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A 71-year-old man had disordered consciousness whose Glasgow Coma Scale was E4V1M5. His blood pressure was high, but there was no abnormality in the cerebrospinal fluid examination. The MRI finding reveals a high-intensity area at the pons without the blood flow interruption. Thus, he has diagnosed with brainstem PRES.
RESUMO
Resuscitative endovascular balloon occlusion of the aorta (REBOA) is performed to treat hemorrhagic shock, whose cause is located below the diaphragm. However, its use in patients with gastrointestinal hemorrhage is relatively rare. The 45-year-old man with a history of dilated cardiomyopathy had experienced epigastric discomfort and had an episode of presyncope. On his presentation, the patient's blood pressure was 82/64 mmHg, heart rate 140/min, and consciousness level GCS E4V5M6. Hemodynamics stabilized rapidly with a transfusion that was administered on an emergency basis, and a blood sample only showed mild anemia (Hb, 11.5 g/dL). The patient was admitted to investigating the presyncope episode, and the planned endoscopy was scheduled the following day. The patient had an episode of presyncope soon and was found in hemorrhagic shock resulting from a duodenal ulcer rapidly deteriorated to cardiac arrest. Although a spontaneous heartbeat was restored with cardiopulmonary resuscitation, the patient's hemodynamics were unstable despite the emergency blood transfusion administered by pumping. Consequently, a REBOA device was placed, resuscitation was continued, and hemostasis was achieved by vascular embolization for the gastroduodenal artery. The patient was subsequently discharged without complications. However, there is no established evidence regarding the REBOA use in upper gastrointestinal hemorrhage, and the investigations that have been reported have been limited. Further, one recent research suggests that appropriate patient selection and early use may improve survival in these life-threatening cases. As was seen in the present case, REBOA can effectively treat upper gastrointestinal hemorrhage by temporarily stabilizing hemodynamics and enabling a hemostatic procedure to be quickly performed during that time. This report also demonstrated the hemodynamics during the combination of intermittent and partial REBOA to avoid the complications of ischemic or reperfusion injury of the intestines or lower extremities.
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AIM: Urgent endoscopy is essential in gastrointestinal (GI) bleeding. Emergency physicians with endoscopy training treat patients with GI bleeding in our hospital. We compared the management and clinical outcomes of GI bleeding cases between those treated by an emergency physician (EP) and those treated by a non-emergency physician (NEP; e.g., gastroenterologist or general surgeon). METHODS: We undertook a retrospective chart review of upper GI bleeding cases treated using endoscopy in the emergency department between 2012 and 2014. We examined patients characteristics, endoscopic findings, hemostatic procedures, need for transfusion, rebleeding and adverse events, length of hospital stay, and mortality. RESULTS: The EP group included 33 patients (39%) and the NEP group included 51 (61%). Patient characteristics and diseases did not differ between the groups. The EP group underwent urgent endoscopy more often (100% versus 86%, P = 0.04). Procedure times were not statistically different between the groups. The EP group had fewer hemostatic procedures (42% versus 65%, P = 0.04). Transfusion requirements were lower in the EP group (0.5 U versus 2.1 U, P = 0.006). There were no statistical differences in rebleeding and adverse events. The length of hospital stay was shorter (8 versus 11 days, P = 0.03) and the in-hospital mortality rate was lower in the EP group (0% versus 13.7%, P = 0.04). CONCLUSION: Short-term outcomes in GI bleeding cases managed by emergency physicians with endoscopy training were comparable to those by gastroenterologists and general surgeons. However, the extent of endoscopic training and experience emergency physicians should have remains unclear.
RESUMO
Blood purification therapy using hemofilters with high adsorbing capabilities has been reported to remove excessive humoral mediators from the blood of patients with sepsis. However, there are insufficient studies of the adsorbates bound to hemofilter membranes. We hypothesized that these adsorbates in acute kidney injury (AKI) patients with sepsis were different from those in patients without sepsis and that proteome analysis of the adsorbates would identify novel substances of sepsis. This study included 20 patients who had AKI upon admission to intensive care units (ICUs) and who received continuous renal replacement therapy using polymethyl methacrylate hemofilters. We isolated adsorbates from the hemofilters after use and performed comprehensive proteome analysis. A total of 429 proteins were identified in these adsorbates. Adsorbates from the hemofilters of patients with sepsis had significantly increased frequency of proteins associated with "immune system process" and "biological adhesion" functions compared to those of non-sepsis patients (P < 0.05). Of 429 proteins, 197 were identified only in sepsis adsorbates. Of these, 3 proteins including carbonic anhydrase 1 (CA1) and leucine-rich alpha-2-glycoprotein (LRG1) were identified in all samples from sepsis patients and have not been previously reported in sepsis patients. Validation analysis of patient serum revealed that patients with sepsis had increased serum levels of CA1 and LRG1 compared to patients without sepsis (P < 0.05). To conclude, there were significant differences in the characteristics of the adsorbates from sepsis and non-sepsis patients. CA1 and LRG1 appear to be novel substances associated with sepsis.