Supernormal Antithrombin Activity Is an Independent Predictor of In-Hospital Mortality in Patients With Sepsis: A Retrospective Observational Study.

Supernormal antithrombin (AT) activity is rare in patients with sepsis. This study compared mortality rate of patients with sepsis and supernormal AT activity with that of other patients. This retrospective study included patients with sepsis from 42 intensive care units (ICUs) in Japan. Patients were included if their AT activity was measured on ICU admission, and if they did not receive AT concentrate. They were categorized into low, normal, and supernormal with respective AT activity of ≤70%, >70% to ≤100%, and >100%. The primary outcome was hospital in-patient mortality. Nonlinear regression analysis showed that mortality risk gradually increased with AT activity in the supernormal range, but without statistical significance. Survival rate was significantly lower in low (67%) and supernormal (57%) AT groups than in the normal AT group (79%; P < .001 and P = .008, respectively). After adjusting for disease severity and AT activity on day 2, supernormal AT activity was the only independent predictor of mortality. Sepsis with supernormal AT activity associated with high mortality, independent of disease severity, might be a predictor of in-hospital mortality.

Relationship Between Initial Vancomycin Trough Levels and Early-Onset Vancomycin-Associated Nephrotoxicity in Critically Ill Patients.

BACKGROUND: Appropriate initial dosing of vancomycin (VCM) is important in improving survival and in preventing nephrotoxicity in critically ill patients, but the potential relationship between initial VCM trough levels and early-onset nephrotoxicity remains unclear. We examined the relationship between initial VCM trough levels and early-onset VCM-associated nephrotoxicity. METHODS: We performed a retrospective study of patients who had therapeutic drug monitoring of VCM with initial trough levels within 4 days after the beginning of VCM administration. We excluded patients who received renal replacement therapy from 2 days before to 7 days after the beginning of VCM administration, were younger than 18 years, or had renal dysfunction before the beginning of VCM administration. Early-onset VCM-associated nephrotoxicity was defined as an increase in serum creatinine level of ≥0.5 mg/dL (44.2 µmol/L) or 50% above baseline for 2 or more consecutive days within 7 days after the beginning of VCM administration. RESULTS: Among 109 enrolled patients, 13 patients had early-onset VCM-associated nephrotoxicity. Its incidence rate was 31.3% in patients with initial trough levels of ≥20g/mL, which was significantly higher than 6.3% in patients with initial trough levels of <10 mg/L. Multiple logistic regression analysis demonstrated that early-onset VCM-associated nephrotoxicity was associated with initial trough levels of ≥20 mg/L (odds ratio, 5.0; 95% confidence interval, 1.3-19.1) and with vasopressor use (odds ratio, 5.0; 95% confidence interval, 1.3-19.1). Kaplan-Meier analysis showed that the probability of nonnephrotoxicity for patients with initial VCM trough levels of ≥20 mg/L was lower compared with patients with trough levels of <15 mg/L. CONCLUSIONS: Initial trough levels of ≥20 mg/L but not ≥15 mg/L were associated with early-onset VCM-associated nephrotoxicity in critically ill patients. Future prospective studies are needed to examine outcomes in critically ill patients achieving initial VCM trough levels of 15-20 mg/L.

Development of new equipment for intra-arrest brain cooling that uses cooled oxygen in the lungs: volunteer study.

Aims: Many experimental studies have reported that intra-arrest cooling during cardiac arrest is a promising treatment to mitigate brain injury. However, there is no clinically established method for cooling the brain during cardiac arrest. We hypothesized that, as blood flow in the lungs must be very slow during cardiopulmonary resuscitation, the blood could be cooled by ventilating the lungs with cooled oxygen like a radiator, and that this cooled blood would in turn cool the brain. The aim of this study was to develop equipment to cool oxygen for this purpose and to confirm its safety on a group of volunteers. Methods: We developed new equipment that cools oxygen by running it through a vinyl chloride coil submerged in a bottle of water and frozen at -80°C. Using this equipment, seven volunteers were given oxygen by mask, and their blood pressure, heart rate, and peripheral saturation of oxygen were measured. The temperature in the mask was also measured. Results: This equipment was able to decrease the temperature in the mask to -5°C at the Jackson Rees circuit for an oxygen flow of 10 L/min. Among the volunteer group, vital signs were unchanged and the temperature in the mask decreased from 30.1 ± 2.6°C (mean ± standard deviation) to 15.9 ± 9.6°C. No adverse effects were observed in the volunteers after experimentation. Conclusion: We successfully developed new equipment to cool oxygen and established its safety in a volunteer study.

Comparison of Outcomes Between Patients Treated by Therapeutic Hypothermia for Cardiac Arrest Due to Cardiac or Respiratory Causes.

Outcome for patients experiencing out-hospital cardiac arrest (OHCA) due to respiratory causes is poor, even with treatment by therapeutic hypothermia (TH). The purpose of this study is to clarify difference in outcome and respiratory state during resuscitation between cases due to respiratory causes versus those due to cardiac causes, to establish alternative strategies for the patient. This study was conducted as a retrospective analysis of patients with post CA syndrome who underwent TH. Patients were divided into two groups according to cause of CA: cardiac (C group) or respiratory (R group). Utstein Style data, outcome, and arterial blood gas (ABG) findings after emergency room admission of the two groups were compared. Of 74 patients treated with TH during the 2-year study period, 49 were placed in the C group and 19 in the R group. The rates of ventricular fibrillation/pulseless ventricular tachycardia at initial rhythm were significantly higher in the C group than in the R group. The rate of favorable neurological outcome was significantly higher in the C group (15/49: 30.6%) than in the R group (1/19: 5.3%) 30 days after resuscitation. In the ABG findings, PaCO2 was significantly higher in the R group than in the C group. For patients experiencing OHCA from respiratory causes, TH was less effective and PaCO2 accumulated immediately after admission. From this, interpretation of the significance of PaCO2 in these patients at the early stage after return of spontaneous circulation should be seriously considered.

Shorter time until return of spontaneous circulation is the only independent factor for a good neurological outcome in patients with postcardiac arrest syndrome.

OBJECTIVE: Few studies have reported factors that result in a better neurological outcome in patients with postcardiac arrest syndrome (PCAS) following return of spontaneous circulation (ROSC). We investigated the factors affecting neurological outcome in terms of both prehospital care and treatments after arrival at hospital in patients with PCAS. METHODS: The study enrolled patients with cardiogenic cardiac arrest who were admitted to an intensive care unit after ROSC with PCAS. We investigated the association of the following factors with outcome: age, gender, witness to event present, bystander cardiopulmonary resuscitation (CPR) performed, ECG waveform at the scene, time interval from receipt of call to arrival of emergency personnel, time interval from receipt of call to arrival at hospital, prehospital defibrillation performed, special procedures performed by emergency medical technician, and time interval from receipt of call to ROSC, coronary angiography/percutaneous coronary intervention (PCI) and therapeutic hypothermia performed. RESULTS: The study enrolled 227 patients with PCAS. Compared with the poor neurological outcome group, the good neurological outcome group had a statistically significant higher proportion of the following factors: younger age, male, witness present, bystander CPR performed, first ECG showed ventricular fibrillation/pulseless ventricular tachycardia, defibrillation performed during transportation, short time interval from receipt of call to ROSC, coronary angiography/PCI and therapeutic hypothermia performed. Of these factors, the only independent factor associated with good neurological outcome was the short time interval from receipt of the call to ROSC. CONCLUSIONS: In the present study, shortening time interval from receipt of call to ROSC was the only important independent factor to achieve good neurological outcome in patients with PCAS.