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OBJECTIVES: The effectiveness of cryoprecipitate (Cryo) in trauma has not been well established; the benefits of Cryo might have been overestimated in previous studies since the difference in the total amount of administered clotting factors was not considered. We aimed to evaluate the benefits of the concurrent use of Cryo in combination with fresh frozen plasma (FFP) for bleeding trauma patients. DESIGN: Retrospective cohort study. SETTING: The American College of Surgeons Trauma Quality Improvement Program database between 2015 and 2019. PATIENTS: Patients who received greater than or equal to 5 units of packed RBCs and at least 1 unit of FFP within the first 4 hours after arrival to a hospital were included and dichotomized according to whether Cryo was used within the first 4 hours of hospital arrival. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: The outcomes of patients treated with Cryo and FFP were compared with those treated with FFP only using propensity score-matching analysis. The dose of administered clotting factors in each group was balanced. The primary outcome was inhospital mortality, and the secondary outcome was the occurrence rate of adverse events. A total of 24,002 patients (Cryo+FFP group: 6,018; FFP only group: 17,984) were eligible for analysis, of whom 4,852 propensity score-matched pairs were generated. Significantly lower inhospital mortality (1,959 patients [40.4%] in the Cryo+FFP group vs 2,142 patients [44.1%] in the FFP only group; odds ratio [OR], 0.86; 95% CI, 0.79-0.93) was observed in the Cryo+FFP group; no significant difference was observed in the occurrence rate of adverse events (1,857 [38.3%] vs 1,875 [38.6%]; OR, 1.02; 95% CI, 0.94-1.10). Several sensitivity analyses showed similar results. CONCLUSIONS: Cryo use combined with FFP was significantly associated with reduced mortality in bleeding trauma patients. Future randomized controlled trials are warranted to confirm these results.
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Hemorragia , Plasma , Fatores de Coagulação Sanguínea/uso terapêutico , Humanos , Razão de Chances , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: The effectiveness and indications of open-chest cardiopulmonary resuscitation (OCCPR) have been still debatable. Although current guidelines state that the presence of signs of life (SOL) is an indication for OCCPR, scientific evidence corroborating this recommendation has been scarce. This study aimed to compare the effectiveness of OCCPR to closed-chest cardiopulmonary resuscitation (CCCPR) in severe trauma patients with SOL upon arrival at the emergency department (ED). METHODS: A retrospective cohort study analyzing data from the Trauma Quality Improvement Program (TQIP) database, a nationwide trauma registry in the USA, between 2010 and 2016 was conducted. Severe trauma patients who had SOL upon arrival at the hospital and received cardiopulmonary resuscitation within the first 6 h of ED admission were identified. Survival to hospital discharge was evaluated using logistic regression analysis, instrumental variable analysis, and propensity score matching analysis adjusting for potential confounders. RESULTS: A total of 2682 patients (OCCPR 1032; CCCPR 1650) were evaluated; of those 157 patients (15.2%) in the OCCPR group and 193 patients (11.7%) in the CCCPR group survived. OCCPR was significantly associated with higher survival to hospital discharge in both the logistic regression analysis (adjusted odds ratio [95% confidence interval] = 1.99 [1.42-2.79], p < 0.001) and the instrumental variable analysis (adjusted odds ratio [95% confidence interval] = 1.16 [1.02-1.31], p = 0.021). In the propensity score matching analysis, 531 matched pairs were generated, and the OCCPR group still showed significantly higher survival at hospital discharge (89 patients [16.8%] in the OCCPR group vs 58 patients [10.9%] in the CCCPR group; odds ratio [95% confidence interval] = 1.66 [1.13-2.42], p = 0.009). CONCLUSIONS: Compared to CCCPR, OCCPR was associated with significantly higher survival at hospital discharge in severe trauma patients with SOL upon ED arrival. Further studies to confirm these results and to assess long-term neurologic outcomes are needed.
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Reanimação Cardiopulmonar/métodos , Ferimentos e Lesões/terapia , Adulto , Serviço Hospitalar de Emergência , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Sinais Vitais , Adulto JovemRESUMO
Acute lung injury (ALI) is a common cause of morbidity in patients after severe injury due to dysregulated inflammation, which is believed to be driven by gut-derived inflammatory mediators carried via mesenteric lymph (ML). We have previously demonstrated that nano-sized extracellular vesicles, called exosomes, secreted into ML after trauma/hemorrhagic shock (T/HS) have the potential to activate immune cells in vitro Here, we assess the function of ML exosomes in the development of T/HS-induced ALI and the role of TLR4 in the ML exosome-mediated inflammatory response. ML exosomes isolated from rats subjected to T/HS stimulated NF-κB activation and caused proinflammatory cytokine production in alveolar macrophages. In vivo experiments revealed that intravenous injection of exosomes harvested after T/HS, but not before shock, caused recruitment of inflammatory cells in the lung, increased vascular permeability, and induced histologic ALI in naive mice. The exosome-depleted supernatant of ML had no effect on in vitro and in vivo inflammatory responses. We also demonstrated that both pharmacologic inhibition and genetic knockout of TLR4 completely abolished ML exosome-induced cytokine production in macrophages. Thus, our findings define the critical role of exosomes secreted into ML as a critical mediator of T/HS-induced ALI through macrophage TLR4 activation.-Kojima, M., Gimenes-Junior, J. A., Chan, T. W., Eliceiri, B. P., Baird, A., Costantini, T. W., Coimbra, R. Exosomes in postshock mesenteric lymph are key mediators of acute lung injury triggering the macrophage activation via Toll-like receptor 4.
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Lesão Pulmonar Aguda/imunologia , Exossomos/microbiologia , Ativação de Macrófagos/imunologia , Choque Hemorrágico/imunologia , Receptor 4 Toll-Like/metabolismo , Lesão Pulmonar Aguda/etiologia , Lesão Pulmonar Aguda/patologia , Animais , Citocinas/biossíntese , Modelos Animais de Doenças , Humanos , Técnicas In Vitro , Mediadores da Inflamação/metabolismo , Linfa/imunologia , Masculino , Camundongos , Camundongos Endogâmicos C57BL , Ratos , Ratos Sprague-Dawley , Choque Hemorrágico/etiologia , Transdução de Sinais , Receptor 4 Toll-Like/antagonistas & inibidores , Receptor 4 Toll-Like/deficiênciaRESUMO
STUDY OBJECTIVE: Although geriatric trauma patients are becoming more common, few large-scale analyses have comprehensively evaluated geriatric-specific characteristics in trauma. This study aims to clarify the age-specific characteristics, outcomes, and predictive accuracy of current trauma scoring systems among geriatric trauma patients. METHODS: Patients with severe trauma, with an Abbreviated Injury Scale score greater than or equal to 3, and registered in the Japan Trauma Data Bank during 2004 to 2015 were retrospectively reviewed. Age-related differences were assessed for injury mechanism, injured region, anatomic and physiologic severity, and inhospital mortality. The mortality risk was evaluated with multivariate mixed-effect models adjusted for Injury Severity Score, Revised Trauma Score, year of injury, and treating facility. Age-related differences in the accuracy of the Injury Severity Score and Revised Trauma Score for predicting inhospital mortality were evaluated with an area under the receiver operating characteristic curve. RESULTS: We identified 127,303 patients, including 67,316 geriatric patients (52.9%) who were aged 60 years or older. The percentage of geriatric patients increased from 31.9% to 59.7% during the study period. The most frequent injury mechanism was ground-level falls (55.2%) and the most frequently injured region was the pelvis and lower extremities (43.7%). Severity-adjusted mixed-effects models revealed a marked age-dependent increase in mortality. Although the Injury Severity Score had similar predictive accuracy among all generations, the accuracy of the Revised Trauma Score decreased with increasing age. CONCLUSION: The characteristics of trauma patients varied widely according to age, and mortality risk increased steadily with increasing age, despite a decrease in anatomic injury severity. The Revised Trauma Score had decreasing predictive accuracy at older ages, suggesting that an alternative measure is needed.
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Distribuição por Idade , Centros de Traumatologia/estatística & dados numéricos , Ferimentos e Lesões/mortalidade , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Feminino , Mortalidade Hospitalar , Humanos , Lactente , Recém-Nascido , Escala de Gravidade do Ferimento , Japão/epidemiologia , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Estudos Retrospectivos , Índices de Gravidade do Trauma , Adulto JovemRESUMO
Vagal nerve stimulation (VNS) has been shown to limit intestinal inflammation following injury; however, a direct connection between vagal terminals and resident intestinal immune cells has yet to be identified. We have previously shown that enteric glia cell (EGC) expression is increased after injury through a vagal-mediated pathway to help restore gut barrier function. We hypothesize that EGCs modulate immune cell recruitment following injury and relay vagal anti-inflammatory signals to resident immune cells in the gut. EGCs were selectively ablated from an isolated segment of distal bowel with topical application of benzalkonium chloride (BAC) in male mice. Three days following BAC application, mice were subjected to an ischemia-reperfusion injury (I/R) by superior mesenteric artery occlusion for 30 min. VNS was performed in a separate cohort of animals. EGC+ and EGC- segments were compared utilizing histology, flow cytometry, immunohistochemistry, and intestinal permeability. VNS significantly reduced immune cell recruitment after I/R injury in EGC+ segments with cell percentages similar to sham. VNS failed to limit immune cell recruitment in EGC- segments. Histologic evidence of gut injury was diminished with VNS application in EGC+ segments, whereas EGC- segments showed features of more severe injury. Intestinal permeability increased following I/R injury in both EGC+ and EGC- segments. Permeability was significantly lower after VNS application compared with injury alone in EGC+ segments only (95.1 ± 30.0 vs. 217.6 ± 21.7 µg/ml, P < 0.05). Therefore, EGC ablation uncouples the protective effects of VNS, suggesting that vagal-mediated signals are translated to effector cells through EGCs.NEW & NOTEWORTHY Intestinal inflammation is initiated by local immune cell activation and epithelial barrier breakdown, resulting in the production of proinflammatory mediators with subsequent leukocyte recruitment. Vagal nerve stimulation (VNS) has been shown to limit intestinal inflammation following injury; however, direct connection between vagal terminals and resident intestinal immune cells has yet to be identified. Here, we demonstrate that intact enteric glia cells are required to transmit the gut anti-inflammatory effects of VNS.
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Inflamação/metabolismo , Intestinos/irrigação sanguínea , Neuroglia/metabolismo , Traumatismo por Reperfusão/metabolismo , Animais , Inflamação/terapia , Mucosa Intestinal/metabolismo , Masculino , Camundongos , Permeabilidade , Traumatismo por Reperfusão/fisiopatologia , Traumatismo por Reperfusão/terapia , Estimulação do Nervo VagoRESUMO
Aim: Extracorporeal cardiopulmonary resuscitation (ECPR) is used to resuscitate patients with cardiac arrest; however, its effect in treating hypothermic cardiac arrest has not been well studied. Therefore, in this study, we aimed to examine the characteristics and outcomes of patients with hypothermic cardiac arrest who underwent ECPR, using a multicenter out-of-hospital cardiac arrest (OHCA) registry in Japan. Methods: Baseline characteristics of patients with hypothermic OHCA and body temperature below 32 °C were assessed. Logistic regression analysis was performed to identify factors associated with in-hospital mortality and neurological outcomes in these patients. Outcomes of hypothermic and cardiogenic OHCA cases were compared using propensity-score matching to investigate differences among subgroups. Results: We included 2,157 patients, with 102 and 1,646 in the hypothermic and cardiogenic groups, respectively. Higher age and longer low-flow time were independent risk factors for mortality, and higher age was an independent risk factor for unfavorable neurological outcomes in the hypothermic OHCA group.Eighty matched pairs were selected during propensity-score matching, and the mortality rate was lower in the hypothermic group than in the cardiogenic group (46.2% vs. 77.5%; p < 0.01). Unfavorable neurological outcome rate was lower in the hypothermic group than in the cardiogenic group (62.5% vs. 87.5%; p < 0.01). Conclusions: Increased age and prolonged low-flow time were identified as negative prognostic factors in patients with hypothermic OHCA who underwent ECPR. These patients showed lower mortality and unfavorable neurological outcome rates than patients with cardiogenic OHCA, suggesting that ECPR is a promising strategy for treating hypothermic OHCA.
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A 45-year-old female presented with gross hematuria. Right renal arteriovenous malformation on abdominal contrast-enhanced computed tomography necessitated urgent transcatheter arterial embolization. Right renal digital subtraction angiography revealed a single tortuous and dilated vessel converging to an aneurysmal dilated vein. To selectively embolize the malformation, we closed the arterial side with a microballoon and attempted glue embolization; filling occurred unexpectedly early, and another balloon on the vein side helped control the renal vein blood flow. Glue embolization was performed without adverse events. Glue embolization for high-flow arteriovenous malformation under balloon occlusion-mediated inflow and outflow control can effectively and safely embolize complete target vessels.
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BACKGROUND: Failure-to-rescue (FTR), defined as death following a major complication, is a metric of trauma quality. The impact of patient frailty on FTR has not been fully investigated, especially in geriatric trauma patients. This study hypothesized that frailty increased the risk of FTR in geriatric patients with severe injury. METHODS: A retrospective cohort study was conducted using the TQIP database between 2015 and 2019, including geriatric patients with trauma (age ≥65 years) and an Injury Severity Score (ISS) > 15, who survived ≥48 hours postadmission. Frailty was assessed using the modified 5-item frailty index (mFI). Patients were categorized into frail (mFI ≥ 2) and nonfrail (mFI < 2) groups. Logistic regression analysis and a generalized additive model (GAM) were used to examine the association between FTR and patient frailty after controlling for age, sex, type of injury, trauma center level, ISS, and vital signs on admission. RESULTS: Among 52,312 geriatric trauma patients, 34.6% were frail (mean mFI: frail: 2.3 vs. nonfrail: 0.9, p < 0.001). Frail patients were older (age, 77 vs. 74 years, p < 0.001), had a lower ISS (19 vs. 21, p < 0.001), and had a higher incidence of FTR compared with nonfrail patients (8.7% vs. 8.0%, p = 0.006). Logistic regression analysis revealed that frailty was an independent predictor of FTR (odds ratio, 1.32; confidence interval, 1.23-1.44; p < 0.001). The GAM plots showed a linear increase in FTR incidence with increasing mFI after adjusting for confounders. CONCLUSION: This study demonstrated that frailty independently contributes to an increased risk of FTR in geriatric trauma patients. The impact of patient frailty should be considered when using FTR to measure the quality of trauma care. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.
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Falha da Terapia de Resgate , Fragilidade , Escala de Gravidade do Ferimento , Centros de Traumatologia , Ferimentos e Lesões , Humanos , Feminino , Masculino , Idoso , Estudos Retrospectivos , Ferimentos e Lesões/complicações , Fragilidade/complicações , Fragilidade/epidemiologia , Idoso de 80 Anos ou mais , Falha da Terapia de Resgate/estatística & dados numéricos , Centros de Traumatologia/estatística & dados numéricos , Idoso Fragilizado/estatística & dados numéricos , Avaliação Geriátrica/métodos , Fatores de RiscoRESUMO
BACKGROUND: Disruption of intestinal barrier caused by intestinal ischemia due to hemorrhagic shock is associated with the pathogenesis of multiple organ dysfunction (MOD) after severe trauma. Mesenteric lymph (ML) plays an important role as a route for transporting inflammatory mediators, including lipids. Postbiotics, such as 10-hydroxy-cis-12-octadecenoic acid (HYA), have received much attention as a treatment option. However, the relationship between postbiotics and MOD has yet to be clarified. The aim of the present study was to analyze lipid metabolites derived from gut microbiota in the intestinal ischemia-reperfusion (IR) rat model. METHODS: Male Sprague-Dawley rats underwent laparotomy, and their ML duct and superior mesenteric artery were exposed. The superior mesenteric artery was clamped for 60 minutes, followed by 120 minutes of reperfusion. The ML and the plasma were collected before and after intestinal IR. Lipids were extracted from plasma and ML, and liquid chromatography-tandem mass spectrometry was performed. RESULTS: The concentration of linoleic acid in plasma samples was not different before and after IR; however, the linoleic acid concentration in the ML samples increased after intestinal IR. Eicosapentaenoic acids and docosahexaenoic related to linoleic acids showed similar changes with IR-induced increase in the ML. The concentration of HYA, a linoleic acid-derived bioactive metabolite produced by gut bacteria, was high in ML samples, while that in plasma samples was low. The relative increase rate of HYA in ML samples after IR was higher than that of the plasma samples (the ML samples: relative increase, 3.23 ± 1.36; the plasma samples: relative increase, 0.95 ± 0.35; n = 3, p = 0.048). CONCLUSION: The present study demonstrated increased linoleic acids and high concentrations of HYA, lipid metabolites derived from gut bacteria in the ML after intestinal IR. These findings may contribute to clarifying the relation between gut microbiota and MOD after severe trauma.
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Microbioma Gastrointestinal , Traumatismo por Reperfusão , Ratos , Masculino , Animais , Ratos Sprague-Dawley , Ácido Linoleico/metabolismo , Isquemia , ReperfusãoRESUMO
BACKGROUND: Acute mesenteric ischemia (AMI) is an emergent vascular disease caused by cessation of the blood supply to the small intestine. Despite advances in the diagnosis, intervention, and surgical procedures, AMI remains a life-threatening condition. Prostaglandin E2 major urinary metabolite (PGE-MUM), the urinary metabolite of prostaglandin E2, is known to be stable in urine and has been suggested to be a valuable biomarker for intestinal mucosal inflammation, such as ulcerative colitis. We therefore investigated whether or not PGE-MUM levels reflect the degree of ischemia in an intestinal ischemia-reperfusion model. METHODS: Male rats were used to establish a superior mesenteric artery occlusion (SMAO) group, in which the superior mesenteric artery was clamped, and a sham group. The clamping times in the SMAO group were either 30 minutes or 60 minutes, and reperfusion times were either 3 hours or 6 hours, after which PGE-MUM values were measured. RESULTS: The histological injury score of the SMAO (30-minute ischemia and 6-hour reperfusion group, 1.8 ± 0.4; 60-minute ischemia and 6-hour reperfusion group, 4.7 ± 0.5) and were significantly greater than that of the sham group (0.4 ± 0.7, p < 0.05). The PGE-MUM levels in the SMAO group (30-minutes ischemia and 6-hour reperfusion group, 483 ± 256; 60-minutes ischemia and 6-hour reperfusion group, 889 ± 402 ng/mL) were significantly higher than in the sham group (30-minute and 6-hour observation group, 51 ± 20; 60-minute and 6-hour observation group, 73 ± 32 ng/mL; p < 0.05). Furthermore, the PGE-MUM value was corrected by the concentration of urinary creatinine (Cr). The PGE-MUM/urinary Cr levels in the SMAO group were also significantly higher than in the sham group ( p < 0.05). CONCLUSION: We found that intestinal ischemia-reperfusion increased urinary PGE-MUM levels depending on the ischemic time. This suggests the potential utility of PGE-MUM as a noninvasive marker of intestinal ischemia.
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Biomarcadores , Modelos Animais de Doenças , Isquemia Mesentérica , Traumatismo por Reperfusão , Animais , Masculino , Ratos , Biomarcadores/urina , Traumatismo por Reperfusão/urina , Traumatismo por Reperfusão/diagnóstico , Traumatismo por Reperfusão/metabolismo , Isquemia Mesentérica/urina , Isquemia Mesentérica/diagnóstico , Ratos Sprague-Dawley , Dinoprostona/urina , Isquemia/urina , Isquemia/diagnóstico , Doença AgudaRESUMO
BACKGROUND: Increased morbidity and mortality in geriatric trauma patients are usually due to decreased physiologic reserve and increased comorbidities. It is unclear whether geriatric trauma case volume and rates correlate with survival. We hypothesized that geriatric patients would have increased survival when treated in high-case volume and rate trauma centers. METHODS: A retrospective cohort study was conducted using the Trauma Quality Improvement Program database between 2015 and 2019. Geriatric trauma patients (≥65 years) with severe injury (Injury Severity Score ≥16) were included. Geriatric case volume (GCV) was defined as the mean annual number of treated geriatric trauma patients, while geriatric case rate (GCR) was the mean annual number of elderly trauma patients divided by all trauma patients in each center. Trauma centers were classified into low-, medium-, and high-volume and rate facilities based on GCV and GCR. The association of GCV and GCR with in-hospital mortality and complication rates was assessed using the generalized additive model (GAM) and multivariate generalized linear mixed model adjusted for patient characteristics (age, sex, Injury Severity Score, Revised Trauma Score, and Modified Frailty Index) as fixed-effect variables and hospital characteristics as random effect variables. RESULTS: A total of 164,818 geriatric trauma patients from 812 hospitals were included in the analysis. The GAM plots showed that the adjusted odds of in-hospital mortality decreased as GCV and the GCR increased. The generalized linear mixed model revealed that both high GCV and high GCR hospitals had lower mortality rates than low GCV and GCR hospitals (adjusted odds ratio [95% confidence interval], high GCV and high GCR centers; 0.82 [0.72-0.92] and 0.81 [0.73-0.90], respectively). CONCLUSION: Both high geriatric trauma volume and rates were associated with decreased mortality of geriatric trauma patients. Consolidation of care for elderly patients with severe injury in specialized high-volume centers may be considered. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.
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Utilização de Instalações e Serviços , Serviços de Saúde para Idosos , Centros de Traumatologia , Ferimentos e Lesões , Idoso , Humanos , Mortalidade Hospitalar , Hospitais , Escala de Gravidade do Ferimento , Estudos Retrospectivos , Resultado do Tratamento , Ferimentos e Lesões/epidemiologia , Ferimentos e Lesões/mortalidade , Ferimentos e Lesões/terapia , Utilização de Instalações e Serviços/estatística & dados numéricosRESUMO
Intestinal ischemia-reperfusion injury leads to proinflammatory responses via gut-derived mediators, and accumulating evidence suggests that exosomes secreted by intestinal epithelial cells are involved in the development of systemic inflammation. Studies have reported changes in protein, lipid, and microRNA (miRNA) expression; however, considering the different experimental conditions, information on the relationships among these biomolecules remains insufficient. The aim of this study was to elucidate the multiple changes that simultaneously occur in exosomes after ischemic stimulation. Here, differentiated human intestinal Caco-2 cells were exposed to 95% air (normoxia group) or 5% O2 (hypoxia group) for 6 h. Cells in each group were subsequently incubated for 24 h in an atmosphere of 5% CO2 plus 95% air. The conditioned medium of each group was collected for isolating intestinal epithelial cell-derived exosomes. Together with proteome analyses, lipid analyses, and miRNA quantification, biological functional assays were performed using monocytic NF-κB reporter cells. Lipid metabolism-related protein expression was upregulated, miRNA levels were slightly altered, and unsaturated fatty acid-containing lysophosphatidylcholine concentration increased after hypoxia and reoxygenation injury; this suggested that the changes in exosomal components associated with ischemia-reperfusion injury activates inflammation, including the NF-κB pathway. This study elucidated the multiple changes that co-occur in exosomes after ischemic stimulation and partially clarified the mechanism underlying exosome-mediated inflammation after intestinal ischemic recanalization.
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Exossomos , MicroRNAs , Traumatismo por Reperfusão , Humanos , NF-kappa B/metabolismo , Células CACO-2 , Exossomos/metabolismo , Traumatismo por Reperfusão/metabolismo , MicroRNAs/genética , MicroRNAs/metabolismo , Células Epiteliais/metabolismo , Isquemia/metabolismo , Hipóxia Celular/fisiologia , Hipóxia/metabolismo , Inflamação/metabolismo , LipídeosRESUMO
Background: We examined the association between body mass index (BMI) and outcomes in patients with out-of-hospital cardiac arrest (OHCA) undergoing extracorporeal cardiopulmonary resuscitation (ECPR). Methods: We retrospectively analyzed the database of an observational multicenter cohort in Japan. Adult patients with OHCA of cardiac etiology who received ECPR between 2013 and 2018 were categorized as follows: underweight, BMI < 18.5; normal weight, BMI = 18.5-24.9; overweight, BMI = 25-29.9; and obese, BMI ≥ 30 kg/m2. The primary outcome was in-hospital mortality; secondary outcomes were unfavorable neurological outcomes at discharge (cerebral performance category ≥ 3) and ECPR-related complications. BMI's association with outcomes was assessed using a logistic regression model adjusted for age, sex, comorbidities, witness/bystander CPR, initial rhythm, prehospital return of spontaneous circulation, and low-flow time. Results: In total, 1,044 patients were analyzed. Their median age was 61 (IQR, 49-69) years; the median BMI was 24.2 (21.5-26.9) kg/m2. The overall rates of in-hospital mortality, unfavorable neurological outcome, and ECPR-related complications were 62.2%, 79.9%, and 31.7%, respectively. In multivariate analysis, the overweight and obese groups had higher in-hospital mortality odds than the normal BMI group (odds ratio [95%CI], 1.37 [1.02-1.85], p = 0.035; and 2.09 [1.31-3.39], p < 0.001, respectively). The odds ratio for unfavorable neurological outcomes increased more in the obese than in the normal BMI group (3.17 [1.69-6.49], p < 0.001). ECPR-related complications were not significantly different among groups. Conclusions: In OHCA patients undergoing ECPR, a BMI ≥ 25 kg/m2 was associated with increased in-hospital mortality, and a BMI ≥ 30 kg/m2 was also associated with a worse neurological outcome.
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Key Clinical Message: We describe a patient who lost her vision because of Lemierre's syndrome. Ophthalmologic complications of Lemierre's syndrome are rare, and very few cases have been reported. Clinicians need to recognize that it is a serious condition that can lead to blindness in some cases. Abstract: Lemierre's syndrome is a systemic septic embolism resulting from thrombophlebitis of the internal jugular vein. We report a case of blindness caused by Lemierre's syndrome, despite prompt diagnosis and early treatment. A 36-year-old woman was transported to our hospital. She presented with fever, facial swelling, and right visual acuity deterioration. Contrast-enhanced computed tomography revealed a retropharyngeal abscess and right internal jugular vein thrombosis. Blood culture revealed Fusobacterium necrophorum, suggesting Lemierre's syndrome. The patient had septic shock and disseminated intravascular coagulation. We diagnosed her visual impairment as orbital-apex syndrome due to spread of inflammation. After 6 weeks of antimicrobial drug treatments, her general condition had improved, and the retropharyngeal abscess had disappeared. On Day 49 of her illness, she was transferred to a rehabilitation hospital, but her visual acuity was not restored. Clinicians should be aware that Lemierre's syndrome can, although rarely, cause blindness.
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Background: Secondary aortoenteric fistula is a fatal cause of gastrointestinal bleeding after aortic reconstructive surgery with a prosthesis. In most cases, the proximal suture line is involved. We herein report a rare case in which the fistula formed between the suture line of inferior mesenteric artery reimplantation and the jejunum. Case Presentation: An 82-year-old man was transferred to our hospital due to hematemesis with severe hypovolemic shock. Although he fell into cardiopulmonary arrest, immediate resuscitation achieved return of spontaneous circulation. As his surgical history of aortic reconstruction and computed tomography findings suggested potential secondary aortoenteric fistula, emergency surgery was carried out. The anastomosis between the inferior mesenteric artery and aortic graft was communicating with the jejunum. Partial jejunal resection was undertaken, and the aortic graft was replaced. Conclusion: The anastomosis between the inferior mesenteric artery and aortic graft in the previous aortic replacement can become the site of secondary aortoenteric fistula.
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BACKGROUND: The benefits of a high plasma-to-red blood cell (RBC) ratio on the survival of injured patients who receive massive transfusions remain unclear, especially in older patients. We aimed to investigate the interaction of age with the plasma-to-RBC ratio and clinical outcomes of trauma patients. METHODS: In this retrospective study conducted from 2013 to 2016, trauma patients who received massive transfusions were included. Using a generalized additive model (GAM),we assessed how the plasma-to-RBC ratio and age affected the in-hospital mortality rates. The association of the plasma-to-RBC ratio [low (< 0.5), medium (0.5-1.0), and high (≥ 1.0)] with in-hospital mortality and the incidence of adverse events were assessed for the overall cohort and for patients stratified into non-geriatric (16-64 years) and geriatric (≥ 65 years) groups using logistic regression analyses. RESULTS: In total, 13,894 patients were included. The GAM plot of the plasma-to-RBC ratio for in-hospital mortality demonstrated a downward convex unimodal curve for the entire cohort. The low-transfusion ratio group was associated with increased odds of in-hospital mortality in the non-geriatric cohort [odds ratio 1.38, 95% confidence interval (CI) 1.22-1.56]; no association was observed in the geriatric group (odds ratio 0.84, 95% CI 0.62-1.12). An increase in the transfusion ratio was associated with a higher incidence of adverse events in the non-geriatric and geriatric groups. CONCLUSION: The association of the non-geriatric age category and plasma-to-RBC ratio for in-hospital mortality was clearly demonstrated. However, the relationship between the plasma-to-RBC ratio with mortality among geriatric patients remains inconclusive.
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BACKGROUND: Hemodynamic stabilization is a core component in the resuscitation of septic shock. However, the optimal target blood pressure remains debatable. Previous randomized controlled trials suggested that uniformly adopting a target mean arterial pressure (MAP) higher than 65 mmHg for all adult septic shock patients would not be beneficial; however, it has also been proposed that higher target MAP may be beneficial for elderly patients, especially those with arteriosclerosis. METHODS: A multicenter, pragmatic single-blind randomized controlled trial will be conducted to compare target MAP of 80-85 mmHg (high-target) and 65-70 mmHg (control) in the resuscitation of septic shock patients admitted to 28 hospitals in Japan. Patients with septic shock aged ≥65 years are randomly assigned to the high-target or control groups. The target MAP shall be maintained for 72 h after randomization or until vasopressors are no longer needed to improve patients' condition. To minimize the adverse effects related to catecholamines, if norepinephrine dose of ≥ 0.1 µg/kg/min is needed to maintain the target MAP, vasopressin will be initiated. Other therapeutic approaches, including fluid administration, hydrocortisone use, and antibiotic choice, will be determined by the physician in charge based on the latest clinical guidelines. The primary outcome is all-cause mortality at 90 days after randomization. DISCUSSION: The result of this trial will provide great insight on the resuscitation strategy for septic shock in the era of global aged society. Also, it will provide the better understanding on the importance of individualized treatment strategy in hemodynamic management in critically ill patients. TRIAL REGISTRATION: UMIN Clinical Trials Registry; UMIN000041775. Registered 13 September 2020.
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Choque Séptico , Adulto , Idoso , Antibacterianos/uso terapêutico , Pressão Sanguínea , Catecolaminas , Humanos , Hidrocortisona/uso terapêutico , Estudos Multicêntricos como Assunto , Norepinefrina/efeitos adversos , Ensaios Clínicos Controlados Aleatórios como Assunto , Choque Séptico/diagnóstico , Choque Séptico/tratamento farmacológico , Método Simples-Cego , Vasoconstritores/efeitos adversos , Vasopressinas/efeitos adversosRESUMO
BACKGROUND: Although the results of previous studies suggested the effectiveness of physician-led prehospital trauma management, it has been uncertain because of the limited number of high-quality studies. Furthermore, the advantage of physician-led prehospital management might have been overestimated due to the shortened prehospital time by helicopter transportation in some studies. The present study aimed to evaluate the effect of physician-led prehospital management independent of prehospital time. Also, subgroup analysis was performed to explore the subpopulation that especially benefit from physician-led prehospital management. METHODS: This retrospective cohort study analyzed the data of Japan's nationwide trauma registry. Severe blunt trauma patients, defined by Injury Severity Score (ISS) ≥16, who were transported directly to a hospital between April 2009 and March 2019 were evaluated. In-hospital mortality was compared between groups dichotomized by the occupation of primary prehospital healthcare provider (i.e., physician or paramedic), using 1:4 propensity score-matched analysis. The propensity score was calculated using potential confounders including patient demographics, mechanism of injury, vital signs at the scene of injury, ISS, and total time from injury to hospital arrival. Subpopulations that especially benefit from physician-led prehospital management were explored by assessing interaction effects between physician-led prehospital management and patient characteristics. RESULTS: A total of 30,551 patients (physician-led: 2976, paramedic-led: 27,575) were eligible for analysis, of whom 2690 propensity score-matched pairs (physician-led: 2690, paramedic-led: 10,760) were generated and compared. Physician-led group showed significantly decreased in-hospital mortality than paramedic-led group (in-hospital mortality: 387 [14.4%] and 1718 [16.0%]; odds ratio [95% confidence interval] = 0.88 [0.78-1.00], p = 0.044). Patients with age < 65 years, ISS ≥25, Abbreviated Injury Scale in pelvis and lower extremities ≥3, and total prehospital time < 60 min were likely to benefit from physician-led prehospital management. CONCLUSIONS: Physician-led prehospital trauma management was significantly associated with reduced in-hospital mortality independent of prehospital time. The findings of exploratory subgroup analysis would be useful for the future research to establish efficient dispatch system of physician team.
Assuntos
Serviços Médicos de Emergência/organização & administração , Ferimentos não Penetrantes/mortalidade , Ferimentos não Penetrantes/terapia , Escala Resumida de Ferimentos , Adulto , Idoso , Auxiliares de Emergência , Feminino , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Japão , Masculino , Pessoa de Meia-Idade , Médicos , Sistema de Registros , Estudos RetrospectivosRESUMO
BACKGROUND: Inflammatory lipid mediators in mesenteric lymph (ML), including arachidonic acid (AA), are considered to play an important role in the pathogenesis of multiple-organ dysfunction after hemorrhagic shock. A previous study suggested that vagus nerve stimulation (VNS) could relieve shock-induced gut injury and abrogate ML toxicity, resulting in the prevention of multiple-organ dysfunction. However, the detailed mechanism of VNS in lymph toxicity remains unclear. The study aimed to investigate the relationship between VNS and inflammatory lipid mediators in ML. METHODS: Male Sprague-Dawley rats underwent laparotomy and superior mesenteric artery obstruction (SMAO) for 60 minutes to induce intestinal ischemia followed by reperfusion and observation. The ML duct was cannulated, and ML samples were obtained both before and after SMAO. The distal ileum was removed at the end of the observation period. In one group of animals, VNS was performed from 10 minutes before 10 minutes after SMAO (5 V, 0.5 Hz). Liquid chromatography-electrospray ionization-tandem mass spectrometry analysis of AA was performed for each ML sample. The biological activity of ML was examined using a monocyte nuclear factor κ-light-chain-enhancer of activated B cells activation assay. Western blotting of phospholipase A2 group IIA (PLA2-IIA) was also performed for ML and ileum samples. RESULTS: Vagus nerve stimulation relieved the SMAO-induced histological gut injury. The concentration of AA and level of nuclear factor κ-light-chain-enhancer of activated B cells activation in ML increased significantly after SMAO, whereas VNS prevented these responses. Western blotting showed PLA2-IIA expression in the ML and ileum after SMAO; however, the appearance of PLA2-IIA band was remarkably decreased in the samples from VNS-treated animals. CONCLUSION: The results suggested that VNS could relieve gut injury induced by SMAO and decrease the production of AA in ML by altering PLA2-IIA expression in the gut and ML.
Assuntos
Ácido Araquidônico/metabolismo , Insuficiência de Múltiplos Órgãos/prevenção & controle , Traumatismo por Reperfusão/terapia , Choque Hemorrágico/complicações , Estimulação do Nervo Vago , Animais , Modelos Animais de Doenças , Humanos , Linfa/imunologia , Linfa/metabolismo , Vasos Linfáticos/patologia , Masculino , Mesentério/patologia , Insuficiência de Múltiplos Órgãos/imunologia , Insuficiência de Múltiplos Órgãos/patologia , Ratos , Ratos Sprague-Dawley , Traumatismo por Reperfusão/imunologia , Traumatismo por Reperfusão/patologia , Choque Hemorrágico/imunologiaRESUMO
BACKGROUND: Gut damage after trauma/hemorrhagic shock contributes to multiple organ dysfunction syndrome. Electrical vagal nerve stimulation is known to prevent gut damage in animal models of trauma/hemorrhagic shock by altering the gut inflammatory response; however, the effect of vagal nerve stimulation on intestinal blood flow, which is an essential function of the vagus nerve, is unknown. This study aimed to determine whether vagal nerve stimulation influences the abdominal vagus nerve activity, intestinal blood flow, gut injury, and the levels of autonomic neuropeptides. METHODS: Male Sprague Dawley rats were anesthetized, and the cervical and abdominal vagus nerves were exposed. One pair of bipolar electrodes was attached to the cervical vagus nerve to stimulate it; another pair of bipolar electrodes were attached to the abdominal vagus nerve to measure action potentials. The rats underwent trauma/hemorrhagic shock (with maintenance of mean arterial pressure of 25 mmHg for 30 min) without fluid resuscitation and received cervical vagal nerve stimulation post-injury. A separate cohort of animals were subjected to transection of the abdominal vagus nerve (vagotomy) just before the start of cervical vagal nerve stimulation. Intestinal blood flow was measured by laser Doppler flowmetry. Gut injury and noradrenaline level in the portal venous plasma were also assessed. RESULTS: Vagal nerve stimulation evoked action potentials in the abdominal vagus nerve and caused a 2-fold increase in intestinal blood flow compared to the shock phase (P < .05). Abdominal vagotomy eliminated the effect of vagal nerve stimulation on intestinal blood flow (P < .05). Vagal nerve stimulation protected against trauma/hemorrhagic shock -induced gut injury (P < .05), and circulating noradrenaline levels were decreased after vagal nerve stimulation (P < .05). CONCLUSION: Cervical vagal nerve stimulation evoked abdominal vagal nerve activity and relieved the trauma/hemorrhagic shock-induced impairment in intestinal blood flow by modulating the vasoconstriction effect of noradrenaline, which provides new insight into the protective effect of vagal nerve stimulation.