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Abstract Hemorrhagic shock is a significant cause of trauma-related mortality. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a less-invasive aortic occlusion maneuver for severe hemorrhagic shock but potentially inducing oxidative stress injuries. In an animal model, this study investigated hydrogen gas inhalation therapy’s potential to mitigate post-REBOA ischemia-reperfusion injuries (IRIs). Ten healthy female swine underwent REBOA placement after induced 40% hemorrhagic shock. They were observed during the IRI phase after a 60-minute Zone 1 occlusion for 180 minutes until euthanasia. 2% hydrogen gas inhalation was started simultaneously with REBOA inflation in the hydrogen group. We evaluated survival time, lactate, and 8-hydroxy-2’-deoxyguanosine (8-OHdG) biomarkers, gross findings, and pathological grades. One swine in the control group died at 90 min, and the remaining animals survived throughout the experiment. Survival analysis showed no significant differences between the two groups (control vs. hydrogen, 4/5 vs. 5/5; Log-rank, P = 0.317). Lactate levels during and after REBOA suggested a tendency towards lower levels in the hydrogen group (10.5 ± 4.2 vs. 7.6 ± 2.3 mmol/L, peak, T = 90). Serum 8-OHdG concentrations showed a lower trend in the hydrogen group (Range: 0.12–0.32 vs. 0.11–0.19 ng/mL). The villi of the ileum were destroyed during REBOA inflation and after reperfusion. Changes in the pathological grade of the ileum demonstrated no significant differences in both groups (2.8 ± 1.0 vs. 2.0 ± 1.0, proximal ileum, T = 240). Hydrogen gas inhalation therapy exhibited no significant difference compared to the control group in survival, lactate level, 8-OHdG, and intestinal mucosal injury following REBOA in a hemorrhagic shock model. Although it may slightly reduce mortality, biomarkers, and intestinal pathology, hydrogen gas inhalation therapy was not shown to have sufficient evidence to mitigate REBOA-IRI.

Background Resuscitative endovascular balloon occlusion of the aorta (REBOA) can temporarily control arterial hemorrhage in torso trauma; however, the abdominal visceral blood flow is also blocked by REBOA. The aim of this study was to evaluate the influence of REBOA on gastrointestinal function.Methods A retrospective review identified all trauma patients admitted to our trauma center between 2008 and 2019. We used propensity score matching analysis to compare the gastrointestinal function between subjects who underwent REBOA and those who did not. Data on demographics, feeding intolerance (FI), time to feeding goal achievement, and complications were retrieved.Results During the study period, 55 patients underwent REBOA. A total of 1694 patients met the inclusion criteria, 27 of whom were a subset of those who underwent REBOA. After 1:1 propensity score matching, the REBOA and no-REBOA groups were assigned 22 patients each. Patients in the REBOA group had a significantly higher incidence of FI (77% vs. 27%; OR, 9.1; 95% CI, 2.31 to 35.7; p=0.002) and longer time to feeding goal achievement (8 vs. 6 days, p=0.022) than patients in the no-REBOA group. Patients in the REBOA group also showed significantly prolonged durations of ventilator use (8 vs. 4 days, p=0.023). Furthermore, there was no difference in the mortality rate between the groups (9% vs. 9%, p=1.000).Conclusions REBOA was associated with gastrointestinal dysfunction. Our study findings can be useful in providing guidance on managing nutrition in trauma patients who undergo REBOA.Level of evidence Level IVStudy type Care management

Aim: This study aimed to assess the association between gasping and survival among out-of-hospital cardiac arrest (OHCA) patients requiring extracorporeal cardiopulmonary resuscitation (ECPR). Methods: This prospective, multicenter, observational study was conducted between 2019 and 2021. We categorized adult patients requiring ECPR into those with or without gasping prior to hospital arrival. The primary outcome was the 30-day survival. We performed multivariable logistic regression analyses fitted with generalized estimating equations and subgroup analyses based on the initial rhythm and age. Results: Of the 9,909 patients with OHCA requiring ECPR, 332 were enrolled in the present study, including 92 (27.7%) and 240 (72.3%) with and without gasping, respectively. The 30-day survival was higher in patients with gasping than in those without gasping (35.9% [33/92] vs. 16.2% [39/240]). In the logistic regression analysis, gasping was significantly associated with improved 30-day survival (adjusted odds ratio: 3.01; 95% confidence interval, 1.64–5.51). Subgroup analyses demonstrated similar trends in patients with an initial non-shockable rhythm and older age. Conclusions: Gasping was associated with improved survival in OHCA patients requiring ECPR, even those with an initial non-shockable rhythm and older age. Clinicians may select the candidates for ECPR appropriately based on the presence of gasping.

Aim: To assess the association between body mass index (BMI) and neurological outcomes among patients with out-of-hospital cardiac arrest (OHCA). Methods: This prospective, multicenter, observational study conducted between 2019 and 2021 included adults with OHCA who were hospitalized after return of spontaneous circulation. Based on the BMI, the patients were categorized as underweight (BMI

Abstract Background The efficacies of fresh frozen plasma and coagulation factor transfusion have been widely evaluated in trauma-induced coagulopathy management during the acute post-injury phase. However, the efficacy of red blood cell transfusion has not been adequately investigated in patients with severe trauma, and the optimal hemoglobin target level during the acute post-injury and resuscitation phases remains unclear. Therefore, this study aimed to examine whether a restrictive transfusion strategy was clinically non-inferior to a liberal transfusion strategy during the acute post-injury phase. Methods This cluster-randomized, crossover, non-inferiority multicenter trial was conducted at 22 tertiary emergency medical institutions in Japan and included adult patients with severe trauma at risk of major bleeding. The institutions were allocated a restrictive or liberal transfusion strategy (target hemoglobin levels: 7–9 or 10–12 g/dL, respectively). The strategies were applied to patients immediately after arrival at the emergency department. The primary outcome was 28-day survival after arrival at the emergency department. Secondary outcomes included transfusion volume, complication rates, and event-free days. The non-inferiority margin was set at 3%. Results The 28-day survival rates of patients in the restrictive (n = 216) and liberal (n = 195) strategy groups were 92.1% and 91.3%, respectively. The adjusted odds ratio for 28-day survival in the restrictive versus liberal strategy group was 1.02 (95% confidence interval: 0.49–2.13). Significant non-inferiority was not observed. Transfusion volumes and hemoglobin levels were lower in the restrictive strategy group than in the liberal strategy group. No between-group differences were noted in complication rates or event-free days. Conclusions Although non-inferiority of the restrictive versus liberal transfusion strategy for 28-day survival was not statistically significant, the mortality and complication rates were similar between the groups. The restrictive transfusion strategy results in a lower transfusion volume. Trial registration number: umin.ac.jp/ctr: UMIN000034405, registration date: 8 October 2018.

Abstract Aim Non‐occlusive mesenteric ischemia (NOMI) is associated with high mortality rates, but definitive treatments have not yet been established. Although experimental animal models are worthwhile, reproducible models that reflect the pathophysiology of NOMI have not been developed. Methods We combined risk factors for NOMI, comprising hemorrhagic shock, systemic vasopressor infusion, and local vasopressor infusion from the superior mesenteric artery (SMA) in swine under maintained anesthesia. Experiment 1 involved full‐intensity (40%) phlebotomy and systemic vasopressor (norepinephrine and epinephrine). Experiment 2 involved full‐intensity (40%) phlebotomy, systemic norepinephrine, and local vasopressor infusion into the SMA. Experiment 3 involved moderate (27%) phlebotomy, systemic norepinephrine infusion, and local epinephrine infusion. We evaluated serum lactate levels, intestinal serosa color, computed tomography (CT) angiography, and pathological findings. Results After inducing hemorrhage, systemic vasopressor alone and in combination with local vasopressin or norepinephrine infusion did not induce ischemic color changes in the intestine. The combination of systemic norepinephrine and local epinephrine (0.5 μg/kg/min) after moderate (27% blood loss) hemorrhage induced gross color change, pathological destruction, and elevation of serum lactate. Patent flow in the SMA was confirmed on CT angiography. Conclusion We established a swine NOMI model with systemic norepinephrine infusion and local epinephrine with moderate hemorrhagic shock.

Abstract Aim A balanced transfusion strategy has been a standard resuscitation method for trauma patients, and adherence to a massive transfusion protocol incorporating balanced transfusion is reported to reduce mortality. This study aimed to assess adherence to balanced transfusion among severely injured patients in Japan. Methods This study analyzes RESTRIC (restrictive transfusion strategy for critically injured patients) trial patients who were cluster‐randomized based on restrictive or liberal transfusion strategy. We defined two transfusion groups: massive transfusion group 1, which includes RBC transfusions of at least eight units within 6 h; and massive transfusion group 2, which includes RBC transfusions of at least 20 units within 24 h. Adherence to balanced transfusion was assessed as the ratios of fresh frozen plasma (FFP) to red blood cells (RBC) and platelet concentrate (PC) to RBC ratio >0.5. Results Among 220 eligible patients, 98 (44.5%) were grouped as massive transfusion group 1 and 38 (17.3%) as massive transfusion group 2. The balanced transfusion in terms of the FFP to RBC ratio was nearly 100% for groups 1 and 2 over all periods. However, the balanced transfusion in terms of the PC to RBC ratio within 6 h were 51.0% for group 1 and 68.4% for group 2. Conclusion This study revealed that while the ratio of FFP to RBC was balanced among patients from the early phase, the ratio of PC to RBC was not fully balanced, particularly in the early phase.

Abstract Background Nitrogen dioxide (NO2) is known to cause lung injury, but there is no established treatment for acute respiratory distress syndrome (ARDS) caused by NO2 inhalation. Case Presentation A 35‐year‐old man was accidentally exposed to NO2 fumes and presented to the emergency department. On admission, his oxygen saturation was 87% on ambient air and he was diagnosed with ARDS caused by NO2 inhalation and immediately intubated; however, hypoxemia and hypercapnia were not ameliorated. Hence, veno‐venous extracorporeal membrane oxygenation (V‐V ECMO) was introduced and the ventilator settings were set for lung‐protective ventilation. Methylprednisolone was also administered. After the initiation of these treatments, oxygenation gradually improved. Therefore, ECMO was weaned off on day 11 and he was extubated on day 12. Conclusion Lung injury caused by NO2 inhalation can cause ARDS, and lung‐protective ventilation with V‐V ECMO induction, as well as glucocorticoid administration, may be effective for this condition.

Abstract Asciminib, a first‐in‐class, allosteric inhibitor of BCR‐ABL1 that acts by STAMP (Specifically Targeting the ABL Myristoyl Pocket), is a novel therapeutic option for patients with chronic myeloid leukemia (CML). In the global, phase 3, open‐label ASCEMBL study in patients with CML in chronic phase (CML‐CP) pretreated with ≥2 tyrosine kinase inhibitors (TKIs) (NCT03106779), asciminib (40 mg twice‐daily) demonstrated significant superiority over the ATP‐competitive TKI bosutinib (500 mg once daily) for the primary endpoint of major molecular response (MMR; BCR::ABL1 transcript levels on the international scale [BCR::ABL1IS] ≤0.1%) at week 24. Here, we report results from a descriptive subgroup analysis of Japanese patients enrolled in ASCEMBL study (data cut‐off: May 25, 2020). Overall, 16 Japanese patients were randomized (asciminib, n = 13; bosutinib, n = 3). At week 24, the MMR rate with asciminib was 30.8% (4/13; 95% confidence interval [CI], 9.09–61.43). BCR::ABL1IS ≤1% and complete cytogenic response (CCyR) at week 24 were 61.5% (8/13 patients) and 50.0% (4/8 patients), respectively. In the bosutinib group, no patient achieved MMR, CCyR, or BCR::ABL1IS ≤1%, but results were limited by the low number of patients. The safety profile of asciminib was comparable to that previously observed in the overall study population. Findings from this Japanese subgroup analysis of the ASCEMBL study support the use of asciminib for the treatment of Japanese patients with CML‐CP previously treated with ≥2 TKIs. ClinicalTrials.gov Identifier: NCT03106779.

Background: Nonoperative management (NOM) is the standard treatment for hemodynamically stable blunt splenic injury (BSI). However, NOM failure is a significant source of morbidity and mortality. We developed a clinical risk scoring system for NOM failure in BSI. Methods: Data from the Japanese Trauma Data Bank from 2008 to 2018 were analyzed. Eligible patients were restricted to those who underwent NOM with high-grade BSI (Organ Injury Scale ≥3). The primary outcome was a predictive score for NOM failure based on risk estimation. Results: There were 1651 patients included in this analysis, among whom 110 (6.7%) patients had NOM failure. Multivariate analysis identified seven variables associated with failed NOM: systolic blood pressure, Glasgow coma scale, Injury Severity Score, other concomitant abdominal injury, pelvic injury, high-grade BSI, and angioembolization. An eight-point predictive score was developed with a cut-off of greater than 5 points (specificity, 98.2%; sensitivity, 25.5%) with an area under the curve of 0.81. Conclusion: The clinical predictive score had good ability to predict NOM failure and may help surgeons to make better decisions for BSI.

Abstract Background The prevalence of extracorporeal cardiopulmonary resuscitation (ECPR) in patients with out-of-hospital cardiac arrest (OHCA) has been increasing rapidly worldwide. However, guidelines or clinical studies do not provide sufficient data on ECPR practice. The aim of this study was to provide real-world data on ECPR for patients with OHCA, including details of complications. Methods We did a retrospective database analysis of observational multicenter cohort study in Japan. Adult patients with OHCA of presumed cardiac etiology who received ECPR between 2013 and 2018 were included. The primary outcome was favorable neurological outcome at hospital discharge, defined as a cerebral performance category of 1 or 2. Results A total of 1644 patients with OHCA were included in this study. The patient age was 18–93 years (median: 60 years). Shockable rhythm in the initial cardiac rhythm at the scene was 69.4%. The median estimated low flow time was 55 min (interquartile range: 45–66 min). Favorable neurological outcome at hospital discharge was observed in 14.1% of patients, and the rate of survival to hospital discharge was 27.2%. The proportions of favorable neurological outcome at hospital discharge in terms of shockable rhythm, pulseless electrical activity, and asystole were 16.7%, 9.2%, and 3.9%, respectively. Complications were observed during ECPR in 32.7% of patients, and the most common complication was bleeding, with the rates of cannulation site bleeding and other types of hemorrhage at 16.4% and 8.5%, respectively. Conclusions In this large cohort, data on the ECPR of 1644 patients with OHCA show that the proportion of favorable neurological outcomes at hospital discharge was 14.1%, survival rate at hospital discharge was 27.2%, and complications were observed during ECPR in 32.7%.

Introduction Abdominal compartment syndrome (ACS) after blunt abdominal trauma is a rare complication that requires early recognition and subsequent surgical intervention for optimal outcome. We aimed to investigate how differences in injured abdominal organs affect ACS development in patients with severe blunt abdominal trauma. Methods This nested case-control study used a nationwide registry of trauma patients, namely, the Japan Trauma Data Bank (JTDB), and only included patients aged ≥ 18 years with blunt severe abdominal trauma, defined as an AIS score of abdomen ≥ 3, sustained between 2004 and 2017. Patients without ACS were used as control subjects and identified using propensity score (PS) matching. Characteristics and outcomes between patients with and without ACS were compared and logistic regression was used to identify specific risk factors for ACS. Results Among 294,274 patients in the JTDB, 11,220 were eligible for inclusion before PS matching, and 150 (1.3%) developed ACS after trauma. PS matching led to the inclusion of 131 and 655 patients with and without ACS, respectively. Compared to controls, patients with ACS had higher number of injured organs in the abdomen and displayed a greater frequency of vascular and pancreatic injuries, need for blood transfusion, and disseminated intravascular coagulopathy, a complication of ACS. In-hospital mortality was higher in patients with ACS than those without ACS (51.1% vs. 26.0%, p < 0.01). Logistic regression analysis revealed that a higher number of injured organs in the abdomen [odds ratio (OR) (95% confidence interval [CI]): 1.76 (1.23–2.53)] and pancreatic injury [OR (95% CI): 1.53 (1.03–2.27)] were independently associated with ACS. Conclusions Greater number of injured organs in abdomen and pancreatic injury are independent risk factors for the development of ACS.

Aim Substantial variations in the utilization of angioembolization have been reported internationally. However, the existence of variations in the utilization of angioembolization in Japan is currently unknown. Methods This was a cross‐sectional study using data from a nationwide trauma registry in Japan. Of the 4,896 registered adult patients with splenic injury, we investigated 3,319 patients in the top 25% of the hospitals that registered the highest number of splenic injury patients in the Japan Trauma Data Bank. The primary outcome of this study was initial angioembolization. We calculated the expected initial angioembolization rates using multiple regression analysis adjusted for patient factors. In addition, we evaluated the range of observed‐to‐expected initial splenic angioembolization ratio for each hospital. Moreover, we assessed whether this ratio was increased with time. Results The frequency of initial splenic angioembolization ranged from 0% to 52%. The median expected initial angioembolization rate, calculated through multiple logistic regression analysis, was 19.7%. The observed‐to‐expected initial splenic angioembolization ratio for each hospital ranged from 0 to 2.36. The observed initial angioembolization rate tended to increase with time (P

Aim: This study aimed to investigate the relationship between transient return of spontaneous circulation (ROSC) before extracorporeal membrane oxygenation (ECMO) initiation and outcomes in out-of-hospital cardiac arrest (OHCA) patients, who were resuscitated with extracorporeal cardiopulmonary resuscitation (ECPR). Methods: This study was a secondary analysis of the SAVE-J II study, which was a retrospective multicentre registry study involving 36 participating institutions in Japan. We classified patients into two groups according to the presence or absence of transient ROSC before ECMO initiation. Transient ROSC was defined as any palpable pulse of ≥1 min before ECMO initiation. The primary outcome was favourable neurological outcomes (cerebral performance categories 1–2). Results: Of 2,157 patients registered in the SAVE-J II study, 1,501 met the study inclusion criteria; 328 (22%) experienced transient ROSC before ECMO initiation. Patients with transient ROSC had better outcomes than those without ROSC (favourable neurological outcome, 26% vs 12%, P

Abstract 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.

Abstract The impact of infection on the prognosis of trauma patients according to severity remains unclear. We assessed the impact of infection complications on in-hospital mortality among patients with trauma according to severity. This retrospective cohort study used a nationwide registry of trauma patients. Patients aged ≥ 18 years with blunt or penetrating trauma who were admitted to intensive care units or general wards between 2004 and 2017 were included. We compared the baseline characteristics and outcomes between patients with and without infection and conducted a multivariable logistic regression analysis to investigate the impact of infection on in-hospital mortality according to trauma severity, which was classified as mild [Injury Severity Score (ISS)

Abstract Background Embolization is widely used for controlling arterial hemorrhage associated with pelvic fracture. However, the effect of a delay in embolization among hemodynamically stable patients at hospital arrival with a pelvic fracture is unknown. Therefore, our aim was to investigate the association between the time to embolization and mortality in hemodynamically stable patients at hospital arrival with a pelvic fracture. Methods A multicenter, retrospective cohort study was undertaken using data from the Japan Trauma Data Bank between 2004 and 2018. Hemodynamically, stable patients with a pelvic fracture who underwent an embolization within 3 h were divided into six groups of 30-min blocks of time until pelvic embolization (0–30, 30–60, 60–90, 90–120, 120–150, and 150–180 min). We compared the adjusted 30-day mortality rate according to time to embolization. Results We studied 620 hemodynamically stable patients with a pelvic fracture who underwent pelvic embolization within 3 h of hemorrhage. The median age was 68 (48–79) years and 55% were male. The median injury severity score was 26 (18–38). Thirty-day mortality was 8.9% (55/620) and 24-h mortality was 4.2% (26/619). A Cochran–Armitage test showed that a 30-min delay for embolization was associated with increased 30-day (p = 0.0186) and 24-hour (p = 0.033) mortality. Mortality within 0–30 min to embolization was 0%. The adjusted 30-day mortality rate increased with delayed embolization and was up to 17.0% (10.2–23.9) for the 150–180 min group. Conclusion Delayed embolization was associated with increased mortality in pelvic fracture with hemodynamic stability at hospital arrival. When you decide to embolize pelvic fracture patients, the earlier embolization may be desirable to promote improved survival regardless of hemodynamics.

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is increasingly used in trauma resuscitation for patients with life-threatening hemorrhage below the diaphragm and may also be used for patients with traumatic cardiac arrest (TCA). Resuscitative thoracotomy with aortic cross clamping (RT-ACC) maneuver was traditionally performed for patients with TCA due to hemorrhagic shock; however, REBOA has been substituted for RT-ACC in selected TCA cases. During cardiopulmonary resuscitation (CPR) in TCA, REBOA increases cerebral and coronary perfusion, and temporary bleeding control. Both animal and clinical studies have reported the efficacy of REBOA for TCA, and a recent observational study suggested that REBOA may contribute to the return of spontaneous circulation after TCA. Although multiple questions remain unanswered, REBOA has been applied to trauma fields as a novel technology.

Abstract Background Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an increasingly used trauma resuscitation procedure, however, there are no reports of whether or not the survival of patients treated with REBOA increases over time. Methods This retrospective cohort study from a nationwide trauma registry in Japan was conducted between 2004 and 2015. Patients treated with REBOA were divided into three calendar year periods: early-period (2004–2007), mid-period (2008–2011), and late-period (2012–2015). The primary outcome of in-hospital survival was compared between the periods (early-period: reference) using mixed effects logistic regression analysis after adjustment for characteristics, trauma severity, and therapeutic choices. Results Of 236,698 trauma patients, 633 patients treated with REBOA were analyzed. Distribution of the patients across periods was as follows: early-period (91), mid-period (276), and late-period (266). In-hospital survival was 39, 49, and 60% in the early-period, mid-period, and late-period, respectively. In regression modeling, the late-period (OR = 2.976, 95% CI = 1.615–5.482) was associated with improved in-hospital survival compared to the early-period, however, the mid-period (OR = 1.614, 95% CI = 0.898–2.904) was not associated with improved survival. Conclusions Survival of patients treated with REBOA during the late-period improved compared with survival during the early-period, after adjustment for characteristics, trauma severity, and therapeutic choices. REBOA may be one of the important factors related to progression of modern trauma treatment.

Angioembolization for hemodynamically unstable patients with pelvic fracture has become the standard of care. However, the selection and extent of contrast of the distal artery in such patients remains undetermined. In this case, an octogenarian man was hit by a truck and was hemodynamically unstable with pelvic fracture. Based on enhanced computed tomography, selective angiography visualized arterial extravasation and the arterial bleeding could be arrested. This approach may be required for the treatment of patients in this setting. Keywords: Pelvic fracture, Unstable hemodynamics, Selective contrast, Resuscitative endovascular balloon occlusion of the aorta

Abstract Background Perforation of a marginal peptic ulcer after pancreaticoduodenectomy (PD) can lead to severe conditions, although its clinical features have not been well reported. In this article, we present three cases of marginal peptic ulcer perforation after PD that we experienced in our institute and attempt to clarify its appropriate treatment and prevention. Case presentation Marginal ulcer perforation confirmed with computed tomography and/or surgical exploration occurred in 3 (1.8%) of 163 consecutive patients who underwent PD (including 160 patients who underwent a total or subtotal stomach-preserving procedure) at our institution. The three patients (one man and two women) had a median age of 77 (65–79) years. Two of these patients had a medical history of duodenal peptic ulcer. All three patients had biliary neoplasms. Two of the patients underwent subtotal stomach-preserving PD with antro-jejunal anastomosis, and the other patient underwent pylorus-preserving PD with duodenal jejunostomy. The perforation occurred with a sudden and severe onset of abdominal pain 34, 94, and 1204 days, respectively, after the PDs. At the time of the perforation, all of the patients had been withdrawn from postoperative prophylactic antipeptic ulcer agents, with the cessation periods ranging from 12 to 1008 days. In addition, all the patients were in fasting conditions for 1 to 13 days just before the perforation. Surgical treatment with direct suturing of the perforated ulcer was performed for two patients, while conservative therapy was performed for one patient. Their primary treatment courses were satisfactory. Chronic antisecretory agent therapy was prescribed for 562, 271, and 2370 days, respectively, from marginal ulcer perforation, and no ulcer recurrence was noted in any of the patients. Conclusions Lack of antisecretory therapy and fasting were considered an essential cause of marginal peptic ulcer perforation after PD. In addition, unlike the native duodenum, the jejunal limb used for reconstruction to a preserved stomach may be at increased risk of ulceration. Chronic permanent administration of antisecretory agents and fasting avoidance are desirable for patients who have undergone stomach-preserving PD to prevent marginal ulcer perforation.

Many blunt trauma injuries have multiple bleeding points and are accompanied by coagulopathy. In contrast, in a non-traumatic injury, the patient often demonstrates a single bleeding site that is rarely accompanied by coagulopathy. Thus, resuscitative endovascular balloon occlusion of the aorta (REBOA) is considered more effective in non-traumatic cases than in traumatic cases. In addition, in non-traumatic cases, REBOA may be used for central blood flow control during definitive hemostasis and prevention of expected massive bleeding. In such cases, REBOA should be used carefully to avoid complications. We describe the indications for and uses of REBOA in non-traumatic cases based on existing evidence.

Aim Limited information exists on the factors associated with prolonged procedural time in embolization for trauma patients. We clarified the clinical application of embolization in trauma patients and factors associated with a prolonged procedure time. Methods Medical records of 162 trauma patients who underwent embolization between January 2007 and December 2020 at a regional trauma care center were reviewed retrospectively. Patients were divided into four embolized body regions: chest, abdomen, pelvis, and other. Patient demographics, trauma mechanism, physiology, trauma severity, embolization procedures, and 30‐day mortality were examined. The outcomes were identifying an embolized body region, embolized arteries, and procedure time. Multiple regression model was created to investigate the factors associated with prolonged procedural time in embolization. Results Embolization was mainly undertaken in pelvic fractures (n = 96, 59%) and abdominal organ injuries (n = 57, 35%) and extended to the chest (n = 17, 10%), and other (n = 20, 12%). Approximately 13% (n = 21) of patients underwent embolization in two or more regions. Embolization was more strictly performed in minor artery injuries, for example, external iliac (n = 15, 16%) and lumbar artery (n = 22, 23%) branches in pelvic fractures, and inferior phrenic artery (n = 2, 3.5%) branches in liver injuries. Multiple regression model indicated that the number of embolized arteries (P = 0.021) and number of embolized regions (P

Abstract For traumatic cardiac arrest (TCA), the effect of prehospital epinephrine administration was unclear. The aim of this study was to evaluate the relationship between prehospital epinephrine administration and survival in patients with TCA caused by traffic collisions. We conducted a nationwide, prospective, population-based observational study involving patients who experienced out-of-hospital cardiac arrest (OHCA) by using the All-Japan Utstein Registry. Blunt trauma patients with TCA who received prehospital epinephrine were compared with those who did not receive prehospital epinephrine. The primary outcome was 1-month survival of patients. The secondary outcome was prehospital return of spontaneous circulation (ROSC). A total of 5,204 patients with TCA were analyzed. Of those, 758 patients (14.6%) received prehospital epinephrine (Epinephrine group), whereas the remaining 4,446 patients (85.4%) did not receive prehospital epinephrine (No epinephrine group). Eleven (1.5%) and 41 (0.9%) patients in the Epinephrine and No epinephrine groups, respectively, survived for 1 month. In addition, 74 (9.8%) and 40 (0.9%) patients achieved prehospital ROSC in the Epinephrine and No epinephrine groups, respectively. In multivariable logistic regression models, prehospital epinephrine administration was not associated with 1-month survival (odds ratio [OR] 1.495, 95% confidence interval [CI] 0.758 to 2.946) and was associated with prehospital ROSC (OR 3.784, 95% CI 2.102 to 6.812). A propensity score-matched analysis showed similar results for 1-month survival (OR 2.363, 95% CI 0.606 to 9,223) and prehospital ROSC (OR 6.870, 95% CI 3.326 to 14.192). Prehospital epinephrine administration in patients with TCA was not associated with 1-month survival, but was beneficial in regard to prehospital ROSC.

Abstract Background Determining the presence of an active arterial hemorrhage in the acute phase is important as a treatment strategy in patients with pelvic fracture. The purpose of this study was to evaluate whether coagulation biomarkers could predict arterial extravasation, especially in pelvic fracture patients with stable hemodynamics. Methods We studied patients with a pelvic fracture who had a systolic blood pressure above 90 mmHg and lactate level less than 5.0 mmol/L on hospital arrival. Patients were divided into two groups: those with arterial extravasation on enhanced computed tomography (CT) or angiography (extravasation [+] group) and those without arterial extravasation (extravasation [−] group). Coagulation biomarkers measured on arrival were statistically compared between the two groups. Predictive ability of arterial extravasation using coagulation biomarkers was evaluated by receiver-operating characteristic analyses provided area under the receiver-operating characteristic curves (AUROC) and diagnostic indicators with optimal cutoff point including sensitivity, specificity, positive and negative predictive values, and diagnostic odds ratio (DOR). Results Sixty patients were analyzed. Fibrin degradation products (FDP), D-dimer, prothrombin time–international normalized ratio (PT–INR), and the ratio of FDP to fibrinogen were significantly higher in the extravasation (+) group than in the extravasation (−) group (FDP, 242 μg/mL [145–355] vs. 96 μg/mL [58–153]; D-dimer, 81 μg/mL [41–140] vs. 39 μg/mL [21–75]; PT–INR, 1.09 [1.05–1.24] vs. 1.02 [0.98–1.08]; and ratio of FDP to fibrinogen, 1.06 [0.85–2.01] vs. 0.46 [0.25–0.74]). The highest AUROC was with a ratio of FDP to fibrinogen of 0.777 (95% confidence interval, 0.656–0.898), and the highest predictive ability in terms of DOR was with a ratio of FDP to fibrinogen (sensitivity, 0.76; specificity, 0.76; DOR 9.90). Conclusion Coagulation biomarker could predict of arterial extravasation in pelvic fracture patients with stable hemodynamics.

Background Limited information exists regarding the clinical characteristics, management practices, and outcomes of pediatric patients with liver injury in Japan. The aim of this study is to evaluate the characteristics, management, and outcome of pediatric patients with liver injury in Japan.Methods We conducted a multicenter, retrospective cohort study using data from the Japan Trauma Data Bank between 2004 and 2018. Pediatric patients with liver injury were classified into the following management groups: nonoperative management (NOM); NOM with angioembolization (AE); operative management (OM). The primary outcome was in-hospital survival, and the secondary outcomes were dispositions, hospital length of stay (LOS), and rate of discharge to home.Results There were 308 pediatric patients with severe liver injury (organ injury scale grades ≥Ⅲ) during the study period; 135 patients had isolated liver injury and 173 patients had non-isolated liver injury. The rates of NOM, NOM with AE, and OM among all patients were 65%, 23%, and 12%, respectively. AE was highly used both in patients with isolated liver injury (27%) and non-isolated liver injury (22%). In-hospital survival of patients with isolated liver injury and those with non-isolated liver injury were 99% and 88%, respectively. Regarding secondary outcomes among patients with isolated liver injury, 82% were admitted to the intensive care unit. LOS was 11 (8–14) days and 82% were discharged to home.Conclusions Our retrospective observational study showed that management of pediatric patients with severe liver injury in Japan was characterized by high utilization of AE. The in-hospital survival rate in Japan was comparable with that of other developed countries.

Aim A lack of known guidelines for the provision of extracorporeal cardiopulmonary resuscitation (ECPR) to patients with out‐of‐hospital cardiac arrest (OHCA) has led to variability in practice between hospitals even in the same country. Because variability in ECPR practice has not been completely examined, we aimed to describe the variability in ECPR practice in patients with OHCA from the emergency department (ED) to the intensive care units (ICU). Methods An anonymous online questionnaire to examine variability in ECPR practice was completed in January 2020 by 36 medical institutions who participated in the SAVE‐J II study. Institutional demographics, inclusion and exclusion criteria, initial resuscitation management, extracorporeal membrane oxygenation (ECMO) initiation, initial ECMO management, intra‐aortic balloon pumping/endotracheal intubation/management during coronary angiography, and computed tomography criteria were recorded. Results We received responses from all 36 institutions. Four institutions (11.1%) had a hybrid emergency room. Cardiovascular surgery was always involved throughout the entire ECMO process in only 14.7% of institutions; 60% of institutions had formal inclusion criteria and 50% had formal exclusion criteria. In two‐thirds of institutions, emergency physicians carried out cannulation. Catheterization room was the leading location of cannulation (48.6%) followed by ED (31.4%). The presence of formal exclusion criteria significantly increased with increasing ECPR volume (P for trend

Neuroleptic malignant syndrome is a rare but life-threatening disorder associated with the use of neuroleptic drugs, and is characterized by fever, altered mental status, muscle rigidity, autonomic instability, myoclonus, elevated creatine kinase levels, rhabdomyolysis, and leukocytosis. Previous reports have shown that most patients with neuroleptic malignant syndrome recover without neurologic sequelae. Some patients with neuroleptic malignant syndrome show reversible magnetic resonance imaging (changes in the brain. The severe neurological impairments do not persist in neuroleptic malignant syndrome patients with reversible lesions. Here, we describe a 66-year-old Japanese woman who was diagnosed with septic shock secondary to obstructive pyelonephritis. She was administered haloperidol for delirium and developed neuroleptic malignant syndrome. Magnetic resonance imaging of the brain showed diffuse hyperintense signals in the cerebellar cortex, cerebellar dentate nucleus, superior cerebellar peduncle, and thalamus on T2-weighted imaging or fluid-attenuated inversion recovery, and in the bilateral substantia nigra and bilateral globus pallidus on diffusion-weighted imaging. Subsequently, the signal intensities of the cerebellar and thalamic lesions diminished and the basal ganglia lesions disappeared, but the severe neurologic sequelae remained. The cerebellum is reportedly particularly sensitive to thermal damage because Purkinje cells are believed to be vulnerable to heat. Although brain imaging studies revealed reversible changes, her disturbance of consciousness was prolonged. Therefore, brain magnetic resonance imaging findings might not reflect the neurologic prognosis in patients with neuroleptic malignant syndrome.

Abstract The aim of this Letter to the Editor was to report some important biases in a recently published Article. We agreed with the notion by Yamamoto et al. that the effects of epinephrine regarding was limited without hemostasis, however, this study had major limitations such as no information on etiology of traumatic cardiac arrest (hemorrhagic or on non-hemorrhagic) and on hemostatic treatment. The results of this study should be interpreted with caution and further analysis is necessary. Finally, we commented on the necessity of future study regarding another vasopressor (ie; vasopressin) on traumatic cardiac arrest based on current evidence.

Objective: The aim of this study was to assess the association between whole blood (WB) and mortality among injured children who received immediate blood transfusion. Background: The use of WB for transfusion therapy in trauma has been revisited, and recent studies have reported an association between WB and improved survival among adults. However, evidence of a similar association lacks in children. Methods: We performed a retrospective cohort study from the American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) between 2020 and 2021. Patients were aged less than or equal to 16 years and had immediate blood transfusion within 4 hours of hospital arrival. Survival at 24 hours and 30 days were compared after creating 1:1 propensity score–matched cohorts, matching for demographics, injury type, vital signs on admission, trauma severity scores, hemorrhage control procedures, hospital characteristics, and the need for massive transfusion. Results: A total of 2729 patients were eligible for analysis. The median age was 14 years (interquartile range: 8–16 years); 1862 (68.2%) patients were male; and 1207 (44.2%) patients were White. A total of 319 (11.7%) patients received WB. After a 1:1 ratio propensity score matching, 318 matched pairs were compared. WB transfusion was associated with improved survival at 24 hours, demonstrating a 42% lower risk of mortality (hazard ratio, 0.58; 95% CI, 0.34–0.98; P=0.042) Similarly, the survival benefit associated with WB transfusion remained consistent at 30 days (hazard ratio, 0.65; 95% CI, 0.46–0.90; P=0.011). Conclusion: The use of WB was associated with improved survival among injured pediatric patients requiring immediate transfusion. [ABSTRACT FROM AUTHOR]