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BACKGROUND: Clostridioides difficile infection is associated with antibiotic use and manifests as diarrhea; however, emerging cases of fulminant diarrhea caused by binary toxin-producing C. difficile unrelated to prior antibiotic exposure have been reported. Although fulminant colitis caused by C. difficile has been documented, instances of intussusception remain scarce. Here, we present a case of adult intussusception with severe hypokalemia and pneumonia resulting from a community-acquired C. difficile infection in Japan. CASE PRESENTATION: An 82-year-old male presented with dizziness, progressive weakness, and diarrhea. Initial vital signs indicated severe respiratory and circulatory distress, and laboratory findings revealed hypokalemia, pneumonia, and septic shock. Imaging confirmed intussusception of the ascending colon. Although colonoscopy suggested a potential tumor, no malignancy was found. The C. difficile rapid test result was positive, indicating community-acquired C. difficile infection. Treatment with vancomycin was initiated; however, intussusception relapsed. Surgical intervention was successful and led to clinical improvement. The patient's complex pathophysiology involved community-acquired C. difficile-induced severe diarrhea, hypokalemia, hypermetabolic alkalosis, and subsequent intussusception. Although adult intussusception is uncommon, this case was uniquely linked to binary toxin-producing C. difficile. The identified strain, SUH1, belonged to a novel sequence type (ST1105) and clade 3, suggesting a highly virulent clone. Resistome analysis aligned with phenotypic susceptibility to metronidazole and vancomycin, confirming their treatment efficacy. CONCLUSION: This case report highlights a binary toxin-producing C. difficile that caused intussusception. The consideration of community-acquired C. difficile in the differential diagnosis of severe enteritis is necessary, even in Japan.
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Clostridioides difficile , Infecções por Clostridium , Infecções Comunitárias Adquiridas , Hipopotassemia , Intussuscepção , Humanos , Masculino , Idoso de 80 Anos ou mais , Clostridioides difficile/isolamento & purificação , Infecções Comunitárias Adquiridas/microbiologia , Infecções Comunitárias Adquiridas/complicações , Infecções por Clostridium/complicações , Infecções por Clostridium/microbiologia , Hipopotassemia/etiologia , Intussuscepção/microbiologia , Intussuscepção/etiologia , Pneumonia/microbiologia , Pneumonia/complicações , Japão , Antibacterianos/uso terapêutico , Diarreia/microbiologia , Diarreia/etiologiaRESUMO
BACKGROUND: The survival rate of patients with critical coronavirus disease-19 (COVID-19) over time is inconsistent in different settings. In Japan, a national database was organized to monitor and share the patient generation across the country in an immediate response to the COVID-19 pandemic. This study aimed to evaluate changes in survival over time and the prognostic factors in critical COVID-19 patients receiving mechanical ventilation with/without extracorporeal membrane oxygenation (ECMO) using the largest database in Japan. METHODS: This is a prospective observational cohort study of patients admitted to intensive care units in Japan with fatal COVID-19 pneumonia receiving mechanical ventilation and/or ECMO. We developed a prospective nationwide registry covering > 80% of intensive care units in Japan, and analyzed the association between patients' backgrounds, institutional ECMO experience, and timing of treatment initiation and prognosis between February 2020 and November 2021. Prognostic factors were evaluated by Kaplan-Meier analysis and Cox proportional hazards analysis. RESULTS: A total of 9418 patients were ventilated, of whom 1214 (13%) received ECMO. The overall survival rate for ventilated patients was 79%, 65% for those receiving ECMO. There have been five outbreaks in Japan to date. The survival rate of ventilated patients increased from 76% in the first outbreak to 84% in the fifth outbreak (p < 0.001). The survival rate of ECMO patients remained unchanged at 60-68% from the first to fifth outbreaks (p = 0.084). Age of ≥ 59 (hazard ratio [HR] 2.17; 95% confidence interval [CI] 1.76-2.68), ventilator days of ≥ 3 before starting ECMO (HR 1.91; 95% CI 1.57-2.32), and institutional ECMO experiences of ≥ 11 (HR 0.70; 95% CI 0.58-0.85) were independent prognostic factors for ECMO. CONCLUSIONS: During five COVID-19 outbreaks in Japan, the survival rate of ventilated patients tended to have gradually improved, and that of ECMO patients did not deteriorate. Older age, longer ventilator days before starting ECMO, and fewer institutional ECMO experiences may be independent prognostic factors for critical COVID-19 patients receiving ECMO.
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COVID-19 , Oxigenação por Membrana Extracorpórea , Humanos , Pandemias , COVID-19/epidemiologia , COVID-19/terapia , Respiração Artificial , Japão/epidemiologia , Estudos Prospectivos , Estudos de Coortes , Sistema de Registros , Estudos RetrospectivosRESUMO
We report two cases of acquired factor XIII deficiency with bleeding events during veno-venous extracorporeal membrane oxygenation (ECMO). Case 1: A 76-year-old man diagnosed with aspiration pneumonia after near-drowning was started on ECMO. Later, the patient presented with hemoptysis and anemia. Blood tests showed a decreased factor XIII activity of 29%. Although the patient recovered after receiving 1200 International Units of factor XIII concentrate, the patient had another episode of decreased factor XIII activity and bloody stool and was treated again with factor XIII concentrate. Case 2: A 48-year-old female diagnosed with pneumonia was started on ECMO. Soon after, she presented with hemoptysis and anemia. Blood tests showed a decreased factor XIII activity of 39%. The patient was treated with 720 IU of factor XIII concentrate with good recovery. Acquired factor XIII deficiency cannot be detected by routine coagulation tests, therefore it may be under-diagnosed in the ICU. Detection of acquired factor XIII deficiency is essential when treating a bleeding ECMO patient.
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Oxigenação por Membrana Extracorpórea/efeitos adversos , Deficiência do Fator XIII/diagnóstico , Hemorragia/etiologia , Idoso , Testes de Coagulação Sanguínea , Deficiência do Fator XIII/etiologia , Feminino , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
BACKGROUND: In most countries, patients receiving mechanical ventilation (MV) are treated in intensive care units (ICUs). However, in some countries, including Japan, many patients on MV are not treated in ICUs. There are insufficient epidemiological data on these patients. Here, we sought to describe the epidemiology of patients on MV in Japan by comparing and contrasting patients on MV treated in ICUs and in non-ICU settings. A preliminary comparison of patient outcomes between ICU and non-ICU patients was a secondary objective. METHODS: Data on adult patients receiving MV for at least 3 days in ICUs or non-ICU settings from April 2010 through March 2012 were obtained from the Quality Indicator/Improvement Project, a voluntary data-administration project covering more than 400 acute-care hospitals in Japan. We excluded patients with cancer-related diagnoses. Patient demographic data and the critical care provided were compared between groups. RESULTS: Over the study period, 17,775 patients on MV were treated only in non-ICU settings, whereas 20,516 patients were treated at least once in ICUs (46.4% vs. 53.6%). Average age was higher in non-ICU patients than in ICU patients (72.8 vs. 70.2, P < 0.001). Mean number of ventilation days was greater in non-ICU patients (11.7 vs. 9.5, P < 0.001). Hospital mortality was higher in non-ICU patients (41.4% vs. 38.8%, P < 0.001). Standard critical care (e.g., arterial line placement, enteral nutrition, and stress-ulcer prevention) was provided significantly less often in non-ICU patients. Multivariate analysis showed that ICU admission significantly decreased hospital mortality (adjusted odds ratio 0.713, 95% CI 0.676 to 0.753). CONCLUSIONS: A large proportion of Japanese patients on MV were treated in non-ICU settings. Analysis of administrative data indicated preliminarily that hospital mortality rates in these patients were higher in non-ICU settings than in ICUs. Prospective analyses comparing non-ICU and ICU patients on MV by severity scoring are needed.
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Respiração Artificial/estatística & dados numéricos , Insuficiência Respiratória/etiologia , Idoso , Bases de Dados Factuais/estatística & dados numéricos , Feminino , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva/organização & administração , Unidades de Terapia Intensiva/estatística & dados numéricos , Japão/epidemiologia , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Estudos Prospectivos , Respiração Artificial/métodos , Insuficiência Respiratória/epidemiologia , Estudos RetrospectivosRESUMO
BACKGROUND: The administration of low-dose intravenous immunoglobulin G (IVIgG) (5 g/day for 3 days; approximate total 0.3 g/kg) is widely used as an adjunctive treatment for patients with sepsis in Japan, but its efficacy in the reduction of mortality has not been evaluated. We investigated whether the administration of low-dose IVIgG is associated with clinically important outcomes including intensive care unit (ICU) and in-hospital mortality. METHODS: This is a post-hoc subgroup analysis of data from a retrospective cohort study, the Japan Septic Disseminated Intravascular Coagulation (JSEPTIC DIC) study. The JSEPTIC DIC study was conducted in 42 ICUs in 40 institutions throughout Japan, and it investigated associations between sepsis-related coagulopathy, anticoagulation therapies, and clinical outcomes of 3195 adult patients with sepsis and septic shock admitted to ICUs from January 2011 through December 2013. To investigate associations between low-dose IVIgG administration and mortalities, propensity score-based matching analysis was used. RESULTS: IVIgG was administered to 960 patients (30.8%). Patients who received IVIgG were more severely ill than those who did not (Acute Physiology and Chronic Health Evaluation (APACHE) II score 24.2 ± 8.8 vs 22.6 ± 8.7, p < 0.001). They had higher ICU mortality (22.8% vs 17.4%, p < 0.001), but similar in-hospital mortality (34.4% vs 31.0%, p = 0.066). In propensity score-matched analysis, 653 pairs were created. Both ICU mortality and in-hospital mortality were similar between the two groups (21.0% vs 18.1%, p = 0.185, and 32.9% vs 28.6%, p = 0.093, respectively) using generalized estimating equations fitted with logistic regression models adjusted for other therapeutic interventions. The administration of IVIgG was not associated with ICU or in-hospital mortality (odds ratio (OR) 0.883; 95% confidence interval (CI) 0.655-1.192, p = 0.417, and OR 0.957, 95% CI, 0.724-1.265, p = 0.758, respectively). CONCLUSIONS: In this analysis of a large cohort of patients with sepsis and septic shock, the administration of low-dose IVIgG as an adjunctive therapy was not associated with a decrease in ICU or in-hospital mortality. TRIAL REGISTRATION: University Hospital Medical Information Network Individual Clinical Trials Registry, UMIN-CTR000012543 . Registered on 10 December 2013.
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Mortalidade Hospitalar , Imunoglobulina G/administração & dosagem , Imunoglobulina G/farmacologia , Sepse/tratamento farmacológico , Choque Séptico/tratamento farmacológico , Idoso , Coagulação Intravascular Disseminada/tratamento farmacológico , Feminino , Humanos , Imunoglobulina G/uso terapêutico , Unidades de Terapia Intensiva/organização & administração , Japão , Masculino , Pessoa de Meia-Idade , Razão de Chances , Pontuação de Propensão , Estudos Retrospectivos , Sepse/mortalidade , Choque Séptico/mortalidadeRESUMO
A 75 year-old-female was transferred to our ICU by an ambulance for refractory hypotension. The patient was suspected to have acute amlodipine (AML) overdose based on the information obtained from patient's family. Serum AML concentration was 355.6 ng/mL on the 1st hospital day. The patient's blood pressure was gradually elevated by intravenous administration of noradrenaline, calcium chlo- ride and insulin, and the patient was transferred to another hospital on the 9th hospital day. The analysis of serum AML concentration showed delayed elimination half life in the early period after the inges- tion. It was thought that decrease in the hepatic clearance of AML by the saturation of metabolism could contribute to the delayed elimination. Severe AML overdose may cause prolonged elimination half-life.
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Anlodipino/intoxicação , Overdose de Drogas , Idoso , Anlodipino/sangue , Intervenção Médica Precoce , Feminino , Humanos , Fatores de TempoRESUMO
Background: Japanese Spotted Fever (JSF) is a Spotted Fever Group (SFG) rickettsiosis caused by Rickettsia japonica. More than 300 cases are diagnosed annually in Japan, and the number of reported cases has been increasing. Correct diagnoses depend on the triad of symptoms and signs, including fever, rash, and eschar, which can be seen at the site of vector bites. JSF is not life-threatening if treated appropriately without diagnostic delay but there are some fatal cases every year. This negligence leads to disseminated intravascular coagulation (DIC) and multiple organ failure (MOF), and poor prognoses, consequently. Prompt diagnosis of JSF is difficult when the aforementioned triad of signs and symptoms is not initially present. Case report: This report describes three JSF cases: an 87-year-old woman with fever, shock, pancytopenia, DIC, and MOF; a 79-year-old man with fever and difficulty in movement; and a 78-year-old man with fever, general fatigue, and appetite loss. All patients had a rash and eschar, which led to prompt diagnosis and appropriate treatment immediately. All patients were treated without any complications. Why should an emergency physician be aware of this?: As mentioned above, JFS can be fatal with delayed diagnoses and treatment initiations. The key for a prompt diagnosis is to recognize the triad of symptoms and signs, which are not often present initially, and it makes JSF diagnosis challenging. Repeated comprehensive physical examinations are essential for prompt diagnosis and improve prognosis of JSF.
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BACKGROUND: Kudoa septempunctata is a recently identified cause of food poisoning. We report three cases of food poisoning due to ingestion of this parasite. CASE REPORTS: Among the 358 people exposed during the same catered meal, 94 (including our 3 patients) developed vomiting and diarrhea within 1-9 h after ingestion of raw muscle from contaminated aquacultured olive flounders (Paralichthys olivaceus). These symptoms occurred frequently but were temporary; only 1 patient was hospitalized for dehydration and was discharged 2 days later. CONCLUSION: In Japan, cases of food poisoning due to eating olive flounder have increased during recent years. This increase should prompt heightened awareness among clinicians diagnosing food poisoning.
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Linguados/parasitologia , Doenças Transmitidas por Alimentos/diagnóstico , Doenças Transmitidas por Alimentos/parasitologia , Myxozoa/patogenicidade , Doenças Parasitárias/diagnóstico , Animais , Diarreia/etiologia , Comportamento Alimentar , Feminino , Humanos , Japão , Pessoa de Meia-Idade , Myxozoa/isolamento & purificação , Reação em Cadeia da Polimerase , Vômito/etiologiaRESUMO
Background Tele-ICUs are increasingly being used in the US. In Japan, young physicians mainly operate rural community hospitals to manage severely ill patients. However, the introduction of the tele-ICU system in Japan is still uncommon. We introduced a tele-ICU system to a community hospital. The objective of this study is to determine if the newly introduced tele-ICU system is being effectively utilized. Methods This is a single-center, retrospective observational study. We introduced the tele-ICU system to the NachiKatsuura Town Onsen Hospital, Japan, in 2019. Thereafter, we retrospectively explored the characteristics of the consulted cases, the time of consultation, the Sequential Organ Failure Assessment (SOFA) score, and the number of consultations by month from 1st July 2019 to 31st March 2020. The main outcome was the monthly number of consultations, and other measures included the clinical characteristics of the consulted cases. Results A total of 81 cases were referred to the tele-ICU system within nine months. Sixty-two cases, excluding those with missing data, were included in the analysis. The number of consultations was almost constant during the study period and was most frequent during the day. The recommendations from tele-ICU physicians were mostly "advice on the treatment plan." The mean SOFA score was 2.56. Conclusions We introduced a Japanese-type tele-ICU system for Japanese rural community hospitals. Many cases from rural community hospitals that were referred to the tele-ICU systems were moderately severe and did not require urgent transportation. These cases are not indicated for emergency transportation and should be treated in rural community hospitals.
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BACKGROUND: In patients with spinal cord diseases, it is difficult to obtain stress electrocardiogram and to evaluate preoperative cardiac risk. We evaluate these patients by chest CT and if the patients have calcified coronary artery, we recommend further testing by coronary arteriogram. METHODS: We evaluated the patients who had undergone coronary arteriogram from January 2008 through December 2009. RESULTS: In 27 out of 158 cases (17.1%) operations were postponed or cancelled. In 12 out of 112 patients with no subjective symptom but with coronary calcification operations were also postponed or cancelled. CONCLUSIONS: Preoperative chest CT and coronary arteriogram are useful for evaluation of preoperative cardiac function.
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Angiografia Coronária , Doença das Coronárias/diagnóstico , Procedimentos Ortopédicos , Período Pré-Operatório , Radiografia Torácica , Tomografia Computadorizada por Raios X , Calcificação Vascular/diagnóstico , Idoso , Feminino , Humanos , Masculino , Fatores de RiscoRESUMO
Negative-pressure pulmonary edema (NPPE) is a non-cardiogenic pulmonary edema caused by a sudden drop in the intrathoracic pressure associated with upper airway obstruction. Takotsubo cardiomyopathy (TCM) can often be triggered by intense stress and is more common in older women. In this case report, we describe a case of NPPE associated with upper airway obstruction and TCM associated with stress by upper airway obstruction in an 85-year-old woman. When encountering pulmonary edema associated with upper airway obstruction in older adults, the possibility of NPPE and TCM complications should be considered.
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Introduction Patients requiring mechanical ventilation (MV) are commonly managed in an intensive care unit (ICU); however, Japan is unique in that many patients are treated in non-ICU settings. The characteristics of these patients, nevertheless, are unknown. We sought to identify disease severity and MV settings of patients in non-ICU. Methods We retrospectively analyzed the clinical data of Kinan Hospital and Owase General Hospital, where there are no ICUs. Data for adult patients who required MV from January through December 2018 were collected. To find the characteristics of patients who have been decided to treat in non-ICU hospitals without early transferring, we analyzed patients who have been treated for more than three days in those hospitals. Results A total of 171 patients received MV; 29 patients were treated for more than three days. Of those, the mortality rate was 44.8% (13 patients). The median age was 80 years (range: 72-84 years). The mean Acute Physiologic Assessment and Chronic Health Evaluation II (APACHE II) score was 20.9 ± 8.1, and predicted mortality was 0.42 ± 0.25. Tidal volume per predicted body weight was 8.8 ± 2.1 mL/kg, and set inspiratory time was 1.6 ± 0.3 seconds. Conclusions We have first described the severity and the initial ventilator setting of MV patients treated for more than three days in non-ICU setting in Japan. The overall predicted mortality was 42%, and the average age of the patients was 80 years. Further research on wider areas and the comparison to the patients treated in ICUs are needed to identify the appropriateness of treating patients in non-ICU settings.
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BACKGROUND: This review aimed to investigate whether bronchoalveolar lavage (BAL) is safe in patients with severe acute respiratory failure (ARF). METHODS: We searched the MEDLINE, CENTRAL, and other databases up to June 2, 2021 for studies that examined BAL for severe ARF. We included all cohort studies and randomized or non-randomized trials, while we excluded case-control studies, case reports, and case series. We evaluated the quality of the evidence using the Grading of Recommendations, Assessment, Development, and Evaluation approach. RESULTS: We included 17 studies (1085 patients) in the meta-analysis. The integrated frequency of death was 0.000% (95% confidence interval [CI]: 0.000-0.045%, I2 = 0.0%). The pooled risk of severe complications of respiratory system, cardiovascular system, and major bleeding was 1.32% (95% CI: 0.000-4.41%, I2 = 84.8%), 0.040% (95% CI: 0.000-0.71%, I2 = 9.3%), and 0.000% (95% CI: 0.000-0.27%, I2 = 0.0%), respectively. In the subgroup analysis with mechanical ventilation during BAL, there were few severe complications of the respiratory system (3/717 patients in 13 studies) and almost no heterogeneity (I2 = 0.0%). CONCLUSIONS: Our study suggests that severe complications of BAL for severe ARF are probably rare, particularly in patients receiving mechanical ventilation. After considering the risks and benefits, it would be worthwhile to consider performing BAL in patients with severe ARF of unknown etiology to pursue its cause. TRIAL REGISTRATION: The protocol was registered with the University Hospital Medical Information Network Clinical Trials Registry (UMIN000040600).
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Síndrome do Desconforto Respiratório , Insuficiência Respiratória , Lavagem Broncoalveolar , Estudos de Coortes , Humanos , Respiração Artificial , Síndrome do Desconforto Respiratório/diagnóstico , Síndrome do Desconforto Respiratório/terapia , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/terapiaRESUMO
Although the respiratory rate is an important vital sign, it is rarely recorded in hospitals given the lack of convenient measurement devices. Posh Wellness Laboratory Inc. (Tokyo, Japan) developed a novel contactless card-type respiratory/heart rate monitoring device that measures electrical impedance variations on the human chest. This study was aimed to test and validate the accuracy of the proposed device compared with conventional medical monitors. To evaluate the card-type monitoring device, we compared the measurements from the device with those from the mechanical ventilators and electrocardiogram monitors. Patients who were hospitalized in the Emergency Department of Shimane University Hospital from April 5 to 30, 2021 were included in this study. A card-type sensor was attached to five patients who agreed to participate in this study. Four of the five patients were receiving mechanical ventilation. The respiratory rate error provided by the card-type sensor remained within 15% compared with the measurements of the conventional medical monitor. In contrast, the heart rate counts were largely different from the measurements. Thus, the proposed device can successfully measure the respiratory rate, whereas heart rate measurements require further improvement. Our small, lightweight, radiation-free, and contactless monitoring device can conveniently measure the respiratory rate of patients. With the improvement of measuring the heart rate, we would like to assess a larger number and a wider range of patients.
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AIM: Chest compression depth (CCD) in cardiopulmonary resuscitation is important. However, lightweight rescuers have difficulty achieving an appropriate depth. Chest compression force (CCFORCE) can be increased by placing the arms at 100° to the patient's frontal plane. In a simulation manikin study, we compared the CCD at 90° and 100° among lightweight Asian females and hypothesized that the CCD would be greater when the arms were placed at 100°. METHODS: We included 35 lightweight female students from Shimane University who performed compressions 30 times each at 90° and 100°. The CCFORCE and CCD and the residual force on the chest wall during decompression for each chest compression were compared using CPRmeter-2. RESULTS: Of the 35 participants, 3 were excluded because their angles deviated from the prescribed angle. Thirty-two participants were categorized according to CCD at 90°: ≤40 mm (group 1), 41-49 mm (group 2), and ≥ 50 mm (group 3). The overall mean CCD increased from 90° to 100° (44.3 ± 8.2 mm vs. 48.1 ± 7.2 mm; p < 0.05). The mean CCD changes between 90° and 100° were 34.4 ± 4.7 mm vs. 42.9 ± 4.8 mm (p < 0.05) in group 1, 44.9 ± 2.5 mm vs. 47.0 ± 4.2 mm (p = 0.17) in group 2, and 53.0 ± 2.7 mm vs. 55.4 ± 5.6 mm (p < 0.05) in group 3. The residual force was greater when the chest compression angle was 100°. CONCLUSION: CCD can be increased for lightweight rescuers when using a forward leaning position of 100° to the frontal plane of the patient. Further research is required to obtain more realistic situations.
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The coronavirus disease 2019 (COVID-19) pandemic has increased the number of patients who require extracorporeal membrane oxygenation (ECMO). To manage the demand for ECMO, Japan ECMOnet for COVID-19 was developed as a "disaster management-like system", utilizing the Cross ICU Searchable Information System (CRISIS) database. This study investigated the effect of the establishment of this disaster management-like system in Japan. This was a nationwide retrospective observational study conducted from 1 February to 31 July in 2020. A total of 187 patients with COVID-19 who received ECMO were included. The median age was 60 years (interquartile range, 53-68), the median length of ventilatory support before ECMO was 3 days (1-5), and the median PaO2 to FiO2 ratio at ECMO initiation was 86 (71.3-101.5). During the study period, 165 telephone consultations were conducted, including general questions about ECMO. Among them, 44 concerned patients who were already on ECMO or who ultimately received ECMO. Further coordination, including transport and ECMO physician dispatch, was provided for 23 cases. Overall, 125/187 (66.8%) patients were successfully weaned from ECMO. This study demonstrated that Japan has achieved favorable survival outcomes for patients with COVID-19 who received ECMO with a disaster management-like system. Further research on the causes of these outcomes is needed.
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RATIONALE: Despite increasing number of left ventricular assist device (LVAD) implantation, standardized cardiopulmonary resuscitation (CPR) protocol for patients with LVAD, especially in out-of-hospital settings are not well known. PATIENT CONCERNS: A 41-year-old LVAD implanted man became cardiac arrest in an out-of-hospital setting. Bystander CPR was started and the patient was brought to our hospital without noticing LVAD. Upon arrival, the medical staff noted the LVAD and that the battery of the LVAD was exhausted. DIAGNOSIS: Cardiac arrest on LVAD. INTERVENTIONS: It took 50 minutes to change the battery, then the patient has become ventricular fibrillation; hence, we introduced extracorporeal membranous oxygenation and defibrillated the patient. After the sinus rhythm was restored, the LVAD started working uneventfully. OUTCOMES: The patient became brain dead. LESSONS: There are several difficulties in treating these patients. First, hemodynamic collapse is difficult to diagnose. Second, chest compression for LVAD implanted patients remains controversial. Third, education to first responders who are not familiar with LVAD are not enough. Appropriate education for those issues is needed.
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Reanimação Cardiopulmonar/métodos , Coração Auxiliar , Parada Cardíaca Extra-Hospitalar/terapia , Adulto , Cardioversão Elétrica , Fontes de Energia Elétrica , Oxigenação por Membrana Extracorpórea , Humanos , Masculino , Parada Cardíaca Extra-Hospitalar/complicações , Fibrilação Ventricular/etiologia , Fibrilação Ventricular/terapiaRESUMO
CASE: Fulminant myocarditis (FM) and septic cardiomyopathy (SC) are two different disease entities, and distinction between them is important. A 34-year-old man had refractory shock, multiple organ failure, and elevation of cardiogenic markers. Echocardiogram showed tachycardia with extended ST elevation, and a rapid test for influenza A virus was positive. He was admitted with suspected FM induced by influenza. OUTCOME: Echocardiography showed severe left ventricular dysfunction and dilatation, but no myocardial edema. Inconsistent with FM, a right heart catheter examination showed preserved cardiac output. Therefore, SC was considered and standard therapy for septic shock was initiated. He was stabilized in the first 72 h without mechanical circulatory support. CONCLUSION: Influenza A infection can cause septic shock accompanied by SC. This condition is confusing in the clinical appearance of FM. However, SC shows critically different features of FM, and it might not occur in the epidemic period.
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TAFRO syndrome and acquired hemophilia A (AHA) are rare, life-threatening diseases; however, the relationship between these two diseases is unknown. A 25-year-old man was transferred to our hospital because of bleeding tendency accompanied by multiple organ failure with generalized edema, massive pleural effusion, and ascites. He was diagnosed with AHA. Bypass therapy for hemostasis and cyclophosphamide with prednisolone to eradicate possible inhibitors were provided. However, he suffered from cardiopulmonary arrest. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was initiated as rescue therapy. His hemodynamic status stabilized and he was weaned from VA-ECMO in 1 week. We confirmed normal FVIII activity and disappearance of the inhibitor, and bypass therapy was discontinued. However, generalized edema with massive ascites, pleural effusion, and renal insufficiency persisted. Bone marrow biopsy showed reticulin fibrosis. These symptoms fulfilled the diagnostic criteria of TAFRO syndrome. He received tocilizumab (TCZ) and steroid was tapered off. After four cycles of TCZ, symptoms of TAFRO syndrome gradually improved. To the best of our knowledge, this is the first report of TAFRO syndrome accompanied by AHA with rescue by VA-ECMO. Additionally, AHA and TAFRO syndrome were well controlled by TCZ.