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ABSTRACT: This study was designed to elucidate the present situation of diagnosis and treatment for mycosis in the field of emergency and critical care medicine following presentation of the diagnosis and treatment guidelines for deep mycosis (in February, 2003).
In patients (administered antimycotics or who have pyrexia showing no response to any antimicrobial drug), medically examined and suspected of having had a fungal infection at 15 medical institutions throughout Japan, participating in the Japanese Society for the Study of Critical Care for Mycosis during the period from May 2003 through August 2004 and with facilities for emergency and critical care medicine, patient background, risk factors, contents of treatment, and patient outcomes were totaled and assessed.
The subjects of this assessment were 125 patients consisting of 87 (69.6%) men and 38 (30.4%) women. Their mean age was 59.6 years, and 36.8% were 70 years of age or older. Intravascular catheterization was conducted in 78.4% of the 125 subjects. Antimycotics were administered to 89 patients, and the frequencies of fluconazole (FLCZ) for the initial administration and during the period of data registration were the highest (74.2% and 80.9%, respectively). The frequency with which a carbapenem antimicrobial drug was administered prior to antimycotics was the highest (41.6%). Blood culture was conducted in 85 patients (68.0%), monitoring culture in 108 (86.4%). Fungi were detected in 10 patients (11.8%) with blood culture and 72 (66.7%) with monitoring culture. The frequency of Candida albicans detection was the highest, 50.0% (5/10), with blood culture. With monitoring culture as well, the frequency of C. albicans detection was the highest, 55.6% (40/72). Alleviation of fever at the completion of registration was recognized in 65.6%. The survival rates at the completion of and at 28 days after the start of data registration of were 78.4% and 69.6%, respectively.
Many patients in the field of emergency and critical care medicine had risk factors for deep mycosis; 11.8% and 66.7% of our 125 subjects were positive on blood and monitoring cultures, respectively. The majority of the fungi detected belonged to the Candida group, and FLCZ was the most frequently used antimycotic.
The Japanese journal of antibiotics 03/2008; 61(1):18-28.
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ABSTRACT: This study was designed to investigate the influence of "The diagnosis and treatment guidelines for deep mycosis" (hereinafter referred to as "the Guidelines") in Japan on the diagnosis and treatment of deep mycosis in the field of emergency and critical care medicine and their influences on patient outcomes.
In patients (administered antimycotics or who had pyrexia showing no response to any antimicrobial drug) medically examined and suspected of having had a fungal infection at 15 medical institutions throughout Japan, participating in the Japanese Society for the Study of Critical Care for Mycosis during the period from May 2003 through August 2004 and with facilities for emergency and critical care medicine, patient background, risk factors, awareness of the Guidelines, diagnosis, contents of treatment, and outcomes were investigated. On the basis of the data pertaining to these items, whether or not the course of diagnosis and treatment for each patient conformed to the diagnosis and treatment recommended in the Guidelines was retrospectively evaluated. Whether or not the treatment had been conducted with antimycotics and the doses recommended in the Guidelines, was also investigated, and outcomes were assessed according to conformity and non-conformity to the Guidelines.
Of the 125 subjects assessed, 55.2% responded that they were conscious of the Guidelines. The subjects who had indications for the Guidelines included 10 (8.0%), who were definitely diagnosed as having had mycosis, 3 (2.4%) who were diagnosed as having had clinical mycosis, and 35 (28.0%) who were suspected of having had mycosis. In the remaining 77 (61.6%), whether their conditions were non-mycosis or mycosis could not be determined. The treatment conformed to the Guidelines in 25 subjects (20.0%), but did not in 23 (18.4%). In 77 subjects (61.6%), whether or not the condition had been mycosis could not be determined. The number of the patients in whom whether or not the treatment had conformed to the Guidelines could be determined was decreased and there was a marked influence of administration of antimycotics, which was based on the assumption that "pyrexia with no response to broad-spectrum antimicrobial drugs persists for at least 3 days" in the Guidelines, was given as the reason. There was no significant difference in outcomes (survival or death) at the end of the study based on whether or not the subject had been conscious of the Guidelines or whether or not the contents of treatment conformed to the Guidelines. The number of days that treatment was administered in the ICU was greater in the treatment conforming to the Guidelines than in that not conforming to the Guidelines, but the difference did not reach statistical significance.
The Guidelines were recognized at the time of treatment by more than half of the patients registered, but there were actually only a few patients in whom the diagnosis and treatment conformed to the Guidelines. One possible reason is considered to be that there was a marked influence of one item of the Guidelines, i.e. "pyrexia without response to broad-spectrum antimicrobial drugs persists for at least 3 days", in patients with suspected mycosis, who receive empirical treatment, in terms of the reason. Future examination is considered to be needed regarding the validity of this item.
The Japanese journal of antibiotics 03/2008; 61(1):29-41.
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Hiroshi Ogura,
Satoshi Gando,
Toshiaki Iba,
Yutaka Eguchi,
Yasuhiro Ohtomo,
Kohji Okamoto,
Kazuhide Koseki,
Toshihiko Mayumi, Atsuo Murata,
Toshiaki Ikeda,
Hiroyasu Ishikura,
Masashi Ueyama,
Shigeki Kushimoto,
Daizoh Saitoh,
Shigeatsu Endo,
Shuji Shimazaki
[show abstract]
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ABSTRACT: Coagulopathy and thrombocytopenia often occur in critically ill patients, and disseminated intravascular coagulation (DIC) can lead to multiple organ dysfunction and a poor outcome. However, the relation between coagulopathy and systemic inflammatory response has not been thoroughly clarified. Thus, we evaluated coagulative activity, organ dysfunction, and systemic inflammatory response syndrome (SIRS) in critically ill patients with thrombocytopenia and examined the balance between coagulopathy and systemic inflammation.
Two hundred seventy-three patients, who were admitted to 13 critical care centers in Japan and fulfilled the criteria of platelet count of less than 150*10(9)/L, were included. Coagulative variables (platelet count, fibrin/fibrinogen degradation products, and DIC scores), organ dysfunction index (Sequential Organ Failure Assessment [SOFA] score), and SIRS score in each patient were evaluated for 4 consecutive days after fulfilling the above entry criteria. The effect of SIRS on coagulopathy and organ dysfunction was evaluated in these patients.
Both the maximum SIRS score and entry SIRS score had significant relation to the maximum SOFA score during the observation period. Coagulation disorders indicated by the minimum platelet count, maximum DIC scores, and positivity for DIC worsened gradually with increases in SIRS scores. Both the minimum platelet count and maximum DIC scores were significantly correlated with the maximum SOFA score, indicating that a relation exists between coagulopathy and organ dysfunction.
In critically ill patients with thrombocytopenia, coagulopathy and organ dysfunction progress with significant mutual correlation, depending on the increase in SIRS scores. The SIRS-associated coagulopathy may play a critical role in inducing organ dysfunction after severe insult.
Shock 11/2007; 28(4):411-7. · 2.85 Impact Factor
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Toshiaki Iba,
Satoshi Gando, Atsuo Murata,
Shigeki Kushimoto,
Daizoh Saitoh,
Yutaka Eguchi,
Yasuhiro Ohtomo,
Kohji Okamoto,
Kazuhide Koseki,
Toshihiko Mayumi,
Toshiaki Ikeda,
Hiroyasu Ishhikura,
Masashi Ueyama,
Yuji Ogura,
Shigeatsu Endo,
Shuji Shimazaki
[show abstract]
[hide abstract]
ABSTRACT: The changes in biomarkers of coagulation or fibrinolysis, anticoagulation, inflammation, and endothelial damage occur in patients with systemic inflammatory response syndrome (SIRS). The purpose of this study is to assess the prognostic value of these markers in patients with SIRS-associated hypercoagulopathy.
Sixty-six SIRS patients with a platelet count less than 15.0 x 10(4)/mm3 in three university hospital intensive care units were enrolled in this prospective, comparative study. Blood samples were obtained on day 0 and day 2. Twelve hemostatic, inflammatory, and vascular endothelial indices were measured and the data were compared between the severe group (patients with a total maximum Sequential Organ Failure Assessment score of 10 or more and nonsurvivors; n = 25) and the less-severe group (Sequential Organ Failure Assessment score <10; n = 41).
Significant changes between the groups were observed in platelet count, fibrin or fibrinogen degradation products, interleukin-6, soluble thrombomodulin, antithrombin (AT) activity, and protein C activity, both on day 0 and on day 2. In contrast, the d-dimer, soluble fibrin, plasmin-[alpha]2-antiplasmin complex, and E-selectin levels were higher in the severe group only on day 2. No significant difference was seen regarding the thrombin-AT complex and total plasminogen activator inhibitor on both days. A comparison of the areas under the receiver operating characteristic curve revealed the AT activity to be the best predictor of a progression of organ dysfunction.
The changes in some hemostatic molecular markers and vascular endothelial markers were conspicuous in patients with organ dysfunction. The AT activity is considered to be the most useful predictor of organ dysfunction.
The Journal of trauma 11/2007; 63(5):1093-8. · 2.48 Impact Factor
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Toshiaki Iba,
Satoshi Gando, Atsuo Murata,
Shigeki Kushimoto,
Daizoh Saitoh,
Yutaka Eguchi,
Yasuhiro Ohtomo,
Kohji Okamoto,
Kazuhide Koseki,
Toshihiko Mayumi,
Toshiaki Ikeda,
Hiroyasu Ishhikura,
Masashi Ueyama,
Yuji Ogura,
Shigeatsu Endo,
Shuji Shimazaki,
the Japanese Association for Acute Medicine Disseminated Intravascular Coagulation Study Group
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ABSTRACT: Introduction: The changes in biomarkers of coagulation or fibrinolysis, anticoagulation, inflammation, and endothelial damage occur in patients with systemic inflammatory response syndrome (SIRS). The purpose of this study is to assess the prognostic value of these markers in patients with SIRS-associated hypercoagulopathy.
Methods: Sixty-six SIRS patients with a platelet count less than 15.0 × 104/mm3 in three university hospital intensive care units were enrolled in this prospective, comparative study. Blood samples were obtained on day 0 and day 2. Twelve hemostatic, inflammatory, and vascular endothelial indices were measured and the data were compared between the severe group (patients with a total maximum Sequential Organ Failure Assessment score of 10 or more and nonsurvivors; n = 25) and the less-severe group (Sequential Organ Failure Assessment score <10; n = 41).
Results: Significant changes between the groups were observed in platelet count, fibrin or fibrinogen degradation products, interleukin-6, soluble thrombomodulin, antithrombin (AT) activity, and protein C activity, both on day 0 and on day 2. In contrast, the d-dimer, soluble fibrin, plasmin-α2-antiplasmin complex, and E-selectin levels were higher in the severe group only on day 2. No significant difference was seen regarding the thrombin-AT complex and total plasminogen activator inhibitor on both days. A comparison of the areas under the receiver operating characteristic curve revealed the AT activity to be the best predictor of a progression of organ dysfunction.
Conclusion: The changes in some hemostatic molecular markers and vascular endothelial markers were conspicuous in patients with organ dysfunction. The AT activity is considered to be the most useful predictor of organ dysfunction.
The Journal of Trauma and Acute Care Surgery. 10/2007; 63(5):1093-1098.
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The Journal of trauma 10/2007; 63(3):E85-7. · 2.48 Impact Factor
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Hiroshi Ogura,
Satoshi Gando,
Toshiaki Iba,
Yutaka Eguchi,
Yasuhiro Ohtomo,
Kohji Okamoto,
Kazuhide Koseki,
Toshihiko Mayumi, Atsuo Murata,
Toshiaki Ikeda,
Hiroyasu Ishikura,
Masashi Ueyama,
Shigeki Kushimoto,
Daizoh Saitoh,
Shigeatsu Endo,
Shuji Shimazaki,
Japanese Association for Acute Medicine Disseminated Intravascular Coagulation Study Group
[show abstract]
[hide abstract]
ABSTRACT: Backgrounds: Coagulopathy and thrombocytopenia often occur in critically ill patients, and disseminated intravascular coagulation (DIC) can lead to multiple organ dysfunction and a poor outcome. However, the relation between coagulopathy and systemic inflammatory response has not been thoroughly clarified. Thus, we evaluated coagulative activity, organ dysfunction, and systemic inflammatory response syndrome (SIRS) in critically ill patients with thrombocytopenia and examined the balance between coagulopathy and systemic inflammation. Patients and Methods: Two hundred seventy-three patients, who were admitted to 13 critical care centers in Japan and fulfilled the criteria of platelet count of less than 150•109/L, were included. Coagulative variables (platelet count, fibrin/fibrinogen degradation products, and DIC scores), organ dysfunction index (Sequential Organ Failure Assessment [SOFA] score), and SIRS score in each patient were evaluated for 4 consecutive days after fulfilling the above entry criteria. The effect of SIRS on coagulopathy and organ dysfunction was evaluated in these patients. Results: Both the maximum SIRS score and entry SIRS score had significant relation to the maximum SOFA score during the observation period. Coagulation disorders indicated by the minimum platelet count, maximum DIC scores, and positivity for DIC worsened gradually with increases in SIRS scores. Both the minimum platelet count and maximum DIC scores were significantly correlated with the maximum SOFA score, indicating that a relation exists between coagulopathy and organ dysfunction. Conclusions: In critically ill patients with thrombocytopenia, coagulopathy and organ dysfunction progress with significant mutual correlation, depending on the increase in SIRS scores. The SIRS-associated coagulopathy may play a critical role in inducing organ dysfunction after severe insult.
Shock 09/2007; 28(4):411-417. · 2.85 Impact Factor
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Satoshi Gando,
Toshiaki Iba,
Yutaka Eguchi,
Yasuhiro Ohtomo,
Kohji Okamoto,
Kazuhide Koseki,
Toshihiko Mayumi, Atsuo Murata,
Toshiaki Ikeda,
Hiroyasu Ishikura,
Masashi Ueyama,
Hiroshi Ogura,
Shigeki Kushimoto,
Daizoh Saitoh,
Shigeatsu Endo,
Shuji Shimazaki
[show abstract]
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ABSTRACT: To validate scoring algorithm criteria established by the Japanese Association for Acute Medicine (JAAM) for disseminated intravascular coagulation (DIC) and to evaluate its diagnostic property by comparing the two leading scoring systems for DIC, from the Japanese Ministry of Health and Welfare (JMHW) and International Society on Thrombosis and Haemostasis (ISTH).
Prospective, multicenter study during a 3-month period.
General critical care center in a tertiary care hospital. Patients: Two hundred seventy-three patients with platelet counts<150x109/L were enrolled.
None.
The JAAM, JMHW, and ISTH DIC scoring algorithms were prospectively applied within 12 hrs of patients meeting the inclusion criteria (day 0) to days 1-3, by global coagulation tests. The numbers of systemic inflammatory response syndrome (SIRS) criteria and Sequential Organ Failure Assessment (SOFA) scores were determined simultaneously. Mortality associated with any cause was also assessed 28 days after the enrollment. All global coagulation tests and SIRS criteria adopted in the JAAM criteria and their cutoff points were validated with use of SOFA scores and mortality rate. DIC diagnostic rate of the JAAM DIC scoring system was significantly higher than that of the other two criteria (p<.001). The JAAM DIC algorithm was the most sensitive for early diagnosis of DIC (p<.001). Patients who fulfilled the JAAM DIC criteria included almost all those whose DIC was diagnosed by the JMHW and ISTH scoring systems. The JAAM DIC scores showed significant correlation with SOFA scores ([rho]=0.499; p<.001). SOFA score and mortality rate worsened in accordance with an increase in the JAAM DIC score. Fibrinogen criteria had little effect in predicting outcome for the DIC patients, and a total score of 4 points in the JAAM scoring system without fibrinogen was closely related to poor prognosis. According to the results, we revised the JAAM criteria by excluding fibrinogen and confirmed that the DIC diagnostic properties of original criteria remained unchanged in the revised JAAM criteria.
The JAAM scoring system has an acceptable property for the diagnosis of DIC. The scoring system identified most of the patients diagnosed by the JMHW and ISTH criteria. Revised JAAM DIC criteria preserved all properties of the original criteria for DIC diagnosis. The revised scoring system can be useful for selecting DIC patients for early treatment in a critical care setting.
Critical Care Medicine 03/2006; 34(3):625-31. · 6.33 Impact Factor
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ABSTRACT: The purpose of this study was to determine the association between bilomas and pseudoaneurysm complications after severe hepatic injury.
Angiography was performed in patients with American Association for the Surgery of Trauma grade > or = III hepatic injury on contrast-enhanced computed tomographic scanning. When contrast extravasation was observed, transarterial embolization (TAE) was performed. After TAE, technetium-99m pyridoxyl-5-methyl-tryptophan cholescintigraphy was performed to detect the coexistence of bilomas. Follow-up angiography was performed when a biloma was detected. Eighty consecutive patients underwent angiography; after angiography, five patients died. The remaining 75 patients who underwent cholescintigraphy were included in this study.
All 11 patients who had bilomas had angiographic evidence of contrast extravasation. The biloma frequency was higher in patients with grades IV and V injuries than in those with grade III injury (p = 0.024). Follow-up angiography revealed pseudoaneurysms in 7 of these 11 patients. All six patients in whom only gelatin sponge pledget injection was used to embolize had pseudoaneurysms. Among them, two patients had computed tomographic evidence of massive intra-abdominal fluid collection. In contrast, only one of five patients who received the combination of gelatin sponge pledget injection and stainless steel coils to permanently embolize injured arteries had a pseudoaneurysm. In this patient, the pseudoaneurysm was found in the peripheral part of the collateral vessels. All patients with pseudoaneurysms underwent repeat TAE and were discharged from the hospital uneventfully.
In patients with high-grade hepatic injury and arterial bleeding who developed biloma, use of a gelatin sponge, an absorbable embolic material, is associated with a risk of pseudoaneurysm formation. Permanent arterial embolization using stainless steel coils is indicated to decrease this risk.
The Journal of trauma 07/2005; 59(1):49-53; discussion 53-5. · 2.48 Impact Factor
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ABSTRACT: To evaluate the use of transcatheter arterial embolization (TAE) in hemodynamically unstable patients with blunt splenic injury in whom there is a transient response to initial fluid resuscitation.
Human subject committee approval and informed consent were obtained. Angiography was performed in patients with contrast material extravasation and/or splenic injury of grade III or higher (American Association for the Surgery of Trauma criteria) at computed tomography (CT). TAE was performed when angiograms showed disruption of terminal splenic branches or arterial extravasation. Among 104 patients with splenic injury, the 15 patients (10 male, five female; mean age, 36.2 years) with a transient response to fluid resuscitation were the subjects of this study. A post hoc analysis was performed for CT grades, angiographic findings, associated injuries, and hemodynamic status in the subjects.
Among 15 patients with a transient response, two had grade III, 11 had grade IV, and two had grade V injuries at CT. Six patients had associated injuries that required TAE. TAE of the spleen and associated injuries was successfully performed in all patients. The mean systolic blood pressure and shock index at the start of TAE were 84.2 mm Hg +/- 9.2 (standard deviation) and 1.46 +/- 0.30, respectively, and those at the completion of TAE were 132.1 mm Hg +/- 18.7 and 0.77 +/- 0.21, respectively (P < .001). The fluid infusion rate within 24 hours after the completion of TAE (132.1 mL/h +/- 71.1) was lower than that from the completion of the initial fluid resuscitation until the completion of TAE (1230.6 mL/h +/- 264.8) (P < .001).
TAE for blunt splenic injury can be performed successfully even in hemodynamically unstable patients with a transient response to initial fluid resuscitation.
Radiology 05/2005; 235(1):57-64. · 5.73 Impact Factor
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Satoshi Gando,
Hideo Wada,
Hidesaku Asakura,
Toshiaki Iba,
Yutaka Eguchi,
Kohji Okamoto,
Yasuhiro Ohtomo,
Kazuo Kawasugi,
Shin Koga,
Kazuhide Koseki,
Hajime Tsuji,
Toshihiko Mayumi, Atsuo Murata,
Masao Nakagawa,
Shigeatu Endo
[show abstract]
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ABSTRACT: New Japanese diagnostic criteria were prepared for disseminated intravascular coagulation (DIC) in critically ill patients and their usefulness was compared with the criteria of the International Society of Thrombosis and Haemostasis (ISTH) and those of the Japan Ministry of Health and Welfare (JMHW). In a retrospective study of patients with platelet counts of less than 150 x10(3)/mL, 52 cases (33.3%), 66 cases (42.3%), and 101 cases (64.7%) were diagnosed as DIC by the ISTH, JMHW, and new Japanese DIC criteria, respectively. The DIC state as diagnosed by the new Japanese DIC criteria included both DIC states as diagnosed by ISTH or JMHW criteria. Some DIC states diagnosed by the JMHW criteria included those diagnosed by ISHT criteria but this was not universal. The mortality of DIC as diagnosed by the ISTH or JMHW criteria was markedly high, compared to that for DIC diagnosed by the new Japanese criteria. The mortality of patients without DIC by ISTH was also high when they were diagnosed as DIC by the new Japanese criteria. The frequency of DIC by each set of diagnostic criteria was significantly higher in patients with infection than in those without infection. The mortality of DIC by each set of diagnostic criteria was significantly higher in patients with infection than in those without infection, and the mortality of overt-DIC by ISTH diagnostic criteria was also high in patients without infection.
Clinical and Applied Thrombosis/Hemostasis 02/2005; 11(1):71-6. · 1.33 Impact Factor
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ABSTRACT: This study aimed to determine whether nonsurgical management using transcatheter arterial embolization (TAE) is safe for patients with blunt multiple trauma who transiently respond to the initial fluid resuscitation.
Contrast computed tomography was performed for patients with blunt abdominal injuries, excluding those who did not respond to initial fluid resuscitation. Angiography was performed for patients with injuries showing contrast extravasation or solid organ injury classified, according to the American Association for the Surgery of Trauma, as grade 3 or higher on computed tomography. Transcatheter arterial embolization was performed when angiography showed arterial extravasation. The protocol was abandoned for any patients who became profoundly hypotensive (with systolic blood pressure 60 mm Hg or lower) during computed tomography or angiography.
Between January 2000 and December 2002, 269 patients with blunt abdominal injuries underwent TAE immediately after admission. Of these patients, 41 had injuries in at least two regions and underwent TAE for these regions. Among them, 22 patients were hemodynamically stable or showed rapid response to fluid resuscitation. The nonsurgical treatment was successful in all these cases. The remaining 19 patients (Injury Severity Score, 37.3 +/- 8.2), who showed a transient response, were the subjects of this study. Of these patients, 15 underwent TAE for injuries in two regions (13 pelvic fractures, 7 splenic injuries, 6 hepatic injuries, 3 facial bleeding, and 1 renal injury), and 4 patients underwent TAE for injuries in three regions (4 had splenic injuries, 3 hepatic injuries, 2 renal injuries, 2 pelvic fractures, and 1 facial bleeding). For all these patients, TAE was successfully performed. Before TAE, the systolic blood pressure was 79.9 +/- 8.4 mm Hg, and the shock index was 1.45 +/- 0.25 mm Hg. After TAE, the corresponding values were 120.6 +/- 19.3 mm Hg and 0.87 +/- 0.16 mm Hg, respectively (p < 0.001). The rate of fluid administration required after TAE (214.2 +/- 139.3 mL/hour) was significantly less than that required before TAE (1244.2 +/- 347.1 mL/hour; range, 632-1,728 mL/hour) (p < 0.001). The deaths of two patients were classified as nonpreventable on the basis of the Trauma and Injury Severity Score (TRISS), and their respective probabilities of survival were determined to be 0.13 and 0.03.
Nonsurgical management using TAE can be performed safely even for patients with blunt multiple trauma who are in hemorrhagic hypotension if their hemodynamics are improved by resuscitation with 2 L of fluid.
The Journal of trauma 08/2004; 57(2):271-6; discussion 276-7. · 2.48 Impact Factor
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Nippon rinsho. Japanese journal of clinical medicine 06/2004; 62 Suppl 5:519-22.
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ABSTRACT: We report a rare case in which abdominal compartment syndrome resulting from venous hemorrhaging developed in a patient with stable pelvic fractures, resulting in a fatal outcome. An 84-year-old man with mild pelvic fractures developed hypovolemic shock and underwent transcatheter arterial embolization. He became hemodynamically stable after the procedure, but became hypotensive for the second time 11 h after admission. Urinary bladder pressure rose to 32 mmHg from 4-7 mmHg. Rebleeding from the pelvis with the development of abdominal compartment syndrome was suspected. Repeated transcatheter arterial embolization and laparotomy were performed; however, 1 min into the procedure, both pupils symmetrically dilated and the light reflex disappeared. This case suggests that brain death can sometimes occur due to abdominal compartment syndrome.
Surgery Today 02/2004; 34(1):82-5. · 1.22 Impact Factor
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ABSTRACT: The purpose of this study was to determine predictors of death in patients with pelvic fracture whose pelvic arterial hemorrhage is controlled successfully by transcatheter arterial embolization (TAE).
From January 1996 to December 2000, 61 patients with a pelvic fracture who had pelvic arterial hemorrhage were treated at our Level I trauma center according to a protocol that assigns a high priority to diagnostic and therapeutic angiography within the algorithm. Angiography is performed before laparotomy in patients with hemoperitoneum, who can be stabilized by fluid resuscitation, and otherwise afterward. External fixation was performed immediately after TAE in the angiography suite. Predictors of outcome were determined retrospectively by univariate and multivariate analysis using anatomic and physiologic parameters.
Forty-eight patients survived and 13 died. TAE successfully controlled pelvic arterial hemorrhage in all patients. Predictors of death included posterior pelvic arterial injury and an elevated Acute Physiology and Chronic Health Evaluation II score (odds ratio, 15.6 and 23.9, respectively). Need for fluid requirements to achieve hemodynamic stability were higher in nonsurvivors than in survivors. Outcome did not correlate with the type of fracture or the Injury Severity Score.
Application of angiography as a therapeutic intervention in patients with pelvic arterial bleeding may reduce the need for surgery, thereby avoiding or minimizing this additional trauma.
The Journal of trauma 11/2003; 55(4):696-703. · 2.48 Impact Factor
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ABSTRACT: A recent important topic in the field of trauma care is the elimination of "preventable death." Since patients' satisfactory prognosis and good recovery mainly depend upon the success of the initial evaluation and care, the responsibility of physicians who first come into contact with trauma patients in the emergency room is especially heavy. Many general surgeons examine trauma patients, although, unfortunately they have few opportunities for training in how to deal with those patients in the present educational program. Traumatology should be one of the most important areas of surgery, and therefore this paper emphasizes that every surgeon needs to be educated and trained in an adequate curriculum of trauma care. The Japanese Association for Acute Medicine could help by offering the Japan Advanced Trauma Evaluation and Care (JATEC) training program. JATEC proposes standardized guidelines as well as a nationwide the educational program for trauma management.
Nippon Geka Gakkai zasshi 04/2003; 104(3):290-3.
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Nihon Naika Gakkai Zasshi 12/2002; 91(11):3126-30.
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[show abstract]
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ABSTRACT: The efficacy of transarterial embolization (TAE) for severe blunt hepatic injury has been reported. We performed a prospective study evaluating the efficacy and the limitation of TAE from January 1996 to December 2000.
All patients with blunt abdominal injury who could be stabilized by fluid resuscitation underwent computed tomographic (CT) scan examinations. Patients with CT scan evidence of hepatic injury were classified into five grades according to CT scan findings on the basis of the injury scale of the American Association for the Surgery of Trauma (Mirvis classification). All patients with CT scan grade 3 to 5 injury underwent angiography. When angiography showed extravasation of contrast medium extending from hepatic arterial branches, TAE was performed.
Of 612 patients with blunt abdominal trauma, 51 had CT scan grade 3 to 5 injury. Thirty-seven of these patients had a CT scan grade 3 injury and 18 underwent TAE. One of 19 patients who did not undergo TAE developed a delayed hemorrhage on day 6 and required a laparotomy. All 13 patients with a CT scan grade 4 injury had angiographic findings of the extravasation. TAE was successful in 11 patients and unsuccessful in 2. Five patients with a CT scan grade 4 injury required laparotomy. One developed a delayed hemorrhage on day 4. The remaining four patients had a major venous injury (a right lobectomy was performed in two with inferior vena cava injury, and a gauze packing in two with hepatic venous injury). One patient with a CT scan grade 5 injury underwent immediate laparotomy after TAE. Laparotomy revealed inferior vena cava injury and a right lobectomy was performed. Only two patients who underwent a lobectomy died of an uncontrollable hemorrhage. All CT scans of patients with hepatic venous or inferior vena cava injury showed a large low-density area (> or = 10 cm) with involvement of these vessels. The volumes of fluid resuscitation needed from admission until TAE ranged from 2,109 to 2,638 mL/h.
It was considered that the combination of the presence of a CT scan grade 4 or 5 lesion and the fluid requirements of more than 2,000 mL/h to maintain normotension indicated the absolute necessity of surgery. We felt that these patients were not candidates for TAE, and should undergo immediate laparotomy.
The Journal of trauma 06/2002; 52(6):1091-6. · 2.48 Impact Factor
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ABSTRACT: We report herein a case of spontaneous rupture of the pancreaticoduodenal artery (PDA) associated with obstruction of the
common hepatic artery. A 68-year-old man was admitted to our hospital following the sudden onset of severe upper abdominal
pain. Computed tomography revealed a large mass formation in the peritoneal cavity. Hemorrhagic shock rapidly developed during
the initial evaluation, necessitating an exploratory laparotomy to be performed in the emergency room. This revealed a large
hematoma in the retroperitoneal space, and a ruptured PDA was sutured. Postoperative angiography showed obstruction of the
common hepatic artery and also suggested that the source of the bleeding was the PDA. Thus, a diagnosis of spontaneous rupture
of a PDA aneurysm associated with occlusion of the common hepatic artery was made. Following this case report, we discuss
the development of true aneurysms of the PDA and the treatment of ruptured true PDA aneurysms resulting in shock.
Surgery Today 01/2001; 31(11):1032-1035. · 1.22 Impact Factor
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ABSTRACT: With DNA chip technology, we could analyze numbers of genes altogether from various samples. To decrease the high mortality rate for burn patients, we should explore novel approaches to treat patients. For this purpose, the change in interferons (IFN), interleukins (IL), and their receptors after burn injury were analyzed. Lymphocytes obtained from two burn patients and four healthy volunteers were analyzed for their gene expression levels using a Macroarray DNA chip technology. Among IFN or IL receptors, IFNγR1, IL1R1, -2Rα, -2Rβ, -2Rγ, -6Rα, and -7R decreased in burn patient, whereas IL5Rα and IL4Rα increased, compared to healthy subjects. In IL and IFN genes, IL1β, IL8, and IL10, showing high expression in the normal subjects, decreased their level after burn injury. The levels for IFNβ1 and IL2, -7, and -16 gene expression decreased, while those for IFNγ, IL1α, -13, and -15 increased, in the patient. These results confirmed that the burn induces a significant shift of the expression level in cytokine-related genes. By carefully analyzing the data, it might be possible to invent a novel therapy for burn patients, such as supplementation of certain cytokine gene.
International Congress Series 1255:79-85.
