Cerebral vasospasm occurring immediately after endoscopic transsphenoidal resection of a pituitary adenoma: A case report.

Background: Cerebral vasospasm is a rare postoperative complication of transsphenoidal pituitary adenoma surgery with potentially severe consequences. These vasospasms generally have a delayed presentation at a mean of 8 postoperative days. We report an unusual case of hyperacute onset of cerebral vasospasm that occurred immediately after surgery. Case Description: A 38-year-old man underwent endoscopic transsphenoidal surgery for a nonfunctioning pituitary adenoma. The patient experienced mild subarachnoid hematoma during surgery. Three hours after surgery, he developed rightward conjugate eye deviation and complete paralysis of the left upper and lower extremities. Diagnostic imaging revealed cerebral vasospasm in both middle cerebral arteries, and symptoms improved after intra-arterial administration of fasudil hydrochloride. Conclusion: There is a need for prompt diagnosis and therapeutic intervention when typical symptoms of cerebral vasospasm, such as paralysis, occur at any time during the postoperative course.

Associations of the staffing structure of intensive care units and high care units on in-hospital mortality among patients with sepsis: a cross-sectional study of Japanese nationwide claims data.

OBJECTIVE: The objective was to analyse the associations of intensive care unit (ICU) and high care unit (HCU) organisational structure on in-hospital mortality among patients with sepsis in Japan's acute care hospitals. DESIGN: Multicentre cross-sectional study. SETTINGS: Patients with sepsis aged ≥18 years who received critical care in acute care hospitals throughout Japan between April 2018 and March 2019 were identified using the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB). INTERVENTIONS: None. PARTICIPANTS: 10 968 patients with sepsis were identified. ICUs were categorised into three groups: type 1 ICUs (fulfilling stringent staffing criteria such as experienced intensivists and high nurse-to-patient ratios), type 2 ICUs (less stringent criteria) and HCUs (least stringent criteria). PRIMARY OUTCOME MEASURE: The study's primary outcome measure was in-hospital mortality. Cox proportional hazards regression analysis was performed to examine the impact of ICU/HCU groups on in-hospital mortality. RESULTS: We analysed 2411 patients (178 hospitals) in the type 1 ICU group, 3653 patients (422 hospitals) in the type 2 ICU group and 4904 patients (521 hospitals) in the HCU group. When compared with the type 1 ICU group, the adjusted HRs for in-hospital mortality were 1.12 (95% CI 1.04 to 1.21) for the type 2 ICU group and 1.17 (95% CI 1.08 to 1.26) for the HCU group. CONCLUSION: ICUs that fulfil more stringent staffing criteria were associated with lower in-hospital mortality among patients with sepsis than HCUs. Differences in organisational structure may have an association with outcomes in patients with sepsis, and this was observed by the NDB.

Paraplegia After Open Surgical Repair Versus Thoracic Endovascular Aortic Repair for Thoracic Aortic Disease: A Retrospective Analysis of Japanese Administrative Data.

OBJECTIVES: To comparatively examine the risk of postoperative paraplegia between open surgical descending aortic repair and thoracic endovascular aortic repair (TEVAR) among patients with thoracic aortic disease. DESIGN: Retrospective cohort study. SETTING: Acute-care hospitals in Japan. PARTICIPANTS: A total of 6,202 patients diagnosed with thoracic aortic disease. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The main outcome of this study was the incidence of postoperative paraplegia. Multiple logistic regression models, using inverse probability of treatment weighting and an instrumental variable (ratio of TEVAR use to open surgical repair and TEVAR uses), showed that the odds ratios of paraplegia for TEVAR (relative to open surgical descending aortic repair) were 0.81 (95% confidence interval: 0.42-1.59; p = 0.55) in the inverse probability of treatment-weighted model and 0.88 (0.42-1.86; p = 0.75) in the instrumental-variable model. CONCLUSIONS: There were no statistical differences in the risk of paraplegia between open surgical repair and TEVAR in patients with thoracic aortic disease. Improved perioperative management for open surgical repair may have contributed to the similarly low incidence of paraplegia in these two surgery types.

Impact of Permissive Hypoxia and Hyperoxia Avoidance on Clinical Outcomes in Septic Patients Receiving Mechanical Ventilation: A Retrospective Single-Center Study.

BACKGROUND: Septic patients often require mechanical ventilation due to respiratory dysfunction, and effective ventilatory strategies can improve survival. The effects of the combination of permissive hypoxia and hyperoxia avoidance for managing mechanically ventilated patients are unknown. This study examines these effects on outcomes in mechanically ventilated septic patients. METHODS: In a retrospective before-and-after study, we examined adult septic patients (aged ≥18 years) requiring mechanical ventilation at a university hospital. On April 1, 2017, our mechanical ventilation policy changed from a conventional oxygenation target (SpO2: ≥96%) to more conservative targets with permissive hypoxia (SpO2: 88-92% or PaO2: 60 mmHg) and hyperoxia avoidance (reduced oxygenation for PaO2 > 110 mmHg). Patients were divided into a prechange group (April 2015 to March 2017; n = 83) and a postchange group (April 2017 to March 2019; n = 130). Data were extracted from clinical records and insurance claims. Using a multiple logistic regression model, we examined the association of the postchange group (permissive hypoxia and hyperoxia avoidance) with intensive care unit (ICU) mortality after adjusting for variables such as Sequential Organ Failure Assessment (SOFA) score and PaO2/FiO2 ratios. RESULTS: The postchange group did not have significantly lower adjusted ICU mortality (0.67, 0.33-1.43; P = 0.31) relative to the prechange group. However, there were significant intergroup differences in mechanical ventilation duration (prechange: 11.0 days, postchange: 7.0 days; P = 0.01) and ICU stay (prechange: 11.0 days, postchange: 9.0 days; P = 0.02). CONCLUSIONS: Permissive hypoxia and hyperoxia avoidance had no significant association with reduced ICU mortality in mechanically ventilated septic patients. However, this approach was significantly associated with shorter mechanical ventilation duration and ICU stay, which can improve patient turnover and ventilator access.

A rare case of atropine-resistant bradycardia following sugammadex administration.

BACKGROUND: Profound bradycardia caused by sugammadex has been reported, although its mechanism is unclear. Herein, we suggest a possible culprit for this phenomenon. CASE PRESENTATION: A 50-year-old woman without comorbidity except mild obesity underwent a transabdominal hysterectomy and right salpingo-oophorectomy. After surgery, sugammadex 200 mg was intravenously administered. Approximately 4 min later, her heart rate decreased to 36 bpm accompanied by hypotension (41/20 mmHg) and ST depression in limb lead electrocardiogram (ECG). Atropine 0.5 mg was injected intravenously without improving the hemodynamics. Intravenous adrenaline 0.5 mg was added despite the lack of signs suggesting allergic reactions. Her heart rate and blood pressure quickly recovered and remained stable thereafter, although 12-lead ECG taken 1 h later still showed ST depression. CONCLUSIONS: In this case, the significant bradycardia appeared attributable to coronary vasospasm (Kounis syndrome) induced by sugammadex, considering the ECG findings and high incidence of anaphylaxis due to sugammadex.

Effectiveness of combined antithrombin and thrombomodulin therapy on in-hospital mortality in mechanically ventilated septic patients with disseminated intravascular coagulation.

Septic patients can develop disseminated intravascular coagulation (DIC), which is characterized by systemic blood coagulation and an increased risk of life-threatening haemorrhage. Although antithrombin (AT) and thrombomodulin (TM) combination anticoagulant therapy is frequently used to treat septic patients with DIC in Japan, its effectiveness in improving patient outcomes remains unclear. In this large-scale multicentre retrospective study of adult septic patients with DIC treated at Japanese hospitals between February 2010 and March 2016, we compared in-hospital mortality between AT monotherapy and AT + TM combination therapy. We performed logistic regression analysis with in-hospital mortality as the dependent variable and anticoagulant therapy as the main independent variable of interest. Covariates included patient demographics, disease severity, and body surface area. The AT group and AT + TM group comprised 1,017 patients from 352 hospitals and 1,205 patients from 349 hospitals, respectively. AT + TM combination therapy was not significantly associated with lower mortality when compared with AT monotherapy (odds ratio: 0.97, 95% confidence interval: 0.78-1.21; P = 0.81). AT + TM combination therapy was also not superior to AT monotherapy in reducing mechanical ventilation or hospitalization durations. Despite its widespread use for treating sepsis with DIC, AT + TM combination therapy is not more effective in improving prognoses than the simpler AT monotherapy.

Bromocriptine use for sudden peripartum cardiomyopathy in a patient with preeclampsia: a case report.

BACKGROUND: Peripartum cardiomyopathy is an uncommon form of heart failure that occurs in otherwise healthy women during pregnancy or until 5 months postpartum. Here, we report a rare case where a female patient underwent cesarean section after the occurrence of preeclampsia and intrauterine fetal death, and developed peripartum cardiomyopathy following postsurgical respiratory distress. The prompt initiation of inotropic drug and bromocriptine therapy quickly restored cardiac function. CASE PRESENTATION: The patient was a 36-year-old woman who underwent emergency cesarean section for a previous preeclampsia and an intrauterine fetal death that occurred after 24 weeks of pregnancy. In addition, the patient had an extremely low platelet count of 5000/µL on admission. She had been diagnosed as idiopathic thrombocytopenic purpura at the age of 29 years old and treated with prednisolone at 15 mg/day. Therefore, the cesarean section was performed under general anesthesia. The patient did not exhibit respiratory or hemodynamic dysfunction during surgery. However, she developed respiratory distress with sinus tachycardia after extubation and was transferred to the intensive care unit. A chest radiograph showed butterfly shadows, and transthoracic echocardiogram confirmed the reduction of left ventricle contractility (ejection fraction 20%). She was diagnosed with peripartum cardiomyopathy and treated immediately with intravenous milrinone, oral bromocriptine, and angiotensin-converting enzyme inhibitor. Respiratory and hemodynamic function improved rapidly, and the patient was moved to the general ward 2 days after surgery. Fourteen days after surgery, the patient had an ejection fraction of 57%. The patient recovered without any further complications and was discharged 24 days after surgery. CONCLUSION: A sudden case of peripartum cardiomyopathy was successfully managed by a prompt diagnosis and treatment with inotropic agents and bromocriptine.

Relief of cardiac tamponade by a congenital partial left-sided pericardial defect in a patient with ruptured acute type A aortic dissection: a case report.

BACKGROUND: Acute type A aortic dissections have an extremely poor prognosis, and cardiac tamponade is a major cause of death in these patients. Here, we describe a case where congenital partial pericardial defect relieved cardiac tamponade caused by ruptured type A aortic dissection. CASE PRESENTATION: A 79-year-old woman was hospitalized after experiencing chest pains and respiratory distress. She developed out-of-hospital cardiopulmonary arrest and was resuscitated with no sequelae 5 days before admission. Computed tomography confirmed pericardial and left pleural effusions, and type A aortic dissection was diagnosed. We began emergency ascending aortic replacement surgery under general anesthesia with propofol and remifentanil and incidentally discovered a congenital partial left-sided pericardial defect that allowed drainage of the hemopericardium and relieved cardiac tamponade. The surgery was successfully performed, and the patient recovered without complications. CONCLUSIONS: We experienced an extremely rare case where a congenital partial pericardial defect relieved cardiac tamponade associated with aortic dissection and contributed to the patient's survival.

Severe Progressive Diffuse Alveolar Hemorrhage in a Patient with Systemic Lupus Erythematosus.

Diffuse alveolar hemorrhage (DAH) refers to the effusion of blood into the alveoli due to damaged pulmonary microvasculature. The ensuing alveolar collapse can lead to severe hypoxemia with poor prognosis. In these cases, it is crucial to provide respiratory care for hypoxemia in addition to treating the underlying disease. Here, we describe our experience with a case involving a 46-year-old woman with severe DAH-induced hypoxemia accompanying systemic lupus erythematosus (SLE). Mechanical ventilation was managed using airway pressure release ventilation (APRV) after intubation. Through APRV-based respiratory care and treatment of the underlying disease, hemoptysis was eliminated and oxygenation improved. The patient did not experience significant barotrauma and was successfully weaned from mechanical ventilation after 25 days in the intensive care unit. This case demonstrates that APRV-based control for respiratory management can inhibit the effusion of blood into the alveoli and achieve mechanical hemostasis, as well as mitigate alveolar collapse. APRV may be a useful method for respiratory care in patients with severe DAH-induced hypoxemia.

The impact of low body mass index on postoperative outcomes in pancreatectomy patients: a retrospective analysis of Japanese administrative data.

PURPOSE: To comparatively examine in-hospital mortality among different underweight body mass index (BMI) categories in pancreatic cancer patients after pancreatectomy in Japan. METHODS: We conducted a large-scale multi-center retrospective cohort study of adult patients with pancreatic cancer who underwent pancreatectomy between April 1, 2010 and March 31, 2016. Patients were classified according to BMI as follows: normal BMI (18.50-24.99 kg/m2), mild thinness (17.00-18.49 kg/m2), moderate thinness (16.00-16.99 kg/m2), and severe thinness (< 16.00 kg/m2). A multivariable logistic regression analysis was performed with in-hospital mortality as the dependent variable and BMI groups as the main independent variable of interest. RESULTS: We analyzed 6173 patients from 332 hospitals. The results showed that the severe thinness group had a longer postoperative hospital stay (34.4 ± 25.6 days) and higher incidence of postoperative pneumonia (5.5%) than the other groups. The generalized estimating equations accounted for patient demographics, surgical procedure, anesthetic technique, activities of daily living score, and Charlson comorbidity index as covariates. Relative to the normal BMI group, the odds ratios for in-hospital mortality were 0.57 (95% confidence interval: 0.26-1.24; P = 0.16) in the mild thinness group, 1.49 (0.64-3.48; P = 0.36) in the moderate thinness group, and 2.54 (1.05-6.08; P = 0.04) in the severe thinness group. CONCLUSION: Severe thinness was significantly associated with a higher risk of mortality, and extremely low BMI should be considered a risk factor in pancreatectomy patients.

Comparison of In-hospital Outcomes Between Transcatheter and Surgical Aortic Valve Replacement in Patients with Aortic Valve Stenosis: A Retrospective Cohort Study Using Administrative Data.

OBJECTIVE: The number of surgeries for valvular heart disease performed in Japan has greatly increased over the past decade, and surgical aortic valve replacements (SAVR) constitute the vast majority of aortic valve replacement procedures. Although transcatheter aortic valve implantation (TAVI) was recently introduced, studies have yet to compare the clinical outcomes between TAVI and SAVR in the Japanese healthcare setting. This study aimed to compare in-hospital outcomes between TAVI and SAVR using a multicenter administrative database. DESIGN: Retrospective cohort study. SETTING: Acute care hospitals in Japan. PARTICIPANTS: A total of 16,775 patients diagnosed with aortic valve stenosis. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The main study outcome measure was in-hospital mortality. Based on multiple logistic regression analysis using inverse probability of treatment weighting, the odds ratio of in-hospital mortality for TAVI (relative to SAVR) was calculated to be 0.36 (95% confidence intervals: 0.13-0.98; p = 0.04). In patients aged 80 years or older, the odds ratio was even lower at 0.34 (95% confidence intervals: 0.15-0.73; p < 0.01). In addition, the incidences of reoperations, hemorrhagic complications, cardiac tamponade, and postoperative infections were significantly higher in the SAVR patients. CONCLUSIONS: This large-scale multicenter comparative analysis of TAVI and SAVR in Japan indicated that TAVI produced better clinical outcomes in patients with aortic valve stenosis. The improved outcomes were particularly notable in patients aged 80 years or older.

Use of High-Flow Nasal Cannula Oxygen Therapy in a Pregnant Woman with Dermatomyositis-Related Interstitial Pneumonia.

A 33-year-old pregnant woman was referred to our hospital with respiratory distress at 30 weeks of gestation. Chest computed tomography (CT) scans revealed pulmonary infiltrates along the bronchovascular bundles and ground-glass opacities in both lungs. Despite immediate treatment with steroid pulse therapy for suspected interstitial pneumonia, the patient's condition worsened. Respiratory distress was slightly alleviated after the initiation of high-flow nasal cannula (HFNC) oxygen therapy (40 L/min, FiO2 40%). We suspected clinically amyopathic dermatomyositis (CADM) complicating rapidly progressive refractory interstitial pneumonia. In order to save the life of the patient, the use of combination therapy with immunosuppressants was necessary. The patient underwent emergency cesarean section and was immediately treated with immunosuppressants while continuing HFNC oxygen therapy. The neonate was treated in the neonatal intensive care unit. The patient's condition improved after 7 days of hospitalization; by this time, she was positive for myositis-specific autoantibodies and was diagnosed with interstitial pneumonia preceding dermatomyositis. This condition can be potentially fatal within a few months of onset and therefore requires early combination immunosuppressive therapy. This case demonstrates the usefulness of HFNC oxygen therapy for respiratory management as it negates the need for intubation and allows for various treatments to be quickly performed.

Impact of hydroxyethyl starch 70/0.5 on acute kidney injury after gastroenterological surgery.

BACKGROUND: Previous studies reported a higher mortality risk and a greater need for renal replacement therapy in patients administered hydroxyethyl starch (HES) rather than other fluid resuscitation preparations. In this study, we investigated the association between 6% HES 70/0.5 use and postoperative acute kidney injury (AKI) in gastroenterological surgery patients. METHODS: We conducted retrospective full-cohort and propensity-score-based analyses of patients who underwent gastroenterological surgery between June 2011 and August 2013 in a Japanese university hospital. The study sample comprised 66 AKI and 2,152 non-AKI patients in the full-cohort analysis and 35 AKI and 1,269 non-AKI patients in the propensity-score-based analysis. Propensity scores were calculated using an ordered logistic regression model in which the dependent variable comprised three groups based on HES infusion volumes (0, 1-999, and ≥ 1,000 ml). The association between HES groups and postoperative AKI incidence was analyzed using multiple logistic regression models. Other candidate independent variables included patient characteristics and intraoperative measures. RESULTS: In the full-cohort analysis, 40 (60.6%) AKI patients were diagnosed as "risk", 15 (22.7%) as "injury," and 11 (16.7%) as "failure". In the propensity-score-based analysis, the corresponding values were 22 (62.9%), 8 (22.9%), and 5 (14.3%). There was no significant association between total infused HES and postoperative AKI incidence in either the full-cohort or the propensity-score-based analysis (P = 0.168 and P = 0.42, respectively). CONCLUSIONS: AKI incidence was not associated with clinical 6% HES 70/0.5 administration in gastroenterological surgery patients treated at a single center.

The relationship between sedative drug utilization and outcomes in critically ill patients undergoing mechanical ventilation.

OBJECTIVES: The objectives of this study were to describe current sedative drug utilization patterns in critically ill patients undergoing mechanical ventilation (MV) in intensive care units (ICUs) in Japanese hospitals and to elucidate the relationship of these utilization patterns with patient clinical outcomes. METHOD: Analysis of hospital claims data derived from the Quality Indicator/Improvement Project identified 12,395 critically ill adult patients who had undergone MV while hospitalized in the ICUs of 114 Japanese hospitals and had been discharged between April 2008 and March 2010. Descriptive statistics were calculated for the daily utilization of sedative drugs, opioids, and muscle relaxants in this patient sample, and the relationship between drug utilization and patient outcomes using Cox proportional hazards analysis were examined. RESULTS: Of the 12,395 patients included in the analysis, 7300 (58.9 %), 580 (4.7 %), and 671 (5.4 %) received sedative drugs, opioids, and muscle relaxants, respectively, for ≥2 days after intubation. Compared to the other patient groups, there was a higher proportion of males in the group given sedative drugs and the patients were significantly younger (P < 0.001). Propofol was the most frequently used sedative drug, followed by benzodiazepines, barbiturates, and dexmedetomidine. The mortality rate was lower and ventilator weaning was earlier among patients who received only propofol than among those who received only benzodiazepines. Muscle relaxants were associated with increased duration of MV. CONCLUSIONS: This is the first study based on a large-scale analysis in Japan to elucidate sedative drug utilization patterns and their relationship with outcomes in critically ill patients. The most commonly used sedative was propofol, which was associated with favorable patient outcomes. Further prospective research must be conducted to discern effective sedative drug utilization.

Rapid development of a spinal epidural hematoma following thoracic epidural catheter removal in an esophageal carcinoma surgical patient: a case report.

BACKGROUND: The occurrence of spinal epidural hematomas associated with the use of epidural catheters is relatively rare. Furthermore, it is unusual for hematoma-associated neurological symptoms to occur within 15 min of removing a catheter. Here, we report our experience with an esophageal carcinoma surgical patient who developed an epidural hematoma almost immediately after catheter removal, resulting in paralysis of his lower extremities. The patient achieved full neurological recovery following prompt diagnosis and surgical intervention. CASE PRESENTATION: A 68-year-old man was admitted with esophageal carcinoma and underwent video-assisted thoracoscopic esophagectomy followed by posterior mediastinal gastric tube reconstruction. During surgery, the patient was administered both general and epidural anesthesia. The epidural catheter was inserted approximately 5 cm into the epidural space at the Th6-7 level. The patient was extubated the following day in the general intensive care unit. Two days after surgery, the d-dimer level was high at 36.9 µg/mL (reference range 0-0.9 µg/mL), and we decided to administer an anticoagulant (enoxaparin sodium) to prevent thrombosis. The epidural catheter was removed 2 h prior to the scheduled administration of enoxaparin sodium. However, the patient reported a complete lack of strength in his lower extremities 15 min after catheter removal. Upon examination, the manual muscle testing score was 1 out of 5, and the patient experienced impaired touch sensation and cold sensation below Th4. An emergency magnetic resonance imaging scan was performed 2 h after catheter removal, which revealed a possible spinal epidural hematoma spreading from Th3 to Th6. Three hours after catheter removal, we began emergency surgery to evacuate the hematoma, which had spread to Th7. After surgery, the patient showed improvements in touch sensation, cold sensation, and motor function. The patient was able to walk 2 days after hematoma removal. CONCLUSIONS: It is highly unusual for a spinal epidural hematoma to develop so rapidly after the removal of an epidural catheter. This case emphasizes the need for vigilant patient monitoring, rapid diagnosis, and prompt surgery to ensure adequate neurological recovery in these patients.

Impact of steroid medication before hospital admission on barotrauma in mechanically ventilated patients with acute respiratory distress syndrome in intensive care units.

PURPOSE: To investigate the association between steroid medication before hospital admission and barotrauma in mechanically ventilated patients with acute respiratory distress syndrome (ARDS). METHODS: An observational single-center retrospective study was conducted using patients admitted to the general intensive care unit (ICU) of a university hospital in Japan. We analyzed 149 mechanically ventilated patients with ARDS hospitalized between March 2008 and March 2011. ARDS was identified according to criteria from the Berlin Definition. Barotrauma was defined as pneumothorax, subcutaneous emphysema, or mediastinal emphysema occurring during mechanical ventilation in the ICU. The influence of steroid medication before hospital admission on barotrauma was studied using multiple logistic regression analysis. RESULTS: There were no differences in baseline patient characteristics except for congestive heart failure, peak pressure during mechanical ventilation, and steroid pulse therapy between the barotrauma and non-barotrauma groups. Logistic regression analysis showed that peak pressure ≥35 cmH2O was associated with barotrauma in patients with ARDS [odds ratio (OR), 17.34; P < 0.01], whereas steroid medication before hospital admission was not a significant factor for barotrauma (OR, 1.63; P = 0.51). CONCLUSIONS: Barotrauma in ARDS patients was associated with higher pressure during mechanical ventilation but not with steroid medication before hospital admission.

[Epidural anesthesia at the L1-2 interspaces enables ambulation after cesarean delivery within less than 3 hours 30 minutes--a new perspective in the use of epidural anesthesia in cesarean deliveries].

BACKGROUND: In cesarean deliveries, it is important to prevent deep vein thrombosis in the lower limbs as this can result in pulmonary embolisms. Taking post-operative analgesia into account it is preferable to use an anesthesia method that allows early ambulation of patients. It is therefore necessary to use epidural anesthesia as a sole anesthesia method for cesarean deliveries. METHODS: In an analysis of 633 cesarean delivery patients who had been administered only epidural anesthesia, we investigated and compared the time to ambulation and cessation of continuous epidural infusion in groups that had received epidural puncture either at L1-2 or L2-3 space. RESULTS: The postoperative time to ambulation in the L1-2 puncture group was 189.9 ± 56.1 minutes. Postoperative analgesia administered via continuous epidural infusion of local anesthetic was discontinued due to remaining paralysis in 2.5% of the L1-2 puncture group, which was significantly lower than the L2- 3 puncture group (7.6%). CONCLUSIONS: Our findings showed that it is possible to utilize only epidural anesthesia for cesarean deliveries. Using lumbar epidural anesthesia with L1-2 puncture reduced a postoperative time to ambulation to less than 3 hours 10 minutes.

An in-hospital mortality equation for mechanically ventilated patients in intensive care units.

OBJECTIVE: To develop an equation model of in-hospital mortality for mechanically ventilated patients in adult intensive care using administrative data for the purpose of retrospective performance comparison among intensive care units (ICUs). DESIGN: Two models were developed using the split-half method, in which one test dataset and two validation datasets were used to develop and validate the prediction model, respectively. Nine candidate variables (demographics: age; gender; clinical factors hospital admission course; primary diagnosis; reason for ICU entry; Charlson score; number of organ failures; procedures and therapies administered at any time during ICU admission: renal replacement therapy; pressors/vasoconstrictors) were used for developing the equation model. SETTING: In acute-care teaching hospitals in Japan: 282 ICUs in 2008, 310 ICUs in 2009, and 364 ICUs in 2010. PARTICIPANTS: Mechanically ventilated adult patients discharged from an ICU from July 1 to December 31 in 2008, 2009, and 2010. MAIN OUTCOME MEASURES: The test dataset consisted of 5,807 patients in 2008, and the validation datasets consisted of 10,610 patients in 2009 and 7,576 patients in 2010. Two models were developed: Model 1 (using independent variables of demographics and clinical factors), Model 2 (using procedures and therapies administered at any time during ICU admission in addition to the variables in Model 1). Using the test dataset, 8 variables (except for gender) were included in multiple logistic regression analysis with in-hospital mortality as the dependent variable, and the mortality prediction equation was constructed. Coefficients from the equation were then tested in the validation model. RESULTS: Hosmer-Lemeshow χ(2) are values for the test dataset in Model 1 and Model 2, and were 11.9 (P = 0.15) and 15.6 (P = 0.05), respectively; C-statistics for the test dataset in Model 1and Model 2 were 0.70 and 0.78, respectively. In-hospital mortality prediction for the validation datasets showed low and moderate accuracy in Model 1 and Model 2, respectively. CONCLUSIONS: Model 2 may potentially serve as an alternative model for predicting mortality in mechanically ventilated patients, who have so far required physiological data for the accurate prediction of outcomes. Model 2 may facilitate the comparative evaluation of in-hospital mortality in multicenter analyses based on administrative data for mechanically ventilated patients.

Development and validation of an acute heart failure-specific mortality predictive model based on administrative data.

BACKGROUND: Acute heart failure (AHF) with its high in-hospital mortality is an increasing burden on healthcare systems worldwide, and comparing hospital performance is required for improving hospital management efficiency. However, it is difficult to distinguish patient severity from individual hospital care effects. The aim of this study was to develop a risk adjustment model to predict in-hospital mortality for AHF using routinely available administrative data. METHODS: Administrative data were extracted from 86 acute care hospitals in Japan. We identified 8620 hospitalized patients with AHF from April 2010 to March 2011. Multivariable logistic regression analyses were conducted to analyze various patient factors that might affect mortality. Two predictive models (models 1 and 2; without and with New York Heart Association functional class, respectively) were developed and bootstrapping was used for internal validation. Expected mortality rates were then calculated for each hospital by applying model 2. RESULTS: The overall in-hospital mortality rate was 7.1%. Factors independently associated with higher in-hospital mortality included advanced age, New York Heart Association class, and severe respiratory failure. In contrast, comorbid hypertension, ischemic heart disease, and atrial fibrillation/flutter were found to be associated with lower in-hospital mortality. Both model 1 and model 2 demonstrated good discrimination with c-statistics of 0.76 (95% confidence interval, 0.74-0.78) and 0.80 (95% confidence interval, 0.78-0.82), respectively, and good calibration after bootstrap correction, with better results in model 2. CONCLUSIONS: Factors identifiable from administrative data were able to accurately predict in-hospital mortality. Application of our model might facilitate risk adjustment for AHF and can contribute to hospital evaluations.

Efficacy of single-dose intravenous immunoglobulin administration for severe sepsis and septic shock.

BACKGROUND: Although some studies conducted outside of Japan have addressed the effectiveness of intravenous immunoglobulins (IVIG) in treating infections, the dosing regimens and amounts used in Japan are very different from those reported. Here, we investigate the effectiveness of single-dose administration of IVIG in sepsis patients in Japan. METHODS: We analyzed 79 patients admitted to the intensive care unit (ICU) of a tertiary care institution due to severe sepsis or septic shock. Patients were randomly divided into a group that was administered standard divided doses of IVIG (5 g/day for 3 days, designated the S group) or a group that was administered a standard single dose of IVIG (15 g/day for 1 day, H group); freeze-dried sulfonated human IVIG was used. The longitudinal assessment of procalcitonin (PCT) levels, C-reactive protein (CRP) levels, white blood cell count, blood lactate levels, IL-6 levels, Sequential Organ Failure Assessment (SOFA) score, and Systemic Inflammatory Response Syndrome (SIRS) was conducted. We also assessed mechanical ventilation duration (days), ICU stay (days), 28-day survival rate, and 90-day survival rate. RESULTS: The study showed no significant differences in PCT levels, CRP levels, 28-day survival rate, and 90-day survival rate between the two groups. However, patients in the H group showed improvements in the various SIRS diagnostic criteria, IL-6 levels, and blood lactate levels in the early stages after IVIG administration. In light of the non-recommendation of IVIG therapy in the Surviving Sepsis Campaign Guidelines 2012, our findings of significant early post-administration improvements are noteworthy. IVIG's anti-inflammatory effects may account for the early reduction in IL-6 levels after treatment, and the accompanying improvements in microcirculation may improve blood lactate levels and reduce SOFA scores. However, the low dosages of IVIG in Japan may limit the anti-cytokine effects of this treatment. Further studies are needed to determine appropriate treatment regimens of single-dose IVIG. CONCLUSIONS: In this study, we investigated the effectiveness of single-dose IVIG treatment in patients with severe sepsis or septic shock. Although there were no significant effects on patient prognoses, patients who were administered single-dose IVIG showed significantly improved IL-6 levels, blood lactate levels, and disease severity scores.