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Wada T, Gando S. Phenotypes of Disseminated Intravascular Coagulation. Thromb Haemost 2024; 124:181-191. [PMID: 37657485 PMCID: PMC10890912 DOI: 10.1055/a-2165-1142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 08/30/2023] [Indexed: 09/03/2023]
Abstract
Two phenotypes of disseminated intravascular coagulation (DIC) are systematically reviewed. DIC is classified into thrombotic and fibrinolytic phenotypes characterized by thrombosis and hemorrhage, respectively. Major pathology of DIC with thrombotic phenotype is the activation of coagulation, insufficient anticoagulation with endothelial injury, and plasminogen activator inhibitor-1-mediated inhibition of fibrinolysis, leading to microvascular fibrin thrombosis and organ dysfunction. DIC with fibrinolytic phenotype is defined as massive thrombin generation commonly observed in any type of DIC, combined with systemic pathologic hyperfibrinogenolysis caused by underlying disorder that results in severe bleeding due to excessive plasmin formation. Three major pathomechanisms of systemic hyperfibrinogenolysis have been considered: (1) acceleration of tissue-type plasminogen activator (t-PA) release from hypoxic endothelial cells and t-PA-rich storage pools, (2) enhancement of the conversion of plasminogen to plasmin due to specific proteins and receptors that are expressed on cancer cells and endothelial cells, and (3) alternative pathways of fibrinolysis. DIC with fibrinolytic phenotype can be diagnosed by DIC diagnosis followed by the recognition of systemic pathologic hyperfibrin(ogen)olysis. Low fibrinogen levels, high fibrinogen and fibrin degradation products (FDPs), and the FDP/D-dimer ratio are important for the diagnosis of systemic pathologic hyperfibrin(ogen)olysis. Currently, evidence-based treatment strategies for DIC with fibrinolytic phenotypes are lacking. Tranexamic acid appears to be one of the few methods to be effective in the treatment of systemic pathologic hyperfibrin(ogen)olysis. International cooperation for the elucidation of pathomechanisms, establishment of diagnostic criteria, and treatment strategies for DIC with fibrinolytic phenotype are urgent issues in the field of thrombosis and hemostasis.
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Affiliation(s)
- Takeshi Wada
- Department of Anesthesiology and Critical Care Medicine, Division of Acute and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Satoshi Gando
- Department of Anesthesiology and Critical Care Medicine, Division of Acute and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
- Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
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Gando S, Levi M, Toh CH. Trauma-induced innate immune activation and disseminated intravascular coagulation. J Thromb Haemost 2024; 22:337-351. [PMID: 37816463 DOI: 10.1016/j.jtha.2023.09.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 09/25/2023] [Accepted: 09/26/2023] [Indexed: 10/12/2023]
Abstract
Dysregulated innate immunity participates in the pathomechanisms of disseminated intravascular coagulation (DIC) in trauma-induced coagulopathy. Accidental and regulated cell deaths and neutrophil extracellular traps release damage-associated molecular patterns (DAMPs), such as histones, nuclear and mitochondrial DNA, and high-mobility group box 1, into circulation immediately after trauma. DAMP-induced inflammation activation releases tissue factor-bearing procoagulant extracellular vesicles through gasdermin D-mediated pore formation and plasma membrane rupture by regulated cell death. DAMPs also evoke systemic inflammation, platelet, coagulation activation, and impaired fibrinolysis associated with endothelial injury, leading to the dysfunction of anticoagulation systems, which are the main pathophysiological mechanisms of DIC. All these processes induce systemic thrombin generation in vivo, not restricted to the injury sites immediately after trauma. Thrombin generation at the site of injury stops bleeding and maintains homeostasis. However, DIC associated with endothelial injury generates massive thrombin, enhancing protease-activated, receptor-mediated bidirectional interplays between inflammation and coagulation, aggravating the diverse actions of thrombin and disturbing homeostasis. Insufficiently regulated thrombin causes disseminated microvascular thrombosis, resulting in tissue hypoxia due to reduced oxygen delivery, and mitochondrial dysfunction due to DAMPs causes tissue dysoxia. In addition, DAMP-induced calcium influx and overload, as well as neutrophil activation, play a role in endothelial cell injury. Tissue hypoxia and cytotoxicity result in multiple organ dysfunction in DIC after trauma. Controls against dysregulated innate immunity evoking systemic inflammation, thrombin generation, and cytotoxicity are key issues in improving the prognosis of DIC in trauma-induced coagulopathy.
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Affiliation(s)
- Satoshi Gando
- Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan; Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan.
| | - Marcel Levi
- Department of Vascular Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands; Department of Medicine, University College London Hospitals NHS Foundation Trust, and Cardio-Metabolic Program - NIHR UCLH/UCL BRC London, London, United Kingdom
| | - Cheng-Hock Toh
- Department of Clinical Infection, Microbiology and Immunology, University of Liverpool, Liverpool, United Kingdom; Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
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Matsuoka T, Fujishima S, Sasaki J, Gando S, Saitoh D, Kushimoto S, Ogura H, Abe T, Shiraishi A, Mayumi T, Kotani J, Takeyama N, Tsuruta R, Takuma K, Yamashita N, Shiraishi SI, Ikeda H, Shiino Y, Tarui T, Nakada TA, Hifumi T, Otomo Y, Okamoto K, Sakamoto Y, Hagiwara A, Masuno T, Ueyama M, Fujimi S, Yamakawa K, Umemura Y. COAGULOPATHY PARAMETERS PREDICTIVE OF OUTCOMES IN SEPSIS-INDUCED ACUTE RESPIRATORY DISTRESS SYNDROME: A SUBANALYSIS OF THE TWO PROSPECTIVE MULTICENTER COHORT STUDIES. Shock 2024; 61:89-96. [PMID: 38010069 DOI: 10.1097/shk.0000000000002269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
ABSTRACT Background: Although coagulopathy is often observed in acute respiratory distress syndrome (ARDS), its clinical impact remains poorly understood. Objectives: This study aimed to clarify the coagulopathy parameters that are clinically applicable for prognostication and to determine anticoagulant indications in sepsis-induced ARDS. Method: This study enrolled patients with sepsis-derived ARDS from two nationwide multicenter, prospective observational studies. We explored coagulopathy parameters that could predict outcomes in the Focused Outcome Research on Emergency Care for Acute Respiratory Distress Syndrome, Sepsis, and Trauma (FORECAST) cohort, and the defined coagulopathy criteria were validated in the Sepsis Prognostication in Intensive Care Unit and Emergency Room-Intensive Care Unit (SPICE-ICU) cohort. The correlation between anticoagulant use and outcomes was also evaluated. Results: A total of 181 patients with sepsis-derived ARDS in the FORECAST study and 61 patients in the SPICE-ICU study were included. In a preliminary study, we found the set of prothrombin time-international normalized ratio ≥1.4 and platelet count ≤12 × 10 4 /μL, and thrombocytopenia and elongated prothrombin time (TEP) coagulopathy as the best coagulopathy parameters and used it for further analysis; the odds ratio (OR) of TEP coagulopathy for in-hospital mortality adjusted for confounding was 3.84 (95% confidence interval [CI], 1.66-8.87; P = 0.005). In the validation cohort, the adjusted OR for in-hospital mortality was 32.99 (95% CI, 2.60-418.72; P = 0.002). Although patients without TEP coagulopathy showed significant improvements in oxygenation over the first 4 days, patients with TEP coagulopathy showed no significant improvement (ΔPaO 2 /FiO 2 ratio, 24 ± 20 vs. 90 ± 9; P = 0.026). Furthermore, anticoagulant use was significantly correlated with mortality and oxygenation recovery in patients with TEP coagulopathy but not in patients without TEP coagulopathy. Conclusion: Thrombocytopenia and elongated prothrombin time coagulopathy is closely associated with better outcomes and responses to anticoagulant therapy in sepsis-induced ARDS, and our coagulopathy criteria may be clinically useful.
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Affiliation(s)
- Tadashi Matsuoka
- Department of Emergency and Critical Care Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Seitaro Fujishima
- Center for Preventive Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Junchi Sasaki
- Department of Emergency and Critical Care Medicine, School of Medicine, Keio University, Tokyo, Japan
| | | | - Daizoh Saitoh
- Division of Traumatology, Research Institute, National Defense Medical College, Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Japan
| | | | | | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
| | - Joji Kotani
- Division of Disaster and Emergency Medicine, Department of Surgery Related, Kobe University Graduate School of Medicine, Japan
| | - Naoshi Takeyama
- Advanced Critical Care Center, Aichi Medical University Hospital, Japan
| | - Ryosuke Tsuruta
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Japan
| | - Kiyotsugu Takuma
- Emergency and Critical Care Center, Kawasaki Municipal Hospital, Japan
| | - Norio Yamashita
- Department of Emergency and Critical Care Medicine, School of Medicine, Kurume University, Japan
| | | | - Hiroto Ikeda
- Department of Emergency Medicine, Trauma and Resuscitation Center, Teikyo University School of Medicine
| | - Yasukazu Shiino
- Department of Acute Medicine, Kawasaki Medical School, Japan
| | - Takehiko Tarui
- Department of Emergency Medical Care, Kyorin University Faculty Health Sciences, Japan
| | - Taka-Aki Nakada
- Department of Emergency and Critical Care Medicine Chiba University Graduate School of Medicine, Japan
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Center, Medical Hospital, Tokyo Medical and Dental University, Japan
| | - Kohji Okamoto
- Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital, Japan
| | - Yuichiro Sakamoto
- Emergency and Critical Care Medicine, Saga University Hospital, Japan
| | - Akiyoshi Hagiwara
- Center Hospital of the National Center for Global Health and Medicine, Japan
| | - Tomohiko Masuno
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Japan
| | - Masashi Ueyama
- Department of Trauma, Critical Care Medicine, and Burn Center, Japan Community Healthcare Organization, Chukyo Hospital, Japan
| | - Satoshi Fujimi
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Japan
| | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Japan
| | - Yutaka Umemura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Japan
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Yamamoto R, Fujishima S, Yamakawa K, Abe T, Ogura H, Saitoh D, Gando S, Sasaki J. Hyperoxia for sepsis and development of acute lung injury with increased mortality. BMJ Open Respir Res 2023; 10:e001968. [PMID: 38097355 PMCID: PMC10729230 DOI: 10.1136/bmjresp-2023-001968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 11/30/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Supraphysiological oxygen administration causes unfavourable clinical outcomes in various diseases. This study aimed to determine whether hyperoxia would be associated with increased mortality in patients with severe infection. METHODS A post-hoc analysis of a nationwide multicentre prospective observational study on sepsis (SPICE Study) was conducted, including adult patients admitted to the intensive care unit with available arterial partial pressure of oxygen (PaO2) at the treatment initiation for severe infection. Hyperoxia was defined as a PaO2 level of ≥300 mm Hg and in-hospital mortality was compared between patients with and without hyperoxia. RESULTS Of the 563 patients eligible for the study, 49 had hyperoxia at treatment initiation for severe infection. The in-hospital all-cause mortality rates of patients with and without hyperoxia were 14 (29.2%) and 90 (17.6%), respectively. Inverse probability weighting analyses with propensity scores revealed the association between hyperoxia and increased in-hospital mortality rate (28.8% vs 18.8%; adjusted OR 1.75 (1.03 to 2.97); p=0.038), adjusting for patient demographics, comorbidities, site of infection, severity of infection, haemodynamic and respiratory status, laboratory data and location of patient at infection development. Acute lung injury developed more frequently in patients with hyperoxia on the following days after infection treatment, whereas sepsis-related mortality was comparable regardless of hyperoxia exposure. CONCLUSION Hyperoxia with PaO2 ≥300 mm Hg at treatment initiation of severe infection was associated with an increased in-hospital mortality rate in patients requiring intensive care. The amount of oxygen to administer to patients with severe infection should be carefully determined. TRIAL REGISTRATION NUMBER University Hospital Medical Information Network Clinical Trial Registry (UMIN000027452).
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Affiliation(s)
- Ryo Yamamoto
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Seitaro Fujishima
- Center for Preventive Medicine, Keio University Hospital, Tokyo, Japan
| | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
| | - Toshikazu Abe
- Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
- Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Daizoh Saitoh
- Division of Traumatology, Research Institute, National Defense Medical College, Tokorozawa, Japan
| | - Satoshi Gando
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
- Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
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Wada T, Yamakawa K, Kabata D, Abe T, Fujishima S, Kushimoto S, Mayumi T, Ogura H, Saitoh D, Shiraishi A, Otomo Y, Gando S. Sepsis-related coagulopathy treatment based on the disseminated intravascular coagulation diagnostic criteria: a post-hoc analysis of a prospective multicenter observational study. J Intensive Care 2023; 11:8. [PMID: 36872342 PMCID: PMC9985865 DOI: 10.1186/s40560-023-00656-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 02/23/2023] [Indexed: 03/07/2023] Open
Abstract
BACKGROUND The development of disseminated intravascular coagulation (DIC) in patients with sepsis has been repeatedly confirmed as a factor associated with poor prognosis. Anticoagulant therapy has been expected to improve sepsis patient outcomes, whereas no randomized controlled trials have demonstrated the survival benefit of anticoagulant therapies in non-specific overall sepsis. Patient selection based on the component of "high disease severity" in addition to "sepsis with DIC" has recently proved important in identifying appropriate targets for anticoagulant therapy. The aims of this study were to characterize "severe" sepsis DIC patients and to identify the patient population benefiting from anticoagulant therapy. METHODS This retrospective sub-analysis of a prospective multicenter study included 1,178 adult patients with severe sepsis from 59 intensive care units in Japan from January 2016 to March 2017. We examined the association of patient outcomes, including organ dysfunction and in-hospital mortality, with the DIC score and prothrombin time-international normalized ratio (PT-INR), one of the components of the DIC score, using multivariable regression models including the cross-product term between these indicators. Multivariate Cox proportional hazard regression analysis with non-linear restricted cubic spline including a three-way interaction term (anticoagulant therapy × the DIC score × PT-INR) was also performed. Anticoagulant therapy was defined as the administration of antithrombin, recombinant human thrombomodulin, or their combination. RESULTS In total, we analyzed 1013 patients. The regression model showed that organ dysfunction and in-hospital mortality deteriorated with higher PT-INR values in the range of < 1.5 and that this trend was more pronounced with higher DIC scores. Three-way interaction analysis demonstrated that anticoagulant therapy was associated with better survival outcome in patients with a high DIC score and high PT-INR. Furthermore, we identified a DIC score ≥ 5 and PT-INR ≥ 1.5 as the clinical threshold for identification of optimal targets for anticoagulant therapy. CONCLUSIONS The combined use of the DIC score and PT-INR helps in selecting the optimal patient population for anticoagulant therapy in sepsis-induced DIC. The results obtained from this study will provide valuable information regarding the study design of randomized controlled trials examining the effects of anticoagulant therapy for sepsis. TRIAL REGISTRATION UMIN-CTR, UMIN000019742. Registered on November 16, 2015.
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Affiliation(s)
- Takeshi Wada
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, N15, W7, Kita-Ku, Sapporo, Japan.
| | - Kazuma Yamakawa
- Department of Emergency Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
| | - Daijiro Kabata
- Department of Medical Statistics, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Toshikazu Abe
- Department of Emergency and Critical Care Medicine, Tsukuba Memorial Hospital, Tsukuba, Japan.,Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan
| | - Seitaro Fujishima
- Center for General Medicine Education, Keio University School of Medicine, Tokyo, Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Toshihiko Mayumi
- Department of Trauma, Critical Care Medicine and Burn Center, Community Healthcare Organization, Chukyo Hospital, Nagoya, Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Daizoh Saitoh
- Division of Traumatology, Research Institute, National Defense Medical College, Tokorozawa, Japan
| | | | - Yasuhiro Otomo
- Trauma and Acute Critical Care Center, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | - Satoshi Gando
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, N15, W7, Kita-Ku, Sapporo, Japan.,Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
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Abe T, Umemura Y, Ogura H, Kushimoto S, Fujishima S, Saitoh D, Gando S. Early versus delayed vasopressor administration in patients with septic shock. Acute Med Surg 2023; 10:e852. [PMID: 37250932 PMCID: PMC10220453 DOI: 10.1002/ams2.852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 03/24/2023] [Accepted: 04/23/2023] [Indexed: 05/31/2023] Open
Abstract
Aim This study aimed to investigate the association of early vasopressor initiation with improved septic shock outcomes. Methods This multicenter observational study was conducted in 17 intensive care units in Japan and included adult patients with sepsis admitted to the intensive care unit from July 2019 to August 2020 and treated with vasopressor therapy. Patients were divided into the early vasopressor group (≤1 h from sepsis recognition) and the delayed vasopressor group (>1 h). The impact of early vasopressor administration on risk-adjusted in-hospital mortality was estimated using logistic regression analyses adjusted by an inverse probability of treatment weighting analysis with propensity scoring. Results Among the 97 patients, 67 received vasopressor therapy within 1 h from sepsis recognition and 30 received vasopressor after 1 h. In-hospital mortality was 32.8% in the early vasopressor group and 26.7% in the delayed vasopressor group (p = 0.543). The adjusted odds ratio for in-hospital mortality was 0.76 (95% confidence interval 0.17-3.29) when comparing patients in the early vasopressor with those in the delayed vasopressor group. The fit curve from the mixed-effects model showed a relatively lower trend toward an infusion volume over time in the early vasopressor group than in the delayed vasopressor group. Conclusion Our study did not reach a definitive conclusion for early vasopressor administration. However, early vasopressor administration may help avoid volume overload in the long course of sepsis care.
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Affiliation(s)
- Toshikazu Abe
- Department of Emergency and Critical Care MedicineTsukuba Memorial HospitalTsukubaJapan
- Health Services Research and Development CenterUniversity of TsukubaTsukubaJapan
- Department of Health Services Research, Faculty of MedicineUniversity of TsukubaTsukubaJapan
| | - Yutaka Umemura
- Division of Trauma and Surgical Critical CareOsaka General Medical CenterOsakaJapan
- Department of Traumatology and Acute Critical MedicineOsaka University Graduate School of MedicineOsakaJapan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical MedicineOsaka University Graduate School of MedicineOsakaJapan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care MedicineTohoku University Graduate School of MedicineSendaiJapan
| | - Seitaro Fujishima
- Center for General Medicine EducationKeio University School of MedicineTokyoJapan
| | - Daizoh Saitoh
- Division of TraumatologyResearch Institute, National Defense Medical CollegeTokorozawaJapan
| | - Satoshi Gando
- Department of Acute and Critical Care MedicineSapporo Tokushukai HospitalSapporoJapan
- Department of Anesthesiology and Critical Care MedicineHokkaido University Faculty of MedicineSapporoJapan
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Wada T, Shiraishi A, Gando S, Kabata D, Yamakawa K, Fujishima S, Saitoh D, Kushimoto S, Ogura H, Abe T, Mayumi T, Otomo Y. Association of antithrombin with development of trauma-induced disseminated intravascular coagulation and outcomes. Front Immunol 2022; 13:1026163. [PMID: 36569855 PMCID: PMC9788110 DOI: 10.3389/fimmu.2022.1026163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 11/18/2022] [Indexed: 12/14/2022] Open
Abstract
Introduction Trauma activates the innate immune system to modulate hemostasis and minimize the damage caused by physiological bodily responses, including the activation of coagulation. Sufficiently severe trauma overwhelms physiological responses and elicits the systemic inflammatory response syndrome, which leads to the onset of disseminated intravascular coagulation (DIC), characterized by dysregulated inflammatory coagulofibrinolytic responses. Impaired anticoagulant mechanisms, including antithrombin, constitutes the pathology of DIC, while the dynamics of antithrombin and relevance to outcomes in trauma-induced coagulopathy have not been fully elucidated. This study investigated the associations of antithrombin activity with DIC onset and outcomes in severely injured patients. Methods This retrospective sub-analysis of a multicenter, prospective study included patients with an injury severity score ≥16. We characterized trauma patients with low antithrombin activity (antithrombin <80% on hospital arrival, n = 75) in comparison with those who had normal antithrombin activity (antithrombin ≥80%, n = 200). Global markers of coagulation and fibrinolysis, molecular biomarkers for thrombin generation (soluble fibrin [SF]), and markers of anticoagulation (antithrombin) were evaluated to confirm the associations of antithrombin with DIC development and outcomes, including in-hospital mortality and the multiple organ dysfunction syndrome (MODS). Results Patients with low antithrombin activity had higher prevalence of shock, transfusion requirements, and in-hospital mortality. Higher DIC scores and more severe organ dysfunction were observed in the low AT group compared to that in the normal AT group. Antithrombin activity on arrival at the hospital was an independent predictor of the development of DIC in trauma patients, and levels of SF increased with lower antithrombin values (antithrombin activity > 85%). Antithrombin activity at 3 h showed good predictive performance for in-hospital mortality, and a multivariable Cox proportional-hazard regression model with a cross-product term between the antithrombin and DIC showed that the in-hospital mortality in patients with DIC increased with decreased antithrombin activity. A multivariable logistic regression model showed that the odds for the development of MODS in patients with DIC increased with lower antithrombin values. Conclusion Decreased antithrombin activity in trauma-induced coagulopathy is associated with poor outcomes through worsening of DIC.
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Affiliation(s)
- Takeshi Wada
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan,*Correspondence: Takeshi Wada,
| | | | - Satoshi Gando
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan,Department of Acute and Critical Care Center, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
| | - Daijiro Kabata
- Department of Medical Statistics, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Kazuma Yamakawa
- Department of Emergency Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
| | - Seitaro Fujishima
- Center for General Medicine Education, Keio University School of Medicine, Tokyo, Japan
| | - Daizoh Saitoh
- Division of Traumatology, Research Institute, National Defense Medical College, Tokorozawa, Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Toshikazu Abe
- Department of Emergency and Critical Care Medicine, Tsukuba Memorial Hospital, Tsukuba, Japan,Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan
| | - Toshihiko Mayumi
- Department of Trauma, Critical Care Medicine, and Burn Center, Japan Community Healthcare Organization, Chukyo Hospital, Nagoya, Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Center, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan
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Abe T, Umemura Y, Ogura H, Kushimoto S, Fujishima S, Saitoh D, Iriyama H, Komori A, Otomo Y, Shiraishi A, Gando S. 276 Relationship Between Fluid Administration in the First Three Hours of Sepsis Resuscitation and Mortality. Ann Emerg Med 2022. [DOI: 10.1016/j.annemergmed.2022.08.303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Gando S, Shiraishi A, Wada T, Yamakawa K, Fujishima S, Saitoh D, Kushimoto S, Ogura H, Abe T, Mayumi T, Sasaki J, Kotani J, Takeyama N, Tsuruta R, Takuma K, Shiraishi SI, Shiino Y, Nakada TA, Okamoto K, Sakamoto Y, Hagiwara A, Fujimi S, Umemura Y, Otomo Y. Effects of tranexamic acid on coagulofibrinolytic markers during the early stage of severe trauma: A propensity score-matched analysis. Medicine (Baltimore) 2022; 101:e29711. [PMID: 35960088 PMCID: PMC9371565 DOI: 10.1097/md.0000000000029711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Tranexamic acid (TXA) reduces the risk of bleeding trauma death without altering the need for blood transfusion. We examined the effects of TXA on coagulation and fibrinolysis dynamics and the volume of transfusion during the early stage of trauma. This subanalysis of a prospective multicenter study of severe trauma included 276 patients divided into propensity score-matched groups with and without TXA administration. The effects of TXA on coagulation and fibrinolysis markers immediately at (time point 0) and 3 hours after (time point 3) arrival at the emergency department were investigated. The transfusion volume was determined at 24 hours after admission. TXA was administered to the patients within 3 hours (median, 64 minutes) after injury. Significant reductions in fibrin/fibrinogen degradation products and D-dimer levels from time points 0 to 3 in the TXA group compared with the non-TXA group were confirmed, with no marked differences noted in the 24-hour transfusion volumes between the 2 groups. Continuously increased levels of soluble fibrin, a marker of thrombin generation, from time points 0 to 3 and high levels of plasminogen activator inhibitor-1, a marker of inhibition of fibrinolysis, at time point 3 were observed in both groups. TXA inhibited fibrin(ogen)olysis during the early stage of severe trauma, although this was not associated with a reduction in the transfusion volume. Other confounders affecting the dynamics of fibrinolysis and transfusion requirement need to be clarified.
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Affiliation(s)
- Satoshi Gando
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, Japan
- Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Japan
- *Correspondence: Satoshi Gando, Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, N33E14, Higashi-ku 065-0033, Japan (e-mail: )
| | | | - Takeshi Wada
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, Japan
| | - Kazuma Yamakawa
- Department of Emergency Medicine, Osaka Medical College, Japan
| | - Seitaro Fujishima
- Center for General Medicine Education, Keio University School of Medicine, Japan
| | - Daizoh Saitoh
- Division of Traumatology, Research Institute, National Defense Medical College, Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Japan
| | - Toshikazu Abe
- Department of Emergency and Critical Care Medicine, Tsukuba Memorial Hospital, Tsukuba, Japan
- Health Services Research and Development Center, University of Tsukuba, Japan
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Japan
| | - Joji Kotani
- Division of Disaster and Emergency Medicine, Department of Surgery Related, Kobe University Graduate School of Medicine, Japan
| | - Naoshi Takeyama
- Advanced Critical Care Center, Aichi Medical University Hospital, Japan
| | - Ryosuke Tsuruta
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Japan
| | - Kiyotsugu Takuma
- Emergency and Critical Care Center, Kawasaki Municipal Hospital, Japan
| | | | - Yasukazu Shiino
- Department of Acute Medicine, Kawasaki Medical School, Japan
| | - Taka-aki Nakada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Japan
| | - Kohji Okamoto
- Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital, Japan
| | - Yuichiro Sakamoto
- Emergency and Critical Care Medicine, Saga University Hospital, Japan
| | - Akiyoshi Hagiwara
- Center Hospital of the National Center for Global Health and Medicine, Japan
| | - Satoshi Fujimi
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Japan
| | - Yutaka Umemura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Center, Medical Hospital, Tokyo Medical and Dental University, Japan
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10
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Mizugaki A, Wada T, Tsuchida T, Gando S. Association of Histones With Coagulofibrinolytic Responses and Organ Dysfunction in Adult Post-cardiac Arrest Syndrome. Front Cardiovasc Med 2022; 9:885406. [PMID: 35837604 PMCID: PMC9273886 DOI: 10.3389/fcvm.2022.885406] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 06/03/2022] [Indexed: 11/23/2022] Open
Abstract
Background Patients successfully resuscitated from cardiac arrest often develop organ dysfunction caused by systemic inflammation and increased coagulation, leading to disseminated intravascular coagulation (DIC). The involvement of histones in DIC and organ dysfunction in patients with sepsis and trauma has been previously reported, raising the probability that histones may also be associated with pathophysiology in patients after cardiac arrest and resuscitation. This study evaluated the relationship between histones and organ dysfunction related to coagulofibrinolytic changes in patients with post-cardiac arrest syndrome (PCAS). Methods This prospective single-center observational study assessed 35 adult patients with PCAS who were divided into two groups, i.e., 15 patients with multiple organ dysfunction syndrome (MODS) and 20 patients without MODS. MODS was defined as a sequential organ failure assessment score of ≥12. The plasma levels of histones and coagulofibrinolytic markers, including soluble fibrin, tissue-type plasminogen activator, plasminogen activator inhibitor-1, plasmin-alpha 2-plasmin inhibitor complex (PIC), and soluble thrombomodulin, were measured in patients with PCAS immediately after admission to the emergency department, and 3 and 24 h after arriving at the hospital. Results PCAS patients with MODS had higher DIC scores [4 (3.0–5.0) vs. 1 (0.0–3.0), p = 0.012] and higher mortality rates (66.7% vs. 20.0%, p = 0.013) than those without MODS. Moreover, patients with MODS exhibited higher histone levels than those without MODS during the early phase of the post-resuscitation period. Severe endothelial injury and higher thrombin and plasmin generation were observed in the MODS group. Plasma levels of histones were positively correlated with those of soluble fibrin immediately after resuscitation (rho = 0.367, p = 0.030) and PIC 3 h after arriving at the hospital (rho = 0.480, p = 0.005). This correlation was prominent in the patient population with MODS (soluble fibrin: rho = 0.681, p = 0.005, PIC: rho = 0.742, p = 0.002). Conclusions This study demonstrated that elevated histone levels were associated with increased levels of thrombin, and subsequent plasmin generation in PCAS patients, especially those with MODS. Further studies are required to elucidate the causal relationship between histones and organ dysfunction related to DIC in PCAS.
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Affiliation(s)
- Asumi Mizugaki
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Takeshi Wada
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
- *Correspondence: Takeshi Wada
| | - Takumi Tsuchida
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Satoshi Gando
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
- Department of Acute and Critical Care Center, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
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11
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Umemura Y, Abe T, Ogura H, Fujishima S, Kushimoto S, Shiraishi A, Saitoh D, Mayumi T, Otomo Y, Hifumi T, Hagiwara A, Takuma K, Yamakawa K, Shiino Y, Nakada TA, Tarui T, Okamoto K, Kotani J, Sakamoto Y, Sasaki J, Shiraishi SI, Tsuruta R, Masuno T, Takeyama N, Yamashita N, Ikeda H, Ueyama M, Gando S. Hour-1 bundle adherence was associated with reduction of in-hospital mortality among patients with sepsis in Japan. PLoS One 2022; 17:e0263936. [PMID: 35157744 PMCID: PMC8843226 DOI: 10.1371/journal.pone.0263936] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 01/30/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The updated Surviving Sepsis Campaign guidelines recommend a 1-hour window for completion of a sepsis care bundle; however, the effectiveness of the hour-1 bundle has not been fully evaluated. The present study aimed to evaluate the impact of hour-1 bundle completion on clinical outcomes in sepsis patients. METHODS This was a multicenter, prospective, observational study conducted in 17 intensive care units in tertiary hospitals in Japan. We included all adult patients who were diagnosed as having sepsis by Sepsis-3 and admitted to intensive care units from July 2019 to August 2020. Impacts of hour-1 bundle adherence and delay of adherence on risk-adjusted in-hospital mortality were estimated by multivariable logistic regression analyses. RESULTS The final study cohort included 178 patients with sepsis. Among them, 89 received bundle-adherent care. Completion rates of each component (measure lactate level, obtain blood cultures, administer broad-spectrum antibiotics, administer crystalloid, apply vasopressors) within 1 hour were 98.9%, 86.2%, 51.1%, 94.9%, and 69.1%, respectively. Completion rate of all components within 1 hour was 50%. In-hospital mortality was 18.0% in the patients with and 30.3% in the patients without bundle-adherent care (p = 0.054). The adjusted odds ratio of non-bundle-adherent versus bundle-adherent care for in-hospital mortality was 2.32 (95% CI 1.09-4.95) using propensity scoring. Non-adherence to obtaining blood cultures and administering broad-spectrum antibiotics within 1 hour was related to in-hospital mortality (2.65 [95% CI 1.25-5.62] and 4.81 [95% CI 1.38-16.72], respectively). The adjusted odds ratio for 1-hour delay in achieving hour-1 bundle components for in-hospital mortality was 1.28 (95% CI 1.04-1.57) by logistic regression analysis. CONCLUSION Completion of the hour-1 bundle was associated with lower in-hospital mortality. Obtaining blood cultures and administering antibiotics within 1 hour may have been the components most contributing to decreased in-hospital mortality.
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Affiliation(s)
- Yutaka Umemura
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Toshikazu Abe
- Department of Emergency and Critical Care Medicine, Tsukuba Memorial Hospital, Tsukuba, Japan
- Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan
- Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Japan
- * E-mail:
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Seitato Fujishima
- Center for General Medicine Education, Keio University School of Medicine, Tokyo, Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | | | - Daizoh Saitoh
- Division of Traumatology, Research Institute, National Defense Medical College, Tokorozawa, Japan
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Center, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke’s International Hospital, Tokyo, Japan
| | - Akiyoshi Hagiwara
- Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan
| | - Kiyotsugu Takuma
- Emergency & Critical Care Center, Kawasaki Municipal Kawasaki Hospital, Kawasaki, Japan
| | - Kazuma Yamakawa
- Department of Emergency Medicine, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Yasukazu Shiino
- Department of Acute Medicine, Kawasaki Medical School, Okayama, Japan
| | - Taka-aki Nakada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Takehiko Tarui
- Department of Emergency Medical Care, Kyorin University Faculty of Health Sciences, Tokyo, Japan
| | - Kohji Okamoto
- Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital, Kitakyushu, Japan
| | - Joji Kotani
- Division of Disaster and Emergency Medicine, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yuichiro Sakamoto
- Emergency and Critical Care Medicine, Saga University Hospital, Saga, Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shin-ichiro Shiraishi
- Department of Emergency and Critical Care Medicine, Aizu Chuo Hospital, Fukushima, Japan
| | - Ryosuke Tsuruta
- Advanced Medical Emergency & Critical Care Center, Yamaguchi University Hospital, Yamaguchi, Japan
| | - Tomohiko Masuno
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Naoshi Takeyama
- Advanced Critical Care Center, Aichi Medical University Hospital, Aichi, Japan
| | - Norio Yamashita
- Advanced Emergency Medical Service Center Kurume University Hospital, Kurume, Japan
| | - Hiroto Ikeda
- Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Masashi Ueyama
- Department of Trauma, Critical Care Medicine, and Burn Center, Japan Community Healthcare Organization, Chukyo Hospital, Nagoya, Japan
- Community Healthcare Organization, Chukyo Hospital, Nagoya, Japan
| | - Satoshi Gando
- Department of Anesthesiology and Critical Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
- Department of Acute and Critical Care Medicine, Sapporo Tokushukai Hospital, Sapporo, Japan
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12
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Nakahashi S, Imai H, Shimojo N, Magata Y, Einama T, Hayakawa M, Wada T, Morimoto Y, Gando S. Effects of the Prone Position on Regional Neutrophilic Lung Inflammation According to 18F-FDG Pet in an Experimental Ventilator-Induced Lung Injury Model. Shock 2022; 57:298-308. [PMID: 34107528 DOI: 10.1097/shk.0000000000001818] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Ventilator-induced lung injury (VILI) can be life-threatening and it is important to prevent the development of VILI. It remains unclear whether the prone position affects neutrophilic inflammation in the lung regions in vivo, which plays a crucial role in the pathogenesis of VILI. This study aimed to assess the relationship between the use of the prone position and the development of VILI-associated regional neutrophilic lung inflammation. Regional neutrophilic lung inflammation and lung aeration during low tidal volume mechanical ventilation were assessed using in vivo 2-deoxy-2-[(18)F] fluoro-D-glucose (18F-FDG) positron emission tomography and computed tomography in acutely experimentally injured rabbit lungs (lung injury induced by lung lavage and excessive ventilation). Direct comparisons were made among three groups: control, supine, and prone positions. After approximately 7 h, tissue-normalized 18F-FDG uptake differed significantly between the supine and prone positions (SUP: 0.038 ± 0.014 vs. PP: 0.029 ± 0.008, P = 0.038), especially in the ventral region (SUP: 0.052 ± 0.013 vs. PP: 0.026 ± 0.007, P = 0.003). The use of the prone position reduced lung inhomogeneities, which was demonstrated by the correction of the disproportionate rate of voxel gas over the given lung region. The progression of neutrophilic inflammation was affected by the interaction between the total strain (for aeration) and the inhomogeneity. The prone position is effective in slowing down the progression of VILI-associated neutrophilic inflammation. Under low-tidal-volume ventilation, the main drivers of its effect may be homogenization of lung tissue and that of mechanical forces.
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Affiliation(s)
- Susumu Nakahashi
- Department of Emergency and Critical Care Center, Mie University Hospital, Tsu, Japan
| | - Hiroshi Imai
- Department of Emergency and Critical Care Center, Mie University Hospital, Tsu, Japan
| | - Nobutake Shimojo
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Yasuhiro Magata
- Department of Molecular Imaging, Institute for Medical Photonics Research, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Takahiro Einama
- Department of Surgery, National Defense Medical College, Tokorozawa, Japan
| | - Mineji Hayakawa
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Takeshi Wada
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Yuji Morimoto
- Division of Anesthesia and Perioperative Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Satoshi Gando
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
- Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
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13
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Gando S, Wada T. Pathomechanisms Underlying Hypoxemia in Two COVID-19-Associated Acute Respiratory Distress Syndrome Phenotypes: Insights From Thrombosis and Hemostasis. Shock 2022; 57:1-6. [PMID: 34172612 PMCID: PMC8662946 DOI: 10.1097/shk.0000000000001825] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 06/10/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The pathomechanisms of hypoxemia and treatment strategies for type H and type L acute respiratory distress syndrome (ARDS) in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-induced coronavirus disease 2019 (COVID-19) have not been elucidated. MAIN TEXT SARS-CoV-2 mainly targets the lungs and blood, leading to ARDS, and systemic thrombosis or bleeding. Angiotensin II-induced coagulopathy, SARS-CoV-2-induced hyperfibrin(ogen)olysis, and pulmonary and/or disseminated intravascular coagulation due to immunothrombosis contribute to COVID-19-associated coagulopathy. Type H ARDS is associated with hypoxemia due to diffuse alveolar damage-induced high right-to-left shunts. Immunothrombosis occurs at the site of infection due to innate immune inflammatory and coagulofibrinolytic responses to SARS-CoV-2, resulting in microvascular occlusion with hypoperfusion of the lungs. Lung immunothrombosis in type L ARDS results from neutrophil extracellular traps containing platelets and fibrin in the lung microvasculature, leading to hypoxemia due to impaired blood flow and a high ventilation/perfusion (VA/Q) ratio. COVID-19-associated ARDS is more vascular centric than the other types of ARDS. D-dimer levels have been monitored for the progression of microvascular thrombosis in COVID-19 patients. Early anticoagulation therapy in critical patients with high D-dimer levels may improve prognosis, including the prevention and/or alleviation of ARDS. CONCLUSIONS Right-to-left shunts and high VA/Q ratios caused by lung microvascular thrombosis contribute to hypoxemia in type H and L ARDS, respectively. D-dimer monitoring-based anticoagulation therapy may prevent the progression to and/or worsening of ARDS in COVID-19 patients.
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Affiliation(s)
- Satoshi Gando
- Acute and Critical Center, Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Takeshi Wada
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
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14
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Wada T, Shiraishi A, Gando S, Yamakawa K, Fujishima S, Saitoh D, Kushimoto S, Ogura H, Abe T, Mayumi T, Sasaki J, Kotani J, Takeyama N, Tsuruta R, Takuma K, Shiraishi SI, Shiino Y, Nakada TA, Okamoto K, Sakamoto Y, Hagiwara A, Fujimi S, Umemura Y, Otomo Y. Pathophysiology of Coagulopathy Induced by Traumatic Brain Injury Is Identical to That of Disseminated Intravascular Coagulation With Hyperfibrinolysis. Front Med (Lausanne) 2021; 8:767637. [PMID: 34869481 PMCID: PMC8634586 DOI: 10.3389/fmed.2021.767637] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 10/20/2021] [Indexed: 01/07/2023] Open
Abstract
Background: Traumatic brain injury (TBI)-associated coagulopathy is a widely recognized risk factor for secondary brain damage and contributes to poor clinical outcomes. Various theories, including disseminated intravascular coagulation (DIC), have been proposed regarding its pathomechanisms; no consensus has been reached thus far. This study aimed to elucidate the pathophysiology of TBI-induced coagulopathy by comparing coagulofibrinolytic changes in isolated TBI (iTBI) to those in non-TBI, to determine the associated factors, and identify the clinical significance of DIC diagnosis in patients with iTBI. Methods: This secondary multicenter, prospective study assessed patients with severe trauma. iTBI was defined as Abbreviated Injury Scale (AIS) scores ≥4 in the head and neck, and ≤2 in other body parts. Non-TBI was defined as AIS scores ≥4 in single body parts other than the head and neck, and the absence of AIS scores ≥3 in any other trauma-affected parts. Specific biomarkers for thrombin and plasmin generation, anticoagulation, and fibrinolysis inhibition were measured at the presentation to the emergency department (0 h) and 3 h after arrival. Results: We analyzed 34 iTBI and 40 non-TBI patients. Baseline characteristics, transfusion requirements and in-hospital mortality did not significantly differ between groups. The changes in coagulation/fibrinolysis-related biomarkers were similar. Lactate levels in the iTBI group positively correlated with DIC scores (rho = −0.441, p = 0.017), but not with blood pressure (rho = −0.098, p = 0.614). Multiple logistic regression analyses revealed that the injury severity score was an independent predictor of DIC development in patients with iTBI (odds ratio = 1.237, p = 0.018). Patients with iTBI were further subdivided into two groups: DIC (n = 15) and non-DIC (n = 19) groups. Marked thrombin and plasmin generation were observed in all patients with iTBI, especially those with DIC. Patients with iTBI and DIC had higher requirements for massive transfusion and emergency surgery, and higher in-hospital mortality than those without DIC. Furthermore, DIC development significantly correlated with poor hospital survival; DIC scores at 0 h were predictive of in-hospital mortality. Conclusions: Coagulofibrinolytic changes in iTBI and non-TBI patients were identical, and consistent with the pathophysiology of DIC. DIC diagnosis in the early phase of TBI is key in predicting the outcomes of severe TBI.
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Affiliation(s)
- Takeshi Wada
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | | | - Satoshi Gando
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan.,Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
| | - Kazuma Yamakawa
- Department of Emergency Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
| | - Seitaro Fujishima
- Center for General Medicine Education, Keio University School of Medicine, Tokyo, Japan
| | - Daizoh Saitoh
- Division of Traumatology, Research Institute, National Defense Medical College, Tokorozawa, Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Toshikazu Abe
- Department of Emergency and Critical Care Medicine, Tsukuba Memorial Hospital, Tsukuba, Japan.,Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Joji Kotani
- Division of Disaster and Emergency Medicine, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Naoshi Takeyama
- Advanced Critical Care Center, Aichi Medical University Hospital, Nagakute, Japan
| | - Ryosuke Tsuruta
- Advanced Medical Emergency & Critical Care Center, Yamaguchi University Hospital, Ube, Japan
| | - Kiyotsugu Takuma
- Emergency & Critical Care Center, Kawasaki Municipal Hospital, Kawasaki, Japan
| | | | - Yasukazu Shiino
- Department of Acute Medicine, Kawasaki Medical School, Kurashiki, Japan
| | - Taka-Aki Nakada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Kohji Okamoto
- Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital, Kitakyushu, Japan
| | - Yuichiro Sakamoto
- Emergency and Critical Care Medicine, Saga University Hospital, Saga, Japan
| | - Akiyoshi Hagiwara
- Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan
| | - Satoshi Fujimi
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Sumiyoshi, Japan
| | - Yutaka Umemura
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Sumiyoshi, Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Center, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan
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15
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Ueno R, Masubuchi T, Shiraishi A, Gando S, Abe T, Kushimoto S, Mayumi T, Fujishima S, Hagiwara A, Hifumi T, Endo A, Komatsu T, Kotani J, Okamoto K, Sasaki J, Shiino Y, Umemura Y. Quick sequential organ failure assessment score combined with other sepsis-related risk factors to predict in-hospital mortality: Post-hoc analysis of prospective multicenter study data. PLoS One 2021; 16:e0254343. [PMID: 34264977 PMCID: PMC8282038 DOI: 10.1371/journal.pone.0254343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 06/25/2021] [Indexed: 11/25/2022] Open
Abstract
This study aimed to assess the value of quick sequential organ failure assessment (qSOFA) combined with other risk factors in predicting in-hospital mortality in patients presenting to the emergency department with suspected infection. This post-hoc analysis of a prospective multicenter study dataset included 34 emergency departments across Japan (December 2017 to February 2018). We included adult patients (age ≥16 years) who presented to the emergency department with suspected infection. qSOFA was calculated and recorded by senior emergency physicians when they suspected an infection. Different types of sepsis-related risk factors (demographic, functional, and laboratory values) were chosen from prior studies. A logistic regression model was used to assess the predictive value of qSOFA for in-hospital mortality in models based on the following combination of predictors: 1) qSOFA-Only; 2) qSOFA+Age; 3) qSOFA+Clinical Frailty Scale (CFS); 4) qSOFA+Charlson Comorbidity Index (CCI); 5) qSOFA+lactate levels; 6) qSOFA+Age+CCI+CFS+lactate levels. We calculated the area under the receiver operating characteristic curve (AUC) and other key clinical statistics at Youden’s index, where the sum of sensitivity and specificity is maximized. Following prior literature, an AUC >0.9 was deemed to indicate high accuracy; 0.7–0.9, moderate accuracy; 0.5–0.7, low accuracy; and 0.5, a chance result. Of the 951 patients included in the analysis, 151 (15.9%) died during hospitalization. The AUC for predicting in-hospital mortality was 0.627 (95% confidence interval [CI]: 0.580−0.673) for the qSOFA-Only model. Addition of other variables only marginally improved the model’s AUC; the model that included all potentially relevant variables yielded an AUC of only 0.730 (95% CI: 0.687–0.774). Other key statistic values were similar among all models, with sensitivity and specificity of 0.55−0.65 and 0.60−0.75, respectively. In this post-hoc data analysis from a prospective multicenter study based in Japan, combining qSOFA with other sepsis-related risk factors only marginally improved the model’s predictive value.
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Affiliation(s)
- Ryo Ueno
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Chiba, Japan
- Australian and New Zealand Intensive Care Research Center, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Takateru Masubuchi
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Atsushi Shiraishi
- Emergency and Trauma Center, Kameda Medical Center, Kamogawa, Japan
- * E-mail:
| | - Satoshi Gando
- Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
- Division of Acute and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Toshikazu Abe
- Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Seitaro Fujishima
- Center for General Medicine Education, Keio University School of Medicine, Tokyo, Japan
| | - Akiyoshi Hagiwara
- Department of Emergency Medicine, Niizashiki Chuo General Hospital, Niiza, Japan
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke’s International Hospital, Tokyo, Japan
| | - Akira Endo
- Trauma and Acute Critical Care Medical Center, Tokyo Medical and Dental University Hospital of Medicine, Tokyo, Japan
| | | | - Joji Kotani
- Division of Disaster and Emergency Medicine, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kohji Okamoto
- Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital, Kitakyushu, Japan
| | - Junichi Sasaki
- Department of Emergency & Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yasukazu Shiino
- Department of Acute Medicine, Kawasaki Medical School, Kurashiki, Japan
| | - Yutaka Umemura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
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16
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Saitoh D, Gando S, Maekawa K, Sasaki J, Fujishima S, Ikeda H, Shiino Y, Takuma K, Nakada TA, Tanaka K, Tasaki O, Nemoto M, Yuzuriha S, Yamaguchi H, Iwase F, Matsuyama S, Matsui K, Yoshimuta K, Yamamura H, Harunari N, Okamoto K, Tanaka H, Saitoh D, Gando S, Maekawa K, Sasaki J, Fujishima S, Ikeda H, Shiino Y, Takuma K, Nakada TA, Tanaka K, Tasaki O, Nemoto M, Yuzuriha S, Yamaguchi H, Iwase F, Matsuyama S, Matsui K, Yoshimuta K, Yamamura H, Harunari N, Okamoto K, Tanaka H. A randomized prospective comparison of the Baxter and Modified Brooke formulas for acute burn resuscitation. Burns Open 2021. [DOI: 10.1016/j.burnso.2021.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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17
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Gando S, Wada T. Thromboplasminflammation in COVID-19 Coagulopathy: Three Viewpoints for Diagnostic and Therapeutic Strategies. Front Immunol 2021; 12:649122. [PMID: 34177896 PMCID: PMC8226122 DOI: 10.3389/fimmu.2021.649122] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 05/28/2021] [Indexed: 01/08/2023] Open
Abstract
Thromboplasminflammation in coronavirus disease 2019 (COVID-19) coagulopathy consists of angiotensin II (Ang II)-induced coagulopathy, activated factor XII (FXIIa)- and kallikrein, kinin system-enhanced fibrinolysis, and disseminated intravascular coagulation (DIC). All three conditions induce systemic inflammation via each pathomechanism-developed production of inflammatory cytokines. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) downregulates angiotensin-converting enzyme 2, leading to an increase in Ang II levels. Ang II-induced coagulopathy comprising platelet activation, thrombin generation, plasminogen activator inhibitor-1 expression and endothelial injury causes thrombosis via the angiotensin II type 1 receptor. SARS-CoV-2 RNA and neutrophil extracellular trap (NET) DNA activate FXII, resulting in plasmin generation through FXIIa- and kallikrein-mediated plasminogen conversion to plasmin and bradykinin-induced tissue-type plasminogen activator release from the endothelium via the kinin B2 receptor. NETs induce immunothrombosis at the site of infection (lungs), through histone- and DNA-mediated thrombin generation, insufficient anticoagulation control, and inhibition of fibrinolysis. However, if the infection is sufficiently severe, immunothrombosis disseminates into the systemic circulation, and DIC, which is associated with the endothelial injury, occurs. Inflammation, and serine protease networks of coagulation and fibrinolysis, militate each other through complement pathways, which exacerbates three pathologies of COVID-19 coagulopathy. COVID-19 coagulopathy causes microvascular thrombosis and bleeding, resulting in multiple organ dysfunction and death in critically ill patients. Treatment targets for improving the prognosis of COVID-19 coagulopathy include thrombin, plasmin, and inflammation, and SARS-CoV-2 infection. Several drugs are candidates for controlling these conditions; however, further advances are required to establish robust treatments based on a clear understanding of molecular mechanisms of COVID-19 coagulopathy.
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Affiliation(s)
- Satoshi Gando
- Acute and Critical Center, Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan.,Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Takeshi Wada
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
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18
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Nagata I, Abe T, Ogura H, Kushimoto S, Fujishima S, Gando S. Intensive care unit model and in-hospital mortality among patients with severe sepsis and septic shock: A secondary analysis of a multicenter prospective observational study. Medicine (Baltimore) 2021; 100:e26132. [PMID: 34032762 PMCID: PMC8154476 DOI: 10.1097/md.0000000000026132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 05/06/2021] [Indexed: 01/04/2023] Open
Abstract
We aimed to determine the association between the intensive care unit (ICU) model and in-hospital mortality of patients with severe sepsis and septic shock.This was a secondary analysis of a multicenter prospective observational study conducted in 59 ICUs in Japan from January 2016 to March 2017. We included adult patients (aged ≥16 years) with severe sepsis and septic shock based on the sepsis-2 criteria who were admitted to an ICU with a 1:2 nurse-to-patient ratio per shift. Patients were categorized into open or closed ICU groups, according to the ICU model. The primary outcome was in-hospital mortality.A total of 1018 patients from 45 ICUs were included in this study. Patients in the closed ICU group had a higher severity score and higher organ failure incidence than those in the open ICU group. The compliance rate for the sepsis care 3-h bundle was higher in the closed ICU group than in the open ICU group. In-hospital mortality was not significantly different between the closed and open ICU groups in a multilevel logistic regression analysis (odds ratio = 0.83, 95% confidence interval; 0.52-1.32, P = .43) and propensity score matching analysis (closed ICU, 21.2%; open ICU, 25.7%, P = .22).In-hospital mortality between the closed and open ICU groups was not significantly different after adjusting for ICU structure and compliance with the sepsis care bundle.
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Affiliation(s)
- Isao Nagata
- Health Services Research and Development Center, University of Tsukuba, Tsukuba, Ibaraki
- Intensive Care Unit, Yokohama City Minato Red Cross Hospital, Yokohama, Kanagawa
| | - Toshikazu Abe
- Health Services Research and Development Center, University of Tsukuba, Tsukuba, Ibaraki
- Department of Health Services Research, Faculty of Medicine, University of Tsukuba
- Department of Emergency and Critical Care Medicine, Tsukuba Memorial Hospital, Tsukuba, Ibaraki
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Osaka
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Miyagi
| | - Seitaro Fujishima
- Center for General Medicine Education, Keio University School of Medicine, Tokyo, Tokyo
| | - Satoshi Gando
- Intensive Care Center, Sapporo Higashi Tokushukai Hospital, Sapporo, Hokkaido, Japan
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19
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Tsuchida T, Wada T, Gando S. Coagulopathy Induced by Veno-Arterial Extracorporeal Membrane Oxygenation Is Associated With a Poor Outcome in Patients With Out-of-Hospital Cardiac Arrest. Front Med (Lausanne) 2021; 8:651832. [PMID: 34017845 PMCID: PMC8130758 DOI: 10.3389/fmed.2021.651832] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 04/06/2021] [Indexed: 12/20/2022] Open
Abstract
Background: In recent years, the use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in patients with cardiopulmonary arrest who do not respond to conventional resuscitation, has increased. However, despite the development of VA-ECMO, the outcomes of resuscitated patients remain poor. The poor prognosis may be attributed to deterioration owing to the post-cardiac arrest syndrome (PCAS); this includes the systemic inflammatory response and coagulation activation caused by the extracorporeal circulation (VA-ECMO circuit) itself. This study aimed to evaluate the coagulofibrinolytic changes caused by VA-ECMO and to identify predictive factors of poor prognosis. Methods: We analyzed 151 cases of PCAS with witnessed cardiac arrest. As biomarkers, platelet counts, prothrombin time ratio, fibrin/fibrinogen degradation products, fibrinogen, antithrombin, and lactate were recorded from blood samples from the time of delivery to the third day of hospitalization. The maximum (max) and minimum (min) values of each factor during the study period were calculated. To evaluate the impact of VA-ECMO on patients with PCAS, we performed propensity score matching between the patients who received and did not receive VA-ECMO. Sub-analysis was performed for the group with VA-ECMO. Results: There were significant differences in all baseline characteristics and demographics except the time from detection to hospital arrival, percentage of cardiopulmonary resuscitations (CPR) by witnesses, and the initial rhythm between the groups. Propensity score matching adjusted for prehospital factors demonstrated that the patients who received VA-ECMO developed significantly severe coagulation disorders. In a sub-analysis, significant differences were noted in the prothrombin time ratio min, fibrinogen max, antithrombin max, and lactate min between survivors and non-survivors. In particular, the prothrombin time ratio min and antithrombin max were strongly correlated with poor outcome. Conclusion: In the present study, significant coagulopathy was observed in patients who received VA-ECMO for CPR. In particular, in patients receiving VA-ECMO, the minimum prothrombin time ratio and maximum antithrombin by day 3 of hospitalization were strongly correlated with poor outcomes. These results suggest that VA-ECMO-induced coagulopathy can be a promising therapeutic target for patients resuscitated by VA-ECMO.
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Affiliation(s)
- Takumi Tsuchida
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Takeshi Wada
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Satoshi Gando
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan.,Department of Acute and Critical Care Center, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
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20
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Yamamoto R, Fujishima S, Sasaki J, Gando S, Saitoh D, Shiraishi A, Kushimoto S, Ogura H, Abe T, Mayumi T, Kotani J, Nakada TA, Shiino Y, Tarui T, Okamoto K, Sakamoto Y, Shiraishi SI, Takuma K, Tsuruta R, Masuno T, Takeyama N, Yamashita N, Ikeda H, Ueyama M, Hifumi T, Yamakawa K, Hagiwara A, Otomo Y. Hyperoxemia during resuscitation of trauma patients and increased intensive care unit length of stay: inverse probability of treatment weighting analysis. World J Emerg Surg 2021; 16:19. [PMID: 33926507 PMCID: PMC8082221 DOI: 10.1186/s13017-021-00363-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 04/16/2021] [Indexed: 12/28/2022] Open
Abstract
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.
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Affiliation(s)
- Ryo Yamamoto
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Seitaro Fujishima
- Center for General Medicine Education, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan.
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Satoshi Gando
- Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan.,Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Daizoh Saitoh
- Division of Traumatology, Research Institute, National Defense Medical College, Tokorozawa, Japan
| | | | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Toshikazu Abe
- Department of General Medicine, Juntendo University, Tokyo, Japan.,Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Joji Kotani
- Division of Disaster and Emergency Medicine, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Taka-Aki Nakada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yasukazu Shiino
- Department of Acute Medicine, Kawasaki Medical School, Kurashiki, Japan
| | - Takehiko Tarui
- Department of Trauma and Critical Care Medicine, Kyorin University School of Medicine, Tokyo, Japan
| | - Kohji Okamoto
- Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital, Kitakyushu, Japan
| | - Yuichiro Sakamoto
- Emergency and Critical Care Medicine, Saga University Hospital, Saga, Japan
| | - Shin-Ichiro Shiraishi
- Department of Emergency and Critical Care Medicine, Aizu Chuo Hospital, Aizuwakamatsu, Japan
| | - Kiyotsugu Takuma
- Emergency & Critical Care Center, Kawasaki Municipal Kawasaki Hospital, Kawasaki, Japan
| | - Ryosuke Tsuruta
- Advanced Medical Emergency & Critical Care Center, Yamaguchi University Hospital, Ube, Japan
| | - Tomohiko Masuno
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Naoshi Takeyama
- Advanced Critical Care Center, Aichi Medical University Hospital, Nagakute, Japan
| | - Norio Yamashita
- Advanced Emergency Medical Service Center, Kurume University Hospital, Kurume, Japan
| | - Hiroto Ikeda
- Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Masashi Ueyama
- Department of Trauma, Critical Care Medicine, and Burn Center, Japan Community Healthcare Organization, Chukyo Hospital, Nagoya, Japan
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
| | - Akiyoshi Hagiwara
- Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Center, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan
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21
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Shiraishi A, Gando S, Abe T, Kushimoto S, Mayumi T, Fujishima S, Hagiwara A, Shiino Y, Shiraishi SI, Hifumi T, Otomo Y, Okamoto K, Sasaki J, Takuma K, Yamakawa K, Hanaki Y, Harada M, Morino K. Quick sequential organ failure assessment versus systemic inflammatory response syndrome criteria for emergency department patients with suspected infection. Sci Rep 2021; 11:5347. [PMID: 33674716 PMCID: PMC7935946 DOI: 10.1038/s41598-021-84743-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 02/17/2021] [Indexed: 12/26/2022] Open
Abstract
Previous studies have shown inconsistent prognostic accuracy for mortality with both quick sequential organ failure assessment (qSOFA) and the systemic inflammatory response syndrome (SIRS) criteria. We aimed to validate the accuracy of qSOFA and the SIRS criteria for predicting in-hospital mortality in patients with suspected infection in the emergency department. A prospective study was conducted including participants with suspected infection who were hospitalised or died in 34 emergency departments in Japan. Prognostic accuracy of qSOFA and SIRS criteria for in-hospital mortality was assessed by the area under the receiver operating characteristic (AUROC) curve. Of the 1060 participants, 402 (37.9%) and 915 (86.3%) had qSOFA ≥ 2 and SIRS criteria ≥ 2 (given thresholds), respectively, and there were 157 (14.8%) in-hospital deaths. Greater accuracy for in-hospital mortality was shown with qSOFA than with the SIRS criteria (AUROC: 0.64 versus 0.52, difference + 0.13, 95% CI [+ 0.07, + 0.18]). Sensitivity and specificity for predicting in-hospital mortality at the given thresholds were 0.55 and 0.65 based on qSOFA and 0.88 and 0.14 based on SIRS criteria, respectively. To predict in-hospital mortality in patients visiting to the emergency department with suspected infection, qSOFA was demonstrated to be modestly more accurate than the SIRS criteria albeit insufficiently sensitive.Clinical Trial Registration: The study was pre-registered in the University Hospital Medical Information Network Clinical Trials Registry (UMIN000027258).
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Affiliation(s)
- Atsushi Shiraishi
- Emergency and Trauma Center, Kameda Medical Center, 929, Higashicho, Kamogawa, Chiba, 296-8602, Japan.
| | - Satoshi Gando
- Division of Acute and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan.,Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
| | - Toshikazu Abe
- Department of General Medicine, Juntendo University, Tokyo, Japan.,Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Seitaro Fujishima
- Center for General Medicine Education, Keio University School of Medicine, Tokyo, Japan
| | - Akiyoshi Hagiwara
- Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan.,Department of Emergency Medicine, Niizashiki Chuo General Hospital, Niiza, Japan
| | - Yasukazu Shiino
- Department of Acute Medicine, Kawasaki Medical School, Kurashiki, Japan
| | - Shin-Ichiro Shiraishi
- Department of Emergency and Critical Care Medicine, Aizu Chuo Hospital, Aizuwakamatsu, Japan
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Center, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kohji Okamoto
- Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital, Kitakyushu, Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Kiyotsugu Takuma
- Emergency and Critical Care Center, Kawasaki Municipal Kawasaki Hospital, Kawasaki, Japan
| | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
| | - Yoshihiro Hanaki
- Department of Emergency and Critical Care Medicine, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan
| | - Masahiro Harada
- Department of Emergency and Critical Care, National Hospital Organization Kumamoto Medical Center, Kumamoto, Japan
| | - Kazuma Morino
- Medical Center for Emergency, Yamagata Prefectural Central Hospital, Yamagata, Japan
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22
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Hagiwara A, Tanaka N, Inaba Y, Gando S, Shiraishi A, Saitoh D, Otomo Y, Ikeda H, Ogura H, Kushimoto S, Kotani J, Sakamoto Y, Shiino Y, Shiraishi SI, Takuma K, Tarui T, Tsuruta R, Nakada TA, Hifumi T, Yamakawa K, Takeyama N, Yamashita N, Abe T, Ueyama M, Okamoto K, Sasaki J, Masuno T, Mayumi T, Fujishima S, Umemura Y, Fujimi S. Predictors of severe sepsis-related in-hospital mortality based on a multicenter cohort study: The Focused Outcomes Research in Emergency Care in Acute Respiratory Distress Syndrome, Sepsis, and Trauma study. Medicine (Baltimore) 2021; 100:e24844. [PMID: 33663106 PMCID: PMC7909210 DOI: 10.1097/md.0000000000024844] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 01/28/2021] [Indexed: 01/05/2023] Open
Abstract
This study aimed to identify prognostic factors for severe sepsis-related in-hospital mortality using the structural equation model (SEM) analysis with statistical causality. Sepsis data from the Focused Outcomes Research in Emergency Care in Acute Respiratory Distress Syndrome, Sepsis, and Trauma study (FORECAST), a multicenter cohort study, was used. Forty seven observed variables from the database were used to construct 4 latent variables. SEM analysis was performed on these latent variables to analyze the statistical causality among these data. This study evaluated whether the variables had an effect on in-hospital mortality. Overall, 1148 patients were enrolled. The SEM analysis showed that the 72-hour physical condition was the strongest latent variable affecting mortality, followed by physical condition before treatment. Furthermore, the 72-hour physical condition and the physical condition before treatment strongly influenced the Sequential Organ Failure Assessment (SOFA) score with path coefficients of 0.954 and 0.845, respectively. The SOFA score was the strongest variable that affected mortality after the onset of severe sepsis. The score remains the most robust prognostic factor and can facilitate appropriate policy development on care.
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Affiliation(s)
- Akiyoshi Hagiwara
- Department of Emergency Medicine, Niizashiki Chuo General Hospital, Saitama
| | - Noriko Tanaka
- Biostatistics Section, Department of Data Science, Clinical Science Center, National Center for Global Health and Medicine, Tokyo
| | - Yosuke Inaba
- Biostatistics Section, Department of Data Science, Clinical Science Center, National Center for Global Health and Medicine, Tokyo
| | - Satoshi Gando
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo
- Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushima Hospital, Sapporo
| | | | - Daizoh Saitoh
- Division of Traumatology, Research Institute, National Defense Medical College, Tokorozawa
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Center, Medical Hospital, Tokyo Medical, and Dental University
| | - Hiroto Ikeda
- Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Miyagi
| | - Joji Kotani
- Department of Disaster and Emergency Medicine, Kobe University Graduate School of Medicine, Kobe
| | - Yuichiro Sakamoto
- Emergency and Critical Care Medicine, Saga University Hospital, Saga
| | - Yasukazu Shiino
- Department of Acute Medicine, Kawasaki Medical School, Kurashiki
| | - Shin-ichiro Shiraishi
- Department of Emergency and Critical Care Medicine, Aizu Chuo Hospital, Aizuwakamatsu
| | - Kiyotsugu Takuma
- Emergency and Critical Care Center, Kawasaki Municipal Kawasaki Hospital, Kawasaki, Kanagawa
| | - Takehiko Tarui
- Department of Trauma and Critical Care Medicine, Kyorin University School of Medicine, Mitaka
| | - Ryosuke Tsuruta
- Advanced Medical Emergency & Critical Care Center, Yamaguchi University Hospital, Ube
| | - Taka-aki Nakada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Chūō, Tokyo
| | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka
| | - Naoshi Takeyama
- Advanced Critical Care Center, Aichi Medical University Hospital, Aichi
| | - Norio Yamashita
- Advanced Emergency Medical Service Center, Kurume University Hospital, Kurume, Fukuoka
| | - Toshikazu Abe
- Department of General Medicine, Juntendo University, Tokyo
| | - Masashi Ueyama
- Department of Trauma, Critical Care Medicine, and Burn Center, Japan Community Healthcare Organization, Chukyo Hospital, Nagoya, Aichi
| | - Kohji Okamoto
- Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Shinjuku City
| | - Tomohiko Masuno
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Bunkyo City, Tokyo
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Fukuoka
| | - Seitaro Fujishima
- Center for General Medicine Education, Keio University School of Medicine, Shinjuku City, Tokyo
| | - Yutaka Umemura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine
| | - Satoshi Fujimi
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Japan
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23
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Komori A, Abe T, Yamakawa K, Ogura H, Kushimoto S, Saitoh D, Fujishima S, Otomo Y, Kotani J, Sakamoto Y, Sasaki J, Shiino Y, Takeyama N, Tarui T, Tsuruta R, Nakada TA, Hifumi T, Iriyama H, Naito T, Gando S. Characteristics and outcomes of frail patients with suspected infection in intensive care units: a descriptive analysis from a multicenter cohort study. BMC Geriatr 2020; 20:485. [PMID: 33218303 PMCID: PMC7677099 DOI: 10.1186/s12877-020-01893-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 11/12/2020] [Indexed: 01/09/2023] Open
Abstract
Background Frailty is associated with morbidity and mortality in patients admitted to intensive care units (ICUs). However, the characteristics of frail patients with suspected infection remain unclear. We aimed to investigate the characteristics and outcomes of frail patients with suspected infection in ICUs. Methods This is a secondary analysis of a multicenter cohort study, including 22 ICUs in Japan. Adult patients (aged ≥16 years) with newly suspected infection from December 2017 to May 2018 were included. We compared baseline patient characteristics and outcomes among three frailty groups based on the Clinical Frailty Scale (CFS) score: fit (score, 1–3), vulnerable (score, 4), and frail (score, 5–9). We conducted subgroup analysis of patients with sepsis defined as per Sepsis-3 criteria. We also produced Kaplan–Meier survival curves for 90-day survival. Results We enrolled 650 patients with suspected infection, including 599 (92.2%) patients with sepsis. Patients with a median CFS score of 3 (interquartile range [IQR] 3–5) were included: 337 (51.8%) were fit, 109 (16.8%) were vulnerable, and 204 (31.4%) were frail. The median patient age was 72 years (IQR 60–81). The Sequential Organ Failure Assessment scores for fit, vulnerable, and frail patients were 7 (IQR 4–10), 8 (IQR 5–11), and 7 (IQR 5–10), respectively (p = 0.59). The median body temperatures of fit, vulnerable, and frail patients were 37.5 °C (IQR 36.5 °C–38.5 °C), 37.5 °C (IQR 36.4 °C–38.6 °C), and 37.0 °C (IQR 36.3 °C–38.1 °C), respectively (p < 0.01). The median C-reactive protein levels of fit, vulnerable, and frail patients were 13.6 (IQR 4.6–24.5), 12.1 (IQR 3.9–24.9), 10.5 (IQR 3.0–21.0) mg/dL, respectively (p < 0.01). In-hospital mortality did not statistically differ among the patients according to frailty (p = 0.19). Kaplan–Meier survival curves showed little difference in the mortality rate during short-term follow-up. However, more vulnerable and frail patients died after 30-day than fit patients; this difference was not statistically significant (p = 0.25). Compared with the fit and vulnerable groups, the rate of home discharge was lower in the frail group. Conclusion Frail and vulnerable patients with suspected infection tend to have poor disease outcomes. However, they did not show a statistically significant increase in the 90-day mortality risk.
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Affiliation(s)
- Akira Komori
- Department of General Medicine, Juntendo University, Tokyo, Japan
| | - Toshikazu Abe
- Department of Emergency and Critical Care Medicine, Tsukuba Memorial Hospital, 1187-299, Kaname, Tsukuba, Ibaraki, 300-2622, Japan. .,Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan. .,Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan.
| | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Daizoh Saitoh
- Division of Traumatology, Research Institute, National Defense Medical College, Tokorozawa, Japan
| | - Seitaro Fujishima
- Center for General Medicine Education, Keio University School of Medicine, Tokyo, Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Center, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | - Joji Kotani
- Division of Disaster and Emergency Medicine, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yuichiro Sakamoto
- Emergency and Critical Care Medicine, Saga University Hospital, Saga, Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yasukazu Shiino
- Department of Acute Medicine, Kawasaki Medical School, Kurashiki, Japan
| | - Naoshi Takeyama
- Advanced Critical Care Center, Aichi Medical University Hospital, Nagakute, Japan
| | - Takehiko Tarui
- Department of Trauma and Critical Care Medicine, Kyorin University School of Medicine, Tokyo, Japan
| | - Ryosuke Tsuruta
- Advanced Medical Emergency & Critical Care Center, Yamaguchi University Hospital, Ube, Japan
| | - Taka-Aki Nakada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Hiroki Iriyama
- Department of General Medicine, Juntendo University, Tokyo, Japan
| | - Toshio Naito
- Department of General Medicine, Juntendo University, Tokyo, Japan
| | - Satoshi Gando
- Division of Acute and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan.,Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
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Umemura Y, Ogura H, Takuma K, Fujishima S, Abe T, Kushimoto S, Hifumi T, Hagiwara A, Shiraishi A, Otomo Y, Saitoh D, Mayumi T, Yamakawa K, Shiino Y, Nakada TA, Tarui T, Okamoto K, Kotani J, Sakamoto Y, Sasaki J, Shiraishi SI, Tsuruta R, Masuno T, Takeyama N, Yamashita N, Ikeda H, Ueyama M, Gando S. Current spectrum of causative pathogens in sepsis: A prospective nationwide cohort study in Japan. Int J Infect Dis 2020; 103:343-351. [PMID: 33221519 DOI: 10.1016/j.ijid.2020.11.168] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 11/10/2020] [Accepted: 11/15/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND There is no one-size-fits-all empiric antimicrobial therapy for sepsis because the pathogens vary according to the site of infection and have changed over time. Therefore, updating knowledge on the spectrum of pathogens is necessary for the rapid administration of appropriate antimicrobials. OBJECTIVE The aim of this study was to elucidate the current spectrum of pathogens and its variation by site of infection in sepsis. METHODS This was a prospective nationwide cohort study of consecutive adult patients with sepsis in 59 intensive care units in Japan. The spectrum of pathogens was evaluated in all patients and in subgroups by site of infection. Regression analyses were conducted to evaluate the associations between the pathogens and mortality. RESULTS The study cohort comprised 1184 patients. The most common pathogen was Escherichia coli (21.5%), followed by Klebsiella pneumoniae (9.0%). However, the pattern varied widely by site of infection; for example, gram-positive bacteria were the dominant pathogen in bone/soft tissue infection (55.7%) and cardiovascular infection (52.6%), but were rarely identified in urinary tract infection (6.4%). In contrast, gram-negative bacteria were the predominant pathogens in abdominal infection (38.4%) and urinary tract infection (72.0%). The highest mortality of 47.5% was observed in patients infected with methicillin-resistant Staphylococcus aureus, which was significantly associated with an increased risk of death (odds ratio 1.88, 95% confidence interval 1.22-2.91). CONCLUSIONS This study revealed the current spectrum of pathogens and its variation based on the site of infection, which is essential for empiric antimicrobial therapy against sepsis.
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Affiliation(s)
- Yutaka Umemura
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan; Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan.
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan.
| | - Kiyotsugu Takuma
- Emergency and Critical Care Center, Kawasaki Municipal Kawasaki Hospital, Kawasaki, Japan.
| | - Seitato Fujishima
- Center for General Medicine Education, Keio University School of Medicine, Shinjuku City, Tokyo, Japan.
| | - Toshikazu Abe
- Department of Emergency and Critical Care Medicine, Tsukuba Memorial Hospital, Tsukuba, Japan; Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan.
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Chuo City, Tokyo, Japan.
| | - Akiyoshi Hagiwara
- Center Hospital of the National Center for Global Health and Medicine, Shinjuku City, Tokyo, Japan.
| | - Atsushi Shiraishi
- Emergency and Trauma Center, Kameda Medical Center, Kamogawa, Chiba, Japan.
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Center, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan.
| | - Daizoh Saitoh
- Division of Traumatology, Research Institute, National Defense Medical College, Tokorozawa, Saitama, Japan.
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan.
| | - Kazuma Yamakawa
- Department of Emergency Medicine, Osaka Medical College, Osaka, Japan.
| | - Yasukazu Shiino
- Department of Acute Medicine, Kawasaki Medical School, Kurashiki, Okayama, Japan.
| | - Taka-Aki Nakada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan.
| | - Takehiko Tarui
- Department of Trauma and Critical Care Medicine, Kyorin University School of Medicine, Mitaka, Tokyo, Japan.
| | - Kohji Okamoto
- Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital, Kitakyushu, Fukuoka, Japan.
| | - Joji Kotani
- Division of Disaster and Emergency Medicine, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan.
| | - Yuichiro Sakamoto
- Emergency and Critical Care Medicine, Saga University Hospital, Nabeshima, Saga, Japan.
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Shinjuku City, Tokyo, Japan.
| | - Shin-Ichiro Shiraishi
- Department of Emergency and Critical Care Medicine, Aizu Chuo Hospital, Aizuwakamatsu, Fukushima, Japan.
| | - Ryosuke Tsuruta
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Ube, Yamaguchi, Japan.
| | - Tomohiko Masuno
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Bunkyo City, Tokyo, Japan.
| | - Naoshi Takeyama
- Advanced Critical Care Center, Aichi Medical University Hospital, Nagakute, Aichi, Japan.
| | - Norio Yamashita
- Advanced Emergency Medical Service Center, Kurume University Hospital, Kurume, Fukuoka, Japan.
| | - Hiroto Ikeda
- Department of Emergency Medicine, Teikyo University School of Medicine, Itabashi, Tokyo, Japan.
| | - Masashi Ueyama
- Department of Trauma, Critical Care Medicine, and Burn Center, Japan Community Healthcare Organization, Chukyo Hospital, Nagoya, Aichi, Japan; Community Healthcare Organization, Chukyo Hospital, Nagoya, Aichi, Japan.
| | - Satoshi Gando
- Department of Anesthesiology and Critical Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan; Department of Acute and Critical Care Medicine, Sapporo Tokushukai Hospital, Higashi, Sapporo, Hokkaido, Japan.
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25
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Sawamura T, Norisue Y, Mima H, Ueta I, Shigemitsu H, Ohno M, Maki J, Ito K, Uemura S, Uesawa H, Gando S, Fujino Y, Nishida O. Withholding and withdrawing of the treatment for major surge in coronavirus disease 2019 (COVID-19) pandemic, from the viewpoint of healthcare resource rationing. ACTA ACUST UNITED AC 2020. [DOI: 10.3918/jsicm.27_509] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Tadashi Sawamura
- Clinical Ethics Committee, Japanese Society of Intensive Care Medicine
| | - Yasuhiro Norisue
- Clinical Ethics Committee, Japanese Society of Intensive Care Medicine
| | - Hiroyuki Mima
- Clinical Ethics Committee, Japanese Society of Intensive Care Medicine
| | - Ikuya Ueta
- Clinical Ethics Committee, Japanese Society of Intensive Care Medicine
| | | | - Mika Ohno
- Clinical Ethics Committee, Japanese Society of Intensive Care Medicine
| | - Jun Maki
- Clinical Ethics Committee, Japanese Society of Intensive Care Medicine
| | - Kaori Ito
- Clinical Ethics Committee, Japanese Society of Intensive Care Medicine
| | - Sakura Uemura
- Clinical Ethics Committee, Japanese Society of Intensive Care Medicine
| | - Hiromi Uesawa
- Clinical Ethics Committee, Japanese Society of Intensive Care Medicine
| | - Satoshi Gando
- Adviser, Clinical Ethics Committee, Japanese Society of Intensive Care Medicine
| | - Yuji Fujino
- Clinical Ethics Committee, Japanese Society of Intensive Care Medicine
| | - Osamu Nishida
- President, Japanese Society of Intensive Care Medicine
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26
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Gando S, Shiraishi A, Wada T, Yamakawa K, Fujishima S, Saitoh D, Kushimoto S, Ogura H, Abe T, Otomo Y. A multicenter prospective validation study on disseminated intravascular coagulation in trauma-induced coagulopathy. J Thromb Haemost 2020; 18:2232-2244. [PMID: 32480432 DOI: 10.1111/jth.14931] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 05/12/2020] [Accepted: 05/18/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Trauma-induced coagulopathy (TIC) may progress to disseminated intravascular coagulation (DIC) due to dysregulated inflammatory and coagulofibrinolytic responses to trauma. OBJECTIVES We explored how DIC and TIC elicit the same coagulofibrinolytic changes which lead to massive transfusion. METHODS Severely injured trauma patients with an injury severity score ≥ 16 were prospectively included. Platelet counts, global markers of coagulation and fibrinolysis and specific markers of thrombin and plasmin generation, anticoagulation, endothelial injury, and inhibition of fibrinolysis were measured at presentation to the emergency department (0 hour) and 3 hour after arrival. The patients were subdivided into those with and without DIC and those with and without TIC using the 0-hour data. Time courses of specific markers and the frequency of massive transfusion were evaluated. The association of various variables with DIC development was also confirmed. RESULTS Two hundred and seventy-six patients were eligible for the analyses. The severity of injury (odds ratio; 1.038, P = .022) and thrombin generation (odds ratio; 1.014, P = .024) were associated with the development of DIC. Both DIC and TIC patients showed increased thrombin generation, insufficient anticoagulation controls, endothelial injury and increased fibrinolysis followed by elevated plasminogen activator inhibitor-1 levels at 0 and 3 hours. The frequency of massive transfusion was higher in both DIC (33.6% vs 7.9%, P < .001) and TIC (50.0% vs 13.3%, P < .001) patients than in those without DIC or TIC, respectively. CONCLUSIONS Disseminated intravascular coagulation and TIC evoked the same coagulofibrinolytic responses in severely injured trauma patients immediately after trauma and needed massive transfusion.
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Affiliation(s)
- Satoshi Gando
- Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | | | - Takeshi Wada
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
| | - Seitaro Fujishima
- Center for General Medicine Education, Keio University School of Medicine, Tokyo, Japan
| | - Daizoh Saitoh
- Division of Traumatology, Research Institute, National Defense Medical College, Tokorozawa, Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Toshikazu Abe
- Department of General Medicine, Juntendo University, Tokyo, Japan
- Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Center, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan
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27
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Squizzato A, Gallo A, Levi M, Iba T, Levy JH, Erez O, Ten Cate H, Solh Z, Gando S, Vicente V, Di Nisio M. Underlying disorders of disseminated intravascular coagulation: Communication from the ISTH SSC Subcommittees on Disseminated Intravascular Coagulation and Perioperative and Critical Care Thrombosis and Hemostasis. J Thromb Haemost 2020; 18:2400-2407. [PMID: 32881338 DOI: 10.1111/jth.14946] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 05/01/2020] [Accepted: 05/28/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND Disseminated intravascular coagulation (DIC), a systemic activation of coagulation, presents with multiple clinical and laboratory manifestations. In this International Society on Thrombosis and Haemostasis (ISTH) communication, we examined the importance of identifying the underlying disorder causing DIC to help physicians in the diagnosis and management of this common and severe condition. METHODS Eight DIC experts participated in a three-step consensus process that searched for published guidelines and diagnostic scores on DIC to create a preliminary list of DIC underlying disorders from those reported in the literature Overall, 13 papers were identified, including three guidelines, one harmonization paper by the ISTH, one ISTH recommendation paper on cancer-associated DIC, five general diagnostic scores, two scores specific for pregnancy, and one specific for children. We then assessed the strength of the evidence on the association between the disease and DIC as many postulated DIC-associated disorders are rare. KEY RESULTS Eight main subgroups - 'severe infection', 'solid tumour', 'haematological neoplasia', 'pregnancy complication', 'vascular disease', 'newborn-complication', 'tissue damage due to internal or external insult', and 'chemical and biological agent' - and a detailed list of specific causes of DIC were provided. CONCLUSIONS & INFERENCES Our results suggest more data are needed to determine the association between DIC and specific diseases such as malignant lymphoma, colorectal cancer, or vasculitis, for which the evidence remains limited. When a patient develops a coagulopathy consistent with DIC, the first step is to immediately search for an underlying disorder, including specific causes that are rarely associated with DIC and to consider that patients may have more than one cause of DIC to identify the principal precipitating disorder to prioritize treatment.
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Affiliation(s)
- Alessandro Squizzato
- Department of Medicine and Surgery, Research Center on Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, Varese and Como, Italy
| | - Andrea Gallo
- Department of Medicine and Surgery, Research Center on Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, Varese and Como, Italy
| | - Marcel Levi
- Department of Medicine, University College London Hospitals NHS Foundation Trust and Cardiometabolic Programme-NIHR UCLH/UCL BRC, London, UK
| | - Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Jerrold H Levy
- Departments of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Offer Erez
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, Soroka University Medical Center, Ben Gurion University of the Negev, Be'er Sheva, Israel
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, MI, USA
| | - Hugo Ten Cate
- Laboratory for Clinical Thrombosis and Hemostasis, Department of Internal Medicine, Cardiovascular Research Institute, Maastricht University Medical Center, Maastricht, Netherlands
| | - Ziad Solh
- Transfusion Medicine Section, Department of Pathology & Laboratory Medicine (PaLM), Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Satoshi Gando
- Acute and Critical Care Center, Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
| | - Vicente Vicente
- Department of Hematology and Clinical Oncology, Hospital General Universitario Morales Meseguer, Instituto Murciano de Investigación Biosanitaria, University of Murcia, Murcia, Spain
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences, University G. D'Annunzio, Chieti-Pescara, Italy
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28
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Thachil J, Tang N, Gando S, Falanga A, Levi M, Clark C, Iba T, Cattaneo M. Type and dose of heparin in Covid-19: Reply. J Thromb Haemost 2020; 18:2063-2064. [PMID: 32329221 PMCID: PMC9770813 DOI: 10.1111/jth.14870] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 04/17/2020] [Indexed: 12/25/2022]
Affiliation(s)
- Jecko Thachil
- Department of Haematology, Manchester University Hospitals, Manchester, UK
| | - Ning Tang
- Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Satoshi Gando
- Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
| | - Anna Falanga
- Depatment of Medicine and Surgery, University of Milan Bicocca, Hospital Papa Giovanni, XXIII, Bergamo, Italy
| | - Marcel Levi
- Department of Medicine and Cardio-metabolic Programme-NIHR UCLH/UCL BRC, University College London Hospitals NHS Foundation Trust, London, UK
| | - Cary Clark
- Director of Programs and Education, International Society on Thrombosis and Haemostasis, Carrboro, UK
| | - Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Marco Cattaneo
- ASST Santi Paolo e Carlo, Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milan, Italy
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Thachil J, Tang N, Gando S, Falanga A, Levi M, Clark C, Iba T. Laboratory haemostasis monitoring in COVID-19. J Thromb Haemost 2020; 18:2058-2060. [PMID: 32324960 PMCID: PMC7264510 DOI: 10.1111/jth.14866] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 04/17/2020] [Indexed: 01/17/2023]
Affiliation(s)
- Jecko Thachil
- Department of Haematology, Manchester University Hospitals, Manchester, UK
| | - Ning Tang
- Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Satoshi Gando
- Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
| | - Anna Falanga
- Department of Medicine and Surgery, University of Milan Bicocca, Hospital Papa Giovanni, XXIII, Bergamo, Italy
| | - Marcel Levi
- Department of Medicine and Cardio-metabolic Programme-NIHR UCLH/UCL BRC, University College London Hospitals NHS Foundation Trust, London, UK
| | - Cary Clark
- Director of Programs and Education, International Society on Thrombosis and Haemostasis, Carrboro, UK
| | - Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
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Thachil J, Tang N, Gando S, Falanga A, Cattaneo M, Levi M, Clark C, Iba T. DOACs and "newer" hemophilia therapies in COVID-19: Reply. J Thromb Haemost 2020; 18:1795-1796. [PMID: 32282993 PMCID: PMC9770941 DOI: 10.1111/jth.14841] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 04/08/2020] [Indexed: 12/25/2022]
Affiliation(s)
- Jecko Thachil
- Department of Haematology, Manchester University Hospitals, Manchester, UK
| | - Ning Tang
- Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Satoshi Gando
- Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
| | - Anna Falanga
- Department of Transfusion Medicine and Hematology, Hospital Papa Giovanni, XXIII, Bergamo, Italy
- University of Milan Bicocca, Bergamo, Italy
| | - Marco Cattaneo
- ASST Santi Paolo e Carlo, Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milan, Italy
| | - Marcel Levi
- Department of Medicine and Cardio-metabolic Programme-NIHR UCLH/UCL BRC, University College London Hospitals NHS Foundation Trust, London, UK
| | - Cary Clark
- Director of Programs and Education, International Society on Thrombosis and Haemostasis, Carrboro, North Carolina
| | - Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
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31
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Abe T, Yamakawa K, Ogura H, Kushimoto S, Saitoh D, Fujishima S, Otomo Y, Kotani J, Umemura Y, Sakamoto Y, Sasaki J, Shiino Y, Takeyama N, Tarui T, Shiraishi SI, Tsuruta R, Nakada TA, Hifumi T, Hagiwara A, Ueyama M, Yamashita N, Masuno T, Ikeda H, Komori A, Iriyama H, Gando S. Epidemiology of sepsis and septic shock in intensive care units between sepsis-2 and sepsis-3 populations: sepsis prognostication in intensive care unit and emergency room (SPICE-ICU). J Intensive Care 2020; 8:44. [PMID: 32612839 PMCID: PMC7324770 DOI: 10.1186/s40560-020-00465-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 06/23/2020] [Indexed: 12/29/2022] Open
Abstract
Background Diagnosing sepsis remains difficult because it is not a single disease but a syndrome with various pathogen- and host factor-associated symptoms. Sepsis-3 was established to improve risk stratification among patients with infection based on organ failures, but it has been still controversial compared with previous definitions. Therefore, we aimed to describe characteristics of patients who met sepsis-2 (severe sepsis) and sepsis-3 definitions. Methods This was a multicenter, prospective cohort study conducted by 22 intensive care units (ICUs) in Japan. Adult patients (≥ 16 years) with newly suspected infection from December 2017 to May 2018 were included. Those without infection at final diagnosis were excluded. Patient’s characteristics and outcomes were described according to whether they met each definition or not. Results In total, 618 patients with suspected infection were admitted to 22 ICUs during the study, of whom 530 (85.8%) met the sepsis-2 definition and 569 (92.1%) met the sepsis-3 definition. The two groups comprised different individuals, and 501 (81.1%) patients met both definitions. In-hospital mortality of study population was 19.1%. In-hospital mortality among patients with sepsis-2 and sepsis-3 patients was comparable (21.7% and 19.8%, respectively). Patients exclusively identified with sepsis-2 or sepsis-3 had a lower mortality (17.2% vs. 4.4%, respectively). No patients died if they did not meet any definitions. Patients who met sepsis-3 shock definition had higher in-hospital mortality than those who met sepsis-2 shock definition. Conclusions Most patients with infection admitted to ICU meet sepsis-2 and sepsis-3 criteria. However, in-hospital mortality did not occur if patients did not meet any criteria. Better criteria might be developed by better selection and combination of elements in both definitions. Trial registration UMIN000027452
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Affiliation(s)
- Toshikazu Abe
- Department of Health Services Research, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8577 Japan.,Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan.,Department of Emergency and Critical Care Medicine, Tsukuba Memorial Hospital, Tsukuba, Japan
| | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Daizoh Saitoh
- Division of Traumatology, Research Institute, National Defense Medical College, Tokorozawa, Japan
| | - Seitaro Fujishima
- Center for General Medicine Education, Keio University School of Medicine, Tokyo, Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Center, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | - Joji Kotani
- Division of Disaster and Emergency Medicine, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yutaka Umemura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yuichiro Sakamoto
- Emergency and Critical Care Medicine, Saga University Hospital, Saga, Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yasukazu Shiino
- Department of Acute Medicine, Kawasaki Medical School, Kurashiki, Japan
| | - Naoshi Takeyama
- Advanced Critical Care Center, Aichi Medical University Hospital, Nagakute, Japan
| | - Takehiko Tarui
- Department of Trauma and Critical Care Medicine, Kyorin University School of Medicine, Tokyo, Japan
| | - Shin-Ichiro Shiraishi
- Department of Emergency and Critical Care Medicine, Aizu Chuo Hospital, Aizuwakamatsu, Japan
| | - Ryosuke Tsuruta
- Advanced Medical Emergency & Critical Care Center, Yamaguchi University Hospital, Ube, Japan
| | - Taka-Aki Nakada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Akiyoshi Hagiwara
- Department of Emergency Medicine, Niizashiki Chuo General Hospital, Niizashiki, Japan
| | - Masashi Ueyama
- Department of Trauma, Critical Care Medicine, and Burn Center, Japan Community Healthcare Organization, Chukyo Hospital, Nagoya, Japan
| | - Norio Yamashita
- Advanced Emergency Medical Service Center, Kurume University Hospital, Kurume, Japan
| | - Tomohiko Masuno
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Hiroto Ikeda
- Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Akira Komori
- Department of General Medicine, Juntendo University, Tokyo, Japan
| | - Hiroki Iriyama
- Department of General Medicine, Juntendo University, Tokyo, Japan
| | - Satoshi Gando
- Division of Acute and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan.,Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
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Shimazui T, Nakada TA, Walley KR, Oshima T, Abe T, Ogura H, Shiraishi A, Kushimoto S, Saitoh D, Fujishima S, Mayumi T, Shiino Y, Tarui T, Hifumi T, Otomo Y, Okamoto K, Umemura Y, Kotani J, Sakamoto Y, Sasaki J, Shiraishi SI, Takuma K, Tsuruta R, Hagiwara A, Yamakawa K, Masuno T, Takeyama N, Yamashita N, Ikeda H, Ueyama M, Fujimi S, Gando S. Significance of body temperature in elderly patients with sepsis. Crit Care 2020; 24:387. [PMID: 32605659 PMCID: PMC7329464 DOI: 10.1186/s13054-020-02976-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 05/12/2020] [Indexed: 01/05/2023]
Abstract
Background Elderly patients have a blunted host response, which may influence vital signs and clinical outcomes of sepsis. This study was aimed to investigate whether the associations between the vital signs and mortality are different in elderly and non-elderly patients with sepsis. Methods This was a retrospective observational study. A Japanese multicenter sepsis cohort (FORECAST, n = 1148) was used for the discovery analyses. Significant discovery results were tested for replication using two validation cohorts of sepsis (JAAMSR, Japan, n = 624; SPH, Canada, n = 1004). Patients were categorized into elderly and non-elderly groups (age ≥ 75 or < 75 years). We tested for association between vital signs (body temperature [BT], heart rate, mean arterial pressure, systolic blood pressure, and respiratory rate) and 90-day in-hospital mortality (primary outcome). Results In the discovery cohort, non-elderly patients with BT < 36.0 °C had significantly increased 90-day mortality (P = 0.025, adjusted hazard ratio 1.70, 95% CI 1.07–2.71). In the validation cohorts, non-elderly patients with BT < 36.0 °C had significantly increased mortality (JAAMSR, P = 0.0024, adjusted hazard ratio 2.05, 95% CI 1.29–3.26; SPH, P = 0.029, adjusted hazard ratio 1.36, 95% CI 1.03–1.80). These differences were not observed in elderly patients in the three cohorts. Associations between the other four vital signs and mortality were not different in elderly and non-elderly patients. The interaction of age and hypothermia/fever was significant (P < 0.05). Conclusions In septic patients, we found mortality in non-elderly sepsis patients was increased with hypothermia and decreased with fever. However, mortality in elderly patients was not associated with BT. These results illuminate the difference in the inflammatory response of the elderly compared to non-elderly sepsis patients.
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Affiliation(s)
- Takashi Shimazui
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo, Chiba, 260-8677, Japan
| | - Taka-Aki Nakada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo, Chiba, 260-8677, Japan.
| | - Keith R Walley
- Centre for Heart Lung Innovation, University of British Columbia, Vancouver, Canada
| | - Taku Oshima
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo, Chiba, 260-8677, Japan
| | - Toshikazu Abe
- Department of General Medicine, Juntendo University, Tokyo, Japan.,Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | | | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Daizoh Saitoh
- Division of Traumatology, Research Institute, National Defense Medical College, Tokorozawa, Japan
| | - Seitaro Fujishima
- Center for General Medicine Education, Keio University School of Medicine, Tokyo, Japan
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Yasukazu Shiino
- Department of Acute Medicine, Kawasaki Medical School, Kurashiki, Japan
| | - Takehiko Tarui
- Department of Trauma and Critical Care Medicine, Kyorin University School of Medicine, Mitaka, Japan
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Center, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kohji Okamoto
- Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital, Kitakyushu, Japan
| | - Yutaka Umemura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Joji Kotani
- Division of Disaster and Emergency Medicine, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yuichiro Sakamoto
- Emergency and Critical Care Medicine, Saga University Hospital, Saga, Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shin-Ichiro Shiraishi
- Department of Emergency and Critical Care Medicine, Aizu Chuo Hospital, Aizuwakamatsu, Japan
| | - Kiyotsugu Takuma
- Emergency & Critical Care Center, Kawasaki Municipal Kawasaki Hospital, Kawasaki, Japan
| | - Ryosuke Tsuruta
- Advanced Medical Emergency & Critical Care Center, Yamaguchi University Hospital, Ube, Japan
| | - Akiyoshi Hagiwara
- Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan
| | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
| | - Tomohiko Masuno
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Naoshi Takeyama
- Advanced Critical Care Center, Aichi Medical University Hospital, Nagakute, Japan
| | - Norio Yamashita
- Advanced Emergency Medical Service Center, Kurume University Hospital, Kurume, Japan
| | - Hiroto Ikeda
- Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Masashi Ueyama
- Department of Trauma, Critical Care Medicine, and Burn Center, Japan Community Healthcare Organization, Chukyo Hospital, Nagoya, Japan
| | - Satoshi Fujimi
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
| | - Satoshi Gando
- Division of Acute and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan.,Acute and Critical Care Center, Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
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Hifumi T, Fujishima S, Ubukata K, Hagiwara A, Abe T, Ogura H, Shiraishi A, Kushimoto S, Saitoh D, Mayumi T, Ikeda H, Ueyama M, Otomo Y, Okamoto K, Umemura Y, Kotani J, Sakamoto Y, Sasaki J, Shiino Y, Shiraishi SI, Takuma K, Tarui T, Tsuruta R, Nakada TA, Yamakawa K, Masuno T, Takeyama N, Yamashita N, Fujimi S, Gando S. Clinical characteristics of patients with severe sepsis and septic shock in relation to bacterial virulence of beta-hemolytic Streptococcus and Streptococcus pneumoniae. Acute Med Surg 2020; 7:e513. [PMID: 32489668 PMCID: PMC7262430 DOI: 10.1002/ams2.513] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 03/16/2020] [Accepted: 04/12/2020] [Indexed: 12/29/2022] Open
Abstract
Aim Combined detailed analysis of patient characteristics and treatment as well as bacterial virulence factors, which all play a central role in the cause of infections leading to severe illness, has not been reported. We aimed to describe the patient characteristics (Charlson comorbidity index [CCI]), treatment (3‐h bundle), and outcomes in relation to bacterial virulence of Streptococcus pneumoniae and beta‐hemolytic Streptococcus (BHS). Methods This sepsis primary study is part of the larger Focused Outcomes Research in Emergency Care in Acute Respiratory Distress Syndrome, Sepsis and Trauma (FORECAST) study, a multicenter, prospective cohort study. We included patients diagnosed with S. pneumoniae and BHS sepsis and examined virulence, defining the high‐virulence factor as follows: S. pneumoniae serotype 3, 31, 11A, 35F, and 17F; Streptococcus pyogenes, emm 1; Streptococcus agalactiae, III; and Streptococcus dysgalactiae ssp. equisimilis, emm typing pattern stG 6792. Included patients were divided into high and normal categories based on the virulence factor. Results Of 1,184 sepsis patients enrolled in the Japanese Association for Acute Medicine’s FORECAST study, 62 were included in the current study (29 cases with S. pneumoniae sepsis and 33 with BHS). The CCI and completion of a 3‐h bundle did not differ between normal and high virulence groups. Risk of 28‐day mortality was significantly higher for high‐virulence compared to normal‐virulence when adjusted for CCI and completion of a 3‐h bundle (Cox proportional hazards regression analysis, hazard ratio 3.848; 95% confidence interval, 1.108–13.370; P = 0.034). Conclusion The risk of 28‐day mortality was significantly higher for patients with high‐virulence compared to normal‐virulence bacteria.
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Affiliation(s)
- Toru Hifumi
- Department of Emergency and Critical Care Medicine St. Luke's International Hospital Emergency Medical Center Tokyo Japan
| | - Seitaro Fujishima
- Center for General Medicine Education School of Medicine Keio University Tokyo Japan
| | - Kimiko Ubukata
- Center for General Medicine Education School of Medicine Keio University Tokyo Japan
| | - Akiyoshi Hagiwara
- Emergency Medicine Center Hospital of the National Center for Global Health and Medicine Tokyo Japan
| | - Toshikazu Abe
- Department of General Medicine Juntendo University Tokyo Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine Osaka University Graduate School of Medicine Suita Japan
| | | | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine Tohoku University Graduate School of Medicine Sendai Japan
| | - Daizoh Saitoh
- Division of Traumatology Research Institute National Defense Medical College Saitama Japan
| | - Toshihiko Mayumi
- Department of Emergency Medicine School of Medicine University of Occupational and Environmental Health Kitakyushu Japan
| | - Hiroto Ikeda
- Department of Emergency Medicine Teikyo University School of Medicine Tokyo Japan
| | - Masashi Ueyama
- Department of Trauma Critical Care Medicine, and Burn Center Japan Community Healthcare Organization, Chukyo Hospital Nagoya Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Medical Center Medical Hospital Tokyo Medical and Dental University Tokyo Japan
| | - Kohji Okamoto
- Department of Surgery Center for Gastroenterology and Liver Disease Kitakyushu City Yahata Hospital Kitakyushu Japan
| | - Yutaka Umemura
- Department of Traumatology and Acute Critical Medicine Osaka University Graduate School of Medicine Suita Japan
| | - Joji Kotani
- Department of Emergency, Disaster and Critical Care Medicine Hyogo College of Medicine Nishinomiya Japan
| | - Yuichiro Sakamoto
- Emergency and Critical Care Medicine Saga University Hospital Saga Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine Keio University School of Medicine Tokyo Japan
| | - Yasukazu Shiino
- Department of Acute Medicine Kawasaki Medical School Kurashiki Japan
| | - Shin-Ichiro Shiraishi
- Department of Emergency and Critical Care Medicine Aizu Chuo Hospital Fukushima Japan
| | - Kiyotsugu Takuma
- Emergency and Critical Care Center Kawasaki Municipal Kawasaki Hospital Kawasaki Japan
| | - Takehiko Tarui
- Department of Trauma and Critical Care Medicine Kyorin University School of Medicine Mitaka Japan
| | - Ryosuke Tsuruta
- Advanced Medical Emergency and Critical Care Center Yamaguchi University Hospital Ube Japan
| | - Taka-Aki Nakada
- Department of Emergency and Critical Care Medicine Chiba University Graduate School of Medicine Chiba Japan
| | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care Osaka General Medical Center Osaka Japan
| | - Tomohiko Masuno
- Department of Emergency and Critical Care Medicine Nippon Medical School Tokyo Japan
| | - Naoshi Takeyama
- Advanced Critical Care Center Aichi Medical University Hospital Nagakute Japan
| | - Norio Yamashita
- Advanced Emergency Medical Service Center Kurume University Hospital Kurume Japan
| | - Satoshi Fujimi
- Division of Trauma and Surgical Critical Care Osaka General Medical Center Osaka Japan
| | - Satoshi Gando
- Division of Acute and Critical Care Medicine Hokkaido University Graduate School of Medicine Sapporo Japan
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Gando S, Shiraishi A, Abe T, Kushimoto S, Mayumi T, Fujishima S, Hagiwara A, Shiino Y, Shiraishi SI, Hifumi T, Otomo Y, Okamoto K, Sasaki J, Takuma K, Yamakawa K. The SIRS criteria have better performance for predicting infection than qSOFA scores in the emergency department. Sci Rep 2020; 10:8095. [PMID: 32415144 PMCID: PMC7228957 DOI: 10.1038/s41598-020-64314-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 04/14/2020] [Indexed: 01/03/2023] Open
Abstract
Systemic inflammatory response syndrome (SIRS) reportedly has a low performance for distinguishing infection from non-infection. We explored the distribution of the patients diagnosed by SIRS (SIRS patients) or a quick sequential organ failure assessment (qSOFA) (qSOFA patients) and confirmed the performance of the both for predicting ultimate infection after hospital admission. We retrospectively analyzed the data from a multicenter prospective study. When emergency physicians suspected infection, SIRS or the qSOFA were applied. The area under the receiver operating characteristic curves (AUC) was used to assess the performance of the SIRS and qSOFA for predicting established infection. A total of 1,045 patients were eligible for this study. The SIRS patients accounted for 91.6% of qSOFA patients and they showed a higher rate of final infection than that of non-SIRS patients irrespective of the qSOFA diagnosis. The AUCs for predicting infection with SIRS and a qSOFA were 0.647 and 0.582, respectively. The SIRS significantly predicted an ultimate infection (AUC, 0.675; p = 0.018) in patients who met the SIRS and qSOFA simultaneously. In conclusion, the SIRS patients included almost all qSOFA patients. SIRS showed a better performance for predicting infection for qSOFA in those who met both definitions.
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Affiliation(s)
- Satoshi Gando
- Division of Acute and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan.
| | - Atsushi Shiraishi
- Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
| | - Toshikazu Abe
- Emergency and Trauma Center, Kameda Medical Center, Kameda, Japan
| | - Shigeki Kushimoto
- Department of General Medicine, Juntendo University, Tokyo Japan; Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan
| | - Toshihiko Mayumi
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Seitaro Fujishima
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Fukuoka, Japan
| | - Akiyoshi Hagiwara
- Center for General Medicine Education, Keio University School of Medicine, Tokyo, Japan
| | - Yasukazu Shiino
- Center Hospital of the National Center for Global Health and Medicine, Tokyo Japan; Department of Emergency Medicine, Niizashiki Chuo General Hospital, Tokyo, Japan
| | | | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, Aizu Chuo Hospital, Aizu, Japan
| | - Yasuhiro Otomo
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Kohji Okamoto
- Trauma and Acute Critical Care Center, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | - Junichi Sasaki
- Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital, Yahata, Japan
| | - Kiyotsugu Takuma
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Kazuma Yamakawa
- Emergency & Critical Care Center, Kawasaki Municipal Kawasaki Hospital, Kawasaki, Japan
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Thachil J, Tang N, Gando S, Falanga A, Cattaneo M, Levi M, Clark C, Iba T. ISTH interim guidance on recognition and management of coagulopathy in COVID-19. J Thromb Haemost 2020; 18:1023-1026. [PMID: 32338827 PMCID: PMC9906133 DOI: 10.1111/jth.14810] [Citation(s) in RCA: 1258] [Impact Index Per Article: 314.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 03/21/2020] [Indexed: 01/08/2023]
Affiliation(s)
- Jecko Thachil
- Department of Haematology, Manchester University Hospitals, Manchester, UK
| | - Ning Tang
- Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Satoshi Gando
- Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
| | - Anna Falanga
- Department of Transfusion Medicine and Hematology, Hospital Papa Giovanni XXIII, Bergamo, Italy
- University of Milan Bicocca, Monza, Italy
| | - Marco Cattaneo
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, ASST Santi Paolo e Carlo, Milan, Italy
| | - Marcel Levi
- Department of Medicine and Cardio-metabolic Programme-NIHR UCLH/UCL BRC, University College London Hospitals NHS Foundation Trust, London, UK
| | - Cary Clark
- Director of Programs and Education, International Society on Thrombosis and Haemostasis, Carrboro, North Carolina
| | - Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
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Gando S, Fujishima S, Saitoh D, Shiraishi A, Yamakawa K, Kushimoto S, Ogura H, Abe T, Mayumi T, Sasaki J, Kotani J, Takeyama N, Tsuruta R, Takuma K, Yamashita N, Shiraishi SI, Ikeda H, Shiino Y, Tarui T, Nakada TA, Hifumi T, Otomo Y, Okamoto K, Sakamoto Y, Hagiwara A, Masuno T, Ueyama M, Fujimi S, Umemura Y. The significance of disseminated intravascular coagulation on multiple organ dysfunction during the early stage of acute respiratory distress syndrome. Thromb Res 2020; 191:15-21. [PMID: 32353745 DOI: 10.1016/j.thromres.2020.03.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 03/25/2020] [Accepted: 03/30/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Multiple organ dysfunction syndrome (MODS) is a predominant cause of death in acute respiratory distress syndrome (ARDS). Disseminated intravascular coagulation (DIC) is recognized as a syndrome that frequently develops MODS. To test the hypothesis that DIC scores are useful for predicting MODS development and that DIC is associated with MODS, we retrospectively analyzed the data of a prospective, multicenter study on ARDS. METHODS Patients who met the Berlin definition of ARDS were included. DIC scores as well as the disease severity and the development of MODS on the day of the diagnosis of ARDS (day 0) and day 3 were evaluated. The primary and secondary outcomes were the development of MODS and the hospital mortality. RESULTS In the 129 eligible patients, the prevalence of DIC was 45.7% (59/129). DIC patients were more seriously ill and exhibited a higher prevalence of MODS on days 0 and 3 than non-DIC patients. The DIC scores on day 0 detected the development of MODS with good area under the receiver operating characteristic curve (0.714, p<.001). DIC on day 0 was significantly associated with MODS on days 0 and 3 (odds ratio 1.53 and 1.34, respectively). Patients with persistent DIC from days 0 to 3 had higher rates of both MODS on day 3 (p=.035) and hospital mortality (p=.031) than the other patients. CONCLUSIONS DIC scores were able to predict MODS, and DIC was associated with MODS during the early stage of ARDS. Persistent DIC may also have role in this association.
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Affiliation(s)
- Satoshi Gando
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Japan; Department of Acute and Critical Care Medicine, Sapporo Tokushukai Hospital, Japan.
| | - Seitaro Fujishima
- Center for General Medicine Education, Keio University School of Medicine, Japan
| | - Daizoh Saitoh
- Division of Traumatology, Research Institute, National Defense Medical College, Japan
| | | | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Japan
| | - Toshikazu Abe
- Department of General Medicine, Juntendo University, Japan; Health Services Research and Development Center, University of Tsukuba, Japan
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Japan
| | - Joji Kotani
- Division of Disaster and Emergency Medicine, Department of Surgery Related, Kobe University Graduate School of Medicine, Japan
| | - Naoshi Takeyama
- Advanced Critical Care Center, Aichi Medical University Hospital, Japan
| | - Ryosuke Tsuruta
- Advanced Medical Emergency & Critical Care Center, Yamaguchi University Hospital, Japan
| | - Kiyotsugu Takuma
- Emergency & Critical Care Center, Kawasaki Municipal Hospital, Japan
| | - Norio Yamashita
- Department of Emergency & Critical Care Medicine, School of Medicine, Kurume University, Japan
| | | | - Hiroto Ikeda
- Department of Emergency Medicine, Trauma and Resuscitation Center, Teikyo University School of Medicine, Japan
| | - Yasukazu Shiino
- Department of Acute Medicine, Kawasaki Medical School, Japan
| | - Takehiko Tarui
- Department of Trauma and Critical Care Medicine, Kyorin University School of Medicine, Japan
| | - Taka-Aki Nakada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Japan
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Center, Medical Hospital, Tokyo Medical and Dental University, Japan
| | - Kohji Okamoto
- Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital, Japan
| | - Yuichiro Sakamoto
- Emergency and Critical Care Medicine, Saga University Hospital, Japan
| | - Akiyoshi Hagiwara
- Center Hospital of the National Center for Global Health and Medicine, Japan
| | - Tomohiko Masuno
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Japan
| | - Masashi Ueyama
- Community Healthcare Organization, Chukyo Hospital, Japan
| | - Satoshi Fujimi
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Japan
| | - Yutaka Umemura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Japan
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Kushimoto S, Abe T, Ogura H, Shiraishi A, Saitoh D, Fujishima S, Mayumi T, Hifumi T, Shiino Y, Nakada TA, Tarui T, Otomo Y, Okamoto K, Umemura Y, Kotani J, Sakamoto Y, Sasaki J, Shiraishi SI, Takuma K, Tsuruta R, Hagiwara A, Yamakawa K, Masuno T, Takeyama N, Yamashita N, Ikeda H, Ueyama M, Fujimi S, Gando S. Impact of blood glucose abnormalities on outcomes and disease severity in patients with severe sepsis: An analysis from a multicenter, prospective survey of severe sepsis. PLoS One 2020; 15:e0229919. [PMID: 32160234 PMCID: PMC7065801 DOI: 10.1371/journal.pone.0229919] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 02/17/2020] [Indexed: 12/29/2022] Open
Abstract
Background Dysglycemia is frequently observed in patients with sepsis. However, the relationship between dysglycemia and outcome is inconsistent. We evaluate the clinical characteristics, glycemic abnormalities, and the relationship between the initial glucose level and mortality in patients with sepsis. Methods This is a retrospective sub-analysis of a multicenter, prospective cohort study. Adult patients with severe sepsis (Sepsis-2) were divided into groups based on blood glucose categories (<70 (hypoglycemia), 70–139, 140–179, and ≥180 mg/dL), according to the admission values. In-hospital mortality and the relationship between pre-existing diabetes and septic shock were evaluated. Results Of 1158 patients, 69, 543, 233, and 313 patients were categorized as glucose levels <70, 70–139, 140–179, ≥180 mg/dL, respectively. Both the Acute Physiological and Chronic Health Evaluation II and Sequential Organ Failure Assessment (SOFA) scores on the day of enrollment were higher in the hypoglycemic patients than in those with 70–179 mg/dL. The hepatic SOFA scores were also higher in hypoglycemic patients. In-hospital mortality rates were higher in hypoglycemic patients than in those with 70–139 mg/dL (26/68, 38.2% vs 43/221, 19.5%). A significant relationship between mortality and hypoglycemia was demonstrated only in patients without known diabetes. Mortality in patients with both hypoglycemia and septic shock was 2.5-times higher than that in patients without hypoglycemia and septic shock. Conclusions Hypoglycemia may be related to increased severity and high mortality in patients with severe sepsis. These relationships were evident only in patients without known diabetes. Patients with both hypoglycemia and septic shock had an associated increased mortality rate.
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Affiliation(s)
- Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
- * E-mail:
| | - Toshikazu Abe
- Department of General Medicine, Juntendo University, Bunkyo, Japan
- Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | | | - Daizoh Saitoh
- Division of Traumatology, Research Institute, National Defense Medical College, Tokorozawa, Japan
| | - Seitaro Fujishima
- Center for General Medicine Education, Keio University School of Medicine, Shinjuku, Japan
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Chuo, Japan
| | - Yasukazu Shiino
- Department of Acute Medicine, Kawasaki Medical School, Kurashiki, Japan
| | - Taka-aki Nakada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chuo-ku, Japan
| | - Takehiko Tarui
- Department of Trauma and Critical Care Medicine, Kyorin University School of Medicine, Mitaka, Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Center, Medical Hospital, Tokyo Medical and Dental University, Bunkyō, Japan
| | - Kohji Okamoto
- Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital, Kitakyushu, Japan
| | - Yutaka Umemura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Joji Kotani
- Department of Disaster and Emergency Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yuichiro Sakamoto
- Emergency and Critical Care Medicine, Saga University Hospital, Saga, Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Shinjuku, Japan
| | - Shin-ichiro Shiraishi
- Department of Emergency and Critical Care Medicine, Aizu Chuo Hospital, Aizuwakamatsu, Japan
| | - Kiyotsugu Takuma
- Emergency & Critical Care Center, Kawasaki Municipal Kawasaki Hospital, Kawasaki, Japan
| | - Ryosuke Tsuruta
- Advanced Medical Emergency & Critical Care Center, Yamaguchi University Hospital, Ube, Japan
| | - Akiyoshi Hagiwara
- Center Hospital of the National Center for Global Health and Medicine, Shinjuku, Japan
| | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
| | - Tomohiko Masuno
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Bunkyo, Japan
| | - Naoshi Takeyama
- Advanced Critical Care Center, Aichi Medical University Hospital, Nagakute, Japan
| | - Norio Yamashita
- Advanced Emergency Medical Service Center Kurume University Hospital, Kurume, Japan
| | - Hiroto Ikeda
- Department of Emergency Medicine, Teikyo University School of Medicine, Itabashi, Japan
| | - Masashi Ueyama
- Department of Trauma, Critical Care Medicine, and Burn Center, Japan Community Healthcare Organization, Chukyo Hospital, Nagoya, Japan
| | - Satoshi Fujimi
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
| | - Satoshi Gando
- Division of Acute and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
- Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
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Moore HB, Gando S, Iba T, Kim PY, Yeh CH, Brohi K, Hunt BJ, Levy JH, Draxler DF, Stanworth S, Görlinger K, Neal MD, Schreiber MA, Barrett CD, Medcalf RL, Moore EE, Mutch NJ, Thachil J, Urano T, Thomas S, Scărlătescu E, Walsh M. Defining trauma-induced coagulopathy with respect to future implications for patient management: Communication from the SSC of the ISTH. J Thromb Haemost 2020; 18:740-747. [PMID: 32112533 DOI: 10.1111/jth.14690] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 11/12/2019] [Accepted: 11/25/2019] [Indexed: 12/22/2022]
Affiliation(s)
- Hunter B Moore
- Department of Surgery, University of Colorado, Denver, CO, USA
| | - Satoshi Gando
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
- Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
| | - Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Paul Y Kim
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | - Calvin H Yeh
- Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, ON,, Canada
| | - Karim Brohi
- Queen Mary University of London, London, UK
- Centre for Trauma Sciences, London, UK
| | | | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Dominik F Draxler
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria,, Australia
| | - Simon Stanworth
- Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Radcliffe Department of Medicine, NIHR Oxford Biomedical Research Centre,, University of Oxford,, Oxford,, UK
| | - Klaus Görlinger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, Essen, Germany
- TEM Innovations GmbH, Munich, Germany
| | - Matthew D Neal
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Martin A Schreiber
- Department of Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Christopher D Barrett
- Koch Institute for Integrative Cancer Research, Center for Precision Cancer Medicine, Massachusetts Institute of Technology, Cambridge, MA, USA
- Division of Acute Care Surgery and Critical Care, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Robert L Medcalf
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria,, Australia
| | - Ernest E Moore
- Ernest E. Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, USA
| | - Nicola J Mutch
- Aberdeen Cardiovascular and Diabetes Centre, School of Medicine, Medical Sciences and Nutrition, Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK
| | - Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, UK
| | - Tetsumei Urano
- Department of Medical Physiology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Scott Thomas
- Beacon Medical Group Trauma and Surgical Research Services, South Bend, IN, USA
| | - Ecaterina Scărlătescu
- Department of Anaesthesia and Intensive Care, Fundeni Clinical Institute, Bucharest, Romania
| | - Mark Walsh
- Beacon Medical Group Trauma and Surgical Research Services, South Bend, IN, USA
- Departments of Emergency and Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, USA
- Indiana University School of Medicine, South Bend Campus, South Bend, IN, USA
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Abe T, Suzuki T, Kushimoto S, Fujishima S, Sugiyama T, Iwagami M, Ogura H, Shiraishi A, Saitoh D, Mayumi T, Iriyama H, Komori A, Nakada TA, Shiino Y, Tarui T, Hifumi T, Otomo Y, Okamoto K, Umemura Y, Kotani J, Sakamoto Y, Sasaki J, Shiraishi SI, Tsuruta R, Hagiwara A, Yamakawa K, Takuma K, Masuno T, Takeyama N, Yamashita N, Ikeda H, Ueyama M, Gando S. History of diabetes may delay antibiotic administration in patients with severe sepsis presenting to emergency departments. Medicine (Baltimore) 2020; 99:e19446. [PMID: 32176076 PMCID: PMC7220469 DOI: 10.1097/md.0000000000019446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Clinical manifestations of sepsis differ between patients with and without diabetes mellitus (DM), and these differences could influence the clinical behaviors of medical staff. Therefore, we aimed to investigate whether pre-existing DM was associated with the time to antibiotics or sepsis care protocols.This was a retrospective cohort study.It conducted at 53 intensive care units (ICUs) in Japan.Consecutive adult patients with severe sepsis admitted directly to ICUs form emergency departments from January 2016 to March 2017 were included.The primary outcome was time to antibiotics.Of the 619 eligible patients, 142 had DM and 477 did not have DM. The median times (interquartile ranges) to antibiotics in patients with and without DM were 103 minutes (60-180 minutes) and 86 minutes (45-155 minutes), respectively (P = .05). There were no significant differences in the rates of compliance with sepsis protocols or with patient-centred outcomes such as in-hospital mortality. The mortality rates of patients with and without DM were 23.9% and 21.6%, respectively (P = .55). Comparing patients with and without DM, the gamma generalized linear model-adjusted relative difference indicated that patients with DM had a delay to starting antibiotics of 26.5% (95% confidence intervals (95%CI): 4.6-52.8, P = .02). The gamma generalized linear model-adjusted relative difference with multiple imputation for missing data of sequential organ failure assessment was 19.9% (95%CI: 1.0-42.3, P = .04). The linear regression model-adjusted beta coefficient indicated that patients with DM had a delay to starting antibiotics of 29.2 minutes (95%CI: 6.8-51.7, P = .01). Logistic regression modelling showed that pre-existing DM was not associated with in-hospital mortality (odds ratio, 1.26; 95%CI: 0.72-2.19, P = .42).Pre-existing DM was associated with delayed antibiotic administration among patients with severe sepsis or septic shock; however, patient-centred outcomes and compliance with sepsis care protocols were comparable.
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Affiliation(s)
- Toshikazu Abe
- Department of General Medicine, Juntendo University, Tokyo
- Health Services Research and Development Center, University of Tsukuba, Tsukuba
| | - Tomoharu Suzuki
- Department of General Medicine, Urasoe General Hospital, Urasoe
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai
| | - Seitaro Fujishima
- Center for General Medicine Education, Keio University School of Medicine
| | - Takehiro Sugiyama
- Health Services Research and Development Center, University of Tsukuba, Tsukuba
- Diabetes and Metabolism Information Center, Research Institute, National Center for Global Health and Medicine, Tokyo
| | - Masao Iwagami
- Health Services Research and Development Center, University of Tsukuba, Tsukuba
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka
| | | | - Daizoh Saitoh
- Division of Traumatology, Research Institute, National Defense Medical College, Tokorozawa
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu
| | - Hiroki Iriyama
- Department of General Medicine, Juntendo University, Tokyo
| | - Akira Komori
- Department of General Medicine, Juntendo University, Tokyo
| | - Taka-aki Nakada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba
| | - Yasukazu Shiino
- Department of Acute Medicine, Kawasaki Medical School, Kurashiki, Japan
| | - Takehiko Tarui
- Department of Trauma and Critical Care Medicine, Kyorin University School of Medicine
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Center, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kohji Okamoto
- Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital, Kitakyushu
| | - Yutaka Umemura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka
| | - Joji Kotani
- Division of Disaster and Emergency Medicine, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe
| | - Yuichiro Sakamoto
- Emergency and Critical Care Medicine, Saga University Hospital, Saga
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo
| | - Shin-ichiro Shiraishi
- Department of Emergency and Critical Care Medicine, Aizu Chuo Hospital, Aizuwakamatsu
| | - Ryosuke Tsuruta
- Advanced Medical Emergency & Critical Care Center, Yamaguchi University Hospital, Ube
| | | | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka
| | - Kiyotsugu Takuma
- Emergency & Critical Care Center, Kawasaki Municipal Kawasaki Hospital, Kawasaki
| | - Tomohiko Masuno
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo
| | - Naoshi Takeyama
- Advanced Critical Care Center, Aichi Medical University Hospital, Nagakute
| | - Norio Yamashita
- Advanced Emergency Medical Service Center, Kurume University Hospital, Kurume
| | - Hiroto Ikeda
- Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo
| | - Masashi Ueyama
- Department of Trauma, Critical Care Medicine, and Burn Center Community Healthcare Organization, Chukyo Hospital, Nagoya
| | - Satoshi Gando
- Division of Acute and Critical Care Medicine, Hokkaido University Graduate School of Medicine
- Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
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40
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Komori A, Abe T, Kushimoto S, Ogura H, Shiraishi A, Saitoh D, Fujishima S, Mayumi T, Naito T, Hifumi T, Shiino Y, Nakada TA, Tarui T, Otomo Y, Okamoto K, Umemura Y, Kotani J, Sakamoto Y, Sasaki J, Shiraishi SI, Takuma K, Tsuruta R, Hagiwara A, Yamakawa K, Masuno T, Takeyama N, Yamashita N, Ikeda H, Ueyama M, Fujimi S, Gando S. Characteristics and outcomes of bacteremia among ICU-admitted patients with severe sepsis. Sci Rep 2020; 10:2983. [PMID: 32076046 PMCID: PMC7031517 DOI: 10.1038/s41598-020-59830-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 02/03/2020] [Indexed: 12/12/2022] Open
Abstract
The clinical implications of bacteremia among septic patients remain unclear, although a vast amount of data have been accumulated on sepsis. We aimed to compare the clinical characteristics and outcomes of severe sepsis patients with and without bacteremia. This secondary analysis of a multicenter, prospective cohort study included 59 intensive care units (ICUs) in Japan between January 2016 and March 2017. The study cohort comprised 1,184 adults (aged ≥ 16 years) who were admitted to an ICU with severe sepsis and diagnosed according to the Sepsis-2 criteria. Of 1,167 patients included in the analysis, 636 (54.5%) had bacteremia. Those with bacteremia had significantly higher rates of septic shock (66.4% vs. 58.9%, p = 0.01) and higher sepsis severity scores, including the Acute Physiology and Chronic Health Evaluation (APACHE) II and the Sequential Organ Failure Assessment (SOFA). No significant difference in in-hospital mortality was seen between patients with and without bacteremia (25.6% vs. 21.0%, p = 0.08). In conclusion, half of severe sepsis patients in ICUs have bacteremia. Although patients with bacteremia had more severe state, between-group differences in patient-centered outcomes, such as in-hospital mortality, have not been fully elucidated.
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Affiliation(s)
- Akira Komori
- Department of General Medicine, Juntendo University, Tokyo, Japan
| | - Toshikazu Abe
- Department of General Medicine, Juntendo University, Tokyo, Japan. .,Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan. .,Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan.
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | | | - Daizoh Saitoh
- Division of Traumatology, Research Institute, National Defense Medical College, Tokorozawa, Japan
| | - Seitaro Fujishima
- Center for General Medicine Education, Keio University School of Medicine, Tokyo, Japan
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Toshio Naito
- Department of General Medicine, Juntendo University, Tokyo, Japan
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Yasukazu Shiino
- Department of Acute Medicine, Kawasaki Medical School, Kurashiki, Japan
| | - Taka-Aki Nakada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Takehiko Tarui
- Department of Trauma and Critical Care Medicine, Kyorin University School of Medicine, Mitaka, Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Center, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kohji Okamoto
- Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital, Kitakyushu, Japan
| | - Yutaka Umemura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Joji Kotani
- Department of Disaster and Emergency Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yuichiro Sakamoto
- Emergency and Critical Care Medicine, Saga University Hospital, Saga, Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shin-Ichiro Shiraishi
- Department of Emergency and Critical Care Medicine, Aizu Chuo Hospital, Aizuwakamatsu, Japan
| | - Kiyotsugu Takuma
- Emergency & Critical Care Center, Kawasaki Municipal Kawasaki Hospital, Kawasaki, Japan
| | - Ryosuke Tsuruta
- Advanced Medical Emergency & Critical Care Center, Yamaguchi University Hospital, Ube, Japan
| | - Akiyoshi Hagiwara
- Department of Emergency Medicine, Niizashiki Chuo General Hospital, Niiza, Japan
| | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
| | - Tomohiko Masuno
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Naoshi Takeyama
- Advanced Critical Care Center, Aichi Medical University Hospital, Nagakute, Japan
| | - Norio Yamashita
- Advanced Emergency Medical Service Center, Kurume University Hospital, Kurume, Japan
| | - Hiroto Ikeda
- Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Masashi Ueyama
- Department of Trauma, Critical Care Medicine, and Burn Center, Japan Community Healthcare Organization, Chukyo Hospital, Nagoya, Japan
| | - Satoshi Fujimi
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
| | - Satoshi Gando
- Division of Acute and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan.,Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
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Iriyama H, Abe T, Kushimoto S, Fujishima S, Ogura H, Shiraishi A, Saitoh D, Mayumi T, Naito T, Komori A, Hifumi T, Shiino Y, Nakada TA, Tarui T, Otomo Y, Okamoto K, Umemura Y, Kotani J, Sakamoto Y, Sasaki J, Shiraishi SI, Takuma K, Tsuruta R, Hagiwara A, Yamakawa K, Masuno T, Takeyama N, Yamashita N, Ikeda H, Ueyama M, Fujimi S, Gando S. Risk modifiers of acute respiratory distress syndrome in patients with non-pulmonary sepsis: a retrospective analysis of the FORECAST study. J Intensive Care 2020; 8:7. [PMID: 31938547 PMCID: PMC6954566 DOI: 10.1186/s40560-020-0426-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 01/01/2020] [Indexed: 11/10/2022] Open
Abstract
Background Predisposing conditions and risk modifiers instead of causes and risk factors have recently been used as alternatives to identify patients at a risk of acute respiratory distress syndrome (ARDS). However, data regarding risk modifiers among patients with non-pulmonary sepsis is rare. Methods We conducted a secondary analysis of the multicenter, prospective, Focused Outcomes Research in Emergency Care in Acute Respiratory Distress Syndrome, Sepsis and Trauma (FORECAST) cohort study that was conducted in 59 intensive care units (ICUs) in Japan during January 2016–March 2017. Adult patients with severe sepsis caused by non-pulmonary infection were included, and the primary outcome was having ARDS, defined as meeting the Berlin definition on the first or fourth day of screening. Multivariate logistic regression modeling was used to identify risk modifiers associated with ARDS, and odds ratios (ORs) and their 95% confidence intervals were reported. The following explanatory variables were then assessed: age, sex, admission source, body mass index, smoking status, congestive heart failure, chronic obstructive pulmonary disease, diabetes mellitus, steroid use, statin use, infection site, septic shock, and acute physiology and chronic health evaluation (APACHE) II score. Results After applying inclusion and exclusion criteria, 594 patients with non-pulmonary sepsis were enrolled, among whom 85 (14.3%) had ARDS. Septic shock was diagnosed in 80% of patients with ARDS and 66% of those without ARDS (p = 0.01). APACHE II scores were higher in patients with ARDS [26 (22–33)] than in those without ARDS [21 (16–28), p < 0.01]. In the multivariate logistic regression model, the following were independently associated with ARDS: ICU admission source [OR, 1.89 (1.06–3.40) for emergency department compared with hospital wards], smoking status [OR, 0.18 (0.06–0.59) for current smoking compared with never smoked], infection site [OR, 2.39 (1.04–5.40) for soft tissue infection compared with abdominal infection], and APACHE II score [OR, 1.08 (1.05–1.12) for higher compared with lower score]. Conclusions Soft tissue infection, ICU admission from an emergency department, and a higher APACHE II score appear to be the risk modifiers of ARDS in patients with non-pulmonary sepsis.
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Affiliation(s)
- Hiroki Iriyama
- 1Department of General Medicine, Juntendo University, 2-1-1 Hongo, 103 Bunkyo-ku, Tokyo, 113-0033 Japan
| | - Toshikazu Abe
- 1Department of General Medicine, Juntendo University, 2-1-1 Hongo, 103 Bunkyo-ku, Tokyo, 113-0033 Japan.,2Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan.,3Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Shigeki Kushimoto
- 4Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Seitaro Fujishima
- 5Center for General Medicine Education, Keio University School of Medicine, Tokyo, Japan
| | - Hiroshi Ogura
- 6Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Atsushi Shiraishi
- 7Emergency and Trauma Center, Kameda Medical Center, Kamogawa, Japan
| | - Daizoh Saitoh
- 8Division of Traumatology, Research Institute, National Defense Medical College, Tokyo, Japan
| | - Toshihiko Mayumi
- 9Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Toshio Naito
- 1Department of General Medicine, Juntendo University, 2-1-1 Hongo, 103 Bunkyo-ku, Tokyo, 113-0033 Japan
| | - Akira Komori
- 1Department of General Medicine, Juntendo University, 2-1-1 Hongo, 103 Bunkyo-ku, Tokyo, 113-0033 Japan
| | - Toru Hifumi
- 10Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Yasukazu Shiino
- 11Department of Acute Medicine, Kawasaki Medical School, Kurashiki, Japan
| | - Taka-Aki Nakada
- 12Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Takehiko Tarui
- 13Department of Trauma and Critical Care Medicine, Kyorin University School of Medicine, Mitaka, Japan
| | - Yasuhiro Otomo
- 14Trauma and Acute Critical Care Center, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kohji Okamoto
- Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital, Kitakyushu, Japan
| | - Yutaka Umemura
- 6Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Joji Kotani
- 16Department of Disaster and Emergency Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yuichiro Sakamoto
- 17Emergency and Critical Care Medicine, Saga University Hospital, Saga, Japan
| | - Junichi Sasaki
- 18Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shin-Ichiro Shiraishi
- Department of Emergency and Critical Care Medicine, Aizu Chuo Hospital, Aizuwakamatsu, Japan
| | - Kiyotsugu Takuma
- 20Emergency & Critical Care Center, Kawasaki Municipal Kawasaki Hospital, Kawasaki, Japan
| | - Ryosuke Tsuruta
- 21Advanced Medical Emergency & Critical Care Center, Yamaguchi University Hospital, Ube, Japan
| | - Akiyoshi Hagiwara
- Department of Emergency Medicine, Niizashiki Chuo General Hospital, Niiza, Japan
| | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
| | - Tomohiko Masuno
- 24Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Naoshi Takeyama
- 25Advanced Critical Care Center, Aichi Medical University Hospital, Nagakute, Japan
| | - Norio Yamashita
- 26Advanced Emergency Medical Service Center, Kurume University Hospital, Kurume, Japan
| | - Hiroto Ikeda
- 27Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Masashi Ueyama
- 28Department of Trauma, Critical Care Medicine, and Burn Center, Japan Community Healthcare Organization, Chukyo Hospital, Nagoya, Japan
| | - Satoshi Fujimi
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
| | - Satoshi Gando
- 29Division of Acute and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan.,30Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
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42
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Abe T, Kushimoto S, Tokuda Y, Phillips GS, Rhodes A, Sugiyama T, Komori A, Iriyama H, Ogura H, Fujishima S, Shiraishi A, Saitoh D, Mayumi T, Naito T, Takuma K, Nakada TA, Shiino Y, Tarui T, Hifumi T, Otomo Y, Okamoto K, Umemura Y, Kotani J, Sakamoto Y, Sasaki J, Shiraishi SI, Tsuruta R, Hagiwara A, Yamakawa K, Masuno T, Takeyama N, Yamashita N, Ikeda H, Ueyama M, Gando S. Implementation of earlier antibiotic administration in patients with severe sepsis and septic shock in Japan: a descriptive analysis of a prospective observational study. Crit Care 2019; 23:360. [PMID: 31744549 PMCID: PMC6862854 DOI: 10.1186/s13054-019-2644-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 10/09/2019] [Indexed: 12/13/2022]
Abstract
Background Time to antibiotic administration is a key element in sepsis care; however, it is difficult to implement sepsis care bundles. Additionally, sepsis is different from other emergent conditions including acute coronary syndrome, stroke, or trauma. We aimed to describe the association between time to antibiotic administration and outcomes in patients with severe sepsis and septic shock in Japan. Methods This prospective observational study enrolled 1184 adult patients diagnosed with severe sepsis based on the Sepsis-2 criteria and admitted to 59 intensive care units (ICUs) in Japan between January 1, 2016, and March 31, 2017, as the sepsis cohort of the Focused Outcomes Research in Emergency Care in Acute Respiratory Distress Syndrome, Sepsis and Trauma (FORECAST) study. We compared the characteristics and in-hospital mortality of patients administered with antibiotics at varying durations after sepsis recognition, i.e., 0–60, 61–120, 121–180, 181–240, 241–360, and 361–1440 min, and estimated the impact of antibiotic timing on risk-adjusted in-hospital mortality using the generalized estimating equation model (GEE) with an exchangeable, within-group correlation matrix, with “hospital” as the grouping variable. Results Data from 1124 patients in 54 hospitals were used for analyses. Of these, 30.5% and 73.9% received antibiotics within 1 h and 3 h, respectively. Overall, the median time to antibiotic administration was 102 min [interquartile range (IQR), 55–189]. Compared with patients diagnosed in the emergency department [90 min (IQR, 48–164 min)], time to antibiotic administration was shortest in patients diagnosed in ICUs [60 min (39–180 min)] and longest in patients transferred from wards [120 min (62–226)]. Overall crude mortality was 23.4%, where patients in the 0–60 min group had the highest mortality (28.0%) and a risk-adjusted mortality rate [28.7% (95% CI 23.3–34.1%)], whereas those in the 61–120 min group had the lowest mortality (20.2%) and risk-adjusted mortality rates [21.6% (95% CI 16.5–26.6%)]. Differences in mortality were noted only between the 0–60 min and 61–120 min groups. Conclusions We could not find any association between earlier antibiotic administration and reduction in in-hospital mortality in patients with severe sepsis.
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Affiliation(s)
- Toshikazu Abe
- Department of General Medicine, Juntendo University, Tokyo, Japan. .,Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan. .,Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan.
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yasuharu Tokuda
- Department of Medicine, Muribushi Project for Okinawa Residency Programs, Urasoe, Japan
| | - Gary S Phillips
- Department of Biomedical Informatics, Ohio State University, Columbus, OH, USA
| | - Andrew Rhodes
- Department of Intensive Care Medicine, St George's University Hospitals Foundation Trust, London, UK
| | - Takehiro Sugiyama
- Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan.,Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan.,Diabetes and Metabolism Information Center, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan.,Department of Public Health/Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Akira Komori
- Department of General Medicine, Juntendo University, Tokyo, Japan
| | - Hiroki Iriyama
- Department of General Medicine, Juntendo University, Tokyo, Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Seitaro Fujishima
- Center for General Medicine Education, Keio University School of Medicine, Tokyo, Japan
| | | | - Daizoh Saitoh
- Division of Traumatology, Research Institute, National Defense Medical College, Tokorozawa, Japan
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Toshio Naito
- Department of General Medicine, Juntendo University, Tokyo, Japan
| | - Kiyotsugu Takuma
- Emergency & Critical Care Center, Kawasaki Municipal Kawasaki Hospital, Kawasaki, Japan
| | - Taka-Aki Nakada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yasukazu Shiino
- Department of Acute Medicine, Kawasaki Medical School, Kurashiki, Japan
| | - Takehiko Tarui
- Department of Trauma and Critical Care Medicine, Kyorin University School of Medicine, Tokyo, Japan
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Center, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kohji Okamoto
- Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital, Kitakyushu, Japan
| | - Yutaka Umemura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Joji Kotani
- Department of Disaster and Emergency Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yuichiro Sakamoto
- Emergency and Critical Care Medicine, Saga University Hospital, Saga, Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shin-Ichiro Shiraishi
- Department of Emergency and Critical Care Medicine, Aizu Chuo Hospital, Aizuwakamatsu, Japan
| | - Ryosuke Tsuruta
- Advanced Medical Emergency & Critical Care Center, Yamaguchi University Hospital, Ube, Japan
| | - Akiyoshi Hagiwara
- Department of Emergency Medicine, Niizashiki Chuo General Hospital, Niiza, Japan
| | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
| | - Tomohiko Masuno
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Naoshi Takeyama
- Advanced Critical Care Center, Aichi Medical University Hospital, Nagakute, Japan
| | - Norio Yamashita
- Advanced Emergency Medical Service Center, Kurume University Hospital, Kurume, Japan
| | - Hiroto Ikeda
- Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Masashi Ueyama
- Department of Trauma, Critical Care Medicine, and Burn Center, Japan Community Healthcare Organization, Chukyo Hospital, Nagoya, Japan
| | - Satoshi Gando
- Division of Acute and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan.,Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
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Gando S, Otomo Y. Trauma-induced coagulopathy: The past, present, and future: A comment. J Thromb Haemost 2019; 17:1567-1569. [PMID: 31479181 DOI: 10.1111/jth.14520] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 05/21/2019] [Indexed: 12/30/2022]
Affiliation(s)
- Satoshi Gando
- Acute and Critical Care Center, Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Center, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan
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Yamakawa K, Gando S, Ogura H, Umemura Y, Kabata D, Shintani A, Shiraishi A, Saitoh D, Fujishima S, Mayumi T, Kushimoto S, Abe T, Shiino Y, Nakada TA, Tarui T, Hifumi T, Otomo Y, Okamoto K, Kotani J, Sakamoto Y, Sasaki J, Shiraishi SI, Takuma K, Tsuruta R, Hagiwara A, Masuno T, Takeyama N, Yamashita N, Ikeda H, Ueyama M, Fujimi S. Identifying Sepsis Populations Benefitting from Anticoagulant Therapy: A Prospective Cohort Study Incorporating a Restricted Cubic Spline Regression Model. Thromb Haemost 2019; 119:1740-1751. [PMID: 31408900 DOI: 10.1055/s-0039-1693740] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Anticoagulant therapy has seldom been achieved in randomized trials targeting nonspecific overall sepsis patients. Although the key components to identify the appropriate target in sepsis may be disseminated intravascular coagulation (DIC) and high disease severity, the interaction and relation of these two components for the effectiveness of therapy remain unknown. OBJECTIVE This article identifies the optimal target of anticoagulant therapy in sepsis. METHODS We used a prospective nationwide cohort targeting consecutive adult severe sepsis patients in 59 intensive care units in Japan to assess associations between anticoagulant therapy and in-hospital mortality according to DIC (International Society on Thrombosis and Haemostasis [ISTH] overt and Japanese Association for Acute Medicine DIC scores) and disease severity (Acute Physiology and Chronic Health Evaluation II [APACHE II] and Sequential Organ Failure Assessment scores). Multivariable Cox proportional hazard regression analysis with nonlinear restricted cubic spline including a two-way interaction term (treatment × each score) and three-way interaction term (treatment × ISTH overt DIC score × APACHE II score) was performed. RESULTS The final study cohort comprised 1,178 sepsis patients (371 received anticoagulants and 768 did not). The regression model including the two-way interaction term showed significant interaction between intervention and disease severity as indicated by the ISTH overt DIC score and APACHE II score (p = 0.046 and p = 0.101, respectively). Three-way interaction analysis revealed that risk hazard was suppressed in the anticoagulant group compared with the control group in the most severe subset of both scores. CONCLUSION Anticoagulant therapy was associated with better outcome according to the deterioration of both DIC and disease severity, suggesting that anticoagulant therapy should be restricted to patients having DIC and high disease severity simultaneously.
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Affiliation(s)
- Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan.,Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Satoshi Gando
- Department of Anesthesiology and Critical Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan.,Acute and Critical Care Center, Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yutaka Umemura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Daijiro Kabata
- Department of Medical Statistics, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Ayumi Shintani
- Department of Medical Statistics, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Atsushi Shiraishi
- Emergency and Trauma Center, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Daizoh Saitoh
- Division of Traumatology, Research Institute, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Seitato Fujishima
- Center for General Medicine Education, Keio University School of Medicine, Kanagawa, Japan
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health Japan, Fukuoka, Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai Japan
| | - Toshikazu Abe
- Department of General Medicine, Juntendo University, Tokyo, Japan.,Health Services Research and Development Center, University of Tsukuba, Tokyo, Japan
| | - Yasukazu Shiino
- Department of Acute Medicine, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Taka-Aki Nakada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Takehiko Tarui
- Department of Trauma and Critical Care Medicine, Kyorin University School of Medicine, Mitaka, Tokyo, Japan
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Center, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kohji Okamoto
- Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital, Kitakyushu, Japan
| | - Joji Kotani
- Division of Disaster and Emergency Medicine, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yuichiro Sakamoto
- Emergency and Critical Care Medicine, Saga University Hospital, Saga, Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | | | - Kiyotsugu Takuma
- Emergency & Critical Care Center, Kawasaki Municipal Hospital, Kawasaki, Kanagawa, Japan
| | - Ryosuke Tsuruta
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Yamaguchi, Japan
| | - Akiyoshi Hagiwara
- Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan
| | - Tomohiko Masuno
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Bunkyo-ku, Tokyo, Japan
| | - Naoshi Takeyama
- Advanced Critical Care Center, Aichi Medical University Hospital, Aichi-gun, Aichi, Japan
| | - Norio Yamashita
- Advanced Emergency Medical Service Center, Kurume University Hospital, Kurume, Fukuoka, Japan
| | - Hiroto Ikeda
- Department of Emergency Medicine, Teikyo University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Masashi Ueyama
- Department of Trauma, Critical Care Medicine, and Burn Center, Japan Community Healthcare Organization, Chukyo Hospital, Nagoya, Aichi, Japan
| | - Satoshi Fujimi
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
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Fujishima S, Gando S, Saitoh D, Kushimoto S, Ogura H, Abe T, Shiraishi A, Mayumi T, Sasaki J, Kotani J, Takeyama N, Tsuruta R, Takuma K, Yamashita N, Shiraishi SI, Ikeda H, Shiino Y, Tarui T, Nakada TA, Hifumi T, Otomo Y, Okamoto K, Sakamoto Y, Hagiwara A, Masuno T, Ueyama M, Fujimi S, Yamakawa K, Umemura Y. Trends in sepsis care in Japan: comparison of two sepsis cohort studies conducted by the Japanese Association for Acute Medicine. Acute Med Surg 2019; 6:425-427. [PMID: 31592327 PMCID: PMC6773632 DOI: 10.1002/ams2.449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Our analysis showed that improved compliance with sepsis bundles was associated with lower in‐hospital mortality over a 7‐year period in Japan, confirming that the SSC has been executed correctly in our country.![]()
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Affiliation(s)
- Seitaro Fujishima
- Center for General Medicine Education Keio University School of Medicine Tokyo Japan
| | - Satoshi Gando
- Division of Acute and Critical Care Medicine Department of Anesthesiology and Critical Care Medicine Hokkaido University Graduate School of Medicine Sapporo Japan.,Department of Acute and Critical Care Medicine Sapporo Higashi Tokushukai Hospital Sapporo Japan
| | - Daizoh Saitoh
- Division of Traumatology Research Institute National Defense Medical College Tokorozawa Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine Tohoku University Graduate School of Medicine Sendai Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine Osaka University Graduate School of Medicine Suita Japan
| | - Toshikazu Abe
- Department of General Medicine Juntendo University Tokyo Japan.,Health Services Research and Development Center University of Tsukuba Tsukuba Japan
| | | | - Toshihiko Mayumi
- Department of Emergency Medicine School of Medicine University of Occupational and Environmental Health KitaKyushu Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine Keio University School of Medicine Tokyo Japan
| | - Joji Kotani
- Division of Disaster and Emergency Medicine Department of Surgery Related Kobe University Graduate School of Medicine Kobe Japan
| | - Naoshi Takeyama
- Advanced Critical Care Center Aichi Medical University Hospital Nagakute Japan
| | - Ryosuke Tsuruta
- Advanced Medical Emergency & Critical Care Center Yamaguchi University Hospital Ube Japan
| | - Kiyotsugu Takuma
- Emergency& Critical Care Center Kawasaki Municipal Hospital Kawasaki Japan
| | - Norio Yamashita
- Department of Emergency & Critical Care Medicine School of Medicine Kurume University Kurume Japan
| | - Shin-Ichiro Shiraishi
- Department of Emergency and Critical Care Medicine Aizu Chuo Hospital Aizuwakamatsu Japan
| | - Hiroto Ikeda
- Department of Emergency Medicine, Trauma and Resuscitation Center Teikyo University School of Medicine Tokyo Japan
| | - Yasukazu Shiino
- Department of Acute Medicine Kawasaki Medical School Kawasaki Japan
| | - Takehiko Tarui
- Department of Trauma and Critical Care Medicine Kyorin University School of Medicine Tokyo Japan
| | - Taka-Aki Nakada
- Department of Emergency and Critical Care Medicine Chiba University Graduate School of Medicine Chiba Japan
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine St. Luke's International Hospital Tokyo Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Center Medical Hospital Tokyo Medical and Dental University Tokyo Japan
| | - Kohji Okamoto
- Department of Surgery Center for Gastroenterology and Liver Disease Kitakyushu City Yahata Hospital Kitakyushu Japan
| | - Yuichiro Sakamoto
- Emergency and Critical Care Medicine Saga University Hospital Saga Japan
| | - Akiyoshi Hagiwara
- Center Hospital of the National Center for Global Health and Medicine Tokyo Japan
| | - Tomohiko Masuno
- Department of Emergency and Critical Care Medicine Nippon Medical School Tokyo Japan
| | - Masashi Ueyama
- Department of Trauma Critical Care Medicine, and Burn Center Japan Community Healthcare Organization Chukyo Hospital Nagoya Japan
| | - Satoshi Fujimi
- Division of Trauma and Surgical Critical Care Osaka General Medical Center Osaka Japan
| | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care Osaka General Medical Center Osaka Japan
| | - Yutaka Umemura
- Department of Traumatology and Acute Critical Medicine Osaka University Graduate School of Medicine Suita Japan
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46
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Gando S, Wada T. Disseminated intravascular coagulation in cardiac arrest and resuscitation. J Thromb Haemost 2019; 17:1205-1216. [PMID: 31102491 DOI: 10.1111/jth.14480] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 05/02/2019] [Accepted: 05/06/2019] [Indexed: 12/13/2022]
Abstract
The aims of this review are to demonstrate that the changes in coagulation and fibrinolysis observed in cardiac arrest and resuscitation can be recognized as disseminated intravascular coagulation (DIC), and to discuss the probability of DIC being a therapeutic target. The appearance of triggers of DIC, such as damage-associated molecular patterns, inflammatory cytokines, and adrenaline, is associated with platelet activation, marked thrombin generation and fibrin formation, insufficient anticoagulation pathways, and increased fibrinolysis by tissue-type plasminogen activator, followed by the suppression of fibrinolysis by plasminogen activator inhibitor-1, in patients with cardiac arrest and resuscitation. Simultaneous neutrophil activation and endothelial injury associated with glycocalyx perturbation have been observed in these patients. The degree of these changes is more severe in patients with prolonged precardiac arrest hypoxia and long no-flow and low-flow times, patients without return of spontaneous circulation, and non-survivors. Animal and clinical studies have confirmed decreased cerebral blood flow and microvascular fibrin thrombosis in vital organs, including the brain. The clinical diagnosis of DIC in patients with cardiac arrest and resuscitation is associated with multiple organ dysfunction, as assessed with the sequential organ failure assessment score, and increased mortality. This review confirms that the coagulofibrinolytic changes in cardiac arrest and resuscitation meet the definition of DIC proposed by the ISTH, and that DIC is associated with organ dysfunction and poor patient outcomes. This evidence implies that established DIC should be considered to be one of the main therapeutic targets in post-cardiac arrest syndrome.
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Affiliation(s)
- Satoshi Gando
- Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
| | - Takeshi Wada
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
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Matsubara T, Yamakawa K, Umemura Y, Gando S, Ogura H, Shiraishi A, Kushimoto S, Abe T, Tarui T, Hagiwara A, Otomo Y, Fujimi S. Significance of plasma fibrinogen level and antithrombin activity in sepsis: A multicenter cohort study using a cubic spline model. Thromb Res 2019; 181:17-23. [PMID: 31325905 DOI: 10.1016/j.thromres.2019.07.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 06/04/2019] [Accepted: 07/01/2019] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Sepsis leads to coagulopathy by the activation of inflammatory mediators and vascular endothelial cell injury. A number of biomarkers are used to evaluate coagulopathy on sepsis. Fibrinogen and antithrombin activity have been reported as biomarkers of coagulopathy; however, the utility of these two markers has not been well established. This study aimed to evaluate the detailed association between these two markers and clinical outcomes in sepsis patients. MATERIALS AND METHODS This was a post hoc analysis of a multicenter, prospective cohort study conducted in 59 intensive care units throughout Japan from January 2016 to March 2017. We included 1103 adult patients with severe sepsis based on the Sepsis-2 criteria. The associations between the coagulation markers and in-hospital mortality were examined using linear and non-linear logistic regression analyses. We also evaluated the associations between the coagulation markers and disseminated intravascular coagulation (DIC) scores. The International Society on Thrombosis and Haemostasis overt DIC score was calculated after subtracting the fibrinogen component. RESULTS The decreased levels of the fibrinogen and antithrombin activity were significantly associated with an increase in mortality (P = 0.011 and 0.002, respectively). In addition, cubic spline regression demonstrated that mortality sharply increased at a fibrinogen level of approximately <200 mg/dL and at an antithrombin activity of approximately <50%. Similarly, the decreased levels of the two markers non-linearly correlated with the elevation of DIC score. CONCLUSIONS The fibrinogen level and antithrombin activity should be reconsidered as unique biomarkers for sepsis and sepsis-induced DIC.
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Affiliation(s)
- Tsunehiro Matsubara
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kazuma Yamakawa
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan; Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan.
| | - Yutaka Umemura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Satoshi Gando
- Department of Anesthesiology and Critical Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan; Acute and Critical Care Center, Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | | | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Toshikazu Abe
- Department of General Medicine, Juntendo University, Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan; Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan
| | - Takehiko Tarui
- Department of Trauma and Critical Care Medicine, Kyorin University School of Medicine, Tokyo, Japan
| | - Akiyoshi Hagiwara
- Department of Emergency Medicine, Niizashiki Chuo General Hospital, Saitama, Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Center, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | - Satoshi Fujimi
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
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Abe T, Tokuda Y, Shiraishi A, Fujishima S, Mayumi T, Sugiyama T, Deshpande GA, Shiino Y, Hifumi T, Otomo Y, Okamoto K, Kotani J, Sakamoto Y, Sasaki J, Shiraishi SI, Takuma K, Hagiwara A, Yamakawa K, Takeyama N, Gando S. In-hospital mortality associated with the misdiagnosis or unidentified site of infection at admission. Crit Care 2019; 23:202. [PMID: 31171006 PMCID: PMC6551884 DOI: 10.1186/s13054-019-2475-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 05/13/2019] [Indexed: 12/29/2022]
Abstract
Background Rapid detection, early resuscitation, and appropriate antibiotic use are crucial for sepsis care. Accurate identification of the site of infection may facilitate a timely provision of appropriate care. We aimed to investigate the relationship between misdiagnosis of the site of infection at initial examination and in-hospital mortality. Methods This was a secondary-multicenter prospective cohort study involving 37 emergency departments. Consecutive adult patients with infection from December 2017 to February 2018 were included. Misdiagnosis of the site of infection was defined as a discrepancy between the suspected site of infection at initial examination and that at final diagnosis, including those infections remaining unidentified during hospital admission, whereas correct diagnosis was defined as site concordance. In-hospital mortality was compared between those misdiagnosed and those correctly diagnosed. Results Of 974 patients included in the analysis, 11.6% were misdiagnosed. Patients diagnosed with lung, intra-abdominal, urinary, soft tissue, and CNS infection at the initial examination, 4.2%, 3.8%, 13.6%, 10.9%, and 58.3% respectively, turned out to have an infection at a different site. In-hospital mortality occurred in 15%. In both generalized estimating equation (GEE) and propensity score-matched models, misdiagnosed patients exhibited higher mortality despite adjustment for patient background, site infection, and severity. The adjusted odds ratios (misdiagnosis vs. correct diagnosis) for in-hospital mortality were 2.66 (95% CI, 1.45–4.89) in the GEE model and 3.03 (95% CI, 1.24–7.38) in the propensity score-matched model. The difference in the absolute risk in the GEE model was 0.11 (0.04–0.18). Conclusions Among patients with infection, misdiagnosed site of infection is associated with a > 10% increase in in-hospital mortality. Electronic supplementary material The online version of this article (10.1186/s13054-019-2475-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Toshikazu Abe
- Department of General Medicine, Juntendo University, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan. .,Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan. .,Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan.
| | - Yasuharu Tokuda
- Department of Medicine, Muribushi Project for Okinawa Residency Programs, Okinawa, Japan
| | | | - Seitaro Fujishima
- Center for General Medicine Education, Keio University School of Medicine, Tokyo, Japan
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Takehiro Sugiyama
- Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan.,Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan.,Diabetes and Metabolism Information Center, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan.,Department of Public Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Gautam A Deshpande
- Department of General Medicine, Juntendo University, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Yasukazu Shiino
- Department of Acute Medicine, Kawasaki Medical School, Kurashiki, Japan
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Center, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kohji Okamoto
- Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital, Kitakyushu, Japan
| | - Joji Kotani
- Department of Disaster and Emergency Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yuichiro Sakamoto
- Emergency and Critical Care Medicine, Saga University Hospital, Saga, Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shin-Ichiro Shiraishi
- Department of Emergency and Critical Care Medicine, Aizu Chuo Hospital, Aizuwakamatsu, Japan
| | - Kiyotsugu Takuma
- Emergency & Critical Care Center, Kawasaki Municipal Kawasaki Hospital, Kawasaki, Japan
| | - Akiyoshi Hagiwara
- Department of Emergency Medicine, Niizashiki Chuo General Hospital, Niiza, Japan
| | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
| | - Naoshi Takeyama
- Advanced Critical Care Center, Aichi Medical University Hospital, Nagakute, Japan
| | - Satoshi Gando
- Division of Acute and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan.,Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
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Gando S, Shiraishi A, Yamakawa K, Ogura H, Saitoh D, Fujishima S, Mayumi T, Kushimoto S, Abe T, Shiino Y, Nakada TA, Tarui T, Hifumi T, Otomo Y, Okamoto K, Umemura Y, Kotani J, Sakamoto Y, Sasaki J, Shiraishi SI, Takuma K, Tsuruta R, Hagiwara A, Masuno T, Takeyama N, Yamashita N, Ikeda H, Ueyama M, Fujimi S, Tasaki O, Mizobata Y, Funakoshi H, Okuyama T, Yamashita I, Kanai T, Yamada Y, Aibiki M, Sato K, Yamashita S, Yamashita S, Yoshida K, Kasaoka S, Kon A, Rinka H, Kato H, Okudera H, Narimatsu E, Fujiwara T, Sugita M, Shichinohe Y, Nakae H, Iiduka R, Murata Y, Nakamura M, Sato Y, Ishikura H, Myojo Y, Tsujita Y, Kinoshita K, Yamaguchi H, Sakurai T, Miyatake S, Saotome T, Yasuda S, Abe T, Ogura H, Umemura Y, Shiraishi A, Kushimoto S, Saitoh D, Fujishima S, Sasaki J, Mayumi T, Shiino Y, Nakada TA, Tarui T, Hifumi T, Otomo Y, Kotani J, Sakamoto Y, Shiraishi SI, Takuma K, Tsuruta R, Hagiwara A, Yamakawa K, Takeyama N, Yamashita N, Ikeda H, Mizushima Y, Gando S. Role of disseminated intravascular coagulation in severe sepsis. Thromb Res 2019; 178:182-188. [DOI: 10.1016/j.thromres.2019.04.025] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 03/23/2019] [Accepted: 04/23/2019] [Indexed: 01/16/2023]
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Vincent JL, Francois B, Zabolotskikh I, Daga MK, Lascarrou JB, Kirov MY, Pettilä V, Wittebole X, Meziani F, Mercier E, Lobo SM, Barie PS, Crowther M, Esmon CT, Fareed J, Gando S, Gorelick KJ, Levi M, Mira JP, Opal SM, Parrillo J, Russell JA, Saito H, Tsuruta K, Sakai T, Fineberg D. Effect of a Recombinant Human Soluble Thrombomodulin on Mortality in Patients With Sepsis-Associated Coagulopathy: The SCARLET Randomized Clinical Trial. JAMA 2019; 321:1993-2002. [PMID: 31104069 PMCID: PMC6547077 DOI: 10.1001/jama.2019.5358] [Citation(s) in RCA: 180] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
IMPORTANCE Previous research suggested that soluble human recombinant thrombomodulin may reduce mortality among patients with sepsis-associated coagulopathy. OBJECTIVE To determine the effect of human recombinant thrombomodulin vs placebo on 28-day all-cause mortality among patients with sepsis-associated coagulopathy. DESIGN, SETTING, AND PARTICIPANTS The SCARLET trial was a randomized, double-blind, placebo-controlled, multinational, multicenter phase 3 study conducted in intensive care units at 159 sites in 26 countries. All adult patients admitted to one of the participating intensive care units between October 2012 and March 2018 with sepsis-associated coagulopathy and concomitant cardiovascular and/or respiratory failure, defined as an international normalized ratio greater than 1.40 without other known etiology and a platelet count in the range of 30 to 150 × 109/L or a greater than 30% decrease in platelet count within 24 hours, were considered for inclusion. The final date of follow-up was February 28, 2019. INTERVENTIONS Patients with sepsis-associated coagulopathy were randomized and treated with an intravenous bolus or a 15-minute infusion of thrombomodulin (0.06 mg/kg/d [maximum, 6 mg/d]; n = 395) or matching placebo (n = 405) once daily for 6 days. MAIN OUTCOME AND MEASURES The primary end point was 28-day all-cause mortality. RESULTS Among 816 randomized patients, 800 (mean age, 60.7 years; 437 [54.6%] men) completed the study and were included in the full analysis set. In these patients, the 28-day all-cause mortality rate was not statistically significantly different between the thrombomodulin group and the placebo group (106 of 395 patients [26.8%] vs 119 of 405 patients [29.4%], respectively; P = .32). The absolute risk difference was 2.55% (95% CI, -3.68% to 8.77%). The incidence of serious major bleeding adverse events (defined as any intracranial hemorrhage; life-threatening bleeding; or bleeding event classified as serious by the investigator, with administration of at least 1440 mL [typically 6 units] of packed red blood cells over 2 consecutive days) was 23 of 396 patients (5.8%) in the thrombomodulin group and 16 of 404 (4.0%) in the placebo group. CONCLUSIONS AND RELEVANCE Among patients with sepsis-associated coagulopathy, administration of a human recombinant thrombomodulin, compared with placebo, did not significantly reduce 28-day all-cause mortality. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01598831.
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Affiliation(s)
- Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Brussels, Belgium
| | - Bruno Francois
- ICU Department, Inserm CIC-1435 & UMR-1092, CHU Dupuytren, Limoges, France
| | - Igor Zabolotskikh
- Department of Anesthesiology, Intensive Care and Transfusiology, Kuban State Medical University, Krasnodar, Russia
| | - Mradul Kumar Daga
- Department of Medicine, Maulana Azad Medical College and associated hospitals, New Delhi, India
| | | | - Mikhail Y. Kirov
- Department of Anesthesiology and Intensive Care Medicine, Northern State Medical University, Arkhangelsk, Russia
| | - Ville Pettilä
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Xavier Wittebole
- Department of Critical Care Medicine, St Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium
| | - Ferhat Meziani
- Faculté de Médecine, Université de Strasbourg (UNISTRA), Hôpitaux Universitaires de Strasbourg, Service de Réanimation, Nouvel Hôpital Civil, Strasbourg, France
| | | | - Suzana M. Lobo
- Intensive Care Division, Hospital de Base, São José do Rio Preto, SP, Brazil
| | - Philip S. Barie
- Departments of Surgery and Medicine, Weill Cornell Medicine, New York, New York
| | - Mark Crowther
- Department of Medicine, McMaster University and St Joseph’s Hospital, Hamilton, Canada
| | - Charles T. Esmon
- Coagulation Biology Laboratory, Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma
| | - Jawed Fareed
- Pathology and Pharmacology, Loyola University Medical Center, Maywood, Illinois
| | - Satoshi Gando
- Acute and Critical Care Center, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
| | | | - Marcel Levi
- Department of Medicine, University College London Hospitals and Cardiometabolic Programme-NIHR UCLH/UCL BRC, London, United Kingdom
| | - Jean-Paul Mira
- Universite´Paris Descartes, Sorbonne Paris Cite´, Faculte´ de Me´-decine Cochin University Hospital, AP-HP, Paris, France
| | - Steven M. Opal
- Division of Infectious Diseases, Rhode Island Hospital, Providence, Rhode Island
| | - Joseph Parrillo
- Department of Medicine, New Jersey Medical School of Rutgers University, Hackenseck
- Heart and Vascular Hospital, Hackensack University Medical Center, Hackensack, New Jersey
| | - James A. Russell
- Department of Medicine, Centre for Heart Lung Innovation, St. Paul's Hospital, Vancouver, Canada
| | - Hidehiko Saito
- National Hospital Organization, Nagoya Medical Center, Nagoya, Japan
| | | | | | - David Fineberg
- Asahi-Kasei Pharma America Corporation, Waltham, Massachusetts
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