Prognosis and sequelae of severe COVID-19 patients after 6 months of hospital discharge: A retrospective cohort study.

Background: We investigated the prognosis, sequelae, and related factors of severe coronavirus disease (COVID-19) patients who required invasive mechanical ventilation 6 months after discharge from the hospital. Methods: COVID-19 patients admitted to Kishiwada Tokusyukai Hospital between April 1, 2020, and May 31, 2021, and treated with an invasive mechanical ventilator were included in this study. We conducted a telephone visit 6 months after discharge to confirm survival and asked questions about sequelae. Results: The mortality rate 6 months after discharge was 7.4%. Tracheostomy (odds ratio [OR], 0.03; 95% confidence interval [CI], 0.003-0.26), high Acute Physiology and Chronic Health Evaluation II score (16.0 [interquartile range [IQR], 11.5-17.2] vs. 11.0 [IQR, 8.0-14.0]), prolonged hospital stay (17.0 [IQR, 12.7-24.5] vs. 10.0 [IQR, 8.0-13.0]), and prolonged ventilation duration (12.5 [IQR, 10.7-20.0] vs. 8.0 [IQR, 6.0-11.0]) were associated with the risk of death. Moreover, 49% of the patients had residual disability. The most common sequelae were hoarseness, respiratory distress on exertion (31% of symptomatic patients), and muscle weakness (22%). The prone positioning therapy (OR, 5.55; 95% CI, 1.35-32.97) was associated with hoarseness, and the use of muscle relaxants (OR, infinity; 95% CI, 1.14-infinity) was a risk factor for muscle weakness. Conclusion: Although the mortality rate after the acute phase of COVID-19 was not high, many patients experienced sequelae. Careful treatment should be continued after the end of acute treatment for patients with prolonged respiratory failure due to COVID-19. Muscle relaxants and prone positioning therapy may cause sequelae and should be performed carefully.

Hereditary Angioedema with Recurrent Abdominal Pain in a Patient with a Novel Mutation.

We describe a patient with hereditary angioedema type I. The patient had experienced recurrent abdominal pain around the time of her menstrual period for 13 years. A laboratory examination showed reduced functional and antigenic levels of C4 and C1 inhibitor (C1-INH). To establish a diagnosis, we carried out a DNA analysis of the patient's C1-INH gene. We determined that the patient was heterozygous for a single base pair transposition of T to C at nucleotide 4429 in exon 4, which had not been reported in the literature. As the patient had no family history of hereditary diseases, it was considered to be a de novo mutation.

[A Case of Cardiac Arrest following Intra-articular Administration of Levobupivacaine during Total Knee Arthroplasty].

A 73-year-old woman with normal cardiac function underwent an elective total knee arthroplasty. After skin closure, levobupivacaine 225 mg was injected into the knee and 25 mg was injected subcutaneously. The patient recovered from general anesthesia 5 min after the surgery. Thirty five min after surgery, while in general radiology department her carotid arterial pulses were not palpable. Cardiopulmonary resuscitation (CPR) was initiated with intravenous (i.v.) administration of adrenaline 1 mg. Circulation was rapidly restored. Coronary angiography demonstrated no coronary stenosis; however, left ventriculography demonstrated takotsubo cardiomyopathy. The patient regained consciousness, but pulmonary edema and renal failure became worse. On postoperative day 2, continuous hemodialysis was instituted. Weaning from ventilatory support was completed on postoperative day 3; hemodialysis was stopped on day 14; and the patient left the intensive care unit on day 15. We believe cardiac arrest may have been precipitated by local anesthetic systemic toxicity (LAST), and administration of i. v. adrenaline 1 mg may have resulted in pulmonary edema. Patients should be carefully observed following local anesthetic with attention given to the side-effects of i. v. adrenaline.

Accuracy of pulse checks in terms of basic life support by lifesavers, as lay persons.

BACKGROUND: The lifesavers responsible for lifesaving at the waterside routinely undergo cardiopulmonary resuscitation (CPR) training, but in Japan, they are considered as lay persons. Lifesavers are likely to have better basic life support skills than lay persons. The objective of this study is to demonstrate that the accuracy of carotid pulse checks by lifesavers is not inferior to that of paramedics and is superior to that of lay persons by using CPR training mannequins. METHODS AND RESULTS: This was an observational study in which the subjects included 48 lifesavers certified by the Japan Lifesaving Association, as well as 16 paramedics and 15 lay persons. The accuracy of the examinees' answers and the time taken to answer in the 3 groups were compared. The accuracy rate was 93% in lifesavers, 94% in paramedics, and the difference was not significant (P=1). The accuracy rate of the lay persons' answers was 63%, with significant differences between this group and the lifesavers (P<0.001) and the paramedics (P<0.001). The average time taken to answer the questions was 6.6 s for the lifesavers and 7.0 s for the paramedics, and the difference was not significant (P=0.44). The average time taken to answer the questions from the lay persons group was 20.5 s, with significant differences between this group and the lifesavers (P<0.001) and the paramedics (P<0.001). CONCLUSIONS: The results of this evaluation, using CPR-training mannequins, to test the accuracy of carotid pulse checks by lifesavers were equivalent to those of paramedics and superior to those of lay persons.

The impact of spontaneous ventilation on distribution of lung aeration in patients with acute respiratory distress syndrome: airway pressure release ventilation versus pressure support ventilation.

BACKGROUND: In this study, we sought to determine which mode, airway pressure release ventilation (APRV) or pressure support ventilation (PSV), decreases atelectasis more in patients with acute lung injury/acute respiratory distress syndrome (ARDS). METHODS: This was a retrospective study in the intensive care unit. Between 2006 and 2007, we identified 18 patients with acute lung injury/ARDS who received either APRV or PSV and had a helical computed tomography scan twice in 3 days. RESULTS: Computed tomography data from the APRV and PSV groups (n = 9 each) were analyzed for 3-dimensional reconstruction and volumetry. Aerated lung regions (normally aerated, poorly aerated, nonaerated, and hyperinflated) were identified by their densities in Hounsfield units. The Pao(2)/Fio(2) ratio and alveolar-arteriolar oxygen gradient after ventilation were improved in both groups (P = 0.008); however, the improvements in the APRV group exceeded those in the PSV group when delivered with equal mean airway pressure (P = 0.018 and 0.015, respectively). Atelectasis decreased significantly from 41% (range, 17%-68%) to 19% (range, 6%-40%) (P = 0.008) and normally aerated volume increased significantly from 29% (range, 13%-41%) to 43% (range, 25%-56%) (P = 0.008) in the APRV group, whereas lung volume did not change in the PSV group. CONCLUSIONS: Spontaneous ventilation during APRV improves lung aeration by decreasing atelectasis. PSV for gas exchange is effective but not sufficient to improve lung aeration. These results indicate that APRV is more efficient than PSV as a mode of primary ventilatory support to decrease atelectasis in patients with ARDS.

Hemorrhagic shock and encephalopathy syndrome--the markers for an early HSES diagnosis.

BACKGROUND: The hemorrhagic shock and encephalopathy syndrome (HSES) is a devastating disease that affects young children. The outcomes of HSES patients are often fatal or manifesting severe neurological sequelae. We reviewed the markers for an early diagnosis of HSES. METHODS: We examined the clinical, biological and radiological findings of 8 patients (4 months to 9 years old) who met the HSES criteria. RESULTS: Although cerebral edema, disseminated intravascular coagulopathy (DIC), and multiple organ failure were seen in all 8 cases during their clinical courses, brain computed tomography (CT) scans showed normal or only slight edema in 5 patients upon admission. All 8 patients had normal platelet counts, and none were in shock. However, they all had severe metabolic acidosis, which persisted even after 3 hours (median base excess (BE), -7.6 mmol/L). And at 6 hours after admission (BE, -5.7 mmol/L) they required mechanical ventilation. Within 12 hours after admission, fluid resuscitation and vasopressor infusion for hypotension was required. Seven of the patients had elevated liver enzymes and creatine kinase (CK) upon admission. Twenty-four hours after admission, all 8 patients needed vasopressor infusion to maintain blood pressure. CONCLUSION: CT scan, platelet count, hemoglobin level and renal function upon admission are not useful for an early diagnosis of HSES. However, the elevated liver enzymes and CK upon admission, hypotension in the early stage after admission with refractory acid-base disturbance to fluid resuscitation and vasopressor infusion are useful markers for an early HSES diagnosis and helpful to indicate starting intensive neurological treatment.

[Vegetable oil-induced acute respiratory distress syndrome (ARDS) in near drowning: evaluation based on extravascular lung water index].

Lipoid pneumonia usually presents after chronic recurrent ingestion of oily substances or accidental aspiration during "fire-eating" demonstrations. Massive exposure by near drowning extremely rare and potentially fatal. We present here a case of survival after total immersion in oil in her workplace. A 66-year-old woman who nearly drowned in a vat of vegetable oil was admitted as an emergency case with severe hypoxia after rescue. Chest computed tomography (CT) findings showed bilateral ground-glass opacity, consolidation, and the case fulfilled the criteria for acute respiratory distress syndrome (ARDS). Bronchoscopy and bronchoalveolar lavage performed on admission indicated oil droplets and marked neutrophilia (67%), which made us diagnose ARDS induced by lipoid pneumonia. We commenced treatment with pulsed steroids and strictly managed fluid balance under mechanical ventilation. Despite immediate improvement in oxygenation, the value of extravascular lung water index (EVLWI) measured by the PiCCO system consistently remained over 30 ml/Kg through her clinical course. We concluded that lipoid pneumonia is characterized by prolonged elevatation of pulmonary vascular permeability.

[Direct hemoperfusion with a polymyxin B-immobilized fiber column eliminates neutrophils and improves pulmonary oxygenation--a comparison of two cases with acute exacerbation of idiopathic pulmonary fibrosis].

Idiopathic pulmonary fibrosis (IPF) is characterized by radiographically evident interstitial infiltrates predominantly affecting the lung bases and by progressive dyspnea and worsening pulmonary function. Acute exacerbation of IPF is recognized widely as an accelerated phase occurring suddenly in the course of IPF, which leads to a catastrophic outcome. No treatment has proven to be effective so far. We describe two cases of acute exacerbation of IPF which were treated by direct hemoperfusion with a polymyxin B-immobilized fiber column (PMX) after steroid pulse therapy. One patient died on the 21st day after direct hemoperfusion and the other is alive at present. The survivor showed significant improvement of pulmonary oxygenation correlating with a decrease in the neutrophil count, SP-D and KL-6 after direct hemoperfusion with PMX. On the other hand, the non-survivor showed no improvement of pulmonary oxygenation, SP-D and KL-6 despite a decrease in neutrophil count comparable with that of the survivor. Neutrophil count which decreased temporarily after direct hemoperfusion with PMX soon convert to increase in the non-survivor, which is a characteristic difference between two. We reached the conclusions that (1) direct hemoperfusion with PMX absorbs neutrophils and this mechanism is effective to improve pulmonary oxygenation, (2) sometimes neutrophil absorption is not enough to control pulmonary inflammation in patients with acute exacerbation of IPF.

[A case of idiopathic ARDS treated by sivelestat sodium and fluid management based on extravascular lung water index].

A 65-year-old woman was given emergency admission with fever, cough and dyspnea. Chest computed tomography (CT) findings showed bilateral ground-glass opacity, consolidation, and this case were fulfilled the criteria for acute respiratory distress syndrome (ARDS). We clinically diagnosed the patient as suffering from idiopathic ARDS including acute interstitial pneumonia (AIP) based on the absence of any known causes of ARDS and systemic immunologic diseases. We started treatment with sivelestat sodium and strictly managed fluid balance under mechanical ventilation. We found this treatment quite effective because there were significant improvements in the extravascular lung water index (EVLWI) measured by the PiCCO system and neutrophile elastase value and in oxygenation and the chest radiograph. This is apparently the first case report in the literature that clearly shows the treatment with sivelestat sodium and strict fluid management ended in a favorable outcome, as reducing EVLWI measured by the PiCCO system in an idiopathic ARDS patient.