Jun Oto

Prognostic value of blood interleukin-6 in the prediction of functional outcome after stroke: A systematic review and meta-analysis

We aimed to quantify the association of blood interleukin-6 (IL-6) concentrations with poor outcome after stroke and its added predictive value over clinical information. Meta-analysis of 24 studies confirmed this association with a weighted mean difference of 3.443 (1.592-5.294) pg/mL, despite high heterogeneity and publication bias. Individual participant data including 4112 stroke patients showed standardized IL-6 levels in the 4th quartile were independently associated with poor outcome (OR=2.346 (1.814-3.033), p<0.0001). However, the additional predictive value of IL-6 was moderate (IDI=1.5%, NRI=5.35%). Overall these results indicate an unlikely translation of IL-6 into clinical practice for this purpose.

Plasma proinflammatory and anti-inflammatory cytokine and catecholamine concentrations as predictors of neurological outcome in acute stroke patients

PurposeProinflammatory and anti-inflammatory cytokines may play a pivotal role in cerebral inflammation, which is implicated in the development of brain injury. Systemic cytokine release is mediated by the sympathetic nervous system and catecholamines. The aim of this study was to investigate which parameters, among plasma levels of interleukin-1β (IL-1β), interleukin-6 (IL-6), interleukin-10 (IL-10), and tumor necrosis factor alpha (TNF-α) and the levels of the catecholamines, epinephrine and norepinephrine, contribute to the clinical outcome in acute stroke patients.MethodsThirty-seven acute stroke patients (ischemic, n = 19; hemorrhagic, n = 18) were enrolled. All of them were admitted to our hospital within 8 h after stroke onset. Neurological status was evaluated by a modified National Institute of Health Stroke Scale (mNIHSS) on admission and by a modified Rankin Scale (mRS) at 1 month. An mRS score of 3 or more at 1 month was considered to indicate poor outcome. Serum samples for the cytokine and catecholamine measurements were collected on admission. Plasma levels of IL-1β, IL-6, IL-10, and TNF-α were determined by an enzyme-linked immunosorbent assay (ELISA) method and epinephrine and norepinephrine concentrations were determined by high-performance liquid chromatography with electrochemical detection (HPLC-EC).ResultsIn the ischemic stroke patients, poor outcome was noted in 9 (47%). There were no significant differences in cytokine or catecholamine concentrations between patients with poor and good outcomes, and there was no association between clinical outcome and cytokine and catecholamine concentrations. In the hemorrhagic stroke patients, poor outcome was noted in 10 (56%). IL-6 and IL-10 levels were higher in patients with poor outcome. On logistic regression analysis, higher values of IL-6 were significantly associated with clinical outcome at 1 month (odds ratio [OR], 1.25; 95% confidence interval [CI], 1.02–1.54).ConclusionIn ischemic stroke, plasma cytokines and catecholamines were not predictors of neurological outcome at 1 month. In hemorrhagic stroke, high levels of IL-6 in the early phase indicated a poor neurological outcome.

A prospective clinical trial on prevention of catheter contamination using the hub protection cap for needleless injection device

BACKGROUND Catheter hub contamination has been recognized as a source of catheter-related bloodstream infections. We have investigated the efficacy of a protection cap for a needleless injection device in preventing intraluminal catheter contamination, compared with a conventional 3-way stopcock. METHODS Adult patients requiring an intravascular catheter placement for at least 48 hours in an intensive care unit were randomly assigned to receive either the needleless injection device with protection cap (test group, n = 31, number of devices = 151) or with a conventional 3-way stopcock (comparator group, n = 33, number of devices = 179). To evaluate intraluminal contamination, we examined the bacteria isolated in the inline bacterial filters, which were attached downstream of the injection ports. RESULTS The incidence of bacterial contamination was significantly different between the groups (test group 2/151 (1.3%) vs comparator group 11/179 (6.2%), P = .04). There was no correlation between the microbial contamination rate and the in situ time of catheter or numbers of injections. CONCLUSION The protection cap for needleless injection devices decreased microbial transfer from the injection port to the intraluminal fluid pathway and lowered the risk of catheter-related bloodstream infections.

Effect of heat and moisture exchanger (HME) positioning on inspiratory gas humidification

BackgroundIn mechanically ventilated patients, we investigated how positioning the heat and moisture exchanger (HME) at different places on the ventilator circuit affected inspiratory gas humidification.MethodsAbsolute humidity (AH) and temperature (TEMP) at the proximal end of endotracheal tube (ETT) were measured in ten mechanically ventilated patients. The HME was connected either directly proximal to the ETT (Site 1) or at before the circuit Y-piece (Site 2: distance from proximal end of ETT and Site 2 was about 19 cm) (Figure. 1). Two devices, Hygrobac S (Mallinckrodt Dar, Mirandola, Italy) and Thermovent HEPA (Smiths Medical International Ltd., Kent, UK) were tested. AH and TEMP were measured with a hygrometer (Moiscope, MERA Co., Ltd., Tokyo, Japan).ResultsHygrobac S provided significantly higher AH and TEMP at both sites than Thermovent HEPA. Both Hygrobac S and with Thermovent HEPA provided significantly higher AH and TEMP when placed proximally to the ETT.ConclusionAlthough placement proximal to the ETT improved both AH and TEMP in both HMEs tested, one HME performed better in the distal position than the other HME in the proximal position. We conclude the both the type and placement of HME can make a significant difference in maintaining AH and TEMP during adult ventilation.

Potential Inadequacy of Automatic Tube Compensation to Decrease Inspiratory Work Load After at Least 48 Hours of Endotracheal Tube Use in the Clinical Setting

BACKGROUND: Endotracheal tubes (ETTs) impose a substantial respiratory work load on mechanically ventilated patients. Automatic tube compensation (ATC) should overcome this flow-dependent resistive work load; however, ETT resistance can be increased by tracheal secretions or ETT deformities. Our bench study investigated whether ATC provides effective respiratory work load relief in used ETTs. METHODS: We enrolled 20 critically ill patients requiring mechanical ventilation for longer than 48 hours. After extubation, we collected the used ETTs and measured the pressure-time products (PTPs) by using a bellows-in-a-box lung model that simulated spontaneous breathing, at a respiratory rate of 10 breaths/min, inspiratory time of 1.0 s, and tidal volumes (VT) of 300 mL, 500 mL, and 700 mL. The ventilator was set at ATC 100% with PEEP of 5 cm H2O and FIO2 of 0.21. The flow and airway pressure at the proximal (Paw) and distal (Ptr) ends of the ETT were recorded, and the PTP integrated from Ptr analyzed. RESULTS: PTP values increased with VT during ATC. Even at 100% ATC the ventilator did not completely compensate for the PTP imposed by the ETT. In used ETTs, peak flow and peak Paw were lower and PTP values were greater than in new ETTs. As VT increased, the percentage difference in the PTP values between the new and used ETTs increased. CONCLUSIONS: ATC does not necessarily compensate for an ETT-imposed respiratory work load. ETT configuration changes and tracheal secretions can increase ETT resistance and decrease the ability of ATC to compensate for the increased respiratory work load.

An adult patient with Kabuki syndrome presenting with Henoch-Schönlein purpura complicated with pulmonary hemorrhage

We present a case of a 33-year-old woman with Kabuki syndrome (KS) presenting with Henoch-Schönlein purpura (HSP). She was admitted to our hospital with a brain abscess in the lateral ventricle and meningitis. She had been diagnosed with KS. Skin eruptions had appeared on her lower extremities, with arthralgia, cough, and hemoptysis. She suddenly developed pulmonary hemorrhage and respiratory failure. We intubated her trachea and started mechanical ventilation in the intensive care unit (ICU). Skin biopsy revealed leukocytoclastic vasculitis with granular depositions of immunoglobulin A (IgA) in dermal vessel walls, and she was diagnosed as having HSP. Supportive management and prednisolone at 20 mg·day−1 cured the pulmonary hemorrhage and respiratory failure. On ICU day 27, she was weaned from mechanical ventilation. Pulmonary hemorrhage as a complication of HSP is rare and sometimes fatal. KS is often associated with an increased incidence of infection and congenital heart disease. Susceptibility to infection and pulmonary hypertension due to congenital heart disease in this patient may have led to the development of the pulmonary hemorrhage. Supportive care and steroid therapy appeared to be beneficial in the treatment of this patient with HSP with pulmonary hemorrhage.

A Comparison of Leak Compensation During Pediatric Noninvasive Ventilation: A Lung Model Study

BACKGROUND: Ventilators used for noninvasive ventilation (NIV) must be able to synchronize in the presence of system leaks. We compared the ability of 7 ICU ventilators and 3 dedicated NIV ventilators to compensate for leaks during pediatric NIV. METHODS: Using a lung simulator, we compared the Maquet Servo-i, Dräger V500, Dräger Carina, Covidien PB840, Respironics V60, Respironics Vision, GE Healthcare/Engström Carestation, CareFusion Avea, Hamilton C3, and Hamilton G5 during increasing (n = 6) and decreasing leaks (n = 6). With a lung simulator we tested 4 leak levels (baseline [BL] 2–3 L/min, L1 5–6 L/min, L2 9–10 L/min, and L3 19–20 L/min); 3 patient weights (10, 20, and 30 kg); and 3 lung mechanics scenarios (normal, obstructive, and restrictive). The ventilator settings were NIV mode, pressure support of 10 cm H2O, and PEEP of 5 cm H2O. The synchronization rate (synchronized cycles/total simulated respirations) was recorded for each ventilator and each leak scenario. Synchronization was defined as triggering without auto-triggering, miss-triggering, delayed cycling, or premature cycling. RESULTS: The mean synchronization rate across all ventilators was 68 ± 27% (range 23–96%) and marked differences existed between the ventilators (P < .001). Significant differences in synchronization rate were observed between the 10-kg model (mean 57 ± 30%, range 17–93%), the 20-kg model (69 ± 30%, 25–98%), and the 30-kg models (77 ± 22%, 28–97%) (P < .001). The synchronization rate for the obstructive model (60 ± 30%, 9–94%) was significantly different from the normal model (71 ± 29%, 18–98%) and the restrictive model (72 ± 28%, 23–98%) (P < .001). The PB840 and the C3 had synchronization rates over 90% overall across all body weights, all lung mechanic profiles, and all leak levels. CONCLUSIONS: Leak compensation in NIV for pediatric use can partially compensate for leaks, but varies widely among ventilators, patient weights, and lung mechanics.

Continuous positive airway pressure and ventilation are more effective with a nasal mask than a full face mask in unconscious subjects: a randomized controlled trial

IntroductionUpper airway obstruction (UAO) is a major problem in unconscious subjects, making full face mask ventilation difficult. The mechanism of UAO in unconscious subjects shares many similarities with that of obstructive sleep apnea (OSA), especially the hypotonic upper airway seen during rapid eye movement sleep. Continuous positive airway pressure (CPAP) via nasal mask is more effective at maintaining airway patency than a full face mask in patients with OSA. We hypothesized that CPAP via nasal mask and ventilation (nCPAP) would be more effective than full face mask CPAP and ventilation (FmCPAP) for unconscious subjects, and we tested our hypothesis during induction of general anesthesia for elective surgery.MethodsIn total, 73 adult subjects requiring general anesthesia were randomly assigned to one of four groups: nCPAP P0, nCPAP P5, FmCPAP P0, and FmCPAP P5, where P0 and P5 represent positive end-expiratory pressure (PEEP) 0 and 5 cm H2O applied prior to induction. After apnea, ventilation was initiated with pressure control ventilation at a peak inspiratory pressure over PEEP (PIP/PEEP) of 20/0, then 20/5, and finally 20/10 cm H2O, each applied for 1 min. At each pressure setting, expired tidal volume (Vte) was calculated by using a plethysmograph device.ResultsThe rate of effective tidal volume (Vte > estimated anatomical dead space) was higher (87.9% vs. 21.9%; P<0.01) and the median Vte was larger (6.9 vs. 0 mL/kg; P<0.01) with nCPAP than with FmCPAP. Application of CPAP prior to induction of general anesthesia did not affect Vte in either approach (nCPAP pre- vs. post-; 7.9 vs. 5.8 mL/kg, P = 0.07) (FmCPAP pre- vs. post-; 0 vs. 0 mL/kg, P = 0.11).ConclusionsnCPAP produced more effective tidal volume than FmCPAP in unconscious subjects.Trial registrationClinicalTrials.gov identifier: NCT01524614.

Chest computed tomography of a patient revealing severe hypoxia due to amniotic fluid embolism: a case report

IntroductionAmniotic fluid embolism is one of the most severe complications in the peripartum period. Because its onset is abrupt and fulminant, it is unlikely that there will be time to examine the condition using thoracic computed tomography (CT). We report a case of life-threatening amniotic fluid embolism, where chest CT in the acute phase was obtained.Case presentationA 22-year-old Asian Japanese primiparous woman was suspected of having an amniotic fluid embolism. After a Cesarean section for cephalopelvic disproportion, her respiratory condition deteriorated. Her chest CT images were examined. CT findings revealed diffuse homogeneous ground-glass shadow in her bilateral peripheral lung fields. She was therefore transferred to our hospital. On admission to our hospitals intensive care unit, she was found to have severe hypoxemia, with SpO2 of 50% with a reservoir mask of 15 L/min oxygen. She was intubated with the support of noninvasive positive pressure ventilation. She was successfully extubated on the sixth day, and discharged from the hospital on the twentieth day.ConclusionThis is the first case report describing amniotic fluid embolism in which CT revealed an acute respiratory distress syndrome-like shadow.

Evaluation of an Automated Endotracheal Tube Cuff Controller During Simulated Mechanical Ventilation

BACKGROUND: Maintaining endotracheal tube cuff pressure within a narrow range is an important factor in patient care. The goal of this study was to evaluate the IntelliCuff against the manual technique for maintaining cuff pressure during simulated mechanical ventilation with and without movement. METHODS: The IntelliCuff was compared to the manual technique of a manometer and syringe. Two independent studies were performed during mechanical ventilation: part 1, a 2-h trial incorporating continuous mannikin head movement; and part 2, an 8-h trial using a stationary trachea model. We set cuff pressure to 25 cm H2O, PEEP to 10 cm H2O, and peak inspiratory pressures to 20, 30, and 40 cm H2O. Clinical importance was defined as both statistically significant (P < .05) and clinically significant (pressure change [Δ] > 10%). RESULTS: In part 1, the change in cuff pressure from before to after ventilation was clinically important for the manual technique (P < .001, Δ = −39.6%) but not for the IntelliCuff (P = .02, Δ = 3.5%). In part 2, the change in cuff pressure from before to after ventilation was clinically important for the manual technique (P = .004, Δ = −14.39%) but not for the IntelliCuff (P = .20, Δ = 5.65%). CONCLUSIONS: There was a clinically important drop in manually set cuff pressure during simulated mechanical ventilation in a stationary model and an even larger drop with movement, but this was significantly reduced by the IntelliCuff in both scenarios. Additionally, we observed that cuff pressure varied directly with inspiratory airway pressure for both techniques, leading to elevated average cuff pressures.