Veno-venous extracorporeal membrane oxygenation for perioperative management of infective endocarditis after COVID-19 with acute respiratory distress syndrome: a case report.

BACKGROUND: Infective endocarditis (IE) is a rare cardiovascular complication in patients with coronavirus disease 2019 (COVID-19). IE after COVID-19 can also be complicated by acute respiratory distress syndrome (ARDS); however, the guidelines for the treatment of such cases are not clear. Here, we report a case of perioperative management of post-COVID-19 IE with ARDS using veno-venous extracorporeal membrane oxygenation (V-V ECMO). CASE PRESENTATION: The patient was a 40-year-old woman who was admitted on day 18 of COVID-19 onset and was administered oxygen therapy, remdesivir, and dexamethasone. The patient's condition improved; however, on day 24 of hospitalization, the patient developed hypoxemia and was admitted to the intensive care unit (ICU) due to respiratory failure. Blood culture revealed Corynebacterium striatum, and transesophageal echocardiography revealed vegetation on the aortic and mitral valves. Valve destruction was mild, and the cause of respiratory failure was thought to be ARDS. Despite continued antimicrobial therapy, ARDS did not improve the patient's condition, and valve destruction progressed; therefore, surgical treatment was scheduled on day 13 of ICU admission. After preoperative consultation with the team, a decision was made to initiate V-V ECMO after the patient was weaned from CPB, with concerns about further worsening of her respiratory status after surgery. The patient returned to the ICU with transition to V-V ECMO, and her circulation remained stable. The patient was weaned off V-V ECMO on postoperative day 33 and discharged from the ICU on postoperative day 47. CONCLUSIONS: ARDS may occur in patients with IE after COVID-19. Owing to concerns about further exacerbation of pulmonary damage, the timing of surgery should be comprehensively considered. Preoperatively, clinicians should discuss perioperative ECMO introduction and configuration.

Arterial oxygen pressure during veno-venous extracorporeal membrane oxygenation may be increased by advancing the tip of the drainage cannula into the superior vena cava: a case report.

A simple and robust method for veno-venous extracorporeal membrane oxygenation (V-V ECMO) involves a drainage cannula into the inferior vena cava via the femoral vein (FV) and a reinfusion cannula into the right atrium (RA) via the internal jugular vein (IJV) (F-J configuration). However, with this method, the arterial oxygen (PaO2) is said to remain below 100 mmHg.Since recently, in our ICU, to prevent drainage failure, we apply a modification from the commonly practiced F-J configuration by advancing the tip of the drainage cannula inserted via the FV into the superior vena cava (SVC) and crossing the reinfusion cannula inserted via the IJV in the RA (F(SVC)-J(RA) configuration). We experienced that this modification can be associated with unexpectedly high PaO2 values, which here we investigated in detail.Veno-arteriovenous ECMO was induced in a 65-year-old male patient who suffered from repeated cardiac arrest due to acute respiratory distress syndrome. His chest X-ray images showed white-out after lung rest setting, consistent with near-absence of self-lung ventilation. Cardiac function recovered and the system was converted to F(SVC)-J(RA) configuration, after which both PaO2 and partial pressure of pulmonary arterial oxygen values remained high above 200 mmHg. Transesophageal echocardiography could not detect right-to-left shunt, and more efficient drainage of the native venous return flow compared to common F-J configuration may explain the increased PaO2.Although the F(SVC)-J(RA) configuration is a small modification of the F-J configuration, it seems to provide a revolutionary improvement in the ECMO field by combining robustness/simplicity with high PaO2 values.

Usefulness of intraoperative transesophageal echocardiography for hemodynamic management of liver transplantation in a patient with massive polycystic liver disease: a case report.

BACKGROUND: Hemodynamic management during anesthesia in liver transplantation for patients with polycystic liver disease (PLD) can be more challenging because of the bleeding and hemodynamic alterations due to the markedly enlarged liver. We hereby report a case of PLD wherein transesophageal echocardiography (TEE) was employed for optimal hemodynamic monitoring during liver transplantation. CASE PRESENTATION: A 61-year-old man was scheduled to undergo liver transplantation for massive PLD. Hemodynamic instability was associated with mechanical displacement of the giant cystic liver. TEE results revealed the collapse of the inferior vena cava due to liver displacement. TEE also detected intrathoracic hemorrhage triggered by detachment from the markedly enlarged liver. CONCLUSION: TEE is a valuable monitoring tool for sharing information with surgeons and diagnostic modality for finding the source of bleeding in liver transplantation for PLD and may contribute majorly to the quality of perioperative management.

Abnormal stenosis of a drainage cannula due to excessive negative pressure during venovenous extracorporeal membrane oxygenation management: a case report.

We report a case in which excessive negative pressure may have been applied to the proximal side hole of a drainage cannula during venovenous extracorporeal membrane oxygenation (V-V ECMO), resulting in abnormal stenosis of the drainage cannula. V-V ECMO was introduced in a 71-year-old male patient who was transferred from another hospital for severe respiratory failure associated with varicella pneumonia and acute respiratory distress syndrome. Drainage was performed using a PCKC-V™ 24Fr (MERA, Japan) cannula via the right femoral vein with the tip of the cannula near the level of the diaphragm under fluoroscopy. Reinfusion was performed via the right internal jugular vein. Due to poor systemic oxygenation, the drainage cannula was withdrawn caudally and refixed to reduce the effect of recirculation. Two days later, drainage pressure dropped rapidly, and frequent ECMO flow interruption occurred due to poor drainage. An abdominal X-ray revealed abnormal stenosis of the proximal side hole site of the drainage cannula. We diagnosed that the drainage cannula was damaged, and it was replaced with another, namely a Medtronic Bio-Medicus™ 25 Fr (GETINGE, Sweden) cannula. However, the removed drainage cannula was not damaged, suggesting that the cannula was temporarily stenosed by momentary excessive negative pressure. In a multi-stage drainage cannula, the main drainage site is the proximal side hole, with little negative pressure applied at the apical foramen in a mock experimental ex vivo drainage test in a water tank. Hence, improvement of a multi-stage drainage cannula is recommended, such as adequate reinforcement of the side hole site with a wire.

Promotion of a venous thromboembolism prevention protocol at a perioperative management center.

Objectives: Perioperative venous thromboembolism (VTE) is a potentially fatal complication, making preoperative VTE diagnosis and secondary thromboprophylaxis important. This study was performed to investigate the impact of promotion of a preoperative VTE protocol at a perioperative management center (PMC) on detecting the preoperative VTE rate and subsequent treatment. Methods: This retrospective study involved patients aged ≥20 years who underwent elective anesthesia. The patients were divided into two groups: the pre-PMC group (January to October 2014, before the opening of the PMC) and the post-PMC group (January to December 2019, after the opening of the PMC). The rates of preoperative lower-limb compression ultrasonography (CUS), VTE detection, anticoagulation therapy, and new postoperative pulmonary embolism (PE) were compared between the two groups. Results: The pre-PMC and post-PMC groups comprised 3737 and 5388 patients, respectively. The preoperative CUS and VTE detection rates were significantly higher in the post-PMC than pre-PMC group (7.2% and 1.43% vs. 25.6% and 3.93%, respectively; P<0.001). There was no significant difference in the rate of anticoagulation therapy in patients with preoperative VTE (88.9% vs. 84.7%, P=0.43). Heparin and direct oral anticoagulants were primarily used in the pre-PMC and post-PMC groups, respectively. The efficacy and safety were comparable between the two groups. No new postoperative PE was detected in either group. Conclusions: Promotion of the preoperative VTE protocol led by the PMC increased the rates of preoperative CUS and preoperative VTE detection. This may aid in secondary thromboprophylaxis in the preoperative period and prevention of postoperative PE.

Postreperfusion Syndrome Presenting as Posttransplant Portal Hypertension due to Prolonged Elevation of Pulmonary Vascular Resistance and the Role of Nitroglycerin in Diagnosis and Treatment: A Case Report of Budd-Chiari Syndrome.

Postreperfusion syndrome is one of the responsible mechanisms of portal hypertension in patients undergoing liver transplantation. And post-transplant portal hypertension causes graft dysfunction. Postreperfusion syndrome is characterized by a decrease in arterial pressure and cardiac output, and an increase in central venous pressure, pulmonary artery pressure, and pulmonary vascular resistance that occurs after the release of the portal vein clamp. Although early recovery from postreperfusion syndrome is desired, there is a little medication therapy such as the administration of calcium chloride, sodium bicarbonate, and beta-agonist for postreperfusion syndrome. We present a case of postreperfusion syndrome manifested as post-transplant portal hypertension and reversed after nitroglycerin administration. A 49-year-old Asian woman was scheduled for liver transplantation because of Budd-Chiari syndrome. After portal vein reperfusion, she experienced severe postreperfusion syndrome. Administration of ephedrine and calcium restored arterial pressure; however, pulmonary artery pressure, pulmonary vascular resistance, and central venous pressure elevations were sustained, causing right ventricular overload. This condition did not improve after hepatic artery reperfusion, and caused post-transplant portal hypertension. After nitroglycerin administration, pulmonary vascular resistance and central venous pressure decreased, mean arterial pressure increased, right heart contractility recovered, and portal hypertension disappeared. Hemodynamic improvement by nitroglycerin administration helped in diagnosing postreperfusion syndrome and avoiding unnecessary splenectomy. If portal vein pressure increases after liver transplantation, the change in hemodynamic parameters by nitroglycerin administration should be assessed, which will lead to accurate diagnosis and appropriate treatment. Furthermore, postreperfusion syndrome should be listed as a differential diagnosis of post-transplant portal hypertension.

Suture trabeculotomy ab interno for secondary glaucoma in Japanese patients with Val30Met hereditary transthyretin amyloidosis.

We retrospectively evaluated surgical outcomes of suture trabeculotomy (SLOT) ab interno for secondary glaucoma in 18 eyes of 12 patients with hereditary transthyretin (ATTRv) amyloidosis with Val30Met mutation. SLOT ab interno was performed between May 2015 and January 2020. All the participants were followed up for at least 12 months. The primary outcome measure was Kaplan-Meier survival. Failure of this treatment was defined as an intraocular pressure (IOP) of ≥ 22 mmHg and a < 20% IOP reduction with or without medication or as additional operations needed to reduce IOP. The mean postoperative follow-up period was 3.5 years (1.2-6.1 years). The SLOT ab interno procedure alone was performed in 17 eyes (94%). Fifteen eyes (83%) had a 360° incision made in Schlemm's canal and 3 eyes (17%) had a 180° incision performed. Cumulative survival values were 0.83, 0.63, and 0.22 at 1, 2, and 3 years, respectively. Ten eyes (56%) needed additional surgery, such as repeated SLOT ab interno, Ahmed glaucoma valve implantation, or MicroPulse transscleral cyclophotocoagulation. Our results here, as well as our previous results with trabeculectomy, suggest that SLOT ab interno may not have a sufficiently long-term effect on secondary glaucoma because of ATTRv amyloidosis.

A Larger Membrane Area Increases Cytokine Removal in Polymethyl Methacrylate Hemofilters.

Blood purification is performed to control cytokines in critically ill patients. The relationship between the clearance (CL) and the membrane area during adsorption is not clear. We hypothesized that the CL increases with the hydrophobic area when hydrophobic binding contributes to cytokine adsorption. We investigated the relationship between the hemofilter membrane area and the CL of the high mobility group box 1 protein (HMGB-1) and interleukin-6 (IL-6). We performed experimental hemofiltration in vitro using polymethyl methacrylate membranes CH-1.8W (1.8 m2) and CH-1.0N (1.0 m2), as well as polysulfone membrane NV-18X (1.8 m2). After adding 100 mg of HMGB1 or 10 µg of IL-6 into the test solution, experimental hemofiltration was conducted for 360 min in a closed-loop circulation system, and the same amount of HMGB1 and IL-6 was added after 180 min. With CH-1.8W and CH-1.0N, both HMGB-1 and IL-6 showed a rapid concentration decrease of more than 70% at 180 min and 360 min after the re-addition. At 15 min, the CL of HMGB-1 was CH-1.8W: 28.4 and CH-1.0N: 19.8, and that of IL-6 was CH-1.8W: 41.1 and CH-1.0N: 25.4. CH-1.8W and CH-1.0N removed HMGB1 and IL-6 by adsorption and CH-1.8W was superior in CL, which increased with a greater membrane area.

Effects of Thrombomodulin in Reducing Lethality and Suppressing Neutrophil Extracellular Trap Formation in the Lungs and Liver in a Lipopolysaccharide-Induced Murine Septic Shock Model.

Neutrophil extracellular trap (NET) formation, an innate immune system response, is associated with thrombogenesis and vascular endothelial injury. Circulatory disorders due to microvascular thrombogenesis are one of the principal causes of organ damage. NET formation in organs contributes to the exacerbation of sepsis, which is defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection. We have previously reported that recombinant human soluble thrombomodulin (rTM) reduces lipopolysaccharide (LPS)-induced NET formation in vitro. Here, we aimed to show that thrombomodulin (TM)-mediated suppression of NET formation protects against organ damage in sepsis. Mice were injected intraperitoneally (i.p.) with 10 mg/kg LPS. rTM (6 mg/kg/day) or saline was administered i.p. 1 h after LPS injection. In the LPS-induced murine septic shock model, extracellular histones, which are components of NETs, were observed in the liver and lungs. In addition, the serum cytokine (interleukin-1ß (IL-1ß), interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), macrophage chemotactic protein-1 (MCP-1), and interleukin-10 (IL-10)) levels were increased. The administration of rTM in this model prevented NET formation in the organs and suppressed the increase in the levels of all cytokines except IL-1ß. Furthermore, the survival rate improved. We provide a novel role of TM in treating inflammation and NETs in organs during sepsis.

Effects of Ripasudil on Open-Angle Glaucoma after Circumferential Suture Trabeculotomy Ab Interno.

We evaluated the effects of ripasudil on the distal aqueous outflow tract in patients with open-angle glaucoma (OAG) who underwent a 360° suture trabeculotomy ab interno followed by ripasudil treatment beginning 1 month postoperatively. We compared 27 of these patients, by using propensity score analysis, with 27 patients in a matched control group who had no ripasudil treatment. We assessed the changes in the mean intraocular pressure (IOP) and the relationship between the IOP changes and background factors. All eyes had a complete 360° Schlemm's canal incision and phacoemulsification. The mean IOP at 1 and 3 months after ripasudil administration were significantly reduced by -1.7 ± 1.9 mmHg (p < 0.0001) and -1.3 ± 2.3 mmHg (p = 0.0081) in the ripasudil group, respectively, but IOP in the control group was not significantly reduced. The IOP reduction was significantly associated with the IOP before ripasudil treatment (p < 0.001). In conclusion, the use of ripasudil for patients with OAG after circumferential incision of the Schlemm's canal produced significant IOP reductions. Ripasudil may affect the distal outflow tract, thereby leading to the IOP reduction.

Usefulness of mirror image processing software for creating images of expected appearance after blepharoptosis surgery.

PURPOSE: This study aims to evaluate the usefulness of creating images of expected appearance after blepharoptosis surgery using mirror image processing software. METHODS: This prospective, observational study included 60 sides from 30 patients with bilateral aponeurotic blepharoptosis who underwent levator resection or aponeurotic repair on both sides. Before surgery, facial photographs were taken after the eyelid on one side was lifted with a curved hook. The mirror images were created from these photographs and were merged with the original photographs for making the whole facial images, which were shown to each patient at the preoperative counseling. At 1 month postoperatively, we asked patients about the usefulness of the mirror images to predict the postoperative appearance at the preoperative counseling and the similarity between the expected and the resultant postoperative appearance using questionnaires. Margin reflex distance-1, eyebrow height, and pretarsal skin height measured on predictive images were compared with those measured at 1 month postoperatively. RESULTS: Twenty-nine patients (96.7%) favorably responded to the usefulness of the mirror images to predict the postoperative appearance, and twenty-five patients (83.3%) accepted the similarity between the expected appearance and the actual postoperative appearance. The predictive images showed significantly lower margin reflex distance-1, higher eyebrow height, and higher pretarsal skin height than the postoperative results (P < 0.001). CONCLUSION: The creation of expected postoperative images was a useful simulation procedure before blepharoptosis surgery for patients to predict the probable postoperative appearance.

12-month randomised trial of 360° and 180° Schlemm's canal incisions in suture trabeculotomy ab interno for open-angle glaucoma.

BACKGROUND/AIMS: To perform a 12-month comparison between the different extents and locations of Schlemm's canal incisions during suture trabeculotomy ab interno for open-angle glaucoma (OAG). METHODS: This is a prospective, single-centre, three-arm randomised trial. A total of 99 eyes of 99 patients were randomly assigned to one of three groups: the 360° incision group (n=34), the upper-180° incision group (n=34) and the lower-180° incision group (n=31). Intraocular pressure (IOP), number of medications and complications were evaluated until 12 months after surgery. Surgical success (with or without medication) was defined as IOP ≤21 mmHg and ≥20% IOP reduction (criterion A) or IOP ≤15 mmHg and ≥20% IOP reduction (criterion B). RESULTS: The mean IOP (±SD) in all eyes was reduced from 18.6 (5.9) mmHg with 3.1 (1.1) medications to 13.7 (3.4) mmHg (20.8% reduction; p<0.001) with 1.4 (1.3) medications (p<0.001) at postoperative 12-month. Each group produced comparable mean reductions in both IOP and the number of medications throughout 12 months of follow-up. Kaplan-Meier cumulative survival analyses showed no significance among these three groups for criterion A and criterion B. Postoperative hyphema with niveau formation occurred significantly more in the 360° group than in the lower-180° group (p=0.031). CONCLUSIONS: The different extents and locations of Schlemm's canal incisions during suture trabeculotomy ab interno for OAG, including the 360° incision, the upper-180° incision and the lower-180° incision, do not affect both the IOP reduction and the medications throughout 12 months of follow-up. TRIAL REGISTRATION NUMBER: UMIN000021169.

Impact of Blood Type O on Mortality of Sepsis Patients: A Multicenter Retrospective Observational Study.

ABO blood groups have been implicated as potential risk factors for various diseases. However, no study has investigated the association between sepsis mortality and ABO blood types. We aimed to evaluate the impact of these blood types on mortality in patients with sepsis and septic shock. This retrospective observational study was conducted at two general hospitals in Japan. Patients diagnosed with sepsis or septic shock were included and divided into four groups based on blood type (O, A, B, and AB). The association between type O vs. other types and 28- and 90-day mortalities was evaluated using multivariate logistic regression analysis adjusted for age, sex, and Sequential (Sepsis-related) Organ Failure Assessment score. This study included 415 patients, of whom 131 (31.6%), 171 (41.2%), 81 (19.5%), and 32 (7.7%) had type O, A, B, and AB, respectively. Blood type O was not associated with 28-day (odds ratio: 1.7 p = 0.08) or 90-day mortality (odds ratio: 1.53, p = 0.091). However, type O was significantly associated with higher 90-day mortality (odds ratio: 3.26, p = 0.009) in patients with septic shock. The role of ABO blood type in risk stratification for septic shock and the mechanisms that potentially affect the prognosis of sepsis patients need further investigation.

Macular pucker formation after macular hole surgery with inverted internal limiting membrane flap technique and silicone oil tamponade.

PURPOSE: The inverted internal limiting membrane (ILM) technique was recently introduced for refractory macular hole. Here, we evaluate a case of macular pucker formation after macular hole surgery using the inverted ILM flap technique and silicone oil tamponade. After undergoing vitrectomy combined with ILM removal, the patient had a good visual prognosis. OBSERVATIONS: A 49-year-old male with macular hole affecting both of his eyes underwent vitrectomies. Three months after the first surgery in his right eye, macular pucker formation was observed in the macula, which was associated with the ILM flap used to cover the macular hole. After peeling the ILM, the macula returned to a normal contour and visual acuity improved. Examination of the removed ILM revealed macrophage-like cells containing silicone oil particles that were responsible for the ILM contraction. CONCLUSIONS AND IMPORTANCE: When using the inverted ILM flap technique and silicone oil, macular pucker may occur after macular hole surgery. Peeling of the ILM flap restored the macular shape and did not reopen the macular hole, thereby improving visual acuity. Thus, silicone oil should be used with caution when performing macular hole surgery with the ILM flap technique.

Lower blood return temperature than core temperature as a causal factor of decreased cardiac output assessed by transpulmonary thermodilution during blood purification.

We aimed to evaluate whether cardiac output assessed by transpulmonary thermodilution during blood purification is affected by the difference between the blood return temperature and core temperature. We applied different blood return temperatures using a thermostat bath during blood purification in four pigs. After the blood return temperature stabilized and blood purification process stopped, the cardiac output assessed by transpulmonary thermodilution was measured. The thermostat bath was set at 35°C, 40°C, 45°C, and 50°C, with the order changed at random; four measurements were made at each temperature. Cardiac function was evaluated by echocardiography when ice-cold saline was administered in a pig. A decrease in the blood return temperature resulted in decreased cardiac output assessed by transpulmonary thermodilution, whereas an increase resulted in increased cardiac output assessed by transpulmonary thermodilution. Echocardiography revealed that the change in the blood return temperature did not affect the left ventricular ejection fraction.

Involvement of ionic interactions in cytokine adsorption of polyethyleneimine-coated polyacrylonitrile and polymethyl methacrylate membranes in vitro.

Polyethyleneimine-coated polyacrylonitrile (AN69ST) and polymethyl methacrylate (PMMA) membranes are effective cytokine-adsorbing hemofilters; however, the cytokine-adsorption mechanism remains elusive. This study investigated the involvement of ionic interactions in cytokine adsorption to a negatively charged AN69ST membrane and neutral-charged PMMA membrane. Experimental hemofiltration was performed for 30 min in a closed-loop circulation system using AN69ST and PMMA hemofilters. Tumor necrosis factor (TNF)-α, interleukin (IL)-6, and IL-8 concentrations in the test solutions were measured at baseline and at 10 min and 30 min into hemofiltration. To investigate the involvement of ionic interactions in cytokine adsorption, cytokine clearance (CL) was calculated at 10 min into hemofiltration and with three types of solutions at various pH levels (7.6, 7.2, and 6.8). During AN69ST hemofiltration, the CLs of TNF-α, IL-6, and IL-8 were 38 ± 6 mL/min, 23 ± 7 mL/min, and 78 ± 3 mL/min, respectively, demonstrating a relationship with their respective isoelectric points. During PMMA hemofiltration, the CL of IL-6 peaked at 31 ± 76 mL/min, with no relationship observed between the CL and isoelectric point. When the pH of the test solution shifted from 7.6 to 6.8, the CLs of TNF-α, IL6, and IL-8 increased in the AN69ST hemofilter; whereas, no such trend was observed in the PMMA hemofilter. These results indicated that Ionic interactions play a role in cytokine adsorption by the AN69ST membrane but not the PMMA membrane and highlight the clinical relevance of this finding, as well as the potential practical applications for further hemofilter design.

In vitro Evaluation of Linezolid and Doripenem Clearance with Different Hemofilters.

INTRODUCTION: Renal replacement therapy (RRT) is widely used in the treatment of septic acute kidney injury. However, little is known about how the adsorption properties of hemofilters used in RRT affect antibiotic concentration. Because a cytokine-adsorption membrane is frequently used in RRT, it is important to determine the antibiotic adsorption capacity of this membrane. OBJECTIVE: The present study aimed to investigate the antibiotic adsorption capacity of different hemofilter membranes by in vitro experiments using 2 antibacterial agents (linezolid and doripenem). METHODS: We performed experimental hemofiltration in vitro using polyacrylonitrile (AN69ST), polymethylmethacrylate (PMMA), and polysulfone (PS) hemofilters for 1,440 min. The test solution was a 1,000-mL substitution fluid containing 30 µg/mL linezolid and 120 µg/mL doripenem. We measured drug concentrations at the inlet, outlet, and filtrate ports of the hemofilters for 1,440 min and calculated the sieving coefficient (SC) and adsorption rate (Ra) of the drugs onto the hemofilters. RESULTS: The amount of linezolid adsorbed onto AN69ST, PMMA, and PS membranes was decreased relative to that in the control group at 15 min (p < 0.05). However, no SC for linezolid was obtained thereafter. The Ra of linezolid onto AN69ST, PMMA, and PS membranes was higher than that in the control group (p < 0.05). In contrast, no significant differences were observed in the concentrations and Ra values of doripenem adsorbed onto AN69ST, PMMA, and PS membranes compared with those in the control group. CONCLUSIONS: Doripenem was not adsorbed onto PMMA, PS, and AN69ST membranes. Linezolid was adsorbed onto PMMA, PS, and AN69ST membranes, but only temporarily, and this did not affect drug bioavailability.

Suppressive effects of the neutrophil elastase inhibitor sivelestat sodium hydrate on interleukin-1ß production in lipopolysaccharide-stimulated porcine whole blood.

OBJECTIVE: Sivelestat sodium hydrate (Siv) is expected to be an effective therapy for acute respiratory distress syndrome, although its mechanism of action is not understood. In this study, we investigated which myeloid cells-derived cytokines were suppressed by Siv. METHODS: Continuous hemofiltration was performed by circulating fresh porcine blood through a semi-closed circuit. To ensure that leukocytes survived for 360 min, 5% glucose, heparin, and air were continuously injected. The control group received continuous administration of lipopolysaccharide (LPS) only, whereas the Siv group received LPS and Siv. Complete blood count, levels of various cytokines, and other variables were compared between the groups. RESULTS: Interleukin (IL)-1ß level was significantly suppressed in the Siv group compared with that in the control group (p<0.05). CONCLUSIONS: The results suggested that Siv suppressed the production of IL-1ß and possibly other cytokines by myeloid cells. Whether this suppression of cytokine production is caused directly by Siv or mediated via suppression of granulocyte elastase should be evaluated in the future.

Thoracic stomach syndrome after whole-stomach esophagectomy for esophageal cancer mimicking tension pneumothorax: a case report.

BACKGROUND: Sudden onset of respiratory failure is one of the most fearful manifestations in intensive care units. Among the differential diagnoses of respiratory failure, tension pneumothorax is a life-threatening disease that requires immediate invasive intervention to drain the air from the thoracic cavity. However, other etiologies with manifestations similar to those of tension pneumothorax should also be considered after whole-stomach esophagectomy for esophageal cancer. We report a rare case of a patient with thoracic stomach syndrome mimicking tension pneumothorax after esophagectomy with whole-stomach reconstruction. CASE PRESENTATION: A 49-year-old Asian woman was admitted to our intensive care unit after esophagectomy for esophageal cancer with whole-stomach reconstruction while under sedation and intubated. Despite initial stable vital signs, the patient rapidly developed tachypnea, low blood pressure, and low oxygen saturation. Chest radiography revealed a mediastinal shift and led to a presumptive diagnosis of tension pneumothorax. Hence, an aspiration catheter was inserted into the right pleural space. However, her clinical symptoms did not improve. Chest computed tomography was performed, which revealed a significantly distended reconstructed stomach that was compressing the nearby lung parenchyma. Her respiration improved immediately after nasogastric tube placement. After the procedure, we successfully extubated the patient. CONCLUSIONS: Similar to tension pneumothorax, thoracic stomach syndrome requires immediate drainage of air from the thoracic cavity. However, unlike tension pneumothorax, this condition requires nasogastric tube insertion, which is the only way to safely remove the accumulated air and avoid possible complications that could occur due to percutaneous drainage. For patient safety, it might be clinically important to place nasogastric tubes after esophagectomy with whole-stomach reconstruction, even if radiographic guidance is required. In addition, clinicians should consider thoracic stomach syndrome as one of the differential diagnoses of respiratory failure after whole-stomach esophagectomy.

Differential effect of lactate in predicting mortality in septic patients with or without disseminated intravascular coagulation: a multicenter, retrospective, observational study.

BACKGROUND: We examined whether high lactate level in septic patients was associated with 90-day mortality based on the patients' disseminated intravascular coagulation (DIC) status. METHODS: We conducted a multicenter, retrospective, observational study of patients admitted to the intensive care unit (ICU) with a suspicion of severe infection and diagnosed with sepsis. Regression analyses were performed to estimate the interaction effect between DIC status and the lactate level. Then, the association between the lactate level and 90-day mortality was assessed in the DIC and non-DIC subgroups. RESULTS: The data of 415 patients were analyzed. We found a significant interaction between DIC status and the lactate level for predicting 90-day mortality (p interaction = 0.04). Therefore, we performed a subgroup analysis and found that high lactate concentration was significantly associated with 90-day mortality in the DIC group (odds ratio = 2.31, p = 0.039) but not in the non-DIC group. CONCLUSIONS: In patients with DIC, a high lactate level significantly predicted 90-day mortality; no such association was found in the non-DIC group. Thus, DIC status may serve as a possible effect modifier of lactate level in predicting mortality in patients with sepsis.