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Introduction: Iliopsoas haematoma (IPH) during extracorporeal membrane oxygenation (ECMO) is a rare bleeding complication that can be fatal due to its progression to abdominal compartment syndrome, but its incidence and risk factors are not well known. We have previously reported an IPH incidence rate of 16% in Japan. Among possible reasons for this high incidence, ethnicity has been hypothesised to play a role. Therefore, we used an international multi-centre cohort registry to test this hypothesis by determining the incidence rate of IPH. Methods: This study was performed using the COVID-19 Critical Care Consortium database, conducted in 30 countries across five continents between 3 January 2020, and 20 June 2022. Results: Overall, 1102 patients received ECMO for COVID-19-related acute respiratory distress syndrome. Of them, only seven were reported to have IPH, indicating an incidence rate of 0.64%, with comparable rates between the countries. The IPH group tended to have a higher mortality rate (71.4%) than the non-IPH group (51%). Conclusions: Overall incidence of IPH in the studied COVID-19 ECMO cohort was 0.64%. Most cases were reported from Japan, Belgium, and Italy. In our study, this rare complication did not appear to be confined to Asian patients. Due to the high fatality rate, awareness about the occurrence of IPH should be recognised. [ABSTRACT FROM AUTHOR]

OBJECTIVES: This study aimed to investigate the current use and impact of pulmonary artery catheters (PACs) in patients with cardiogenic shock (CS) who underwent Impella support. DESIGN: This was a prospective multicenter observational study between January 2020 and December 2021 that registered all patients with drugrefractory acute heart failure and in whom the placement of an Impella 2.5, CP, or 5.0 pump was attempted or successful in Japan. SETTING: Cardiac ICUs in Japan. PATIENTS: Between January 2020 and December 2021, a total of 3112 patients treated with an Impella were prospectively enrolled in the Japan registry for percutaneous ventricular assist device (J-PVAD). Among them, 2063 patients with CS were divided into two groups according to the PAC use. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary endpoint was the 30-day mortality, and the secondary endpoints were hemolysis, acute kidney injury, sepsis, major bleeding unrelated to the Impella, and ventricular arrhythmias within 30 days. PACs were used in 1358 patients (65.8%) who underwent an Impella implantation. The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) was significantly higher in the patients with PACs than in those without. Factors associated with PAC use were the prevalence of hypertension, out-of-hospital cardiac arrest, New York Heart Association classification IV, the lesser prevalence of a heart rate less than 50, and the use of any catecholamine. The primary and secondary endpoints did not significantly differ according to the PAC use. Focusing on the patients with VA-ECMO use, the 30-day mortality and hemolysis were univariately lower in the patients with PACs. CONCLUSIONS: The J-PVAD findings indicated that PAC use did not have a significant impact on the short-term outcomes in CS patients undergoing Impella support. Further prospective studies are required to explore the clinical implications of PAC-guided intensive treatment strategies in these patients. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Signs of life (SOLs) during cardiac arrest (gasping, pupillary light reaction, or any form of body movement) are suggested to be associated with favorable neurologic outcomes in out-of-hospital cardiac arrest (OHCA). While data has demonstrated that extracorporeal cardiopulmonary resuscitation (ECPR) can improve outcomes in cases of refractory cardiac arrest, it is expected that other contributing factors lead to positive outcomes. This study aimed to investigate whether SOL on arrival is associated with neurologic outcomes in patients with OHCA who have undergone ECPR. DESIGN: Retrospective multicenter registry study. SETTING: Thirty-six facilities participating in the Study of Advanced life support for Ventricular fibrillation with Extracorporeal circulation in Japan II (SAVE-J II). PATIENTS: Consecutive patients older than 18 years old who were admitted to the Emergency Department with OHCA between January 1, 2013, and December 31, 2018, and received ECPR. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients were classified into two groups according to the presence or absence of SOL on arrival. The primary outcome was a favorable neurologic outcome (Cerebral Performance Category 1 or 2) at discharge. Of the 2157 patients registered in the SAVE-J II database, 1395 met the inclusion criteria, and 250 (17.9%) had SOL upon arrival. Patients with SOL had more favorable neurologic outcomes than those without SOL (38.0% vs. 8.1%; p < 0.001). Multivariate analysis showed that SOL on arrival was independently associated with favorable neurologic outcomes (odds ratio, 5.65 [95% CI, 3.97-8.03]; p < 0.001). CONCLUSIONS: SOL on arrival was associated with favorable neurologic outcomes in patients with OHCA undergoing ECPR. In patients considered for ECPR, the presence of SOL on arrival can assist the decision to perform ECPR. [ABSTRACT FROM AUTHOR]

Background: Bleeding is the most common complication in out-of-hospital cardiac arrest (OHCA) patients receiving extracorporeal cardiopulmonary resuscitation (ECPR). No studies comprehensively described the incidence rate, timing of onset, risk factors, and treatment of bleeding complications in OHCA patients receiving ECPR in a multicenter setting with a large database. This study aimed to analyze the risk factors of bleeding during the first day of admission and to comprehensively describe details of bleeding during hospitalization in patients with OHCA receiving ECPR in the SAVE-J II study database. Methods: This study was a secondary analysis of the SAVE-J II study, which is a multicenter retrospective registry study from 36 participating institutions in Japan in 2013–2018. Adult OHCA patients who received ECPR were included. The primary outcome was the risk factor of bleeding complications during the first day of admission. The secondary outcomes were the details of bleeding complications and clinical outcomes. Results: A total of 1,632 patients were included. Among these, 361 patients (22.1%) had bleeding complications during hospital stay, which most commonly occurred in cannulation sites (14.3%), followed by bleeding in the retroperitoneum (2.8%), gastrointestinal tract (2.2%), upper airway (1.2%), and mediastinum (1.1%). These bleeding complications developed within two days of admission, and 21.9% of patients required interventional radiology (IVR) or/and surgical interventions for hemostasis. The survival rate at discharge of the bleeding group was 27.4%, and the rate of favorable neurological outcome at discharge was 14.1%. Multivariable logistic regression analysis showed that the platelet count (< 10 × 104/μL vs > 10 × 104/μL) was significantly associated with bleeding complications during the first day of admission (adjusted odds ratio [OR]: 1.865 [1.252–2.777], p = 0.002). Conclusions: In a large ECPR registry database in Japan, up to 22.1% of patients experienced bleeding complications requiring blood transfusion, IVR, or surgical intervention for hemostasis. The initial platelet count was a significant risk factor of early bleeding complications. It is necessary to lower the occurrence of bleeding complications from ECPR, and this study provided an additional standard value for future studies to improve its safety. [ABSTRACT FROM AUTHOR]

Background: In the chain of survival for Out-of-hospital cardiac arrest (OHCA), each component of care contributes to improve the prognosis of the patient with OHCA. The SARS-CoV-2 (COVID-19) pandemic potentially affected each part of care in the chain of survival. The aim of this study was to compare prehospital care, in-hospital treatment, and outcomes among OHCA patients before and after the COVID-19 pandemic. Methods: We analyzed data from a multicenter prospective study in Kanto area, Japan, named SOS-KANTO 2017. We enrolled patients who registered during the pre-pandemic period (September 2019 to December 2019) and the post-pandemic period (June 2020 to March 2021). The main outcome measures were 30-day mortality and the proportion of favorable outcomes at 1 month, and secondary outcome measures were changes in prehospital and in-hospital treatments between the pre- and post-pandemic periods. Results: There were 2015 patients in the pre-pandemic group, and 5023 in the post-pandemic group. The proportion of advanced airway management by emergency medical service (EMS) increased (p < 0.01), and EMS call-to-hospital time was prolonged (p < 0.01) in the post- versus pre-pandemic group. There were no differences between the groups in defibrillation, extracorporeal membrane oxygenation, or temperature control therapy (p = 0.43, p = 0.14, and p = 0.16, respectively). Survival rate at 1 month and favorable outcome rate at 1 month were lower (p = 0.01 and p < 0.01, respectively) in the post- versus pre-pandemic group. Conclusion: Survival rate and favorable outcome rate 1 month after return of spontaneous circulation of OHCA worsened, EMS response time was prolonged, and advanced airway management by EMS increased in the post- versus pre-pandemic group; however, most prehospital and in-hospital management did not change between pre- and post-COVID-19 pandemic. [ABSTRACT FROM AUTHOR]

Aim: Although the number of global studies on ECMO, which is an important support system in the treatment of COVID-19 related respiratory failure, has increased in recent months, there is still no bibliometric study on the use of ECMO in COVID-19 in the literature. The aim of this study is to analyze the scientific articles on the use of ECMO in COVID-19 by statistical and bibliometric methods. Method: Articles published between 2019–2022 about the use of ECMO in COVID-19 were obtained from the Web of Science (WoS) database and analyzed using statistical and bibliometric methods. Spearman correlation coefficient was used for correlation studies. Network visualization maps were used to identify effe analysis and trending topics. Results: A total of 1197 publications were found. 758 (63.3%) of these publications were articles. The top 3 contributing countries to the literature were USA (257, 33.9%), Germany (102, 13.4%) and Japan (87, 11.5%). The top 3 most active institutions were League of European Research Universities (90), Harvard University (50), and Udice French Research Universities (39). The top 3 journals with the highest count of publications were ASAIO Journal (n = 36), Frontiers in Medicine (22), and Perfusion-UK (n = 20). According to the average count of citations per article, the most influential journals were JAMA (1319), Intensive Care Medicine (327), and Lancet (95.7), respectively. We have shared a summary of 758 articles in this comprehensive bibliometric study on the use of ECMO in COVID-19. Conclusion: It can be said that the use of ECMO in COVID-19 has been the trending topic recently and most of the studies are from countries in the ELSO Awards of Excellence list which indicates that the follow-up of ECMO in certain centers and teams can also be influencing the publications. This article can be a useful resource for clinicians, scientists, and students concerning global output for ECMO use in COVID-19. [ABSTRACT FROM AUTHOR]

Objective: To investigate the effect on early mobilization in patients undergoing extra-corporeal membrane oxygenation (ECMO) and acute blood purification therapy in the intensive care unit (ICU). Methods: We conducted this multicenter retrospective cohort study by collecting data from six ICUs in Japan. Consecutive patients who were admitted to the ICU, aged =18 years, and received mechanical ventilation for >48 hours were eligible. The analyzed were divided into two groups: ECMO/blood purification or control group. Clinical outcomes; time to first mobilization, number of total ICU rehabilitations, mean and highest ICU mobility scale (IMS); and daily barrier changes were also investigated. Results: A total of 204 patients were included in the analysis, 43 in the ECMO/blood purification group and 161 in the control group. In comparison of clinical outcome, the ECMO/blood purification group had a significantly longer time to first mobilization: ECMO/blood purification group 6 vs. control group 4 (p=0.003), higher number of total ICU rehabilitations: 6 vs. 5 (p=0.042), lower mean: 0 vs. 1 (p=0.043) and highest IMS: 2 vs. 3 (p=0.039) during ICU stay. Circulatory factor were most frequently described as barriers to early mobilization on days 1 (51%), 2 (47%), and 3 (26%). On days 4 to 7, the most frequently described barrier was consciousness factors (21%, 16%, 19%, and 21%, respectively). Conclusion: The results of this study comparing the ECMO/blood purification group and the untreated group in the ICU showed that the ECMO/blood purification group had significantly longer days to mobilization and significantly lower mean and highest IMS. [ABSTRACT FROM AUTHOR]

Globalization in Asia and consequent strengthening of healthcare economic factors in tandem with an increasing heart failure (HF) population have enhanced potential for development and progress in the fields of HF medicine and mechanical circulatory support (MCS). In Japan, there are unique opportunities to investigate the outcome of acute and chronic MCS and a national registry for percutaneous and implantable left ventricular assist device (LVAD) including Impella pumps has been established. A Peripheral extracorporeal membrane oxygenation (ECMO) for acute MCS has been used in more than 7000 patients annually and Impella usage in more than 4000 patients over the past 4 years was noted. Recently, a novel centrifugal pump with hydrodynamically levitated impeller was developed and approved for mid‐term extracorporeal circulatory support. In terms of chronic MCS more than 1200 continuous flow LVADs have been implanted during the past decade, and 2‐year survival rate after primary LVAD implantation is 91%. Because of donor organ shortage, more than 70% of heart transplant recipients required LVAD support for more than 3 years and prevention and treatment of complications during long‐term LVAD support have become important. Five important topics including hemocompatibility‐related complications, LVAD infections, aortic valve insufficiency, right ventricular failure and cardiac recovery during LVAD support are discussed in this review for improving clinical outcomes. Findings from Japan will continue to provide useful information regarding MCS for the Asia‐Pacific region and beyond. [ABSTRACT FROM AUTHOR]

Aim: To compare the clinical outcomes among women diagnosed with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection during pregnancy, and their neonates, during the period when the Omicron variant predominated in Japan with those of the pre‐Omicron variant period. Methods: We conducted a retrospective single‐center cohort study between August 1, 2020, and June 30, 2022. The cohort was divided into pre‐Omicron group (August 1, 2020 to November 30, 2021) and Omicron group (December 1, 2021 to June 30, 2022). The primary outcome was maternal intensive care unit (ICU) admission during the perinatal period. The secondary outcomes were maternal oxygen administration before and after delivery, preterm birth (PTB), and low birth weight (LBW). Results: During the study period, 81 pregnant women were admitted to the hospital with SARS‐CoV‐2 infection (pre‐Omicron period, n = 28; Omicron period, n = 53). SARS‐CoV‐2 infection during the Omicron period was associated with lower risk of maternal ICU admission (adjusted‐odds ratio [aOR]: 0.10, 95% confidence interval [CI]: 0.01–1.23, p = 0.072), oxygen administration via a nasal cannula or mask (aOR: 0.18, 95% CI: 0.03–0.96, p = 0.045), PTB (aOR: 0.15, 95% CI: 0.04–0.51, p = 0.002), and LBW (aOR: 0.13, 95% CI: 0.03–0.55, p = 0.005). Conclusion: Among pregnant women, SARS‐CoV‐2 infection during the Omicron period was associated with reduced risk of maternal ICU admission, requiring supplemental oxygen, PTB, and LBW. This can be attributable to lower virulence of the Omicron variant and higher vaccination coverage during the Omicron period. [ABSTRACT FROM AUTHOR]

This study aimed to evaluate the clinical effects of high-dose methylprednisolone therapy in hospitalized patients with severe coronavirus disease (COVID-19) who required oxygen therapy, but not noninvasive/invasive mechanical ventilation or extracorporeal membrane oxygenation therapy. This retrospective observational study that was conducted from April 2021 to October 2021 at a secondary hospital in Japan enrolled patients who were administered 6 mg/day dexamethasone as an initial corticosteroid treatment on admission (dexamethasone group) and those who were administered ≥ 250 mg/day methylprednisolone (methylprednisolone group). Of the 42 participants, 40.5% (17/42) were included in the methylprednisolone group. The incidence of transfer to a tertiary hospital did not differ significantly between the methylprednisolone and dexamethasone groups (5.9% vs. 20%, p = 0.37), and in-hospital mortality was similar in both the groups (0% vs. 4%, p = 1.00). Participants in the methylprednisolone group had a significantly longer duration of oxygen therapy than the dexamethasone group (median (interquartile range) 8.5 (5.5–11.2) days vs. 4 (2.0–7.5) days, p < 0.05). Compared to dexamethasone, high-dose methylprednisolone therapy did not provide any added benefits for patients with severe COVID-19 who did not require respiratory mechanical support. [ABSTRACT FROM AUTHOR]

Aims/Introduction: To assess the association of undiagnosed diabetes mellitus and its acute‐to‐chronic glycemic ratio with clinical outcome in patients hospitalized with coronavirus disease 2019 (COVID‐19) using a large‐scale nationwide registry in Japan. Materials and Methods: Overall, 4,747 patients were included between July 2021 and January 2022. We evaluated blood glucose and glycated hemoglobin levels at admission, and calculated the acute‐to‐chronic glycemic ratio for each non‐diabetes mellitus, undiagnosed diabetes mellitus and pre‐existing diabetes mellitus group. The primary composite outcome comprised in‐hospital mortality, invasive mechanical ventilation, extracorporeal membrane oxygenation support, intensive care unit admission and transfer to a more advanced medical facility. Results: Compared with the non‐diabetes mellitus group, the undiagnosed diabetes mellitus group was significantly associated with a worse COVID‐19 outcome (odds ratio 2.18, 95% confidence interval 1.50–3.18). In patients with undiagnosed diabetes mellitus, the 3rd tertile of the acute‐to‐chronic glycemic ratio was linked with a worse COVID‐19 outcome compared with the 1st tertile (odds ratio 3.33, 95% confidence interval 1.43–7.77), whereas glycated hemoglobin levels were not; among patients with pre‐existing diabetes mellitus, glycated hemoglobin levels were linked with a worse outcome. Conclusions: Among patients with undiagnosed diabetes mellitus with COVID‐19, the magnitude of elevation of blood glucose from chronic to acute levels is associated with worse outcomes. [ABSTRACT FROM AUTHOR]

Purpose: Many patients with coronavirus disease 2019 require mechanical ventilation and tracheostomy. However, the timing and indications for tracheostomy are controversial. This study assessed 11 patients with coronavirus disease 2019 who underwent tracheostomy with clinical information and retrospective analyses. Methods: A single-center retrospective observational study was performed on patients with coronavirus disease 2019 who underwent tracheostomy between 2020 and 2021. Results: Failure to wean was the most common indication for tracheostomy, followed by extracorporeal membrane oxygenation decannulation and the need for secretion management. After tracheostomy, six patients (54.5%) were liberated from the ventilator. The time from intubation to tracheostomy (21.1 ± 9.14 days) was correlated with the duration of ventilator dependency (36.83 ± 20.45 days, r2 = 0.792, p = 0.018). The mean Acute Physiological and Chronic Health Evaluation II score was significantly lower in the ventilator-liberated group (23 ± 2.77) than in the non-ventilator-liberated group (31 ± 6.13, p = 0.0292). Furthermore, patients with Acute Physiological and Chronic Health Evaluation II scores of < 27 points achieved ventilator liberation and a long-term survival (p = 0.0006). Conclusions: This study describes the outcomes of a cohort of patients who underwent tracheostomy after intubation for coronavirus disease 2019. The Acute Physiological and Chronic Health Evaluation II score predicted whether or not the patient could achieve ventilator liberation. [ABSTRACT FROM AUTHOR]

Background: Identifying predictive factors for coronavirus disease 2019 (COVID-19) is crucial for risk stratification and intervention. Kidney dysfunction contributes to the severity of various infectious diseases. However, the association between on-admission kidney dysfunction and the clinical outcome in COVID-19 patients is unclear. Methods: This study was a multicenter retrospective observational cohort study of COVID-19 patients, diagnosed by polymerase chain reaction. We retrospectively analyzed 500 COVID-19 patients (mean age: 51 ± 19 years) admitted to eight hospitals in Japan. Kidney dysfunction was defined as a reduced estimated glomerular filtration rate (< 60 mL/min/1.73 m2) or proteinuria (≥ 1 + dipstick proteinuria) on admission. The primary composite outcome included in-hospital death, extracorporeal membrane oxygenation, mechanical ventilation (invasive and noninvasive methods), and intensive care unit (ICU) admission. Results: Overall, 171 (34.2%) patients presented with on-admission kidney dysfunction, and the primary composite outcome was observed in 60 (12.0%) patients. Patients with kidney dysfunction showed higher rates of in-hospital death (12.3 vs. 1.2%), mechanical ventilation (13.5 vs. 4.0%), and ICU admission (18.1 vs. 5.2%) than those without it. Categorical and multivariate regression analyses revealed that kidney dysfunction was substantially associated with the primary composite outcome. Thus, on-admission kidney dysfunction was common in COVID-19 patients. Furthermore, it correlated significantly and positively with COVID-19 severity and mortality. Conclusions: On-admission kidney dysfunction was associated with disease severity and poor short-term prognosis in patients with COVID-19. Thus, on-admission kidney dysfunction has the potential to stratify risks in COVID-19 patients. [ABSTRACT FROM AUTHOR]

Introduction: Extracorporeal membrane oxygenation (ECMO) and Continuous renal replacement therapy (CRRT) are treatments for critically ill patients with respiratory failure and acute kidney injury. However, no reliable factors have been identified to predict survival in patients treated with both ECMO and CRRT. The aim of this study was to identify prognostic factors for discharging intensive care unit (ICU) patients who required CRRT during ECMO. Methods: We retrospectively analyzed data from patients who required CRRT in addition to the ECMO, between April 2015 and March 2018. The patients were divided into two groups: patients who survived and patients who died during ICU hospitalization. We determined their demographic and clinical characteristics, Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, Simplified Acute Physiology Score II (SAPS II) scores, and sequential organ failure assessment (SOFA) scores. Further, we assessed whether these characteristics differed between individuals who did or did not survive the ICU hospitalization. Results: We found that the APACHE II and SAPS II scores differed significantly between both ECMO and CRRT treated patients who did or did not survive hospitalization. Further, intracranial hemorrhage during ECMO and CRRT therapy was associated with lower survival rate. Conclusions: Using APACHE II and SAPS II scores might be helpful in making treatment decisions for patients treated with ECMO and CRRT. Intracranial hemorrhage could be a poor prognostic factor. Our findings indicate the potential utility of APACHE II and SAPS II scores to predict mortality in patients treated with both ECMO and CRRT. [ABSTRACT FROM AUTHOR]

Aim: Extracorporeal cardiopulmonary resuscitation (ECPR) is performed in refractory out-of-hospital cardiac arrest (OHCA) patients, and the eligibility has been conventionally determined based on three criteria (initial cardiac rhythm, time to hospital arrival within 45 minutes, and age <75 years) in Japan. Owing to limited information, this study descriptively determined neurological outcomes after applying the three criteria among OHCA patients who underwent ECPR.Methods: This study conducted a post-hoc analysis of data from the Comprehensive Registry of Intensive Care for OHCA Survival (CRITICAL) study. This was a multi-institutional prospective observational study of OHCA patients in Osaka Prefecture, Japan. All adult (aged ≥18 years) OHCA patients with internal medical causes treated with ECPR between 1 July 2012 and 31 December 2019 were evaluated. We described one-month neurological favourable outcomes based on the three criteria (initial shockable, time to hospital arrival within 45 minutes, and age <75 years), and we compared them using the chi-square test.Results: Among 18,379 patients screened from the CRITICAL study database, we included 517 OHCA patients treated by ECPR; 311 (60.2%) patients met all three criteria. Favourable neurological outcomes were as follows: patients meeting no or one criterion: 2.3% (1/43), those meeting two criteria: 8% (13/163), and those meeting all criteria: 16.1% (50/311) (P-value = 0.004).Conclusions: In this study, approximately 60% of patients treated by ECPR met the three criteria (initial shockable, time to hospital arrival within 45 minutes, and age <75 years), and the greater the number of criteria met, the better were the neurological outcomes achieved. [ABSTRACT FROM AUTHOR]

There are two types of pressure injuries: self‐load‐related pressure injuries (PIs) and medical device‐related pressure injuries (MDRPIs), but the differences in risk factors between PIs and MDRPIs have not yet been clarified. If risk factors for PIs and MDRPIs differ, preventive interventions should take this into account. This is a prospective cohort study aimed to determine the cumulative incidence of PIs and MDRPIs in critically ill patients and to identify corresponding risk factors. The study included 1418 patients who were admitted to the critical care medical center of a single university hospital in Tokyo, Japan, between 1 December 2019 and 31 August 2020. The Kaplan–Meier method was used to calculate the cumulative incidence of PIs and MDRPIs. Furthermore, the Cox proportional hazards model was used to analyse the predictors in both the PI and MDRPI incidence and non‐incidence groups. Predictors were based on data from the 0th disease day. The cumulative incidence of PIs and MDRPIs was 4.6/1000 person‐days and 3.6/1000 person‐days, respectively. Multivariate analysis using the Cox proportional hazards model showed that common risk factors for the occurrence of PIs and MDRPIs were possession of PI on admission, higher blood lactate, blood purification therapy, and positional restriction. The risk factors for PIs only were diabetes mellitus, septic shock, and a lower serum albumin level, while the risk factors for MDRPIs only were the D‐dimer level and extracorporeal membranous oxygenation treatment. Therefore, prophylactic interventions need to consider these different risk factors. [ABSTRACT FROM AUTHOR]

Background: Target temperature management (TTM) is an effective component of treating out-of-hospital cardiac arrest (OHCA) after return of spontaneous circulation in conventional cardiopulmonary resuscitation. However, therapeutic hypothermia (32–34 °C TTM) is not recommended based on the results of recent studies. Extracorporeal cardiopulmonary resuscitation (ECPR) with veno-arterial extracorporeal membrane oxygenation is another promising therapy for OHCA, but few studies have examined the effectiveness of ECPR with TTM. Therefore, we hypothesized that ECPR with TTM could have the effectiveness to improve the neurological outcomes for adults following witnessed OHCA, in comparison to ECPR without TTM. Methods: We performed retrospective subanalyses of the Japanese Association for Acute Medicine OHCA registry. We focused on adults who underwent ECPR for witnessed OHCA. We performed univariate (the Mann–Whitney U test and Fisher's exact test), multivariable (logistic regression analyses), and propensity score analyses (the inverse probability of the treatment-weighting method) with to compare the neurological outcomes between patients with or without TTM, among all eligible patients, patients with a cardiogenic cause, and patients divided into subgroups according to the interval from collapse to pump start (ICPS) (> 30, > 45, or > 60 min). Results: We analyzed data for 977 patients. Among 471 patients treated with TTM, the target temperature was therapeutic hypothermia in 70%, and the median interval from collapse to target temperature was 249 min. Propensity score analysis showed a positive association between TTM and favorable neurological outcomes in all patients (odds ratio 1.546 [95% confidence interval 1.046–2.286], P = 0.029), and in patients with ICPS of > 30 or > 45 min, but not in those with ICPS of > 60 min. The propensity score analysis also showed a positive association between TTM and favorable neurological outcomes in patients with a cardiogenic cause (odds ratio 1.655 [95% confidence interval 1.096–2.500], P = 0.017), including in all ICPS subgroups (> 30, > 45, and > 60 min). Conclusion: Within patients who underwent ECPR following OHCA, ECPR with TTM could show the potential of improvement in the neurological outcomes, compared to ECPR without TTM. [ABSTRACT FROM AUTHOR]

Introduction: Several randomized controlled trials have compared the effectiveness of favipiravir with that of placebo. However, evidence regarding its effect on nonsevere, early-stage coronavirus disease 2019 (COVID-19) remains insufficient. Methods: We used the COVID-19 Registry Japan, a nationwide registry of inpatients with COVID-19, for evaluating the effectiveness of favipiravir on patients with nonsevere, early-stage COVID-19. Eligible patients, who did not need supplementary oxygen therapy at admission, were classified according to two regimens (starting favipiravir therapy within 4 days from admission vs. no favipiravir during hospitalization) and were then compared using a three-step method (cloning, censoring, and weighting). The primary outcome was supplementary oxygen requirement during hospitalization, and the secondary outcomes were the need for invasive mechanical ventilation or extracorporeal membrane oxygenation (IMV/ECMO) and overall mortality at 30 days. Results: A total of 7654 cases were analyzed. The "start favipiravir" regimen did not show substantial differences in the primary outcome [hazard ratio 0.825, 95% confidence interval (CI) 0.657–1.04, p = 0.098] and both of the secondary outcomes [need for IMV/ECMO and overall 30-day mortality, hazard ratio 1.02 (95% CI 0.649–1.60) and 0.869 (95% CI 0.519–1.46), p = 0.929 and 0.594, respectively]. Conclusions: In this large cohort from a COVID-19 registry, favipiravir was not associated with a positive effect on the clinical outcome on patients with nonsevere, early-stage COVID-19, suggesting that it is not an essential drug for COVID-19 treatment. [ABSTRACT FROM AUTHOR]

To evaluate the effectiveness of remdesivir in the early stage of nonsevere COVID-19. Although several randomized controlled trials have compared the effectiveness of remdesivir with that of a placebo, there is limited evidence regarding its effect in the early stage of nonsevere COVID-19 cases. We evaluated the effectiveness of remdesivir in the early stage of nonsevere COVID-19 using the COVID-19 Registry Japan, a nationwide registry of hospitalized patients with COVID-19 in Japan. Two regimens ("start remdesivir" therapy within 4 days from admission versus no remdesivir during hospitalization) among patients without the need for supplementary oxygen therapy were compared by a 3-step processing (cloning, censoring, and weighting) method. The primary outcome was a supplementary oxygen requirement during hospitalization. Secondary outcomes were 30-day in-hospital mortality and the risk of invasive mechanical ventilation or extracorporeal membrane oxygenation (IMV/ECMO). The data of 12,487 cases met our inclusion criteria. The "start remdesivir" regimen showed a lower risk of supplementary oxygen requirement (hazard ratio [HR]: 0.850, 95% confidence interval [CI]: 0.798–0.906, p value < 0.001). Both 30-day in-hospital mortality and risk of IMV/ECMO introduction were not significantly different between the 2 regimens (HRs: 1.04 and 0.983, 95% CI: 0.980–1.09 and 0.906–1.07, p values: 0.210 and 0.678, respectively). Remdesivir might reduce the risk of oxygen requirement during hospitalization in the early stage of COVID-19; however, it had no positive effect on the clinical outcome and reduction in IMV/ECMO requirement. [ABSTRACT FROM AUTHOR]

Delta variant of concern (VOC) is the current predominant severe acute respiratory coronavirus type 2 strain causing coronavirus disease 2019 (COVID-19); however, information regarding the impact of the Delta VOC on clinical features and outcomes in pediatric patients with COVID-19 is limited. We conducted a retrospective observational study using the data of patients <18 years of age in COVIREGI-JP, the COVID-19 registry in Japan. The patients were divided into two groups according to the timing of enrollment in the registry (pre-Delta VOC era, October 2020 to May 2021; and Delta VOC era, August to October 2021), and the clinical characteristics and outcomes were compared between the two groups. During the study period, 950 and 349 pediatric patients were registered in the pre-Delta VOC and Delta VOC eras, respectively. The median patient age was younger and the proportion of patients with underlying diseases was higher in the Delta VOC era than that in the pre-Delta VOC era (10.0 vs 7.0 years, P < 0.001, and 7.4% [n = 70] vs. 12.6% [n = 44], P = 0.004, respectively). Significantly more patients were admitted to the intensive care unit in the Delta VOC era than in the pre-Delta VOC era (1.4% [ n = 5] vs. 0.1% [n = 1], P = 0.006), but no patient in either group died or required mechanical ventilation or extracorporeal membrane oxygenation throughout the study period, suggesting that the overall outcomes in children with COVID-19 remained favorable even in the Delta VOC era in Japan. [ABSTRACT FROM AUTHOR]

Veno‐venous extracorporeal membrane oxygenation (VV ECMO) is an effective and proven adjunct support for various severe respiratory failures requiring invasive mechanical ventilation and cardiovascular support. In response to the rapidly increasing number of COVID‐19 patients in Japan, we launched an ECMO support team comprised of multidisciplinary experts including physicians, nurses, perfusionists, and bioethicists in preparation for the threat of a pandemic. From April 2 to July 15, 2020, Tokyo Medical and Dental University hospital treated 104 PCR confirmed COVID‐19 patients. Among those, 34 patients were admitted to intensive care unit (ICU) and 5 patients required VV ECMO. All management related to ECMO was decided by the ECMO support team in addition to participation of the ECMO support team in daily multidisciplinary rounds in the ICU. Median age was 54 years old. Duration from onset to mechanical ventilation (MV) and MV to ECMO were 8 and 7 days, respectively. Four patients (80%) were successfully weaned off from ECMO. One patient died after 81 days of ECMO run. Four patients were discharged and recovered to their prehospital quality of life without major disability. We achieved a high survival rate using ECMO in our low volume ECMO institution during the COVID‐19 pandemic. Multidisciplinary decision‐making and a team approach for the unclear pathology with an emerging infectious disease was effective and contributed to the survival rate. [ABSTRACT FROM AUTHOR]

Background: Whether acute respiratory failure in patients with interstitial lung disease is reversible remains uncertain. Consequently, indications for extracorporeal membrane oxygenation in these patients are still controversial, except as a bridge to lung transplantation. The objective of this study was to clarify in-hospital mortality and prognostic factors in interstitial lung disease patients undergoing extracorporeal membrane oxygenation.Methods: In this case-control study using the Japanese Diagnosis Procedure Combination database, hospitalized interstitial lung disease patients receiving invasive mechanical ventilation and extracorporeal membrane oxygenation from 2010 to 2017 were reviewed. Patients' characteristics and treatment regimens were compared between survivors and non-survivors to identify prognostic factors. To avoid selection biases, patients treated with extracorporeal membrane oxygenation as a bridge to lung transplantation were excluded.Results: A total of 164 interstitial lung disease patients receiving extracorporeal membrane oxygenation were included. Their in-hospital mortality was 74.4% (122/164). Compared with survivors, non-survivors were older and received high-dose cyclophosphamide, protease inhibitors, and antifungal drugs more frequently, but macrolides and anti-influenza drugs less frequently. On multivariate analysis, the following factors were associated with in-hospital mortality: advanced age (odds ratio [OR] 1.043; 95% confidence interval [CI] 1.009-1.078), non-use of macrolides (OR 0.305; 95% CI 0.134-0.698), and use of antifungal drugs (OR 2.416; 95% CI 1.025-5.696).Conclusions: Approximately three-quarters of interstitial lung disease patients undergoing extracorporeal membrane oxygenation died in hospital. Moreover, advanced age, non-use of macrolides, and use of antifungal drugs were found to correlate with a poor prognosis. [ABSTRACT FROM AUTHOR]

Background: Many studies have been published about critically ill coronavirus disease 2019 (COVID-19) during the early phases of the pandemic but the characteristic or survival of critically ill Japanese patients have not yet been investigated. We sought to investigate the characteristics, inflammatory laboratory finding trends, and outcomes among critically ill Japanese patients who were admitted to the intensive care unit (ICU) with the first wave of COVID-19. Methods: A retrospective observational study was performed in a single institution in the center of Tokyo. Laboratory-confirmed COVID-19 patients admitted to the ICU from March 19 to April 30, 2020 were included. Trends for significant inflammatory laboratory findings were analyzed. In-hospital death, days of mechanical ventilation or oxygen supplementation, days of ICU or hospital stay were followed until May 26, 2020. Results: Twenty-four patients were included. Median age was 57.5 years, and 79% were male. The neutrophil-tolymphocyte ratio was elevated to a median of 10.1 on admission and peaked on Day 10 of illness. Seventeen patients were intubated on Day 11 of illness and received mechanical ventilation. One patient underwent extracorporeal membrane oxygenation. The majority (88%) received systemic steroids, including 16 patients who received high dose methylprednisolone (500-1000 mg). Favipiravir was used in 38% of patients. Two patients, including 1 who refused intensive care, died. Eighteen patients were discharged. Median length of ICU and hospital stay for all patients was 6 and 22 days, respectively. Median length of ventilator dependency was 7 days. Four patients underwent a tracheostomy and received prolonged ventilation for more than 21 days. One patient receiving mechanical ventilation died. All survivors discontinued ventilator use. Conclusions: Mortality was remarkably low in our single institutional study. Three survivors received mechanical ventilation for more than 3 weeks. Trends of clinically significant laboratory markers reflected the clinical course of COVID-19. [ABSTRACT FROM AUTHOR]

Background: Extracorporeal cardiopulmonary resuscitation (ECPR) with extracorporeal membrane oxygenation (ECMO) is a promising therapy for out-of-hospital cardiac arrest (OHCA) compared with conventional cardiopulmonary resuscitation (CCPR). The no and low-flow time (NLT), the interval from collapse to reperfusion to starting ECMO or to the return of spontaneous circulation (ROSC) in CCPR, is associated with the neurological outcome of OHCA. Because the effects of target temperature management (TTM) on the outcomes of ECPR are unclear, we compared the neurological outcomes of OHCA between ECPR and CCPR without TTM. Methods: We performed retrospective subanalyses of the Japanese Association for Acute Medicine OHCA registry. Witnessed cases of adult cardiogenic OHCA without TTM were selected. We performed univariate, multivariable and propensity score analyses to compare the neurological outcomes after ECPR or CCPR in all eligible patients and in patients with NLT of > 30 min or > 45 min. Results: We analysed 2585 cases. Propensity score analysis showed negative result in all patients (odds ratio 0.328 [95% confidence interval 0.141–0.761], P = 0.010). However, significant associated with better neurological outcome was shown in patients with NLT of > 30 min or > 45 min (odds ratio 2.977 [95% confidence interval 1.056–8.388], P = 0.039, odds ratio 5.099 [95% confidence interval 1.259–20.657], P = 0.023, respectively). Conclusion: This study revealed significant differences in the neurological outcomes between ECPR and CCPR without TTM, in patients with NLT of > 30 min. [ABSTRACT FROM AUTHOR]

Mechanical complications (MCs) following acute myocardial infarction (AMI), such as ventricular septal rupture (VSR), free-wall rupture (FWR), and papillary muscle rupture (PMR), are fatal. However, the risk factors of in-hospital mortality among patients with MCs have not been previously reported in Japan. The purpose of this study was to evaluate the prognostic factors of in-hospital mortality in these patients. The study cohort consisted of 233 consecutive patients with MCs from the registry of 10 facilities in the Cardiovascular Research Consortium-8 Universities (CIRC-8U) in East Japan between 1997 and 2014 (2.3% of 10,278 AMI patients). The authors conducted a retrospective observational study to analyse the correlation between the subtypes of MCs with in-hospital mortality, clinical data, and medical treatment. We observed a decreasing incidence of MC (1997–2004: 3.7%, 2005–2010: 2.1%, 2011–2014: 1.9%, p < 0.001). In-hospital mortality among patients with MCs was 46%. Thirty-three percent of patients with MCs were not able to undergo surgical repair due to advanced age or severe cardiogenic shock. In-hospital mortality among patients who had undergone surgical repair was 29% (VSR: 21%, FWR: 33%, PMR: 60%). In patients with MCs, hazard ratio for in-hospital mortality according to multivariate analysis of without surgical repair was 5.63 (95% CI 3.54–8.95). In patients with surgical repair, the hazard ratios of blow-out-type FWR (5.53, 95% confidence interval (CI) 2.22–13.76), those with renal dysfunction (3.11, 95% CI 1.37–7.05), and those receiving venoarterial extracorporeal membrane oxygenation (VA-ECMO) (3.79, 95% CI 1.81–7.96) were significantly high. Although primary percutaneous coronary intervention (PCI) is associated with decreased incidence of MCs, high in-hospital mortality persisted in patients with MCs that also presented with renal dysfunction and in those requiring VA-ECMO. Early detection and surgical repair of MCs are essential. [ABSTRACT FROM AUTHOR]

Aim: Patients with accidental hypothermia without vital signs increasingly receive venoarterial extracorporeal membrane oxygenation (VA-ECMO). However, there is limited knowledge regarding the efficacy of this advanced rewarming method. We aimed to determine whether VA-ECMO improved outcomes in patients with accidental hypothermia without vital signs, using a large nationwide inpatient database in Japan.Methods: Using the Japanese Diagnosis Procedure Combination inpatient database from July 2010 to March 2017, we identified patients diagnosed with accidental hypothermia who received closed-chest cardiac massage in-hospital on the day of admission. Patients who received VA-ECMO on the day of admission were allocated to the VA-ECMO group, and those who received cardiopulmonary resuscitation (CPR) only were allocated to the conventional CPR group. The primary outcome was in-hospital mortality, and the secondary outcome was a Japan Coma Scale status of "alert consciousness" at discharge. Propensity score-matching analyses were performed to compare the outcomes.Results: We identified 1661 eligible patients during the 81-month study period, and 318 (19%) received VA-ECMO on the day of admission. Crude in-hospital mortality was 65% in the VA-ECMO group and 84% in the conventional CPR group. Propensity score-matching analyses demonstrated significantly lower in-hospital mortality (risk difference: -13%; 95% confidence interval: -21% to -5.1%) and a higher proportion of "alert consciousness" at discharge (risk difference: 8.3%; 95% confidence interval: 1.9%-15%) in the VA-ECMO group compared with the conventional CPR group.Conclusion: VA-ECMO was associated with higher survival and favourable neurological outcomes compared with conventional CPR alone in patients with accidental hypothermia without vital signs. [ABSTRACT FROM AUTHOR]

This study aimed to evaluate the effect of different reperfusion strategies on neurological outcomes in patients with pulmonary embolism who received venoarterial extracorporeal membrane oxygenation (VA-ECMO) for out-of-hospital cardiac arrest (OHCA). This was a post-hoc analysis of a multicenter retrospective cohort study conducted in 36 institutions in Japan over six years. We included patients who underwent VA-ECMO and were diagnosed with pulmonary embolism caused by OHCA. Neurological outcomes were evaluated on the basis of the cerebral performance category at hospital discharge. We also assessed the association between reperfusion strategies and successful separation from ECMO. Among the 78 included patients, approximately half were successfully weaned from ECMO. Hospital mortality and favorable neurological outcomes at hospital discharge were 60.3% and 17.9%, respectively. Thirty-one patients (39.7%) underwent reperfusion strategies after ECMO, including 13 who received systemic thrombolytic therapy and 18 who underwent mechanical reperfusion strategy. After adjusting for prespecified covariates using the competing risk model, reperfusion strategies increased ECMO separation rate (systemic thrombolytic therapy: subdistribution hazard ratio [sHR] 2.24, 95% confidence interval [CI] 1.21–4.17, P = 0.011; mechanical reperfusion strategy: sHR 1.70, 95% CI 0.86–3.41, P = 0.129) compared with anticoagulation therapy alone, whereas higher cardiac Sequential Organ Failure Assessment score decreased ECMO separation rate (sHR 0.81, 95% CI 0.67–0.97, P = 0.020). Favorable neurological outcomes were observed in less than 20% of patients with OHCA due to pulmonary embolism undergoing ECMO. Reperfusion strategies may be associated with shorter ECMO durations in these patients. https://center6.umin.ac.jp/cgi-open-bin/ctr%5fe/ctr%5fview.cgi?recptno =R000041577 (unique identifier: UMIN000036490). [ABSTRACT FROM AUTHOR]

Determining the number of nurses required for patients with coronavirus disease receiving mechanical ventilation and/or veno-veno extracorporeal membrane oxygenation is important to provide quality care. Therefore, we conducted this cross-sectional survey of 725 intensive care units in Japan. Data from 152 units with experience of managing patients with coronavirus disease who required tracheal intubation were analyzed. The median number of nurses required for a patient receiving mechanical ventilation or veno-veno extracorporeal membrane oxygenation was two. This number was more than that according to the Japanese standard determined by government. We conclude that more nursing staff is required for caring for patients critically ill with coronavirus disease in intensive care units. [ABSTRACT FROM AUTHOR]

Purpose: Despite extensive research on enteral nutrition (EN) for patients in shock, it remains unclear whether this should be postponed in patients with cardiogenic or obstructive shock requiring venoarterial extracorporeal membrane oxygenation (VA-ECMO). In this study, we aimed to compare outcomes of early and delayed EN for patients with cardiogenic or obstructive shock requiring VA-ECMO.Methods: In this retrospective database study drawing on the Japanese Diagnosis Procedure Combination inpatient database from July 2010 to March 2016, we identified patients with cardiogenic or obstructive shock who had received VA-ECMO for more than 2 days. We allocated the patients to two groups: those who received EN within 2 days (early) or 3 days or more (delayed) after starting VA-ECMO. We then used a marginal structural model to analyze associations between early EN and various outcomes, including in-hospital mortality and 28-day mortality.Results: We identified 1769 eligible patients during the 69-month study period, 220 of whom (12%) received early EN. After using a marginal structural model to adjust for baseline and time-dependent confounders, we found that the early EN group showed significantly lower in-hospital mortality [hazard ratio 0.78, 95% confidence interval (95% CI) 0.62-0.98, P = 0.032] and lower 28-day mortality (hazard ratio 0.74, 95% CI 0.56-0.97, P = 0.031) than the delayed EN group.Conclusions: According to this retrospective database study, early EN is not associated with harm but rather with lower mortality in patients with cardiogenic or obstructive shock requiring at least 2 days of VA-ECMO. [ABSTRACT FROM AUTHOR]

Introduction Tele-echocardiography can ensure prompt diagnosis and prevent the unnecessary transport of infants without critical congenital heart disease, particularly at isolated locations lacking access to tertiary care medical centers. Methods We retrospectively reviewed all infants who underwent tele-echocardiography at a remote 16-bed level IIIB NICU from June 2005 to March 2014. Tele-echocardiograms were completed by cardiac sonographers in Okinawa, Japan, and transmitted asynchronously for review by pediatric cardiologists in Hawaii. Results During the study period 100 infants received 192 tele-echocardiograms: 46% of infants had tele-echocardiograms completed for suspected patent ductus arteriosus, 28% for suspected congenital heart disease, 12% for possible congenital heart disease in the setting of likely pulmonary hypertension, and 10% for possible congenital heart disease in the setting of other congenital anomalies. Of these, 17 patients were aeromedically evacuated for cardiac reasons; 12 patients were transported to Hawaii, while five patients with complex heart disease were transported directly to the United States mainland for interventional cardiac capabilities not available in Hawaii. Discussion This study demonstrates the use of tele-echocardiography to guide treatment, reduce long and potentially risky trans-Pacific transports, and triage transports to destination centers with the most appropriate cardiac capabilities. [ABSTRACT FROM AUTHOR]

Background There have been few reports on the outcome of extracorporeal membrane oxygenation ( ECMO) in newborn Japanese infants. Methods A review was carried out of 61 neonates with ECMO between January 1995 and December 2015 at a single center. ECMO was used in neonates with oxygenation index >20 after conventional treatment. Background factors, such as etiology, vascular access mode (veno-venous [ VV] or veno-arterial [ VA]), number of days with ECMO, and early ECMO (within 24 h after birth), were analyzed in relation to outcome with respect to survival to hospital discharge ( SHD). Results Survival to hospital discharge was achieved in 35 infants (57%), while the remaining 26 died during hospital stay. Gestational age at birth was significantly higher and number of days with ECMO was significantly lower in SHD infants compared with those with adverse outcome (median, 4.0 vs 5.5 days, respectively; P = 0.008). The SHD rate was significantly higher for those with VV than VA vascular access mode (78%, 18/23 vs 45%, 17/38, respectively; P = 0.016), and for those with than without early ECMO (72%, 28/39 vs 32%, 7/22, respectively; P = 0.003). The SHD rate was relatively high in neonates with meconium aspiration syndrome (86%, 12/14), persistent pulmonary hypertension associated with hypoxic ischemic encephalopathy (75%, 6/8), and emphysema (80%, 4/5). On stepwise logistic regression analysis two independent factors of SHD were identified: early ECMO ( OR, 9.63; 95% CI: 2.47-37.6) and ECMO length <8 days ( OR, 8.05; 95% CI: 1.94-33.5). Conclusions Neonates with early ECMO and those with ECMO duration <8 days may benefit from ECMO with respect to SHD. [ABSTRACT FROM AUTHOR]

To elucidate the effectiveness of extracorporeal membrane oxygenation (ECMO) in accidental hypothermia (AH) patients with and without cardiac arrest (CA), including details of complications. This study was a multicentre, prospective, observational study of AH in Japan. All adult (aged ≥18 years) AH patients with body temperature ≤32 °C who presented to the emergency department between December 2019 and March 2022 were included. Among the patients, those with CA or circulatory instability, defined as severe AH, were selected and divided into the ECMO and non-ECMO groups. We compared 28-day survival and favourable neurological outcomes at discharge between the ECMO and non-ECMO groups by adjusting for the patients' background characteristics using multivariable logistic regression analysis. Among the 499 patients in this study, 242 patients with severe AH were included in the analysis: 41 in the ECMO group and 201 in the non-ECMO group. Multivariable analysis showed that the ECMO group was significantly associated with better 28-day survival and favourable neurological outcomes at discharge in patients with CA compared to the non-ECMO group (odds ratio [OR] 0.17, 95% confidence interval [CI]: 0.05–0.58, and OR 0.22, 95%CI: 0.06–0.81). However, in patients without CA, ECMO not only did not improve 28-day survival and neurological outcomes, but also decreased the number of event-free days (ICU-, ventilator-, and catecholamine administration-free days) and increased the frequency of bleeding complications. ECMO improved survival and neurological outcomes in AH patients with CA, but not in AH patients without CA. [ABSTRACT FROM AUTHOR]

Background: Patients resuscitated after cardiac arrest are reportedly at high risk for infection and sepsis, especially those treated with targeted temperature management (TTM). There is, however, limited evidence suggesting that early antibiotic use improves patient outcomes. We examined the hypothesis that early treatment with antibiotics reduces mortality in patients with cardiac arrest receiving TTM. Methods: We identified 2803 patients with cardiogenic out-of-hospital cardiac arrest (OHCA) that were treated with TTM and were admitted to 371 hospitals that contribute to the Japanese Diagnosis Procedure Combination inpatient database between July 2007 and March 2013. Of these, 1272 received antibiotics within the first 2 days (antibiotics) and 1531 did not (control). We generated 802 propensity score-matched pairs. Results: There was no significant difference in 30-day mortality between the groups (control vs. antibiotics; 33.0 % vs. 29.9 %; difference, 3.1 %; 95 % confidence interval [CI], -1.4 to 7.7 %, p = 0.18). Analysis using the hospital antibiotics prescribing rate as an instrumental variable showed that antibiotic use was not significantly associated with a reduction in 30-day mortality (6.6 %, CI 95 %, -0.5 to 13.7 %, p = 0.28). A subgroup analysis of patients who required extracorporeal membrane oxygenation (ECMO) indicated a significant difference in 30-day mortality between the 2 groups (62.9 % vs. 43.5 %; difference 19.3 %, CI 95 %, 5.9 to 32.7 %, p = 0.005). In the instrumental variable model, the estimated reduction in 30-day mortality associated with antibiotics was 18.2 % (CI 95 %, 21.3 to 34.4 %, p = 0.03) in ECMO patients. Conclusions: Although there was no significant association between the use of antibiotics and mortality after overall cardiogenic OHCA treated with TTM, antibiotics may be beneficial in patients who require ECMO. [ABSTRACT FROM AUTHOR]

Williams syndrome is a contiguous gene deletion syndrome resulting from a heterozygous deletion on chromosome 7q11.23, and is characterized by distinctive facial features and supravalvular aortic stenosis (SVAS). This syndrome rarely presents unpredictable cardiac death, and yet, as illustrated in the present case, it is still not possible to predict it, even on close monitoring. We herein describe the case of a 6-year-old Japanese girl with Williams syndrome, who had sudden cardiac collapse due to cardiac infarction after pharyngitis. Cardiac failure followed a critical course that did not respond to catecholamine support or heart rest with extracardiac mechanical support. Although marked coronary stenosis was not present, the left coronary cusp abnormally adhered to the aortic wall, which may synergistically cause coronary ostium occlusion with SVAS. Altered hemodynamic state, even that caused by the common cold, may lead to critical myocardial events in Williams syndrome with SVAS. [ABSTRACT FROM AUTHOR]

The viscosity obtained from pressure-flow characteristics of an oxygenator may help to detect factors that change oxygenator resistance. The objective of this study was to model pressure-flow characteristics of a membrane oxygenator with an integrated arterial filter and to quantify their influence on apparent viscosity of non-Newtonian fluids. One Newtonian fluid (glycerin solution) and two non-Newtonian fluids (whole bovine blood and a human red blood cell suspension) were perfused through an oxygenator and their pressure-flow characteristics examined systematically. Four resistance parameters for the pressure gradient characteristics approximation equation were obtained by the least squares method from the relational expression of pressure-flow characteristics and viscosity. For all three fluids, a non-linear flow to pressure change was observed with a coefficient of determination of almost 1 by exponential approximation. The glycerin solution had a higher pressure gradient (10-70%) than the other fluids; the apparent viscosity of the non-Newtonian fluids was around 35% lower than the static one measured by a torsional oscillation viscometer. Overall, our study demonstrated that the influence on the apparent viscosity of non-Newtonian fluids can be quantified by pressure gradient differences in a membrane oxygenator with an integrated arterial filter. [ABSTRACT FROM AUTHOR]

Background The aim of this study was to clarify how extracorporeal membrane oxygenation ( ECMO) is used to treat congenital diaphragmatic hernia ( CDH) in Japan. Methods We completed a nationwide survey of CDH involving 614 infants. The subjects included 43 patients who underwent ECMO. We compared the clinical data of the patients who did and did not survive ≥90 days, and analyzed the 24 h blood gas data in isolated CDH cases in both groups. Results Of the 43 CDH patients, non-isolated CDH associated with other life-threatening or chromosomal anomalies was diagnosed in six patients. Only one of these six patients was able to discontinue ECMO and survived, and the other five died shortly after birth. The other 37 patients all had isolated CDH. The reason for initiating ECMO in 31 of these patients was persistent pulmonary hypertension of the newborn ( PPHN). In the 37 patients with isolated CDH, ECMO was initiated within 24 h after birth. Sixteen patients (37%) survived ≥90 days, and intact discharge was possible in eight cases. Among the isolated CDH patients, on ROC analysis of the lowest oxygenation index ( OI) to predict 90 day survival, the cut-off was 15. Conclusions ECMO is used to treat PPHN starting from an early period after birth, but the mortality and morbidity are not favorable. For lowest OI, the index used to predict survival following ECMO, the cut-off was 15. [ABSTRACT FROM AUTHOR]

An editorial is presented on the Treatment for congenital diaphragmatic hernia. Topics discussed include Modern treatment of Congenital diaphragmatic hernia (CDH) has steadily progressed by improved understanding and better management of deranged cardiopulmonary physiology and recognition of the role of delayed surgical repair; and the improvement of survival rate(s) of CDH is attributed to increasing prenatal diagnosis (%), emergent intubation at birth, gentle ventilation.

B Conclusions: b The current ECPR data including 1,463 OHCA patients showed 13.3% of favorable neurological outcomes at hospital discharge in unselected OHCA patients. This study aimed to assess patient characteristics, outcomes, and complications of ECPR practice in patients with OHCA. B Introduction: b Several observational extracorporeal cardiopulmonary resuscitation (ECPR) studies with clinical data have been published; however, those studies have the great limitations with relatively small numbers, and the real-world data of ECPR in out-of-hospital cardiac arrest (OHCA) patients is lacking. [Extracted from the article]

Purpose: To evaluate procedures and outcomes of extracorporeal membrane oxygenation (ECMO) therapy applied to 2009 influenza A(H1N1) severe respiratory failure patients in Japan. Methods: This observational study used database information about adults who received ECMO therapy for H1N1-related severe respiratory failure from April 1, 2010 to March 31, 2011. Results: Fourteen patients from 12 facilities were enrolled. Anti-influenza drugs were used in all cases. Before the start of ECMO, the lowest PaO/FiO was median (interquartile) of 50 (40-55) mmHg, the highest peak inspiratory pressure was 30 (29-35) cmHO, and mechanical ventilation had been applied for at least 7 days in 5 patients. None of the facilities had extensive experience with ECMO for respiratory failure (6 facilities, no previous experience; 5 facilities, one or two cases annually). The blood drainage cannula was smaller than 20 Fr. in 10 patients (71.4 %). The duration of ECMO was 8.5 (4.0-10.8) days. The duration of each circuit was only 4.0 (3.2-5.3) days, and the ECMO circuit had to be renewed 19 times (10 cases). Thirteen patients (92.9 %) developed adverse events associated with ECMO, such as oxygenator failure, massive bleeding, and disseminated intravascular coagulation. The survival rate was 35.7 % (5 patients). Conclusion: ECMO therapy for H1N1-related severe respiratory failure in Japan has very poor outcomes, and most patients developed adverse events. However, this result does not refute the effectiveness of ECMO. One possible cause of these poor outcomes is the lack of satisfactory equipment, therapeutic guidelines, and systems for patient transfer to central facilities. [ABSTRACT FROM AUTHOR]

Background--Extracorporeal membrane oxygenation (ECMO) and percutaneous coronary intervention (PCI) may be useful in cardiopulmonary resuscitation. However, little is known about the combination of ECMO and intra-arrest PCI. This study investigated the efficacy of rapid-response ECMO and intra-arrest PCI in patients with cardiac arrest complicated by acute coronary syndrome who were unresponsive to conventional cardiopulmonary resuscitation. Methods and Results--This multicenter cohort study was conducted with the use of the database of ECMO in Hiroshima City, Japan. Between January 2004 and May 2011, rapid-response ECMO was performed in 86 patients with acute coronary syndrome who were unresponsive to conventional CPR. The median age of the study patients was 63 years, and 81% were male. Emergency coronary angiography was performed in 81 patients (94%), and intra-arrest PCI was performed in 61 patients (71%). The rates of return of spontaneous heartbeat, 30-day survival, and favorable neurological outcomes were 88%, 29%, and 24%, respectively. All of the patients who received intra-arrest PCI achieved return of spontaneous heartbeat. In patients who survived up to day 30, the rate of out-of-hospital cardiac arrest was lower (58% versus 28%; P=0.01), the intra-arrest PCI was higher (88% versus 70%; P=0.04), and the time interval from collapse to the initiation of ECMO was shorter (40 [25-51] versus 54 minutes [34-74 minutes]; P=0.002). Conclusions--Rapid-response ECMO plus intra-arrest PCI is feasible and associated with improved outcomes in patients who are unresponsive to conventional cardiopulmonary resuscitation. On the basis of these findings, randomized studies of intra-arrest PCI are needed. [ABSTRACT FROM AUTHOR]

Extracorporeal membrane oxygenation (ECMO) has emerged as an effective mechanical support following cardiac surgery with respiratory and cardiac failure. However, there are no clear indications for ECMO use after pediatric cardiac surgery. We retrospectively reviewed medical records of 76 pediatric patients [mean age, 10.8 months (0–86); mean weight, 5.16 kg (1.16–16.5)] with congenital heart disease who received ECMO following cardiac surgery between January 1997 and October 2010. Forty-five patients were treated with an aggressive ECMO approach (aggressive ECMO group, April 2005–October 2010) and 31 with a delayed ECMO approach (delayed ECMO group, January 1997–March 2005). Demographics, diagnosis, operative variables, ECMO indication, and duration of survivors and non-survivors were compared. Thirty-four patients (75.5%) were successfully weaned from ECMO in the aggressive ECMO group and 26 (57.7%) were discharged. Conversely, eight patients (25.8%) were successfully weaned from ECMO in the delayed ECMO group and two (6.5%) were discharged. Forty-five patients with shunted single ventricle physiology (aggressive: 29 patients, delayed: 16 patients) received ECMO, but only 15 (33.3%) survived and were discharged. The survival rate of the aggressive ECMO group was significantly better when compared with the delayed ECMO group (p<0.01). Also, ECMO duration was significantly shorter among the aggressive ECMO group survivors (96.5 ± 62.9 h, p<0.01). Thus, the aggressive ECMO approach is a superior strategy compared to the delayed ECMO approach in pediatric cardiac patients. The aggressive ECMO approach improved our outcomes of neonatal and pediatric ECMO. [ABSTRACT FROM PUBLISHER]

We report here Japan’s first pediatric perfusion survey. It covers practices from January 2007 through December 2009. Of the 70 congenital heart centers contacted, 53 (76%) completed the survey. They reported performing 3,379 pediatric cardiopulmonary bypass (CPB) procedures in 2009, 3,408 in 2008, and 3,358 in 2007.Twenty-eight percent of all centers used CPB circuits with a priming volume between 151-200 ml. All centers used pre-bypass ultrafiltration and only 6% used retrograde autologous priming. A biomaterial-coated circuit was used by 78% of the centers, a roller pump as the arterial pump by 91%, vacuum-assisted venous drainage by 39%, dilutional ultrafiltration by 48%, and modified ultrafiltration at the end of the procedure by 30%. A regional oxygen saturation monitor was used by 69% of the centers and high flow (150-200 ml/kg/min) management with alpha-stat blood gas control was standard during moderate to normothermic CPBs. Crystalloid cardioplegia solution was used as myocardial protection by 56% of the centers, electronic recording of monitoring data by 51%. The centers performed 98 pediatric extracorporeal membrane oxygenation procedures in 2007, 109 in 2008, and 119 in 2009; 58% of the centers used a centrifugal pump. This survey provides a description of the current practice in Japan. Future surveys will identify trends and rate of change in practice. [ABSTRACT FROM PUBLISHER]

The coronavirus disease 2019 (COVID-19) pandemic has increased the number of patients who require extracorporeal membrane oxygenation (ECMO). To manage the demand for ECMO, Japan ECMOnet for COVID-19 was developed as a "disaster management-like system", utilizing the Cross ICU Searchable Information System (CRISIS) database. This study investigated the effect of the establishment of this disaster management-like system in Japan. This was a nationwide retrospective observational study conducted from 1 February to 31 July in 2020. A total of 187 patients with COVID-19 who received ECMO were included. The median age was 60 years (interquartile range, 53–68), the median length of ventilatory support before ECMO was 3 days (1–5), and the median PaO2 to FiO2 ratio at ECMO initiation was 86 (71.3–101.5). During the study period, 165 telephone consultations were conducted, including general questions about ECMO. Among them, 44 concerned patients who were already on ECMO or who ultimately received ECMO. Further coordination, including transport and ECMO physician dispatch, was provided for 23 cases. Overall, 125/187 (66.8%) patients were successfully weaned from ECMO. This study demonstrated that Japan has achieved favorable survival outcomes for patients with COVID-19 who received ECMO with a disaster management-like system. Further research on the causes of these outcomes is needed. [ABSTRACT FROM AUTHOR]

The epidemiological and clinical characteristics, treatments, and outcomes of patients with coronavirus disease 2019 (COVID-19) who are admitted to the intensive care unit (ICU) have not been adequately evaluated in Japan. We analyzed the registry data of 205 patients with COVID-19 admitted to the ICU between February and November 2020, in Osaka Prefecture, Japan. A Cox proportional hazards model was used to assess the association between epidemiological factors and mortality among ICU patients. Of the 205 ICU patients, 161 (78.5%) were men and 149 (72.7%) were older than 60 years. A total of 117 patients (57.1%) had comorbidities. The most common symptoms at diagnosis were mild (n = 131, 63.9%). A total of 187 patients (91.2%) received mechanical ventilation, and 32 patients (15.6%) required extracorporeal membrane oxygenation. Patients were followed up for a median of 25 days after ICU admission. A total of 147 patients (71.7%) were alive at discharge, and 58 patients (28.3%) died. The hazard ratio for mortality among patients aged >80 years was 6.02 (95% confidence interval: 2.10−17.25) in the multivariable model, which was higher than that among those aged ≤59 years. These results are useful for recognizing the clinical course of this infection in ICU patients. [ABSTRACT FROM AUTHOR]

The author suggests the importance of an organized extracorporeal membrane oxygenation (ECMO)-based respiratory program in Japan. He describes ECMO as an expanded clinical application of cardiopulmonary bypass introduced in the 1950s that allowed a longer period of support than other oxygenators. He cites a study in Great Britain which found the efficacy of ECMO in neonates with severe respiratory failure. He also references a study by S. Takeda et al on ECMO for 2009 influenza in Japan.

Background: For patients treated with extracorporeal membrane oxygenation (ECMO), employing a well-coordinated, multidisciplinary team specializing in ECMO has reportedly been effective in delivering better clinical outcomes. This study aims to assess the impact of establishing such a specialized team for patients treated with ECMO. Method: This retrospective cohort study was performed at a tertiary-care hospital in Japan. We reviewed medical records of all consecutive patients treated with ECMO during October 2010–September 2016. The results obtained in pre-ECMO team cases (PRE group; October 2011–September 2012) and post-ECMO team cases (POST group; October 2014–September 2015) were compared. Results: The results obtained in pre-ECMO team cases (PRE group; October 2011–September 2012) and post-ECMO team cases (POST group; October 2014–September 2015) were compared. During the study period, 177 patients were treated with ECMO. Before the introduction of ECMO team, an average of 22.7 patients underwent ECMO treatment per year; after establishing ECMO team, this number increased to 36.3 patients per year. ECMO was applied mainly to cardiac arrest patients 52/69 (75%). The PRE (n = 27) and POST (n = 42) groups did not differ with regard to the survival rate to hospital discharge, ECMO duration, ventilator days, and length of hospital stay. However, PaO2 and positive end-expiratory pressure were significantly higher in the POST group at 6 h after ECMO initiation than those in the PRE group [367 (186–490) vs. 239 (113–430) mmHg, p = 0.047 and 8 (5–10) vs. 7 (5–8) cmH2O, p = 0.01, respectively]. In addition, data recording the detailed time points of ECMO initiation was conducted in significantly more cases in the POST group (28/126 (22%) than in the PRE group (6/81 (7%); p = 0.01). Conclusions: Following the establishment of an ECMO team, the survival rate of patients treated with ECMO, ECMO duration, and length of hospital stay were not improved. However, the number of ECMO cases increased and the recording of clinical data was improved. [ABSTRACT FROM AUTHOR]