Carnitine Deficiency in Intensive Care Unit Patients Undergoing Continuous Renal Replacement Therapy: A Single-center Retrospective Study.

Introduction: Carnitine deficiency is common in patients undergoing intermittent hemodialysis and may also occur during continuous renal replacement therapy (CRRT). We evaluated intensive care unit (ICU) patients undergoing CRRT for carnitine deficiency and its associated risk factors. Methods: This was a single-center, retrospective, observational study performed between June 2019 and March 2020. The primary outcome was the incidence of carnitine deficiency in ICU patients undergoing CRRT. Results: Eighty-eight patients underwent 103 blood carnitine concentration measurements. The median age was 68 years (interquartile range: 55-80), Acute Physiology and Chronic Health Evaluation II score was 28 (24-33), Sequential Organ Failure score was 8.5 (5-11), Nutrition Risk in Critically Ill score was 6 (5-7), and blood carnitine concentration was 66.1 µmol/L (51.8-83.3). In total, 34 of 88 patients (38.6%) were found to have carnitine deficiency; however, there was no significant difference in the proportions of patients with carnitine deficiency characterized by disease. CRRT was performed in 44 (50%) patients, and the median blood total carnitine concentration measured after 24 h of CRRT without changing the settings was 65.5 µmol/L (48.6-83.3). The purification volume of CRRT and blood carnitine concentration were negatively correlated (R = -0.63; P = 0.02). Conclusions: Carnitine deficiency is seen in patients receiving CRRT and may increase in incidence as the purification volume increases, requiring regular monitoring.

Distal radial approach for arterial pressure monitoring with a long catheter provides safe and stable monitoring in the intensive care unit: A single-center retrospective study.

BACKGROUND: To compare the distal radial artery approach (DRA) with a longer catheter to DRA with a shorter catheter in arterial catheter (AC) placement in the intensive care unit (ICU). METHODS: This was a single-center retrospective cohort study of DRA with a long catheter (60 mm) for arterial catheterization in the ICU. DRA with a short catheter (25-30 mm) was used in the control group, and the groups were compared using multivariate regression analysis. The primary study endpoint was the incidence of unplanned AC removal. The secondary endpoint was the incidence of other inappropriate events, namely loss of arterial pressure waveforms, bleeding, catheter-related infection, pressure ulcer, and other complications associated with the AC. RESULTS: In this study, the DRA with a long catheter was used in 50 patients. No unplanned AC removals or other inappropriate events occurred, and there were no complications associated with the DRA. The DRA procedural success rate was 100%. There was no significant difference in hemostasis times between the groups. Loss of arterial waveforms was an early predictor of unplanned AC removal. CONCLUSIONS: The DRA with a long catheter provided stable monitoring and was associated with a low unplanned removal rate. This method has the advantages of fewer complications and shorter hemostasis time compared with the DRA with a short catheter, and may become a new AC option in the ICU.

Multiple trauma complicated by traumatic vertebral artery injury without cervical vertebral injury: A case report.

Background: Blunt traumatic vertebral artery injury is commonly associated with head and cervical spinal trauma. However, those associated with chest or upper extremity injuries without cervical spine-related trauma are rare. Case presentation: A 94-year-old woman was injured in a motor vehicle crash. She was diagnosed with traumatic subarachnoid hemorrhage, bilateral subdural hematomas, right vertebral artery injury, and right clavicle fracture. No cervical spine injuries were observed. It was possible that the fracture fragment of the right clavicle may have directly injured the right vertebral artery. Coil embolization was performed for the vertebral artery injury. The patient had a good postoperative course and was transferred to the hospital for rehabilitation on day 65. Conclusion: Regarding the high-risk injury mechanism, blunt traumatic vertebral artery injuries in the V1-2 segment may occur in cases with clavicle fractures.

Evaluation of a new insertion site for arterial pressure line in intensive care unit management: a prospective study.

The arterial pressure line (A-line) is primarily inserted through the radial artery. However, accidental removal due to joint movement can be problematic in the intensive care unit (ICU). This study aimed to evaluate the safety and effectiveness of A-line insertion in the ICU through the distal radial approach (DRA), which is used in cardiac catheterization. This single-center, prospective, comparative study included 200 patients (≥ 20 years) who were brought to our hospital for emergency care and required A-line insertion. Patients were quasi-randomized to the traditional radial approach (TRA) or DRA. Data were recorded at the time of A-line insertion, administration, and removal. We evaluated the vessel diameter, number of punctures, success of the procedure, presence of complications, such as infection during management, and time taken for hemostasis after catheter removal. The primary endpoint was the accidental removal rate. Due to incomplete information, data were collected for 193 patients (96 TRA and 97 DRA). Successful procedures were observed in 95 of the 96 patients with TRA and 94 of the 97 patients with DRA. Guidewire use during insertion was significantly more common in the DRA group (P < 0.01) and post-puncture splint fixation was significantly more common in the TRA group (P < 0.01). Accidental removal, the primary endpoint, was observed in 10 patients with TRAs and 11 patients with DRAs, with no significant difference between the two groups (P > 0.99). DRA is as safe and effective as the TRA, suggesting that it is useful as a new A-line insertion site.

Hybrid surgery for blunt aortic injury with rupture: a case report.

BACKGROUND: Blunt thoracic aortic injury is one of the most lethal traumatic injuries. Ruptured cases often result in cardiac arrest before arrival at the hospital, and survival is rare. CASE PRESENTATION: A female patient in her 30 s was struck by an automobile while she was walking across an intersection. She was in a state of shock when emergency services arrived and was in cardiac arrest shortly after arriving at the hospital. A left anterolateral thoracotomy revealed a massive hemothorax secondary to thoracic aortic rupture. In addition, the patient had multiple traumas, including maxillary, pelvic, and lumbar burst fractures. We attempted to directly suture the aortic lesion; however, the increasing blood pressure caused the suture to break. We used a thoracic stent graft while ensuring permissive hypotension. Her postoperative prognosis was positive, and she was transferred to another hospital 85 days later. CONCLUSIONS: We successfully performed a hybrid surgery combining thoracotomy and endovascular repair for this emergency case of blunt thoracic aortic injury with rupture.

Safety of arterial catheterization using the distal radial approach in intensive care unit management: A pilot study.

BACKGROUND: Arterial catheter (A-line) is essential for managing severely ill patients, and the radial artery is the most common insertion site in the intensive care unit (ICU). However, many accidental removals occur because the insertion site of A-line in the traditional radial approach (TRA) overlaps with the joint flexion. Recent reports have shown no significant difference in the complication rates between coronarography using the distal radial approach (DRA) and that using TRA. However, to date, no report has examined accidental removals of DRA in the ICU. This study aimed to retrospectively evaluate the safety of the DRA A-line in ICU management. METHODS: This retrospective, descriptive, and observational study enrolled patients who underwent A-line insertion using the DRA at the authors' facility, which is a university hospital with approximately 1100 beds, from January 1, 2019 to August 31, 2019. The participants' clinical data were extracted from their medical records. The primary outcome was the number of accidental removals. RESULTS: The study included 20 patients with a median age of 70 (interquartile range (IQR): 58.5-77) years: 10 patients with traumas, 6 with cerebral hemorrhages, 2 with gastrointestinal perforations, and 2 with other diagnoses. The number of punctures was 1 in 15 patients, 2 in 4 patients, and 3 in 1 patient. Only 1 patient required ultrasound guidance, whereas 12 patients required the use of guidewires. The median duration after insertion was 3 (IQR 2.5-5.5) days. Accidental removal was noted in only one patient. No other complications were observed during the period from insertion to removal. CONCLUSIONS: DRA may be a safe option for insertion of a new A-line in the ICU.

Efficacy of median sacral artery embolization for treating severe pelvic fractures: a retrospective study.

OBJECTIVE: Transcatheter arterial embolization (TAE) of bilateral internal iliac arteries (IIAs) in patients with a hemodynamically unstable pelvic fracture is associated with a low mortality rate. The persistence of unstable hemodynamics after IIA embolization indicates the involvement of other arteries, such as the median sacral artery (MSA). This study aimed to evaluate the efficacy of MSA embolization. METHODS: In this single-center, retrospective, observational study, medical records of patients who underwent MSA angiography or embolization for pelvic fractures (n = 21) between January 2007 and August 2019 were reviewed. The percentage of patients achieving hemodynamic stabilization by MSA embolization was calculated. RESULTS: Fifteen patients underwent MSA embolization, and the remaining six underwent MSA angiography. The shock index value was significantly higher after MSA embolization than that before MSA embolization in hemodynamically unstable patients who underwent this procedure. The success rate of MSA selection was 100%. One patient presented with urinary retention because of bladder and rectal disorders after MSA embolization. The 30-day survival rate was 85.7%. CONCLUSIONS: Severe pelvic fractures, such as a Dennis Zone III fracture and suicidal jumper's fracture due to trauma from a fall, may require MSA embolization.

Advanced do-not-attempt-resuscitation directives and emergency medical services for out-of-hospital cardiopulmonary arrest patients in Japan: a pilot study.

AIMS: We investigated how do-not-attempt-resuscitation (DNAR) orders are currently used, and we examined the emergency medical team responses for out-of-hospital cardiac arrest (OHCA) cases in Japan. METHODS: The sample for this prospective study comprised all OHCA cases attended to by the Sagamihara Municipal Fire Department emergency medical services between May 30, 2019 and February 15, 2020. Data were recorded by the responding emergency medical team. RESULTS: There were 396 OHCA cases. The mean age was 75 ± 18 years, and individuals aged 65 years or older accounted for 80.6%. Approximately 70% of the patients had an underlying disease. A DNAR order was available in only 45 (11.4%) of the cases, of which 12 (26.7%) were written, 27 (60%) were verbally confirmed, and six (13.3%) were confirmed in some other way or both. The home physician was present and able to confirm the patient's death in only one of the DNAR cases. In 43 (95.6%) of the cases, the emergency medical team carried out cardiopulmonary resuscitation despite a DNAR order; of them, a total of 17 (37.8%) patients were transported to a tertiary emergency hospital. CONCLUSIONS: Our analyses indicate the under-utilization of DNAR advance directives and advance care planning (which are important for better end-of-life care) in Japan. Currently, an emergency medical team could be required to attempt resuscitation against an individuals' clear DNAR order. In the future, legal arrangements regarding the handling of DNAR directives on site may be required to respect patients' wishes.

Diagnosis of skin and soft tissue infections using near-infrared spectroscopy.

AIM: Skin and soft tissue infections are classified into cellulitis and necrotizing fasciitis, which are difficult to distinguish. Necrotizing fasciitis has a poor prognosis and requires immediate intensive care. The diagnostic gold standard is to incise the lesion to determine whether necrosis has reached the fascia. We aimed to show that these infections can be differentiated using near-infrared spectroscopy. METHODS: We describe two cases in an observational study about the utility of near-infrared spectroscopy. Case 1 involved a 77-year-old man with a chief complaint of pain, redness, and swelling in the right lower leg for 1 week. Computed tomography of his legs showed no gas formation. Case 2 involved an 82-year-old man. He visited another hospital because of pain, redness, and swelling in the right thigh. Based on the X-ray examination, necrotizing fasciitis was suspected, and he was transferred to our hospital. RESULTS: In Case 1, the regional oxygen saturation value was lower on the lesion side (41%) than on the healthy side (55%). We confirmed the depth of invasion by incision, leading to a diagnosis of necrotizing fasciitis. In Case 2, the thigh's regional oxygen saturation was higher on the affected side (76%) than on the healthy side (61%). An incision was made for diagnosis, but the fascia was not necrotized. Thus, we diagnosed cellulitis and provided conservative treatment using antibiotics. CONCLUSION: Near-infrared spectroscopy can be utilized to measure tissue blood flow, and it could be useful as a non-invasive diagnostic tool for skin and soft tissue infections.

Life-threatening traumatic epistaxis due to massive bleeding into the maxillary sinus.

A 77-year-old woman with no medical history fell, and her face was strongly impacted on the ground. On arrival at our hospital, her initial vital signs were stable. She underwent an endoscopy to stop the bleeding. However, identification of the origin of the bleeding failed, and her injury resulted in hemorrhagic shock during the procedure. Head to face contrast computed tomography showed extravasation of contrast media into the maxillary sinus. Transcatheter arterial embolization was performed for the ruptured infraorbital artery branching from the maxillary artery. She recovered from the "shock" state after transcatheter arterial embolization and was admitted to the intensive care unit. There were no complications associated with transcatheter arterial embolization during hospitalization. For this case, early recognition of an active hemorrhage was challenging because the hemorrhage was pooled in the sinuses. Although epistaxis is sometimes fatal, transcatheter arterial embolization can be the first choice for the treatment of life-threatening epistaxis, owing to its safety and effectiveness.

Pancreatitis in a Patient with Severe Coronavirus Disease Pneumonia Treated with Veno-venous Extracorporeal Membrane Oxygenation.

Severe coronavirus disease (COVID-19) can induce serious complications, including acute respiratory distress syndrome, septic shock, and acute kidney injury. However, few reports have associated COVID-19 with pancreatitis. We herein report the case of a 55-year-old patient who developed acute pancreatitis associated with severe COVID-19 pneumonia and was successfully treated with veno-venous extracorporeal membrane oxygenation (ECMO). Elevated pancreatic enzymes levels and computed tomography findings led to the diagnosis of acute pancreatitis due to COVID-19. Although we found that severe COVID-19 pneumonia can lead to pancreatitis, the underlying pathophysiology remains unknown.

Intravascular treatment for ruptured facial artery aneurysm via percutaneous cardiopulmonary support device: A case report.

Even in cases of cardiac arrest caused by hemorrhagic shock, when reliable control of the bleeding source is possible, ECPR may be an effective treatment option if anticoagulant therapy is well-managed and is withdrawn early.