Kenya Kawakita

Fever Control Management Is Preferable to Mild Therapeutic Hypothermia in Traumatic Brain Injury Patients with Abbreviated Injury Scale 3–4: A Multi-Center, Randomized Controlled Trial

In our prospective, multi-center, randomized controlled trial (RCT)-the Brain Hypothermia (B-HYPO) study-we could not show any difference on neurological outcomes in patients probably because of the heterogeneity in the severity of their traumatic condition. We therefore aimed to clarify and compare the effectiveness of the two therapeutic temperature management regimens in severe (Abbreviated Injury Scale [AIS] 3-4) or critical trauma patients (AIS 5). In the present post hoc B-HYPO study, we re-evaluated data based on the severity of trauma as AIS 3-4 or AIS 5 and compared Glasgow Outcome Scale score and mortality at 6 months by per-protocol analyses. Consequently, 135 patients were enrolled. Finally, 129 patients, that is, 47 and 31 patients with AIS 3-4 and 36 and 15 patients with AIS 5 were allocated to the mild therapeutic hypothermia (MTH) and fever control groups, respectively. No significant intergroup differences were observed with regard to age, gender, scores on head computed tomography (CT) scans, and surgical operation for traumatic brain injury (TBI), except for Injury Severity Score (ISS) in AIS 5. The fever control group demonstrated a significant reduction of TBI-related mortality compared with the MTH group (9.7% vs. 34.0%, p = 0.02) and an increase of favorable neurological outcomes (64.5% vs. 51.1%, p = 0.26) in patients with AIS 3-4, although the latter was not statistically significant. There was no difference in mortality or favorable outcome in patients with AIS 5. Fever control may be considered instead of MTH in patients with TBI (AIS 3-4).

Venomous snake bites: clinical diagnosis and treatment

Snake bites are life-threatening injuries that can require intensive care. The diagnosis and treatment of venomous snake bites is sometimes difficult for clinicians because sufficient information has not been provided in clinical practice. Here we review the literature to present the proper management of bites by mamushi, habu, and yamakagashi snakes, which widely inhabit Japan and other Asian countries. No definite diagnostic markers or kits are available for clinical practice; therefore, definitive diagnosis of snake-venom poisoning requires positive identification of the snake and observation of the clinical manifestations of envenomation. Mamushi (Gloydius blomhoffii) bites cause swelling and pain that spreads gradually from the bite site. The platelet count gradually decreases due to the platelet aggregation activity of the venom and can decrease to <100,000/mm3. If the venom gets directly injected into the blood vessel, the platelet count rapidly decreases to <10,000/mm3 within 1 h after the bite. Habu (Protobothrops flavoviridis) bites result in swelling within 30 min. Severe cases manifest not only local signs but also general symptoms such as vomiting, cyanosis, loss of consciousness, and hypotension. Yamakagashi (Rhabdophis tigrinus) bites induce life-threatening hemorrhagic symptoms and severe disseminated intravascular coagulation with a fibrinolytic phenotype, resulting in hypofibrinogenemia and increased levels of fibrinogen degradation products. Previously recommended first-aid measures such as tourniquets, incision, and suction are strongly discouraged. Once airway, breathing, and circulation have been established, a rapid, detailed history should be obtained. If a snake bite is suspected, hospital admission should be considered for further follow-up. All venomous snake bites can be effectively treated with antivenom. Side effects of antivenom should be prevented by sufficient preparation. Approved antivenoms for mamushi and habu are available. Yamakagashi antivenom is used as an off-label drug in Japan, requiring clinicians to join a clinical research group for its use in clinical practice.

Impact of neurointensivist-managed intensive care unit implementation on patient outcomes after aneurysmal subarachnoid hemorrhage

PURPOSE The purpose of the study is to evaluate the impact of neurointensivist-managed intensive care unit (NIM-ICU) implementation for patients admitted with aneurysmal subarachnoid hemorrhage (SAH). METHODS This study retrospectively evaluated 234 patients (mean age, 61.7 years; male, 67) admitted with SAH between January 1, 2001, and March 31, 2014. Neurologic outcomes between patients admitted from January 2001 to December 2006 (intensivist-managed intensive care unit group) and January 2007 to March 2014 (NIM-ICU group) were compared. The primary outcome was the incidence of a good neurologic outcome at discharge (GO; the modified Ranking Scale score: GO, 0-2; poor neurological outcome, 3-6) at discharge. RESULTS Neurointensivist-managed intensive care unit was initiated for 151 (64.5%) of 234 patients. Univariate analysis demonstrated significantly better outcomes for NIM-ICU group vs intensivist-managed intensive care unit group (GOs, 58.3% vs 41.0%, respectively, P = .01). Multivariate logistic regression was used to evaluate NIM-ICU efficacy for SAH patients, but NIM-ICU was not significantly associated with GOs (P = .054). Subgroup analysis of patient grading by Hunt and Kosnik grades I to II showed that NIM-ICU implementation was an independent predictor of GOs (odds ratio, 4.54; 95% confidence interval, 1.08-22.17; P = .04). CONCLUSION Neurointensivist-managed intensive care unit may improve neurologic outcomes in SAH patients with Hunt and Kosnik grades I to II.

Effect of admission glasgow coma scale motor score on neurological outcome in out-of-hospital cardiac arrest patients receiving therapeutic hypothermia

BACKGROUND Because the initial (on admission) Glasgow Coma Scale (GCS) examination has not been fully evaluated in comatose survivors of cardiac arrest (CA) who receive therapeutic hypothermia (TH), the aim of the present study was to determine any association between the admission GCS motor score and neurologic outcomes in patients with out-of-hospital CA who receive TH. METHODSANDRESULTS In the J-PULSE-HYPO study registry, patients with bystander-witnessed CA were eligible for inclusion. Patients were divided into 3 groups based on GCS motor score (1, 2-3, and 4-5) to assess various effects on neurologic outcome. Univariate and multivariate analyses were performed to identify independent predictors of good neurologic outcome at 90 days. Of 452 patients, 302 were enrolled. There was a significant difference among the 3 patient groups with regard to neurologic outcome at 90 days in the univariate analysis. Multiple logistic regression analyses showed that the GCS motor score on admission, age >65 years, bystander cardiopulmonary resuscitation, the time from collapse to return of spontaneous circulation, and pupil size <4 mm were independent predictors of a good neurologic outcome at 90 days in cases of CA (GCS motor score, 4-5: odds ratio, 8.18; 95% confidence interval: 1.90-60.28; P<0.01). CONCLUSIONS GCS motor score is an independent predictor of good neurologic outcome at 90 days in patients sustaining out-of-hospital CA who receive TH.

The impact of age on outcomes of elderly ED patients ventilated due to community acquired pneumonia

OBJECTIVES There is no consensus on whether mechanical ventilation should be initiated for advanced age with community-acquired pneumonia (CAP). This study investigated the effects of age on the outcomes of mechanical ventilation in the emergency department (ED) for advanced age with CAP. METHODS We retrospectively investigated the medical records of advanced age (age, ≥65 years) with CAP who required mechanical ventilation in the ED of our hospital between January 2006 and December 2012. The patients were divided into 65 to 74, 75 to 84, and 85 years or older age groups. The following outcomes were measured: number of patients weaned from mechanical ventilation, in-hospital mortality, ventilator-free days, and intensive care unit days. Multiple logistic regression analysis was used to identify risk factors associated with mortality and weaning from mechanical ventilation. RESULTS Seventy-one patients (mean age, 79.5 years) were included. The overall in-hospital mortality rate was 43.7%. No significant differences were observed among the 3 groups with regard to weaning from mechanical ventilation (P=.59), in-hospital mortality (P=.90), ventilator-free days (P=.83), or intensive care unit days (P=.12). Age was not significantly associated with weaning from mechanical ventilation or in-hospital mortality among advanced age. Diabetes mellitus was an independent factor for weaning from mechanical ventilation (P=.048) and was relatively associated with mortality (P=.051). CONCLUSIONS Age, in itself, may not be a factor limiting the initiation of mechanical ventilation in the ED in advanced age with CAP. Further studies should determine appropriate indications for mechanical ventilation in the ED for these patients.

Clinical experience with an active intravascular rewarming technique for near-severe hypothermia associated with traumatic injury

Hypothermia and acidosis are secondary causes of trauma-related coagulopathy. Here we report the case of a 72-year-old patient with severe trauma who suffered near-severe hypothermia despite the initiation of standard warming measures and was successfully managed with active intravascular rewarming. The patient was involved in a road traffic accident and was transported to a hospital. He was diagnosed with massive right-sided hemothorax, blunt aortic injury, burst fractures of the eighth and ninth thoracic vertebrae, and open fracture of the right tibia. He was referred to our hospital, where emergency surgery was performed to control bleeding from the right hemothorax. During surgery, the patient demonstrated progressive heat loss despite standard rewarming measures, and his temperature decreased to 32.4°C. Severe acidosis was also observed. A Cool Line® catheter was inserted into the right femoral vein and lodged in the inferior vena cava, and an intravascular balloon catheter system was utilized for aggressive rewarming. The automated target core temperature was set at 37°C, and the maximum flow rate was used. His core temperature reached 36.0°C after 125 min of intravascular rewarming. The severe acidosis was also resolved. The main active bleeding site was not identified, and coagulation hemostasis as well as rewarming enabled us to control bleeding from the vertebral bodies, lung parenchyma, and pleura. The total volume of intraoperative bleeding was 5,150 mL, and 20 units of red cell concentrate and 16 units of fresh frozen plasma were transfused. After surgery, he was transferred to the intensive care unit under endotracheal intubation and mechanical ventilation. His hemodynamic condition stabilized after surgery. The rewarming catheter was removed on day 2 of admission, and no bleeding, infection, or thrombosis associated with catheter placement was observed. Extubation was performed on day 40, and his subsequent clinical course was uneventful. He recovered well following rehabilitation and was discharged on day 46. These findings suggest that active intravascular rewarming should be considered as an aggressive, additional rewarming technique in patients with near-severe hypothermia associated with traumatic injury.

Cerebral metabolism monitoring during hypothermia following resuscitation from cardiopulmonary arrest

BACKGROUND The aim of the present study was to evaluate cerebral metabolism monitoring during therapeutic hypothermia for global ischemic brain damage after cardiopulmonary resuscitation (CPR). METHODS Jugular venous sampling and positron emission tomography (PET) were used. Seven comatose patients with cardiopulmonary arrest underwent hypothermia treatment as soon as possible after CPR. The body temperature of these patients was maintained at 34 degrees C for 72 h. Rewarming was performed at a rate of 1 degrees C/day. To monitor jugular venous saturation (SjO2) and lactate (lac-JV), a fiberoptic catheter was inserted into the jugular bulb. Oxygen extraction fraction (OEF) was calculated using the difference between arterial oxygen saturation (SaO2) and SjO2. 18F-fluorodeoxyglucose (FDG) PET was performed to investigate cerebral glucose metabolism at the end of therapeutic hypothermia. FINDINGS The OEF was significantly increased at the end of hypothermia in four patients with favorable outcome on the Glasgow Outcome Scale (hypothermia onset 15.3 +/- 2.0% vs. hypothermia end 30.3 +/- 2.8%, P < 0.05). In three patients with unfavourable outcome (severe or worse on the Glasgow Outcome Scale), end hypothermia OEF tended to be low. There was also a reduction in FDG uptake in these three patients with unfavourable outcome. The lac-JV was significantly decreased at the end ofhypothermia treatment compared with hypothermia onset (27.7 +/- 7.4 vs. 6.0 +/- 3.0 mg/dL, P < 0.05). CONCLUSIONS The measurement of cerebral metabolism parameters, especially OEF, might be useful for estimation of hypothermia therapy in patients with unconsciousness after resuscitation after cardiac arrest.

Prognostic factors of Streptococcus pneumoniae infection in adults

OBJECTIVES The mortality of severe sepsis has markedly decreased since the implementation of the Surviving Sepsis Campaign guidelines. The next logical step is to examine the necessity of individualized management guidelines for targeted therapy against specific bacteria. Streptococcus pneumoniae is the leading cause of community-acquired severe sepsis; however, little is known regarding the prognostic factors in adult patients with S pneumoniae sepsis. We aimed to identify prognostic factors in patients with S pneumoniae sepsis and to explore a subgroup of patients at high risk for death with detailed Sequential Organ Failure Assessment (SOFA) score analysis. METHODS We retrospectively reviewed the records of patients with S pneumoniae infection treated between 1st January 2006 and 31st July 2012. We identified prognostic factors for 28-day mortality using univariate and multivariate logistic regression models. RESULTS Of 171 patients (median age, 72 years) with S pneumoniae infection who were included in this study, the 28-day mortality was 17% (29/171). The SOFA score (odds ratio, 2.25; 95% confidence interval, 1.60-3.18; P < .001) and bacteremia (odds ratio, 19.0; 95% confidence interval, 4.06-90.20; P < .001) were identified as prognostic factors for the 28-day mortality. In a subgroup analysis with a cutoff value of the SOFA score determined by receiver operating characteristic analysis, patients with bacteremia and a SOFA score of at least 7 had a significantly higher mortality than did patients without bacteremia and a SOFA score lower than 7 (84% vs 0%, respectively). CONCLUSIONS Bacteremia and a SOFA score at least 7 were independent prognostic factors of poor outcome in S pneumoniae sepsis.

Hyperbaric oxygen therapy for consciousness disturbance following head injury in subacute phase

BACKGROUND Hyperbaric oxygen (HBO) therapy has been shown to improve outcome after brain injury, however its mechanisms are not understood. The purpose of the present study was to investigate the effect of hyperbaric oxygen (HBO) therapy on the cerebral circulation and metabolism of patients with disturbances in consciousness after head injury in the subacute phase. METHODS Seven head injury patients underwent HBO treatment after leaving the intensive care unit. Oxygen (100% O2, 2.7 atm absolute) was delivered to patients in a hyperbaric chamber for 60 min every 24 h (total five treatments/patient). Cerebral circulation monitoring (mean flow velocity: mFV, and pulsatility index: PI at horizontal portion of middle cerebral artery by transcranial Doppler) and cerebral metabolism monitoring (arterio-jugular venous difference of oxygen: AJDO2 and jugular venous lactate: lac-JV) before and after the series of treatments were evaluated. FINDINGS Both PI and lac-JV were significantly decreased after HBO theatment, while there were no significant changes in mFV and AJDO2. The decreased PI and lac-JV after HBO therapy might indicate that this treatment couples cerebral circulation and metabolism. CONCLUSIONS The measurement of cerebral circulation and metabolism parameters, especially PI and lac-JV, is useful for estimation of effect of HBO therapy in patients with distubances in consciousness after head injury in the subacute phase.

Association of brain metabolites with blood lactate and glucose levels with respect to neurological outcomes after out-of-hospital cardiac arrest: A preliminary microdialysis study

AIM Out-of-hospital cardiac arrest (OHCA) is associated with poor prognosis. Cerebral microdialysis (CMD) is an efficient sampling technique to detect neurochemical changes in brain interstitial tissue. In this retrospective study, we hypothesised that there are different CMD levels between patients with favourable and unfavourable neurological outcomes. METHODS Data of patients with OHCA admitted to Kagawa University Hospital and administered therapeutic hypothermia (TH) were collected. Using a CMD probe, extracellular glucose, lactate and pyruvate levels were measured hourly along with intracranial perfusion pressure (ICP) and cerebral perfusion pressure (CPP) for the initial 72h during TH. The lactate/pyruvate (LP) ratio was calculated. Patients were divided into favourable [Glasgow-Pittsburgh cerebral performance category 1-2 at 30days after cardiac arrest] or unfavourable neurological outcome groups. CMD biochemical markers and blood lactate and glucose levels were compared between two groups. RESULTS Ten patients were included. ICP was significantly higher in the unfavourable than in the favourable neurological outcome group; there were no significant differences with respect to CPP. The CMD LP ratio in the unfavourable outcome group progressively increased; significant differences were observed on days 2, 3 and 4 (p<0.01). Significant differences in blood lactate levels were observed between the groups only on day 3.5. CMD and blood glucose levels were higher in the unfavourable than in the favourable outcome group during TH. CONCLUSION The association of CMD levels with long-term outcomes would be better defined in a large randomised prospective study.AIM Out-of-hospital cardiac arrest (OHCA) is associated with poor prognosis. Cerebral microdialysis (CMD) is an efficient sampling technique to detect neurochemical changes in brain interstitial tissue. In this retrospective study, we hypothesised that there are different CMD levels between patients with favourable and unfavourable neurological outcomes. METHODS Data of patients with OHCA admitted to Kagawa University Hospital and administered therapeutic hypothermia (TH) were collected. Using a CMD probe, extracellular glucose, lactate and pyruvate levels were measured hourly along with intracranial perfusion pressure (ICP) and cerebral perfusion pressure (CPP) for the initial 72h during TH. The lactate/pyruvate (LP) ratio was calculated. Patients were divided into favourable [Glasgow-Pittsburgh cerebral performance category 1-2 at 30days after cardiac arrest] or unfavourable neurological outcome groups. CMD biochemical markers and blood lactate and glucose levels were compared between two groups. RESULTS Ten patients were included. ICP was significantly higher in the unfavourable than in the favourable neurological outcome group; there were no significant differences with respect to CPP. The CMD LP ratio in the unfavourable outcome group progressively increased; significant differences were observed on days 2, 3 and 4 (p<0.01). Significant differences in blood lactate levels were observed between the groups only on day 3.5. CMD and blood glucose levels were higher in the unfavourable than in the favourable outcome group during TH. CONCLUSION The association of CMD levels with long-term outcomes would be better defined in a large randomised prospective study.