Akira Hoshiai

Prediction of blood culture results by measuring procalcitonin levels and other inflammatory biomarkers.

BACKGROUND It would be helpful if we could predict positive or negative blood culture results. This study considered the usefulness of measuring procalcitonin (PCT) level and standard clinical biomarkers such as white blood cell (WBC) count, C-reactive protein (CRP) level, and platelet (PLT) count to predict blood culture results. METHOD We retrospectively analyzed the data from 422 specimens collected at our emergency center within the preceding 36 consecutive months. Primary component analysis (PCA) was used for detecting the degree of the relational contribution of each of the 4 biomarkers to the blood culture results. RESULTS Procalcitonin alone (cut-off value, 0.5 ng/mL) yielded a positive blood culture rate of 34.0%. Procalcitonin plus 3 biomarkers (WBC, CRP, and PLT) analyzed by PCA yielded 45.9% or 35.3% when a case was in the first or fourth quadrant, which was significantly higher than cases in the second or third quadrant. Primary component analysis also revealed that positive blood culture results were mainly affected by primary component 1, to which PCT and PLT (not WBC or CRP) predominantly contribute. CONCLUSION Although it is difficult to predict blood culture results, even using 4 biomarkers analyzed by PCA, our new finding that blood culture results are affected not by WBC and CRP, but mainly by PCT and PLT, might help explain the mechanism of sepsis.

Procalcitonin levels predict to identify bacterial strains in blood cultures of septic patients

BACKGROUND We examined whether the values obtained from principal component analysis (PCA) on laboratory tests can be used to predict bacterial infections and identify bacterial strains in blood culture (BC). METHOD This study is a single-center retrospective analysis of 315 patients suspected of having sepsis. We applied PCA on procalcitonin (PCT) and laboratory test biomarkers, namely, platelet (PLT), white blood cell, and C-reactive protein (CRP) as well as BC. RESULTS Principal component analysis showed that PCT, CRP, and PLT contributions to component 1 were associated with bacterial infection. The number of patients who had BC-negative results, gram-positive cocci (GPC), and gram-negative rods (GNRs) were 124, 28, and 19, respectively. The mean value of component 1 in GNR-positive patients was 1.58±1.41 and was significantly higher than that in GPC-positive patients (0.28±0.87; P<.0001). Furthermore, the mean values of component 1 in both GNR- and GPC-positive patients were significantly higher than that in BC-negative patients (-0.31±0.65; P<.0001 and P<.002, respectively). One certain range showing higher value more than 2.00 for component 1 and -1.00 for component 2 only included GNR-positive patients. There were no BC-positive patients who showed less than -1.00 for component 1. CONCLUSION The present results obtained by PCA on laboratory tests involving PCT, PLT, white blood cell, and CRP suggest the potential of PCA-obtained values to not only predict bloodstream infection but also identify bacterial strains. This provides some clinical significance in the management of sepsis in acute care.

High-grade traumatic torso visceral injury with hemodynamic instability: effectiveness of transarterial embolization using n-butyl cyanoacrylate

Trauma patients with uncontrolled hemorrhage encountering coagulopathy are often associated with poor outcome. Recently, the concept of damage control interventional radiology, which focuses on “speedy stoppage of bleeding” by interventional radiology among trauma patients with hemodynamic instability and acute traumatic coagulopathy, was proposed as an alternative to damage control surgery. N‐butyl cyanoacrylate (NBCA) has been used as a liquid embolic agent in various non‐traumatic situations, where it has been shown to have a high technical success rate and low recurrent bleeding rate, especially in patients with coagulopathy. In this case, we treated a young patient with hemodynamic instability caused by a high‐grade hepatic injury, who underwent arterial embolization (AE) using NBCA assisted with resuscitative endovascular balloon occlusion of the aorta and achieved successful hemostasis. A review of published works using PUBMED was carried out, and 10 published reports involving 23 trauma patients who underwent AE using NBCA were identified. Among them, only four reports involving five trauma patients with torso visceral injuries were identified. Three of five patients who were hemodynamically unstable underwent AE using NBCA, resulting in the stabilization of hemodynamics. We concluded that AE with resuscitative endovascular balloon occlusion of the aorta as a damage control interventional radiology procedure might be acceptable for the hemodynamically unstable hepatic injury, and NBCA could be one of the effective hemostatic agents for this purpose, in cases of trauma‐induced coagulopathy.

A rare case of obscure gastrointestinal bleeding: Small bowel varices flowing into the inferior epigastric vein

Ectopic varices include all varices except esophageal or gastric varices and comprise large portosystemic venous collaterals that occur anywhere in the abdomen. Ectopic varices are relatively rare; however, approximately 5% are related to gastrointestinal bleeding. Ectopic varices usually occur in the rectum, duodenum, or colon, and portal hypertension is the most common cause. Hemodynamic profiles of ectopic varices remain unknown, and extensive bleeding from these structures occurs because diagnosis and treatment are difficult. Here we report a case of obscure gastrointestinal bleeding (GIB) due to ectopic varices in the small intestine that flowed into the inferior epigastric vein. Our observations suggest that when obscure GIB is detected in patients with either cirrhosis or post-surgical history including incisional hernia, it is essential to acquire multilanar reconstruction images and volume-rendered 3-dimensional reconstruction of computed tomography scans to investigate the complex venous supply and optimize decisions for therapy.

1186: 7 FR INTRA-AORTIC BALLOON OCCLUSION CATHETERS FOR REBOA: A COMPARISON WITH 10 FR CATHETERS.

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) of an existing data set tracking phasing and mobility of patients in a multisystem ICU (MICU) from May 6, 2015 to January 2016 was used. The phasing protocol ranged from phase 0 to phase 5 (0 no mobility, 1A nursing initiated bed mobility, 1B therapy initiated mobility, 2 sitting edge of bed, 3 out of bed to chair, 4 standing, 5 ambulation). A patient was deemed phased if documented in the medical record. Compliance with phasing was calculated against the total number of patients admitted to the MICU. Compliance with mobility was calculated using the total number of patients phased a level 3 or higher against patients who were documented out of bed. Results: Data on a total of 2486 patient ICU days was collected. Of the 2486 patient ICU days, phasing was completed 1880 days (76%). Of the patients who were phased to be OOB (N=927) a total of 783 (84%) were documented out of bed which achieved initial goal of 80%. 32% of all patient days were spent with time out of bed. Conclusions: Department goals can be achieved using a multidisciplinary team approach to an early mobility program in a MICU. Further research will need to look specifically at patient outcomes and fiscal impact once the program has been established.

Anti‐NMDAR encephalitis: case report and diagnostic issues

A 20‐year‐old woman developed acute psychotic symptoms and altered level of consciousness. She presented with neck stiffness, tremulous arms, facial dyskinesia, and distension of the lower abdomen. Pelvic magnetic resonance imaging showed bilateral ovarian teratomas. Anti‐N‐methyl‐D‐aspartate receptor antibodies were detected in her cerebrospinal fluid.