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.

High versus low positive end-expiratory pressure setting in patients receiving veno-venous extracorporeal membrane oxygenation support for severe acute respiratory distress syndrome: study protocol for the multicentre, randomised ExPress SAVER Trial.

INTRODUCTION: While limiting the tidal volume to 6 mL/kg during veno-venous extracorporeal membrane oxygenation (V-V ECMO) to ameliorate lung injury in patients with acute respiratory distress syndrome (ARDS) is widely accepted, the best setting for positive end-expiratory pressure (PEEP) is still controversial. This study is being conducted to investigate whether a higher PEEP setting (15 cmH2O) during V-V ECMO can decrease the duration of ECMO support needed in patients with severe ARDS, as compared with a lower PEEP setting. METHODS AND ANALYSIS: The study is an investigator-initiated, multicentre, open-label, two-arm, randomised controlled trial conducted with the participation of 20 intensive care units (ICUs) at academic as well as non-academic hospitals in Japan. The subjects of the study are patients with severe ARDS who require V-V ECMO support. Eligible patients will be randomised equally to the high PEEP group or low PEEP group. Recruitment to the study will continue until a total of 210 patients with ARDS requiring V-V ECMO support have been randomised. In the high PEEP group, PEEP will be set at 15 cmH2O from the start of V-V ECMO until the trials for liberation from V-V ECMO (or until day 28 after the allocation), while in the low PEEP group, the PEEP will be set at 5 cmH2O. Other treatments will be the same in the two groups. The primary endpoint of the study is the number of ECMO-free days until day 28, defined as the length of time (in days) from successful libration from V-V ECMO to day 28. The secondary endpoints are mortality on day 28, in-hospital mortality on day 60, ventilator-free days during the first 60 days and length of ICU stay. ETHICS AND DISSEMINATION: Ethics approval for the trial at all the participating hospitals was obtained on 27 September 2022, by central ethics approval (IRB at Hiroshima University Hospital, C2022-0006). The results of this study will be presented at domestic and international medical congresses, and also published in scientific journals. TRIAL REGISTRATION NUMBER: The Japan Registry of Clinical Trials jRCT1062220062. Registered on 28 September 2022. PROTOCOL VERSION: 28 March 2023, version 4.0.

Thoracic endovascular aortic repair for avulsion of aortic branches in a trauma patient requiring resuscitative thoracotomy: a case report.

BACKGROUND: Resuscitative thoracotomy is a lifesaving procedure for trauma patients that are hemodynamically unstable. Cross-clamping of the descending thoracic aorta is an essential procedure performed during resuscitative thoracotomy in patients with impending cardiac arrest. Although complications related to resuscitative thoracotomy have been reported, there is no report on avulsion of aortic branches related to cross-clamping of the descending aorta and its appropriate management. CASE PRESENTATION: We present the case of a 42-year-old woman who sustained blunt trauma due to an accidental fall. The patient was hemodynamically unstable and required resuscitative thoracotomy with cross-clamping of the thoracic aorta. However, hemorrhage from avulsion of aortic branches related to aortic cross-clamping was identified. Initially, transcatheter arterial embolization was attempted to achieve hemostasis; however, when that proved ineffective, thoracic endovascular aortic repair was performed, which resulted in successful hemorrhage control without any sequelae. CONCLUSIONS: Thoracic endovascular aortic repair may be a management option for aortic branch avulsion due to cross-clamping of the descending aorta during resuscitative thoracotomy.

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.

A novel protein of Erysipelothrix rhusiopathiae that confers haemolytic activity on Escherichia coli.

Erysipelothrix rhusiopathiae, the cause of swine erysipelas and human erysipeloid, produces a haemolysin. A recombinant plasmid, pHLY, conferring haemolytic activity on Escherichia coli was isolated from a genomic library of Ery. rhusiopathiae strain Tama-96. This plasmid was stable in RecA- E. coli, but unstable in a RecA+ strain. A spontaneous deletion plasmid, pMini-HLY, also conferring haemolytic activity was derived from pHLY. Two ORFs were detected in pHLY. Analysis of pMini-HLY and other deletion clones established that ORF2 was associated with haemolytic activity. The sequence of ORF1 was highly homologous to those of transposases in the IS30 family. The deletion which generated pMini-HLY was between two short direct repeat (DR) sequences flanking the ORF1 sequence, and there were inverted repeat sequences inside the two DR sequences, suggesting an insertion element. No sequence homology to the deduced amino acid sequence of ORF2 was detected in the databases, but its sequence was characteristic of a surface lipoprotein. Western blot analysis, using antiserum against the 16 kDa protein produced from ORF2, found the protein to be commonly distributed in all Erysipelothrix species.