AimContinuous renal replacement therapy (CRRT) with a cytokine‐adsorbing hemofilter (CAH) is effective in the treatment of sepsis. Two filter types, namely polymethyl methacrylate (PMMA) and surface‐treated AN69 (AN69ST) hemofilters, have been successfully used for CRRT, but no direct comparisons have been published to date. This study compared the efficacy, as measured by 28‐day survival rates, of PMMA and AN69ST hemofilters in patients receiving CAH‐CRRT.MethodsThis retrospective observational study reviewed the medical records of 142 patients who received CAH‐CRRT between November 2013 and February 2015.ResultsThe 28‐day survival rates were higher in the AN69ST group than in the PMMA group for patients with or without sepsis (all patients, 79.4% versus 54.1%; patients with sepsis, 77.3% versus 50.0%; patients without sepsis, 83.3% versus 57.5%; P < 0.05). No significant differences were observed regarding 28‐day survival rates of patients with or without sepsis (AN69ST, 77.3% versus 83.3%; P = 0.51; PMMA, 50.0% versus 57.5%; P = 0.61) using the same hemofilter.ConclusionThe AN69ST hemofilter could be more effective than PMMA hemofilters for improving the survival outcomes of patients with or without sepsis.

Severe coronavirus disease (COVID-19) can induce serious complications, including acute respiratory distress syndrome, septic shock, and acute kidney injury. However, few reports have associated COVID-19 with pancreatitis. We herein report the case of a 55-year-old patient who developed acute pancreatitis associated with severe COVID-19 pneumonia and was successfully treated with veno-venous extracorporeal membrane oxygenation (ECMO). Elevated pancreatic enzymes levels and computed tomography findings led to the diagnosis of acute pancreatitis due to COVID-19. Although we found that severe COVID-19 pneumonia can lead to pancreatitis, the underlying pathophysiology remains unknown.

Background The joint committee of the Japanese Society of Intensive Care Medicine/Japanese Respiratory Society/Japanese Society of Respiratory Care Medicine on ARDS Clinical Practice Guideline has created and released the ARDS Clinical Practice Guideline 2021. Methods The 2016 edition of the Clinical Practice Guideline covered clinical questions (CQs) that targeted only adults, but the present guideline includes 15 CQs for children in addition to 46 CQs for adults. As with the previous edition, we used a systematic review method with the Grading of Recommendations Assessment Development and Evaluation (GRADE) system as well as a degree of recommendation determination method. We also conducted systematic reviews that used meta-analyses of diagnostic accuracy and network meta-analyses as a new method. Results Recommendations for adult patients with ARDS are described: we suggest against using serum C-reactive protein and procalcitonin levels to identify bacterial pneumonia as the underlying disease (GRADE 2D); we recommend limiting tidal volume to 4–8 mL/kg for mechanical ventilation (GRADE 1D); we recommend against managements targeting an excessively low SpO2 (PaO2) (GRADE 2D); we suggest against using transpulmonary pressure as a routine basis in positive end-expiratory pressure settings (GRADE 2B); we suggest implementing extracorporeal membrane oxygenation for those with severe ARDS (GRADE 2B); we suggest against using high-dose steroids (GRADE 2C); and we recommend using low-dose steroids (GRADE 1B). The recommendations for pediatric patients with ARDS are as follows: we suggest against using non-invasive respiratory support (non-invasive positive pressure ventilation/high-flow nasal cannula oxygen therapy) (GRADE 2D), we suggest placing pediatric patients with moderate ARDS in the prone position (GRADE 2D), we suggest against routinely implementing NO inhalation therapy (GRADE 2C), and we suggest against implementing daily sedation interruption for pediatric patients with respiratory failure (GRADE 2D). Conclusions This article is a translated summary of the full version of the ARDS Clinical Practice Guideline 2021 published in Japanese (URL: https://www.jsicm.org/publication/guideline.html). The original text, which was written for Japanese healthcare professionals, may include different perspectives from healthcare professionals of other countries.

Purpose To validate our previously designed transcatheter arterial embolization (TAE) technique for bilateral iliac arteries in unstable pelvic fractures, which is designed to also prevent gluteal necrosis and avoid vasopressors. Methods We retrospectively analyzed the data of patients with pelvic fractures who underwent our new TAE procedure to determine the incidence of subsequent gluteal necrosis. We also compared certain variables between patients who underwent TAE before 2005 using a different technique and developed gluteal necrosis and patients who underwent TAE in 2005 and onward using our technique. Gluteal necrosis was confirmed by a radiologist based on imaging findings. Results Seventy patients with pelvic fractures who underwent our TAE technique met the inclusion criteria (bilateral iliac arterial embolization and no embolic agent other than a gelatin sponge). Patients’ median age was 47.5 years, 33 were male, and 92.9% (65/70) had unstable fractures. Sixty-eight patients had severe multiple trauma. No patients developed gluteal necrosis following our TAE procedure and the overall survival rate was 82.9% (58/70). We found no statistically significant difference in procedure time between the previous and new technique, although the new procedure tended to be shorter. Furthermore, overall survival did not significantly differ between the groups. Multiple regression analysis revealed that TAE procedure time and external pelvic fracture fixation were independently related to gluteal necrosis. Conclusions Our non-selective bilateral iliac arterial embolization procedure involves arresting shock quickly, resulting in no post-procedure gluteal necrosis. The procedure involves cutting the gelatin sponge rather than “pumping” and avoids the use of vasopressors.

Objective : To describe the clinical utility and technical aspects of the candy-plug technique using an Excluder aortic extender (Ex-cuff) for false lumen (FL) occlusion in chronic aortic dissection. Materials and Methods : This is a retrospective study analyzing seven consecutive patients (mean age, 63 years; range, 44–78 years; 6 men) with aneurysmal dilatation or rupture in chronic aortic dissection. All patients had undergone thoracic endovascular aortic repair with FL occlusion using this technique. We assessed technical (deployment accuracy) and clinical (no FL backflow on the latest contrast-enhanced computed tomography) success. Results : Technical success was obtained in six patients (86%). Technical failure was caused by the malposition of the candy-plug. The mean follow-up period was 593 days (range, 222–1225 days). Clinical success was obtained in four (57%), and incomplete Amplatzer Vascular Plug (AVP) embolization was seen in two. There was no enlarged FL after the procedure, and all patients are alive during the follow-up periods. Conclusion : The candy-plug technique using an Ex-cuff may be a feasible option; however, it takes time to achieve complete AVP embolization. Therefore, using additional embolic materials should be considered when we use it for the rupture case. (This is a translation of Jpn J Endovasc Interv 2018; 19: 29–35.)

BackgroundThe resuscitative endovascular balloon occlusion of the aorta, because of its efficacy and feasibility, has been widely used in treating patients with severe torso trauma. However, complications developing around the site proximal to the occlusion by resuscitative endovascular balloon occlusion of the aorta have almost never been studied.Case presentationA 50-year-old Japanese woman fell from a height of approximately 10 m. At initial arrival, her respiratory rate was 24 breaths/minute, her blood oxygen saturation was 95% under 10 L/minute oxygenation, her pulse rate was 90 beats per minute, and her blood pressure was 180/120 mmHg. Mild lung contusion, hemopneumothorax, unstable pelvic fracture, and retroperitoneal bleeding with extravasation of contrast media were observed in initial computed tomography. As her vital signs had deteriorated during computed tomography, a 7-French aortic occlusion catheter (RESCUE BALLOON®, Tokai Medical Products, Aichi, Japan) was inserted and inflated for aortic occlusion at the first lumbar vertebra level and transcatheter arterial embolization was performed for the pelvic fracture. Her bilateral internal iliac arteries were embolized with a gelatin sponge; however, the embolized sites presented recanalization as coagulopathy appeared. Her bilateral internal iliac arteries were re-embolized by n-butyl-2-cyanoacrylate. The balloon was deflated 18 minutes later. After embolization, repeat computed tomography was performed and a massive hemothorax, which had not been captured on arrival, had appeared in her left pleural cavity. Thoracotomy hemostasis was performed and a hemothorax of approximately 2500 ml was aspirated to search for the source of bleeding. However, clear active bleeding was not captured; resuscitative endovascular balloon occlusion of the aorta may have been the cause of the increased bleeding of the thoracic injury at the proximal site of the aorta occlusion.ConclusionsIt is necessary to note that the use of resuscitative endovascular balloon occlusion of the aorta may increase bleeding in sites proximal to occlusions, even in the case of minor injuries without active bleeding at the initial diagnosis.

The incidence of thrombotic complications is extremely high among severe coronavirus disease 2019 (COVID-19) patients in the intensive care unit. Various factors such as a cytokine storm due to an excessive immune response to inflammation, hypoxemia, and disseminated intravascular coagulation are considered predisposing factors for thrombotic complications. A 55-year-old Japanese man intubated eight days previously was referred to our hospital because of a severe COVID-19 pneumonia diagnosis after his pharyngeal swab tested positive for severe acute respiratory syndrome coronavirus 2 using reverse transcription-polymerase chain reaction. The patient continued to remain hypoxic (PaO 2 /FiO 2 ratio <100 mmHg) at the referring hospital. On admission, we initiated veno-venous extracorporeal membrane oxygenation (VV-ECMO). Unfractionated heparin and nafamostat mesylate were used as anticoagulants during VV-ECMO. Despite adequate anticoagulant therapy, he developed pulmonary infarction due to pulmonary embolism followed by hemoptysis. On day 10 following admission, his oxygen saturation dropped from 95% to 88%, with a marked decrease in his ventilator tidal volume, accompanied by an inability to ventilate the patient. Thereafter, we increased the VV-ECMO flow and exchanged his endotracheal tube. The lumen of the removed tracheal tube was found to be occluded by a large-sized blood coagulum. There was no further episode of tube occlusion. The patient was discharged in a walkable state on day 39 following admission. Endotracheal tube obstruction secondary to hemoptysis should be suggested in patients with COVID-19 requiring ventilator support, as they are unable to perform frequent endotracheal tube suctions owing to the risk of infection.

Background Non-operative management with Transcatheter arterial embolization(TAE) was the first line of treatment for severe blunt liver injury in hemodynamically stable patients, but in the case of hemodynamically unstable, Operative management(OM) was recommended. We evaluated the efficacy of TAE in our hospital where intervention radiology was available 24 hours a day if the patient responds to initial infusion therapy even unstable.Methods We conducted a retrospective study of severe blunt liver injury of AAST Organ Injury Scale(OIS) grade 3–5 transported to our hospital between 2005 and 2019. If the patient responded to initial infusion therapy, even though hemodynamically unstable(Shock Index ≧ 1), CT was taken and initial treatment was decided. We compared patients who underwent OM or TAE on initial treatment.Results 62 patients were included (8 OM, 54 TAE), with a mean ISS of 26.6, in hospital mortality of 6%(13% OM VS 6% TAE, p = 0.50), hemodynamically unstable of 35% (88% OM VS 28% TAE, p < 0.01) and Time from Door to start OM/TAE 81.8 min(120.0 OM VS 76.1 TAE, p = 0.02). Unstable patients who undergo TAE were associated with 7% in hospital mortality and 7% clnical failure. After logistic regression the choice of treatment was not a predictor of outcome, the predictor of in-hospital mortality death was GCS on arrival(OR0.48, P < 0.01), hemodynamically unstable was independent predictor of duration of ICU ≧ 7 days(OR 3.80, p = 0.05) and massive blood transfusion(OR 7.25, p = 0.01). the predictor of complication was OIS grade4-5(OR 6.61 p < 0.01).Conclusions The strategy of performing TAE even in the presence of hemodynamically unstable in a facility where TAE can be performed promptly was acceptable mortality and clinical failure. The choice of treatment did not affect the outcome, and hemodynamically unstable and OIS affected the prognosis.