Laparoscopy for emergency abdominal surgery is associated with reduced physical functional decline in older patients: a cohort study.

BACKGROUND: An increasing number of older patients require emergency abdominal surgery for acute abdomen. They are susceptible to surgical stress and lose their independence in performing daily activities. Laparoscopic surgery is associated with faster recovery, less postoperative pain, and shorter hospital stay. However, few studies have examined the relationship between laparoscopic surgery and physical functional decline. Thus, we aimed to examine the relationship between changes in physical function and the surgical procedure. METHODS: In this was a single-center, retrospective cohort study, we enrolled patients who were aged ≥ 65 years and underwent emergency abdominal surgery for acute abdomen between January 1, 2019, and December 31, 2021. We assessed their activities of daily living using the Barthel Index. Functional decline was defined as a decrease of ≥ 20 points in Barthel Index at 28 days postoperatively, compared with the preoperative value. We evaluated an association between functional decline and surgical procedures among older patients, using multiple logistic regression analysis. RESULTS: During the study period, 852 patients underwent emergency abdominal surgery. Among these, 280 patients were eligible for the analysis. Among them, 94 underwent laparoscopic surgery, while 186 underwent open surgery. Patients who underwent laparoscopic surgery showed a less functional decline at 28 days postoperatively (6 vs. 49, p < 0.001). After adjustments for other covariates, laparoscopic surgery was an independent preventive factor for postoperative functional decline (OR, 0.22; 95% CI, 0.05-0.83; p < 0.05). CONCLUSIONS: In emergency abdominal surgery, laparoscopic surgery reduces postoperative physical functional decline in older patients. Widespread use of laparoscopic surgery can potentially preserve patient quality of life and may be important for the better development of emergency abdominal surgery.

Appropriate Endotracheal Tube Position for Percutaneous Dilatational Tracheostomy: A Single-Center Observational Study.

Aim This study aimed to investigate the appropriate endotracheal tube (ETT) position during percutaneous dilatational tracheostomy (PDT). Methods This single-center observational study included hospitalized patients who underwent surgical tracheostomy (ST) between August 2021 and October 2022. During ST, the trachea was opened, and the ETT was pulled out visually. It stopped when the ETT was no longer visible, and the tracheostomy tube was placed in the trachea. The ETT position was measured by considering the ETT position during ST to be the appropriate position during PDT. The correlation between the measured ETT position and patient characteristics was evaluated. A prediction equation for the ETT position was derived from the derivation group, and validation of the prediction equation was evaluated by the validation group. Results Forty-six and 15 patients were in the derivation and validation groups, respectively. Weight, duration of intubation, and in-hospital mortality were significantly different between the two groups. The measured ETT position correlated with body height (r=0.60, p<0.001) and sex (r=0.45, p=0.002), while the ETT position before ST showed a weak correlation (r=0.34, p=0.020). The predicted and measured values in the validation group correlated with each other (r=0.58, p=0.024). Conclusion The appropriate ETT position for PDT correlates with body height, and the equation "body height×0.112-0.323 cm" was derived. This predictive equation may be useful as a guide for ETT positioning during PDT puncture.

Superior mesenteric artery embolism associated with Cisplatin-induced aortic thrombosis.

Cardiovascular complications of cancer therapy are among the most important factors affecting cancer prognosis. Cisplatin-induced aortic thrombosis is rare but can be life-threatening in the event of peripheral embolism. In this report, we describe a case of superior mesenteric artery (SMA) embolism associated with cisplatin-induced aortic thrombosis. A 66-year-old male, diagnosed with esophageal cancer, initiated systemic chemotherapy with a regimen consisting of 5-fluorouracil and cisplatin, combined with radiotherapy. After 7 days of chemoradiotherapy, the patient developed a floating thrombus in the ascending aorta and an SMA embolism; chemoradiotherapy was then discontinued. Laparoscopy revealed an ischemic small intestine that required resection; intravenous unfractionated heparin was initiated 3 days after. Computed tomography showed disappearance of the floating aortic thrombus and reduce SMA thrombus size. Early detection of cisplatin-induced aortic thrombosis may prevent fatal outcomes in symptomatic peripheral embolisms, such as SMA embolism, considering anticoagulation, and discontinuation of cisplatin-based chemotherapy may cause resolution of thrombus events.

Predictive value of total psoas muscle index for postoperative physical functional decline in older patients undergoing emergency abdominal surgery.

BACKGROUND: Older individuals increasingly require emergency abdominal surgeries. They are susceptible to surgical stress and loss of independence in performing daily activities. We hypothesized that the psoas muscle volume would be significantly associated with postoperative functional decline (FD) in older patients undergoing emergency abdominal surgery and aimed to evaluate the use of the psoas muscle volume on computed tomography (CT) scans. METHODS: A retrospective, single-center study of patients aged ≥ 65 years who had undergone emergency abdominal surgery between January 2019 and June 2021 was performed. We assessed patients' activities of daily living using the Barthel Index. FD was defined as a ≥ 5-point decrease between preoperative and 28-day postoperative values. The psoas muscle volume was measured by CT, which was used for diagnosis, and normalized by height to calculate total psoas muscle index (TPI). We evaluated associations between FD and TPI using receiver operating characteristics (ROC) analysis and multiple logistic regression analysis. RESULTS: Of 238 eligible patients, 71 (29.8%) had clinical postoperative FD. Compared to the non-FD group, the FD group was significantly older and had a higher proportion of females, higher Charlson Comorbidity Index, lower body mass index, higher American Society of Anesthesiology score, lower serum albumin level, and lower TPI. ROC analyses revealed that TPI had the highest area under the curve (0.802; 95% confidence interval [CI], 0.75-0.86). A multivariable logistic regression model revealed that low TPI was an independent predictor of postoperative FD (odds ratio, 0.14; 95% CI, 0.06-0.32). CONCLUSIONS: TPI can predict postoperative FD due to emergency abdominal surgery. Identification of patients who are at high risk of FD before surgery may be useful for enhancing the regionalized system of care for emergency general surgery.

Common and uncommon vascular injuries and endovascular treatment associated with pelvic blunt trauma: a real-world experience.

Pelvic fractures are common in cases of blunt trauma, which is strongly associated with mortality. Transcatheter arterial embolization is a fundamental treatment strategy for fatal arterial injuries caused by blunt pelvic trauma. However, vascular injuries due to blunt pelvic trauma can show various imaging findings other than arterial hemorrhage. We present a pictorial review of common and uncommon vascular injuries, including active arterial bleeding, pseudoaneurysm, arteriovenous fistula, arterial occlusion, vasospasm, and active venous bleeding. Knowledge of these vascular injuries can help clinicians select the appropriate therapeutic strategy and thus save lives.

Hemostatic Achievement After Introduction of Venovenous Extracorporeal Membrane Oxygenation for Severe Multiple Trauma: A Case Study.

Venovenous extracorporeal membrane oxygenation (VV-ECMO) is indicated for patients with severe respiratory failure who cannot be managed with a ventilator. We report a case of severe chest trauma with an injury severity score of 66, in which hemostasis was achieved after VV-ECMO. A 29-year-old male patient sustained a fall injury from a 4-m cliff. The fall resulted in significant traumatic cerebral hemorrhage, bilateral pulmonary contusion, hemothorax, pelvic fracture, and limb fracture. During transcatheter arterial embolization, the patient continued to bleed from the left lung and showed progressive hypoxemia. In addition, the patient was unable to maintain tidal volume and experienced hypercapnia, and thus, VV-ECMO was introduced, followed by a thoracotomy to stop the bleeding. On the third day of hospitalization, the patient was weaned off VV-ECMO, and on day 35, he was transferred to a rehabilitation hospital for recovery. VV-ECMO may serve as a "bridge" until hemostatic maneuvers for severe chest trauma are completed and may contribute to help ensure adequate respiration.

Extravasation and outcomes in computed tomography and angiography in patients with pelvic fractures requiring transcatheter arterial embolization: A single-center observational study.

BACKGROUND: Extravasation on contrast-enhanced computed tomography (CECT) is a helpful indicator of the need for transcatheter arterial embolization (TAE) for pelvic fractures. However, previous reports were inconsistent on cases in which angiography is necessary, even though there is no extravasation on computed tomography. This study aimed to describe and analyze the contradictory findings in cases where extravasation is observed on angiography but not on CECT, to contribute to improved management of patients with pelvic fractures. METHODS: This was a retrospective single-center study. Patients with pelvic fractures who underwent CECT and TAE between 2014 and 2020 were included. We classified the patients into three groups: CECT and angiography with extravasation (CT+Angio+), CECT with no extravasation and angiography with extravasation (CT-Angio+), and CECT with extravasation and angiography without extravasation (CT+Angio-). RESULTS: A total of 113 patients were included in the study: the CT+Angio+ group had 54 patients, CT-Angio+ group, 47; and CT+Angio- group, 12. The CT-Angio+ group had a significantly longer time from arrival to CECT than the CT+Angio+ group (27 minutes vs. 23 minutes, p < 0.05). The CT-Angio+ group had significantly more blood transfusions (fresh frozen plasma, platelets) within 24 hours than the CT+Angio- group did (p < 0.05), and ventilator management days (p < 0.05) and intensive care unit stays (p < 0.05) were significantly longer. CONCLUSION: There was no significant difference in outcomes among the three groups. There was no difference in severity, transfusion volume, or mortality in patients with pelvic fractures needing TAE, classified as CT-Angio+, compared with that of CT+Angio+ patients. Even in the absence of extravasation in the pelvic region on CECT, angiography or TAE may still be necessary. LEVEL OF EVIDENCE: Therapeutic/Care Management, Level IV.

A simulation study of high-flow versus normal-flow three-way stopcock for rapid fluid administration in emergency situations: A randomised crossover design.

BACKGROUND: Initial fluid resuscitation is presumed to be important for treating shock in the resuscitation phase. However, little is known how quickly and easily a physician could perform a rapid infusion with a syringe. OBJECTIVES: We hypothesised that using a high-flow three-way stopcock (HTS) makes initial fluid resuscitation faster and easier than using a normal-flow three-way stopcock (NTS). METHODS: This was a simulation study with a prospective, nonblinded randomised crossover design. Twenty physicians were randomly assigned into two groups. Each participant used six peripheral intravenous infusion circuits, three with the HTS and the others with the NTS, and three cannulae, 22, 20, and 18 gauge (G). The first group started with the HTS first, while the other started with the NTS first. They were asked to inject the fluid as quick as possible. We compared the time until the participants finished rapid infusions of 500 ml of 0.9% saline and the practitioner's effort. RESULTS: In infusion circuits attached with the 22G cannula, the mean difference using the HTS and the NTS (95% confidence interval [CI]) was 16.30 ml/min (7.65-24.94) (p < 0.01). In those attached with the 20G cannula, the mean difference (95% CI) was 23.47 (12.43-34.51) (p < 0.01). In those attached with the 18G cannula, the mean difference (95% CI) was 42.53 (28.68-56.38) (p < 0.01). CONCLUSIONS: This study revealed that the push-and-pull technique using the HTS was faster, easier, and less tiresome than using the NTS, with a statistically significant difference. In the resuscitation phase, initial and faster infusion is important. If only a single physician or other staff member such as a nurse is attending or does not have accessibility to any other devices in such an environment where medical resources are scarce, performing the push-and-pull technique using the HTS could help a physician to perform fluid resuscitation faster. By setting up the HTS instead of the NTS from the beginning, we would be able to begin fluid resuscitation immediately while preparing other devices.

Use of near-infrared imaging using indocyanine green associates with the lower incidence of postoperative complications for intestinal and mesenteric injury.

Anastomotic leakage after intestinal resection is one of the most serious complications of surgical intervention for hollow viscus injury. Adequate vascular perfusion of the anastomotic site is essential to prevent anastomotic leakage. Near-infrared imaging using indocyanine green (NIR-ICG) is useful for the objective assessment of vascular perfusion. The aim of this study was to evaluate the association of NIR-ICG with intestinal and mesenteric injuries. This was a retrospective, single-center study of patients undergoing surgery for intestinal and mesenteric injuries. NIR-ICG was used to evaluate vascular perfusion. Postoperative complications were assessed between NIR-ICG and non-NIR-ICG groups.The use of NIR-ICG was associated with a lower incidence of Clavien-Dindo grade ≥ III complications with a statistical tendency (p = 0.076). When limited to patients that underwent intestinal resection, the use of NIR-ICG was significantly associated with a lower risk of perioperative complications (p = 0.009). The use of NIR-ICG tended to associate with the lower incidence of postoperative complications after intestinal and mesenteric trauma surgery. NIR-ICG was associated with a significantly lower risk of complications in patients undergoing intestinal resection. The NIR-ICG procedure is simple and quick and is expected to be useful for intestinal and mesenteric trauma.

Temporal change in Syndecan-1 as a therapeutic target and a biomarker for the severity classification of COVID-19.

BACKGROUND: Coronavirus disease 2019 (COVID-19) pneumonitis associated with severe respiratory failure is associated with high mortality. The pathogenesis of COVID-19 is associated with microembolism or microvascular endothelial injuries. Here, we report that syndecan-1 (SDC-1), a component of the endothelial glycocalyx, may be a biomarker of severity classification for COVID-19 related to endothelial injury. METHODS AND ANALYSIS: We analyzed the data of COVID-19 patients for 1 year from February 2020 at Yokohama City University Hospital and Yokohama City University Medical Center Hospital. We selected COVID-19 patients who required admission care, including intensive care, and analyzed the classification of severe and critical COVID-19 retrospectively, using various clinical data and laboratory data with SDC-1 by ELISA. RESULTS: We analyzed clinical and laboratory data with SDC-1 in five severe COVID-19 and ten critical COVID-19 patients. In the two groups, their backgrounds were almost the same. In laboratory data, the LDH, CHE, and CRP levels showed significant differences in each group (P = 0.032, P < 0.0001, and P = 0.007, respectively) with no significant differences in coagulation-related factors (platelet, PT-INR, d-dimer, ISTH score; P = 0.200, 0.277, 0.655, and 0.36, respectively). For the clinical data, the SOFA score was significantly different from admission day to day 14 of admission (p < 0.0001). The SDC-1 levels of critical COVID-19 patients were significantly higher on admission day and all-time course compared with the levels of severe COVID-19 patients (P = 0.009 and P < 0.0001, respectively). CONCLUSIONS: Temporal change of SDC-1 levels closely reflect the severity of COVID-19, therefore, SDC-1 may be a therapeutic target and a biomarker for the severity classification of Covid-19.

Combining IL-6 and SARS-CoV-2 RNAaemia-based risk stratification for fatal outcomes of COVID-19.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic rapidly increases the use of mechanical ventilation (MV). Such cases further require extracorporeal membrane oxygenation (ECMO) and have a high mortality. OBJECTIVE: We aimed to identify prognostic biomarkers pathophysiologically reflecting future deterioration of COVID-19. METHODS: Clinical, laboratory, and outcome data were collected from 102 patients with moderate to severe COVID-19. Interleukin (IL)-6 level and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA copy number in plasma were assessed with ELISA kit and quantitative PCR. RESULTS: Twelve patients died or required ECMO owing to acute respiratory distress syndrome despite the use of MV. Among various variables, a ratio of oxygen saturation to fraction of inspired oxygen (SpO2/FiO2), IL-6, and SARS-CoV-2 RNA on admission before intubation were strongly predictive of fatal outcomes after the MV use. Moreover, among these variables, combining SpO2/FiO2, IL-6, and SARS-CoV-2 RNA showed the highest accuracy (area under the curve: 0.934). In patients with low SpO2/FiO2 (< 261), fatal event-rate after the MV use at the 30-day was significantly higher in patients with high IL-6 (> 49 pg/mL) and SARS-CoV-2 RNAaemia (> 1.5 copies/µL) compared to those with high IL-6 or RNAaemia or without high IL-6 and RNAaemia (88% vs. 22% or 8%, log-rank test P = 0.0097 or P < 0.0001, respectively). CONCLUSIONS: Combining SpO2/FiO2 with high IL-6 and SARS-CoV-2 RNAaemia which reflect hyperinflammation and viral overload allows accurately and before intubation identifying COVID-19 patients at high risk for ECMO use or in-hospital death despite the use of MV.

A Case of Central Pontine Myelinolysis Occurred During Treatment of Hyperosmolar Hyperglycemic Syndrome.

Central pontine myelinolysis (CPM) is a rare demyelinating condition which has been reported to occur in a variety of clinical settings, but most commonly in association with a rapid rise in plasma osmolality during correction of chronic hyponatremia. The clinical consequences can vary from a mild motor weakness that resolves completely over time to the devastating locked-in syndrome. In this presentation, we report a case of hyperosmolar hyperglycemic syndrome (HHS) with ponto-occipital disintegration. A 71-year-old female was transferred to our ER by an ambulance due to consciousness disorder and continuous fever for 10 days. We diagnosed septic shock caused by urinary tract infection (UTI), cerebral multiple infarctions, acute kidney injury (AKI) and HHS without treatment for diabetes. Then, we started therapeutic interventions for them based on the guideline with severe control for blood sugar (BS; primary 1635 mg/dl) under insulin therapy and hypernatremia (primary 153 mEq/l) under crystal infusion control in advanced care unit, apparently on routine lab data. However, the initial serum sodium value of 153 mEq/l was slowly compensated to 148 mEq/l in 60 hours under guideline on routine lab data, the initial compensated sodium value with osmolality was changed from 178 mEq/l to 150 mEq/l in the period. She recovered from her primary diagnosis and unconsciousness. After stabilized sepsis and HHS, we detected CPM on brain MRI due to following up multiple cerebral infarctions with left leg paralysis and verbal disorder. She gradually recovered over several months with intensive rehabilitation and eventually regained near normal functional capacity with stabilized BS. When we consider HHS with hypernatremia, it may be necessary to pay attention to not only to BS control and sodium control according to the guideline but also to osmolality changes to prevent CPM.

An evaluation of venous thromboembolism by whole-body enhanced CT scan for critical COVID-19 pneumonia with markedly rises of coagulopathy related factors: a case series study.

BACKGROUND: Coronavirus disease (COVID-19) pneumonitis associated with severe respiratory failure has a high mortality rate. Based on recent reports, the most severely ill patients present with coagulopathy, and disseminated intravascular coagulation (DIC)-like massive intravascular clot formation is frequently observed. Coagulopathy has emerged as a significant contributor to thrombotic complications. Although recommendations have been made for anticoagulant use for COVID-19, no guidelines have been specified. We describe four cases of critical COVID-19 with thrombosis detected by enhanced CT scan. The CT findings of all cases demonstrated typical findings of COVID-19 and pulmonary embolism or deep venous thrombus without critical exacerbation. Two patients died of respiratory failure due to COVID-19. DISCUSSION: Previous reports have suggested coagulopathy with thrombotic signs as the main pathological feature of COVID-19, but no previous reports have focused on coagulopathy evaluated by whole-body enhanced CT scan. Changes in hemostatic biomarkers, represented by an increase in D-dimer and fibrin/fibrinogen degradation products, indicated that the essence of coagulopathy was massive fibrin formation. Although there were no clinical symptoms related to their prognosis, critical COVID-19-induced systemic thrombus formation was observed. CONCLUSIONS: Therapeutic dose anticoagulants should be considered for critical COVID-19 because of induced coagulopathy, and aggressive follow-up by whole body enhanced CT scan for systemic venous thromboembolism (VTE) is necessary.

Environmental maintenance with effective and useful zoning to protect patients and medical staff from COVID-19 infection.

AIM: The coronavirus disease 2019 (COVID-19) pandemic has accelerated all over the world, and global health-care systems have become overwhelmed with potentially infectious patients seeking testing and care. It is essential to set up effective and useful zoning to prevent the spread of infection to and from medical staff or other patients with effective use of standard precautions with personal protective equipment (PPE). METHODS: We repurposed a general ward into an acute care unit for severe COVID-19 patients taking into consideration airflow, the direction of movement of medical staff, and prevention of the spread of infection to medical staff and other patients. We checked the daily condition and body temperature of all medical staff for 60 days. RESULTS: There was no evidence of COVID-19 infection in any medical staff or other patients during the period thanks to effective and useful zoning with PPE. CONCLUSION: Special wards and rooms should be set up for future protection of medical staff and other patients, and prevent the explosion of COVID-19 infection with effective and useful zoning with PPE.

COVID-19 pneumonia: infection control protocol inside computed tomography suites.

A novel coronavirus (severe acute respiratory syndrome coronavirus 2) causes a cluster of pneumonia cases in Wuhan, China. It spread rapidly and globally. CT imaging is helpful for the evaluation of the novel coronavirus disease 2019 (COVID-19) pneumonia. Infection control inside the CT suites is also important to prevent hospital-related transmission of COVID-19. We present our experience with infection control protocol for COVID-19 inside the CT suites.

Does the conventional landmark help to place the tip of REBOA catheter in the optimal position? A non-controlled comparison study.

Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) for patients with traumatic torso hemorrhagic shock is available to keep a minimum level of circulatory status as a bridge to definitive therapy. However, the trajectory for placement of REBOA in the aorta has not yet been clearly defined. Methods: We conducted a retrospective observational cohort study in the two tertiary critical care and emergency center from December 2014 to October 2018. A total of 28 patients who underwent focused assessment with sonography for trauma (FAST) were studied via contrast computed tomography (CT), and 27 were analyzed. Results: We divided patients into two groups based on our CT findings. The REBOA deflate group included 16 patients, and the inflate group included 11 patients. The median trace value (interquartile range) of the blood vessel center line from the common femoral artery to the tip of REBOA (blood vessel length) and the length of REBOA itself from the common femoral artery to the tip of REBOA (REBOA insertion length) were 56.2 cm (54.5-57.2) and 55.2 cm (54.2-55.6), respectively (p < 0.0001) for the deflated group, and 51.4 cm (42.1-56.6) and 50.3 cm (42.3-55.0) (p = 0.594), respectively, for the inflated group. Conclusions: If REBOA was deflated, it was placed 1.0 cm longer than the insertion length of REBOA catheter itself, but that was not the case when inflating REBOA. The individual difference was large to the extent that the balloon inflated and the extent to which the balloon was pushed back toward the caudal depending on the degree of blood pressure. Further studies would be needed to validate the study findings.