Long-term psychiatric disorders in families of severe COVID-19 patients.

Aim: The present study aimed to describe in detail the changes to and assess the risk factors for poor long-term outcomes of psychiatric disorders in families of COVID-19 patients. Methods: A single-center, retrospective study using questionnaires. Family members of patients admitted to the intensive care unit (ICU) with severe COVID-19 participated. Psychiatric disorders refer to the psychological distress such as anxiety, depression, and posttraumatic stress disorder (PTSD) experienced by the patient's family. Results: Forty-six family members completed the survey and were analyzed. Anxiety, depression, and PTSD occurred in 24%, 33%, and 2% of family members, respectively, and psychiatric disorders occurred in 39%. On multivariable analysis, living in the same house with the patient was independently associated with a lower risk of psychiatric disorders in families of COVID-19 patients (OR, 0.180; 95% CI, 0.036-0.908; p = 0.038). Furthermore, four family members overcame psychiatric disorders, and six family members newly developed psychiatric disorders during the one-year follow-up period. Conclusion: Approximately 40% of family members had long-term psychiatric disorders, and some of them overcame the psychiatric disorders, and some newly developed psychiatric disorders over the one-year follow-up. Living in the same house with the patient was possibly significantly associated with the reduction of long-term symptoms of psychiatric disorders, but this result must be interpreted with care. Further large studies are needed to examine the factors associated with the long-term mental status of family members.

Risk factors for bleeding complications in patients undergoing extracorporeal cardiopulmonary resuscitation following out-of-hospital cardiac arrest: a secondary analysis of the SAVE-J II study.

BACKGROUND: Bleeding is the most common complication in out-of-hospital cardiac arrest (OHCA) patients receiving extracorporeal cardiopulmonary resuscitation (ECPR). No studies comprehensively described the incidence rate, timing of onset, risk factors, and treatment of bleeding complications in OHCA patients receiving ECPR in a multicenter setting with a large database. This study aimed to analyze the risk factors of bleeding during the first day of admission and to comprehensively describe details of bleeding during hospitalization in patients with OHCA receiving ECPR in the SAVE-J II study database. METHODS: This study was a secondary analysis of the SAVE-J II study, which is a multicenter retrospective registry study from 36 participating institutions in Japan in 2013-2018. Adult OHCA patients who received ECPR were included. The primary outcome was the risk factor of bleeding complications during the first day of admission. The secondary outcomes were the details of bleeding complications and clinical outcomes. RESULTS: A total of 1,632 patients were included. Among these, 361 patients (22.1%) had bleeding complications during hospital stay, which most commonly occurred in cannulation sites (14.3%), followed by bleeding in the retroperitoneum (2.8%), gastrointestinal tract (2.2%), upper airway (1.2%), and mediastinum (1.1%). These bleeding complications developed within two days of admission, and 21.9% of patients required interventional radiology (IVR) or/and surgical interventions for hemostasis. The survival rate at discharge of the bleeding group was 27.4%, and the rate of favorable neurological outcome at discharge was 14.1%. Multivariable logistic regression analysis showed that the platelet count (< 10 × 104/µL vs > 10 × 104/µL) was significantly associated with bleeding complications during the first day of admission (adjusted odds ratio [OR]: 1.865 [1.252-2.777], p = 0.002). CONCLUSIONS: In a large ECPR registry database in Japan, up to 22.1% of patients experienced bleeding complications requiring blood transfusion, IVR, or surgical intervention for hemostasis. The initial platelet count was a significant risk factor of early bleeding complications. It is necessary to lower the occurrence of bleeding complications from ECPR, and this study provided an additional standard value for future studies to improve its safety.

Frequency, clinical characteristics, and outcomes of pneumonia in patients with out-of-hospital cardiac arrest undergoing extracorporeal cardiopulmonary resuscitation.

Aim: This study aimed to describe the frequency, clinical characteristics, and outcomes of pneumonia in OHCA patients treated with ECPR in a multicenter setting. Methods: This is a secondary analysis of the SAVE-J II study, which was a multicenter, retrospective cohort of OHCA patients treated with ECPR. Age, sex, comorbidities, presence of witnessed CA, presence of bystander CPR, initial rhythm, cause of CA, low-flow time, initiation of targeted temperature management, details of sputum culture, pneumonia, and prophylactic antibiotic use were recorded. Pneumonia was diagnosed when the patients met all the clinical, radiologic, and microbiologic criteria acquired after hospitalization. Results: In total, 1,986 patients were included in the analysis, and 947 (48%) died during the first 2 days of admission. A prophylactic antibiotic was used in 712 (35.9%) patients. Overall, the hazard of death was high on days 1 and 2 of admission, exceeding 20% on both days; 251 (12.6%) patients developed pneumonia during hospitalization, and the hazard of pneumonia development remained high (>2%) in the first 7 days of admission.Staphylococcus aureus and Klebsiella species were commonly identified in the sputum culture. Among patients who survived the first 7 days, the odds ratio (OR) of those with pneumonia and unfavorable neurological outcomes defined by cerebral performance category 3-5 was approximately 1. In those who survived the first 10 days, the OR was greater than 1 with a wide confidence interval. Conclusions: This is the first study describing details of pneumonia in OHCA patients treated with ECPR using a large dataset.

A Case of Sudden Cardiac Arrest After Brainstem Infarction.

Research on the causes of sudden cardiac arrest (CA) after ischemic stroke, especially disruption of the autonomic nervous system's central control, has recently focused more on the widespread cortical and subcortical network than on autonomic circuits at the spinal and brainstem level. However, no clinical case of sudden CA requiring cardiopulmonary resuscitation (CPR) after brainstem infarction has been reported. We report a case of a 78-year-old woman who died suddenly from a brainstem infarction. Her husband heard a falling sound and found her unresponsive and lying with agonal breathing. The initial cardiac rhythm was pulseless electrical activity confirmed by emergency medical technicians. Recovery of spontaneous circulation was achieved after CPR. Basilar artery occlusion was shown on computed tomography, but no other findings that could have caused CA were found. Targeted temperature management was initiated, but she died on hospital day 22. Brainstem infarction may cause sudden CA; therefore, definitive treatment may achieve better outcomes.

Clinical characteristics and outcomes after extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest patients with an initial asystole rhythm.

AIM: This study aimed to describe the characteristics of cases of out-of-hospital cardiac arrest (OHCA) with an initial asystole rhythm in which extracorporeal cardiopulmonary resuscitation (ECPR) was introduced and discuss the clinical indications for ECPR in such patients. METHODS: This was a secondary analysis of the SAVE-J II study, a retrospective, multicentre, registry study involving 36 participating institutions in Japan. Patients with an initial asystole rhythm were selected. Favourable neurological outcomes (cerebral performance categories 1-2) constituted the primary outcome. RESULTS: In total, 202 patients met the inclusion criteria, with favourable neurological outcomes at hospital discharge in 12 patients (5.9%). Causes of cardiac arrest with favourable neurological outcomes were hypothermia (7 cases), acute coronary syndrome (2 cases), arrhythmia (2 cases), and pulmonary embolism (1 case). Among patients with non-hypothermia (temperature ≥32 °C) on hospital arrival with the cardiac rhythm of asystole or pulseless electrical activity (PEA) on arrival, all 107 patients (66 asystole, 41 PEA) who lacked one or more of the requirements (witness; bystander CPR; signs of life or pupil < 5 mm) had unfavourable neurological outcomes. All 5 cases with favourable neurological outcomes, except for 1 case with a short duration of no-flow time that was highly suspected based on the patient's history, met all the requirements on hospital arrival. CONCLUSIONS: A total of 202 ECPR cases with an initial asystole rhythm, including 12 patients with favourable neurological outcomes, were described. Even if the initial cardiac rhythm is asystole, ECPR could be considered if certain conditions are met.

Outcome of extracorporeal membrane oxygenation use in severe accidental hypothermia with cardiac arrest and circulatory instability: A multicentre, prospective, observational study in Japan (ICE-CRASH study).

AIM: To elucidate the effectiveness of extracorporeal membrane oxygenation (ECMO) in accidental hypothermia (AH) patients with and without cardiac arrest (CA), including details of complications. METHODS: This study was a multicentre, prospective, observational study of AH in Japan. All adult (aged ≥18 years) AH patients with body temperature ≤32 °C who presented to the emergency department between December 2019 and March 2022 were included. Among the patients, those with CA or circulatory instability, defined as severe AH, were selected and divided into the ECMO and non-ECMO groups. We compared 28-day survival and favourable neurological outcomes at discharge between the ECMO and non-ECMO groups by adjusting for the patients' background characteristics using multivariable logistic regression analysis. RESULTS: Among the 499 patients in this study, 242 patients with severe AH were included in the analysis: 41 in the ECMO group and 201 in the non-ECMO group. Multivariable analysis showed that the ECMO group was significantly associated with better 28-day survival and favourable neurological outcomes at discharge in patients with CA compared to the non-ECMO group (odds ratio [OR] 0.17, 95% confidence interval [CI]: 0.05-0.58, and OR 0.22, 95%CI: 0.06-0.81). However, in patients without CA, ECMO not only did not improve 28-day survival and neurological outcomes, but also decreased the number of event-free days (ICU-, ventilator-, and catecholamine administration-free days) and increased the frequency of bleeding complications. CONCLUSIONS: ECMO improved survival and neurological outcomes in AH patients with CA, but not in AH patients without CA.

Postintensive Care Syndrome-Family Associated With COVID-19 Infection.

To assess the prevalence of and risk factors for postintensive care syndrome in family (PICS-F) in the COVID-19 era. DESIGN: A single-center retrospective study using questionnaires and telephone calls. SETTING: An ICU at St. Luke's International Hospital. PATIENTS: Patients who were treated for COVID-19-related acute respiratory distress syndrome between March 23, 2020, and September 30, 2021, and their family members participated. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: PICS-F refers to the psychologic distress such as anxiety, depression, and posttraumatic stress disorder (PTSD) experienced by the patient's family. The primary outcome was PICS-F occurrence. Furthermore, factors related to PICS-F development were identified using statistical analysis. Of 85 patients with COVID-19 who were admitted to the ICU, 57 family members consented to the study and completed the survey, and 54 family members' data were analyzed. The median age of family members was 53.5 years, 68.5% were female, and 46.3% were spouses. The median age of patients was 55.5 years, and 83.3% were male. During their ICU stay, 68.5% received invasive mechanical ventilation, 11.1% received venovenous extracorporeal membrane oxygenation, and 11.1% underwent tracheostomy. The median ICU and hospital stays were 7 and 22 days, respectively. Overall PICS-F occurred in 33%. Anxiety, depression, and PTSD occurred in 24%, 26%, and 4% of family members, respectively. The prevalence of all three components of PICS-F was 4%. Multivariable analysis showed that Family Satisfaction with the ICU Survey (FS-ICU) scores were independently associated with PICS-F development (odds ratio, 0.941; 95% CI, 0.891-0.983; p = 0.005). CONCLUSIONS: One-third of family members of COVID-19 patients admitted to the ICU had symptoms of PICS-F. These results suggest that measurement of FS-ICU may be helpful as a predictor of PICS-F development. In addition, increasing the level of ICU care satisfaction of the family members may prevent PICS-F.

Persistent Air Embolism after Blunt Chest Trauma with Recovery to Pre-Existing Consciousness Level: A Case Report and Literature Review.

We report the case of a 71-year-old woman in whom cerebral air embolism resulted from blunt chest trauma. The woman had been lying on her left side for a while after the injury, and air traveled to the right side of the brain. As a result, a cerebral infarction occurred in the right cerebral hemisphere that caused loss of consciousness for more than 40 days. The patient recovered consciousness eventually; thus, it is important to monitor the improvement in a patient's state of consciousness, with repeated multi-modality imaging evaluations over a long period.

Empyema with fistula successfully treated with a comprehensive approach including bronchial blocker and embolization receiving veno-venous extracorporeal membrane oxygenation.

BACKGROUND: Complicated empyema accompanied by bronchopleural fistula (BPF) has high mortality. The treatment strategy for severe respiratory failure due to empyema with BPF has yet to be established. CASE PRESENTATION: A 70-year-old man was brought to our hospital and diagnosed with right empyema, BPF (at bronchi B4-10), and secondary left pneumonia. We initiated drainage followed by veno-venous extracorporeal membrane oxygenation due to the severe hypoxia. First, the patient underwent endoscopic treatment with obstructive materials (known as endobronchial Watanabe spigot [EWS]) at B8-10, and was weaned off veno-venous extracorporeal membrane oxygenation on day 7. A secondary EWS was carried out at B4-6. A combination of medical treatments (drainage, antibiotics, nutritional therapy, and rehabilitation) improved his general condition. The patient was able to leave the hospital on foot. CONCLUSION: A comprehensive approach could explain the success of the medical treatment. The principal components are the repeated application of EWS as damage control.

Clinical characteristics and outcomes of critically ill COVID-19 patients in Tokyo: a single-center observational study from the first wave.

BACKGROUND: Many studies have been published about critically ill coronavirus disease 2019 (COVID-19) during the early phases of the pandemic but the characteristic or survival of critically ill Japanese patients have not yet been investigated. We sought to investigate the characteristics, inflammatory laboratory finding trends, and outcomes among critically ill Japanese patients who were admitted to the intensive care unit (ICU) with the first wave of COVID-19. METHODS: A retrospective observational study was performed in a single institution in the center of Tokyo. Laboratory-confirmed COVID-19 patients admitted to the ICU from March 19 to April 30, 2020 were included. Trends for significant inflammatory laboratory findings were analyzed. In-hospital death, days of mechanical ventilation or oxygen supplementation, days of ICU or hospital stay were followed until May 26, 2020. RESULTS: Twenty-four patients were included. Median age was 57.5 years, and 79% were male. The neutrophil-to-lymphocyte ratio was elevated to a median of 10.1 on admission and peaked on Day 10 of illness. Seventeen patients were intubated on Day 11 of illness and received mechanical ventilation. One patient underwent extracorporeal membrane oxygenation. The majority (88%) received systemic steroids, including 16 patients who received high dose methylprednisolone (500-1000 mg). Favipiravir was used in 38% of patients. Two patients, including 1 who refused intensive care, died. Eighteen patients were discharged. Median length of ICU and hospital stay for all patients was 6 and 22 days, respectively. Median length of ventilator dependency was 7 days. Four patients underwent a tracheostomy and received prolonged ventilation for more than 21 days. One patient receiving mechanical ventilation died. All survivors discontinued ventilator use. CONCLUSIONS: Mortality was remarkably low in our single institutional study. Three survivors received mechanical ventilation for more than 3 weeks. Trends of clinically significant laboratory markers reflected the clinical course of COVID-19.

One-Year Outcomes of Postintensive Care Syndrome in Critically Ill Coronavirus Disease 2019 Patients: A Single Institutional Study.

IMPORTANCE: Postintensive care syndrome has a strong impact on coronavirus disease 2019 survivors. OBJECTIVES: Assess the 1-year prevalence of postintensive care syndrome after coronavirus disease 2019. DESIGN SETTING AND PARTICIPANTS: This was a single-center prospective cohort using questionnaires and telephone calls from 4 months to 1 year after ICU discharge. Patients who were treated for coronavirus disease 2019-related acute respiratory distress between March 19, 2020, and April 30, 2020, participated. MAIN OUTCOMES AND MEASURES: Postintensive care syndrome was evaluated according to physical, mental, and cognitive domains. We surveyed the 8-item standardized Short Form questionnaire for assessing physical postintensive care syndrome; the Impact of Event Scale-Revised and the Hospital Anxiety and Depression Scale for assessing mental postintensive care syndrome; and Short-Memory Questionnaire for assessing cognitive postintensive care syndrome. The primary outcome was postintensive care syndrome occurrence of any domain at 1 year. Furthermore, the co-occurrence of the three postintensive care syndrome domains was assessed. RESULTS: Eighteen patients consented to the study and completed the survey. The median age was 57.5 years, and 78% of the patients were male. Median Acute Physiology and Chronic Health Evaluation-II score was 18. During ICU stay, 78% received invasive mechanical ventilation, and 83% received systemic steroid administration. Early mobilization was implemented in 61%. Delirium occurred in 44%. The median days of ICU and hospital stay were 6 and 23.5, respectively. Overall postintensive care syndrome occurrence was 67%. Physical, mental, and cognitive postintensive care syndrome occurred in 56%, 50%, and 33% of patients, respectively. The co-occurrence of all three domains of postintensive care syndrome was 28%. Age and Acute Physiology and Chronic Health Evaluation-II scores were higher, and systemic steroids were more commonly used in the postintensive care syndrome groups compared with the nonpostintensive care syndrome groups. Chronic symptoms were more common in the postintensive care syndrome groups than the nonpostintensive care syndrome groups. CONCLUSIONS AND RELEVANCE: Patients who suffered critical illness from coronavirus disease 2019 had a high frequency of postintensive care syndrome after 1 year. Long-term follow-up and care should be continuously offered.

Association between inflammation in acute phase and early onset pneumonia in patients with out-of-hospital cardiac arrest treated with extracorporeal cardiopulmonary resuscitation.

BACKGROUND: Early onset pneumonia (EOP) in patients with cardiac arrest treated with targeted temperature management is a recently debated issue. We assessed the association between C-reactive protein (CRP) levels and development of EOP in patients treated with extracorporeal cardiopulmonary resuscitation (ECPR). METHODS AND RESULTS: We reviewed the data of all patients admitted to our hospital after out-of-hospital cardiac arrest treated with ECPR between April 2006 and April 2019 who survived for at least 48 h. We collected demographic data, cardiac arrest characteristics, prophylactic antibiotic use, and neurologic outcomes. Diagnosis of EOP was made based on clinical, radiological, and microbiological criteria. The primary endpoint was the association between the incidence of EOP and CRP levels from day 1 to day 4. A total of 55 patients were included, of which 20 developed EOP. CRP levels on days 3 and 4 were significantly elevated in patients who developed EOP (13.1 [11.8-21.1] mg/dL versus 11.6 [7.4-15.2] mg/dL, P = 0.005; and 19.0 [16.9-27.1] mg/dL versus 14.7 [7.4-21.2] mg/dL, P = 0.019, respectively). In the multivariable logistic regression model, the CRP level on day 3 was significantly associated with the development of EOP (odds ratio 1.22; 95% confidence interval 1.06-1.41; P = 0.001). CONCLUSIONS: Increased inflammation in acute phase was associated with development of EOP in patients treated with ECPR.

Neuroleptic malignant syndrome in patients with COVID-19.

We report the first two cases of Coronavirus Disease 2019 (COVID-19) who were receiving intensive care including favipiravir, and were clinically diagnosed with neuroleptic malignant syndrome (NMS) to focus attention on NMS in COVID-19 management. Case 1: A 46-year-old-man with acute respiratory distress syndrome (ARDS) caused by COVID-19 infection was being administered favipiravir. Fentanyl, propofol, and rocuronium were also given. On day 3, midazolam administration was initiated for deep sedation. On day 5, his high body temperature increased to 41.2 °C, creatine kinase level elevated, and he developed tachycardia, tachypnea, altered consciousness, and diaphoresis. NMS was suspected, and supportive therapy was initiated. High-grade fever persisted for 4 days and subsided on day 9. Case 2: A 44-year-old-man with ARDS caused by COVID-19 infection was being treated with favipiravir. On day 5, risperidone was started for delirium. On day 7, his body temperature suddenly increased to 40.8 °C, his CK level elevated, and he developed tachycardia, tachypnea, altered consciousness, and diaphoresis. NMS diagnosis was confirmed, and both, favipiravir and risperidone were discontinued on day 8. On the same day, his CK levels decreased, and his body temperature normalized on day 9. Patients with COVID-19 infection frequently require deep sedation and develop delirium; therefore, more attention should be paid to the development of NMS in patients who are being administered such causative agents. The mechanism underlying the occurrence of NMS in COVID-19 patients treated with favipiravir remains unknown. Therefore, careful consideration of NMS development is necessary in the management of COVID-19 patients.

Development of acute kidney injury with massive granular casts and microscopic hematuria in patients with COVID-19: two case presentations with literature review.

BACKGROUND: Complications of acute kidney injury (AKI) are common in patients with coronavirus disease in 2019 (COVID-19). However, clinical characteristics of COVID-19-associated AKI are poorly described. We present two cases of severe COVID-19 patients with AKI. CASE PRESENTATION: A 77-year-old woman was suspected of having vancomycin-associated AKI, and a 45-year-old man was suspected of having heme pigment-induced AKI caused by rhabdomyolysis. The granular cast, which is known to be a valuable diagnostic tool for confirming the diagnosis of acute tubular necrosis, was detected in both patients at the onset of AKI. Interestingly, both patients also developed microscopic hematuria at the occurrence of AKI, and one patient had elevated d-dimer and low platelet levels simultaneously. CONCLUSIONS: Some reports suggested that COVID-19-associated microangiopathy contributed to the kidney damage. Therefore, it is possible that our patients might have accompanied renal microangiopathy, and that this pathological background may have caused exaggerated tubular damage by vancomycin or heme pigment. The etiology of AKI in patients with COVID-19 is multifactorial. Superimposition of nephrotoxin(s) and virus-associate intra-renal microangiopathy may be a crucial trigger of kidney injury leading to severe AKI in COVID-19 patients. Therefore, in COVID-19 patients, risk factors for AKI should be taken into consideration to prevent its progression into severe AKI.