Correlation between normally aerated lung and respiratory system compliance at clinical high positive end-expiratory pressure in patients with COVID-19.

Normally aerated lung tissue on computed tomography (CT) is correlated with static respiratory system compliance (Crs) at zero end-expiratory pressure. In clinical practice, however, patients with acute respiratory failure are often managed using elevated PEEP levels. No study has validated the relationship between lung volume and tissue and Crs at the applied positive end-expiratory pressure (PEEP). Therefore, this study aimed to demonstrate the relationship between lung volume and tissue on CT and Crs during the application of PEEP for the clinical management of patients with acute respiratory distress syndrome due to COVID-19. Additionally, as a secondary outcome, the study aimed to evaluate the relationship between CT characteristics and Crs, considering recruitability using the recruitment-to-inflation ratio (R/I ratio). We analyzed the CT and respiratory mechanics data of 30 patients with COVID-19 who were mechanically ventilated. The CT images were acquired during mechanical ventilation at PEEP level of 15 cmH2O and were quantitatively analyzed using Synapse Vincent system version 6.4 (Fujifilm Corporation, Tokyo, Japan). Recruitability was stratified into two groups, high and low recruitability, based on the median R/I ratio of our study population. Thirty patients were included in the analysis with the median R/I ratio of 0.71. A significant correlation was observed between Crs at the applied PEEP (median 15 [interquartile range (IQR) 12.2, 15.8]) and the normally aerated lung volume (r = 0.70 [95% CI 0.46-0.85], P < 0.001) and tissue (r = 0.70 [95% CI 0.46-0.85], P < 0.001). Multivariable linear regression revealed that recruitability (Coefficient = - 390.9 [95% CI - 725.0 to - 56.8], P = 0.024) and Crs (Coefficient = 48.9 [95% CI 32.6-65.2], P < 0.001) were significantly associated with normally aerated lung volume (R-squared: 0.58). In this study, Crs at the applied PEEP was significantly correlated with normally aerated lung volume and tissue on CT. Moreover, recruitability indicated by the R/I ratio and Crs were significantly associated with the normally aerated lung volume. This research underscores the significance of Crs at the applied PEEP as a bedside-measurable parameter and sheds new light on the link between recruitability and normally aerated lung.

Prediction of the future number of fall-related emergency medical services calls in older individuals.

BACKGROUND: Falls among older individuals contribute significantly to the rise in ambulance transport use. To recognize the importance of future countermeasures, we estimated the projected number and percentage of fall-related emergency medical service (EMS) calls. METHODS: We examined the sex, age group, and location of falls among patients aged ≥ 65 years who contacted emergency services in Sapporo City from 2013 to 2021. Annual fall-related calls per population subgroup were calculated, and trends were analyzed. Four models were used to estimate the future number of fall-related calls from the 2025-2060 projected population: (1) based on the 2022 data, estimates from the 2013-2022 data using (2) Poisson progression, (3) neural network, (4) estimates from the 2013-2019 data using neural network. The number of all EMS calls was also determined using the same method to obtain the ratio of all EMS calls. RESULTS: During 2013-2022, 70,262 fall-related calls were made for those aged ≥ 65 years. The rate was higher indoors among females and outdoor among males in most age groups and generally increased with age. After adjusting for age, the rate increased by year. Future estimates of the number of fall calls are approximately double the number in 2022 in 2040 and three times in 2060, with falls accounting for approximately 11% and 13% of all EMS calls in 2040 and 2060, respectively. CONCLUSION: The number of fall-related EMS calls among older people is expected to increase in the future, and the percentage of EMS calls will also increase; therefore, countermeasures are urgently needed.

Chest CT findings in severe acute respiratory distress syndrome requiring V-V ECMO: J-CARVE registry.

BACKGROUND: Chest computed tomography findings are helpful for understanding the pathophysiology of severe acute respiratory distress syndrome (ARDS). However, there is no large, multicenter, chest computed tomography registry for patients requiring veno-venous extracorporeal membrane oxygenation (V-V ECMO). The aim of this study was to describe chest computed tomography findings at V-V ECMO initiation and to evaluate the association between the findings and outcomes in severe ARDS. METHODS: This multicenter, retrospective cohort study enrolled patients with severe ARDS on V-V ECMO, who were admitted to the intensive care units of 24 hospitals in Japan between January 1, 2012, and December 31, 2022. RESULTS: The primary outcome was 90-day in-hospital mortality. The secondary outcomes were the successful liberation from V-V ECMO and the values of static lung compliance. Among the 697 registry patients, of the 582 patients who underwent chest computed tomography at V-V ECMO initiation, 394 survived and 188 died. Multivariate Cox regression showed that traction bronchiectasis and subcutaneous emphysema increased the risk of 90-day in-hospital mortality (hazard ratio [95% confidence interval] 1.77 [1.19-2.63], p = 0.005 and 1.97 [1.02-3.79], p = 0.044, respectively). The presence of traction bronchiectasis was also associated with decreased successful liberation from V-V ECMO (odds ratio: 0.27 [0.14-0.52], p < 0.001). Lower static lung compliance was associated with some chest computed tomography findings related to changes outside of pulmonary opacity, but not with the findings related to pulmonary opacity. CONCLUSIONS: Traction bronchiectasis and subcutaneous emphysema increased the risk of 90-day in-hospital mortality in patients with severe ARDS who required V-V ECMO.

Prognostic Significance of Signs of Life in Out-of-Hospital Cardiac Arrest Patients Undergoing Extracorporeal Cardiopulmonary Resuscitation.

OBJECTIVES: Signs of life (SOLs) during cardiac arrest (gasping, pupillary light reaction, or any form of body movement) are suggested to be associated with favorable neurologic outcomes in out-of-hospital cardiac arrest (OHCA). While data has demonstrated that extracorporeal cardiopulmonary resuscitation (ECPR) can improve outcomes in cases of refractory cardiac arrest, it is expected that other contributing factors lead to positive outcomes. This study aimed to investigate whether SOL on arrival is associated with neurologic outcomes in patients with OHCA who have undergone ECPR. DESIGN: Retrospective multicenter registry study. SETTING: Thirty-six facilities participating in the Study of Advanced life support for Ventricular fibrillation with Extracorporeal circulation in Japan II (SAVE-J II). PATIENTS: Consecutive patients older than 18 years old who were admitted to the Emergency Department with OHCA between January 1, 2013, and December 31, 2018, and received ECPR. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients were classified into two groups according to the presence or absence of SOL on arrival. The primary outcome was a favorable neurologic outcome (Cerebral Performance Category 1 or 2) at discharge. Of the 2157 patients registered in the SAVE-J II database, 1395 met the inclusion criteria, and 250 (17.9%) had SOL upon arrival. Patients with SOL had more favorable neurologic outcomes than those without SOL (38.0% vs. 8.1%; p < 0.001). Multivariate analysis showed that SOL on arrival was independently associated with favorable neurologic outcomes (odds ratio, 5.65 [95% CI, 3.97-8.03]; p < 0.001). CONCLUSIONS: SOL on arrival was associated with favorable neurologic outcomes in patients with OHCA undergoing ECPR. In patients considered for ECPR, the presence of SOL on arrival can assist the decision to perform ECPR.

Prehospital Advanced Airway Management and Ventilation for Out-of-Hospital Cardiac Arrest with Prehospital Return of Spontaneous Circulation: A Prospective Observational Cohort Study in Japan.

BACKGROUND: The relationship among advanced airway management (AAM), ventilation, and oxygenation in patients with out-of-hospital cardiac arrest (OHCA) who achieve prehospital return of spontaneous circulation (ROSC) has not been validated. This study was designed to evaluate ventilation and oxygenation for each AAM technique (supraglottic devices [SGA] or endotracheal intubation [ETI]) using arterial blood gas (ABG) results immediately after hospital arrival. METHODS: This observational cohort study, using data from the Japanese Association for Acute Medicine OHCA Registry, included patients with OHCA with prehospital and hospital arrival ROSC between July 1, 2014, and December 31, 2019. The primary outcomes were the partial pressure of carbon dioxide in the arterial blood (PaCO2) and partial pressure of oxygen in the arterial blood (PaO2) in the initial ABG at the hospital for each AAM technique (SGA or ETI) performed by paramedics. The secondary outcome was favorable neurological outcome (cerebral performance category [CPC] 1 or 2) for specific PaCO2 levels, which were defined as good ventilation (PaCO2 ≤45 mmHg) and insufficient ventilation (PaCO2 >45 mmHg). RESULTS: This study included 1,527 patients. Regarding AAM, 1,114 and 413 patients were ventilated using SGA and ETI, respectively. The median PaCO2 and PaO2 levels were 74.50 mmHg and 151.35 mmHg in the SGA group, while 66.30 mmHg and 173.50 mmHg in the ETI group. PaCO2 was significantly lower in the ETI group than in the SGA group (12.55 mmHg; 95% CI 15.27 to 8.20, P-value < 0.001), while no significant difference was found in PaO2 by multivariate linear regression analysis. After stabilizing inverse probability of weighting (IPW), the adjusted odds ratio for favorable neurological outcome at 1 month was significant in the good ventilation group compared to the insufficient ventilation cohort (adjusted odds ratio = 2.12, 95%CI: 1.40 to 3.19, P value < 0.001). CONCLUSION: The study showed that in OHCA patients with prehospital ROSC, the PaCO2 levels in the initial ABG were lower in the group with AAM by ETI than in the SGA group. Furthermore, patients with prehospital ROSC and PaCO2 ≤45 mmHg on arrival had an increased odds of favorable neurological outcome after stabilized IPW adjustment.

Effect of prehospital advanced airway management on out-of-hospital cardiac arrest due to asphyxia: A JAAM-OHCA registry-based observational study in Japan.

Aim: To investigate the relationship between prehospital advanced airway management (AAM) and neurological outcomes in patients with asphyxia-related out-of-hospital cardiac arrest (OHCA). Methods: We retrospectively analyzed data from the Japanese Association for Acute Medicine OHCA registry between June 2014 and December 2017. Patients with asphyxia-related cardiac arrest aged ≥18 years were included. The primary outcome was a 1-month favorable neurological outcome (cerebral performance category [CPC] 1-2). Results: Of the 34,754 patients in the 2014-2017 JAAM-OHCA Registry, 1956 were included in our analysis. Cerebral performance category 1-2 was observed in 31 patients (1.6%), while CPC 3-5 was observed in 1925 patients (98.4%). Although prehospital AAM was associated with unfavorable neurological outcomes (odds ratio [OR], 0.269; 95% confidence interval [CI], 0.114-0.633; p = 0.003) in the univariate analysis, the association was not significant in the multivariate analysis. Compared with the AAM group, the non-AAM group showed increased rates of cardiac arrest after emergency medical service contact (4.3 vs. 7.2%, p = 0.009) and Glasgow Coma Scale ≥4 at hospital admission (1.9% vs. 4.7%, p = 0.004). Among the 903 patients for whom the time to return of spontaneous circulation (ROSC) could be calculated, the time from witnessed cardiac arrest to ROSC was significantly shorter (median, 8.5 vs. 37.0 min; p < 0.001) for those with favorable neurological outcomes than for those without. Conclusion: Prehospital AAM is not associated with improved neurological outcomes among those with asphyxia-related OHCA. However, the time from cardiac arrest to the first ROSC was significantly shorter among those with favorable outcomes.

Associated organs and system with COVID-19 death with information of organ support: a multicenter observational study.

BACKGROUND: The organ dysfunction that is associated with death in COVID-19 patients has not been determined in multicenter epidemiologic studies. In this study, we evaluated the major association with death, concomitant organ dysfunction, and proportion of multiple organ failure in deaths in patients with COVID-19, along with information on organ support. METHODS: We performed an observational cohort study using the Japanese multicenter research of COVID-19 by assembling a real-world data (J-RECOVER) study database. This database consists of data on patients discharged between January 1 and September 31, 2020, with positive SARS-CoV-2 test results, regardless of intensive care unit admission status. These data were collected from the Diagnosis Procedure Combination and electronic medical records of 66 hospitals in Japan. The clinician identified and recorded the organ responsible for the death of COVID-19. RESULTS: During the research period, 4,700 patients with COVID-19 were discharged from 66 hospitals participating in the J-RECOVER study; of which, 272 patients (5.8%) from 47 institutions who died were included in this study. Respiratory system dysfunction (87.1%) was the leading association with death, followed by cardiovascular (4.8%), central nervous (2.9%), gastrointestinal (2.6%), and renal (1.1%) dysfunction. Most patients (96.7%) who died of COVID-19 had respiratory system damage, and about half (48.9%) had multi-organ damage. Of the patients whose main association with death was respiratory dysfunction, 120 (50.6%) received mechanical ventilation. CONCLUSION: This study showed that although respiratory dysfunction was the most common association with death in many cases, multi-organ dysfunction was associated with death due to COVID-19.

Long-term prognostic significance of gasping in out-of-hospital cardiac arrest patients undergoing extracorporeal cardiopulmonary resuscitation: a post hoc analysis of a multi-center prospective cohort study.

BACKGROUND: Gasping during resuscitation has been reported as a favorable factor for out-of-hospital cardiac arrest. We examined whether gasping during resuscitation is independently associated with favorable neurological outcomes in patients with refractory ventricular fibrillation or pulseless ventricular tachycardia (VF/pVT) undergoing extracorporeal cardiopulmonary resuscitation ECPR. METHODS: Data from a 2014 study on advanced cardiac life support for ventricular fibrillation with extracorporeal circulation in Japan (SAVE-J), which examined the efficacy of ECPR for refractory VF/pVT, were analyzed. The primary endpoint was survival with a 6-month favorable neurological outcome in patients who underwent ECPR with or without gasping during resuscitation. Multivariate logistic regression analysis was performed to evaluate the association between gasping and outcomes. RESULTS: Of the 454 patients included in the SAVE-J study, data from 212 patients were analyzed in this study after excluding those with missing information and those who did not undergo ECPR. Gasping has been observed in 47 patients during resuscitation; 11 (23.4%) had a favorable neurological outcome at 6 months. Multivariate logistic regression analysis showed that gasping during resuscitation was independently associated with a favorable neurological outcome (odds ratio [OR], 10.58 [95% confidence interval (CI) 3.22-34.74]). The adjusted OR for gasping during emergency medical service transport and on arrival at the hospital was 27.44 (95% CI 5.65-133.41). CONCLUSIONS: Gasping during resuscitation is a favorable factor in patients with refractory VF/pVT. Patients with refractory VF/pVT with continuously preserved gasping during EMS transportation to the hospital are expected to have more favorable outcomes.

Multisystem inflammatory syndrome in adults with COVID-19 requiring mechanical ventilation: A retrospective cohort study.

Aim: Multisystem inflammatory syndrome in adults (MIS-A) is a hyperinflammatory multisystem condition associated with coronavirus disease (COVID-19). Critically ill COVID-19 patients may develop multiorgan damage and elevated inflammatory responses, thus making it difficult to differentiate between progression to organ damage due to COVID-19 itself or MIS-A. This study aimed to explore the characteristics and complications of MIS-A in critical COVID-19 patients. Methods: The Japan Extracorporeal Membrane Oxygenation (ECMO) Network and ICU Collaboration Network developed a web-based database system called the CRoss Intensive Care Unit Searchable Information System (CRISIS) to monitor critical COVID-19 patients throughout Japan. We retrospectively identified patients with MIS-A among critical COVID-19 patients enrolled from March 2020 to December 2021, using CRISIS. Our MIS-A definition required patients to be at least 18 years of age, have laboratory evidence of inflammation, severe dysfunction of at least two extrapulmonary organ systems, and no plausible alternative diagnoses. Results: Of the 1052 patients, 26 (2.5%) were diagnosed with MIS-A. The MIS-A patients had a higher likelihood of using ECMO (13% vs. 46%, p < 0.001) and lower overall survival (77% vs. 42%, p < 0.001) than non-MIS-A patients. More than 80% of the MIS-A cases occurred 3 weeks after the COVID-19 onset. Conclusion: Multisystem inflammatory syndrome in adults can occur in 2.5% of critically ill COVID-19 patients, and the mortality rate is high. Multisystem inflammatory syndrome in adults may be considered when there is a re-elevation of the unexplained inflammatory response and severe dysfunction of at least two extrapulmonary organ systems several weeks after the onset of COVID-19.

Fatal Gastrointestinal Disorders Due to COVID-19: A Case Series.

Patients with coronavirus disease 2019 (COVID-19) primarily develop respiratory symptoms, which sometimes can be serious. Respiratory failure is the most common cause of death from COVID-19. This disease also causes gastrointestinal (GI) symptoms. However, there are limited reports that severe GI disorders caused by COVID-19 can be fatal. Herein, we report three cases of fatal GI disorders caused by COVID-19. All patients developed severe pneumonia requiring mechanical ventilation and venovenous extracorporeal membrane oxygenation (V-V ECMO) support. The respiratory status improved, and the patients could be weaned off support. However, severe watery diarrhea (over a few liters per day) developed after the onset of respiratory failure. The CT, endoscopic, and pathological findings were similar to those observed in GI graft-versus-host disease (GI-GVHD). Despite various efforts, the GI disorders did not improve, and all patients died of multiple organ failures associated with sepsis due to intestinal mucosal disruption. COVID-19 can cause fatal GI disorders and may have similar characteristics to GI-GVHD. Further investigation will contribute to a comprehensive understanding of fatal GI disorders due to COVID-19.

Extension of Selection Time for the Emergency Destination of Patients with a Fever Due to the Coronavirus Disease 2019 Pandemic: A Difference-in-differences Analysis.

Objective During the coronavirus disease 2019 (COVID-19) pandemic period, an extended total activity time (TAT) in emergency cases has been reported, especially in febrile patients. A brief selection time (ST) regarding the transport of patients to designated hospitals is vital to achieving a good outcome. However, to our knowledge, no studies have reported the impact of the COVID-19 pandemic on the ST. We therefore examined the impact of a fever on the ST for the transportation of emergency patients during the COVID-19 pandemic. Methods We analyzed emergency medical services (EMS) data in Sapporo between January 2015 and December 2020. The primary outcome was the ST for the emergency destination of patients. The secondary outcomes were the number of inquiries, time from emergency call to arrival at the scene [call-to-scene time (CST)], time from arrival at the hospital to return base [arrival-to-return time (ART)], and TAT. We used a multivariable linear regression model to estimate the difference-in-differences effect. Results A total of 383,917 patients who were transported to the hospital were enrolled within the study period. The mean ST was 5.8 minutes in 2019 and 7.1 minutes in 2020. The difference-in-differences analyses showed that the mean ST increased by 2.52 minutes (p<0.001), the mean ART by 3.10 minutes (p<0.001), and the mean TAT by 7.27 minutes (p<0.001) for patients with a fever during the COVID-19 period. Conclusion This study showed that febrile patients had a longer ST, ART, and TAT during the 2020 COVID-19 period. Considering the COVID-19 pandemic and the threat of future pandemics, regional infection control and information-sharing should be conducted to reduce the EMS activity time.

Ischemia-induced intestinal de-epithelization and consequent cholangitis lenta after usage of extracorporeal membrane oxygenation in COVID-19 patients: an autopsy series.

Since its discovery in late 2019, severe acute respiratory syndrome coronavirus 2 has spread around the world, causing millions of deaths due to coronavirus disease 2019 (COVID-19). Numerous clinical and post-mortem investigations of COVID-19 cases have found myriad clinical and pathological manifestations of the disease. In this report, we present three autopsy cases in which, despite weaning from extracorporeal membrane oxygenation (ECMO), extensive intestinal epithelial shedding, probably due to ischemia, was followed by massive watery diarrhea and the spread of infection via the portal vein due to bacterial translocation, which resulted in cholangitis lenta. Thrombophilia was attributed to ECMO usage and COVID-19-related vascular endothelial damage. These cases provide instructive findings showing that the loss of the intestinal barrier may be the underlying cause of severe watery diarrhea and liver failure in COVID-19 patients, especially with ECMO usage.

Correlation between the hysteresis of the pressure-volume curve and the recruitment-to-inflation ratio in patients with coronavirus disease 2019.

BACKGROUND: Since the response to lung recruitment varies greatly among patients receiving mechanical ventilation, lung recruitability should be assessed before recruitment maneuvers. The pressure-volume curve (PV curve) and recruitment-to-inflation ratio (R/I ratio) can be used bedside for evaluating lung recruitability and individualing positive end-expiratory pressure (PEEP). Lung tissue recruitment on computed tomography has been correlated with normalized maximal distance (NMD) of the quasi-static PV curve. NMD is the maximal distance between the inspiratory and expiratory limb of the PV curve normalized to the maximal volume. However, the relationship between the different parameters of hysteresis of the quasi-static PV curve and R/I ratio for recruitability is unknown. METHODS: We analyzed the data of 33 patients with severe coronavirus disease 2019 (COVID-19) who received invasive mechanical ventilation. Respiratory waveform data were collected from the ventilator using proprietary acquisition software. We examined the relationship of the R/I ratio, quasi-static PV curve items such as NMD, and respiratory system compliance (Crs). RESULTS: The median R/I ratio was 0.90 [interquartile range (IQR), 0.70-1.15] and median NMD was 41.0 [IQR, 37.1-44.1]. The NMD correlated significantly with the R/I ratio (rho = 0.74, P < 0.001). Sub-analysis showed that the NMD and R/I ratio did not correlate with Crs at lower PEEP (- 0.057, P = 0.75; and rho = 0.15, P = 0.41, respectively). On the contrary, the ratio of Crs at higher PEEP to Crs at lower PEEP (Crs ratio (higher/lower)) moderately correlated with NMD and R/I ratio (rho = 0.64, P < 0.001; and rho = 0.67, P < 0.001, respectively). CONCLUSIONS: NMD of the quasi-static PV curve and R/I ratio for recruitability assessment are highly correlated. In addition, NMD and R/I ratio correlated with the Crs ratio (higher/lower). Therefore, NMD and R/I ratio could be potential indicators of recruitability that can be performed at the bedside.

Pneumomediastinum as patient self-inflicted lung injury in patients with acute respiratory distress syndrome due to COVID-19: a case series.

Background: In patients with coronavirus disease (COVID-19) due to severe acute respiratory syndrome coronavirus 2 infection, pneumomediastinum has been increasingly reported in cases of noninvasive oxygen therapy, including high-flow nasal cannula, and invasive mechanical ventilation. However, its pathogenesis is still not understood. Case Presentation: We report two cases of pneumomediastinum in acute respiratory distress syndrome (ARDS) caused by COVID-19. In both cases, control of spontaneous breathing with neuromuscular blocking agents resulted in resolution of pneumoperitoneum. Conclusion: The improvement of pneumomediastinum with control of spontaneous breathing suggested patient self-inflicted lung injury as a possible mechanism in this case series. In ARDS cases with pneumomediastinum, in addition to controlling plateau pressure with conventional lung protective ventilation, spontaneous breathing should be controlled if the patient's inspiratory effort is suspected to be strong.

Continuous renal replacement therapy using a cellulose triacetate hemofilter for severe coronavirus disease.

Background: In patients with severe coronavirus disease (COVID-19), the use of acrylonitrile hemofilters can reduce cytokine concentrations. However, acrylonitrile hemofilters can easily coagulate, and the effect of hemofilters on improvement in patient prognosis remains unclear. Therefore, we aimed to investigate the changes in serum cytokine concentrations, alleviation of organ damage, and improvement in patient prognosis with continuous renal replacement therapy (CRRT) using a cellulose triacetate (CTA) filter with excellent anticoagulation property in patients with severe COVID-19. Methods: This was a retrospective, single-center study conducted by the Advanced Critical Care Center in Sapporo Medical University Hospital, Japan. Seven patients with severe COVID-19 between March 01 and June 30, 2020, were included. The patients were under mechanical ventilation and received continuous blood purification therapy with a CTA filter. We summarized the CRRT status and patient prognosis and measured their serum cytokine (interleukin [IL]-1ß, IL-4, IL-6, IL-8, IL-10, tumor necrosis factor-α, and interferon-γ) and serum marker levels, before and after CRRT. In addition, we evaluated the changes in their respiratory status, hemodynamics, and organ dysfunction scores. The average age of the patients was 61.5 years, and five patients were male. Extracorporeal membrane oxygenation was used in five patients. The treatment outcome included three deaths. Results: The median CRRT duration was 7 days. The hemofilter was replaced once a day. After CRRT, the IL-6 concentration decreased from 393 to 85 pg/mL (p = 0.016), the Krebs von den Lungen-6 concentration decreased from 554 to 350 U/mL, and the PaO2/FiO2 ratio increased significantly from 90 to 248, and therefore, oxygenation improved. In addition, the norepinephrine dose and lactate level decreased, and the circulation tended to improve; however, the renal function and Sequential Organ Failure Assessment score did not change. Conclusions: The serum IL-6 level decreased, and the respiratory status improved upon CRRT using a CTA filter in patients with severe COVID-19.

Benefits of Hypothermia for Young Patients with Acute Subdural Hematoma: A Computed Tomography Analysis of the Brain Hypothermia Study.

Therapeutic hypothermia for severe traumatic brain injury (TBI) has been repeatedly studied, but no past studies have assessed the detailed head computed tomography (CT) findings. We sought to investigate individual CT findings of severe TBI patients treated with targeted temperature management utilizing the head CT database obtained from the Brain Hypothermia study. Enrolled patients underwent either mild therapeutic hypothermia (32.0°C-34.0°C) or fever control (35.5°C-37.0°C). We assessed individual head CT images on arrival and after rewarming and investigated the correlations with outcomes. The initial CT data were available for 125 patients (hypothermia group = 80, fever control group = 45). Baseline characteristics and CT findings, such as hematoma thickness and midline shift, were similar in all aspects between the two groups. The favorable outcomes in the hypothermia and fever control groups were 38 (47.5%) and 24 (53.3%; p = 0.53) for all 125 patients, respectively; 21 (46.7%) vs. 10 (38.5%; p = 0.50) for 71 patients with acute subdural hematoma (SDH), respectively; and 12 (75.0%) vs. 4 (36.4%; p = 0.045) in 27 young adults (≤50 years) with acute SDH, respectively. There was a trend toward favorable outcomes for earlier time to reach 35.5°C (190 vs. 377 min, p = 0.052) and surgery (155 vs. 180 min, p = 0.096) in young patients with acute SDH. The second CT image revealed progression of the brain injury. This study demonstrated the potential benefits of early hypothermia in young patients with acute SDH, despite no difference in CT findings between the two groups. However, the small number of cases involved hindered the drawing of definitive conclusions. Future studies are warranted to validate the results.

Disseminated mucormycosis in a patient with severe COVID-19 on venovenous extracorporeal membrane oxygenation: A case report.

Background: Since the global outbreak of coronavirus disease 2019 (COVID-19), there have been several reports of mucormycosis as a secondary complication. However, the disseminated type of mucormycosis is extremely rare. Case: A 58-year-old male patient with COVID-19 started receiving venovenous extracorporeal membrane oxygenation because of severe respiratory failure. During hospitalization, intra-abdominal hemorrhage occurred and an emergency laparotomy was performed. Subsequently, the patient suffered septic shock, and part of the small intestines and the abdominal wall became necrotic. Finally, the patient died. At autopsy, he was diagnosed with disseminated mucormycosis. Conclusion: Disseminated mucormycosis should be considered in patients with COVID-19 with refractory sepsis unresponsive to broad-spectrum antimicrobial therapy.

Cases of prolonged cardiac arrest with preserved gasping successfully resuscitated with ECPR.

Longer cardiopulmonary resuscitation (CPR) time is associated with worsened neurological outcomes in out-of-hospital cardiac arrest (OHCA). Gasping during CPR is a favorable neurological predictor for OHCA. Recently, the efficacy of extracorporeal cardiopulmonary resuscitation (ECPR) in refractory cardiac arrest has been reported. However, the significance of gasping in refractory cardiac arrest patients with long CPR durations treated with ECPR is still unclear. We report two cases of cardiac arrest with gasping that were successfully resuscitated by ECPR, despite extremely long low-flow times. In case 1, a 58-year-old man presented with cardiac arrest and ventricular fibrillation (VF). Gasping was observed when the patient arrived at the hospital. ECPR was initiated 82 min after cardiac arrest. The patient was diagnosed with hypertrophic cardiomyopathy. ECMO was withdrawn on day 4, and the patient was discharged without neurological impairment. In case 2, a 49-year-old man experienced cardiac arrest with VF, and his gasping was preserved during transportation. On arrival, VF persisted, and gasping was observed; therefore, ECMO was initiated 93 min after cardiac arrest. He was diagnosed with acute myocardial infarction. ECMO was withdrawn on day 4 and he was discharged from the hospital without any neurological impairment. Resuscitation and ECPR should not be abandoned in case of preserved gasping, even when the low-flow time is extremely long.