基本情報
- 所属
- 自治医科大学 附属さいたま医療センター内科系診療部救急科 講師
- J-GLOBAL ID
- 201701001479141743
- Researcher ID
- E-5987-2016
- researchmap会員ID
- B000275391
- 外部リンク
研究分野
1論文
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BMC cardiovascular disorders 22(1) 466-466 2022年11月5日BACKGROUND: Out-of-hospital cardiac arrest (OHCA) with shockable rhythms, including ventricular fibrillation and pulseless ventricular tachycardia, is associated with better prognosis and neurological outcome than OHCA due to other rhythms. Antiarrhythmic drugs, including lidocaine and amiodarone, are often used for defibrillation. This study aimed to compare the effects of lidocaine and amiodarone on the prognosis and neurological outcome of patients with OHCA due to shockable rhythms in a real-world setting. METHODS: We conducted a retrospective observational study using a multicenter OHCA registry of 91 participating hospitals in Japan. We included adult patients with shockable rhythms, such as ventricular fibrillation and pulseless ventricular tachycardia, who were administered either lidocaine or amiodarone. The primary outcome was 30-day survival, and the secondary outcome was a good neurological outcome at 30 days. We compared the effects of lidocaine and amiodarone for patients with OHCA due to shockable rhythms for these outcomes using logistic regression analysis after propensity score matching (PSM). RESULTS: Of the 51,199 patients registered in the OHCA registry, 1970 patients were analyzed. In total, 105 patients (5.3%) were administered lidocaine, and 1865 (94.7%) were administered amiodarone. After performing PSM with amiodarone used as the reference, the odds ratios and 95% confidence intervals of lidocaine use for 30-day survival and 30-day good neurological outcome were 1.44 (0.58-3.61) and 1.77 (0.59-5.29), respectively. CONCLUSION: The use of lidocaine and amiodarone for patients with OHCA due to shockable rhythms within a real-world setting showed no significant differences in short-term mortality or neurological outcome. There is no evidence that either amiodarone or lidocaine is superior in treatment; thus, either or both drugs could be administered.
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Cureus 14(11) e31636 2022年11月We aimed to compare the efficacy of therapeutic hypothermia for 24, 48, and 72 h, and normothermia following pediatric cardiac arrest. We searched the Cochrane Central Register of Controlled Trials, MEDLINE via Ovid, World Health Organization International Clinical Trials Platform Search Portal, and ClinicalTrials.gov. from their inception to December 2021. We included randomized controlled trials and observational studies evaluating target temperature management (TTM) in children aged < 18 years with the return of spontaneous circulation (ROSC) after cardiac arrest. We compared four intervention groups (normothermia, therapeutic hypothermia for 24 h (TTM 24h), therapeutic hypothermia for 48 h (TTM 48h), and therapeutic hypothermia for 72 h (TTM 72h)) using network meta-analysis. The outcomes were survival and favorable neurological outcome at 6 months or more. Seven studies involving 1008 patients and four studies involving 684 patients were included in the quantitative synthesis of survival and neurological outcome, respectively. TTM for 72 h was associated with a higher survival rate, compared to normothermia (RR 1.75 (95% CI 1.27-2.40)) (very low certainty), TTM 24h (RR 1.53 (95% CI 1.06-2.19)) (low certainty), and TTM 48h (RR 1.54 (95% CI 1.06-2.22)) (very low certainty). TTM for 72 h was also associated with favorable neurological outcomes compared with normothermia (RR 9.36 (95% CI 2.04-42.91)), or TTM 48h (RR 8.15 (95% CI 1.6-40.59)) (all very low certainty). TTM for 24 h was associated with favorable neurological outcome, compared with normothermia (RR 8.02 (95% CI 1.28-50.50)) (very low certainty). In the ranking analysis, the hierarchies for efficacy for survival and favorable neurological outcome were TTM 72h > TTM 48h > TTM 24h > normothermia. Although prolonged therapeutic hypothermia might be effective in pediatric patients with ROSC after cardiac arrest, the evidence to support this result is only weak to very weak. There is no conclusive evidence regarding the effectiveness and length of therapeutic hypothermia and high-quality RCRs comparing long-length therapeutic hypothermia to short-length hypothermia and normothermia are needed.
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The Journal of emergency medicine 63(2) 221-231 2022年8月BACKGROUND: Previous studies have shown an association between hyperoxemia and mortality in patients with out-of-hospital cardiac arrest (OHCA) after cardiopulmonary resuscitation (CPR); however, evidence is lacking in the extracorporeal CPR (ECPR) setting. OBJECTIVE: The aim of this study was to test the hypothesis that hyperoxemia is associated with poor neurological outcomes in patients treated by ECPR. METHODS: The Japanese Association for Acute Medicine OHCA Registry is a multicenter, prospective, observational registry of patients from 2014 to 2017. Adult (18 years or older) patients who had undergone ECPR after OHCA were included. Eligible patients were divided into two groups based on the partial pressure of oxygen in arterial blood (PaO2) levels at 24 h after ECPR: the high-PaO2 group (n = 242) defined as PaO2 ≥ 157 mm Hg (median) and the low-PaO2 group (n = 211) defined as PaO2 60 to < 157 mm Hg. The primary outcome was the favorable neurological outcome, defined as a Cerebral Performance Categories Scale score of 1 to 2 at 30 days after OHCA. RESULTS: Of 34,754 patients with OHCA, 453 patients were included. The neurological outcome was significantly lower in the high-PaO2 group than in the low-PaO2 group (15.9 vs. 33.5%; p < 0.001). After adjusting for potential confounders, high PaO2 was negatively associated with favorable neurological outcomes (adjusted odds ratio [aOR] 0.48; 95% confidence interval [CI] 0.24-0.97; p = 0.040). In a multivariate analysis with multiple imputation, high PaO2 was also negatively associated with favorable neurological outcomes (aOR 0.63; 95% CI 0.49-0.81; p < 0.001). CONCLUSIONS: Hyperoxemia was associated with worse neurological outcomes in OHCA patients with ECPR.
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BMC cardiovascular disorders 22(1) 163-163 2022年4月11日BACKGROUND: To investigate the impact of hyperoxia that developed immediately after extracorporeal membrane oxygenation (ECMO)-assisted cardiopulmonary resuscitation (ECPR) on patients' short-term neurological outcomes after out-of-hospital cardiac arrest (OHCA). METHODS: This study retrospectively analyzed data from the Japanese OHCA registry from June 2014 to December 2017. We analyzed adult patients (≥ 18 years) who had undergone ECPR. Eligible patients were divided into the following three groups based on their initial partial pressure of oxygen in arterial blood (PaO2) levels after ECMO pump-on: normoxia group, PaO2 ≤ 200 mm Hg; moderate hyperoxia group, 200 mm Hg < PaO2 ≤ 400 mm Hg; and extreme hyperoxia group, PaO2 > 400 mm Hg. The primary and secondary outcomes were 30-day favorable neurological outcomes. Logistic regression statistical analysis model of 30-day favorable neurological outcomes was performed after adjusting for multiple propensity scores calculated using pre-ECPR covariates and for confounding factors post-ECPR. RESULTS: Of the 34,754 patients with OHCA enrolled in the registry, 847 were included. The median PaO2 level was 300 mm Hg (interquartile range: 148-427 mm Hg). Among the eligible patients, 277, 313, and 257 were categorized as normoxic, moderately hyperoxic, and extremely hyperoxic, respectively. Moderate hyperoxia was not significantly associated with 30-day neurologically favorable outcomes compared with normoxia as a reference (adjusted odds ratio, 0.86; 95% confidence interval: 0.55-1.35; p = 0.51). However, extreme hyperoxia was associated with less 30-day neurologically favorable outcomes when compared with normoxia (adjusted odds ratio, 0.48; 95% confidence interval: 0.29-0.82; p = 0.007). CONCLUSIONS: For patients with OHCA who received ECPR, extreme hyperoxia (PaO2 > 400 mm Hg) was associated with 30-day poor neurological outcomes. Avoidance of extreme hyperoxia may improve neurological outcomes in patients with OHCA treated with ECPR.
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Oxford medical case reports 2022(3) omac021 2022年3月
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Frontiers in medicine 9 1037274-1037274 2022年INTRODUCTION: Phlebitis is an important complication in patients with peripheral intravascular catheters (PIVCs). Although an association between body mass index (BMI) and phlebitis has been suggested, the risk of phlebitis according to BMI has not been well elucidated. Therefore, in this study, we analyzed the risk of phlebitis according to BMI in patients in the intensive care unit (ICU). MATERIALS AND METHODS: This study undertook a secondary analysis of the data from a prospective multicenter observational study assessing the epidemiology of phlebitis at 23 ICUs in Japan. Patients admitted into the ICU aged ≥18 years with a new PIVC inserted after ICU admission were consecutively enrolled and stratified into the following groups based on BMI: Underweight (BMI < 18.5 kg/m2), normal weight (18.5 ≤ BMI < 25.0 kg/m2), and overweight/obese (BMI ≥ 25.0 kg/m2). The primary outcome was phlebitis. The risk factors for phlebitis in each BMI-based group were investigated using a marginal Cox regression model. In addition, hazard ratios and 95% confidence intervals were calculated. RESULTS: A total of 1,357 patients and 3,425 PIVCs were included in the analysis. The mean BMI for all included patients was 22.8 (standard deviation 4.3) kg/m2. Among the eligible PIVCs, 455; 2,041; and 929 were categorized as underweight, normal weight, and overweight/obese, respectively. In the underweight group, catheter size ≥ 18 G and amiodarone administration were independently associated with the incidence of phlebitis. Drug administration standardization was associated with the reduction of phlebitis. In the normal weight group, elective surgery as a reason for ICU admission, and nicardipine, noradrenaline, and levetiracetam administration were independently associated with the incidence of phlebitis. Heparin administration was associated with the reduction of phlebitis. In the overweight/obese group, the Charlson comorbidity index, catheter size ≥ 18 G, and levetiracetam administration were independently associated with the incidence of phlebitis. Catheters made from PEU-Vialon (polyetherurethane without leachable additives) and tetrafluoroethylene were associated with the reduction of phlebitis. CONCLUSION: We investigated the risk factors for peripheral phlebitis according to BMI in ICU and observed different risk factors in groups stratified by BMI. For example, in underweight or overweight patients, large size PIVCs could be avoided. Focusing on the various risk factors for phlebitis according to patients' BMIs may aid the prevention of phlebitis.
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Frontiers in medicine 9 965706-965706 2022年INTRODUCTION: Peripheral intravascular catheters (PIVCs) are inserted in most patients admitted to the intensive care unit (ICU). Previous research has discussed various risk factors for phlebitis, which is one of the complications of PIVCs. However, previous studies have not investigated the risk factors based on the patient's severity of illness, such as the Acute Physiology and Chronic Health Evaluation (APACHE) II score. Different treatments can be used based on the relationship of risk factors to the illness severity to avoid phlebitis. Therefore, in this study, we investigate whether the risk factors for phlebitis vary depending on the APACHE II score. MATERIALS AND METHODS: This study was a post hoc analysis of the AMOR-VENUS study involving 23 ICUs in Japan. We included patients with age ≥ 18 years and consecutive admissions to the ICU with PIVCs inserted during ICU admission. The primary outcome was phlebitis, and the objective was the identification of the risk factors evaluated by hazard ratio (HR) and 95% confidence interval (CI). The cut-off value of the APACHE II score was set as ≤15 (group 1), 16-25 (group 2), and ≥26 (group 3). Multivariable marginal Cox regression analysis was performed for each group using the presumed risk factors. RESULTS: A total of 1,251 patients and 3,267 PIVCs were analyzed. Multivariable marginal Cox regression analysis reveals that there were statistically significant differences among the following variables evaluated HR (95%CI): (i) in group 1, standardized drug administration measures (HR, 0.4 [0.17-0.9]; p = 0.03) and nicardipine administration (HR, 2.25 [1.35-3.75]; p < 0.01); (ii) in group 2, insertion in the upper arm using the forearm as a reference (HR, 0.41 [0.2-0.83]; p = 0.01), specified polyurethane catheter using polyurethane as a reference (HR, 0.56 [0.34-0.92]; p = 0.02), nicardipine (HR, 1.9 [1.16-3.12]; p = 0.01), and noradrenaline administration (HR, 3.0 [1.52-5.88]; p < 0.01); (iii) in group 3, noradrenaline administration (HR, 3.39 [1.14-10.1]; p = 0.03). CONCLUSION: We found that phlebitis risk factors varied according to illness severity. By considering these different risk factors, different treatments may be provided to avoid phlebitis based on the patient's severity of illness.
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Acute medicine & surgery 9(1) e723 2022年Surgical site infections (SSIs) and catheter-related bloodstream infections (CRBSIs) caused by bacteria from surfaces poorly disinfected with chlorhexidine gluconate (CHG) and povidone-iodine (PVP-I) are increasing. Olanexidine gluconate (OLG) was developed in 2015 in Japan to prevent SSI and CRBSI caused by bacteria resistant to CHG and PVP-I. This scoping review aimed to identify the knowledge gap between what is known and what is not known about the disinfection efficacy of OLG. We searched MEDLINE through PubMed, the Cochrane Central Register of Controlled Trials, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the International Clinical Trials Registry Platform search database, ClinicalTrials.gov, and the Web-based database of Japanese medical articles for works published to July 18, 2021. Manual reference searches were also carried out. A total of 131 studies were screened. Forty-seven studies were included in this review and classified into two major categories: studies on pharmacological effects and spectrum (n = 29) and studies on clinical and adverse effects (n = 18). Olanexidine gluconate showed bactericidal activity against methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci, in addition to common Gram-positive and Gram-negative bacteria. In clinical settings, although there is limited evidence on SSI prevention, 1.5% OLG might be more effective than 10% PVP-I and 1% CHG in preventing SSI. However, the clinical usefulness of OLG is unclear due to the limited number of clinical studies. Also, clinical research is limited to studies targeting SSI prevention, and there are no clinical studies on CRBSI. Further clinical studies are needed on SSI and CRBSI prevention.
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Frontiers in medicine 9 810449-810449 2022年INTRODUCTION: Sudden cardiac arrest causes numerous deaths worldwide. High-quality chest compressions are important for good neurological recovery. Arterial pressure is considered useful to monitor the quality of chest compressions by the American Heart Association. However, arterial pressure catheter might be inconvenient during resuscitation. Conversely, cerebral regional oxygen saturation (rSO2) during resuscitation may be associated with a good neurological prognosis. Therefore, we aimed to evaluate the correlation between mean arterial pressure and rSO2 during resuscitation to evaluate rSO2 as an indicator of the quality of chest compressions. MATERIALS AND METHODS: This study was a single-center, prospective, observational study. Patients with out-of-hospital cardiac arrest who were transported to a tertiary care emergency center in Japan between October 2014 and March 2015 were included. The primary outcome was the regression coefficient between mean arterial pressure (MAP) and rSO2. MAP and rSO2 were measured during resuscitation (at hospital arrival [0 min], 3, 6, 9, 12, and 15 min), and MAP was measured by using an arterial catheter inserted into the femoral artery. For analysis, we used the higher value of rSO2 obtained from the left and right forehead of the patient measured using a near-infrared spectrometer. Regression coefficients were calculated using the generalized estimating equation with MAP and systolic arterial pressure as response variables and rSO2 as an explanatory variable since MAP and rSO2 were repeatedly measured in the same patient. Since the confounding factors between MAP or systolic arterial pressure and rSO2 were not clear clinically or from previous studies, the generalized estimating equation was analyzed using a univariate analysis. RESULTS: In this study, 37 patients were analyzed. The rSO2 and MAP during resuscitation from hospital arrival to 15 min later were expressed as follows: (median [interquartile range, IQR]): rSO2, 29.5 (24.3-38.8)%, and MAP, 36.5 (26-46) mmHg. The regression coefficient (95% CI) of log-rSO2 and log-MAP was 0.42 (0.03-0.81) (p = 0.035). CONCLUSION: The values of rSO2 and MAP showed a mild but statistically significant association. rSO2 could be used to assess the quality of chest compressions during resuscitation as a non-invasive and simple method.
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Frontiers in medicine 9 867602-867602 2022年INTRODUCTION: The appropriate arterial partial pressure of oxygen (PaO2) in patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest (OHCA) remains unclear. The present study aimed to investigate the relationship between hyperoxia and 30-day survival in patients who underwent ECPR. MATERIALS AND METHODS: This single-center retrospective cohort study was conducted between January 2010 and December 2018. OHCA patients who underwent ECPR were included in the study. Exclusion criteria were (1) age <18 years, (2) death within 24 h after admission, (3) return of spontaneous circulation at hospital arrival, and (4) hypoxia (PaO2 < 60 mmHg) 24 h after admission. Based on PaO2 at 24 h after admission, patients were classified into normoxia (60 mmHg ≤ PaO2 ≤ 100 mmHg), mild hyperoxia (100 mmHg < PaO2 ≤ 200 mmHg), and severe hyperoxia (PaO2 > 200 mmHg) groups. The primary outcome was 30-day survival after cardiac arrest, while the secondary outcome was 30-day favorable neurological outcome. Multivariate logistic regression analysis for 30-day survival or 30-day favorable neurological outcome was performed using multiple propensity scores as explanatory variables. To estimate the multiple propensity score, we fitted a multinomial logistic regression model using the patients' demographic, pre-hospital, and in-hospital characteristics. RESULTS: Of the patients who underwent ECPR in the study center, 110 were eligible for the study. The normoxia group included 29 cases, mild hyperoxia group included 46 cases, and severe hyperoxia group included 35 cases. Mild hyperoxia was not significantly associated with survival, compared with normoxia as the reference (adjusted odds ratio, 1.06; 95% confidence interval: 0.30-3.68; p = 0.93). Severe hyperoxia was also not significantly associated with survival compared to normoxia (adjusted odds ratio, 1.05; 95% confidence interval: 0.27-4.12; p = 0.94). Furthermore, no association was observed between oxygenation and 30-day favorable neurological outcomes. CONCLUSIONS: There was no significant association between hyperoxia at 24 h after admission and 30-day survival in OHCA patients who underwent ECPR.
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IDCases 29 e01543 2022年This report presents the case of a 51-year-old woman on an immunosuppressant drug and steroids, who presented with general fatigue and was admitted to the intensive care unit. Her serum procalcitonin, lactate, aspartate aminotransferase, and alanine aminotransferase levels and white blood cell counts were elevated. Computed tomography revealed gas formation in her liver, and her culture results revealed Edwardsiella tarda and Escherichia coli infections. She underwent percutaneous transhepatic abscess drainage in addition to antimicrobial administration. She was discharged after 40 days. Cases of emphysematous liver abscess with Edwardsiella tarda infections are rarely reported in the literature and may present in patients with poorly controlled type 2 diabetes. The fatality rate associated with the condition is markedly high.
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The American journal of emergency medicine 50 811.e1-811.e2 2021年12月A cholinergic crisiss is a state characterized by excess acetylcholine owing to the ingestion of cholinesterase inhibitors or cholinergic agonists. We report the first case of a cholinergic crisis after the ingestion of a carpronium chloride solution, a topical solution used to treat alopecia, seborrhea sicca, and vitiligo. An 81-year-old woman with no prior medical history was transported to our emergency department because the patient had disturbance of consciousness after ingesting three bottles of FUROZIN® solution (90 mL, 4500 mg as carpronium chloride). A family member who found the patient called for emergency medical services (EMS) personnel, who contacted the patient ten minutes after ingestion. The patient's Glasgow Coma Scale score was 12 (E4V3M5), and vital signs were as follows: blood pressure, 80/40 mmHg; heart rate, 40 beats/min. The patient vomited repeatedly in the ambulance. On arrival to the ED, the patient's systolic blood pressure and heart rate temporarily decreased to 80 mmHg and 40 beats/min, respectively. Seventy-eight minutes after ingestion, gastric lavage was performed. The patient's symptoms, which included excess salivation, sweating, and hot flush, improved 24 h after ingestion, and the patient's vital signs stabilized without atropine or vasopressors. On the second day of admission, the patient was examined by a psychiatrist and discharged without suicidal ideation. Carpronium chloride has a chemical structure similar to that of acetylcholine; therefore, it exhibits both cholinergic and local vasodilatory activities. There is limited information on the pharmacokinetics of ingested carpronium chloride; therefore, physicians should be made aware that ingesting a carpronium chloride solution may cause a cholinergic crisis.
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日本集中治療医学会雑誌 28(Suppl.2) 186-186 2021年9月
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Journal of intensive care 9(1) 53-53 2021年8月25日The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members.As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.
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Medicine 100(8) e24736 2021年2月26日ABSTRACT: In diverticular bleeding, extravasation detected by computed tomography indicates active bleeding. It is unclear whether an endoscopic procedure is the best method of hemostasis for diverticular bleeding. This retrospective study was conducted to examine the effectiveness of endoscopic hemostasis in preventing diverticular rebleeding with extravasation visualized by contrast-enhanced computed tomography.This single-center, retrospective, the observational study utilized data from an endoscopic database. Adult patients admitted to our hospital due to diverticular bleeding diagnosed by colonoscopy were included. We compared the data between the extravasation-positive and extravasation-negative groups. The primary outcome was the proportion of successful hemostasis without rebleeding within 1 month after the first endoscopic procedure. Altogether, 69 patients were included in the study (n = 17, extravasation-positive group; n = 52, extravasation-negative group). The overall rebleeding rate was 30.4% (21/69). The rebleeding rate was higher in the extravasation-positive group than in the extravasation-negative group, although without a statistically significant difference. However, among the patients who underwent endoscopic hemostasis, the rebleeding rate was significantly higher in the extravasation-positive group than in the extravasation-negative group (50% [8/16] vs 10.5% [2/19], p = .022). In the extravasation-positive group, all 8 patients with rebleeding underwent repeat colonoscopy. Of these, 5 patients required additional clips; bleeding was controlled in 3 patients, while arterial embolization or surgery was required for hemostasis in 2 patients. None of the remaining 3 patients with rebleeding in the extravasation-positive group required clipping; thus, their conditions were only observed.Many patients with diverticular bleeding who exhibited extravasation on computed tomography experienced rebleeding after endoscopic hemostasis. However, bleeding in more than half of these patients could be stopped by 2 endoscopic procedures, without performing transcatheter arterial embolization or surgery even if rebleeding occurred. Some serious major complications due to such invasive interventions are reported in the literature, but colonoscopic complications did not occur in our patients. Endoscopic hemostasis may be the preferred and effective first-line therapy for patients with diverticular bleeding who have extravasation, as visualized by contrast-enhanced computed tomography.
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Acute medicine & surgery 8(1) e687 2021年BACKGROUND: Procalcitonin, a biomarker used to detect systemic bacterial infection, can be elevated in other conditions. Some case reports have suggested procalcitonin elevation induced by drug overdose. CASE PRESENTATION: A 20-year-old woman with insignificant medical history presented with vomiting, fever, and impaired consciousness. Her vital signs showed an altered mental status (Glasgow Coma Scale score, 11 [E4V1M6]) and high fever (38.0°C), and no significant neurological signs were detected. Laboratory tests revealed that her serum procalcitonin level was significantly high (>10 ng/dL). Gradually, her level of consciousness improved, and she admitted that she had taken an overdose of sympathomimetic drugs. She was discharged from the hospital on day 5 without any problems. CONCLUSION: Drug overdose is seldom mentioned as one of the causes of serum procalcitonin level elevation. Sympathomimetic drug overdose can be one of the causes of procalcitonin elevation.
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Acute medicine & surgery 8(1) e659 2021年The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members. As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.
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Frontiers in medicine 8 660367-660367 2021年Background: Advanced Life Support (ALS) is regarded to be associated with improved survival in pre-hospital trauma care when compared to Basic Life Support (BLS) irrespective of lack of evidence. The aim of this study is to ascertain ALS improves survival for trauma in prehospital settings when compared to BLS. Methods: We searched PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials for published controlled trials (CTs), and observational studies that were published until Aug 2017. The population of interest were adults (>18 years old) trauma patients who were transported by ground transportation and required resuscitation in prehospital settings. We compared outcomes between the ALS and BLS groups. The primary outcome was in-hospital mortality and secondary outcomes were neurological outcome and time spent on scene. Results: We identified 2,502 studies from various databases and 10 studies were included in the analysis (two CTs, and eight observational studies). The outcomes were not statistically significant between the ALS and BLS groups (pooled OR 1.14; 95% CI 0.95 to 1.36 for mortality, pooled OR 1.12; 95% CI 0.88 to 1.42 for good neurological outcomes, pooled mean difference -0.96; 95% CI-6.64 to 4.72 for on-scene time) in CTs. In observational studies, ALS prolonged on-scene time and increased mortality (pooled OR 1.56; 95% CI: 1.31 to 1.86 for mortality, and pooled mean difference, 1.26; 95% CI: 0.07 to 2.45 for on-scene time). Conclusions: In prehospital settings, the present study showed no advantages of ALS on the outcomes in patients with trauma compared to BLS.
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Journal of general and family medicine 21(5) 188-190 2020年9月 査読有りAn 82-year-old man with untreated diabetes mellitus (DM) had anterior chest wall swelling and ulcers 2 years following blunt chest trauma. Contrast-enhanced computed tomography revealed sternal fracture with osteolytic change and subcutaneous abscess. Blood and sternal cultures were positive for methicillin-susceptible Staphylococcus aureus (MSSA). Transesophageal echocardiogram showed vegetation on the right coronary cusp and moderate aortic regurgitation. The patient received a diagnosis of infective endocarditis associated with chronic sternal osteomyelitis complicated by subcutaneous abscess because of MSSA. This case report showed that trivial trauma in patients with uncontrolled DM can cause chronic sternal osteomyelitis resulting in infective endocarditis.
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The Journal of emergency medicine 59(2) 227-237 2020年8月 査読有りBACKGROUND: The influence of institutional volume of out-of-hospital cardiac arrest (OHCA) cases on outcomes remains unclear. OBJECTIVES: This study evaluated the relationship between institutional volume of adult, nontraumatic OHCA cases and 1-month favorable neurologic outcomes. METHODS: This study retrospectively analyzed data between January 2012 and March 2013 from a prospective observational study in the Kanto area of Japan. We analyzed adult patients with nontraumatic OHCA who underwent cardiopulmonary resuscitation by emergency medical service personnel and in whom spontaneous circulation was restored. Based on the institutional volume of OHCA cases, we divided institutions into low-, middle-, or high-volume groups. The primary and secondary outcomes were 1-month favorable neurologic outcomes and 1-month survival, respectively. A multivariate logistic regression analysis adjusted for propensity score and in-hospital variables was performed. RESULTS: Of 2699 eligible patients, 889, 898, and 912 patients were transported to low-volume (40 institutions), middle-volume (14 institutions), and high-volume (9 institutions) centers, respectively. Using low-volume centers as the reference, transport to a middle- or high-volume center was not significantly associated with a favorable 1-month neurologic outcome (adjusted odds ratio [OR] 1.21 [95% confidence interval {CI} 0.84-1.75] and adjusted OR 0.77 [95% CI 0.53-1.12], respectively) or 1-month survival (adjusted OR 1.10 [95% CI 0.82-1.47] and adjusted OR 0.76 [95% CI 0.56-1.02], respectively). CONCLUSIONS: Institutional volume was not significantly associated with favorable 1-month neurologic outcomes or 1-month survival in OHCA. Further investigation is needed to determine the association between hospital characteristics and outcomes in patients with OHCA.
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GASTROENTEROLOGY 158(6) S328-S328 2020年5月 査読有り0
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CRITICAL CARE MEDICINE 48 2020年1月 査読有り
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Oxford medical case reports 2019(9) omz095-411 2019年9月 査読有り
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BMJ open 9(8) e028172 2019年8月10日 査読有りINTRODUCTION: Over the past decades, the treatment for blunt splenic injuries has shifted from operative to non-operative management. Interventional radiology such as splenic arterial embolisation generally increases the success rate of non-operative management. However, the type of intervention, such as the first definitive treatment for haemostasis (interventional radiology or surgery) in blunt splenic injuries is unclear. Therefore, we aim to clarify whether interventional radiology improves mortality in patients with blunt splenic trauma compared with operative management by conducting a systematic review and meta-analysis. METHODS AND ANALYSIS: We will search the following electronic bibliographic databases to retrieve relevant articles for the literature review: Medline, Embase and the Cochrane Central Register of Controlled Trials. We will include controlled trials and observational studies published until September 2018. We will screen search results, assess the study population, extract data and assess the risk of bias. Two review authors will extract data independently, and discrepancies will be identified and resolved through a discussion with a third author where necessary. Data from eligible studies will be pooled using a random-effects meta-analysis. Statistical heterogeneity will be assessed by using the Mantel-Haenszel χ² test and the I² statistic, and any observed heterogeneity will be quantified using the I² statistic. We will conduct sensitivity analyses according to several factors relevant for the heterogeneity. ETHICS AND DISSEMINATION: Our study does not require ethical approval as it is based on the findings of previously published articles. This systematic review will provide guidance on selecting a method for haemostasis of splenic injuries and may also identify knowledge gaps that could direct further research in the field. Results will be disseminated through publication in a peer-reviewed journal and presentations at relevant conferences. PROSPERO REGISTRATION NUMBER: CRD42018108304.
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Oxford medical case reports 2019(6) omz042 2019年6月 査読有りAcute ischemic stroke (AIS) caused by major vessel occlusion has potentially poor outcomes. Early successful recanalization after symptom onset is an important factor for favorable outcomes of AIS. We present the case of a 74-year-old man with AIS who underwent the entire process from diagnosis to thrombolysis and endovascular treatment in a hybrid emergency room (ER) equipped with a multidetector computed tomography (CT) scanner and an angiography suite set-up. A hybrid ER can facilitate evaluation and definitive interventions in patients with AIS more quickly and safely and in one place, without the requirement for transfer to a CT scanner or angiography suite set-up. In the present case, the door-to-puncture time and door-to-reperfusion time were 85 and 159 min, respectively, which were shorter than those in the group conventionally treated for stroke in our institution. Further study is needed to confirm the effect of the hybrid ER system.
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Resuscitation 137 161-167 2019年4月 査読有りAIM: To evaluate volume-outcome relationship in paediatric out-of-hospital cardiac arrest (OHCA). METHODS: This post hoc analysis of the SOS-KANTO 2012 study included data of paediatric OHCA patients <18 years old who were transported to the 53 emergency hospitals in the Kanto region of Japan between January 2012 and March 2013. Based on the paediatric OHCA case volume, the higher one-third of institutions (more than 10 paediatric OHCA cases during the study period) were defined as high-volume centres, the middle one-third institutions (6-10 cases) were defined as middle-volume centres and the lower one-third of institutions (less than 6 cases) were defined as low-volume centres. The primary outcome measurement was survival at 1 month after cardiac arrest. Multivariate logistic regression analysis for 1-month survival and paediatric OHCA case volume were performed after adjusting for multiple propensity scores. To estimate the multiple propensity score, we fitted a multinomial logistic regression model, which fell into one of the three groups as patient demographics and prehospital factors. RESULTS: Among the eligible 282 children, 112, 82 and 88 patients were transported to the low-volume (36 institutions), middle-volume (11 institutions) and high-volume (6 institutions) centres, respectively. Transport to a high-volume centre was significantly associated with a better 1-month survival after adjusting for multiple propensity score (adjusted odds ratio, 2.55; 95% confidence interval, 1.05-6.17). CONCLUSION: There may be a relationship between institutional case volume and survival outcomes in paediatric OHCA.
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Acute medicine & surgery 6(1) 87-88 2019年1月 査読有り
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Journal of general and family medicine 19(4) 141-142 2018年7月 査読有り(A) Computed tomography of the brain showing no abnormal finding. (B) Magnetic resonance imaging of the brain showing a T1-weighted area of hyperintensity in the left putamen, caudate nucleus, and globus pallidum with sparing of the internal capsule (arrow). (C) T2*-weighted image showing hypointensity in the left putamen, caudate nucleus, and globus pallidum (arrowhead). (D) T2-weighted image showing no abnormal finding.
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Journal of medical case reports 11(1) 318-318 2017年11月11日 査読有りBACKGROUND: Cardiopulmonary resuscitation-related bleeding, especially internal mammary artery injuries, can become life-threatening complications after initiating venoarterial extracorporeal membrane oxygenation owing to the frequent involvement of concomitant anticoagulant treatment, antiplatelet treatment, targeted temperature management, and bleeding coagulopathy. We report the cases of five patients who experienced this complication and discuss their management. CASE PRESENTATION: We retrospectively evaluated five patients with cardiopulmonary resuscitation-related internal mammary artery injuries who were treated between February 2011 and February 2016 at our institution. All five patients were Asian men, aged 56 to 68-years old, who had received concomitant intravenously administered unfractionated heparin (3000 units) with antiplatelet therapy. Four patients received targeted temperature management. The injuries and hematomas were detected using contrast-enhanced computed tomography in all cases. Three patients were treated using transcatheter arterial embolization within 6 hours following cardiopulmonary arrest, and two were resuscitated and received appropriate treatment following early recognition of their injuries. Two patients died of hemorrhagic shock with delayed intervention. Four of the five patients had excessively prolonged activated partial thromboplastin times before their interventions. CONCLUSIONS: Computed tomography should be performed as soon as possible after the return of spontaneous circulation to identify injuries and consider appropriate treatments for patients who have experienced cardiac arrest. Delayed bleeding may develop after treating hypovolemic shock and relieving arterial spasms; therefore, transcatheter arterial embolization should be performed aggressively to prevent delayed bleeding even in the absence of extravasation. This approach may be superior to thoracotomy because it is less invasive, causes less bleeding, and can selectively stop arterial bleeding sooner. A 3000-unit intravenous bolus of unfractionated heparin may be redundant; heparin-free extracorporeal cardiopulmonary resuscitation may be a more appropriate alternative. Unfractionated heparin treatment can commence after the bleeding has stopped.
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World neurosurgery 106 185-192 2017年10月 査読有りBACKGROUND: Rapid decompression with trepanation and drainage in an emergency room has been proposed as a potentially effective initial intervention for early-stage acute subdural hemorrhage; however, the actual safety and efficacy of the procedure remain unclear. The aim of this study was to evaluate the feasibility of emergency trepanation as an initial treatment for acute subdural hemorrhage. METHODS: We investigated patients with thick subdural hemorrhages who had undergone craniotomy between 2004 and 2015 in Japan using a nationwide trauma registry (the Japan Trauma Data Bank). The endpoint was survival at discharge. We compared patients who underwent trepanation in an emergency room with those who did not undergo trepanation, and adjusted for potential confounders using a multivariate logistic regression model. RESULTS: During the study period, 236,698 patients were registered in the Japan Trauma Data Bank. Of the 1391 patients who were eligible for analysis, 305 had undergone trepanation in an emergency room. The survival rate was 37.7% in patients who had undergone emergency trepanation and 59.3% in those who had not. Performing emergency trepanation was significantly associated with decreased survival even after adjusting for possible confounders (adjusted odds ratio, 0.55; 95% confidence interval, 0.40-0.76; P < 0.001). CONCLUSIONS: Our results indicate that performing trepanation in an emergency room is associated with a decreased survival rate.
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Scandinavian journal of trauma, resuscitation and emergency medicine 25(1) 95-95 2017年9月16日 査読有りBACKGROUND: We investigated the relationship between neurological outcomes and duration from cardiac arrest (CA) to the initiation of extracorporeal membrane oxygenation (ECMO) (CA-to-ECMO) in patients with out-of-hospital cardiac arrest (OHCA) treated with extracorporeal cardiopulmonary resuscitation (ECPR) and determined the ideal time at which ECPR should be performed. METHODS: During the time period in which this study was conducted, 3451 patients experienced OHCA. This study finally included 79 patients aged 18 years or older whose OHCA had been witnessed and who underwent ECPR in the emergency room between January 2011 and December 2015. Our primary endpoint was survival to hospital discharge with good neurological outcomes (a cerebral performance category of 1 or 2). RESULTS: Of the 79 patients included, 11 had good neurological outcomes. The median duration from CA-to-ECMO was significantly shorter in the good neurological outcome group (33 min, interquartile range [IQR], 27-50 vs. 46 min, IQR, 42-56: p = 0.03). After controlling for potential confounders, we found that the adjusted odds ratio of CA-to-ECMO time for a good neurological outcome was 0.92 (95% confidence interval: 0.87-0.98, p = 0.007). The area under the receiver operating characteristic curve of CA-to-ECMO for predicting a good neurological outcome was 0.71, and the optimal CA-to-ECMO cutoff time was 40 min. The dynamic probability of survival with good neurological outcomes based on CA-to-ECMO time showed that the survival rate with good neurological outcome decreased abruptly from over 30% to approximately 15% when the CA-to-ECMO time exceeded 40 min. DISCUSSION: In this study, CA-to-ECMO time was significantly shorter among patients with good neurological outcomes, and significantly associated with good neurological outcomes at hospital discharge. In addition, the probability of survival with good neurological outcome decreased when the CA-to-ECMO time exceeded 40 minutes. The indication for ECPR for patients with OHCA should include several factors. However, the duration of CPR before the initiation of ECMO is a key factor and an independent factor for good neurological outcomes in patients with OHCA treated with ECPR. Therefore, the upper limit of CA-to-ECMO time should be inevitably included in the indication for ECPR for patients with OHCA. In the present study, there was a large difference in the rate of survival to hospital discharge with good neurological outcome between the patients with a CA-to-ECMO time within 40 minutes and those whose time was over 40 minutes. Based on the present study, the time limit of the duration of CPR before the initiation of ECMO might be around 40 minutes. We should consider ECPR in patients with OHCA if they are relatively young, have a witness and no terminal disease, and the initiation of ECMO is presumed to be within this time period. CONCLUSIONS: The duration from CA-to-ECMO was significantly associated with good neurological outcomes. The indication for patients with OHCA should include a criterion for the ideal time to initiate ECPR.
MISC
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日本救急医学会雑誌 32(S1) S1-S411 2021年2月日本集中治療医学会と日本救急医学会は,合同の特別委員会を組織し,2016年に発表した日本版敗血症診療ガイドライン(J-SSCG)2016の改訂を行った。本ガイドライン(J-SSCG2020)の目的は,J-SSCG2016と同様に,敗血症・敗血症性ショックの診療において,医療従事者が患者の予後改善のために適切な判断を下す支援を行うことである。改訂に際し,一般臨床家だけでなく多職種医療者にも理解しやすく,かつ質の高いガイドラインとすることによって,広い普及を目指した。J-SSCG2016ではSSCG2016にない新しい領域[ICU-acquircd weakness(ICU-AW)とpost-intensive care syndrome(POCS),体温管理など]を取り上げたが,J-SSCG2020では新たに注目すべき4領域(Patient-and Family-Centered Care, sepsis treatment system,神経集中治療,ストレス潰瘍)を追加し,計22領域とした。重要な118の臨床課題(clinical question:CQ)をエビデンスの有無にかかわらず抽出した。これらのCQには,本邦で特に注目されているCQも含まれる。多領域にわたる大規模ガイドラインであることから,委員25名を中心に,多職種(看護師,理学療法士,臨床工学技士,薬剤師)および患者経験者も含めたワーキンググループメンバー,両学会の公募によるシステマティックレビューメンバーによる総勢226名の参加・協力を得た。また,中立的な立場で横断的に活躍するアカデミックガイドライン推進班をJ-SSCG2016に引き続き組織した。将来への橋渡しとなることを企図して,多くの若手医師をシステマティックレビューチーム・ワーキンググループに登用し,学会や施設の垣根を越えたネットワーク構築も進めた。作成工程においては,質の担保と作業過程の透明化を図るために様々な工夫を行い,パブリックコメント募集は計2回行った。推奨作成にはGRADE方式を取り入れ,修正Delphi法を用いて全委員の投票により推奨を決定した。結果,118CQに対する回答として,79個のGRADEによる推奨,5個のGPS(good practice statement),18個のエキスパートコンセンサス,27個のBQ(background question)の解説,および敗血症の定義と診断を示した。新たな試みとして,CQごとに診療フローなど時間軸に沿った視覚的情報を取り入れた。J-SSCG2020は,多職種が関わる国内外の敗血症診療の現場において,ベッドサイドで役立つガイドラインとして広く活用されることが期待される。なお,本ガイドラインは,日本集中治療医学会と日本救急医学会の両機関誌のガイドライン増刊号として同時掲載するものである。(著者抄録)
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日本集中治療医学会雑誌 28(Suppl.) S1-S411 2021年2月日本集中治療医学会と日本救急医学会は,合同の特別委員会を組織し,2016年に発表した日本版敗血症診療ガイドライン(J-SSCG)2016の改訂を行った。本ガイドライン(J-SSCG2020)の目的は,J-SSCG2016と同様に,敗血症・敗血症性ショックの診療において,医療従事者が患者の予後改善のために適切な判断を下す支援を行うことである。改訂に際し,一般臨床家だけでなく多職種医療者にも理解しやすく,かつ質の高いガイドラインとすることによって,広い普及を目指した。J-SSCG2016ではSSCG2016にない新しい領域[ICU-acquircd weakness(ICU-AW)とpost-intensive care syndrome(POCS),体温管理など]を取り上げたが,J-SSCG2020では新たに注目すべき4領域(Patient-and Family-Centered Care, sepsis treatment system,神経集中治療,ストレス潰瘍)を追加し,計22領域とした。重要な118の臨床課題(clinical question:CQ)をエビデンスの有無にかかわらず抽出した。これらのCQには,本邦で特に注目されているCQも含まれる。多領域にわたる大規模ガイドラインであることから,委員25名を中心に,多職種(看護師,理学療法士,臨床工学技士,薬剤師)および患者経験者も含めたワーキンググループメンバー,両学会の公募によるシステマティックレビューメンバーによる総勢226名の参加・協力を得た。また,中立的な立場で横断的に活躍するアカデミックガイドライン推進班をJ-SSCG2016に引き続き組織した。将来への橋渡しとなることを企図して,多くの若手医師をシステマティックレビューチーム・ワーキンググループに登用し,学会や施設の垣根を越えたネットワーク構築も進めた。作成工程においては,質の担保と作業過程の透明化を図るために様々な工夫を行い,パブリックコメント募集は計2回行った。推奨作成にはGRADE方式を取り入れ,修正Delphi法を用いて全委員の投票により推奨を決定した。結果,118CQに対する回答として,79個のGRADEによる推奨,5個のGPS(good practice statement),18個のエキスパートコンセンサス,27個のBQ(background question)の解説,および敗血症の定義と診断を示した。新たな試みとして,CQごとに診療フローなど時間軸に沿った視覚的情報を取り入れた。J-SSCG2020は,多職種が関わる国内外の敗血症診療の現場において,ベッドサイドで役立つガイドラインとして広く活用されることが期待される。なお,本ガイドラインは,日本集中治療医学会と日本救急医学会の両機関誌のガイドライン増刊号として同時掲載するものである。(著者抄録)
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Intensivist 13(1) 141-157 2021年1月＜文献概要＞肺血栓塞栓症(PTE)は,無症状から心停止に至るまで幅広い重症度を含んだ疾患であり,治療方針決定には患者背景,血行動態の把握に加えて,バイオマーカーや画像検査による右室機能障害の評価,出血性合併症リスクを総合的に勘案したリスク層別化が必須である。また,抗凝固療法,血栓溶解療法,カテーテル治療,外科的治療など,さまざまな治療オプションがあり,複雑化している。pulmonary embolism response team(PERT)を各施設で組織することにより,より迅速で適切な臨床判断ができる可能性がある。ICUは今後も肺血栓塞栓症管理において,重要な役割を果たすことになろう。
共同研究・競争的資金等の研究課題
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日本学術振興会 科学研究費助成事業 2021年4月 - 2026年3月
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日本学術振興会 科学研究費助成事業 若手研究 2020年4月 - 2023年3月