Takeshi Umegaki

The impact of acute organ dysfunction on patients' mortality with severe sepsis

Background: Severe sepsis leads to organ failure and results in high mortality. Organ dysfunction is an independent prognostic factor for intensive care unit (ICU) mortality. The objective of the present study was to determine the effect of acute organ dysfunction for ICU mortality in patients with severe sepsis using administrative data. Materials and Methods: A multicenter cross-sectional study was performed in 2008. The study was conducted in 112 teaching hospitals in Japan. All cases with severe sepsis in ICU were identified from administrative data. Results: Administrative data acquired for 4196 severe septic cases of 75,069 cases entered in the ICU were used to assess patient outcomes. Cardiovascular dysfunction was identified as the most major organ dysfunction (73.0%), and the followings were respiratory dysfunction (69.4%) and renal dysfunction (39.0%), respectively. The ICU mortality and 28-day means 28-day from ICU entry. were 18.8% and 27.7%, respectively. After adjustment for age, gender, and severity of illness, the hazard ratio of 2, 3, and ≥4, the organ dysfunctions for one organ failure on ICU mortality was 1.6, 2.0, and 2.7, respectively. Conclusions: We showed that the number of organ dysfunction was a useful indicator for ICU mortality on administrative data. The hepatic dysfunction was the highest mortality among organ dysfunctions. The hazard ratio of ICU death in severe septic patients with multiple organ dysfunctions was average 2.2 times higher than severe septic patients with single organ dysfunction.

Efficacy of single-dose intravenous immunoglobulin administration for severe sepsis and septic shock

BackgroundAlthough some studies conducted outside of Japan have addressed the effectiveness of intravenous immunoglobulins (IVIG) in treating infections, the dosing regimens and amounts used in Japan are very different from those reported. Here, we investigate the effectiveness of single-dose administration of IVIG in sepsis patients in Japan.MethodsWe analyzed 79 patients admitted to the intensive care unit (ICU) of a tertiary care institution due to severe sepsis or septic shock. Patients were randomly divided into a group that was administered standard divided doses of IVIG (5 g/day for 3 days, designated the S group) or a group that was administered a standard single dose of IVIG (15 g/day for 1 day, H group); freeze-dried sulfonated human IVIG was used. The longitudinal assessment of procalcitonin (PCT) levels, C-reactive protein (CRP) levels, white blood cell count, blood lactate levels, IL-6 levels, Sequential Organ Failure Assessment (SOFA) score, and Systemic Inflammatory Response Syndrome (SIRS) was conducted. We also assessed mechanical ventilation duration (days), ICU stay (days), 28-day survival rate, and 90-day survival rate.ResultsThe study showed no significant differences in PCT levels, CRP levels, 28-day survival rate, and 90-day survival rate between the two groups. However, patients in the H group showed improvements in the various SIRS diagnostic criteria, IL-6 levels, and blood lactate levels in the early stages after IVIG administration. In light of the non-recommendation of IVIG therapy in the Surviving Sepsis Campaign Guidelines 2012, our findings of significant early post-administration improvements are noteworthy. IVIGs anti-inflammatory effects may account for the early reduction in IL-6 levels after treatment, and the accompanying improvements in microcirculation may improve blood lactate levels and reduce SOFA scores. However, the low dosages of IVIG in Japan may limit the anti-cytokine effects of this treatment. Further studies are needed to determine appropriate treatment regimens of single-dose IVIG.ConclusionsIn this study, we investigated the effectiveness of single-dose IVIG treatment in patients with severe sepsis or septic shock. Although there were no significant effects on patient prognoses, patients who were administered single-dose IVIG showed significantly improved IL-6 levels, blood lactate levels, and disease severity scores.

Emergency airway management of an extremely low-birth-weight infant with subglottic stenosis

1 Frei FJ, Ummenhofer W. Difficult intubation in paediatrics. Paediatr Anaesth 1996; 6: 251–263. 2 Hansen TG, Joensen H, Henneberg SW. Laryngeal mask airway guided tracheal intubation in a neonate with the Pierre Robin syndrome. Acta Anaesthesiol Scand 1995; 39: 129. 3 Bhardwaj N, Yaddanapudi S, Makkar S. Retrograde tracheal intubation. Anesth Analg 2006; 103: 1628–1629. 4 Howardy-Hansen P, Berthelsen P. Fibreoptic bronchoscopic nasotracheal intubation of a neonate with Pierre Robin syndrome. Anaesthesia 1988; 43: 121–122. 5 Byhahn C, Meininger D, Walcher F et al. Prehospital emergency endotracheal intubation using the Bonfils intubation fiberscope. Eur J Emerg Med 2007; 14: 43–46.

Severe Progressive Diffuse Alveolar Hemorrhage in a Patient with Systemic Lupus Erythematosus

Diffuse alveolar hemorrhage (DAH) refers to the effusion of blood into the alveoli due to damaged pulmonary microvasculature. The ensuing alveolar collapse can lead to severe hypoxemia with poor prognosis. In these cases, it is crucial to provide respiratory care for hypoxemia in addition to treating the underlying disease. Here, we describe our experience with a case involving a 46-year-old woman with severe DAH-induced hypoxemia accompanying systemic lupus erythematosus (SLE). Mechanical ventilation was managed using airway pressure release ventilation (APRV) after intubation. Through APRV-based respiratory care and treatment of the underlying disease, hemoptysis was eliminated and oxygenation improved. The patient did not experience significant barotrauma and was successfully weaned from mechanical ventilation after 25 days in the intensive care unit. This case demonstrates that APRV-based control for respiratory management can inhibit the effusion of blood into the alveoli and achieve mechanical hemostasis, as well as mitigate alveolar collapse. APRV may be a useful method for respiratory care in patients with severe DAH-induced hypoxemia.

The Influence of Human Soluble Recombinant Thrombomodulin on In-Hospital Mortality in Patients with Acute Respiratory Distress Syndrome and Disseminated Intravascular Coagulation: A Retrospective Multicenter Study

Background: Patients with acute respiratory distress syndrome (ARDS) often develop disseminated intravascular coagulation (DIC), which can worsen clinical outcomes. Anticoagulant therapy such as human soluble recombinant thrombomodulin (rTM) treatment may help to resolve DIC and improve prognoses. This study analyzes the influence of rTM treatment on in-hospital mortality in patients with both ARDS and DIC. Methods: In a retrospective cohort study, we examined 75 patients with ARDS and DIC who had been admitted to the intensive care units of 3 university hospitals between March 1, 2008 and February 29, 2016. Data were extracted from clinical records. Subjects were divided into a control group comprising 38 patients who were not administered rTM and an rTM group comprising 37 patients who were administered rTM. Kaplan-Meier survival analysis was performed to produce survival curves and the log-rank test was used to compare survival between the 2 groups. We conducted a Cox proportional hazards regression analysis where the dependent variable was in-hospital mortality and the main independent variable of interest was the use of rTM; the hazard ratio of rTM use was calculated. Results: The variables of with P values below 0.2 were age (P=0.15), source of sepsis (P=0.17), rTM use (P=0.02) and AT concentrate use (P=0.17) between the survivors and non-survivors. There was no significant difference in the ARDS severity levels between the rTM group and the control group (P=0.71). In-hospital mortality was significantly lower (P=0.02) in the rTM group (37.8%) than in the control group (65.8%). The hazard ratio of rTM use for mortality was 0.49 (95% confidence interval: 0.26-0.95; P=0.03). In addition, the log-rank test showed that the rTM group had significantly better survival than the control group (P=0.04). Conclusion: Our study indicates that rTM treatment significantly improved prognoses in patients with both ARDS and DIC.

Effect of High-Dose Intravenous Immunoglobulin Administration on the Levels of Interleukin-6 in Patients with Sepsis

Background: Intravenous immunoglobulin (IVIG) is administered to patients with sepsis to improve clinical outcomes. Here, we report the effectiveness of highdose IVIG therapy in patients with sepsis admitted to a teaching hospital. Methods: We analyzed 55 patients admitted to intensive care unit (ICU) due to sepsis. The patients were categorized into 2 groups depending on their IVIG dose: Patients administered high-dose (15 g/day for 3 days; total of 45 g) sulfonated human IVIG were designated the HD group, and those administered a standard divided dose (5 g/day for 3 days; total of 15 g) were designated the S group. The courses of interleukin (IL)-6 values were examined. Results: The HD and S groups comprised 13 and 42 patients, respectively. The Log10 IL-6 values on Day 1 for HD and S groups were 3.3 ± 1.0 pg/mL and 3.4 ± 0.9 pg/mL (p=0.79). The repeated two-way ANOVA revealed no statistical inter-group difference for time course between 2 groups (p=0.42). The median Sequential Organ Failure Assessment (SOFA) scores on the day of ICU admission of the HD and S groups were 13.0 and 11.0, respectively (p=0.03). The most frequency of infection sources was abdomen in two groups, and there was no statistical difference for infection sources (p=0.18). The 28 day mortality rates for the HD and S groups were 30.8% and 14.3% (p=0.17), respectively. Conclusion: This study showed that IVIG dose had no significant effect on IL-6 values despite of slightly lower course in high-dose IVIG group.

A comparison of in-hospital outcomes between transcatheter and surgical aortic valve replacement in patients with aortic valve stenosis: A retrospective cohort study using administrative data

OBJECTIVE The number of surgeries for valvular heart disease performed in Japan has greatly increased over the past decade, and surgical aortic valve replacements (SAVR) constitute the vast majority of aortic valve replacement procedures. Although transcatheter aortic valve implantation (TAVI) was recently introduced, studies have yet to compare the clinical outcomes between TAVI and SAVR in the Japanese healthcare setting. This study aimed to compare in-hospital outcomes between TAVI and SAVR using a multicenter administrative database. DESIGN Retrospective cohort study. SETTING Acute care hospitals in Japan. PARTICIPANTS A total of 16,775 patients diagnosed with aortic valve stenosis. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The main study outcome measure was in-hospital mortality. Based on multiple logistic regression analysis using inverse probability of treatment weighting, the odds ratio of in-hospital mortality for TAVI (relative to SAVR) was calculated to be 0.36 (95% confidence intervals: 0.13-0.98; p = 0.04). In patients aged 80 years or older, the odds ratio was even lower at 0.34 (95% confidence intervals: 0.15-0.73; p < 0.01). In addition, the incidences of reoperations, hemorrhagic complications, cardiac tamponade, and postoperative infections were significantly higher in the SAVR patients. CONCLUSIONS This large-scale multicenter comparative analysis of TAVI and SAVR in Japan indicated that TAVI produced better clinical outcomes in patients with aortic valve stenosis. The improved outcomes were particularly notable in patients aged 80 years or older.

Use of High-Flow Nasal Cannula Oxygen Therapy in a Pregnant Woman with Dermatomyositis-Related Interstitial Pneumonia

A 33-year-old pregnant woman was referred to our hospital with respiratory distress at 30 weeks of gestation. Chest computed tomography (CT) scans revealed pulmonary infiltrates along the bronchovascular bundles and ground-glass opacities in both lungs. Despite immediate treatment with steroid pulse therapy for suspected interstitial pneumonia, the patients condition worsened. Respiratory distress was slightly alleviated after the initiation of high-flow nasal cannula (HFNC) oxygen therapy (40 L/min, FiO2 40%). We suspected clinically amyopathic dermatomyositis (CADM) complicating rapidly progressive refractory interstitial pneumonia. In order to save the life of the patient, the use of combination therapy with immunosuppressants was necessary. The patient underwent emergency cesarean section and was immediately treated with immunosuppressants while continuing HFNC oxygen therapy. The neonate was treated in the neonatal intensive care unit. The patients condition improved after 7 days of hospitalization; by this time, she was positive for myositis-specific autoantibodies and was diagnosed with interstitial pneumonia preceding dermatomyositis. This condition can be potentially fatal within a few months of onset and therefore requires early combination immunosuppressive therapy. This case demonstrates the usefulness of HFNC oxygen therapy for respiratory management as it negates the need for intubation and allows for various treatments to be quickly performed.

Comparison of continuous intraarterial blood gas analysis and transcutaneous monitoring to measure oxygen partial pressure during one-lung ventilation

We compared the oxygen partial pressure during one-lung ventilation measured by CBGA with that measured by a TMD which was lent to us for this investigation. Right upper pulmonary lobectomy was planned for a 60year-old man. A 20-G cannula was placed into the left radial artery and the CBGA sensor was inserted via this cannula. The TMD sensor was attached to the left brachium. After the patient was adjusted to the left lateral position, the CBGA device was calibrated, using blood gas values measured with a blood gas analyzer (ABL735; Radiometer). The CBGA data were recorded (one measure per second) directly into a personal computer, and the TMD data (one measure for each 10s interval) were initially stored in the measuring device and then imported into the computer after the operation. The oxygen partial pressures measured using CBGA and TMD were compared for each 1-min interval. Figure 1 presents the changes in the two parameters. During the first few minutes, the oxygen partial pressure measured by the TMD increased gradually during the stabilization period. When one-lung ventilation was initiated, both CBGA and TMD oxygen partial pressures decreased suddenly. After the end of the one-lung Comparison of continuous intraarterial blood gas analysis and transcutaneous monitoring to measure oxygen partial pressure during one-lung ventilation

Use of the laryngeal mask airway in nasally intubated patients.

One-lung ventilation (OLV) is a standard technique for thoracic anaesthesia. There are several methods to facilitate OLV including bronchial blocker balloons used with a conventional tracheal tube and specially designed tracheal tubes such as the double-lumen tube or the Univent tube. However, these techniques are often difficult in patients with a poor airway [1]. The ProSeal Laryngeal Mask Airway (PLMA) (IntaventOrthofix, Maidenhead, UK) may be used to establish an airway in patients with a difficult airway or intubation [2,3]. We used a PLMA with a bronchial blocker to provide OLV in a patient who was difficult to intubate. A 76 year-old male was scheduled for biopsy of a pleural tumour. He had a herniated cervical disk and paraesthesia of the left arm. He had limited neck extension and his Mallampati score was two. He refused an awake intubation. Anaesthesia was induced with in-line manual stabilisation of the neck and mask ventilation was easy. The laryngoscopic view with a Macintosh blade was grade three (modified Cormack and Lehane). A size five PLMA was easily inserted without neck extension and a patent airway established. A bronchial blocker (Coopdech Bronchial Blocker Tube, Daiken Medical Co Ltd, Osaka, Japan) was inserted through the PLMA (See Fig. 3). The tip of the blocker impinged against the aryepiglottic fold. However, tightening the curvature of the tip and rotating the blocker overcame this difficulty and it was guided into the left main bronchus with a fibreoptic bronchoscope. A satisfactory operative field was achieved and the biopsy was performed uneventfully in 40 min. The PLMA was removed with the patient fully awake and breathing spontaneously. In our opinion, a PLMA with a bronchial blocker can provide an alternative method for OLV in a patient with a difficult airway or intubation. However, the disadvantages of this method should be kept in mind. Damage to the mucosa or nerve tissue in the larynx and trachea may occur due to direct compression by the blocker during prolonged surgery.