Sho Nachi

Antithrombin Supplementation and Mortality in Sepsis-induced Disseminated Intravascular Coagulation: A Multicenter Retrospective Observational Study

ABSTRACT Supplemental doses of antithrombin (AT) are widely used to treat sepsis-induced disseminated intravascular coagulation (DIC) in Japan. However, evidence on the benefits of AT supplementation for DIC is insufficient. This multicenter retrospective observational study aimed to clarify the effect of AT supplementation on sepsis-induced DIC using propensity score analyses. Data from 3,195 consecutive adult patients admitted to 42 intensive care units for severe sepsis treatment were retrospectively analyzed; 1,784 patients were diagnosed with DIC (n = 715, AT group; n = 1,069, control group). Inverse probability of treatment-weighted propensity score analysis indicated a statistically significant association between AT supplementation and lower in-hospital all-cause mortality (n = 1,784, odds ratio [95% confidence intervals]: 0.748 [0.572–0.978], P = 0.034). However, quintile-stratified propensity score analysis (n = 1,784, odds ratio: 0.823 [0.646–1.050], P = 0.117) and propensity score matching analysis (461 matching pairs, odds ratio: 0.855 [0.649–1.125], P = 0.263) did not show this association. In the early days after intensive care unit admission, the survival rate was statistically higher in the propensity score-matched AT group than in the propensity score-matched control group (P = 0.007). In DIC patients without concomitant heparin administration, similar results were observed. In conclusion, AT supplementation may be associated with reduced in-hospital all-cause mortality in patients with sepsis-induced DIC. However, the statistical robustness of this connection was not strong. In addition, although the number of transfusions needed in patients with AT supplementation increased, severe bleeding complications did not.

Comparison of two pediatric flail chest cases

Flail chest is a rare complication in pediatric patients with blunt chest trauma. There is no general consensus on which treatment is most appropriate for flail chest in pediatric patients, although it has been reported that surgical fixation is associated with beneficial outcomes for flail chest in adults.The present report described two pediatric cases of flail chest, which was rare in pediatric blunt trauma. In small children, functional residual capacity is smaller, and the thorax is pliable due to high thoracic compliance. Therefore, it is only advisable to select intubation and mechanical ventilation treatment. Likewise, in pediatric flail chest, the available evidence does not suggest that ventilator management protocols should be adopted routinely, and the treatment for pediatric flail chest was not established completely.There were not huge different between the described patients, including injury severity and ventilation setting. However, one had a relapse of flail chest after extubation and chest taping was required, while the other patient’s condition was stable after decannulation.As described above, it is difficult to predict a recurrence of flail chest in pediatric patients even if treatment goes well. Therefore, T-piece trial should be considered prior to extubation.

Simple pneumopericardium due to blunt trauma progressing to tension pneumopericardium during transportation

Patients with simple pneumopericardium due to blunt thoracic trauma occasionally progressed to tension pneumopericardium, although pneumopericardium is believed to be benign in general. A 65-year-old man had both arms caught in a grinding machine and his face struck hard at work. He was diagnosed with bilateral degloving injuries of both arms and mediastinal emphysema on computed tomography. He required transfer to an advanced emergency medical service center for treatment. Although he was hemodynamically stable then, the patients condition deteriorated during transportation. The patient returned to the local hospital as cardiopulmonary resuscitation continued, repeat computed tomography was performed, which showed a substantial pneumopericardium and exacerbation of mediastinal and subcutaneous emphysema. After then, cardiopulmonary resuscitation was discontinued because there was no response. For the patient to be rescued in this situation, thoracotomy is required, although it should be reserved for patients with evidence of hemodynamic compromise attributable to cardiac tamponade.

Chronic contained rupture of the descending thoracic aorta due to infection by Escherichia coli

A 71-year-old man presented with hemoptysis due to chronic contained rupture of the descending thoracic aorta after sepsis by Escherichia coli complicated with transrectal biopsy of the prostate, and underwent urgent graft replacement. The aorta had an almost normal caliber and ruptured into the left lung without abscess. The perforated site of the lung was filled with gelatin-resorcinol-formaldehyde glue, and the defect of the aortic wall was closed. Without graft infection, lung abscess, or sepsis, the patient was discharged followed by 1 month’s intravenous administration of cefazolin and piperacillin sensitive to Escherichia coli after the surgery.

Progressive Acute Abdominal Aortic Syndrome

Vilacosta and associates have recently described the pathology of a new cardiovascular syndrome, acute aortic syndrome. This syndrome embraces a heterogeneous group of patients with a similar clinical profile that includes penetrating atherosclerotic aortic ulcer, intramural aortic haematoma, and classic aortic dissection. The authors describe progressive acute abdominal aortic syndrome, in which the penetration of the ulcer occurred at the dorsal end of the abdominal aorta and progressed rapidly and cranially.

Cardiopulmonary Resuscitation Performance may Improve with Consideration of Performer’s Characteristics

Background: In basic life support, chest compressions are a very important and basic skill. Acquiring the ability to perform chest compressions is affected by individual characteristics such as physique and physical strength, although all persons can learn to Perform Cardiopulmonary Resuscitation (CPR), including chest compressions. The aim of this study was to examine differences in physique between males and females and Basic Life Support (BLS) skill using a portable manikin with automated corrective feedback.Methods: Participants were 120 fourth-year preclinical dental school students (87 males, 33 females). For skill assessment, students performed chest compressions and single rescuer CPR using a Laerdal Resusci Anne Skill Reporter TM manikin for 2 minutes each before and after CPR. Outcome measures were (1) compression depth (mm), (2) compression rate (number of compressions per minute), (3) compression release depth (recoil, mm), and (4) hand position before and after the BLS course.Results: After the BLS course, compression depth and rate improved significantly. Both before and after the BLS course, male students performed deeper chest compressions than female students. In females, the duration of acceptable chest compressions was significantly shorter than in males.Conclusion: CPR performance was significantly different between males and females, probably due to differences in physique. Therefore, it is necessary for individualized instruction adapted to the learner’s characteristics.

The profile of Japanese Association for Acute Medicine - out-of-hospital cardiac arrest registry in 2014-2015

To describe the registry design of the Japanese Association for Acute Medicine – out‐of‐hospital cardiac arrest (JAAM‐OHCA) Registry as well as its profile on hospital information, patient and emergency medical service characteristics, and in‐hospital procedures and outcomes among patients with OHCA who were transported to the participating institutions.

Take with a pinch of salt! Wild plants labeled “edible” may be poisonous

Dear Editor, It is widely believed that wild plants purchased from farmer’s markets are safe, because farmers often have a lot of experience collecting edible wild plants, and are so-called “experts” in the field. However, occasionally, this assumption is wrong. A 60-year-old man, who had disturbed consciousness and dizziness, was transported to our hospital by ambulance. His family, who rode in the ambulance, also felt dizziness and dysarthria during transportation. They had bought a wild plant labeled “Senecio cannabifolius” (Hangonsou in Japanese), which was sold as an edible plant, and consumed it 1 h before the ambulance was called. The patient had eaten many rhizomes of the plant, in particular. On arrival his Glasgow Coma Scale score was 12 (eye, 4; verbal, 3; motor, 5). Both pupils were 4 mm, and light reflexes were slow. His heart rate was 99 b.p.m. and blood pressure was 148/111 mmHg. No abnormal findings were detected by computed tomography. On admission, the patient underwent enforced sedation with midazolam because of restlessness, and tracheal intubation was carried out. Food poisoning caused by Scopolia japonica (Hashiridokoro in Japanese), which is very similar in shape to Senecio cannabifolius, was suspected. Activated carbon and magnesium citrate were used for decontamination after gastric lavage. The patient improved and was discharged 4 days after hospitalization. Scopolia japonica is poisonous; in particular, the rhizomes and roots are toxic. The main ingredients causing poisoning are tropane alkaloids, which cause vomiting, mydriasis, and abnormal excitement and, in the worst case, results in death. The 80-year-old man that provided Scopolia japonica to the patient was an expert who had more than 20 years of experience collecting edible wild plants. He explained that the distinction between Senecio cannabifolius and Scopolia japonica was very difficult because he collected these plants when the buds appeared (Fig. 1). There were five packs of these products; the patient of this case bought two packs. A woman in the same town ate one pack and was admitted to hospital; she reportedly recovered. A couple from another prefecture had also consumed one pack, but their symptoms were comparatively light, and they did not visit a hospital for treatment. It is unknown who purchased the other pack. This farmer’s market was closed down, and he was sent the papers pertaining to a criminal case by the Public Prosecutors Office. In Japan, there still exist rural customs for collecting edible wild plants, and many cases of accidental wild plant poisoning are reported every year. However, this case is the first report in Japan where the poisoning was caused by wild plants purchased from an expert, not through self-picking. In addition, it is expected that mistakes like this will increase as Japan is becoming a super-aging society. To prevent future recurrence, it is required that some kind of management system for wild plant handling be introduced, for example, the establishment of an audit system to ascertain whether gathered wild plants are edible or not.