Hyperoxemia during resuscitation of trauma patients and increased intensive care unit length of stay: inverse probability of treatment weighting analysis

Background

Information on hyperoxemia among patients with trauma has been limited, other than traumatic brain injuries. This study aimed to elucidate whether hyperoxemia during resuscitation of patients with trauma was associated with unfavorable outcomes.

Methods

A post hoc analysis of a prospective observational study was carried out at 39 tertiary hospitals in 2016–2018 in adult patients with trauma and injury severity score (ISS) of > 15. Hyperoxemia during resuscitation was defined as PaO₂ of ≥ 300 mmHg on hospital arrival and/or 3 h after arrival. Intensive care unit (ICU)-free days were compared between patients with and without hyperoxemia. An inverse probability of treatment weighting (IPW) analysis was conducted to adjust patient characteristics including age, injury mechanism, comorbidities, vital signs on presentation, chest injury severity, and ISS. Analyses were stratified with intubation status at the emergency department (ED). The association between biomarkers and ICU length of stay were then analyzed with multivariate models.

Results

Among 295 severely injured trauma patients registered, 240 were eligible for analysis. Patients in the hyperoxemia group (n = 58) had shorter ICU-free days than those in the non-hyperoxemia group [17 (10–21) vs 23 (16–26), p < 0.001]. IPW analysis revealed the association between hyperoxemia and prolonged ICU stay among patients not intubated at the ED [ICU-free days = 16 (12–22) vs 23 (19–26), p = 0.004], but not among those intubated at the ED [18 (9–20) vs 15 (8–23), p = 0.777]. In the hyperoxemia group, high inflammatory markers such as soluble RAGE and HMGB-1, as well as low lung-protective proteins such as surfactant protein D and Clara cell secretory protein, were associated with prolonged ICU stay.

Conclusions

Hyperoxemia until 3 h after hospital arrival was associated with prolonged ICU stay among severely injured trauma patients not intubated at the ED.

Trial registration

UMIN-CTR, UMIN000019588. Registered on November 15, 2015.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13017-021-00363-2.

Prevalence of umbilical artery Doppler waveform abnormality during the early second trimester and the subsequent variation of waveforms in monochorionic diamniotic twin pregnancies: A prospective cohort study

AIM

To investigate the prevalence of qualitative abnormal umbilical artery Doppler waveforms (Abnormal UA) during the early second trimester and the subsequent variation of waveforms in monochorionic diamniotic (MCDA) twin pregnancies.

METHODS

This prospective cohort study included 153 MCDA twin pregnancies. Pulsed Doppler examinations for UA were performed at four points, including the free-loop (FL) and near the placental cord insertion site (CI) of each UA, between 16 and 17 weeks' gestation. Cases were classified into positive diastolic waveforms (Type I), persistent Abnormal UA (Type II), and intermittent Abnormal UA (Type III). When the diastolic velocity in UA Doppler was positive twice after different sequential recordings, the cases were determined to have achieved normalization. Follow-up Doppler examinations of the UA were performed at 24, 28, and 32 weeks' gestation.

RESULTS

Of all 153 cases, 38 (25%; 19 Type II and 19 Type III cases) showed Abnormal UA at the first examination. Abnormal UA was detectable at FL in all selective intrauterine growth restriction (sIUGR) cases, whereas it was noted only at CI site in some non-sIUGR cases. Abnormal UA normalized in 12 (63%) Type II and 15 (79%) Type III cases.

CONCLUSIONS

A quarter of MCDA twin pregnancies in the early second trimester demonstrated Abnormal UA. In MCDA twins with Abnormal UA between 16 and 17 weeks' gestation, it is preferable to follow them up to consider the possibility of normalization of Abnormal UA as well as features of UA waveforms specific to FL and CI.

Accuracy for Mortality Prediction With Additive Biomarkers Including Interleukin-6 in Critically Ill Patients: A Multicenter Prospective Observational Study

OBJECTIVES

Several inflammation markers have been reported to be associated with unfavorable clinical outcomes in critically ill patients. We aimed to elucidate whether serum interleukin-6 concentration considered with Sequential Organ Failure Assessment score can better predict mortality in critically ill patients.

DESIGN

A prospective observational study.

SETTING

Five university hospitals in 2016-2018.

PATIENTS

Critically ill adult patients who met greater than or equal to two systemic inflammatory response syndrome criteria at admission were included, and those who died or were discharged within 48 hours were excluded.

INTERVENTIONS

Inflammatory biomarkers including interleukin (interleukin)-6, -8, and -10; tumor necrosis factor-α; C-reactive protein; and procalcitonin were blindly measured daily for 3 days. Area under the receiver operating characteristic curve for Sequential Organ Failure Assessment score at day 2 according to 28-day mortality was calculated as baseline. Combination models of Sequential Organ Failure Assessment score and additional biomarkers were developed using logistic regression, and area under the receiver operating characteristic curve calculated in each model was compared with the baseline.

MEASUREMENTS AND MAIN RESULTS

Among 161 patients included in the study, 18 (11.2%) did not survive at day 28. Univariate analysis for each biomarker identified that the interleukin-6 (days 1-3), interleukin-8 (days 0-3), and interleukin-10 (days 1-3) were higher in nonsurvivors than in survivors. Analyses of 28-day mortality prediction by a single biomarker showed interleukin-6, -8, and -10 at days 1-3 had a significant discrimination power, and the interleukin-6 at day 3 had the highest area under the receiver operating characteristic curve (0.766 [0.656-0.876]). The baseline area under the receiver operating characteristic curve for Sequential Organ Failure Assessment score predicting 28-day mortality was 0.776 (0.672-0.880). The combination model using additional interleukin-6 at day 3 had higher area under the receiver operating characteristic curve than baseline (area under the receiver operating characteristic curve = 0.844, area under the receiver operating characteristic curve improvement = 0.068 [0.002-0.133]), whereas other biomarkers did not improve accuracy in predicting 28-day mortality.

CONCLUSIONS

Accuracy for 28-day mortality prediction was improved by adding serum interleukin-6 concentration to Sequential Organ Failure Assessment score.

Nationwide survey of intrauterine blood transfusion for fetal anemia in Japan

AIM

The present study investigated the current situation regarding intrauterine blood transfusion (IUT) for fetal anemia in Japan.

METHODS

We conducted a nationwide, multicenter, retrospective cohort questionnaire survey for cases that underwent IUT from 2011 to 2015. The questionnaire required perioperative information, indications, details of the procedure, procedure-related complications, and neonatal morbidity.

RESULTS

A total of 100 IUT procedures were performed in 66 cases at 19 institutions during the study period. The most frequent indication of IUT was complicated monochorionic diamniotic (MCDA) twins in 28 (42.4%) cases, followed by 16 (24.2%) cases of red-cell alloimmunization, and 10 (15.2%) cases of parvovirus B19 infection. IUT was performed through the umbilical cord in the vast of majority cases (92%). Bleeding from the IUT site was the most common adverse event (40%). Two cases (2%) underwent emergency cesarean section after the procedure. There were no cases of rupture of membrane or intrauterine infection after IUT. The neonatal survival rate was 77.3% in the 66 total cases and 64% in the hydrops cases. The neonatal survival rates in MCDA twins, red-cell alloimmunization, and parvovirus B19 infection were 75%, 93.8%, and 70%, respectively.

CONCLUSIONS

IUT was performed for mainly three indications in Japan: MCDA twins, red-cell alloimmunization, and parvovirus B19 infection. The incidences of severe adverse events seemed very low. The outcomes after IUT were favorable with variations in survival rates according to indications. However, further studies with long-term follow-up will be required to assess the effectiveness of IUT, especially for complicated MCDA twins.

Utility of remnant liver volume for predicting posthepatectomy liver failure after hepatectomy with extrahepatic bile duct resection

BACKGROUND

Hepatectomy with extrahepatic bile duct resection is associated with a high risk of posthepatectomy liver failure (PHLF). However, the utility of the remnant liver volume (RLV) in cholangiocarcinoma has not been studied intensively.

METHODS

Patients who underwent major hepatectomy with extrahepatic bile duct resection between 2002 and 2018 were reviewed. The RLV was divided by body surface area (BSA) to normalize individual physical differences. Risk factors for clinically relevant PHLF were evaluated with special reference to the RLV/BSA.

RESULTS

A total of 289 patients were included. The optimal cut-off value for RLV/BSA was determined to be 300 ml/m2. Thirty-two patients (11.1 per cent) developed PHLF. PHLF was more frequent in patients with an RLV/BSA below 300 ml/m2 than in those with a value of 300 ml/m2 or greater: 19 of 87 (22 per cent) versus 13 of 202 (6.4 per cent) (P < 0.001). In multivariable analysis, RLV/BSA below 300 ml/m2 (P = 0.013), future liver remnant plasma clearance rate of indocyanine green less than 0.075 (P = 0.031), and serum albumin level below 3.5 g/dl (P = 0.015) were identified as independent risk factors for PHLF. Based on these risk factors, patients were classified into three subgroups with low (no factors), moderate (1-2 factors), and high (3 factors) risk of PHLF, with PHLF rates of 1.8, 14.8 and 63 per cent respectively (P < 0.001).

CONCLUSION

An RLV/BSA of 300 ml/m2 is a simple predictor of PHLF in patients undergoing hepatectomy with extrahepatic bile duct resection.

The real-time reverse transcription-polymerase chain reaction threshold cycle values for severe acute respiratory syndrome coronavirus 2 predict the prognosis of coronavirus disease 2019 pneumonia

The clinical course of coronavirus disease 2019 (COVID-19) varies from mild to critical. We retrospectively examined whether clinical and laboratory findings on admission could predict COVID-19 prognosis. Among various factors associated with COVID-19 severity, our results indicated that the real-time reverse transcription-polymerase chain reaction (RT-PCR) threshold cycle (Ct) values for severe acute respiratory syndrome coronavirus 2 were the most useful predictor of COVID-19 prognosis.

Difficulty removing dialysis cuff catheter after its adhesion to the right atrium

We describe the case of an elderly Japanese female who had experienced diabetic nephropathy since the year 20xx and had been undergoing dialysis treatment while receiving vascular access interventional therapy (VAIVT) for arteriovenous fistula (AVF) occlusion. The patient visited the clinic/hospital in 20xx+10 with the AVF occlusion; emergency VAIVT was performed but blood flow could not be resumed. The patient was not admitted and was treated as an outpatient, and thus a cuff catheter (Split stream catheter: SST28 cm, Medcomp) was inserted. An infection developed and was successfully treated with antibiotics. The dialysis treatment continued without issue. One year after the cuff catheter's insertion, the patient was admitted due difficulty breathing. Despite continued dialysis treatment with the catheter, the patient died 15 days post-admission. The removal of the catheter proved to be difficult. An autopsy was approved, and the area around the catheter was examined. The adhesion of the catheter to the right atrium was observed, but no infection was detected in the bloodstream. This case illustrates that dialysis with the use of a cuff catheter can be effective.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020)

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members. As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.

Japanese rapid/living recommendations on drug management for COVID-19

The coronavirus disease (COVID-19) has spread worldwide since early 2020, and there are still no signs of resolution. The Japanese Clinical Practice Guidelines for the Management of Sepsis and Septic Shock (J-SSCG) 2020 Special Committee created the Japanese rapid/living recommendations on drug management for COVID-19 using the experience of creating the J-SSCGs. The Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) approach was used to determine the certainty of the evidence and strength of the recommendations. The first edition of this guideline was released on 9 September, 2020, and this document is the revised edition (version 3.1) (released 30 March, 2021). Clinical questions (CQs) were set for the following seven drugs: favipiravir (CQ1), remdesivir (CQ2), hydroxychloroquine (CQ3), corticosteroids (CQ4), tocilizumab (CQ5), ciclesonide (CQ6), and anticoagulants (CQ7). Favipiravir is recommended for patients with mild COVID-19 not requiring supplemental oxygen (GRADE 2C); remdesivir for moderate COVID-19 patients requiring supplemental oxygen/hospitalization (GRADE 2B). Hydroxychloroquine is not recommended for all COVID-19 patients (GRADE 1B). Corticosteroids are recommended for moderate COVID-19 patients requiring supplemental oxygen/hospitalization (GRADE 1B) and severe COVID-19 patients requiring ventilator management/intensive care (GRADE 1A); however, their use is not recommended for mild COVID-19 patients not requiring supplemental oxygen (GRADE 1B). Tocilizumab is recommended for moderate COVID-19 patients requiring supplemental oxygen/hospitalization (GRADE 2B). Anticoagulant therapy is recommended for moderate COVID-19 patients requiring supplemental oxygen/hospitalization and severe COVID-19 patients requiring ventilator management/intensive care (GRADE 2C). We hope that these clinical practice guidelines will aid medical professionals involved in the care of COVID-19 patients.

Japanese rapid/living recommendations on drug management for COVID-19: updated guidelines (September 2021)

BACKGROUND

The coronavirus disease 2019 (COVID-19) has spread worldwide since early 2020, and there are still no signs of resolution. The Japanese Clinical Practice Guidelines for the Management of Sepsis and Septic Shock (J-SSCG) 2020 Special Committee created the Japanese rapid/living recommendations on drug management for COVID-19 using the experience of creating the J-SSCG.

METHODS

The Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) approach was used to determine the certainty of the evidence and strength of the recommendations. The first edition of this guideline was released on September 9, 2020, and this document is the revised edition (version 4.0; released on September 9, 2021). Clinical questions (CQs) were set for the following seven drugs: favipiravir (CQ1), remdesivir (CQ2), corticosteroids (CQ4), tocilizumab (CQ5), anticoagulants (CQ7), baricitinib (CQ8), and casirivimab/imdevimab (CQ9). Two CQs (hydroxychloroquine [CQ3] and ciclesonide [CQ6]) were retrieved in this updated version.

RECOMMENDATIONS

Favipiravir is not suggested for all patients with COVID-19 (GRADE 2C). Remdesivir is suggested for patients with moderate COVID-19 requiring supplemental oxygen/hospitalization (GRADE 2B). Corticosteroids are recommended for patients with moderate COVID-19 requiring supplemental oxygen/hospitalization (GRADE 1B) and for patients with severe COVID-19 requiring mechanical ventilation/intensive care (GRADE 1A); however, their administration is not recommended for patients with mild COVID-19 not requiring supplemental oxygen (GRADE 1B). Tocilizumab is suggested for patients with moderate COVID-19 requiring supplemental oxygen/hospitalization (GRADE 2B). Anticoagulant administration is recommended for patients with moderate COVID-19 requiring supplemental oxygen/hospitalization and patients with severe COVID-19 requiring mechanical ventilation/intensive care (good practice statement). Baricitinib is suggested for patients with moderate COVID-19 requiring supplemental oxygen/hospitalization (GRADE 2C). Casirivimab/imdevimab is recommended for patients with mild COVID-19 not requiring supplemental oxygen (GRADE 1B). We hope that these updated clinical practice guidelines will help medical professionals involved in the care of patients with COVID-19.

Association between maternal height and mode of delivery in nulliparous Japanese women

AIM

The primary aim of this study was to examine the association between maternal height and mode of delivery in nulliparous Japanese women. The secondary aim was to examine the association between maternal height and maternal and neonatal morbidities.

METHODS

This retrospective cohort study included women who gave birth at Osaka Women's and Children's Hospital, a tertiary perinatal center in Japan, from January 2015 to December 2017. Nulliparous Japanese women with singleton gestation, who went into labor at term were included in the study. The primary outcome was mode of delivery, and the secondary outcomes were maternal and neonatal morbidities. The relationships between maternal height and the outcomes were evaluated using multivariate logistic regression analysis adjusted for potential confounders. Maternal height was categorized into five groups with 5-cm increments for the analysis.

RESULTS

A total of 1593 women were analyzed in this study. Shorter women had higher rate of cesarean delivery (CD) than taller women. There were no significant differences in the rates of operative vaginal delivery, maternal morbidity and neonatal morbidity among the maternal-height groups. The adjusted odds ratios (95% confidential interval) of maternal heights of <150 cm, 150-154 cm, 160-164 cm and ≥165 cm for CD, compared with a maternal height of 155-159 cm, were 3.56 (1.79-7.09), 1.68 (1.06-2.64), 0.63 (0.40-1.00) and 0.57 (0.30-1.01), respectively.

CONCLUSION

Shorter nulliparous Japanese women were more likely to undergo intrapartum CD. However, the rates of maternal and neonatal morbidities in shorter women were similar to those in taller women.

Prevalence of Extraplacental Anastomoses in Monochorionic Twin Pregnancies

OBJECTIVES

To evaluate the prevalence of extraplacental anastomoses (EPA) and the factors associated.

METHODS

A retrospective study including 144 placentas from monochorionic diamniotic (MCDA) twins delivering at one institution was performed. EPA were defined as any intertwin anastomosis located outside the chorionic plate on macroscopic inspection. The association with perinatal factors and with umbilical cord insertion site was analyzed.

RESULTS

The prevalence of EPA was 4.9% (7/144). Velamentous cord insertion of both twins was significantly associated with the presence of EPA in the multivariate logistic regression model (p = 0.045).

DISCUSSION

EPA was found in ≈5% of MCDA twin pregnancies.

In vivo clonal analysis of aging hematopoietic stem cells

Hematopoietic stem cells (HSCs) are characterized by two key features: Self-renewal ability and multilineage differentiation potential (multipotentiality). With aging, these key features gradually change. This is thought to be related to hematological diseases. However, clonal in vivo analysis assessing the potential of HSCs to differentiate along erythroid and platelet lineages ("five-lineage tracing") has not been performed in the aged bone marrow. By contrast, in young HSCs clonal in vivo analysis combined with five-lineage tracing has provided us with novel insights into HSC biology. Understanding HSC aging at the clonal level will help us to elucidate aging mechanisms and disease progression. We review recent progress towards understanding HSC aging at the clonal cell level in the transplantation setting.

[Valve-sparing Root Reimplantation for Stanford Type A Acute Aortic Dissection Combined with Aortic Root Dilation and Bicuspid Aortic Valve;Report of a Case]

A 45-year-old male developed Stanford type A acute aortic dissection combined with aortic root dilation and congenital bicuspid aortic valve (BAV). He had a Sieveres type 0 BAV, lateral subtype with right and left cusps. Valve-sparing root reimplantation was performed with decalcification of the cusps. Transthoracic echocardiography(TTE) at discharge revealed no aortic regurgitation, and peak velocity of BAV was 2.15 m/second, mean pressure gradient was 9.6 mmHg and aortic valve area was 2.15 cm2. TTE after 6 months revealed only slight elevation of the peak velocity to 2.78 m/second. To perform successful reimplantation in the case of BAV, anatomic orientation of the cusps should be approximately at 180° and the tissue of the cusps should either be normal or have only minor abnormalities. Valve-sparing root reimplantation for BAV needs a careful follow-up for progression of the aortic valve dysfunction.

Remodeling of projections from ventral hippocampus to prefrontal cortex in Alzheimer's mice

Emotional dysregulation often accompanies cognitive deficits in Alzheimer's disease (AD). The hippocampus, most notably damaged by AD pathology, is classified into the cognition-bound posterior and emotion-bound anterior hippocampi. Since the anterior hippocampus or its rodent counterpart, the ventral hippocampus (VH), sends dense afferents to the prefrontal cortex (PFC) and the basolateral amygdala (BLA), the two structures implicated in fear responses, we investigated whether these afferents are modified in 3xTg AD model mice. An anterograde dextrin tracer injected into VH revealed that axons in PFC were more ramified in 3xTg than wild-type (WT) mice, with the synaptic density reduced. The VH projections to BLA were not affected. Intracellular accumulation of amyloid β (Aβ) or Aβ-like immunoreactivity was found in PFC and BLA neurons alike. Behaviorally, in the 2-way active avoidance test, the frequency of chamber change was higher, with the test performance better, in 3xTg than WT mice, suggesting a distorted contextual fear in the 3xTg group. Given the essential involvement of parts of PFC in contextual fear responses and that of BLA in fear responses in general, the observed remodeling of VH-to-PFC afferents and the accumulation of intracellular Aβ in BLA and PFC pyramidal cells might exercise critical influences on enhanced avoidance behavior in 3xTg mice.

Defense of bombardier beetles against avian predators

Bombardier beetles (Coleoptera, Carabidae, Brachininae) possess a remarkable defense mechanism where a hot chemical spray is released from the tip of their abdomen, with an audible explosive sound. To date, the repellent properties of these chemicals have been tested against a limited number of taxa, such as amphibians and insects. To investigate the impact of bombardier beetle defenses on avian predators, feeding trials were conducted using the bombardier beetle (Pheropsophus jessoensis) and the Japanese quail (Coturnix japonica), a sympatric and generalist predator. All naïve, hand-reared quail attacked live beetles, indicating the absence of an innate aversion to them. However, most of the quail rejected consuming the beetles whether or not the beetles sprayed them with chemicals. Naïve quail also rejected dead P. jessoensis individuals. These results support the recent hypothesis that it is not essential for P. jessoensis to spray noxious chemicals to deter predators. We also found that some of the quail exposed to live P. jessoensis remembered to avoid them for up to 5 weeks. Our results provide the first evidence of the repelling effects of bombardier beetle defense mechanisms on avian predators.

Oxygen administration in patients recovering from cardiac arrest: a narrative review

High oxygen tension in blood and/or tissue affects clinical outcomes in several diseases. Thus, the optimal target PaO₂ for patients recovering from cardiac arrest (CA) has been extensively examined. Many patients develop hypoxic brain injury after the return of spontaneous circulation (ROSC); this supports the need for oxygen administration in patients after CA. Insufficient oxygen delivery due to decreased blood flow to cerebral tissue during CA results in hypoxic brain injury. By contrast, hyperoxia may increase dissolved oxygen in the blood and, subsequently, generate reactive oxygen species that are harmful to neuronal cells. This secondary brain injury is particularly concerning. Although several clinical studies demonstrated that hyperoxia during post-CA care was associated with poor neurological outcomes, considerable debate is ongoing because of inconsistent results. Potential reasons for the conflicting results include differences in the definition of hyperoxia, the timing of exposure to hyperoxia, and PaO₂ values used in analyses. Despite the conflicts, exposure to PaO₂ > 300 mmHg through administration of unnecessary oxygen should be avoided because no obvious benefit has been demonstrated. The feasibility of titrating oxygen administration by targeting SpO₂ at approximately 94% in patients recovering from CA has been demonstrated in pilot randomized controlled trials (RCTs). Such protocols should be further examined.

Resuscitative endovascular balloon occlusion of the aorta and traumatic out-of-hospital cardiac arrest: A nationwide study

OBJECTIVE

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a less-invasive method for temporary hemostasis compared with cross-clamping the aorta through resuscitative thoracotomy (RT). Although the survival benefits of REBOA remained unclear, pathophysiological benefits were identified in patients with traumatic out-of-hospital cardiac arrest (t-OHCA). We examined the clinical outcomes of t-OHCA with the hypothesis that REBOA would be associated with higher survival to discharge compared with RT.

METHODS

A retrospective cohort study was conducted using the Japan Trauma Data Bank (2004-2019). Adult patients with t-OHCA who had arrived without a palpable pulse and undergone aortic occlusion were included. Patients were divided into REBOA or RT groups, and propensity scores were developed using age, mechanism of injury, presence of signs of life, presence of severe head and/or chest injury, Injury Severity Score, and transportation time. Inverse probability weighting by propensity scores was performed to compare survival to discharge between the 2 groups.

RESULTS

Among 13,247 patients with t-OHCA, 1483 were included in this study. A total of 144 (9.7%) patients were treated with REBOA, and 5 of 144 (3.5%) in the REBOA group and 10 of 1339 (0.7%) in the RT group survived to discharge. The use of REBOA was significantly associated with increased survival to discharge (odds ratio, 4.78; 95% confidence interval, 1.61-14.19), which was confirmed by inverse probability weighting (adjusted odds ratio, 3.73; 95% confidence interval, 1.90-7.32).

CONCLUSIONS

REBOA for t-OHCA was associated with higher survival to discharge. These results should be validated by further research.

Delays in Surgical Intervention and Temporary Hemostasis Using Resuscitative Endovascular Balloon Occlusion of the aorta (REBOA): Influence of Time to Operating Room on Mortality

BACKGROUND

The optimal candidates for resuscitative endovascular balloon occlusion of the aorta (REBOA) remain unclear. We hypothesized that patients who experience delays in surgical intervention would benefit from REBOA.

METHODS

Using the Japan Trauma Databank (2014-2019), patients transferred to the operating room (OR) within 3 h were identified. Patients treated with REBOA were matched with those without REBOA using propensity scores, and further divided based on the transfer time to OR: ≤ 1 h (early), 1-2 h (delayed), and >2 h (significantly-delayed). Survival to discharge was compared.

RESULTS

Among 5258 patients, 310 underwent REBOA. In 223 matched pairs, patients treated with REBOA had improved survival (56.5% vs. 31.8%; p < 0.01), although in-hospital mortality was reduced by REBOA only in the delayed and significantly-delayed subgroups (HR = 0.43 [0.28-0.65] and 0.42 [0.25-0.71]).

CONCLUSIONS

REBOA-treated trauma patients who experience delays in surgical intervention (>1 h) have improved survival.