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Abstract Although bilateral simultaneous total knee arthroplasty (BSTKA) is an effective treatment for bilateral knee osteoarthritis, safety concerns and lack of precise patient selection criteria persist. The purpose of this retrospective study was to determine the complication rate and the role of frailty in patient selection for BSTKA. We analyzed data from 434 patients who underwent BSTKA between February 2012 and January 2021, examining demographic factors and preoperative blood test results. Complications occurred in 77 patients (18%), with anemia requiring transfusion being the most common (26 patients, 5.9%). In the univariate analysis, age ≥ 75 years, age-adjusted Charlson Comorbidity Index ≥ 5, age-adjusted 5-factor modified Frailty Index (aamFI-5) ≥ 3, hemoglobin ≤ 11.0 g/dL, albumin ≤ 3.5 g/dL, estimated glomerular filtration rate

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.

Introduction While limiting the tidal volume to 6 mL/kg during veno-venous extracorporeal membrane oxygenation (V-V ECMO) to ameliorate lung injury in patients with acute respiratory distress syndrome (ARDS) is widely accepted, the best setting for positive end-expiratory pressure (PEEP) is still controversial. This study is being conducted to investigate whether a higher PEEP setting (15 cmH2O) during V-V ECMO can decrease the duration of ECMO support needed in patients with severe ARDS, as compared with a lower PEEP setting.Methods and analysis The study is an investigator-initiated, multicentre, open-label, two-arm, randomised controlled trial conducted with the participation of 20 intensive care units (ICUs) at academic as well as non-academic hospitals in Japan. The subjects of the study are patients with severe ARDS who require V-V ECMO support. Eligible patients will be randomised equally to the high PEEP group or low PEEP group. Recruitment to the study will continue until a total of 210 patients with ARDS requiring V-V ECMO support have been randomised. In the high PEEP group, PEEP will be set at 15 cmH2O from the start of V-V ECMO until the trials for liberation from V-V ECMO (or until day 28 after the allocation), while in the low PEEP group, the PEEP will be set at 5 cmH2O. Other treatments will be the same in the two groups. The primary endpoint of the study is the number of ECMO-free days until day 28, defined as the length of time (in days) from successful libration from V-V ECMO to day 28. The secondary endpoints are mortality on day 28, in-hospital mortality on day 60, ventilator-free days during the first 60 days and length of ICU stay.Ethics and dissemination Ethics approval for the trial at all the participating hospitals was obtained on 27 September 2022, by central ethics approval (IRB at Hiroshima University Hospital, C2022-0006). The results of this study will be presented at domestic and international medical congresses, and also published in scientific journals.Trial registration number The Japan Registry of Clinical Trials jRCT1062220062. Registered on 28 September 2022.Protocol version 28 March 2023, version 4.0.

Abstract Resuscitative endovascular balloon occlusion of the aorta (REBOA) increases proximal blood pressure while inducing distal ischemia of visceral organs. The evaluation of distal ischemia severity during REBOA is a prerequisite for safe resuscitation of haemorrhagic shock patients with REBOA. We evaluated changes in blood flow and organ perfusion due to the degree of occlusion using dynamic 4D-computed tomography (CT). We compared the results with those of a previous study on euvolemic status. Delayed enhancement of the inferior vena cava (IVC) without retrograde flow was observed in the 4D-volume rendering images in the high-degree occlusion. The time-density curve (TDC) of the liver parenchyma (liver perfusion) and superior mesenteric vein (SMV) demonstrated a decreased peak density and a delayed peak in high-degree occlusion. The change rate of the area under the TDC of the liver and SMV decreased linearly as the degree of occlusion increased (PV, Y = −1.071*X + 106.8, r2 = 0.972, P = 0.0003; liver, Y = −1.050*X + 101.8, r2 = 0.933, P = 0.0017; SMV, Y = −0.985*X + 100.3, r2 = 0.952, P = 0.0009). Dynamic 4D-CT revealed less severe IVC congestion during P-REBOA in haemorrhagic shock than in euvolemia. Analyses of TDC of the liver and SMV revealed a linear change in organ perfusion, regardless of intravascular volume.

Abstract The relationship between fluid management and the severity of illness, duration of treatment, and outcome of coronavirus disease 2019 (COVID-19) is not fully understood. This study aimed to evaluate whether weight change during hospitalization was associated with COVID-19 severity, length of hospital stay, and route of admission. In this study, we assessed the effectiveness of fluid restriction management in patients with severe COVID-19. COVID-19 patients admitted to our hospital between July 2020 and October 2021 were analyzed. Patients were treated with standard drug therapy based on the Japanese guidelines and respiratory support according to the severity of the disease. Early enteral nutrition, defecation management, and anticoagulation therapy were also administered. Fluid restriction management was performed using furosemide and continuous renal replacement therapy as needed unless hemodynamic instability or hyperlactatemia was present. Patient background, route of admission (ambulance, A; transfer, T), weight at admission and discharge, the severity of illness (oxygen therapy, G1; mechanical ventilation, G2; extracorporeal membrane oxygenation, G3), in-hospital mortality, and length of hospital stay were analyzed. There were 116 subjects: G1 (n = 48), G2 (n = 43), and G3 (n = 25), with ages (median [IQR]) of 58 (47–70), 65 (53–71.5), 56 (51–62) years, 40 (83.3%), 31 (72.1%), and 19 (76.0%) males, respectively. Hospital stays were 4.5 (2–7), 10 (7–16), and 18 (15–26) days, and the in-hospital mortality rates were 0 (0%), 7 (16.3%), and 8 (32%), respectively. Body mass index on admission was 26 (23.1–30.2), 27.1 (22.7–31.1), and 31.5 (27.1–33.1) kg/m2, and weight loss during admission was 1.1 (0–2.9), 4.6 (2.3–5.7), 9.2 (5.6–10.5) kg (P

Abstract Background Uterine rupture is a major cause of postpartum hemorrhage (PPH) that requires surgery. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is also helpful for PPH. However, the effectiveness of REBOA in PPH with cardiac arrest is unknown. Case Presentation A 40‐year‐old woman developed hemorrhagic shock due to uterine rupture after an induced delivery. She developed cardiac arrest, but was rescued by cardiopulmonary resuscitation (CPR), REBOA, a hysterectomy, and pelvic gauze packing. The hemodynamics were too unstable to move to the operating room. Then we initiated the CPR assisted with REBOA and decided to activate massive transfusion and perform laparotomy in the emergency room. She was finally discharged home without neurological sequelae. Conclusion Our damage control strategy, including REBOA‐assisted CPR, contributed to saving the life of a patient with a life‐threatening PPH.

Abstract Background Capnocytophaga canimorsus is an oral commensal bacteria in dogs and may cause severe infection following a dog bite. This is a case of fatal C. canimorsus sepsis with acute infectious purpura fulminans (AIPF) in a healthy patient with splenic hypoplasia. Case Presentation A healthy 49‐year‐old man was admitted to the intensive care unit (ICU) for septic shock and AIPF 4 days after a dog bite to his mouth. Computed tomography revealed a small spleen measuring 53 cm3 but no other source of infection. Despite intensive care, the patient died of multiple organ failure and progressive shock on the fifth ICU day. Polymerase chain reaction of blood samples identified the C. canimorsus gene on a later day. Conclusion Capnocytophaga canimorsus from dog bites may cause fatal AIPF. Splenic hypoplasia and bite wounds in well‐perfused areas such as the oral cavity are possible risk factors for sepsis. All dog bites should warrant medical attention.

Abstract An 88‐year‐old man ingested coins accidentally and developed mediastinitis and septic shock. Esophageal injuries by sharped‐shape foreign bodies are often reported, but esophageal perforation by round coins is rare. Even rounded‐shape foreign bodies that are unlikely to injure esophagus may lead to severe outcomes.

Abstract Background Numerous patients who receive hemodialysis (HD) undergo total knee arthroplasty (TKA) due to advanced knee joint arthritis. However, there are few studies that describe the clinical outcomes and complications of TKA in HD patients. This study investigated the mid-term results of TKA in patients undergoing HD. Methods This single-center retrospective study compared clinical and surgical outcomes following TKA in patients who were receiving HD with those who were not. We used propensity scores to match 21 knees of 18 patients who received HD to 706 knees of 569 patients who had not received HD, from a total of 727 knees (587 patients) that underwent primary unilateral TKA. The clinical outcomes were evaluated using the American Knee Society Score-knee (AKSS-knee) and AKSS-function scores. The primary surgical outcome measure was the number of knees with postoperative complications. Results In both the HD and non-HD groups, postoperative AKSS-knee and function scores significantly improved when compared to preoperative values. Postoperative AKSS-knee and function scores were not significantly different between the groups. The number of knees with postoperative complications was larger in the HD group than the non-HD group within the first postoperative month, 0–12 months, 12–24 months, 0–24 months, and two years after surgery. Additionally, in the HD group, more complications occurred in the first month than any subsequent month in the two years after surgery. Conclusions TKA improves AKSS-knee and function scores equivalently for HD patients and non-HD patients. However, HD patients develop more complications after TKA, especially within the first month. Therefore, surgeons who perform TKA for HD patients should obtain informed consent after explaining the possible complications, and HD patients should be carefully observed following TKA.

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.

Post-partum hemorrhage (PPH) requires medical resources to resuscitate hemorrhagic shock patients. The concept of damage control surgery in obstetrics has become widespread, and resuscitative endovascular balloon occlusion of the aorta (REBOA) can be a means of resuscitation in PPH. However, the potential benefits of endovascular strategies in obstetrics are not fully understood. This review aims to share the knowledge and experience of the endovascular strategy in the field of obstetrics among both interventional radiologists and obstetricians through the summary of the literature and multi-specialty expert consensus in the Japanese Society of Diagnostic Interventional Radiology in Emergency, Critical care and Trauma (DIRECT). The endovascular strategies include REBOA, arterial embolization, and common or internal iliac artery balloon occlusion (CIABO or IIABO). Uterine artery embolization achieves rapid definitive hemostasis while leaving fertility with a less invasive procedure. N-butyl-2-cyanoacrylate (NBCA) should be chosen as needed for coagulopathy. The obestetrics team (obstetricians and midwives) and the resuscitation team (doctors from emergency medicine, anesthesiology, interventional radiology, and nurses) would each have to develop a command system, and control and cooperate in parallel. The consensus for the timing of arterial access and the patient’s positioning for pelvic examination and femoral arterial access should be established in advance.

Arterial access is essential in the resuscitation of trauma and hemorrhagic shock patients and can be effectively used for rapid endovascular treatment such as resuscitative endovascular balloon occlusion of the aorta (REBOA) and interventional radiology (IVR), continuous invasive hemodynamic monitoring, and frequent blood tests. In the REBOA procedure, obtaining arterial access is the first and most critical step. Arterial access can be obtained in three ways: (1) blind/landmark technique, (2) ultrasound-guided technique or (3) surgical cutdown technique. Regardless of which technique is chosen, it is crucial to recognize external landmarks before implementing any technique. In ultrasound-guided puncture, there are two types of techniques: short-axis puncture and long-axis puncture. There are two methods for actual puncture: the single-wall puncture method and the double-wall puncture method. In cases of hemorrhagic shock, the double-wall puncture method is advantageous when it is necessary to obtain arterial access quickly and reliably. The cutdown technique is useful when the femoral artery cannot be identified through ultrasound guidance or cannot be punctured for a long time owing to puncture-induced hematoma or obesity. This technique should be used without hesitation if it is evaluated to be more rapid and reliable than an ultrasound-guided puncture.

It is well known that whole body computed tomography (WBCT) scans in hemodynamically unstable trauma patients (HUPs) should not be performed due to time concerns. Recently, with the shortening of CT scan time accomplished by quick preparation and scanning, WBCT in the patient population utilizing resuscitative endovascular balloon occlusion of the aorta (REBOA) in trauma cases could lead to better subsequent management, especially for patients with unknown bleeding points without known mechanism of injury, possible traumatic brain injury, and geriatric trauma with coagulopathy. During a CT scan with contrast, the REBOA balloon is not necessarily deflated further. The training of the CT scan team could shorten the CT room stay time to under 5 min. The images should be read quickly following focused assessment of the scans for trauma by trauma radiologists. REBOA WBCT scans in HUPs with appropriate protocols and image readings might be the tool for choosing a better management in order to restrain hemorrhage.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been accepted as a useful bridging tool to definitive hemostasis in refractory hemorrhagic shock. Although there is insufficient evidence of the target blood pressure under the utilization of REBOA, it may be reasonable to avoid excessive blood pressure elevation. Invasive blood pressure monitoring proximal to the aortic occlusion is desirable during REBOA. The zone of the aorta is selected and changed according to the location of injuries and the physiological conditions. The key to successful REBOA management is to set up an independent REBOA coordinator for systemic management. This review article aims to explain the procedures of proper REBOA management, so as to fill the knowledge gap between educational courses, which highlight the indications and safe procedures of the device, and the critical settings faced in clinical practice.

Although resuscitative endovascular balloon occlusion of the aorta (REBOA) is a useful technique for achieving temporary hemostasis until radical hemostasis is achieved, it is necessary to understand and learn its correct use to avoid complications. The procedure of REBOA preparation, insertion, balloon inflation and deflation, and removal and the key points of the technique at each stage are described in this article. In addition, it expounds on the complications of REBOA and REBOA inflation time.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a resuscitation procedure for severe hemorrhagic shock. While complete occlusion of the aorta could be effective for the control of blood flow, there is always a concern for ischemia-reperfusion injury of the distal organs from the balloon catheter. REBOA can control the degree of occlusion by changing the injection volume of the balloon catheter. Partial REBOA and intermittent REBOA are some of the strategies of REBOA, with which less ischemia-perfusion injury is done, rather than complete occlusion of the aorta, although evidence on partial REBOA and intermittent REBOA is still limited. This review aims to share the practical knowledge of partial REBOA and intermittent REBOA, thorough the current literature and Japanese multi-specialty expert consensus.

Numerous complications have been reported regarding the use of resuscitative endovascular balloon occlusion of the aorta (REBOA). Complications can be broadly classified into the following six categories: arterial access-related, REBOA catheter insertion-related, balloon positioning-related, balloon inflation-related, balloon deflation-related, and sheath placement and removal-related. REBOA operators must be knowledgeable about these possible complications and their management, along with its utility. A strong commitment to using REBOA safely and complication-free is essential to the skillful use of REBOA.

In traumatic hemorrhagic shock, there are situations where rapid aortic occlusion is required. In such cases, the best aortic occlusion should be determined based on the situation. Therefore, it is essential to understand the various types of aortic occlusion, their characteristics, and their indications. However, aortic occlusion is not hemostasis but temporary proximal control of arterial bleeding; definitive hemostasis should not be delayed even if blood pressure is elevated after aortic occlusion. We describe the indications, characteristics and implementation of each aortic occlusion and the comparison between resuscitative thoracotomy with aortic cross-clamp (RTACC) and resuscitative endovascular balloon occlusion of the aorta (REBOA). It is not necessary to discuss the superiority or inferiority of RTACC and REBOA. The appropriate determination of a combination of these tactics will increase the range of strategies and tactics.

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.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) increases proximal aortic pressure in order to maintain central organ perfusion pressure, and simultaneously regulates distal arterial flow by endovascular aortic occlusion, which is applied during subdiaphragmatic hemorrhage. This article briefly introduces the history of REBOA and discusses its potential effectiveness and harmfulness. The article also mentions the technical aspects of REBOA, and reconsiders the term “REBOA” and “resuscitation.” The risks of aortic occlusion and ischemia-reperfusion injury have not been fully elucidated. It is hoped that REBOA can be used appropriately as a powerful option for the resuscitation of hemorrhagic patients and save the lives of as many patients as possible. The Society of Diagnostic and Interventional Radiology in Emergency, Critical Care, and Trauma will publish continuous medical education articles on REBOA.

In trauma bays, resuscitation as a bridge to definitive hemorrhage control to avoid cardiac arrest is challenging. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a resuscitation procedure for refractory hemorrhagic shock. The REBOA procedure itself is simple compared to other endovascular procedures, such as angioembolization or stent graft placement. However, adequate REBOA implementation requires a complete understanding of its potential risks and simulation training. We should be aware that REBOA is not a hemostatic device, but a bridge to definitive hemorrhage control; furthermore, it is not a magical device that can improve the critical situation in trauma resuscitation. For appropriate use, we herein describe the indication of REBOA in trauma resuscitation based on existing evidence.

Introduction Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been used as a bridge to definitive bleeding control of subdiaphragmatic injury. Since previous observational studies have poorly adjusted for confounding factors, it is necessary to incorporate REBOA-specific and time-varying covariates in the model. We hypothesised that REBOA improves the survival of haemodynamically unstable torso trauma patients after comparing the REBOA group with a matched control group (non-REBOA group).Methods and analysis The Japanese Association for the Surgery of Trauma-REBOA Study is a prospective, multicentre, matched cohort study organised by the Clinical Trial Committee of the Japanese Association for the Surgery of Trauma. To minimise observational study biases, this study will prospectively register traumatic shock patients who require bleeding control within 60 min upon arrival at the emergency department, with in-hospital mortality as the primary outcome. After the data set is fixed, the missing values for all variables will be imputed using the multiple imputation technique. In the primary analysis, propensity scores for the probability of REBOA decision (regardless of the actual REBOA deployment) will be calculated from the baseline information using a logistic regression generalised linear mixed-effects model, which will be performed for both the REBOA use and non-REBOA use groups.Ethics and dissemination This study was approved by the ethics committee of each participating hospital. The results will be disseminated to the participating hospitals, submitted to peer-reviewed journals for publication and presented at congresses.Trial registration number UMIN Clinical Trials Registry (UMIN000035458).

A 53-year-old man underwent thoracic endovascular aortic repair for persistent false lumen perfusion and limb salvage because of type A aortic dissection, severe lower-limb ischemia, and bleeding (mediastinal hematoma, bilateral lung contusion, liver injury, and splenic injury) caused by blunt trauma. We embolized the left supreme intercostal artery to control active mediastinal hemorrhage. Acute hemorrhage and leg ischemia were well controlled; however, residual blood flow in the false lumen persisted. We performed a Zone 2 thoracic endovascular aortic repair and discharged the patient on day 67. Thoracic endovascular aortic repair is a practical option for treating traumatic type A dissection.

Abstract Renal and urogenital injuries occur in approximately 10-20% of abdominal trauma in adults and children. Optimal management should take into consideration the anatomic injury, the hemodynamic status, and the associated injuries. The management of urogenital trauma aims to restore homeostasis and normal physiology especially in pediatric patients where non-operative management is considered the gold standard. As with all traumatic conditions, the management of urogenital trauma should be multidisciplinary including urologists, interventional radiologists, and trauma surgeons, as well as emergency and ICU physicians. The aim of this paper is to present the World Society of Emergency Surgery (WSES) and the American Association for the Surgery of Trauma (AAST) kidney and urogenital trauma management guidelines.

Abstract Duodeno-pancreatic and extrahepatic biliary tree injuries are rare in both adult and pediatric trauma patients, and due to their anatomical location, associated injuries are very common. Mortality is primarily related to associated injuries, but morbidity remains high even in isolated injuries. Optimal management of duodeno-bilio-pancreatic injuries is dictated primarily by hemodynamic stability, clinical presentation, and grade of injury. Endoscopic and percutaneous interventions have increased the ability to non-operatively manage these injuries. Late diagnosis and treatment are both associated to increased morbidity and mortality. Sequelae of late presentations of pancreatic injury and complications of severe pancreatic trauma are also increasingly addressed endoscopically and with interventional radiology procedures. However, for moderate and severe extrahepatic biliary and severe duodeno-pancreatic injuries, immediate operative intervention is preferred as associated injuries are frequent and commonly present with hemodynamic instability or peritonitis. The aim of this paper is to present the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) duodenal, pancreatic, and extrahepatic biliary tree trauma management guidelines.

Aim Effective courses are essential for highly invasive procedures such as resuscitative endovascular balloon occlusion of the aorta. However, the coronavirus disease pandemic has forced the postponement of on‐site educational courses due to transmission concerns. Few studies have examined the effectiveness of Web‐based education in highly invasive procedures. To address this knowledge gap, this study aimed to investigate whether knowledge acquisition and confidence after the Web‐based course are different from those acquired after the on‐site course, using pre‐ and postcourse test scores. Methods The increase in scores before and after the course was compared between the on‐site and Web‐based courses. The questions reflected knowledge about seven different topics in the course modules. In addition, participants were asked about their self‐rated confidence about three topics before and after the course. Results Thirty learners completed the on‐site course, and 21 learners completed the Web‐based course. Forty‐seven learners completed both the precourse and postcourse tests. In both courses, the difference between the precourse and postcourse test scores showed a statistically significant increase in knowledge (on‐site course: increased score, 1.8; 95% confidence interval, 0.8 to 2.8; Web‐based course: increased score, 1.6, 95% confidence interval, 0.5 to 2.5). However, the difference was not statistically significant in the self‐rated confidence scores about “sheath and catheter removal” among learners of the Web‐based course. Conclusion Knowledge increased significantly in both the on‐site and Web‐based courses. However, the Web‐based course might not be sufficient to give learners confidence in the procedures.

Introduction Resuscitation using blood products is critical during the acute postinjury period. However, the optimal target haemoglobin (Hb) levels have not been adequately investigated. With the restrictive transfusion strategy for critically injured patients (RESTRIC) trial, we aim to compare the restrictive and liberal red blood cell (RBC) transfusion strategies.Methods and analysis This is a cluster-randomised, crossover, non-inferiority trial of patients with severe trauma at 22 hospitals that have been randomised in a 1:1 ratio based on the use of a restrictive or liberal transfusion strategy with target Hb levels of 70–90 or 100–120 g/L, respectively, during the first year. Subsequently, after 1-month washout period, another transfusion strategy will be applied for an additional year. RBC transfusion requirements are usually unclear on arrival at the emergency department. Therefore, patients with severe bleeding, which could lead to haemorrhagic shock, will be included in the trial based on the attending physician’s judgement. Each RBC transfusion strategy will be applied until 7 days postadmission to the hospital or discharge from the intensive care unit. The outcomes measured will include the 28-day survival rate after arrival at the emergency department (primary), the cumulative amount of blood transfused, event-free days and frequency of transfusion-associated lung injury and organ failure (secondary). Demonstration of the non-inferiority of restrictive transfusion will emphasise its clinical advantages.Ethics and dissemination The trial will be performed according to the Japanese and International Ethical guidelines. It has been approved by the Ethics Committee of each participating hospital and The Japanese Association for the Surgery of Trauma (JAST). Written informed consent will be obtained from all patients or their representatives. The results of the trial will be disseminated to the participating hospitals and board-certified educational institutions of JAST, submitted to peer-reviewed journals for publication, and presented at congresses.Trial registration number UMIN Clinical Trials Registry; UMIN000034405. Registered 8 October 2018.

Abstract Background The outcomes of multiple injury patients with concomitant torso hemorrhage and traumatic brain injury (TBI) are very poor. The hybrid emergency room system (HERS) is a trauma management system designed to complete resuscitation, computed tomography (CT), surgery, angioembolization, and intracranial pressure (ICP) monitoring all in one trauma resuscitation room without patient transfer. We aimed to review the outcomes of polytrauma patients who underwent concurrent bleeding control and ICP monitoring using the HERS. Methods In this retrospective observational study, we enrolled patients who underwent concurrent bleeding control and ICP monitoring using the HERS between August 2011 and June 2018. Initial data on vital signs, Injury Severity Score (ISS), probability of survival (Ps) calculated by the Trauma and Injury Severity Score (TRISS), intervention type, 28-day mortality, and Extended Glasgow Outcome Scale at 6 months after injury were collected. Continuous variables were expressed as the median (25th and 75th percentiles) and categorical variables as numbers (%). Results Ten patients were included in the analysis. The injury severity of the patients was as high as an ISS of 58 (50–64) and TRISS Ps of 0.15 (0.02–0.36). Seven of the 10 (70%) patients had hemodynamic instability within 30 min from arrival. The recorded durations from arrival to events were CT examination 9 (6–16) min, bleeding control procedure 29 (22–42) min, and neurosurgical intervention 39 (31–53) min. Four of the 10 patients (40%) survived to discharge, and two of them (20%) were able to live independently at 6 months after injury. Conclusions The concurrent performance of bleeding control procedure and ICP monitoring would be feasible in HERS settings among polytrauma patients with exsanguinating hemorrhage and TBI.

The concept of EndoVascular resuscitation and Trauma Management (EVTM) has recently been proposed to refer to the use of endovascular techniques for resuscitation, haemorrhage control, and definitive trauma management. Although the popularity of resuscitative endovascular balloon occlusion of the aorta (REBOA) has been growing, the use of the EVTM or CT imaging is still limited in hemodynamically unstable patients. To overcome the current limitations, the Hybrid Emergency Room System (HERS) was introduced in 2011. HERS consists of an operating table with an angiographic C-arm and a sliding CT scanner system in the resuscitation area, which allows all emergency diagnostic and therapeutic interventions without relocating the patient. This paper deals with current limitations of EVTM and proposes solutions with HERS. In the HERS environment, patients can undergo IR in the resuscitation room, which may expand the indications of IR to include hemodynamically unstable patients. HERS can also reduce CT scanning time to identify unexpected injuries or traumatic brain injury. It also allows prompt neurosurgical intervention simultaneously with haemorrhage control. REBOA is a viable adjunct treatment for refractory haemorrhagic shock but its procedure-related complications must be considered. REBOA can be performed more safely, rapidly, and accurately in HERS, followed by immediate definitive haemostasis. In addition, HERS may safely extend the application of REBOA-CT to identify accurate injury site. HERS may be an ideal EVTM solution for the trinity of surgery, endovascular treatment, and imaging in trauma care. We will continue to explore the most radical and safest EVTM in the HERS environment.

Background: Angioembolization is a widely accepted method for an effective and useful hemostasis procedure in pelvic fracture (PF) patients. We evaluated and introduced the time course of the initial management and angiogra-phy in hemodynamically unstable pelvic fracture patients. Methods: We retrospectively reviewed 56 PF patients who underwent interventional radiology (IR) from May 2010 to Dec 2016. We defined arrival to angiography time (ATAT), and this was recorded in all enrolled patients in which the first angiography image represented the initiation of angiography. We also evaluated total embolization time (TET) and single artery embolization time (SAET; time for artery selection, injection, embolization, and confirmation). Results: The median ATAT and TET were respectively 73 and 33 minutes. They were much faster than the previous reports. Conclusions: Our trauma IR strategy with a specialized team might contribute to a shortening of the management time

Diagnostic and interventional radiology (IR) techniques have recently shown significant efficacy in trauma care when combined with surgical procedures. A multifaceted approach to traffic accidents has reduced the number of trauma patients in Japan, which has necessitated simulation education to provide practical experience and ensure proficiency. The objective of this paper is to report the educational development of endovascular and hybrid workshops in Japan. The Japanese Society of Diagnostic and Interventional Radiology in Emergency, Critical care, and Trauma (DIRECT) was established in 2011 to maximize the benefit of diagnostic and IR in emergency or trauma settings. DIRECT conducts trauma endovascular workshops for emergency medicine physicians, acute care surgeons, and IR physicians. From July 2011 to June 2016, DIRECT has conducted 14 simulator workshops, six endovascular workshops using a porcine model, and four hybrid trauma management workshops, of which two were conducted with porcine models. The simulation workshop was designed for novice learners and included resuscitative endovascular balloon occlusion of the aorta (REBOA) deployment using a pressurized silicone model, catheter and guidewire manipulation with a three-dimensional (3D) vessel silicone model and virtual fluoroscopic simulator, and metallic coil deployment. Porcine simulations for intermediate-level physicians were conducted and endovascular tools included different occlusion materials. In the hybrid strategy model, by using a porcine model of injury, the participants combined both surgical and endovascular procedures such as REBOA, selective balloon occlusion, and N-butyl cyanoacrylate embolization. DIRECT is a vital bridge between emergency/trauma and IR, and workshops are essential for improved trauma care.

The trauma pan-scan (TPS) offers particular benefits in trauma care. Resuscitative endovascular balloon occlusion of the aorta (REBOA) may provide an opportunity to scan hemodynamically unstable (HU) polytrauma patients; however, the benefits and risks of REBOA-TPS remain unknown. The rationale for TPS in HU patients is to choose the best intervention and to quickly achieve hemostasis rather than directly initiating surgery without scanning. TPS would most greatly benefit geriatric trauma patients and those with coagulopathies with unidentified bleeding sources, particularly noncavitary hemorrhage in blunt trauma and accompanying brain injury, because TPS may predict unexpected physiological collapse via anatomical imaging. Computed tomography (CT) is a common cause of flow disruption, but specific trauma team training was shown to reduce the time spent in the CT room from 16.8 to 7.3 minutes (P < 0.001). While REBOA-TPS cannot be utilized widely or indiscriminately, its appropriate use may increase the number of salvageable trauma patients.

PurposeAlthough vancomycin (VCM) is not absorbed from healthy intestinal mucosa, elevations in the serum VCM concentrations have been reported in some cases. The aims of this study are to evaluate the necessity of therapeutic drug monitoring (TDM) during enteral VCM administration in critically ill patients.Materials and methodsIn this retrospective study, we enrolled 19 patients admitted to our intensive care unit who were treated with enteral VCM from December 2006 to January 2014. Clinical factors were compared between two groups: Group E whose serum concentrations were detectable, and Group N whose concentrations were below the detection limit of the VCM assay.ResultsGroup E comprises 7 patients, and Group N comprises 12 patients. The fasting duration in Group E was significantly longer compared with that in Group N (17 vs. 8 days, p = 0.023). Furthermore, there was a significant correlation between the serum VCM concentrations and the fasting duration (r = 0.79, p

PurposeThe final decision for discharge from the intensive care unit (ICU) is uncertain because it is made according to various patient parameters; however, it should be made on an objective evaluation. Previous reports have been inconsistent and unreliable in predicting post-ICU mortality. To identify predictive factors associated with post-ICU mortality, we analyzed physiological and laboratory data at ICU discharge.MethodsPatients admitted to our ICU between September 2012 and August 2013 and staying for critical care>2 days were included. Sequential Organ Failure Assessment (SOFA) score; systemic inflammatory response syndrome score; white blood cell count; and serum C reactive protein, procalcitonin (PCT), interleukin-6 (IL-6), lactate, albumin, and hemoglobin levels were recorded. The primary end point was 90-day mortality after ICU discharge. Two hundred eighteen patients were enrolled (195 survivors, 23 non-survivors).ResultsNon-survivors presented a higher SOFA score and serum PCT, and IL-6 levels, as well as lower serum albumin and hemoglobin levels. Serum PCT, albumin, and SOFA score were associated with 90-day mortality in multiple logistic regression analysis. Hosmer-Lemeshow test showed chi-square value of 6.96, and P value of 0.54. The area under the curve (95% confidence interval) was 0.830 (0.771-0.890) for PCT, 0.688 (0.566-0.810) for albumin, 0.861 (0.796-0.927) for SOFA score, and increased to 0.913 (0.858-0.969) when these were combined. Serum PCT level at 0.57 ng/mL, serum albumin at 2.5 g/dL and SOFA score at 5.5 predict 90-day mortality, and high PCT, low albumin and high SOFA groups had significantly higher mortality. Serum PCT and SOFA score were significantly associated with survival days after ICU discharge in Cox regression analysis.ConclusionsSerum PCT level and SOFA score at ICU discharge predict post-ICU mortality and survival days after ICU discharge. The combination of these two and albumin level might enable accurate prediction.