Katsutoshi Tanno

Extracorporeal cardiopulmonary resuscitation for patients with out-of-hospital cardiac arrest of cardiac origin: a propensity-matched study and predictor analysis.

Objective:Encouraging results of extracorporeal cardiopulmonary resuscitation for patients with refractory cardiac arrest have been shown. However, the independent impact on the neurologic outcome remains unknown in the out-of-hospital population. Our objective was to compare the neurologic outcome following extracorporeal cardiopulmonary resuscitation and conventional cardiopulmonary resuscitation and determine potential predictors that can identify candidates for extracorporeal cardiopulmonary resuscitation among patients with out-of-hospital cardiac arrest of cardiac origin. Design:Post hoc analysis of data from a prospective observational cohort. Setting:A tertiary care university hospital in Sapporo, Japan (January 2000 to September 2004). Patients:A total of 162 adult patients with witnessed cardiac arrest of cardiac origin who had undergone cardiopulmonary resuscitation for longer than 20 minutes (53 in the extracorporeal cardiopulmonary resuscitation group and 109 in the conventional cardiopulmonary resuscitation group). Interventions:None. Measurements and Main Results:The primary endpoint was neurologically intact survival at three months after cardiac arrest. We used propensity score matching to reduce selection bias and balance the baseline characteristics and clinical variables that could potentially affect outcome. This matching process selected 24 patients from each group. The impact of extracorporeal cardiopulmonary resuscitation was estimated in matched patients. Intact survival rate was higher in the matched extracorporeal cardiopulmonary resuscitation group than in the matched conventional cardiopulmonary resuscitation group (29.2% [7/24] vs. 8.3% [2/24], log-rank p = 0.018). According to the predictor analysis, only pupil diameter on hospital arrival was associated with neurologic outcome (adjusted hazard ratio, 1.39 per 1-mm increase; 95% confidence interval, 1.09–1.78; p = 0.008). Conclusions:Extracorporeal cardiopulmonary resuscitation can improve neurologic outcome after out-of-hospital cardiac arrest of cardiac origin; furthermore, pupil diameter on hospital arrival may be a key predictor to identify extracorporeal cardiopulmonary resuscitation candidates.

Outcome from severe accidental hypothermia with cardiac arrest resuscitated with extracorporeal cardiopulmonary resuscitation

PURPOSE This study aimed to identify factors of neurologic prognosis in severe accidental hypothermic patients with cardiac arrest. BASIC PROCEDURES This retrospective observational study was performed in a tertiary care university hospital in Sapporo, Japan (January 1994 to December 2012). We investigated 26 patients with accidental hypothermic cardiac arrest resuscitated with extracorporeal cardiopulmonary resuscitation (ECPR). We evaluated the neurologic outcome in patients who were resuscitated with ECPR at discharge from hospital. MAIN FINDINGS In those 26 patients, their median age was 50.5 years; and 69.2% were male. The cause of hypothermia was exposure to cold air in 46.1%, submersion in 46.1%, and avalanche in 7.8%. Ten (38.5%) of these patients survived to favorable neurological outcome at discharge. Factors associated with favorable neurological outcome were a cardiac rhythm other than asystole (P = .009), nonasphyxial hypothermia (P = .006), higher pH (P = .01), and lower serum lactate (P = .01). In subgroup analyses, the patients with hypothermic cardiac arrest due to submersion or avalanche (asphyxia group) showed no factors associated with good neurological outcome, whereas the nonasphyxia group showed a significantly lower core temperature (P = .02) and a trend towards a lower serum lactate (P = .09). PRINCIPAL CONCLUSIONS Patients with hypothermic cardiac arrest due to nonasphyxial hypothermia have improved neurologic outcomes when treated with ECPR compared to patients with asphyxial hypothermic cardiac arrest. Further investigation is needed to develop a prediction rule for patients with nonasphyxial hypothermic cardiac arrest to determine which patients would benefit from treatment with ECPR.

Acquisition of a Transposon Encoding Extended-Spectrum β-Lactamase SHV-12 by Pseudomonas aeruginosa Isolates during the Clinical Course of a Burn Patient

ABSTRACT Three of seven clonally related Pseudomonas aeruginosa strains isolated from a burn patient produced the extended-spectrum β-lactamase (ESBL) SHV-12. Its gene was flanked by two IS26 elements with a large transposon (>24 kb). The transposon also contained at least five IS26 elements and a gene encoding the amikacin resistance determinant aminoglycoside 6′-N-acetyltransferase type Ib [aac(6′)-Ib]. It was inserted into the gene PA5317 in the P. aeruginosa chromosome.

Successful treatment of severe accidental hypothermia with cardiac arrest for a long time using cardiopulmonary bypass - report of a case

Accidental hypothermia is defined as an unintentional decrease in body temperature to below 35°C, and cases in which temperatures drop below 28°C are considered severe and have a high mortality rate. This study presents the case of a 57-year-old man discovered drifting at sea who was admitted to our hospital suffering from cardiac arrest. Upon admittance, an electrocardiogram indicated asystole, and the patients temperature was 22°C. Thirty minutes of standard CPR and external rewarming were ineffective in raising his temperature. However, although he had been in cardiac arrest for nearly 2 h, it was decided to continue resuscitation, and a cardiopulmonary bypass (CPB) was initiated. CPB was successful in gradually rewarming the patient and restoring spontaneous circulation. After approximately 1 month of rehabilitation, the patient was subsequently discharged, displaying no neurological deficits. The successful recovery in this case suggests that CPB can be considered a useful way to treat severe hypothermia, particularly in those suffering from cardiac arrest.

Therapeutic temperature modulation in severe or moderate traumatic brain injury: a propensity score analysis of data from the Nationwide Japan Neurotrauma Data Bank

OBJECTIVE In patients with severe traumatic brain injury (TBI), a randomized controlled trial revealed that outcomes did not significantly improve after therapeutic hypothermia (TH) or normothermia (TN). However, avoiding pyrexia, which is often associated with intracranial disorders, might improve clinical outcomes. The objective of this study was to compare neurological outcomes among patients with moderate and severe TBI after therapeutic temperature modulation (TTM) in the absence of other interventions. METHODS Data from 1091 patients were obtained from the Japan Neurotrauma Data Bank Project 2009, a cohort observational study. Patients with cardiac arrest, those with a Glasgow Coma Scale score of 3 and dilated fixed pupils, and those whose cause of death was injury to another area of the body were excluded, leaving 687 patients aged 16 years or older in this study. The patients were divided into 2 groups: the TTM group underwent TN (213 patients) or TH (82 patients), and the control group (392 patients) did not receive TTM. The primary end point for this study was the rate of poor outcome at hospital discharge, and the secondary end point was in-hospital death. Out of the 208 total items in the database, 29 variables that could potentially affect outcome were matched using the propensity score (PS) method in order to reduce selection bias and balance the baseline characteristics. RESULTS From each group, 141 patients were extracted using the PS-matching process. Among the patients in the TTM group, 29 had undergone TH and 112 had undergone TN. In a log-rank test using Kaplan-Meier survival curves, no significant differences in patient outcome or death were observed between the 2 groups (poor outcome, p = 0.83; death, p = 0.18). A Cox proportional-hazards regression analysis established the HR for poor outcome and mortality at 1.03 (95% CI 0.78-1.36, p = 0.83) and 1.34 (95% CI 0.87-2.07, p = 0.18), respectively. CONCLUSIONS There was no clear improvement in neurological outcomes after TTM in patients with moderate or severe TBI. To elucidate the role of TTM in patients with these injuries, a prospective study is needed with long-term follow-up using specific target temperatures.

A hematoma of the esophagus causing the trachea to stenose.

Abstract. We report a case of spontaneous intramural hematoma of the esophagus (SIHE) with severe dyspnea due to compression of the trachea. SIHE is a rare hematoma that commonly presents with chest pain, epigastralgia, hematemesis, and dysphagia. Dyspnea is not a common symptom; it has been reported in only one patient, who underwent surgery. In our case, intubation of the compressed trachea prevented it from becoming more stenosed, and an operation was not needed. Another unusual feature of this case is the endoscopic findings. Endoscopic examination in SIHE has often revealed the presence of a dark red, bluish, or purplish bulge, suggesting the presence of a clot or blood in the esophageal wall. In our case, the bulge revealed by endoscopy in the esophageal lumen was white at first, before later turning dark red.

Preliminary report of contrast-enhanced computed tomography for patients with a percutaneous cardiopulmonary support system.

The purpose of this study was to investigate a suitable protocol of contrast-enhanced computed tomography (CECT) in cases with a cardiopulmonary support system. Contrast-enhanced computed tomography with intra-arterial injection (IAI) of contrast medium (CM) via a perfusion cannula showed sufficient contrast enhancement in 2 cases of cardiac decompensation (CD). Contrast-enhanced computed tomography with intravenous injection of CM showed insufficient and delayed contrast enhancement of the aorta in 2 cases of CD and 3 cases of pulseless electrical activity. We encourage administration of CM by means of IAI.