Kyoko Unemoto

Retrospective study of the effectiveness of Intra-Aortic Balloon Occlusion (IABO) for traumatic haemorrhagic shock

IntroductionIntra-aortic balloon occlusion (IABO) is useful for proximal vascular control, by clamping the descending aorta, in traumatic haemorrhagic shock. However, there are limited clinical studies regarding its effectiveness. This study aimed at investigating the effectiveness of IABO for traumatic haemorrhagic shock.MethodsThis retrospective, observational study included trauma patients who underwent IABO at the Emergency and Critical Care Center of Nippon Medical School Tama-Nagayama Hospital between January 2009 and March 2013. 14 patients were included to this study who were in shock on arrival (systolic blood pressure [SBP] <90 mmHg or shock index ≥1), underwent IABO for resuscitation and temporary haemostasis, and subsequently underwent haemostatic intervention (operation or transcatheter arterial embolization). Patient characteristics, physiological status, SBP, heart rate (HR), initial fluid and blood transfusion, time course, and total occlusion time were compared before and after IABO as well as between the survived (n = 5) and non-survived (n = 9) groups.ResultsThe majority of patients experienced blunt injuries, with an average injury severity score of 29.5. The liver, pelvis, spleen, and mesenterium represented the majority of injured organs. SBP, but not HR, was significantly higher after IABO than before IABO (123.1 vs. 65.5 mmHg, P = 0.0001). The revised trauma score and probability of survival were significantly different between the survived and non-survived groups (both, P = 0.04). The survived group required significantly less blood transfusion volume than the non-survived group (20 vs. 33.7 red blood cell units, P = 0.04). In addition, the survived group required a significantly shorter total occlusion time than the non-survived group (46.2 vs. 224.1 min, P = 0.002).ConclusionsIABO was used for relatively severe trauma patients. SBP was significantly higher after IABO, but was not related to survival. However, blood transfusion volume and total occlusion time were related to survival; therefore, it is important to reduce or shorten these parameters, i.e., immediate definitive haemostasis. IABO is effective for traumatic haemorrhagic shock; however, it is also important to consider these points and potential complications.

Cerebral endothelial injury in severe head injury: the significance of measurements of serum thrombomodulin and the von Willebrand factor.

Thrombomodulin (TM), which is located in the surface of the endothelium in the arteries, veins, and capillaries of major organs such as the brain, lungs, liver, kidneys, skeletal muscles, and gastrointestinal tract, is one of several indicators of endothelial injury. Von Willebrand factor (vWf), which is synthesized by endothelial cells, is also an endothelial specific glycoprotein. The serum level of vWf increases in response to various stimuli without endothelial injury. An elevated serum level of vWf may suggest endothelial activation in severe head injury. We hypothesize that the degree of cerebral endothelial activation or injury depends on the type of head injury and that measuring the TM and vWf is useful for predicting delayed traumatic intracerebral hematoma (DTICH), produced by weakness of the vessel wall, occuring either as a direct or indirect effect of head injury. The values of vWf in focal brain injury (ranging from 332.5 +/- 52.8% to 361.7 +/- 86.2%) were significantly higher than those in diffuse axonal injury from 2 h to 7 days after the injury occurred (ranging from 201.6 +/- 59.5% to 242.5 +/- 51.7%). The serum level of TM in focal brain injury (ranging from 3.84 +/- 1.54 to 4.12 +/- 1.46 U/mL) was higher than that in diffuse axonal injury (ranging from 2.96 +/- 0.63 to 3.67 +/- 1.70 U/mL), but these differences were not statistically significant. In patients with DTICH, TM was significantly higher than in patients without DTICH (p < 0.01). The results of our study demonstrate that the degree of endothelial activation in focal brain injury was significantly higher than in diffuse brain injury. In addition, the serum level of TM in patients with DTICH was significantly higher than in patients without DTICH. These findings suggest that cerebral tissue injury is often accompanied by cerebral endothelial activation, and that these two phenomena should be distinguished from each other. The levels of serum TM and vWf appear to be good indicators of the cerebral endothelial injury and of endothelial activation in severe head injury.

Optimal range of global end-diastolic volume for fluid management after aneurysmal subarachnoid hemorrhage: a multicenter prospective cohort study.

Objectives:Limited evidence supports the use of hemodynamic variables that correlate with delayed cerebral ischemia or pulmonary edema after aneurysmal subarachnoid hemorrhage. The aim of this study was to identify those hemodynamic variables that are associated with delayed cerebral ischemia and pulmonary edema after subarachnoid hemorrhage. Design:A multicenter prospective cohort study. Setting:Nine university hospitals in Japan. Patients:A total of 180 patients with aneurysmal subarachnoid hemorrhage. Interventions:None. Measurements and Main Results:Patients were prospectively monitored using a transpulmonary thermodilution system in the 14 days following subarachnoid hemorrhage. Delayed cerebral ischemia was developed in 35 patients (19.4%) and severe pulmonary edema was developed in 47 patients (26.1%). Using the Cox proportional hazards model, the mean global end-diastolic volume index (normal range, 680–800 mL/m2) was the independent factor associated with the occurrence of delayed cerebral ischemia (hazard ratio, 0.74; 95% CI, 0.60–0.93; p = 0.008). Significant differences in global end-diastolic volume index were detected between the delayed cerebral ischemia and non–delayed cerebral ischemia groups (783 ± 25 mL/m2 vs 870 ± 14 mL/m2; p = 0.007). The global end-diastolic volume index threshold that best correlated with delayed cerebral ischemia was less than 822 mL/m2, as determined by receiver operating characteristic curves. Analysis of the Cox proportional hazards model indicated that the mean global end-diastolic volume index was the independent factor that associated with the occurrence of pulmonary edema (hazard ratio, 1.31; 95% CI, 1.02–1.71; p = 0.03). Furthermore, a significant positive correlation was identified between global end-diastolic volume index and extravascular lung water (r = 0.46; p < 0.001). The global end-diastolic volume index threshold that best correlated with severe pulmonary edema was greater than 921 mL/m2. Conclusions:Our findings suggest that global end-diastolic volume index impacts both delayed cerebral ischemia and pulmonary edema after subarachnoid hemorrhage. Maintaining global end-diastolic volume index slightly above normal levels has promise as a fluid management goal during the treatment of subarachnoid hemorrhage.

Measurements of cortical cellular pH by intracranial tonometer in severe head injury.

ObjectiveTo evaluate the cortical cellular damage in acute severe head injury, we measured the cortical cellular pH by using an intracranial tonometer made in our institution. DesignProspective, 3.5-yr data collection. SettingUniversity hospital trauma intensive care unit. PatientsSeverely head-injured patients (n = 29) with Glasgow Coma Scale score <8. InterventionRoutine emergency neurologic procedure. Measurements and Main ResultsWe made 98 measurements of cortical cellular pH by intracranial tonometer in 29 severely head-injured patients in the acute phase. Each patient’s intracranial pressure was recorded, and in 16 patients, the saturation of jugular venous oxygen was monitored. The outcome at 6 months after injury was significantly better in patients having a cortical cellular pH of >7.2 than those with <7.2. The cerebral perfusion pressure and cortical cellular pH correlated significantly (p < .0001). ConclusionsOur study suggests the usefulness of measurement of cortical cellular pH by intracranial tonometer for evaluating the severity of focal anaerobic cerebral metabolism and predicting patient prognosis.

Amiodarone or nifekalant upon hospital arrival for refractory ventricular fibrillation after out-of-hospital cardiac arrest

BACKGROUND We evaluated the association between nifekalant or amiodarone on hospital admission and in-hospital mortality for cardiac arrest patients with persistent ventricular fibrillation on hospital arrival. METHODS This was a retrospective cohort study using the Japanese Diagnosis Procedure Combination inpatient database. We identified 2961 patients who suffered cardiogenic out-of-hospital cardiac arrest and who had ventricular fibrillation on hospital arrival between July 2007 and March 2013. Patients were categorized into amiodarone (n=2353) and nifekalant (n=608) groups, from which 525 propensity score-matched pairs were generated. RESULTS We found a significant difference in the admission rate between the nifekalant and amiodarone groups in propensity score-matched groups (75.6% vs. 69.3%, respectively; difference, 6.3%; 95% confidence interval (CI), 0.9-11.7). An analysis using the hospital nifekalant/amiodarone rate as an instrumental variable found that receiving nifekalant was associated with an improved admission rate (22.2%, 95% CI, 11.9-32.4). We found no significant difference in in-hospital mortality between the nifekalant and amiodarone groups (81.5% vs. 82.1%, respectively; difference, -0.6%; 95% CI, -5.2 to 4.1). Instrumental variable analysis showed that receiving nifekalant was not associated with reduced in-hospital mortality (6.2%, 95% CI, -2.4 to 14.8). CONCLUSIONS This nationwide study suggested no significant in-hospital mortality association between nifekalant and amiodarone for cardiogenic out-of-hospital cardiac arrest patients with ventricular fibrillation/persistent ventricular tachycardia on hospital arrival. Although nifekalant may potentially improve hospital admission rates compared with amiodarone for these patients, further studies are required to confirm our results.

Recent trends in 30-day mortality in patients with blunt splenic injury: A nationwide trauma database study in Japan

Background Splenic injury frequently occurs after blunt abdominal trauma; however, limited epidemiological data regarding mortality are available. We aimed to investigate mortality rate trends after blunt splenic injury in Japan. Methods We retrospectively identified 1,721 adults with blunt splenic injury (American Association for the Surgery of Trauma splenic injury scale grades III–V) from the 2004–2014 Japan Trauma Data Bank. We grouped the records of these patients into 3 time phases: phase I (2004–2008), phase II (2009–2012), and phase III (2013–2014). Over the 3 phases, we analysed 30-day mortality rates and investigated their association with the prevalence of certain initial interventions (Mantel-Haenszel trend test). We further performed multiple imputation and multivariable analyses for comparing the characteristics and outcomes of patients who underwent TAE or splenectomy/splenorrhaphy, adjusting for known potential confounders and for within-hospital clustering using generalised estimating equation. Results Over time, there was a significant decrease in 30-day mortality after splenic injury (p < 0.01). Logistic regression analysis revealed that mortality significantly decreased over time (from phase I to phase II, odds ratio: 0.39, 95% confidence interval: 0.22–0.67; from phase I to phase III, odds ratio: 0.34, 95% confidence interval: 0.19–0.62) for the overall cohort. While the 30-day mortality for splenectomy/splenorrhaphy diminished significantly over time (p = 0.01), there were no significant differences regarding mortality for non-operative management, with or without transcatheter arterial embolisation (p = 0.43, p = 0.29, respectively). Conclusions In Japan, in-hospital 30-day mortality rates decreased significantly after splenic injury between 2004 and 2014, even after adjustment for within-hospital clustering and other factors independently associated with mortality. Over time, mortality rates decreased significantly after splenectomy/splenorrhaphy, but not after non-operative management. This information is useful for clinicians when making decisions about treatments for patients with blunt splenic injury.

Endoscopic Treatment of Boerhaave Syndrome Using Polyglycolic Acid Sheets and Fibrin Glue: A Report of Two Cases

Boerhaave syndrome, the spontaneous perforation of the esophagus, is an emergency, life-threatening condition. Current endoscopic treatment options include clipping and stenting, but the use of polyglycolic acid (PGA) sheets for treating the condition has not been reported. In recent years, PGA sheets have been used after endoscopic submucosal dissection to prevent perforations and stricture formation in patients treated for early-stage carcinoma. We report the cases of two patients with Boerhaave syndrome who were successfully treated using PGA sheets. The present clinical outcomes suggest that the use of PGA sheets is feasible and safe for treating patients with Boerhaave syndrome, and that they may be another treatment option.