Kunihiko Maekawa

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

PURPOSEnThis study aimed to identify factors of neurologic prognosis in severe accidental hypothermic patients with cardiac arrest.nnnBASIC PROCEDURESnThis 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.nnnMAIN FINDINGSnIn 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).nnnPRINCIPAL CONCLUSIONSnPatients 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.

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

OBJECTIVEnIn 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.nnnMETHODSnData 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.nnnRESULTSnFrom 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.nnnCONCLUSIONSnThere 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.

Blind subxiphoid pericardiotomy to relieve critical acute hemopericardium: a final report

PurposePercutaneous catheter drainage (PCD) has been considered a standard method of relieving acute cardiac tamponade. Although conventional subxiphoid pericardiotomy is useful even for clotted hemopericardium, it has been believed to be unsuitable for emergency treatment because it is a time-consuming procedure. We report our modified pericardiotomy technique that can be used for emergency management.MethodsWe designed a prospective observational study to evaluate blind subxiphoid pericardiotomy (BSP) for critical cardiac tamponade due to hemopericardium. Emergency patients (nxa0= 148) with acute hemopericardium secondary to trauma (nxa0=xa012), acute aortic disease (nxa0=xa0122), or cardiac rupture following acute myocardial infarction (nxa0=xa014) were the subjects. Early results were compared between the BSP group (nxa0=xa053) and the PCD group (nxa0=xa095).ResultsBSP was effective at relieving cardiac tamponade in all 53 cases, but PCD was ineffective in 12 cases (12.6xa0%, pxa0=xa00.008). Procedure-related complication rates of BSP and PCD were 0 and 16.8xa0%, respectively (pxa0=xa00.002). Survival rates for the BSP and PCD groups were 18.9 and 6.3xa0%, respectively (pxa0=xa00.018). Since 2005, when we discarded the restriction that only board-certified surgeons should perform BSP, acute care physicians (including trainees) have performed BSP for 22 patients without procedure-related complications.ConclusionsBSP was safe and effective for cardiac tamponade due to acute hemopericardium. Critical complications during PCD for hemopericardium could not be avoided in some cases because of clots in the pericardium.

Differences in coagulofibrinolytic changes between post-cardiac arrest syndrome of cardiac causes and hypoxic insults: a pilot study

Dear Editor, Post-cardiac arrest syndrome (PCAS) is often involved in coagulofibrinolytic disorder, which occurs as a result of systemic ischemia and reperfusion. We are under the clinical impression that PCAS patients who experience cardiac arrest due to hypoxia are inclined to suffer from severe coagulopathy and that their condition is associated with a worse prognosis in comparison to patients in whom cardiac arrest occurs in association with a cardiogenic event. The present study is a subgroup analysis of our previous study. Thirteen patients with PCAS caused by cardiogenic cardiac arrest (the cardiogenic group) and 13 patients with PCAS caused by hypoxia-related cardiac arrest (the hypoxia group) were enrolled in the present study. Soluble fibrin (SF) and plasmin-a2 plasmin inhibitor complex (PPIC), which are markers of thrombin activation and plasmin activation, respectively, were measured. Figure 1 shows the serial changes in the plasma levels of SF and PPIC. On day 1, the levels of SF in the hypoxia group were significantly higher than that in the cardiogenic group. Moreover, the levels of PPIC in the hypoxia group were significantly elevated in comparison to the cardiogenic group on day 1. When a good outcome was defined as cerebral performance categories 1 or 2, and a poor outcome was defined as cerebral performance categories 3–5, the cardiogenic group showed a more favorable outcome than the hypoxia group (good / poor: 4/9 versus 0/13, respectively; P = 0.003). The intervals between the receipt of the emergency call and the return of spontaneous circulation in the hypoxia and cardiogenic groups did not differ to a statistically significant extent (cardiogenic versus hypoxia, 38.9 4.2 min versus 31.1 2.3 min, P = 0.111). Our previous study suggested that the SF levels of PCAS patients with disseminated intravascular coagulation (DIC) were significantly higher than those in patients without DIC. Systemic hypoxia, ischemia, and reperfusion cause endothelial damage with a consequent increase in tissue factor activity, which forms a complex with factor VII/ VIIa, and the complex results in the generation of thrombin. Moreover, anoxia and endothelial injury lead to hyperfibrinolysis. These findings indicate that the hypoxiainduced endothelial injury of the hypoxic PCAS patients was more serious. This could result in more severe coagulopathy with hyperfibrinolysis, leading to a poorer outcome. This may be due to the differences in the pre-cardiac arrest conditions of patients with cardiogenic and hypoxic PCAS. Hypoxic cardiac arrest is affected by both hypoxia due to circulatory arrest and pre-cardiac arrest hypoxia, followed by more severe endothelial damage and coagulofibrinolytic changes. The results of the present study are also supported by the previous study, which showed that patients with cardiogenic PCAS had a better chance of surviving until discharge and a more favorable long-term outcome than patients with a non-cardiac etiology, including a