Prognostic factors in patients with septic shock in digestive surgery who have undergone direct hemoperfusion with polymyxin B-immobilized fibers: a retrospective observational study.

BACKGROUND: Direct hemoperfusion with polymyxin B-immobilized fiber (PMX-DHP) has been widely used for patients with septic shock around the world, but the prognostic factors have not been fully understood. We conducted a retrospective analysis to determine the prognostic factors in patients with septic shock who underwent PMX-DHP. METHODS: Twenty-nine patients with septic shock who underwent PMX-DHP were included in the study. The patients were divided into groups based on survival (n = 23) and non-survival (n = 6) 28 days after PMX-DHP, and the clinical data for the two groups before and after PMX-DHP were compared. RESULTS: In non-survivors, the vasopressor dependency index before PMX-DHP was significantly higher (p = 0.046), and the leukocyte count before PMX-DHP was significantly lower (p = 0.024) than in survivors. Furthermore, base excess after PMX-DHP was significantly lower in non-survivors (p = 0.007) than in survivors. The optimal cutoff points of the vasopressor dependency index, leukocyte count, and base excess identified by receiver operating characteristic curves were 0.499/mmHg, 1360/µL, and -6.4 mmol/L, respectively. And the score using these three cutoffs, termed the prognostic score, was related to the prognosis of septic shock patients who underwent PMX-DHP (area under the curve = 0.946). CONCLUSIONS: The prognostic score, using three parameters which are immediately and readily available in early phase after starting PMX-DHP, might be useful to predict the prognosis of these patients.

Perioperative management for placement of tracheobronchial stents.

Tracheobronchial stenting was performed under general anesthesia, with (six patients) or without (two patients) muscle relaxant, in eight patients suffering from carcinoma. All patients had presented preoperatively with dyspnea, exhibiting Hugh-Jones grade 4 or 5. Three patients had been mechanically ventilated before the procedure. The procedure was performed under general anesthesia with flexible bronchoscopic guidance. Stent placement was performed either through an orotracheal tube (four patients) or through a transtracheal tube (two patients) in those who had no upper tracheal stenosis, while it was performed through a laryngeal mask airway in two patients with upper tracheal stenosis. During the procedure, arterial hemoglobin oxygen saturation (Sp(O(2)) decreased in all patients, despite fraction of inspired oxygen (FI(O(2)) being maintained at 1.0. Except for two patients, one of whom developed superior vena cava syndrome and one, tension pneumothorax after stent placement, there were no complications resulting from stent placement. Six patients were weaned from mechanical ventilation (0-24 days after the procedure). Two of the three patients who had been on mechanical ventilation preoperatively could not be weaned. Stent insertion is an effective treatment for tracheobronchial stenosis, but its indications in patients with malignancy who have been mechanically ventilated prior to stenting should further be evaluated.

[Postoperative nausea and vomiting after open heart surgery].

We investigated the incidence of the postoperative nausea and vomiting (PONV) following cardiac surgery with cardiopulmonary bypass. We conducted a prospective study of 65 cases with direct interviews by anesthesiologists who are blind to this protocol every 6 hours during ICU stay. There were no differences in age, body mass index, dose of fentanyl, operating time, cardiopulmonary bypass time and ventilation time in ICU between PONV(+) and PONV(-). Incidence of PONV was 43%, but 70% of female patients complained of PONV. Prophylactic antiemetic strategy might be clinically relevant to female patients who are to undergo open heart surgery with cardiopulmonary bypass.

[A case of severe septicemia due to Aeromonas hydrophila].

Septicemia by Aeromonas hydrophila (A. hydrophila) developed in a 69-year-old female with a history of uncompensated liver cirrhosis. She was admitted to our hospital, complaining of fever, vomiting, diarrhea, and pain as well as swelling of the left lower extremity. Seven hours later, skin of the left extremity developed bullae and became discolored. Although she was treated with infusion of antibiotics plus dopamine, continuous hemodiafiltration, glucose-insulin therapy and mechanical ventilation, she fell in severe septic shock, and died 23 hours after admission. A. hydrophila was isolated from both blood and bullous fluid. Mortality rate of septicemia due to A. hydrophila is reported ranging from 29% to 73%. Patients with liver disease have poor prognosis. Morbidity of this septicemia depends on pre-infection conditions, especially on liver functions. Early surgical debridement and antimicrobial therapy is recommended, but rapid worsening often results in death. We have to pay attention to infection of A. hydrophila especially in patients with liver cirrhosis.