Evaluation of characteristics and prognosis of COVID-19 patients requiring invasive mechanical ventilation during dominance of nonvariant, alpha, delta, and omicron variants in tertiary hospitals of Japan.

BACKGROUND: In November 2021, the B.1.1.529 (omicron) variant of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was detected in South Africa and subsequently rapidly spread around the world. Despite the reduced severity of the omicron variants, many patients become severely ill after infection and undergo invasive mechanical ventilation, but there are few reports on their background and prognosis throughout all variant periods. This study aimed to evaluate risk factors affecting patients requiring invasive mechanical ventilation with each variant of COVID-19 pandemic in Japan from nonvariants to omicron variants. METHOD: This retrospective observational study was conducted at the Department of Emergency and Critical Care Medicine, Kansai Medical University Hospital and Kansai Medical University Medical Center, Osaka, Japan, from March 2020 to March 2023. Eligible patients were those who underwent invasive ventilation for COVID-19 pneumonia. We set the primary endpoint as in-hospital mortality. Multivariable logistic regression analysis adjusted for clinically important variables was performed to evaluate the clinical outcomes. RESULTS: We included 377 patients: 118 in the Nonvariant group, 154 in the Alpha group, 42 in the Delta group, and 63 patients in the Omicron group. Mortality rates for each group were 23.7% for the Nonvariant group, 12.3% for the Alpha group, 7.1% for the Delta group, and 30.5% for the Omicron group. Patient age was significantly associated with increased mortality (adjusted odds ratio [AOR]: 1.097; 95% confidence interval [CI]: 1.057-0.138, P < 0.001). Immunodeficiency (AOR: 3.388, 95% CI: 1.377-8.333, P = 0.008), initial SOFA score (AOR: 1.190, 95% CI: 1.056-1.341, P = 0.004), dialysis prior to COVID-19 (AOR: 3.695, 95% CI: 1.117-11.663, P = 0.026), and smoking history (AOR: 2.548, 95% CI: 1.153-5.628, P = 0.021) were significantly associated with increased mortality. Differences in variants were not significant factors associated with high mortality. CONCLUSION: We compared the background and prognosis of patients with COVID-19 pneumonia requiring invasive mechanical ventilation between SARS-CoV-2 variants. In these patients, differences in variants did not affect prognosis. Hospital mortality in critically ill COVID-19 patients was significantly higher in the older patients with bacterial coinfection, or patients with immunodeficiency, COPD, and chronic renal failure on dialysis.

Efficacy of the shoelace technique for extremity fasciotomy wounds due to compartment syndrome.

BACKGROUND: The shoelace technique for compartment syndrome allows application of sustained tightening tension to an entire wound and intermittent tightening of the shoelace without requiring its replacement or anesthesia. We retrospectively evaluated the usefulness of the shoelace technique in the management of extremity fasciotomy wounds before and after its introduction in our institution. METHODS: We targeted 25 patients who were diagnosed as having compartment syndrome and underwent extremity fasciotomy at our hospital from April 2012 to December 2021. The N group, comprising 12 patients treated without the shoelace technique, and the S group, comprising 13 patients treated with the shoelace technique, were compared retrospectively for each outcome. RESULTS: There were no significant differences between the two groups in patient background. Compared with the N group patients, all of the S group patients avoided skin grafting (S group: n = 0, 0%; N group: n = 6, 50.0%; p < 0.01). However, there was no significant difference in the number of days to final wound closure (S group: 39.5 [IQR 24.3-58.0] days; N group: 24.0 [IQR 18.5-31.0] days, p = 0.06). CONCLUSIONS: We considered the shoelace technique to be a useful wound closure method for fasciotomy wounds caused by compartment syndrome because it can significantly reduce the need for skin grafting and tends to shorten the wound closure period.

Improved neurologically favorable survival after OHCA is associated with increased pre-hospital advanced airway management at the prefecture level in Japan.

Out-of-hospital cardiac arrest (OHCA) has high incidence and mortality. The survival benefit of pre-hospital advanced airway management (AAM) for OHCA remains controversial. In Japan, pre-hospital AAM are performed for OHCA by emergency medical services (EMS), however the relationship between resuscitation outcomes and AAM at the prefecture level has not been evaluated. The purpose of this study was to describe the association between AAM and neurologically favorable survival (cerebral performance category (CPC) ≦2) at prefecture level. This was a retrospective, population-based study of adult OHCA patients (≧ 18) from January 1, 2014 to December 31, 2017 in Japan. We excluded patients with EMS witnessed arrests. We also only included patients that had care provided by an ELST with the ability to provided AAM and excluded cases that involved prehospital care delivered by a physician. We categorized OHCA into four quartiles (four group: G1-G4) based on frequency of pre-hospital AAM approach rate by prefecture, which is the smallest geographical classification unit, and evaluated the relationship between frequency of pre-hospital AAM approach rates and CPC ≦ 2 for each quartile. Multivariable logistic regression was used to assess effectiveness of AAM on neurologically favorable survival. Among 493,577 OHCA cases, 403,707 matched our inclusion criteria. The number of CPC ≦ 2 survivors increased from G1 to G4 (p for trend < 0.001). In the adjusted multivariable regression, higher frequency of pre-hospital AAM approach was associated with CPC ≦ 2 (p < 0.001). High prefecture frequency of pre-hospital AAM approach was associated with neurologically favorable survival (CPC ≦ 2) in OHCA.

EFFECTS OF 2-METHYL-2-THIAZOLINE ON CIRCULATORY DYNAMICS AND INTESTINAL VASCULAR SYSTEM IN RABBITS WITH ENDOTOXIC SHOCK.

ABSTRACT: We hypothesized that circulatory and jejunal mucosal blood flow would improve after 2-methyl-2thiazoline (2MT) administration in endotoxic shock. This study aimed to evaluate changes in systemic circulation and in superior mesenteric venous (SMV) blood flow and jejunal mucosal tissue blood flow of the intestinal vascular system over time after administration of 2MT in rabbits with endotoxic shock. We created four groups (n = 6 each): control group, LPS (1 mg/kg) group, 2MT (80 mg/kg) group, and LPS-2MT group. As indicators of circulation, we measured MAP, heart rate, cardiac index, lactic acid level, SMV blood flow, and jejunal mucosal tissue blood flow every 30 min from 0 to 240 min. The drop in MAP observed in the LPS group was suppressed by 2MT administration. Superior mesenteric venous blood flow dropped temporarily with LPS administration but then rose thereafter. After administration of 2MT to the LPS group, SMV blood flow began to rise earlier than that in the LPS group and did not decline below that of the control group thereafter. In the LPS group, jejunal mucosal tissue blood flow transiently decreased and then increased but at a lower level than that in the control group. However, in the LPS-2MT group, although a transient decrease in jejunal mucosal tissue blood flow was observed, its flow then improved to the level of the control group. An interaction between 2MT and LPS was observed for jejunal mucosal tissue blood flow from 90 to 180 min and at 240 min (P < 0.05). We showed that 2MT maintained MAP and improved SMV blood flow and jejunal mucosal tissue blood flow. In a rabbit model of endotoxic shock, 2MT had a positive effect on MAP and jejunal mucosal tissue blood flow.

Study of damage control strategy for non-traumatic diseases: a single-center observational study.

BACKGROUND: Damage control strategy (DCS) has been introduced not only for trauma but also for acute abdomen, but its indications and usefulness have not been clarified. We examined clinical characteristics of patients who underwent DCS and compared clinical characteristics and results with and without DCS in patients with septic shock. METHODS: We targeted a series of endogenous abdominal diseases in Kansai Medical University Hospital from April 2013 to March 2019. Clinical characteristics of 26 patients who underwent DCS were examined. Then, clinical characteristics and results were compared between the DCS group (n = 26) and non-DCS group (n = 31) in 57 patients with septic shock during the same period. RESULTS: All 26 patients who underwent DCS had septic shock, low mean arterial pressure (MAP) before the start of surgery, and required high-dose norepinephrine administration intraoperatively. Their discharge mortality rate was 12%. Among the patients with septic shock, the DCS group had a higher SOFA score (P = 0.008) and MAP was lower preoperatively, but it did not increase even with intraoperative administration of large amounts of fluid replacement and vasoconstrictor. There was no significant difference in 28-day mortality and discharge mortality between the two groups. CONCLUSIONS: DCS may be useful in patients with severe septic shock.

Lacosamide poisoning improved by hemodialysis.

Background: Lacosamide (LCM) is a third-generation antiepileptic drug that has been proven to be effective and safe, with few side-effects. Case Presentation: A woman aged in her 20s was transported to our hospital because of decreased consciousness. Many drugs, such as LCM (328 tablets) and perampanel hydrate (81 tablets), were found in her car. Her Glasgow Coma Scale score was 14. She was intubated and managed with mechanical ventilation, and she was treated with activated charcoal. Subsequently, hemodialysis (HD) was initiated due to the appearance of clonic convulsions. After 4 h of HD, no seizures were noted. The patient was weaned from the ventilator 18 h after admission and discharged on day 4. Her blood LCM level was 91.7 µg/mL on admission and 68.1 and 18.3 µg/ml before and after HD, respectively. Conclusion: Hemodialysis was carried out in this severe case of LCM poisoning and was found to be effective.

Evaluation of urinary extravasation after non-operative management of traumatic renal injury: a multi-center retrospective study.

PURPOSE: Urinary extravasation is one of the major complications after non-operative management of traumatic renal injury and may lead to urinary tract infection and sepsis. The purpose of this study was to evaluate these factors in patients with traumatic renal injury. METHODS: This was a multi-center, retrospective, observational study performed at three tertiary referral hospitals in Osaka prefecture. We included patients with traumatic renal injury transported to the centers between January 2008 and December 2018. We excluded patients who either died or underwent nephrectomy within 24 h after admission. We investigated the occurrence of urinary extravasation and the related factors after traumatic renal injury using multivariable logistic regression analysis. RESULTS: In total, 146 patients were eligible for analysis. Their median age was 44 years and 68.5% were male. Their median Injury Severity Score was 17. Renal injuries were graded as American Association for Surgery of Trauma (AAST) grade I in 33 (22.6%), II in 27 (18.5%), III in 38 (26.0%), IV in 28 (19.2%), and V in 20 (13.7%) patients. Urinary extravasation was diagnosed in 26 patients (17.8%) and was statistically significantly associated with AAST grades IV-V (adjusted odds ratio, 33.8 [95% confidence interval 7.12-160], p < 0.001). CONCLUSION: We observed urinary extravasation in 17.8% of patients with non-operative management of traumatic renal injury and the diagnosed was made in mostly within 7 days after admission. In this study, the patients with AAST grade IV-V injury were associated with having urinary extravasation.

Effectiveness of near-infrared spectroscopy-guided continuous chest compression resuscitation without rhythm check in patients with out-of-hospital cardiac arrest: The prospective multicenter TripleCPR 16 study.

BACKGROUND: The proportion of adult patients with return of spontaneous circulation (ROSC) following out-of-hospital cardiac arrest (OHCA) remains unchanged since 2012. A better resuscitation strategy is needed. This study evaluated the effectiveness of a regional cerebral oxygen saturation (rSO2)-guided resuscitation protocol without rhythm check based on our previous study. METHODS: Because defibrillation is the definitive therapy that should be performed without delay for shockable rhythm, the study subjects were OHCA patients with non-shockable rhythm on hospital arrival at three emergency departments. They were divided into three groups based on their baseline rSO2 value (%): ≥50, ≥40 to <50, or <40. Continuous chest compression without rhythm checks was performed for 16 minutes or until a maximum increase in rSO2 of 10%, 20%, or 35% was achieved in each group, respectively. This intervention cohort was compared with a historical control cohort regarding the probability of ROSC using inverse probability of treatment weighting (IPTW) with propensity score. RESULTS: The control and intervention cohorts respectively included 86 and 225 patients. The rate of ROSC was not significantly different between the groups (adjusted OR 0.91 [95% CI, 0.64-1.29], P = 0.60), but no serious adverse events occurred. Sensitivity analyses 1 and 2 showed a significant difference or positive tendency for higher probability of ROSC (adjusted OR 1.63 [95% CI, 1.22-2.17], P < 0.001) (adjusted OR 1.25 [95% CI, 0.95-1.63], P = 0.11). CONCLUSIONS: This trial suggested that a new cardiopulmonary resuscitation protocol with different rhythm check timing could be created using the rSO2 value. Clinical trial number: UMIN000025684.

Outcomes of patients with OHCA of presumed cardiac etiology that did not achieve prehospital restoration of spontaneous circulation: The All-Japan Utstein Registry experience.

BACKGROUND: Correct identification of futile prehospital resuscitation for out-of-hospital cardiac arrest (OHCA) may reduce unnecessary transports. Prehospital return of spontaneous circulation (ROSC) is considered by many to be an important predictor of outcome. The purpose of this study was to evaluate OHCA victims without prehospital ROSC characteristics and their outcomes in relation to the universal Termination of Resuscitation (TOR) rule. METHODS: A retrospective, population-based review of OHCA victims without prehospital ROSC from January 1, 2010 to December 31, 2017 in the All-Japan Utstein Registry. We compared those that met the universal TOR rule and those that did not for the primary outcome: one-month survival with neurologically favorable Cerebral Performance Category (CPC) 1 or 2. RESULTS: 989,929 OHCA cases, 18 years of age or older, were registered in the All-Japan Utstein Registry and 525,801 cases were of presumed cardiac origin and had no prehospital ROSC. Of these, the one-month CPC was 1 or 2 for 3957 cases (0.8%). In the 'no ROSC' group who also met the TOR rule, the number of cases was 433,571 with a one-month survival of 0.9% (3799 cases), and the proportion with a CPC 1or 2 was 0.2% (699 cases). CONCLUSIONS: Continued resuscitation and transport of cases with no field ROSC who fulfill the TOR rule is futile and could be considered for adoption in Japan.

Combination of Procalcitonin Value on Hospital Admission and Its Subsequent Change in Value Is Associated With the Prognosis of Sepsis.

To evaluate the relationship between the procalcitonin value in blood on hospital admission and its subsequent change and prognosis among sepsis patients. DESIGN: A single-center, retrospective, observational study. SETTING: Critical care center in Japan. PATIENTS: Sepsis patients 18 years old or older admitted from January 1, 2015, to March 31, 2018. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: Among 173 sepsis patients enrolled, the median age was 74 years old (interquartile range, 64-79 yr old), and there were 102 men. The median value of procalcitonin in blood on hospital admission was 14.8 ng/mL (interquartile range, 3.5-78.4 ng/mL), and the median change in serum procalcitonin value between hospital admission and the next day was 0 ng/mL (interquartile range, -4.5 to 5.2 ng/mL). Mortality at 28 days after hospital admission was 5.8% (10/173). In univariate logistic regression analysis, elderly (crude odds ratio, 5.314; 95% CI, 1.094-25.806; p = 0.044), procalcitonin value of less than 33.2 ng/mL on hospital admission (p = 0.007), and change in serum procalcitonin of less than 0.0 ng/mL (crude odds ratio, 5.056; 95% CI, 1.041-24.545; p = 0.046) were associated with mortality at 28 days after hospital admission. The mortality of patients with a procalcitonin value of less than 33.2 ng/mL on hospital admission and change in serum procalcitonin of less than 0.0 ng/mL was 18.6% (8/43) and was significantly higher than that of other patients (p < 0.001). CONCLUSIONS: Our study showed the sepsis patients with a procalcitonin value in blood of less than 33.2 ng/mL on hospital admission and change in serum procalcitonin of less than 0.0 ng/mL had high mortality at 28 days after hospital admission.

Effects of Norepinephrine on the Intestinal Vascular System in Rabbits With Endotoxic Shock.

ABSTRACT: We hypothesized that jejunal mucosal tissue blood flow would decrease following norepinephrine (NE) administration in endotoxic shock. We aimed of this study to evaluate changes in superior mesenteric venous (SMV) blood flow and jejunal mucosal tissue blood flow of the intestinal vascular system over time by administration of NE in rabbits with endotoxic shock. We created four groups (n = 8 each): control group, lipopolysaccharide (LPS; 1 mg/kg) group, NE (2 µg/kg/min) group, and LPS+NE group. As indicators of circulation, we measured mean arterial blood pressure (MAP), cardiac output, SMV blood flow, and jejunal mucosal tissue blood flow every 30 min from 0 to 240 min. The drop in MAP observed in the LPS group was suppressed by NE administration. SMV blood flow dropped temporarily with LPS administration, but then rose thereafter. Administration of NE to the LPS group suppressed the transient decline in SMV blood flow, which did not drop below that of the control group. In the LPS group, jejunal mucosal tissue blood flow transiently dropped and then rose, reflecting the pattern in SMV blood flow. In the LPS+NE group, however, although there was no drop in SMV blood flow, jejunal mucosal tissue blood flow remained low. An interaction between NE and LPS was observed regarding jejunal mucosal tissue blood flow from 90 to 180 min (P = 0.033). We showed that NE maintained MAP and SMV blood flow but decreased jejunal mucosal tissue blood flow. In a rabbit model of endotoxic shock, NE had a negative effect on jejunal mucosal tissue blood flow.

Propofol suppresses ventricular arrhythmias: a case report of acute caffeine intoxication.

BACKGROUND: Caffeine is widely used as a stimulant drug throughout the world, and fatal arrhythmia is a known side-effect. We experienced a patient with caffeine intoxication causing fatal arrhythmias who was successfully treated with the infusion of propofol. CASE PRESENTATION: A 27-year-old woman was transferred to our hospital with nausea and poor general condition after intentional ingestion of 23.2 g of caffeine tablets. She was in cardiac arrest due to ventricular fibrillation just before hospital arrival. Advanced life support including defibrillation was started immediately, and we succeeded in resuscitating her 23 min later. Although she suffered from polymorphic ventricular premature beats and frequent transition to ventricular fibrillation, propofol administration converted her from a ventricular arrhythmia to sinus rhythm. CONCLUSION: We report this case focusing on the cardiovascular effects of propofol and the lipid sink phenomenon. As a result, propofol could have the potential to suppress ventricular arrhythmias.

Factors associated with bowel necrosis in patients with hepatic portal venous gas and pneumatosis intestinalis.

AIM: Historically, the presence of hepatic portal venous gas (HPVG) and pneumatosis intestinalis (PI) have been reported to be associated with bowel necrosis and fatal outcome. However, there are no criteria to judge whether bowel necrosis has occurred. We aimed to examine the factors associated with bowel necrosis in patients with HPVG and PI. METHODS: The study comprised 25 patients who were diagnosed as having HPVG and/or PI based on computed tomography (CT) findings in the Department of Emergency and Critical Care Medicine, Kansai Medical University Hospital (Osaka, Japan) between April 2013 and August 2017. We compared various factors, including clinical history, severity of present illness, laboratory data, and CT findings, and examined whether they were related to bowel necrosis. RESULTS: Both Sequential Organ Failure Assessment scores and total bilirubin levels were significantly higher in the necrosis group than those in the non-necrosis group (P = 0.03 and P = 0.02, respectively). The quantity of portal venous gas observed on computed tomography was associated with bowel necrosis in patients with HPVG. In contrast, the presence of air-type PI, defined as PI with emphysema covering the total circumference of the intestine in the absence of wall edema, and the presence of free air were significantly higher in the non-necrosis group (both P < 0.01). CONCLUSIONS: This study showed that the quantity of HPVG was associated with bowel necrosis, whereas the presence of free air or air-type PI was associated with non-necrosis of the bowel.

A strategy for improving the prognosis of non-occlusive mesenteric ischemia (NOMI): a single-center observational study.

AIM: The purpose of this study was to determine the prognostic factors of non-occlusive mesenteric ischemia (NOMI) and to examine treatment strategies that could improve its prognosis. METHODS: We retrospectively identified 30 patients who underwent emergency laparotomy for NOMI in Kansai Medical University Hospital (Hirakata, Japan) from April 2013 to December 2017. We examined prognostic factors related to discharge outcome and also examined the prognostic impact of open abdominal management and second look operation strategy (OSS) by dividing the patients into the non-OSS group and the OSS group. RESULTS: The primary end-point was a prognostic factor for outcome at discharge of the 30 patients. The outcome at discharge was compared between the survival group and the death group. Multivariate analysis was undertaken on two items from the univariate analysis that showed a significant difference (computed tomography findings of intestinal pneumatosis and acute disseminated intravascular coagulation [DIC] score). As a result, there was a significant difference in the factors of intestinal pneumatosis (odds ratio = 0.054; 95% confidence interval, 0.005-0.607; P = 0.018) and DIC score (odds ratio = 1.892; 95% confidence interval, 1.077-3.323; P = 0.027). The secondary end-point was the treatment outcome before and after the application of OSS. Operation time was significantly shorter and the amount of bleeding was also significantly less in the OSS group. CONCLUSION: Computed tomography findings of intestinal pneumatosis and the acute disseminated intravascular coagulation score were found to be prognostic factors for survival in patients with NOMI. Aggressive laparotomy to determine the definitive diagnosis is needed and OSS could be useful to improve patient prognosis for survival from NOMI.

Gastric emphysema with portal emphysema due to superior mesenteric artery syndrome developing septic shock: a case report.

BACKGROUND: Superior mesenteric artery syndrome (SMAS) is often associated with gastric dilatation but, very rarely, it can be associated with gastric emphysema. In addition, there are few reported cases accompanied by septic shock. CASE PRESENTATION: A 64-year-old man was transferred to our hospital with vomiting and abdominal distention. He went into shock and showed impaired consciousness. Blood biochemistry tests showed elevated levels of C-reactive protein. An abdominal computed tomography scan revealed a dilated stomach and proximal duodenum, and constriction of the third portion of the duodenum with gastric and portal emphysema. We thus diagnosed him with gastric and portal emphysema associated with SMAS that progressed to septic shock. We treated him conservatively by giving antibiotics and undertaking gastric drainage and feeding by way of the jejunum through a double elementary diet tube. CONCLUSION: This is the first report to describe a case of SMAS with gastric and portal emphysema that progressed to septic shock.

Study of the prognostic factor of the colon perforation case with the pan-peritonitis that needed emergency surgery: a single-center observational study.

AIM: We divided patients treated with emergency surgery for pan-peritonitis caused by colon perforation into the survival group and the death group based on outcome at postoperative day 30 and examined the prognostic factors for colon perforation. METHODS: The prognostic factors for colon perforation in 76 consecutive patients who underwent emergency surgery at Kansai Medical University Hospital (Hirakata, Japan) from April 2011 to March 2017 were investigated based on outcome at postoperative day 30. RESULTS: The average age of the 76 patients (41 men/35 women) was 73 years, and the causative disease of colon perforation was malignant/benign in 18/58 cases, with ileocecal perforation site in 8 cases, ascending colon in 6, transverse colon in 2, descending colon in 4, sigmoid colon in 49, and rectum in 7. All patients received laparotomy with irrigation drainage, and 9 patients (11.8%) were dead at 30 days. Upon comparing the 67 survivors with the 9 dead patients, we recognized a significant difference on preoperative spread of ascites on computed tomography (CT) (P = 0.002) in univariate analysis and on acute disseminated intravascular coagulation (DIC) score (odds ratio 2.289; 95% confidence interval, 1.188-4.410; P = 0.013) in multivariate analysis. CONCLUSION: In our hospital, the preoperative acute DIC score was found to be a prognostic factor for colon perforation accompanied by pan-peritonitis. Appropriate evaluation of the spread of ascites on the preoperative CT might also help predict patient prognosis.

Takotsubo cardiomyopathy in the intensive care unit.

AIMS: An angiographic examination is necessary for the diagnosis of takotsubo cardiomyopathy (TTC). However, in the intensive care unit (ICU), intensivists often see patients in whom TTC cannot be diagnosed because they cannot undertake angiography due to the patient's poor general condition. We defined such cases as clinical TTC (cTTC) and investigated the incidence and background of cTTC in the ICU at Kansai Medical University Hospital (Osaka, Japan). METHODS: The study involved 5,084 patients who were admitted to the ICU of Kansai Medical University Hospital between January 2013 and December 2017. We retrospectively investigated the frequency and background of TTC and cTTC. RESULTS: Of the 5,084 patients, 5 (0.09%) patients admitted to the ICU were diagnosed as having TTC and 19 patients (0.37%) were diagnosed as having cTTC. The most common primary disease among the evaluated patients was sepsis (n = 10) followed by subarachnoid hemorrhage (SAH) (n = 5). Ten of the 335 patients with sepsis (3.0%) were admitted to the ICU with complications due to cTTC. Their blood pressure and heart rate on admission tended to be high, and their Sequential Organ Failure Assessment scores tended to be low. Five of the 172 patients with SAH (2.9%) were admitted to the ICU with complications due to cTTC. These patients were often classified as grade 5 on the Hunt and Hess scale. CONCLUSION: Our study suggests that patients with sepsis or SAH are complicated with cTTC in the ICU. In addition, there might be no correlation between the severity of sepsis and the development of TTC.

Ventricular septal perforation after blunt chest trauma due to blows from a fist.

Case: A 40-year-old man received fist blows to his chest and abdomen. He presented with external jugular vein distention and facial congestion. Chest X-ray showed bilateral pulmonary congestion. A Levine V/VI holosystolic murmur was audible. Echocardiography showed left-to-right shunt flow across the perimembranous region of the ventricular septum. The diameter of the hole was approximately 13 mm. We diagnosed ventricular septal perforation, started an infusion, and administered vasopressors. However, circulatory dynamics could not be maintained. The ventricular septal perforation was repaired directly with mattress sutures through the right ventricle. A small residual ventricular septal perforation was detected, which was repaired with a patch sutured through the left ventricle. Outcome: The patient was discharged without cardiovascular complications 43 days after admission. Conclusion: Ventricular septal perforation following blunt chest trauma is a rare form of cardiac trauma. It is important to consider the timing of the operation and the best method to ensure cardiac repair.

Vasodilating prostaglandin E1 does not reproduce interleukin-1ß-induced oxygen metabolism abnormalities in rabbits.

Background: We have reported that administration of recombinant human interleukin (IL)-1ß induced circulatory shock in rabbits by causing overproduction of vasodilating prostaglandin(s) and simultaneously impaired oxygen metabolism by causing an abnormal dependence of oxygen consumption (VO2) on oxygen delivery (DO2). The present study was carried out to compare the effect of administration of exogenous PGE1 with that of IL-1ß on oxygen metabolism. Methods: Sixteen rabbits were assigned to one of three groups and given a single injection of 10 µg/kg IL-1ß (IL-1ß group, n = 5), continuous infusion of 1 µg/kg/min PGE1 (PGE1 group, n = 6), or saline (control group, n = 5). All rabbits were subjected to stepwise cardiac tamponade to decrease DO2 by inflating a balloon placed into the pericardial sac. The VO2/DO2 relation was analyzed by the dual-line method. Results: Both IL-1ß and PGE1 decreased the baseline value of mean arterial pressure by approximately 25% without inducing significant alteration of the cardiac index. With respect to the VO2/DO2 relation, the slope of the supply-independent line was significantly increased in the IL-1ß group (y = 0.13x + 6.4), but not in the PGE1 group (y = 0.01x + 10.0) compared to that in the control group (y = 0.05x + 8.7). Conclusion: These results indicate that simple vasodilation and hypotension induced by administration of PGE1 are insufficient to account for the abnormal oxygen metabolism induced by IL-1ß.

C4d deposits on the surface of RBCs in trauma patients and interferes with their function.

OBJECTIVE: Complement system is activated in patients with trauma. Although complement activation is presumed to contribute to organ damage and constitutional symptoms, little is known about the involved mechanisms. Because complement components may deposit on RBCs, we asked whether complement deposits on the surface of RBC in trauma and whether such deposition alters RBC function. DESIGN: A prospective experimental study. SETTING: Research laboratory. SUBJECTS: Blood samples collected from 42 trauma patients and 21 healthy donors. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: RBC and sera were collected from trauma patients and control donors. RBCs from trauma patients (n = 40) were found to display significantly higher amounts of C4d on their surface by flow cytometry compared with RBCs from control (n = 17) (p < 0.01). Increased amounts of iC3b were found in trauma sera (n = 27) (vs 12 controls, p < 0.01) by enzyme-linked immunosorbent assay. Incubation of RBC from universal donors (type O, Rh negative) with trauma sera (n = 10) promoted C4d deposition on their surface (vs six controls, p< 0.05). Complement-decorated RBC (n = 6) displayed limited their deformability (vs six controls, p < 0.05) in two-dimensional microchannel arrays. Incubation of RBC with trauma sera (n = 10) promoted the phosphorylation of band 3, a cytoskeletal protein important for the function of the RBC membrane (vs eight controls, p < 0.05), and also accelerated calcium influx (n = 9) and enhanced nitric oxide production (n = 12) (vs four and eight controls respectively, p < 0.05) in flow cytometry. CONCLUSIONS: Our study found the presence of extensive complement activation in trauma patients and presents new evidence in support of the hypothesis that complement activation products deposit on the surface of RBC. Such deposition could limit RBC deformability and promote the production of nitric oxide. Our findings suggest that RBC in trauma patients malfunctions, which may explain organ damage and constitutional symptoms that is not accounted for otherwise by previously known pathophysiologic mechanisms.