Arino Yaguchi

Early Lactate Clearance Is Associated With Improved Outcomes in Patients With Postcardiac Arrest Syndrome: A Prospective, Multicenter Observational Study (sos-kanto 2012 Study)

Objectives: To determine whether early lactate reduction is associated with improved survival and good neurologic outcome in patients with out-of-hospital cardiac arrest. Design: Ad hoc data analysis of a prospective, multicenter observational study. Setting: Out-of-hospital cardiac arrest patients at 67 emergency hospitals in Kanto, Japan between January 2012 and March 2013. Patients: Adult patients with out-of-hospital cardiac arrest admitted to the hospital after successful resuscitation were identified. Interventions: Blood lactate concentrations were measured at hospital admission and 6 h after hospital admission. Early lactate clearance was defined as the percent change in lactate level 6 h after a baseline measurement. Measurements and Main Results: The 543 patients (mean age, 65u2009±u200916 yr; 72.6% male) had a mean lactate clearance of 42.4% ± 53.7%. Overall 30-day survival and good neurologic outcome were 47.1% and 27.4%, respectively. The survival proportion increased with increasing lactate clearance (quartile 1, 29.4%; quartile 2, 42.6%; quartile 3, 51.5%; quartile 4, 65.2%; p < 0.001). Multivariate logistic regression analysis showed that lactate clearance quartile was an independent predictor of the 30-day survival and good neurologic outcome. In the Cox proportional hazards model, the frequency of mortality during 30 days was significantly higher for patients with lactate clearance in quartile 1 (hazard ratio, 3.12; 95% CI, 2.14–4.53), quartile 2 (hazard ratio, 2.13; 95% CI, 1.46–3.11), and quartile 3 (hazard ratio, 1.49; 95% CI, 1.01–2.19) than those with lactate clearance in quartile 4. Furthermore, multivariate logistic regression analysis revealed that lactate clearance was a significant predictor of good neurologic outcome at 30 days after hospital admission. Conclusions: Effective lactate reduction over the first 6 hours of postcardiac arrest care was associated with survival and good neurologic outcome independently of the initial lactate level.

High D-dimer levels predict a poor outcome in patients with severe trauma, even with high fibrinogen levels on arrival : a multicenter retrospective study

ABSTRACT Elevated D-dimer level in trauma patients is associated with tissue damage severity and is an indicator of hyperfibrinolysis during the early phase of trauma. To investigate the interacting effects of fibrinogen and D-dimer levels on arrival at the emergency department for massive transfusion and mortality in severe trauma patients in a multicenter retrospective study. This study included 519 adult trauma patients with an injury severity score ≥16. Patients with ≥10 units of red cell concentrate transfusion and/or death during the first 24u200ah were classified as having a poor outcome. Receiver operating characteristic curve analysis for predicting poor outcome showed the optimal cut-off fibrinogen and D-dimer values to be 190u200amg/dL and 38u200amg/L, respectively. On the basis of these values, patients were divided into four groups: low D-dimer (<38u200amg/L)/high fibrinogen (>190u200amg/dL), low D-dimer (<38u200amg/L)/low fibrinogen (⩽190u200amg/dL), high D-dimer (≥38u200amg/L)/high fibrinogen (>190u200amg/dL), and high D-dimer (≥38u200amg/L)/low fibrinogen (⩽190u200amg/dL). The survival rate was lower in the high D-dimer/low fibrinogen group than in the other groups. Moreover, the survival rate was lower in the high D-dimer/high fibrinogen group than in the low D-dimer/high fibrinogen and low D-dimer/low fibrinogen groups. High D-dimer level on arrival is a strong predictor of early death or requirement for massive transfusion in severe trauma patients, even with high fibrinogen levels.

Development of Novel Criteria of the “lethal Triad” as an Indicator of Decision Making in Current Trauma Care: A Retrospective Multicenter Observational Study in Japan

Objectives: To evaluate the utility of the conventional lethal triad in current trauma care practice and to develop novel criteria as indicators of treatment strategy. Design: Retrospective observational study. Settings: Fifteen acute critical care medical centers in Japan. Patients: In total, 796 consecutive trauma patients who were admitted to emergency departments with an injury severity score of greater than or equal to 16 from January 2012 to December 2012. Interventions: None. Measurements and Main Results: All data were retrospectively collected, including laboratory data on arrival. Sensitivities to predict trauma death within 28 days of prothrombin time international normalized ratio greater than 1.50, pH less than 7.2, and body temperature less than 35°C were 15.7%, 17.5%, and 15.9%, respectively, and corresponding specificities of these were 96.4%, 96.6%, and 93.6%, respectively. The best predictors associated with hemostatic disorder and acidosis were fibrin/fibrinogen degradation product and base excess (the cutoff values were 88.8 µg/mL and –3.05 mmol/L). The optimal cutoff value of hypothermia was 36.0°C. The impact of the fibrin/fibrinogen degradation product and base excess abnormality on the outcome were approximately three- and two-folds compared with those of hypothermia. Using these variables, if the patient had a hemostatic disorder alone or a combined disorder with acidosis and hypothermia, the sensitivity and specificity were 80.7% and 66.8%. Conclusions: Because of the low sensitivity and high specificity, conventional criteria were unsuitable as prognostic indicators. Our revised criteria are assumed to be useful for predicting trauma death and have the potential to be the objective indicators for activating the damage control strategy in early trauma care.

Mechanical Cardiopulmonary Resuscitation and Hospital Survival Among Adult Patients With Nontraumatic Out‐of‐Hospital Cardiac Arrest Attending the Emergency Department: A Prospective, Multicenter, Observational Study in Japan (SOS‐KANTO [Survey of Survivors after Out‐of‐Hospital Cardiac Arrest in Kanto Area] 2012 Study)

Background Mechanical cardiopulmonary resuscitation (mCPR) for patients with out‐of‐hospital cardiac arrest attending the emergency department has become more widespread in Japan. The objective of this study is to determine the association between the mCPR in the emergency department and clinical outcomes. Methods and Results In a prospective, multicenter, observational study, adult patients with out‐of‐hospital cardiac arrest with sustained circulatory arrest on hospital arrival were identified. The primary outcome was survival to hospital discharge. The secondary outcomes included a return of spontaneous circulation and successful hospital admission. Multivariate analyses adjusted for potential confounders and within‐institution clustering effects using a generalized estimation equation were used to analyze the association of the mCPR with outcomes. Between January 1, 2012 and March 31, 2013, 6537 patients with out‐of‐hospital cardiac arrest were eligible; this included 5619 patients (86.0%) in the manual CPR group and 918 patients (14.0%) in the mCPR group. Of those patients, 28.1% (1801/6419) showed return of spontaneous circulation in the emergency department, 20.4% (1175/5754) had hospital admission, 2.6% (168/6504) survived to hospital discharge, and 1.2% (75/6419) showed a favorable neurological outcome at 1 month after admission. Multivariate analyses revealed that mCPR was associated with a decreased likelihood of survival to hospital discharge (adjusted odds ratio, 0.40; 95% confidence interval, 0.20–0.78; P=0.005), return of spontaneous circulation (adjusted odds ratio, 0.71; 95% confidence interval, 0.53–0.94; P=0.018), and hospital admission (adjusted odds ratio, 0.57; 95% confidence interval, 0.40–0.80; P=0.001). Conclusions After accounting for potential confounders, the mCPR in the emergency department was associated with decreased likelihoods of good clinical outcomes after adult nontraumatic out‐of‐hospital cardiac arrest. Further studies are needed to clarify circumstances in which mCPR may benefit these patients.

Does the number of emergency medical technicians affect the neurological outcome of patients with out-of-hospital cardiac arrest?

Background: It is unclear whether the number of paramedics in an ambulance improves the outcome of patients with out‐of‐hospital cardiac arrest (OHCA) or not. Methods and Results: This study was a prospective, observational study conducted on patients with OHCA. Patients were divided into the One‐paramedic group (Group O) and the Two‐or‐more‐paramedic group (Group T) and we analyzed the differences. Patients who were treated with only basic life support during transportation, and whose cause of cardiac arrest were extrinsic cause such as trauma and poisoning were excluded. Good neurological outcome was defined as cerebral performance category (CPC) 1 or 2. In Group O, there were 1516 patients (male/female, 922/594). In Group T, there were 2932 patients (male/female, 1798/1134). Return of spontaneous circulation (ROSC) was obtained in 528 patients (34.8%) in Group O and 1058 patients (36.1%) in Group T (p = 0.589). 320 patients (21.1%) in Group O and 656 patients (22.4%) in Group T were admitted to hospital after ROSC (p = 0.461). At 90 days, there were 57 survivors (3.8%) in Group O and 114 survivors (3.9%) in Group T (p = 0.873). At 90 days, 14 patients (0.9%) in Group T had a CPC of 1 or 2, while 30 patients (1.0%) in Group T did so (p = 0.87). From the results of logistic regression analysis, age [odds ratio (OR): 0.983, 95% confidence interval (CI): 0.952–0.993], witnessed OHCA (OR: 4.583, 95% CI: 1.587–13.234), and shockable rhythm as first documented (OR: 19.67, 95% CI: 9.181–42.13) were associated with good outcome. Conclusion: The number of paramedics in an ambulance did not affect the outcome in OHCA patients.

Changes in atropine use for out-of-hospital cardiac arrest patients with non-shockable rhythm between 2002 and 2012

Atropine sulfate was recommended in the resuscitation guideines for patients with out-of-hospital cardiac arrest (OHCA) ue to non-shockable rhythms [i.e. asystole or pulseless electric ctivity (PEA)] until the early 2000s. However, no prospective ontrolled clinical trials have examined atropine use in nonhockable rhythms; several observational clinical studies have ailed to demonstrate any benefit of routine atropine use in cariac arrest.1,2 In the 2010 international guidelines, atropine use as no longer recommended for routine management of cardiac rrest patients with non-shockable rhythms.3 However, the actual hanges in atropine use in clinical situations after 2010 remain nknown. We therefore evaluated the changes in atropine use for ardiac arrest patients with non-shockable rhythms before and fter the 2010 guidelines. We here report a post-hoc analysis of the survey of survivors fter out-of-hospital cardiac arrest in the Kanto region (SOSANTO) in 20022 and 2012,4 a study that was done between eptember 2002 and December 2003, and between January 2012 nd December 2012, respectively. The two studies were prospec-

Hyperfibrinolysis in severe isolated traumatic brain injury may occur without tissue hypoperfusion: A retrospective observational multicentre study

BackgroundHyperfibrinolysis is a critical complication in severe trauma. Hyperfibrinolysis is traditionally diagnosed via elevated D-dimer or fibrin/fibrinogen degradation product levels, and recently, using thromboelastometry. Although hyperfibrinolysis is observed in patients with severe isolated traumatic brain injury (TBI) on arrival at the emergency department (ED), it is unclear which factors induce hyperfibrinolysis. The present study aimed to investigate the factors associated with hyperfibrinolysis in patients with isolated severe TBI.MethodsWe conducted a multicentre retrospective review of data for adult trauma patients with an injury severity scoreu2009≥u200916, and selected patients with isolated TBI (TBI group) and extra-cranial trauma (non-TBI group). The TBI group included patients with an abbreviated injury score (AIS) for the headu2009≥u20094 and an extra-cranial AISu2009<u20092. The non-TBI group included patients with an extra-cranial AISu2009≥u20093 and head AISu2009<u20092. Hyperfibrinolysis was defined as a D-dimer levelu2009≥u200938xa0mg/L on arrival at the ED. We evaluated the relationships between hyperfibrinolysis and injury severity/tissue injury/tissue perfusion in TBI patients by comparing them with non-TBI patients.ResultsWe enrolled 111 patients in the TBI group and 126 in the non-TBI group. In both groups, patients with hyperfibrinolysis had more severe injuries and received transfusion more frequently than patients without hyperfibrinolysis. Tissue injury, evaluated on the basis of lactate dehydrogenase and creatine kinase levels, was associated with hyperfibrinolysis in both groups. Among patients with TBI, the mortality rate was higher in those with hyperfibrinolysis than in those without hyperfibrinolysis. Tissue hypoperfusion, evaluated on the basis of lactate level, was associated with hyperfibrinolysis in only the non-TBI group. Although the increase in lactate level was correlated with the deterioration of coagulofibrinolytic variables (prolonged prothrombin time and activated partial thromboplastin time, decreased fibrinogen levels, and increased D-dimer levels) in the non-TBI group, no such correlation was observed in the TBI group.ConclusionsHyperfibrinolysis is associated with tissue injury and trauma severity in TBI and non-TBI patients. However, tissue hypoperfusion is associated with hyperfibrinolysis in non-TBI patients, but not in TBI patients. Tissue hypoperfusion may not be a prerequisite for the occurrence of hyperfibrinolysis in patients with isolated TBI.