Akiko Akashi

Association between delay to coronary reperfusion and outcome in patients with acute coronary syndrome undergoing extracorporeal cardiopulmonary resuscitation

AIM The prognostic effect of early coronary reperfusion therapy with extracorporeal cardiopulmonary resuscitation (ECPR) in patients with cardiac arrest due to acute coronary syndrome (ACS) has yet to be clarified. We investigated the relationship between time interval from collapse to start of ECPR (CtoE) and coronary reperfusion (CtoR) time and neurological outcome in patients with cardiac arrest due to ACS. METHODS A cohort of 119 consecutive patients (63±12 years old) with ACS who underwent ECPR and percutaneous coronary intervention(PCI) at our hospital was registered from January 2005 to June 2016. We analyzed patient clinical outcome, which was defined as survival with good neurological outcome at 30 days. We divided the patients into four groups according to CtoR time: Group 1 (time<60min: n=19), Group 2 (60≤time<90min: n=19), Group 3 (time≥90min: n=70) and Group 4 (unsuccessful coronary reperfusion: n=11). RESULTS One hundred patients (84%) were successful of PCI. A Kaplan-Meier curve showed that Group 1 had the best outcome among the four groups (good neurological outcome at 30 days; 74% vs 37% vs 23% vs 9%, P<0.0001). In receiver operating characteristics analysis for good neurological outcome at 30 days, the cutoff values for CtoE was 40min. The delay CtoE and CtoR time were independent predictors of poor neurological outcome at 30 days after adjusting multiple confounders (CtoE time; Hazard ratio (HR):1.026, 95% confidential intervals(CI): 1.011-1.042, P=0.001), (CtoR time; HR: 1.004, 95% CI: 1.001-1.008, P=0.020). CONCLUSIONS A shorter CtoE and CtoR predicts better clinical outcome in patients with ACS undergoing ECPR.

Prognostic effect of estimated glomerular filtration rate in patients with cardiogenic shock or cardiac arrest undergoing percutaneous veno-arterial extracorporeal membrane oxygenation

BACKGROUND Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) can improve survival in patients with cardiogenic shock or cardiac arrest. We investigated the association between initial renal function and clinical outcome in patients undergoing VA-ECMO for cardiogenic shock and cardiac arrest. METHODS This was a single-center, retrospective cohort study of 287 patients who underwent ECMO at our hospital from January 2005 to December 2014. We excluded 70 patients with non-cardiogenic events. The remaining 217 patients were divided into 2 groups according to initial estimated glomerular filtration rate (eGFR): Initial high eGFR (non-renal failure: non-RF) group: eGFR≥60ml/min/1.73m2 (n=73) and initial low eGFR (RF) group: eGFR<60ml/min/1.73m2 (n=144). Clinical outcome was defined as all-cause death at 30 days after extracorporeal life support. RESULTS VA-ECMO was begun in 87% of patients for cardiac arrest. The non-RF group was significantly younger (51.6 vs. 62.6 years), had lower body mass index (22.8 vs. 24.7kg/m2), lower blood urea nitrogen (14.4 vs. 23.9mg/dl), and lower K (4.0 vs. 4.5mEq/l, all p<0.05) than the RF group. Incidence of all-cause death at 30 days was significantly lower in the non-RF than RF group (49% vs. 76%, p<0.0001). Initial low eGFR was an independent predictor of mortality after adjustment for multiple cofounders (OR: 4.08, 95% CI: 1.77-9.42, p<0.001). Kaplan-Meier curve showed better outcome in the non-RF versus RF group (p=0.0009). CONCLUSION An initial low eGFR may predict worse clinical outcome in patients undergoing VA-ECMO for cardiogenic shock and cardiac arrest.

Unilateral cardiogenic pulmonary edema associated with acute mitral regurgitation

Two cases of cardiogenic unilateral pulmonary edema are reported. Both patients presented to the emergency department with dyspnea, and chest radiography revealed unilateral infiltration, which mimics pulmonary disease. However, the patients were diagnosed with cardiogenic pulmonary edema, because echocardiography showed severe mitral regurgitation with an eccentric jet.

A case of circumferential type A aortic dissection with intimal intussusception diagnosed using repeat transthoracic echocardiography examination

Sometimes it is difficult to diagnose circumferential aortic dissection with enhanced computed tomography alone. A 58‐year‐old woman presented with sudden‐onset chest discomfort and loss of consciousness. Transthoracic echocardiogram showed mild aortic regurgitation. Enhanced computed tomography scans showed no obvious intimal tear or flap at the proximal ascending aorta, but an intimal flap was observed from the aortic arch to both common iliac arteries. Stanford type B dissection was tentatively diagnosed. Repeat detailed transthoracic echocardiography examination showed an intimal tear and flap at the ascending aorta; prolapse into the left ventricle caused severe aortic regurgitation. Type A aortic dissection was definitively diagnosed; emergent operation showed a circumferential intimal tear originating from the ascending aorta.

Flunitrazepam overdose induces brilliant-blue gastric fluid

Dear Editor We report the case of a patient with flunitrazepam overdose who presented with brilliant blue-stained gastric fluid. A 37-year-old woman who had a history of borderline personality disorder was transported to our hospital with disturbance of consciousness by the emergency medical service. On arrival, the Glasgow Coma Scale score was 6/ 15 (eye 1, verbal 1, motor 4), and both pupils were approximately 3 mm in diameter and reactive to light. Her blood pressure was 104/76 mmHg, heart rate was 64 b.p.m., respiratory rate was 10 breaths/min, and oxygen saturation was 99% on 6 L of oxygen. She did not smell of alcohol, and had airway constriction. Endotracheal intubation was performed, and 100 mL blue-colored gastric fluid was aspirated after nasogastric intubation (Fig. 1). Laboratory results on arrival were as follows: serum sodium level, 141 mmol/L; serum calcium level, 9.0 mg/ dL; urea nitrogen level, 6.2 mg/dL; and blood glucose level, 119 mg/dL. Head computed tomography scan yielded normal findings. The emergency medical service informed us about her medical history, and empty pressthrough packages (32 tablets of 2 mg flunitrazepam, 52 tablets of 5 mg nitrazepam, and 87 tablets of 25 mg quetiapine) were found in her living room. Rapid urine toxicology screening test revealed positive results for benzodiazepines. She was diagnosed with the above drug overdoses, and admitted to our hospital. She was extubated 3 days post-admission, and discharged after a psychiatric examination without any sequelae. Our case highlighted the brilliant-blue gastric fluid due to flunitrazepam overdose. Flunitrazepam is a central nervous system depressant that belongs to the class of drugs known as benzodiazepines. While flunitrazepam produces sedative-hypnotic, anti-anxiety, and muscle relaxant effects, it is also used in combination with alcohol to produce an exaggerated intoxication, and misused to physically and psychologically incapacitate victims targeted for sexual assault. This drug has never been approved for medical use by the US Food and Drug Administration. In Japan, the white color of flunitrazepam (Silece; Eisai, Tokyo, Japan, and Rohypnol; Chugai, Tokyo, Japan: Basel, Switzerland) tablets has been changed to blue to prevent its use for criminal purposes by the Ministry of Health since July 1, 2015. Although intended to prevent crime, there are some medical merits. If we could not diagnose the cause of the altered consciousness, the blue-colored gastric fluid could signify a possible overdose; we could then anticipate the patient’s altered consciousness to resolve, knowing its half-life (10–30 h). We retrospectively evaluated the medical records of patients with drug overdose between July 2015 and July 2017 at our institution. Of the 90 patients identified, bluecolored gastric fluid was found in four patients. The diagnosis of flunitrazepam was confirmed with oral evidence in two patients; for one patient it was suspected based on the drug history, but there was no evidence from the medical history of the other patient. There are several limitations to making a diagnosis based on the blue-colored gastric fluid. First, Silece and Rohypnol expire 4 and 5 years, respectively, from the date of manufacture (both have been changed from

Hemodialysis for removal of dabigatran in a patient with gastric hemorrhage

An 82‐year‐old man taking dabigatran was admitted with syncope. Computed tomography showed extravasation from the stomach. Laboratory data revealed renal insufficiency and prolonged activated partial thromboplastin time. The gastric endoscopy showed a gastric ulcer with an exposed vessel. However, an endoscopic hemostatic procedure failed to completely stop the bleeding. The patient experienced cardiac arrest from hypotensive shock. Spontaneous circulation returned after 5 min of resuscitation. After endoscopy, computed tomography showed a gastric perforation. For dabigatran removal, the patient underwent a 6‐h hemodialysis session. Thrombin activity and thrombin–antithrombin complex increased during hemodialysis, while activated partial thromboplastin time decreased.

Diverticulitis-induced pylephlebitis possibly misdiagnosed as biliary duct obstruction

A 59‐year‐old Asian man presented to our emergency department with hypogastrium pain, loss of appetite, and diarrhea. On admission, he was hypotensive and jaundiced. Laboratory test results revealed thrombocytopenia, hypercreatininemia, and hyperbilirubinemia. Color Doppler sonography showed no blood flow in the right and left branches of the portal vein, which seemed similar to biliary obstruction. Enhanced computed tomography showed portal vein thrombi, consistent with pylephlebitis; a broad‐spectrum antibiotic and an anticoagulant were administered.