Clinical outcomes of antithrombin III supplementation in an overt disseminated intravascular coagulation: a longitudinal single-institutional experience and retrospective analysis.

BACKGROUND: Antithrombin is a small plasma glycoprotein synthesized in the liver that belongs to the serpin family of serine protease inhibitors and inactivates several enzymes in the coagulation pathway. It plays a leading major factor on coagulation pathway, therefore administration of antithrombin is essential to treat serious clinical conditions such as disseminated intravascular coagulation (DIC). Despite the theoretical benefits of antithrombin supplementation, the optimal antithrombin activity for heparin efficacy and the benefits of antithrombin supplementation in various disease entities are not yet fully understood. METHODS: The strict administration guidelines on antithrombin III in cases of DIC by the National Health Insurance Service and the Ministry of Food and Drug Safety complied as follows: antithrombin levels below 20 mg/dL in adults; antithrombin activity below 70% of normal in adults; total administration period of antithrombin must be carefully limited to within maximum 3 days, and the total administration dose must be below 7,000 international unit (IU), (loading dose, 1,000 IU in 1 hour: maintenance dose, 500 IU every 6 hours for 3 days). RESULTS: We identified 76 eligible for analysis according to the above-mentioned criteria in our institution (male/female, 59/17). Forty-four were identified to the non-survivor group and 32 patients were recognized as the survivor group. The baseline parameters in the non-survivor and survivor groups were comparable with no significant differences in age (66.5±18.1 vs. 66.0±16.2 years, P=0.90), sex (32/12 vs. 27/5, P=0.35), hospital length of stay (31.1±34.5 vs. 31.2±26.1 days, P=0.99), sequential organ failure assessment (SOFA) (7.3±2.5 vs. 6.6±2.0, P=0.22), simplified acute physiology score II (SAPS II) (46.0±8.8 vs. 43.5±9.2, P=0.23), cause for DIC (P=0.95), and underlying disease (P=0.38). The levels of antithrombin III on the day just before the administration significantly lower in the non-survivor groups than in the survivor groups (50.1%±13.6% vs. 57.6%±12.5%, P=0.01). The hemoglobin level in the 2nd day and 7th day after antithrombin III administration was significantly different between the non-survivor and survivor groups (9.9±1.9 vs. 11.0±2.0 g/dL, P=0.01, and 9.4±1.8 vs. 10.5±1.6 g/dL, P=0.006). The antithrombin III levels on the day of administration [area under the curve (AUC) =0.672] demonstrated significantly better prediction of mortality than the A antithrombin III levels on 1st day (AUC =0.552), the 2nd day (AUC =0.624), and 7th day (AUC =0.593). CONCLUSIONS: Our study suggests that the antithrombin administration may be effective tools for DIC treatment, and may be more positively considered, especially in the cases of DIC, which is a frequent complication of septic shock, sepsis, and other critical disease entities and which is associated with a high level of mortality. Furthermore, our study also suggests that the total doses and periods of antithrombin administration, which recommended by national guidelines, may be insufficient, therefore prolongation of period and increase of total dose of antithrombin supplement might be necessary.

Limitations of surface EMG estimate of parasternal intercostal to infer neural respiratory drive.

BACKGROUND: Recently, surface EMG of parasternal intercostal muscle has been incorporated in the "ERS Statement of Respiratory Muscle Testing" as a clinical technique to monitor the neural respiratory drive (NRD). However, the anatomy of the parasternal muscle risks confounding EMG "crosstalk" activity from neighboring muscles. OBJECTIVES: To determine if surface "parasternal" EMG: 1) reliably estimates parasternal intercostal EMG activity, 2) is a valid surrogate expressing neural respiratory drive (NRD). METHODS: Fine wire electrodes were implanted into parasternal intercostal muscle in 20 severe COPD patients along with a pair of surface EMG electrodes at the same intercostal level. We recorded both direct fine wire parasternal EMG (EMGPARA) and surface estimated "parasternal" EMG (SurfEMGpara) simultaneously during resting breathing, volitional inspiratory maneuvers, apnoea with extraneous movement of upper extremity, and hypercapnic ventilation. RESULTS: Surface estimated "parasternal" EMG showed spurious "pseudobreathing" activity without any airflow while real parasternal EMG was silent, during apnoea with body extremity movement. Surface estimated "parasternal" EMG did not faithfully represent real measured parasternal EMG. Surface estimated "parasternal" EMG was significantly less active than directly measured parasternal EMG during all conditions including baseline, inspiratory capacity and hypercapnic ventilation. Bland-Altman analysis showed consistent bias between direct parasternal EMG recording and surface estimated EMG during stimulated breathing. CONCLUSION: Surface "parasternal" EMG does not consistently or reliably express EMG activity of parasternal intercostal as recorded directly by implanted fine wires. A chest wall surface estimate of parasternal intercostal EMG may not faithfully express NRD and is of limited utility as a biomarker in clinical applications.

Effect of Topical Lidocaine Patch on Postoperative Pain Management in Laparoscopic Appendectomy: A Randomized, Double-Blind, Prospective Study.

BACKGROUND: Adequate pain control is a major concern in the immediate postoperative period. In multiple strategies for postoperative pain management, topical analgesics have significant advantages of minimizing severe side effects caused by oral and parenteral administration and drug-drug interactions. Therefore, we studied the effect of lidocaine patch on postoperative pain control in laparoscopic appendectomy. PATIENTS AND METHODS: This randomized double-blind prospective controlled study enrolled 40 acute appendicitis cases that were treated by laparoscopic appendectomy and randomly divided into two groups. Lidocaine patches containing lidocaine 175 mg was applied to the umbilical trocar site of each patient, and pain intensity was assessed with the visual analog scale every 6 hours up to 48 hours after laparoscopic appendectomy. RESULTS: There was no significant difference in age, gender, body mass index, the American society of anesthesiologists score, comorbidity, or underlying disease between the lidocaine patch and control groups. The postoperative pain scores were lower in the lidocaine patch group than in the control group, but statistical significance was not noted at the trocar site or the right lower quadrant of the abdomen (P = .320 and P = .903, respectively). The mean amounts of pethidine used after surgery were significantly smaller in the lidocaine patch group than in the control group (0.10 ± 0.31 mg versus 0.25 ± 0.79 mg, P < .001). CONCLUSIONS: The results of this study suggest that lidocaine patch application to the trocar site after laparoscopic appendectomy may have a positive effect on the management of postoperative pain and can eliminate the need to inject additional analgesics for further postoperative pain control.

Hypovolemic shock caused by delayed-onset superior gluteal artery rupture, successfully treated with arteriographic embolization.

INTRODUCTION: Rupture of the superior gluteal artery (SGA) is usually associated with pelvic bone fractures and acetabular fractures secondary to blunt trauma. However, despite recent advances in technologies and tools, rupture of the SGA remains a challenging problem because it is difficult to manage and is frequently associated with significantly high mortality and morbidity. PATIENTS AND METHODS: We present a case of an 82-year-old man, who presented to our emergency department after a cultivator turnover accident and who showed stable initial vital signs and manifested only as blunt buttock traumatic contusion without any pelvic bone or acetabular fracture, which resulted in delayed massive bleeding from the SGA on eight days after trauma. RESULTS: A hypovolemic shock and abrupt 4.2 g/dl hemoglobin decrease caused by massive bleeding from delayed-onset SGA rupture, was successfully treated with urgent angiographic embolization. CONCLUSIONS: A delayed SGA bleeding should be considered in late-onset shock associated with blunt buttock trauma. Furthermore, early detection and embolization not only prevent further complications, such as compartment syndrome and hypovolemic shock, but also eliminate the need for any surgical interventions.

Advanced Age as a Predictor of Survival and Weaning in Venoarterial Extracorporeal Oxygenation: A Retrospective Observational Study.

Background. In most reports on ECMO treatment, advanced age is classified as a contraindication to VA ECMO. We attempted to investigate whether advanced age would be a main risk factor deciding VA ECMO application and performing VA ECMO support. We determined whether advanced age should be regarded as an absolute or relative contraindication to VA ECMO and could affect weaning and survival rates of VA ECMO patients. Methods. VA ECMO was performed on 135 adult patients with primary cardiogenic shock between January 2010 and December 2014. Successful weaning was defined as weaning from ECMO followed by survival for more than 48 hours. Results. Among the 135 patients, 35 survived and were discharged uneventfully, and the remaining 100 did not survive. There were significant differences in survival between age groups, and older age showed a lower survival rate with statistical significance (P = .01). By multivariate logistic regression analysis, age was not significantly associated with in-hospital mortality (P = .83) and was not significantly associated with VA ECMO weaning (P = .11). Conclusions. Advanced age is an undeniable risk factor for VA ECMO; however, patients of advanced age should not be excluded from the chance of recovery after VA ECMO treatment.

The learning curve of single-port laparoscopic appendectomy performed by emergent operation.

BACKGROUND: Single-port laparoscopic appendectomy (SPLA) has the advantage of minimizing abdominal incision scars with patient satisfaction. However, it has the following disadvantages: it provides a narrower surgical field than conventional laparoscopic appendectomy, which requires a considerably longer operative time to achieve surgical skills. This study was conducted to evaluate the learning curve for SPLA. METHODS: This study included a total of 120 patients with acute abdomen who visited our emergency department and were diagnosed with acute appendicitis between March 2013 and February 2015. They underwent SPLA by a single surgeon. Patients were divided into 4 groups of 30 patients each according to operation dates. Operative time, time to resume oral intake, length of hospital stay, and postoperative complications were analyzed. RESULTS: The mean operative time was 59.9 ± 19.9 min. It was shortened after completion of 30 operations and remained unchanged until it was further shortened after completion of 90 operations. There was no significant difference in time to resumption of oral intake or length of hospital stay between the 4 groups. Postoperative complications occurred in 18 patients, but the frequency of the complications was not significantly different between the 4 groups. CONCLUSIONS: The results of this study suggest that surgeons can achieve surgical skills for SPLA after completion of 30 operations and more experienced surgical skills by SPLA successfully after completion of 90 operations.

Retained guidewire penetrating through the aorta into the thorax: an unusual cause of recurrent bilateral pneumothorax.

Although numerous complications of the Seldinger technique have been reported in the literature, only a few complications are related to guidewires. We here report a case of a patient with a guidewire lost and retained in the aorta during vertebral artery stenting. Unfortunately, the guidewire in the aorta was not detected for 5 years, and it penetrated through the aorta into the left thorax, leading to recurrent left pneumothorax. No physician identified the wandering guidewire in the left thorax, and the recurrent left pneumothorax was only managed with closed thoracostomy drainage several times. After 4 months, the patient presented to our hospital with repeated severe chest pain, and newly developed right pneumothorax was diagnosed on chest X-rays. We meticulously evaluated the radiological findings of the other hospitals to identify the cause of the recurrent pneumothorax and discovered that the lost and wandering guidewire had crossed over from the left to the right thorax through the anterior mediastinum. The guidewire was identified as the cause of the recurrent bilateral pneumothorax, and the patient was successfully treated with video-assisted thoracoscopic surgery without any events.