 2 では,37 日前から 当日まで MCH は 33.0 から 34.2 pg と変動は小さかった が,MCV は fl 前後から CPA 当日の fl へと大 きく変化した (Fig. 4B). 5. 水中毒症の 2 例の MCV の経時的変化について 症例 1 では, 入院当日には血清 Na は meq/l, 血清 Cl は 80.0 meq/l と低ナトリウム血症, 低クロー ル血症を認め,MCV は 87.0 fl であった. 電解質は第 1, 第 2 病日と改善したが,MCV は依然として 87.5 fl 前後 に留まったが, 第 4 病日には 91.4 fl へと変化した (Fig. Fig. 1 Relationship between serum Na and Cl levels. normal ranges in both serum sodium and chloride, respectively. Normal ranges of both serum sodium and chloride are meq/l and meq/l, respectively. Fig. 2 Relationship between HT/Hb ratio and Hb level. normal range in Ht/Hb ratio.
3 山本俊郎 : 浴槽内溺死の赤血球に及ぼす影響 157 5A). 同様に, 症例 2 でも, 入院当日に認められた低ナ トリウム血症 (105.5 meq/l) と低クロール血症 (72.0 meq/l) は第 1 病日には改善傾向にあったが, MCV は当日の 89.1 fl から殆ど変化せずに, 第 5, 第 6 Fig. 3 Relationship between MCV and MCH levels. normal ranges in both MCV and MCH, respectively. MCV mean corpuscular volume, MCH mean corpuscular hemoglobin. 病日に 96.5 fl 前後に増加した (Fig. 5B). IV 考察身体の水没に因る窒息のうち, 気道内に吸引したものが海水の場合には海水溺水, 淡水の場合は淡水溺水と言われている. 淡水溺水では, 肺胞内に吸引された水がサーファクタントの表面張力特性を変化させる結果, 肺胞が虚脱し, 肺胞内の水は浸透圧勾配に逆らって速やかに血管内に吸収されるため 3), 心肺停止後も水没し続ける溺死では時間経過と共に肺胞内に大量の水が移行し血漿量 ( 溶媒 ) を増加させ,Na や Cl の電解質量 ( 溶質 ) は変わらないことから低ナトリウム血症や低クロール血症になったと考えられる 2). 同様に, 赤血球数に変化は無いので Ht は低下し Ht/Hb 値も低下すると予想したが,Ht/Hb 値は正常値を上回るものが 92.3% と大多数を占めた. 水中毒における横紋筋融解症の発生機序の 1 つに細胞外浸透圧の低下により細胞が膨張し, 細胞膜が脆弱化して細胞内酵素が逸脱するという説がある 4). 浴 Fig. 4A Change of both MCV and MCH levels in drowning case 1. Fig. 5A Change of both MCV and serum Na and Cl levels in water intoxication case 1. Fig. 4B Change of both MCV and MCH Levels in drowning case 2. MCV mean corpuscular volume MCH mean corpuscular hemoglobin. Fig. 5B Change of both MCV and serum Na and Cl levels in water intoxication case 2. MCV mean corpuscular volume.
4 158 日本温泉気候物理医学会雑誌第 80 巻第 3 号 (2017) 槽内 CPA 症例の経時的変化から,MCV は溺死当日に増大し, 第 1 病日から低下し安定したことから, 主に Na と Cl イオン濃度で決まる血漿浸透圧が低下し, その結果赤血球は膨化し, その膨張率が血漿量の増加による Ht の減少率を上回ったことが原因と思われた. 検索した医学中央雑誌と MEDLINE ではこの様な MCV の変化についての報告はなかった. 大量の水分摂取が原因で低ナトリウム血症と低クロール血症を引き起こす水中毒症の MCV の変化と比較したが, その変化は浴槽内 CPA とは明らかに異なった. 水中毒症で MCV を維持する生体反応の作用機序は不明だが, 浴槽内 CPA ではそれらの機序が作用せず, 単に浸透圧に基づく変化だけが MCV に生じたものと思われた. この MCV の変化は浴槽内溺水の病態を良く説明し得るが, 発症時 1 回の血液検査結果だけでは MCV の増加を断定できないことが問題となる. 外来に通院中であった浴槽内 CPA 症例の様に最近の平時の MCV と発症時のものが比較できると, 赤血球の膨張から細胞外浸透圧の低下した病態を指摘することが可能になる. V 結語浴槽内溺水では, 希釈により低下した血漿浸透圧が赤血球を膨張させ,MCV を増加させた. 血漿量の増加による Ht の減少が赤血球の膨化により相殺されるために, Ht は減少しないことが明らかになった. 利益相反本論文には利益相反に該当する事項はありません. 引用文献 1) 辻岡三南子 : 溺水 溺死. 慶応保健研究 2007; 18(1): )Modell JH, Davis JH: Electrolyte change in human drowning victims. Anesthesiology 1969; 30(4): ) 今泉均, 升田好樹 : 溺水による急性肺障害. 医学のあゆみ ( 別冊 : 呼吸器疾患 Ver. 5)2007; )Rizzieri DA: Rhabdomyolysis after correction of hyponatremia due to psychogenic polydipsia. Mayo Clin Proc 1995; 70:
5 山本俊郎 : 浴槽内溺死の赤血球に及ぼす影響 159 The Effect of Drowning in a Bathtub on Erythrocytes in Victims Toshiro YAMAMOTO Abstract Objective: The aim of the present study was to investigate the effect of bathtub drowning on erythrocytes in victims. Methods: Thirty-nine consecutive victims with CPA were included in the present study and consisted of 16 males and 23 females, 8-95 years of age, median 78 years old. Data on the arrival examination were analyzed, which consisted of serum sodium (Na) and chloride (Cl), hematocrit (Ht)/hemoglobin (Hb) ratio, mean corpuscular volume (MCV) and mean corpuscular hemoglobin (MCH). In addition, the changes of MCV level in accordance with treatment in two bathtub drowning victims, one who was resuscitated and the other who had been under treatment in our hospital, were compared with those in two water intoxication patients. Results: Of the 39 victims, 18 showed serum Na levels to be lower than normal range (NR) but no victim showed one higher than NR. In serum Cl level, 22 victims showed levels below NR but no one showed a level above NR. As to the value for the Ht/Hb ratio, the ratios were within NR in only three victims and were above NR in the rest. In MCH, three victims showed levels below NR and one victim showed a level above NR. In MCV, 16 victims showed levels above NR but no one showed a level below NR. The comparison of MCV between drowning victims and water intoxication patients pointed out a difference in the effect on treatment: in cases of drowning, MCV increased only on the day of the event and returned to baseline the next day, whereas in cases of water intoxication, MCV remained unchanged for a few days after treatment and then increased. Conclusion: It is well known that freshwater drowning induces both hyponatremia and hypochloremia, which are caused by water transferred from alveoli to blood vessels. The increased MCV in bathtub drowning victims is induced by the expansion of erythrocytes through lower osmotic pressure, which exceeds the decreased change in hematocrit due to hemodilution, although the mechanism of the change in MCV in water intoxication cases is not identified. Key words: drowning in bathtub, erythrocyte, mean corpuscular volume, mean corpuscular hemoglobin, osmotic pressure Department of Medical Management, National Hospital Organization Yokohama Medical Center Harajuku, Totsuka-ku, Yokohama, Kanagawa , Japan TEL: , FAX:
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Title 泌尿器科領域に於ける17-Ketosteroidの研究 17-Ketosteroidの臨床的研究 第 III 篇 : 尿 Author(s) 卜部, 敏入 Citation 泌尿器科紀要 (1958), 4(1): 3-31 Issue Date URL
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