Yoshihiro Kinoshita

Possible role of increased oxidant stress in multiple organ failure after systemic inflammatory response syndrome

ObjectiveHost response to infection and other forms of tissue injury have been termed systemic inflammatory response syndrome (SIRS). This inflammatory response can frequently be accompanied by oxidative injury in one or more organ systems in the body. The objective of this report was to clarify the possible role of oxidative stress in the development of multiple organ failure (MOF) in patients with SIRS. DesignProspective clinical study. SettingIntensive care unit in a university hospital. PatientsA total of 214 consecutive patients (mean age, 57.1 ± 17.4 yrs; range, 13 to 84 yrs; 148 men and 66 women). At the time of admission, 139 patients fulfilled the clinical criteria for SIRS. InterventionsNone. Measurements and Main ResultsWe measured plasma concentrations of thiobarbituric acid reactant substances (TBARS), as an index of oxidative stress, every day from the point of admission to the intensive care unit until discharge or death. Furthermore, all variables of the SIRS score and the Sequential Organ Failure Assessment score were collected every day. At the time of admission, plasma TBARS concentrations in SIRS patients with MOF were significantly higher than those in SIRS patients without MOF (2.3 ± 0.9 vs. 1.9 ± 0.6 nmol/mL, p < .01), and there was a significant correlation between plasma TBARS concentration and Sequential Organ Failure Assessment score (r2 = .18, p < .001). Furthermore, the duration of SIRS persistence was significantly associated with the percentage increase in plasma TBARS concentration during SIRS persistence in those patients in whom the duration of SIRS was confirmed (r2 = .73, p < .001). The duration of SIRS was significantly higher in patients who developed MOF than in patients who did not develop MOF (6.9 vs. 3.2 days, p < .001). The percentage increase in plasma TBARS concentration during SIRS was also significantly higher in patients who developed MOF than in patients who did not develop MOF (57.1% vs. 15.8%, p < .001). ConclusionsIt can be concluded that processes of oxidative stress in connection with continued SIRS may promote the development of MOF.

Epidemiological survey of Vibrio vulnificus infection in Japan between 1999 and 2003

The frequency of Vibrio vulnificus infection is very rare and there are many questions regarding its epidemiology in Japan. To investigate the clinical course and epidemiology of V. vulnificus infection in Japan, we performed a retrospective questionnaire survey in which 1693 hospitals from all over Japan were surveyed, including advanced life saving emergency centers and dermatology institutions. Of the 1693 hospitals, we received answers from 1045. Ninety‐four cases were confirmed as V. vulnificus infections during 1999 and 2003. Sixty‐eight (72.3%) of the 94 patients had the septic type infection with a mortality rate of 75.0% (51/68 patients died). The prognosis of patients with the septic type was worse than that of the wound type (P < 0.001). V. vulnificus infections occurred from June to November and none occurred in winter. Many infections occurred in western Japan with the majority of infections (50/94) occurring in Kyushu. In particular, 43 infections occurred in marine coastal areas of the Ariake and Yatsushiro Seas, which have many tidelands. Seventy‐seven of 89 patients (86.5%) had liver function impairment as an underlying disease, and 53 (59.6%) had liver cirrhosis, of whom nine (10.1%) suffered from liver cancer. The incidence of V. vulnificus infection was different according to districts. Geographic and climatic factors also contributed to the occurrence of V. vulnificus infection.

Comparison of the McGrath MAC video laryngoscope and the Pentax Airwayscope during chest compression: a manikin study

We tested the utility of the McGrath MAC® (McG) video laryngoscope during chest compression compared with the Pentax Airwayscope® (AWS). We recruited 59 participants into the simulation study. The difference in the time to intubation (TTI [sec]) between without and with chest compression was significant for the AWS attempts (median 13, range 6–28 vs. median 15, range 6–72, p = 0.0247) but not significant for the McG attempts (median 16, range 6–75 vs. median 16, range 6–71); however, the difference of the TTIs is not serious clinically. The utility of the two devices during chest compressions is almost similar although their characteristics are different.

A validation of presepsin levels in kidney dysfunction patients: four case reports

Here, we measured presepsins (PSPs) in four patients with acute kidney injury (AKI) or chronic kidney disease (CKD) and discuss the relationship between PSP and kidney dysfunction.Case 1: an 83-year-old man was admitted to the ICU to manage postoperative respiratory failure with AKI. He had undergone resection for rectal cancer and ileal conduit replacement. On day 1 in the ICU, Escherichia coli (E. coli) was isolated by urine culture. PSP level (pg/ml) on day 2 was 2,745 without elevation of other conventional biomarkers. On day 6, the patient was diagnosed with severe sepsis, and E. coli was isolated by blood culture. By then, PSP had risen to 3,977, along with elevation of other conventional biomarkers. His kidney function recovered gradually after continuous administration of hemodiafiltration; however, PSP continued to rise up to 6,051, along with high systemic inflammatory response syndrome (SIRS) and Acute Physiology and Chronic Health Evaluation (APACHE) II values. The patient expired on day 13 due to multiple organ failure. Case 2: a 78-year-old woman with CKD on hemodialysis (HD) was admitted to the ICU after cardiovascular surgery. Continuous HD was administered postoperatively, and PSP ranged from 1,473–1,870 without signs of sepsis. Temporary elevation of other conventional biomarkers was observed postoperatively. Case 3: a 74-year-old woman with CKD on HD was admitted to the ICU after neurosurgery. She underwent intermittent HD postoperatively, and PSP ranged from 1,240–1,935 without sepsis symptoms. Temporary elevation of other conventional biomarkers was observed postoperatively. Case 4: a 62-year-old man with CKD was admitted to the ICU to control gastrointestinal bleeding. PSP was 606 without signs of infection or elevation of other conventional biomarkers. In cases 2, 3, and 4, bacteria were not isolated in blood cultures. Patients’ clinical prognoses were good, with low or moderate SIRS and APACHE II scores.PSP in kidney dysfunction patients will be high despite non-infectious conditions. Therefore, evaluation of PSP in kidney dysfunction patients will be difficult. Further investigation is needed to clarify the relationship between PSP and kidney dysfunction.

The duration of SIRS before organ failure is a significant prognostic factor of sepsis

BackgroundThe mortality rate of patients complicated with sepsis-associated organ failure remains high in spite of intensive care treatment. The purpose of this study was to define the duration of systemic inflammatory response syndrome (SIRS) before organ failure (DSOF) and determine the value of DSOF as a prognostic factor in septic patients.MethodsThis retrospective cohort study was conducted in an 11-bed medical and surgical intensive care unit (ICU) in a university hospital. The primary endpoint was in-hospital mortality of the septic patients.ResultsOne hundred ten septic patients with organ failure and/or shock were enrolled in this study. The in-hospital mortality rate was 36.9%. The median DSOF was 28.5 h. As a metric variable, DSOF was a statistically significant prognostic factor according to univariate analysis (survivor: 74.7 ± 9.6 h, non-survivor: 58.8 ± 16.5 h, p = 0.015). On the basis of the ROC curve, we defined an optimal cutoff of 24 h, with which we divided the patients as follows: group 1 (n = 50) comprised patients with a DSOF ≤24 h, and group 2 (n = 60) contained patients with a DSOF >24 h. There were statistically significant differences in the in-hospital mortality rate between the two groups (52.0% vs. 25.0%, p = 0.004). Furthermore, by multivariate analysis, DSOF ≤24 h (odds ratio: 5.89, 95% confidence interval: 1.46-23.8, p = 0.013) was a significant independent prognostic factor.ConclusionDSOF may be a useful prognostic factor for severe sepsis.

A resuscitated case of cardiopulmonary arrest due to massive hemoptysis caused by a ruptured thoracic aortic aneurysm

Dear Editor, We report a resuscitated case of cardiopulmonary arrest (CPA) following massive hemoptysis due to a ruptured thoracic aortic aneurysm (TAA). A 73-year-old man was admitted with a sudden onset of hemoptysis. He presented with atrial fibrillation, and he had been taking warfarin (1 mg/day). He had not been previously diagnosed as having a TAA and had had no episode of hemoptysis. On admission, he was lucid with the following vital data: blood pressure, 143/107 mmHg; pulse rate, 90–110 b.p.m.; respiratory rate, 20/min. His breathing sound was reduced in his left lung field. Laboratory tests showed: hemoglobin, 14.7 g/dL; total leukocyte count, 10,800/mm; platelet count, 135,000/mm; PT (INR), 1.17; d-dimer, 29.4 μg/mL. A chest X-ray revealed a hazy shadow in the patient’s left lung field (Fig. 1A). A contrast-enhanced chest computed tomography scan showed a leakage of the contrast material from the TAA and consolidated lung tissue adjacent to the TAA (Fig. 1B). He was diagnosed as having a ruptured TAA into the tracheobronchial trees or the lung, and an emergent endovascular stent-grafting was scheduled. Just before the induction of general anesthesia, CPA following sudden massive hemoptysis occurred. He was intubated immediately, and we started cardiopulmonary resuscitation (CPR). An endovascular intervention was also started under the CPR. We inserted the stent-graft through the femoral artery with fluoroscopy guidance. After the dilation of the stent-graft with an endovascular balloon, the patient was resuscitated. The duration of the CPR was 67 min; however, we had to interrupt the chest compression several times during the fluoroscopy guidance. During the CPR, his electrocardiogram revealed pulseless electrical activity and mechanical ventilation was continued with 100% oxygen; however, the lowest PaO2 was 52 mmHg and the highest PaCO2 was 98 mmHg. The lowest value of

Pupil diameter for confirmation of brain death in adult organ donors in Japan

The criteria for brain death in Japan include a bilateral pupil diameter of ≥4 mm. We evaluated the appropriateness of a 4‐mm pupil diameter in adult brain‐dead donors in Japan.

Infective Endocarditis Caused by Odontogenic Infection withDentinogenesis Imperfecta in Jeune Syndrome

Osteogenesis imperfecta is main symptom in an autosomal recessive Jeune syndrome. Odontogenic infection by dentinogenesis imperfecta and poor oral hygiene is not known and Infective Endocarditis (IE) as a life threatening complication is the first report in Jeune syndrome. Case: A 13-year-old female patient presented with fever, disturbed consciousness, and convulsion. She had Jeune syndrome with mitral regurgitation and mental retardation. Cerebral hemorrhage, vegetation of mitral valve and poor oral hygiene demonstrated clinical definite diagnosis of IE by Duke Criteria. Bacterial aneurysm would cause to be cerebral hemorrhage that was no worsening by Computed Tomography. Vancomycin or Linezolid was treated after MRSA was detected in blood culture. Decayed teeth were removed as source of IE. Consciousness level and inflammation response were improved and no sign of infection was confirmed by frequent echocardiogram and blood culture. Outcome: Patient was discharged the hospital after she had no symptoms with appropriate treatment. Conclusion: Observation of oral hygiene and consideration of IE as the differential diagnosis are beneficial in a severe infectious disease of unknown origin with osteogenesis imperfecta, Jeune syndrome. Antibiotics therapy, oral hygiene and teeth extraction are effective for IE caused by decayed teeth with dentinogenesis imperfecta.

Comparison of the conventional Macintosh laryngoscope, the Pentax Airwayscope, and the McGrath MAC video laryngoscope under restricted cervical motion: a manikin study

We compared the utility of the conventional Macintosh laryngoscope, the Pentax Airway Scope, and the McGrath MAC video laryngoscope under restricted cervical motion using a manikin.

Healthy baby delivered vaginally from a brain-dead mother: Healthy neonate from brain-dead mother

A pregnant (20 gestational weeks) 32‐year‐old woman was found in cardiac arrest. Spontaneous circulation returned after 15 min. She became brain dead on the 13th hospital day. The patient was in stable circulatory condition under nasal desmopressin and 20–30 mg/day of hydrocortisone. On the 92nd hospital day at gestational week 33 + 3 days, natural labor began and a healthy 2,130‐g girl (Apgar 6/8) was delivered vaginally with minimum assistance.