Permissive untreated pseudoaneurysm concept in damage control interventional radiology for traumatic pancreaticoduodenal artery injury.

Background: Angioembolization for traumatic pancreaticoduodenal artery injury with unstable circulation, which characteristically requires a prolonged procedure time, does not yet have a standardized strategy for damage control interventional radiology. Case Presentation: We encountered two cases of rare traumatic pancreaticoduodenal artery injury wherein the patients were saved by a multidisciplinary team with a shared goal of clinical success, rather than the procedural success of angioembolization. Both patients treated with angioembolization had residual pseudoaneurysm or faint extravasation in the pancreaticoduodenal artery arcade. We prioritized critical care with preemptive plasma transfusion and aggressive blood pressure control, and planned repeat angiography. The patients showed no clinical signs of rebleeding or pseudoaneurysm based on computed tomography during follow-up. Conclusion: Our findings suggest that the permissive untreated pseudoaneurysm concept can be useful in developing damage control interventional radiology strategies for trauma cases with challenging time limitations, such as traumatic pancreaticoduodenal artery injury with circulatory collapse.

Successful coil embolization of a ruptured aneurysm of the arc of Riolan artery.

The arc of Riolan (AOR) is an anastomosis between the middle and left colic arteries. Aneurysms of the AOR are very rare visceral artery aneurysms. A 44-year-old man presented with abdominal pain and loss of consciousness. Computed tomography and angiography showed hemorrhagic ascites around the liver and spleen. An irregularly dilated artery was visible within a hematoma in the upper left region of the abdomen, consistent with a ruptured pseudoaneurysm of the AOR. Transcatheter arterial embolization was performed with microcoils. The patient's abdominal pain disappeared after embolization, and no symptoms of intestinal ischemia were observed. To our knowledge, this is the first case of an AOR aneurysm with AOR dilation due to dissection of the celiac artery that was successfully treated by coil embolization.

Activities of daily living and psychiatric symptoms after intensive care unit discharge among critically ill patients with or without tracheostomy: a single center longitudinal study.

Aim: Tracheostomy is widely performed in critically ill patients who require prolonged mechanical ventilation. Long-term morbidity (post-intensive care syndrome) in tracheostomized patients is not widely reported, however, so we evaluate it here. Methods: This is a sub-analysis of a single center prospective longitudinal study, which assessed activities of daily living (ADL) and psychiatric symptoms in adult patients emergently admitted to the intensive care unit (ICU). We evaluated association between these symptoms and tracheostomy by posting questionnaires at 3 and 12 months after ICU discharge. Results: We analyzed 107 patients (15 patients with tracheostomy) at 3 months and 74 patients (13 patients with tracheostomy) at 12 months after ICU discharge. ADL tended to be lower in patients with tracheostomy than in those without tracheostomy at 3 months after ICU discharge (65 [10-100] versus 95 [59-100]; P = 0.28, 7/15 [47%] versus 30/102 [30%] Barthel Index scored ≤ 60; P = 0.23), however there were no significant differences. Psychiatric symptoms were not different between the groups at 3 months and again at 12 months. Conclusion: Activities of daily living disability and psychiatric symptoms were not significantly worse in patients with tracheostomy at 3 and 12 months from ICU discharge compared with patients without tracheostomy. Despite the limited number in our cohort, our study may inform shared decision making concerning tracheostomy for critically ill patients and their families.

Incidence and Risk Factors of Worsened Activities of Daily Living Status Three Months after Intensive Care Unit Discharge among Critically Ill Patients: A Prospective Cohort Study.

Background: We aimed to determine risk factors associated with worsened activity of daily living (ADL) status three months after intensive care unit (ICU) discharge. Methods: In this prospective, observational study, we enrolled critically ill adult patients that were emergently admitted to an ICU. We assessed ADL status by Barthel index score prior to ICU admission and three months after ICU discharge. The primary outcome was worsened ADL status, defined as a ≥10 decrease in Barthel index score. Results: We enrolled 102 patients (median age was 72 years old, 55% were male, and 87% received mechanical ventilation during ICU stay), and 42 patients (41%) had worsened ADL status three months after discharge from ICU. Multivariate analysis revealed that older age (>70 years old; adjusted odds ratio (aOR) 3.68; 95% confidence interval (95%CI) 1.33−10.19), high burden of chronic illness (aOR 4.11; 95%CI 1.43−11.81), and longer duration of mechanical ventilation (≥4 days; aOR 2.83; 95%CI 1.04−7.69) were independent risk factors for worsened ADL status at three months. Conclusions: Almost half of the critically ill adult patients in this cohort had worsened ADL status after ICU discharge. Older age, high burden of chronic illness, and longer duration of mechanical ventilation were risk factors for worsened ADL status.

Multisystem inflammatory syndrome in adults after acute coronavirus disease 2019 in a Japanese woman: A case report.

Multisystem inflammatory syndrome in adults (MIS-A) is a rare and emerging syndrome after coronavirus disease 2019 (COVID-19). To the best of our knowledge, Japanese cases of MIS-A are rarely reported. Here, we describe a case of MIS-A in a 44-year-old Japanese woman presenting with multiorgan dysfunction (i.e., cardiovascular and mucocutaneous involvement) and markedly elevated inflammatory markers 2 weeks after recovery from COVID-19. Treatment with intravenous immunoglobulins and corticosteroids resolved her symptoms. On the 13th day, she was discharged from the hospital with no recurrences on follow-up. This study highlights the importance of recognizing this emerging syndrome when treating patients with multiorgan dysfunction after COVID-19.

Subjective symptoms and their association with psychiatric symptoms 3 months after ICU discharge: sub-analysis of a single-center prospective observational study.

BACKGROUND: Despite a growing volume of literature on post-intensive care syndrome, we know little about how subjective symptoms affect intensive care unit survivors in the long term. AIMS: This study aimed to elucidate the prevalence of subjective symptoms and to determine the clinical importance of post-intensive care syndrome by evaluating the association between these symptoms and psychiatric symptoms. We evaluated new-onset or worsening subjective symptoms and psychiatric symptoms in 81 patients at 3 months after discharge from an intensive care unit. RESULTS: More than half of patients had at least one subjective symptom, such as weakness (n = 31), fatigue (n = 23), malaise (n = 14), body pain (n = 14), or insomnia (n = 9). CONCLUSIONS: The presence of subjective symptoms is associated with worse psychiatric symptoms (post-traumatic stress disorder, anxiety, and depression) at 3 months after ICU discharge. We found insomnia was particularly strongly associated with psychiatric symptoms in our study group. TRIAL REGISTRATION: UMIN Clinical Trial Registry no. UMIN000023743, September 1, 2016.

Primary success of electrical cardioversion for new-onset atrial fibrillation and its association with clinical course in non-cardiac critically ill patients: sub-analysis of a multicenter observational study.

BACKGROUND: Electrical cardioversion (ECV) is widely used to restore sinus rhythm in critically ill adult patients with atrial fibrillation, although its prognostic value is uncertain. This study aims to elucidate the clinical meaning of successful ECV. METHODS: This is a sub-analysis of the AFTER-ICU study, a multicenter prospective study with a cohort of 423 adult non-cardiac patients with new-onset atrial fibrillation (AF). Patients that underwent ECV within 7 days after initial onset of AF were included in the sub-analysis. We compared intensive care unit (ICU) and overall hospital mortality, survival time within 30 days, cardiac rhythm at ICU discharge, and the length of ICU and overall hospital stay between patients whose sinus rhythm was restored immediately after the first ECV session (primary success group) and those in whom it was not restored (unsuccessful group). To find the factors related to the primary success of ECV, we also compared patient characteristics, the delivered energy, and pretreatment. RESULTS: Sixty-five patients received ECV and were included in this study. Although 35 patients (54%) had primary success, recurrence of AF occurred in 24 of these patients (69%). At ICU discharge, three patients still had AF in the unsuccessful group, but no patients in the primary success group still had AF. ICU mortality was 34% in the primary success group and 17% in the unsuccessful group (P = 0.10). Survival time within 30 days did not differ between the groups. Delivered energy and pretreatment were not associated with primary success of ECV. CONCLUSIONS: The primary success rate of ECV for new-onset AF in adult non-cardiac ICU population was low, and even if it succeeded, the subsequent recurrence rate was high. Primary success of ECV did not affect the rate of mortality. Pretreatment and delivered energy were not associated with the primary success of ECV. TRIAL REGISTRATION: UMIN clinical trial registry, the Japanese clinical trial registry (registration number: UMIN000026401 , March 31, 2017).

Comparison of Uterine Necrosis After Uterine Artery Embolization with Soluble Gelatin Sponge Particles or Tris-acryl Gelatin Microspheres in Swine.

PURPOSE: To compare the recanalization of the uterine arteries and uterine necrosis after uterine artery embolization (UAE) using either soluble gelatin sponge particles (SGS), which dissolve in saline, or tris-acryl gelatin microspheres (MS), which are permanent embolic materials, in swine. METHODS: Fourteen uteri in seven swine were divided into two groups for embolization with either 500-1000 µm SGS (SGS group) or 500-700 µm MS (MS group) (seven uteri per group). The uterine arteries were embolized using SGS or MS, and angiography was performed to evaluate recanalization of the uterine arteries immediately, 1, 2, 3, 4, 5, and 6 h, and 3 days after embolization. On day 3, the uteri were removed to determine the macroscopic necrosis rate and for histopathologic examination. RESULTS: In the SGS group, four uterine arteries were completely recanalized, two were partially recanalized, and one was still occluded 5 h after embolization. In contrast, all seven uterine arteries in the MS group were still occluded 6 h after embolization. The complete recanalization rate at 3 days was significantly greater in the SGS group than in the MS group (100.0% vs. 14.3%, respectively; P = .0047). The mean uterine necrosis rate was not significantly different between the SGS and MS groups (15.0 ± 15.7% vs. 26.8 ± 13.3%, respectively; P = .096). The mean smallest arterial diameter containing embolic materials was 48.2 ± 22.0 µm (range 21-109 µm) for SGS and 446.7 ± 107.0 µm (range 352-742 µm) for MS (P < .0001). CONCLUSION: The uterine arteries recanalized earlier in the SGS group than in the MS group and the uterine necrosis rates were similar in both groups. SGS have the potential for a more distal penetration in comparison with MS.

Combination of delirium and coma predicts psychiatric symptoms at twelve months in critically ill patients: A longitudinal cohort study.

PURPOSE: We aimed to determine any associations between delirium and comas during intensive care unit (ICU) stay, and long-term psychiatric symptoms and disability affecting activity of daily living (ADL). MATERIALS AND METHODS: In this prospective observational study, we enrolled critically ill adult patients that were emergently admitted to an ICU. We assessed psychiatric symptoms and disability affecting ADL at three and twelve months after ICU discharge. RESULTS: Among the 81 and the 47 patients that responded to the questionnaires at three and twelve months, 22 (27%) and 13 (28%) patients experienced delirium, respectively. During their ICU stay, 28 (35%) and 21 (45%) had been in comas, respectively. At three and twelve months, 51 (63%) and 23 (49%) of patients experienced composite psychiatric symptoms or disability affecting ADL, respectively. After adjusting predefined confounders, the combination of delirium and comas was an independent risk factor for the presence of composite psychiatric symptoms or disability affecting ADL (adjusted odds ratio [aOR] 3.38; 1.10-10.38 at three months; aOR 8.28; 1.48-46.46 at twelve months). CONCLUSIONS: In critically ill adults, combination of delirium and comas during ICU stay is a predictor of psychiatric symptoms or ADL disability. TRIAL REGISTRATION: UMIN Clinical Trial Registry no. UMIN000023743, September 1, 2016.

Utility of a prediction model for delirium in intensive care unit patients (PRE-DELIRIC) in mechanically ventilated patients with sepsis.

AIM: Delirium frequently develops in patients with sepsis during their intensive care unit (ICU) stay, which is associated with increased morbidity and mortality. A prediction model for delirium in patients in ICU, PRE-DELIRIC, has been utilized in overall ICU patients, but its utility is uncertain among patients with sepsis. This study aims to examine the utility of PRE-DELIRIC to predict delirium in mechanically ventilated patients with sepsis. METHODS: This is a post hoc analysis of a randomized clinical trial in eight Japanese ICUs, which aimed to evaluate the sedative strategy with/without dexmedetomidine in adult mechanically ventilated patients with sepsis. The Confusion Assessment Method for the ICU was used every day to assess for delirium throughout their ICU stay. We excluded patients who were delirious on the first day of ICU, those who were under sustained coma throughout their ICU stay, and those who stayed in the ICU less than 24 h. The discriminative ability of PRE-DELIRIC was evaluated by measuring the area under the receiver operating characteristic curve (AUROC). RESULTS: Of the 201 patients enrolled in the trial, we analyzed 158 patients. The mean age was 69.4 ± 14.0 years, and 99 patients (63%) were men. Delirium occurred at least once during the ICU stay of 63 patients (40%). The AUROC of PRE-DELIRIC was 0.60 (95% confidence interval, 0.50-0.69). Subgroup analyses indicated that PRE-DELIRIC was useful in those with Sequential Organ Failure Assessment score >8 with AUROC of 0.65 (95% confidence interval, 0.51-0.77). CONCLUSIONS: The PRE-DELIRIC model could not predict delirium in mechanically ventilated patients with sepsis.

Activities of daily living status and psychiatric symptoms after discharge from an intensive care unit: a single-center 12-month longitudinal prospective study.

AIM: In post-intensive care syndrome (PICS), long-term survivors of critical illness present various physical and mental symptoms that can persist for years after discharge. Post-intensive care syndrome in Japan has not been well described, so this study aims to elucidate its epidemiology. METHODS: We undertook a single-center prospective longitudinal cohort study in a mixed intensive care unit (ICU) in a Japanese tertiary hospital. Adult patients emergently admitted to the ICU were eligible for inclusion in the study. To assess activity of daily living (ADL) status and psychiatric symptoms, we posted a questionnaire at 3 and 12 months after discharge from the ICU. We evaluated ADL status, anxiety, depression, and post-traumatic stress disorder symptoms using the Barthel index, Hospital Anxiety and Depression Scale, and Impact of Event Scale - Revised, respectively. RESULTS: Enrolled in this study were 204 patients. We received responses from 117/147 (80%) and 74/98 (76%) patients at 3 and 12 months, respectively. At 3 months, the prevalence of ADL disability, anxiety, depression, and post-traumatic stress disorder symptoms was 32%, 42%, 48%, and 20%, respectively. At 12 months, the prevalence was 22%, 33%, 39%, and 21%, respectively. The prevalence of any symptoms was 66% at 3 months and 55% at 12 months. Barthel index score at 12 months was improved significantly from that at 3 months. Hospital Anxiety and Depression Scale and Impact of Event Scale - Revised scores at 12 months showed no improvement. CONCLUSIONS: At 3 and 12 months after ICU discharge, over half of our Japanese patients suffered ADL disability and/or psychiatric symptoms. The ADL disability improved at 1 year, but psychiatric symptoms did not.

Dexmedetomidine improved renal function in patients with severe sepsis: an exploratory analysis of a randomized controlled trial.

BACKGROUND: Dexmedetomidine has been reported to improve organ dysfunction in critically ill patients. In a recent randomized controlled trial (Dexmedetomidine for Sepsis in Intensive Care Unit (ICU) Randomized Evolution [DESIRE]), we demonstrated that dexmedetomidine was associated with reduced mortality risk among patients with severe sepsis. We performed this exploratory sub-analysis to examine the mechanism underlying improved survival in patients sedated with dexmedetomidine. METHODS: The DESIRE trial compared a sedation strategy with and without dexmedetomidine among 201 mechanically ventilated adult patients with sepsis across eight ICUs in Japan. In the present study, we included 104 patients with Acute Physiology and Chronic Health Evaluation II (APACHE II) scores of ≥ 23 (54 in the dexmedetomidine [DEX] group and 50 in the non-dexmedetomidine [non-DEX] group). Initially, we compared the changes in the sequential organ failure assessment (SOFA) scores from the baseline within 6 days after randomization between groups. Subsequently, we evaluated the variables comprising the organ component of the SOFA score that showed relevant improvement in the initial comparison. RESULTS: The mean patient age was 71.0 ± 14.1 years. There was no difference in the median APACHE II score between the two groups (29 [interquartile range (IQR), 25-31] vs. 30 [IQR, 25-33]; p = 0.35). The median SOFA score at the baseline was lower in the DEX group (9 [IQR, 7-11] vs. 11 [IQR, 9-13]; p = 0.01). While the renal SOFA subscore at the baseline was similar for both groups, it significantly decreased in the DEX group on day 4 (p = 0.02). During the first 6 days, the urinary output was not significantly different (p = 0.09), but serum creatinine levels were significantly lower (p = 0.04) in the DEX group. The 28-day and in-hospital mortality rates were significantly lower in the DEX group (22% vs. 42%; p = 0.03, 28% vs. 52%; p = 0.01, respectively). CONCLUSION: A sedation strategy with dexmedetomidine is associated with improved renal function and decrease mortality rates among patients with severe sepsis. TRIAL REGISTRATION: This trial was registered on ClinicalTrials.gov (NCT01760967) on January 1, 2013.

Effect of Dexmedetomidine on Lactate Clearance in Patients With Septic Shock: A Subanalysis of a Multicenter Randomized Controlled Trial.

Lactate clearance is useful to guide initial resuscitation of patients with septic shock. We conducted this study to evaluate whether dexmedetomidine increases lactate clearance in patients with septic shock. This was a randomized controlled trial that involved a post hoc subgroup analysis. Adult patients with septic shock under ventilation were randomized to receive sedation strategy with or without dexmedetomidine (60 in the dexmedetomidine and 51 in the nondexmedetomidine groups). The primary outcome was the lactate clearance at 6 h, defined as the percent decrease in lactate from randomization to 6 h after. The median Acute Physiology and Chronic Health Evaluation II score was 25 (interquartile range 19-31). The median serum lactate value at randomization was lower in the dexmedetomidine group than in the nondexmedetomidine group (4.0 mmol/L vs. 4.8 mmol/L; P = 0.053). The lactate clearance at 6 h was higher in the dexmedetomidine group, although this was not statistically significant (23.3 ±â€Š29.8 vs. 11.1 ±â€Š54.4, mean difference 12.2, 95% confidence interval (CI), -4.4 to 28.8). After adjusting for the lactate level at randomization, lactate clearance at 6 h was significantly higher in the dexmedetomidine group (adjusted mean difference 18.5, 95% CI, 2.2-34.9). There was no statistically significant difference in the 28-day mortality between the dexmedetomidine and the nondexmedetomidine groups (13 [22%] vs. 18 [35%] patients, P = 0.11). In conclusion, among mechanically ventilated patients with septic shock, sedation with dexmedetomidine resulted in increased lactate clearance compared with sedation without dexmedetomidine.