Recognition of the characteristic epidemiology and clinical features of this disease is important, and positive debridement should be performed on suspicion. When the illness reaches an advanced stage, however, amputation should be the immediate treatment of choice.
Argatroban was used as the anticoagulant during cardiopulmonary bypass (CPB) in a patient with heparin-induced thrombocytopenia (HIT) type II undergoing mitral valve replacement. Dosage was reduced because of preoperative congestive liver disorder. Perioperative coagulability was poor, and, ultimately, failure of hemostasis led to a fatal outcome. Although argatroban use as an anticoagulant for HIT is reported, the optimal dose has not been established. During long-term CPB, increasing the total dosage may extend anticoagulant ability, leading to dose dependence. Because no antagonist for argatroban exists, failure of hemostasis might occur.
We aimed to clarify the changes in respiratory mechanics and factors associated with them in artificial pneumothorax two-lung ventilation in video-assisted thoracoscopic esophagectomy in the prone position (PP-VATS-E) for esophageal cancer. Data of patients with esophageal cancer, who underwent PP-VATs-E were retrospectively analyzed. Our primary outcome was the change in the respiratory mechanics after intubation (T1), in the prone position (T2), after initiation of the artificial pneumothorax two-lung ventilation (T3), at 1 and 2 h (T4 and T5), in the supine position (T6), and after laparoscopy (T7). The secondary outcome was identifying factors affecting the change in dynamic lung compliance (Cdyn). Sixty-seven patients were included. Cdyn values were significantly lower at T3, T4, and T5 than at T1 (p < 0.001). End-expiratory flow was significantly higher at T4 and T5 than at T1 (p < 0.05). Body mass index and preoperative FEV1.0% were found to significantly influence Cdyn reduction during artificial pneumothorax and two-lung ventilation (OR [95% CI]: 1.29 [1.03–2.24] and 0.20 (0.05–0.44); p = 0.010 and p = 0.034, respectively]. Changes in driving pressure were nonsignificant, and hypoxemia requiring treatment was not noted. This study suggests that in PP-VATs-E, artificial pneumothorax two-lung ventilation is safer for the management of anesthesia than conventional one-lung ventilation (UMIN Registry: 000042174).
To determine the prophylactic effect of using combined 1% alcoholic chlorhexidine gluconate and chlorhexidine gel-impregnated dressings (CGCD) on catheter-related thrombosis (CRT) in critically ill patients. This retrospective cohort study was performed in an intensive care unit from November 2009 to August 2014. The CRT incidence diagnosed with ultrasound examination was compared between patients applying CGCD and combined 10% aqueous povidone-iodine and standard transparent dressings (PITD) after central venous catheter insertion into the internal jugular vein for ≥ 48 h. CRT was stratified into early (within 7 days) and late (days 8–14) thromboses. Multivariate analyses using logistic regression models clarified the relationships between early- and late-CRT risks and skin antiseptic and catheter site dressing combinations. CRT occurred in 74 of 134 patients (55%), including 52 with early CRT and 22 with late CRT. Patients receiving CGCD had a significantly lower incidence of early CRT than those receiving PITD (odds ratio = 0.18; 95% confidence interval = 0.07–0.45, p < .001). No significant association was evident between using CGCD and late CRT (p = .514). Compared to PITD, CGCD reduced the CRT risk over 7 days in critically ill patients.
UMIN Clinical Trials Registry: UMIN000037492.
Rationale:
Chronic disseminated intravascular coagulation (DIC) associated with thoracic aortic aneurysm is characterized by enhanced fibrinolysis and is thought to be stable in the compensated/asymptomatic stage, with few bleeding symptoms. However, DIC can lead to decompensated/hemorrhagic stage disseminated intravascular coagulation, resulting in severe bleeding diathesis, and there is currently no established strategy for treatment of DIC in aortic aneurysms.
Patient concerns:
A 77-year-old woman underwent angiography and cardiac catheterization, before descending aortic replacement surgery. She developed DIC in postprocedure week 2 with extensive, uncontrollable massive subcutaneous hemorrhage.
Diagnoses:
Her acute-phase DIC score was 7 points, and the risk of mortality within 30 days after surgery according to the JapanSCORE was estimated to be 33.6%.
Interventions:
Therapy was a combination of recombinant human soluble thrombomodulin (rhTM) and an aortic stent-graft treatment.
Outcomes:
Short-term improvements were seen in both DIC and bleeding diathesis. The thoracic aortic aneurysm with severe DIC was eventually corrected by administration of rhTM.
Lessons:
We report the use of rhTM as an effective, novel anticoagulant drug with anti-inflammatory activity for treating DIC with suppressed fibrinolysis, which is typically associated with sepsis. In patients with a high hemorrhagic diathesis, in whom preoperative control of DIC cannot be achieved with conventional anticoagulation and radical surgical repair cannot be performed, a combination of rhTM and endovascular therapy may be a powerful new treatment option.
要約: 【目的】 中心静脈カテーテル (central venous catheter, CVC) によるカテーテル関連血栓 症 (catheter-related thrombosis, CRT) の発症頻度と経過, 発症要因, 合併症と転帰を調査した。 【方法】 2009 年 11 月-2010 年 11 月に CVC を用いた患者を対象に,超音波を用い CRT を観察 した。 【結果】 CRT の頻度は患者 100 人中 67 人,カテーテル 205 本中 107 本 (52%) であり,大 腿静脈に比べ内頸静脈で多かった (63%対 28%,P < 0.001) 。CRT 発症群では,非発症群に比 べ感染性併発症を多く認めた (67%対 45%,P = 0.04) 。中心静脈カテーテル関連血流感染症 は,CRT 非発症例に比べ発症例で多く合併した (9%対 1%,P = 0.008) 。ICU 滞在日数は CRT 発症群で延長したが死亡率に有意差はなかった。 【結論】 CRT は 52%と高頻度に発症し,感染 症との関連性が示唆された。 Key words: ① central venous catheter-related thrombosis, ② central line associated bloodstream infection, ③ pulmonary embolism 中心静脈カテーテル関連血栓症
Abstract
Investigation of central venous catheter-related thrombosis in intensive care patientsObjectives: To investigate the incidence of central venous catheter-related thrombosis (CRT), risk factors, complication and convalescence in critically ill patients. Methods: This observational study comprised patients with central venous catheters (CVCsWe used ultrasonography to detect CRT. Results: The incidence of CRT was 107/205 cases of CVCs (52%) in 67/100 patients. The incidence of CRT at internal jugular vein was higher than the incidence at femoral vein (63% vs 28%, P < 0.001). Patients with CRT often complicated any infection in comparison with patients without CRT (67% vs 45%, P = 0.04). Rates of central line-associated bloodstream infection were higher among CVCs with CRT than CVCs without CRT (9% vs 1%, P = 0.008). Length of ICU stay for patients with CRT was prolonged in comparison with patients without CRT, whereas mortality rate was comparable between patients with CRT and patients without CRT. Conclusions: CRT occurred in 52% of 205 CVCs and might be related with infection.
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