Yusuke Iizuka

Recombinant human soluble thrombomodulin and mortality in sepsis-induced disseminated intravascular coagulation : a multicentre retrospective study

Recombinant human soluble thrombomodulin (rhTM) is a novel class of anticoagulants for treating disseminated intravascular coagulation (DIC). Although rhTM is widely used in clinical settings throughout Japan, there is limited clinical evidence supporting the use of rhTM in patients with sepsis-induced DIC. Furthermore, rhTM is not approved for DIC treatment in other countries. This study aimed to clarify the survival benefits of rhTM administration in critically ill patients. Data from 3,195 consecutive adult patients who were admitted to 42 intensive care units for the treatment of severe sepsis or septic shock between January 2011 and December 2013 were retrospectively analysed, and 1,784 patients were diagnosed with DIC based on the scoring algorithm from the Japanese Association for Acute Medicine DIC (n = 645, rhTM group; n = 1,139, control group). Propensity score matching created 452 matched pairs, and logistic regression analysis revealed a significant association between rhTM administration and lower in-hospital all-cause mortality in the propensity score-matched groups (odds ratio, 0.757; 95 % confidence interval, 0.574-0.999, p = 0.049). Inverse probability of treatment weighted and quintile-stratified analyses also revealed significant associations between rhTM administration and lower in-hospital all-cause mortality. Survival time in the propensity score-matched rhTM group was significantly longer than that in the propensity score-matched control group (hazard ratio, 0.781; 95 % confidence interval, 0.624-0.977, p = 0.03). Bleeding complications were not more frequent in the rhTM groups. In conclusion, this study demonstrated that rhTM administration is associated with reduced in-hospital all-cause mortality among patients with sepsis-induced DIC.

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.

Suvorexant is associated with a low incidence of delirium in critically ill patients: a retrospective cohort study: Suvorexant and decrease in delirium

Benzodiazepine use is a risk factor for the development of delirium in adult intensive care unit (ICU) patients. Suvorexant is an alternative to benzodiazepines to induce sleep, but the incidence of delirium in critically ill patients is unknown. We undertook this retrospective study to investigate the incidence of delirium in patients who receive suvorexant in the ICU.

Successful treatment of nonocclusive mesenteric ischemia after aortic valve replacement with continuous arterial alprostadil infusion: A case report

Highlights • Serum lactate level is a useful clinical marker of nonocclusive mesenteric ischemia.• Some patients with NOMI may be unresponsive to continuous arterial infusion of papaverine.• Continuous arterial infusion of PGE1 may limit the extent of resection in refractory NOMI.

Different hemoglobin thresholds for transfusion in patients with severe sepsis and septic shock

Hemoglobin (Hb) level transfusion thresholds in patients with sepsis who develop anemia have long been a matter of debate. In a randomized controlled trial comparing thresholds of Hb ≤ 7 g/dL vs. ≤ 9 g/dL in patients with severe sepsis and septic shock, comparable outcomes including mortality were obtained [1], while in an observational study of those patients, higher Hb levels were associated with lower mortality [2]. During the resuscitation phase of septic shock, a substantial number of clinicians may have used a higher threshold of hemoglobin at 10 g/dL, as recommended in the Surviving Sepsis Campaign Guideline 2008 [3].

Low dose immunoglobulin g for treatment of severe sepsis and septic shock

As an adjunctive treatment in sepsis, patients administered high-dose (0.9g/kg body weight) intravenous immunoglobulin G (IvIgG) did not have a significant survival benefit in a randomized control study (The SBITS study) (1). However, low-dose ivIgG (5g/day 3days) might have some utilities including earlier defervescence and improvements of clinical signs and symptoms (2).

Dislocation of a detached electrode from a pacing Swan–Ganz catheter in the hepatic vasculature

To the Editor: The pacing pulmonary artery catheter (PAC) is very efficacious in some cases, but it can be associated with a rare complication specifically associated with its placement. Here we describe the case of an electrode that became detached from the pacing PAC, only to be visualized later in the liver of the patient on the postoperative computed tomography (CT) images. An 80-year-old, 35-kg woman presented for valve replacement for aortic stenosis, mitral regurgitation and annuloplasty for tricuspid regurgitation. Under general anesthesia, the right internal jugular vein (RIJV) of the patient was cannulated with a central venous catheter (8.5French AVA 3Xi multi-lumen sheath introducer catheter; Edwards Lifesciences, Irvine, CA) with two infusion lumens and an introducer. A pacing PAC (model D205HF7; Edwards Lifesciences), which had five built-in electrodes integrated for atrial and/or ventricular pacing, was inserted through the introducer. Repeated attempts to advance the PAC blindly failed. When the operator withdrew the PAC through the introducer, he felt light resistance and shortly thereafter noticed that the second electrode from the top for ventricular pacing was missing from the PAC (Fig. 1a, b). The introducer was immediately examined to determine the cause(s) of the detachment, but no cause was identified. A second pacing PAC was inserted again through the introducer from the RIJV under mobile C-arm fluoroscopic guidance. Thereafter the patient successfully underwent the surgical procedure. The patient had an uneventful postoperative course, and subsequent CT imaging revealed that the metallic tip of the first pacing PAC was in the posterior region of the hepatic right lobe (Fig. 1c). The patient did not suffer from liver dysfunction during the postoperative course, and liver function has remained normal . The electrode consists of elgiloy alloy (Co–Cr–Ni alloy) that is characterized by its high strength, ductility, corrosion resistance and excellent fatigue life over a wide temperature range. It is used widely to construct clips for cerebrovascular aneurysms, carotid arterial stents, among others. The dimensions of the electrode are 2 9 2 mm. At the time of detachment, catheter intervention would have been almost impossible because the electrode was caught in a fragment of the vein that was too small. We therefore chose medical observation and would have, if necessary, performed hepatectomy with its associated surgical risk. A literature search of the PubMed databases revealed only two case reports comparable to our case [1, 2]. In these two reported cases, the three detached electrodes that remained in the body had gone into the pulmonary vasculature; in one case report, two electrodes were retrieved from within the introducer. In our case, the fragment was H. Aoyama (&) Y. Otsuka K. Asaka T. Murayama Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, Saitama Medical Center, Amanuma-cho 1-847, Omiya-ku, Saitama 330-8503, Japan e-mail: h.aoyama@omiya.jichi.ac.jp