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Although existing guidelines recommend commencing cannulation for extracorporeal cardiopulmonary resuscitation (ECPR) within 10-20 minutes of failed conventional resuscitation efforts for cardiac arrest, there is little supportive evidence. The present study aimed to determine the association of low-flow duration with survival-to-discharge rate in in-hospital cardiac arrest patients who received ECPR.A nationwide retrospective cohort study analyzed a nationwide inpatient database in Japan. Low-flow duration was defined as the time interval from initiation of chest compression to termination of chest compression. We assessed the association between low-flow duration and survival-to-discharge rate by predicting estimates with covariate adjustment stratified by categories of low-flow duration.More than 1,600 acute-care hospitals in Japan.All in-hospital cardiac arrest patients greater than or equal to 18 years old who received ECPR during hospitalization from July 2010 to March 2018.None.Among 303,319 in-hospital cardiac arrest patients, 9,844 (3.2%) received ECPR in 697 hospitals during the study period and 9,433 were eligible in the study. The overall survival-to-discharge rate was 20.5% (1,932/9,433). The median low-flow duration was 26.0 minutes (interquartile range, 12.0-46.0 min) in the overall cohort. The highest and lowest estimated survival-to-discharge rates were 35.1% in the group with low-flow duration 0-5 minutes and 7.9% in the group with low-flow duration greater than 90 minutes. The estimated survival-to-discharge rate dropped sharply by about 20% during the first 35 minutes of low-flow duration (decreasing by about 3% every 5 min), followed by small decreases after the first 35 minutes.The estimated survival-to-discharge rate was markedly decreased by approximately 20% during the first 35 minutes of low-flow duration. Whether we should wait for the first 10-20 minutes of cardiac arrest without preparing for ECPR is questionable.

OBJECTIVES To determine whether a progressive early mobilization protocol improves patient outcomes, including in-hospital mortality and total hospital costs. DESIGN Retrospective preintervention and postintervention quality comparison study. SETTINGS Single tertiary community hospital with a 12-bed closed-mixed ICU. PATIENTS All consecutive patients 18 years old or older were eligible. Patients who met exclusion criteria or were discharged from the ICU within 48 hours were excluded. Patients from January 2014 to May 2015 were defined as the preintervention group (group A) and from June 2015 to December 2016 was the postintervention group (group B). INTERVENTION Maebashi early mobilization protocol. MEASUREMENTS AND MAIN RESULTS Group A included 204 patients and group B included 187 patients. Baseline characteristics evaluated include age, severity, mechanical ventilation, and extracorporeal membrane oxygenation, and in group B additional comorbidities and use of steroids. Hospital mortality was reduced in group B (adjusted hazard ratio, 0.25; 95% CI, 0.13-0.49; p < 0.01). This early mobilization protocol is significantly associated with decreased mortality, even after adjusting for baseline characteristics such as sedation. Total hospital costs decreased from $29,220 to $22,706. The decrease occurred soon after initiating the intervention and this effect was sustained. The estimated effect was $-5,167 per patient, a 27% reduction. Reductions in ICU and hospital lengths of stay, time on mechanical ventilation, and improvement in physical function at hospital discharge were also seen. The change in Sequential Organ Failure Assessment score and Sequential Organ Failure Assessment score at ICU discharge were significantly reduced after the intervention, despite a similar Sequential Organ Failure Assessment score at admission and at maximum. CONCLUSIONS In-hospital mortality and total hospital costs are reduced after the introduction of a progressive early mobilization program, which is significantly associated with decreased mortality. Cost savings were realized early after the intervention and sustained. Further prospective studies to investigate causality are warranted.

Aim: Acute aortic dissection has been considered a contraindication for extracorporeal cardiopulmonary resuscitation (ECPR). However, studies are lacking regarding the epidemiology and effectiveness of ECPR for this condition. We aimed to examine whether ECPR for acute aortic dissection during cardiac arrest is effective or not. Methods: Using the Japanese Diagnosis Procedure Combination inpatient database from July 2010 to March 2018, we identified all emergently hospitalized adults who received ECPR on the day of admission. ECPR was defined as receiving both chest compressions and percutaneous extracorporeal membrane oxygenation on the day of hospital admission. In-hospital mortality and neurological outcomes were compared between patients with and without acute aortic dissection. We also calculated the incremental cost-effectiveness ratio of ECPR for acute aortic dissection. Results: We identified 10,238 patients who received ECPR on the day of admission. Of these, 398 patients (3.9%) had acute aortic dissection. In-hospital mortality was 98% in the acute aortic dissection group and 79% in the non-acute aortic dissection group. Seven patients (1.8%) in the acute aortic dissection group survived to discharge after ECPR; of these, six patients had good neurological outcomes at discharge. The incremental cost-effectiveness ratio of ECPR for patients with acute aortic dissection was estimated at 159,337 US dollars per quality-adjusted life year gained. Conclusion: ECPR successfully rescued a small number of acute aortic dissection patients with cardiac arrest; however, the cost burden of ECPR for acute aortic dissection patients was unacceptably high.

Introduction: There are few studies on the differential effects of mild therapeutic hypothermia (MTH) according to the risk class in post-cardiac arrest syndrome (PCAS) patients. Objective: The aim of this study was to evaluate the differential effects of MTH against therapeutic normothermia (TN) for PCAS patients according to our risk classification tool (rCAST). Methods: We used data from the out-of-hospital cardiac arrest (OHCA) registry of the Japanese Association for Acute Medicine (JAAM), which is a multi-center, prospective registry of OHCA patients who were transported to critical care medical centers or hospitals with an emergency care department across Japan. We classified eligible PCAS patients treated with MTH or TN on the basis of our rCAST score which was previously developed by us: low severity group (≤5.5), moderate severity group (6-14), and high severity group (≥14.5). The differential effects of MTH vs. TN for their neurological outcome in the 3 severity categories were evaluated by interaction analysis, and the effect of MTH vs. TN in each group was assessed by multivariate logistic regression analysis and propensity score analysis. The good neurological outcome was defined as a Cerebral Performance Categories score ≤2 at 30 days. Results: Among 12,024 OHCA patients in the registry, data of 460 PCAS patients treated by MTH or TN were analyzed (96 patients; the low score, 192; the moderate score, and 172; the high score group). There was a statistically significant interaction effect between MTH/TN and their neurological outcome at 30 days in the 3 categories (p = 0.022). MTH was significantly associated with good neurological outcome at 30 days in PCAS patients of moderate severity group both in the multivariate logistic regression analysis (adjusted odds ratio, 3.09; 95% confidence interval, 1.13-8.49; p = 0.029) and the propensity score analysis (p = 0.030), while it was not in low and high severity group. Conclusions: The effect of MTH in PCAS patients differed according to the severity of PCAS, and MTH was significantly associated with a good neurological outcome as compared to TN in the moderate severity group.

Supplemental doses of antithrombin (AT) are widely used to treat sepsis-induced disseminated intravascular coagulation (DIC) in Japan. However, evidence on the benefits of AT supplementation for DIC is insufficient. This multicenter retrospective observational study aimed to clarify the effect of AT supplementation on sepsis-induced DIC using propensity score analyses. Data from 3,195 consecutive adult patients admitted to 42 intensive care units for severe sepsis treatment were retrospectively analyzed; 1,784 patients were diagnosed with DIC (n = 715, AT group; n = 1,069, control group). Inverse probability of treatment-weighted propensity score analysis indicated a statistically significant association between AT supplementation and lower in-hospital all-cause mortality (n = 1,784, odds ratio [95% confidence intervals]: 0.748 [0.572-0.978], P = 0.034). However, quintile-stratified propensity score analysis (n = 1,784, odds ratio: 0.823 [0.646-1.050], P = 0.117) and propensity score matching analysis (461 matching pairs, odds ratio: 0.855 [0.649-1.125], P = 0.263) did not show this association. In the early days after intensive care unit admission, the survival rate was statistically higher in the propensity score-matched AT group than in the propensity score-matched control group (P = 0.007). In DIC patients without concomitant heparin administration, similar results were observed. In conclusion, AT supplementation may be associated with reduced in-hospital all-cause mortality in patients with sepsis-induced DIC. However, the statistical robustness of this connection was not strong. In addition, although the number of transfusions needed in patients with AT supplementation increased, severe bleeding complications did not.

Introduction: The trauma-induced coagulopathy is well-known pathophysiology of severely injured trauma patients. However, the difference due to the injury type is not well researched. The aim of this study is to investigate the difference of coagulopathy between the blunt and penetrating trauma. PATIENTS and Methods: Single-center retrospective study was conducted. The electrical record of patients admitted from April 2008 to March 2017 were reviewed and penetrating trauma patients with injury severity score (ISS) 9 or more were enrolled. The case-control matching with blunt trauma patients was performed, adjusting for ISS, Shock-Index, the need for transfusion, and lactate level at the hospital arrival. After the matching, 5 points of hemoglobin, fibrinogen, platelet, prothrombin-time percentage (PT%), fibrin/fibrinogen degradation products (FDP), and D-dimer in their clinical course were statistically compared. Results: 8 patients were matched. FDP at hospital arrival was significantly higher in the blunt group compared to the penetrating group (Median 7.85 vs 92.8; p Conclusion: In the acute and early phase of severe traumatic injury, the hyperfibrinolysis of blunt trauma can be significantly more severe than that of penetrating trauma.

Introduction: The lactate has been widely recognized as a marker of tissue hypoxia/hypoperfusion. Hyperlactatemia is common among patients requiring critical care, and lactate levels and their trend may be reliable markers of illness severity and mortality. Elevated plasma lactate levels have been recommended as a parameter for hemodynamic resuscitation. The aim of this study is to investigate the predictive value of the lactate levels at the scene of injury for the need for Massive Transfusion (MT). Patients and Methods: A single-center retrospective diagnostic study was conducted. The records of the emergency medical service (EMS) between Sep. 2012 and Apr. 2017 were reviewed and adult high-energy trauma patients transported by the EMS were included. The data about the lactate levels and the need for MT (10 units or more of packed red blood cells transfusion within 24 hours of injury) was collected, and the predictive value of the lactate levels at the scene of injury was analyzed by the area under the receiver operating characteristic curve (AUROC). Our EMS system is always with specialized emergency physician, and lactate level was measured by portable equipment. Results: 1039 patients were enrolled and 1025 patients were analyzed after exclusion of 14 patients with insufficient data. The mean age was 55.0 years, 77.6% male, 98.1% blunt trauma, and 6.6% underwent MT. The AUROC of the lactate levels at the scene of injury for MT was 0.91 [95% confidential interval; 0.90-0.93]. Conclusion: The lactate levels at the scene of injury can accurately predict the need for Massive Transfusion. The further investigation is warranted.

Background: Determination of the need for massive transfusion (MT) at the scene of injury is ideal for early activation of a MT protocol. We created and reported The Pre-hospital Traumatic Bleeding Severity Score (ph-TBSS) that is a simple and highly accurate scoring system to predict the need for MT at the scene of injury. However, the comparison study about the predictive value between the ph-TBSS and other MT predictors is not performed. Patients and Methods: A diagnostic comparison study using the registry data of the Gunma Prefectural Helicopter Emergency Medical Service (HEMS) was conducted. Records between Sep. 2012 and Apr. 2017 were reviewed, and adult trauma patients transported by the HEMS were included. A physician in the HEMS is always on board, primary survey including abdominal sonography scanning is performed at the scene of injury, and lactate was measured by portable equipment. The potential predictors of MT (10 units or more of packed red blood cells transfusion within 24 hours of injury) at the scene of injury were defined as following; The ph-TBSS, Assessment of Blood Consumption (ABS) score, the shock index, lactate concentration, and the presence of cold sweat. Each predictor was retrospectively calculated or reviewed from the registry data. Each predictive value was analyzed by the area under the receiver operating characteristic curve (AUROC) and the AUROC comparison analysis was performed. Results: 1025 patients were analyzed. Each AUROC for MT was following; ph-TBSS vs ABC score vs shock index vs lactate concentration vs presence of cold sweat = 0.97 [0.96-0.98] vs 0.83 [0.81-0.85] vs 0.89 [0.87-0.91] vs 0.91 [0.90-0.93] vs 0.70 [0.67-0.72]. The AUROC of the ph-TBSS was significantly higher compared to the AUROC of the other predictors (Bonferroni adjusted p Conclusion: At the scene of injury, the ph-TBSS represented the highest predictive value for MT, compared to the ABC score, shock index, lactate concentration, or presence of cold sweat.

Many hemodynamically stable patients with blunt abdominal solid organ injuries are successfully managed nonoperatively, while unstable patients often require urgent laparotomy. Recently, therapeutic angioembolization has been used in the treatment of intra-abdominal hemorrhage in hemodynamically unstable patients. We undertook this study to review a series of hemodynamically unstable patients with abdominal solid organ injuries managed nonoperatively with angioembolization and resuscitative endovascular balloon occlusion of the aorta.The institutional review board approved this study. All patients were appropriately resuscitated with transfusions, and angiography was performed after computed tomography. Resuscitative endovascular balloon occlusion of the aorta was performed before computed tomography in all patients.Seven patients underwent resuscitative endovascular balloon occlusion of the aorta following severe blunt abdominal trauma. The 28-day survival rate was 86% (6 of 7). There were no complications related to the procedure.We describe the first clinical series of hemodynamically unstable patients with abdominal solid organ injury treated nonoperatively with angioembolization and resuscitative endovascular balloon occlusion of the aorta. Survival rate was 86%, supporting the need for further study of this modality as an adjunct to the nonoperative management of patients with severe traumatic injuries.Therapeutic study, level V.

The ability to easily predict the need for massive transfusion may improve the process of care, allowing early mobilization of resources. There are currently no clear criteria to activate massive transfusion in severely injured trauma patients. The aims of this study were to create a scoring system to predict the need for massive transfusion and then to validate this scoring system.We reviewed the records of 119 severely injured trauma patients and identified massive transfusion predictors using statistical methods. Each predictor was converted into a simple score based on the odds ratio in a multivariate logistic regression analysis. The Traumatic Bleeding Severity Score (TBSS) was defined as the sum of the component scores. The predictive value of the TBSS for massive transfusion was then validated, using data from 113 severely injured trauma patients. Receiver operating characteristic curve analysis was performed to compare the results of TBSS with the Trauma-Associated Severe Hemorrhage score and the Assessment of Blood Consumption score.In the development phase, five predictors of massive transfusion were identified, including age, systolic blood pressure, the Focused Assessment with Sonography for Trauma scan, severity of pelvic fracture, and lactate level. The maximum TBSS is 57 points. In the validation study, the average TBSS in patients who received massive transfusion was significantly greater (24.2 [6.7]) than the score of patients who did not (6.2 [4.7]) (p0.01). The area under the receiver operating characteristic curve, sensitivity, and specificity for a TBSS greater than 15 points was 0.985 (significantly higher than the other scoring systems evaluated at 0.892 and 0.813, respectively), 97.4%, and 96.2%, respectively.The TBSS is simple to calculate using an available iOS application and is accurate in predicting the need for massive transfusion. Additional multicenter studies are needed to further validate this scoring system and further assess its utility.Prognostic study, level III.

BACK GROUND: The aggressive administration of plasma has been recommended for the improvement of traumatic coagulopathy. The survival benefit has been found in trauma resuscitation with rich plasma, and this benefit seems to be related to early use of this blood product. However, to our knowledge, no method for the recognition or prediction of traumatic cougulopathy at the point of a patient’s arrival has been established. The aim of this study was to test the predictive value of massive transfusion prediction scores for early traumatic coagulopathy. METHOD: We reviewed records of severe trauma patients admitted to our center from Jan. 2008 to Mar. 2014, whose Injury Severity Score was 16 or more. Traumatic Bleeding Severity Score (TBSS), Trauma Associated Severe Hemorrhage Score (TASH Score), and Assessment of Blood Consumption Score (ABC Score) were calculated. Early traumatic coagulopathy was defined as 150mg/dl or less of fibrinogen and 1.5 or more of PT-INR within 6 hours from injury, although transfusion and crystalloid infusion was provider dependent. Cardiopulmonary arrest patients on arrival and simple head or spine trauma patients were excluded. Each predictive value for early traumatic coagilopathy was tested by area under the receiver operating characteristic curve (AUC). Receiver operating characteristic curve comparison was performed to compare the accuracy between TBSS, TASH Score, and ABC Score. Each spearman’s rank correlation coefficient for the amount of fresh frozen plasma transfused within 24 hours form injury was checked. RESULT: 388 patients were enrolled in this study. The AUC of TBSS (0.927) was significantly higher than that of TASH Score (0.856) or ABC Score (0.726) (both Bonferoni adjusted p Conclusion: Massive transfusion prediction scores can also predict the early traumatic coagulopathy. TBSS had the highest predictive value and strong correlation between the score and the needed plasma. The calculation of TBSS is simple. Therefore, TBSS will rapidly predict the need for rich plasma transfusion.

Back Ground: The aging of society is progressing rapidly, and the aging of the trauma patient has also progressed over time. Age-related physiologic or anatomic loss of organ function, muscle atrophy, osteoporosis, and reduction in the average amount of subcutaneous tissue may lead to more serious effects of a traumatic injury. The aim of this study is to investigate the effect of patient’s age in the need for massive transfusion. Material and Methods: This study was conducted at a single institution, all patients in this study experienced blunt traumatic injuries. Patients with out-of-hospital cardiac arrest or isolated head trauma were excluded. We reviewed data from severely injured trauma patients admitted between Jan. 2008 and Mar. 2012. The following parameters were evaluated: age, sex, systolic blood pressure (SBP), heart rate (HR), Glasgow Coma Scale (GCS), results of the Focused Assessment with Sonography for Trauma (FAST), unstable pelvic fracture, femoral fracture, serum lactate, base excess, hemoglobin level (Hb), platelet count (Plt), prothrombin time (PT), antithrombotic agents, active outer bleeding, and Injury Severity Score (ISS). Massive transfusion was defined as the transfusion of 10 or more units of packed red blood cells, within 24 hours of the time of injury. We compared the parameters in patients who underwent massive transfusion (the MT group) with those who did not (the non-MT group), and independent contributed variables were detected by multiple logistic regression analysis. Results: 232 patients were included. Age, positive FAST, serum lactate, active outer bleeding, the presence of unstable pelvic fracture, and ISS in the MT group were all significantly greater than in the non-MT group. SBP, GCS, Hb, Plt, and PT were significantly less in the MT group than in the non-MT group. Age (p=0.02), SBP (p Conclusion: Elderly blunt trauma patient tended to be transfused massively, and consideration of the patient’s age is important to predict the need for massive transfusion in severe blunt trauma patients.

Objective: Anaphylaxis is a multi-system syndrome resulting from the release of chemical mediators upon exposure to an allergen. Biphasic anaphylactic reactions may occur due to secondary elevation of the chemical mediators following the initial reaction. The initial treatment of anaphylaxis generally includes adrenaline injection, which results in decreased chemical mediator release. We hypothesize that continuous intravenous administration, rather than intramuscular injection of adrenaline, may inhibit the release of chemical mediators following the initial reaction, and thereby prevent biphasic reactions. Accordingly, in this study, we aimed to investigate the occurrence of biphasic reactions according to the type of administration of adrenaline. Methods: We included patients with anaphylaxis admitted to our hospital, who were treated with adrenaline between April 2005 and March 2014. We retrospectively investigated the occurrences of biphasic reactions after admission in patients treated with continuous intravenous adrenaline or intramuscular adrenaline injections. Patients were excluded if they had received intravenous bolus or complex methods of administration. The risk of biphasic reactions according to the method of administration was analyzed by logistic regression. Results: A total of 104 patients were included in the study (continuous intravenous administration: 56, intramuscular injection: 48). Eight patients (7.69%) experienced biphasic reactions, out of which one had received continuous intravenous administration, and seven had received intramuscular injection (p = 0.02). No patient had received adrenaline during the biphasic reaction in the continuous intravenous administration group compared to the three patients in the intramuscular injection group (p = 0.10). Logistic regression analysis revealed that the odds ratio of biphasic reactions for continuous intravenous administration vs. intramuscular injection of adrenaline was 0.11 (p = 0.04, 95% confidence interval: 0.01-0.90). Conclusions: Continuous intravenous administration of adrenaline may prevent the biphasic reaction of anaphylaxis.