Masashi Kishi

Analysis of 2,702 Traumatized Patients in the 1995 Hanshin-awaji Earthquake

BACKGROUND This study was undertaken to define the factors that affected the final outcome of trauma patients in the Hanshin-Awaji earthquake. METHODS Medical records of patients admitted to 95 hospitals within or surrounding the affected area during the first 15 days after the quake were reviewed. RESULTS There were 2,702 traumatized patients. One-third of the patients were transported to hospitals in the surrounding area and had a mortality rate of 3%. The remainder, who were treated in the affected hospitals, showed a significantly higher mortality rate (8%; p < 0.05). Intensive care was provided for 513 patients, most of whom suffered from crush syndrome or from injuries to vital organs; these patients had a high mortality rate. Patients with other types of injuries had a lower mortality rate. CONCLUSION Crush syndrome and injuries to vital organs were potentially life-threatening. We believe that early transportation of such patients to undamaged hospitals with the ability to provide intensive care would have improved the survival rate.

Fluid resuscitation and systemic complications in crush syndrome: 14 Hanshin-Awaji earthquake patients.

BACKGROUND Crush syndrome is a form of traumatic rhabdomyolysis characterized by systemic involvement, in which acute renal failure is potentially life-threatening. METHODS Clinical and laboratory data of 14 crush-syndrome patients transferred to a tertiary emergency department after the Hanshin-Awaji earthquake were analyzed. The patients were buried under collapsed houses for the average of 6.7 +/- 5.7 (SD) hours (range, 1 to 24 hours). They were referred to us 6 to 250 hours after the earthquake. RESULTS Of those who arrived at our institution within 40 hours, 25% (two of eight) developed renal failure, whereas all six patients who arrived after 40 hours developed renal failure. Peak serum creatine kinase ranged from 6,677 to 134,200 U/L (51,674 +/- 41,776). Renal failure was highly associated with massive muscle damage (serum creatine kinase above 25,000 U/L) and insufficient initial fluid resuscitation (below 10,000 mL/2 days). CONCLUSIONS Prompt and adequate, if not massive, fluid resuscitation is the key to preventing renal failure after such injury.

Characteristics of infection and leukocyte count in severely head-injured patients treated with mild hypothermia.

OBJECTIVE This study was designed to characterize the infectious complications and kinetics of leukocyte count in severely head-injured patients treated with mild hypothermia. PATIENTS AND METHODS We retrospectively analyzed the incidence and severity of infectious complications as well as daily changes in leukocyte count in 41 severely head-injured patients treated with mild hypothermia (group H). They were retrospectively compared with 25 severely head-injured patients treated with high-dose barbiturates (group B) and to 25 other severely head-injured patients treated with no barbiturates (group N). RESULTS Initial intracranial pressure was significantly higher in group H than in the other groups. No significant differences existed in the incidence of pneumonia or meningitis among the three groups, whereas the incidence of bacteremia was significantly higher in group H than in the other two groups. Pneumonia was significantly more severe in group H than in the other groups. In six patients of group H, pneumonia spread fulminantly to become life threatening. Daily changes in total leukocyte count showed the same pattern, consisting of a peak, a nadir, and a second peak in all groups. Total leukocyte count was, however, significantly lower during the first 2 weeks in group H than in the other two groups. Lymphocyte and neutrophil counts were also lower in group H. CONCLUSION Infectious complications were more severe and leukocyte counts were lower in patients treated with mild hypothermia, who also had the highest initial intracranial pressures, than in patients treated with conventional therapies. Measures against increased susceptibility to infection and leukocyte suppression should be explored.

Pentoxifylline attenuates reperfusion injury in skeletal muscle after partial ischemia.

Leukocytes have been shown to contribute to ischemia-reperfusion injury in skeletal muscle. Pentoxifylline (PTXF), a xanthine-derived phosphodiesterase inhibitor, has received recent attention because of its action on leukocytes. To clarify the effects of PTXF in reperfusion injury, we measured the resting transmembrane potential difference ( E m) and evaluated postcapillary venule microcirculation using intravital microscopy in rat skeletal muscle during ischemia and reperfusion. The infrarenal aorta was clamped for 90 min and then reperfused for 60 min. Persistent depolarization of the resting E m was observed in an ischemia-reperfusion (IR) group and was significantly repolarized in a PTXF group during the reperfusion period. The tissue water content was significantly reduced in the PTXF group, although no difference was noted in the tissue lactate content. Flowing erythrocyte velocity and wall shear rate in the PTXF group were significantly higher than in the IR group during the reperfusion period but without significant differences in vessel diameter and hemoglobin oxygenation. Blood flow measured by laser-Doppler flowmeter was also significantly improved in the PTXF group. Furthermore, the adherent leukocyte count was significantly reduced in the PTXF group during this same period. These results indicate that PTXF attenuated reperfusion-associated membrane injury and tissue edema and that PTXF suppressed leukocyte adhesion and improved hindlimb blood flow during the reperfusion period.

Effect of Serum Albumin Concentration on Neurological Outcome After Out-of-Hospital Cardiac Arrest (from the CRITICAL [Comprehensive Registry of Intensive Cares for OHCA Survival] Study in Osaka, Japan)

The aim of this study was to assess whether serum albumin concentration upon hospital arrival had prognostic indications on out-of-hospital cardiac arrest (OHCA). This prospective, multicenter observational study conducted in Osaka, Japan (the CRITICAL [Comprehensive Registry of Intensive Cares for OHCA Survival] study), enrolled all patients with consecutive OHCA transported to 14 participating institutions. We included adult patients aged ≥18 years with nontraumatic OHCA who achieved return of spontaneous circulation and whose serum albumin concentration was available from July 2012 to December 2014. Based on the serum albumin concentration upon hospital arrival, patients were divided into quartiles (Q1 to Q4), namely, Q1 (<2.7 g/dl), Q2 (2.7 to 3.1 g/dl), Q3 (3.1 to 3.6 g/dl), and Q4 (≥3.6 g/dl). The primary outcome was 1-month survival with favorable neurological outcome (cerebral performance category scale 1 or 2). During the study period, a total of 1,269 patients with OHCA were eligible for our analyses. The highest proportion of favorable neurological outcome was 33.5% (109 of 325) in the Q4 group, followed by 13.2% (48 of 365), 5.0% (13 of 261), and 3.5% (11 of 318) in the Q3, Q2, and Q1 groups, respectively. In the multivariable logistic regression analysis, the proportion of favorable neurological outcome in the Q4 group was significantly higher, compared with that in the Q1 group (adjusted odds ratio 8.61; 95% confidence interval 4.28 to 17.33). The adjusted proportion of favorable neurological outcome increased in a stepwise manner across increasing quartiles (p for trend <0.001). Higher serum albumin concentration was significantly and independently associated with favorable neurological outcome in a dose-dependent manner.