Modifications of peripheral perfusion in patients with vasopressor-dependent septic shock treated with polymyxin B-direct hemoperfusion.

Abnormal peripheral perfusion (PP) worsens the prognosis of patients with septic shock. Polymyxin B-direct hemoperfusion (PMX-DHP) increases blood pressure and reduces vasopressor doses. However, the modification of PP following administration of PMX-DHP in patients with vasopressor-dependent septic shock have not yet been elucidated. A retrospective exploratory observational study was conducted in patients with septic shock treated with PMX-DHP. Pulse-amplitude index (PAI), vasoactive inotropic score (VIS), and cumulative fluid balance data were extracted at PMX-DHP initiation (T0) and after 24 (T24) and 48 (T48) h. Changes in these data were analyzed in all patients and two subgroups (abnormal PP [PAI < 1] and normal PP [PAI ≥ 1]) based on the PAI at PMX-DHP initiation. Overall, 122 patients (abnormal PP group, n = 67; normal PP group, n = 55) were evaluated. Overall and in the abnormal PP group, PAI increased significantly at T24 and T48 compared with that at T0, with a significant decrease in VIS. Cumulative 24-h fluid balance after PMX-DHP initiation was significantly higher in the abnormal PP group. PMX-DHP may be an effective intervention to improve PP in patients with abnormal PP; however, caution should be exercised as fluid requirements may differ from that of patients with normal PP.

Allergen-Related Coronary Vasospasm "Kounis Syndrome" Requiring Administration of Epinephrine and a Coronary Vasodilator.

Kounis syndrome is an anaphylactic reaction leading to acute coronary syndrome. The acute treatment of anaphylaxis is epinephrine; however, epinephrine may cause coronary vasoconstriction, reduce coronary blood flow, increase myocardial oxygen demand, and worsen myocardial ischemia. On the other hand, coronary vasodilation, a treatment for acute coronary syndrome, can aggravate hypotension in patients with anaphylaxis. Herein, the authors report a case of type II Kounis syndrome, with vasospasm in a patient with coronary disease, requiring the administration of epinephrine and a coronary vasodilator for resuscitation. The authors administered intravenous epinephrine continuously from lower dosages and performed delicate titration. The coronary vasodilator nicorandil, which has little effect on hemodynamics, also was administered. These treatments improved hemodynamics without complications. Circulatory management that considers both anaphylaxis and coronary lesions is crucial to improve prognosis in this syndrome.

Importance of respiratory rate for the prediction of clinical deterioration after emergency department discharge: a single-center, case-control study.

Aim: The purpose of the present study was to investigate the predictors of clinical deterioration soon after emergency department (ED) discharge. Methods: We undertook a case-control study using the ED database of the Nagano Municipal Hospital (Nagano, Japan) from January 2012 to December 2013. We selected adult patients with medical conditions who revisited the ED with deterioration within 2 days of ED discharge (deterioration group). The deterioration group was compared with a control group. Results: During the study period, 15,724 adult medical patients were discharged from the ED. Of these, 170 patients revisited the ED because of clinical deterioration within 2 days. Among the initial vital signs, respiratory rate was less frequently recorded than other vital signs (P < 0.001 versus all other vital signs in each group). The frequency of recording each vital sign did not differ significantly between the groups. Overall, patients in the deterioration group had significantly higher respiratory rates than those in the control group (21 ± 5/min versus 18 ± 5/min, respectively; P = 0.002). A binary logistic regression analysis revealed that respiratory rate was an independent risk factor for clinical deterioration (unadjusted odds ratio, 1.15; 95% confidence interval, 1.04-1.26; adjusted odds ratio, 1.15; 95% confidence interval, 1.01-1.29). Conclusions: An increased respiratory rate is a predictor of early clinical deterioration after ED discharge. Vital signs, especially respiratory rate, should be carefully evaluated when making decisions about patient disposition in the ED.

Total wrist arthrodesis with wrist fusion rod in patients with rheumatoid arthritis.

OBJECTIVES: This study aims to retrospectively review the short-term surgical outcome of wrist fusion using wrist fusion rod (WFR). PATIENTS AND METHODS: Six wrists of four female patients (mean age 56 years; range 51 to 62 years) with advanced stage rheumatoid arthritis of Larsen IV or V were performed total wrist fusion using WFR. Clinical outcome was assessed using a numeric rating scale of pain satisfaction level. Bony fusion, correction of palmar subluxation and ulnar deviation, rod bending angle, wrist fusion angle, and complications were assessed from radiographs. RESULTS: All wrists achieved painless wrist stability with bony fusion of the radiocarpal joint. Both the palmar subluxation and ulnar deviation were corrected in all patients. Two radiographic complications were observed: rod fracture in one patient and a radiolucent line in proximal metacarpal bone in another patient. Both complications might have occurred as a result of instability of the third carpometacarpal joint, but neither influenced clinical outcome. Wrist fusion angle was smaller than rod bending angle at final observation. CONCLUSION: Wrist fusion using WFR is an option for the treatment of advanced stage rheumatoid arthritis of wrist. According to our experience, the stability of third carpometacarpal joint should be assessed before surgery, and this joint should be fused if required. The bending angle of the intramedullary rod does not directly form the wrist fusion angle in contrast to the case with a dorsal wrist fusion plate.