Peak value of serum KL-6 may be useful for predicting poor prognosis of severe COVID-19 patients.

BACKGROUND: Serum Krebs von den Lungen 6 (KL-6), which reflects alveolar epithelial injury, was reported to be useful to predict the progression of pneumonitis induced by COVID-19 in the early phase. This study aimed to evaluate the peak value of serum KL-6 during hospitalization for COVID-19 to discover a more useful biomarker for predicting prognosis in COVID-19 patients. METHODS: In this retrospective, single-center, observational study, we analyzed the data of 147 hospitalized patients who required supplemental oxygen, high-flow oxygen therapy, or invasive mechanical ventilation for respiratory failure due to COVID-19 from March 2020 to February 2021. We extracted data on patient sex, age, comorbidities, treatment, and biomarkers including the initial and peak values of KL-6. Inclusion criteria were examination of the studied biomarkers at least once within 3 days of admission, then at least once a week, and at a minimum, at least twice during the entire hospitalization. Area under the receiver operating curve (AUC) was analyzed to determine the accuracy of several biomarkers including KL-6 and LDH for predicting poor prognosis defined as survivors requiring invasive mechanical ventilation for over 28 days or non-survivors of COVID-19. Univariable and multivariate logistic regression analyses were performed to investigate the prognostic value of the baseline characteristics and biomarkers. RESULTS: Among the 147 patients, 108 (73.5%) had a good prognosis and 39 (26.5%) had a poor prognosis. The AUC analysis indicated that peak KL-6 showed precise accuracy in the discrimination of patients with poor prognosis (AUC 0.89, p < 0.001). The best cut-off value for KL-6 concentration was 966 U/mL (sensitivity 81.6%, specificity84.3%). After adjustment, increasing peak values of KL-6 or LDH were associated with a high risk of poor prognosis, with an adjusted odds ratio of 1.35 for peak value of KL-6, per 100 U/mL increase (95% CI 1.17-1.57, p < 0.001) and 2.16 for peak value of LDH, per 100 U/L increase (95% CI 1.46-3.20, p < 0.001). CONCLUSIONS: Peak values of KL-6 and LDH measured during hospitalization might help to identify COVID-19 patients with respiratory failure who are at higher risk for a poor prognosis.

Hemophagocytic syndrome with severe sepsis caused by Capnocytophaga canimorsus.

Capnocytophaga canimorsus, commonly transmitted by dog bites, can cause severe sepsis, and the mortality rate is very high. We experienced a case of hemophagocytic lymphohistiocytosis (HLH) complicated by severe sepsis caused by C. canimorsus. A 58-year-old man with no remarkable medical history was admitted to another hospital with fever and mild consciousness disorder developed 3 days after being bitten by his dog. The next day, the patient developed disseminated intravascular coagulation and shock and was transferred to our emergency medical center. Blood tests showed hyperferritinemia and cytopenia, and bone marrow aspiration was performed. As a result, we diagnosed severe sepsis and HLH. Once antibiotic and steroid therapy was started, the patient's infection and cytopenia improved. Unfortunately, the patient's fingers and toes required amputation, but his life was saved, and he was discharged from hospital. Because HLH may be hidden in such cases, it may be necessary to measure serum ferritin and perform bone marrow aspiration if hyperferritinemia is suspected.

First installation of a dual-room IVR-CT system in the emergency room.

Computed tomography (CT) embedded in the emergency room has gained importance in the early diagnostic phase of trauma care. In 2011, we implemented a new trauma workflow concept with a sliding CT scanner system with interventional radiology features (IVR-CT) that allows CT examination and emergency therapeutic intervention without relocating the patient, which we call the Hybrid emergency room (Hybrid ER). In the Hybrid ER, all life-saving procedures, CT examination, damage control surgery, and transcatheter arterial embolisation can be performed on the same table. Although the trauma workflow realized in the Hybrid ER may improve mortality in severe trauma, the Hybrid ER can potentially affect the efficacy of other in/outpatient diagnostic workflow because one room is occupied by one severely injured patient undergoing both emergency trauma care and CT scanning for long periods. In July 2017, we implemented a new trauma workflow concept with a dual-room sliding CT scanner system with interventional radiology features (dual-room IVR-CT) to increase patient throughput. When we perform emergency surgery or interventional radiology for a severely injured or ill patient in the Hybrid ER, the sliding CT scanner moves to the adjacent CT suite, and we can perform CT scanning of another in/outpatient. We believe that dual-room IVR-CT can contribute to the improvement of both the survival of severely injured or ill patients and patient throughput.

Idarucizumab for a traumatic head injury patient taking dabigatran.

BACKGROUND: Dabigatran is one of the four drugs currently used as a direct oral anticoagulant in Japan. Idarucizumab, which specifically targets dabigatran, was recently approved in Japan. We present a case of intracranial hemorrhage in a traumatic brain injury patient taking dabigatran who was treated by administering idarucizumab. CASE PRESENTATION: A 72-year-old man was injured in a traffic accident and was transferred to our emergency room. On arrival, his Glasgow Coma Scale score was 14 (eye, 3; verbal, 5; motor, 6), and his other vital signs were stable. Computed tomography (CT) imaging on arrival showed a small intracranial hematoma. A second CT 3 h later revealed expansion of the hematoma. We received information that he was taking dabigatran only after the second CT. Idarucizumab was then promptly administered, and emergency craniotomy for hematoma removal was performed. There was no tendency for bleeding during the operation, and blood transfusion was not required during the perioperative period. Although the patient underwent additional surgery for subdural effusion and hydrocephalus, his postoperative course was uneventful. He was transferred to a rehabilitation hospital on postoperative day 102. CONCLUSION: We managed a patient taking dabigatran who suffered traumatic intracranial hemorrhage by administering idarucizumab preoperatively without the need for blood transfusion perioperatively. We suggest that idarucizumab could be a potent therapeutic bridge to definitive surgical management in such patients with traumatic brain injury who are taking dabigatran.

A case of blunt thoracic aortic injury requiring ECMO for acute malperfusion before TEVAR.

BACKGROUND: Blunt thoracic aortic injury (BTAI) is associated with a high mortality rate and the paradigm of treating patients with BTAI currently favours thoracic endovascular aneurysm repair (TEVAR) if possible. In BTAI, lethal malperfusion caused by a pseudoaneurysm has rarely been reported. We present the first report of a successful case in which a pseudoaneurysm causing the infrequent occurrence of lethal malperfusion and subsequent acute severe ischaemia in the distal portion of the thoracic descending aorta was overcome by veno-arterial extracorporeal membrane oxygenation (VA ECMO) as a bridging therapy until the initiation of TEVAR. CASE PRESENTATION: An adult woman was transferred to our emergency room after injuries sustained by falling from height. Her vital signs were unstable on admission. CT examination revealed the multiple injuries: traumatic subarachnoid haemorrhage, severe unstable pelvic fracture, and a grade III injury of the thoracic aorta. We made the decision to perform TEVAR after external fixation and transcatheter arterial embolization (TAE) for the pelvic injury. During preparations for TEVAR, her lower limbs rapidly felt cold, and her blood lactate level and serum potassium rapidly increased. By the clinical data and ultrasonography and lower extremity Doppler, we diagnosed severe ischaemia in distal portion of the descending aorta caused by a pseudoaneurysm proximal to the descending thoracic aorta. Because we still had not prepared for TEVAR, we immediately started VA ECMO until TEVAR could begin. After the initiation of VA ECMO, her lactate and potassium levels could be controlled. Under VA ECMO support, she underwent TEVAR. After inpatient rehabilitation, she was discharged home without neurologic sequelae. CONCLUSIONS: VA ECMO could be an important, less-invasive treatment as a bridging therapy for acute severe malperfusion syndrome until TEVAR is initiated for BTAI.

Ventricular septal perforation after blunt chest trauma due to blows from a fist.

Case: A 40-year-old man received fist blows to his chest and abdomen. He presented with external jugular vein distention and facial congestion. Chest X-ray showed bilateral pulmonary congestion. A Levine V/VI holosystolic murmur was audible. Echocardiography showed left-to-right shunt flow across the perimembranous region of the ventricular septum. The diameter of the hole was approximately 13 mm. We diagnosed ventricular septal perforation, started an infusion, and administered vasopressors. However, circulatory dynamics could not be maintained. The ventricular septal perforation was repaired directly with mattress sutures through the right ventricle. A small residual ventricular septal perforation was detected, which was repaired with a patch sutured through the left ventricle. Outcome: The patient was discharged without cardiovascular complications 43 days after admission. Conclusion: Ventricular septal perforation following blunt chest trauma is a rare form of cardiac trauma. It is important to consider the timing of the operation and the best method to ensure cardiac repair.