Association between Postoperative Adjuvant Vasodilator Therapy and In-Hospital Mortality for Non-Occlusive Mesenteric Ischemia: A Nationwide Observational Study.

BACKGROUND: Although several clinical guidelines recommend vasodilator therapy for non-occlusive mesenteric ischemia (NOMI) and immediate surgery when bowel necrosis is suspected, these recommendations are based on limited evidence. METHODS: In this retrospective nationwide observational study, we used information from the Japanese Diagnosis Procedure Combination inpatient database from July 2010 to March 2018 to identify patients with NOMI who underwent abdominal surgeries on the day of admission. We compared patients who received postoperative vasodilator therapy (vasodilator group) with those who did not (control group). Vasodilator therapy was defined as venous and/or arterial administration of papaverine and/or prostaglandin E1 within 2 days of admission. The primary outcome was in-hospital mortality. Secondary outcomes included the prevalence of additional abdominal surgery performed ≥3 days after admission and short bowel syndrome. RESULTS: We identified 928 eligible patients (149 in the vasodilator group and 779 in the control group). One-to-four propensity score matching yielded 149 and 596 patients for the vasodilator and control groups, respectively. There was no significant difference in in-hospital mortality between the groups (control vs. vasodilator, 27.5% vs. 30.9%; risk difference, 3.4%; 95% confidence interval, -4.9 to 11.6; p=0.42) and no significant difference in the prevalences of abdominal surgery, bowel resection ≥3 days after admission, and short bowel syndrome. CONCLUSIONS: Postoperative vasodilator use was not significantly associated with a reduction in in-hospital mortality or additional abdominal surgery performed ≥3 days after admission in surgically treated NOMI patients.

Effectiveness of vacuum-assisted wound closure and mesh-mediated fascial traction in open abdomen management.

PURPOSE: To determine the effectiveness of vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) in patients undergoing open abdomen management (OAM). METHODS: Data from cases with OAM for at least five days who were admitted to our institution between January 2011 and December 2020 were included. We compared the patient's age, sex, medical history, indication for initial surgery, APACHE II scores, indication for OAM, operative time, intraoperative blood loss, intraoperative transfusion, success of primary fascial closure (rectus fascial closure and bilateral anterior rectus abdominis sheath turnover flap method), success of planned ventral hernia, duration of OAM, and in-hospital mortality between patients undergoing VAWCM (VAWCM cases, n = 27) and vacuum-assisted wound closure (VAWC) alone (VAWC cases, n = 25). RESULTS: VAWCM cases had a significantly higher success rate of primary fascial closure (70% vs. 36%, p = 0.030) and lower in-hospital mortality (26% vs. 72%, p = 0.002) than VAWC cases. A multivariate logistic regression analysis showed that VAWCM was an independent factor influencing in-hospital mortality (odds ratio, 0.14; 95% confidence interval: 0.04-0.53; p = 0.004). CONCLUSION: VAWCM is associated with an increased rate of successful primary fascial closure and may reduce in-hospital mortality.

Delayed stomach necrosis in a patient with injured celiac artery branches after penetrating abdominal trauma.

Injuries of the celiac artery and its branches are rare, but potentially lethal. Ligation of these arteries is performed to control significant hemorrhage. However, few reports have described the adverse effects of ligating these arteries. A 69-year-old woman with a self-inflicted stab wound was brought to our hospital. Her blood pressure could not be measured, therefore aortic cross-clamping was performed, and epinephrine was administered for resuscitation, an emergency laparotomy was performed, and the roots of splenic artery and common hepatic artery were ligated. The left gastric artery which was anomalous and arose directly from the aorta, was also injured and had to be ligated. Norepinephrine was required after the surgery. Enhanced computed tomography performed on hospital day 4 revealed a disrupted celiac artery. The patient developed gastric necrosis on hospital day 23 and, hence, underwent total gastrectomy was performed. The possibility of delayed stomach necrosis should be considered during the postoperative management of patients who undergo ligation of all of the celiac artery branches and experience global hypoperfusion after the surgery.

Two Cases of Bronchial Artery Racemose Hemangioma Successfully Treated with Bronchial Artery Embolization.

Rupture of a racemose hemangioma causing dilatation and tortuosity of the bronchial artery can result in massive bleeding and respiratory failure. Bronchial artery embolization (BAE) can treat this life-threatening condition, as we show in two cases. The first case was of an 89-year-old female complaining of sudden-onset chest and back pain. Bronchial artery angiography demonstrated a racemose hemangioma with a 2 cm aneurysm. The second case was of a 50-year-old male with hemoptysis and dyspnea, eventually requiring intubation. Bronchial arteriography showed a racemose hemangioma and a bronchial artery-pulmonary arterial fistula. BAE was successfully performed in both cases, with no recurrent hemorrhage. Therapeutic interventions in bronchial artery racemose hemangiomas include lobectomy or segmentectomy, bronchial arterial ligation, and BAE. BAE should be considered as first-line therapy for bleeding racemose hemangiomas of the bronchial artery because of its low risk of adverse effects on respiratory status, minimal invasiveness, and faster patient recovery.

Timing and order of surgeries for thoracic trauma with multiple injuries: A case report.

The timing and order of multiple surgeries for patients with multiple thoracic injuries have not been standardized. A 75-year-old man, who was injured because of a closing elevator door, underwent intubation, bilateral chest drain insertion, and massive blood transfusion due to shock and respiratory distress. Computed tomography showed hemopneumothorax with extravasation, tracheobronchial injury, aortic injury, thoracic vertebral anterior dislocation, and multiple rib fractures. He was hospitalized and underwent embolization on the day of admission. Next, veno-venous extracorporeal membrane oxygenation (VV-ECMO) was conducted to address severe respiratory failure. The most crucial aspect of the management was treating the tracheobronchial injury because weaning the patient off the VV-ECMO depended on the success of the repair. Thus, the tracheobronchial repair was performed 7-10 days after injury. A right intrathoracic hematoma removal was performed on the third day and a thoracic endovascular aortic repair on the fifth day. The tracheobronchial repair was performed on the ninth day followed by the posterior thoracic fusion on the 18th day. The patient was successfully weaned off the VV-ECMO and mechanical ventilation on the 24th and 46th days, respectively. Early surgery is not always ideal when managing thoracic trauma cases involving multiple sites. Rather, the treatment should be individualized, and the essential surgical procedures should be timed appropriately.

Transileocolic endovascular treatment by a hybrid approach for severe acute portal vein thrombosis with bowel necrosis: Two case reports.

BACKGROUND: Acute portal vein thrombosis (PVT) with bowel necrosis is a fatal condition with a 50%-75% mortality rate. This report describes the successful endovascular treatment (EVT) of two patients with severe PVT. CASE SUMMARY: The first patient was a 22-year-old man who presented with abdominal pain lasting 3 d. The second patient was a 48-year-old man who presented with acute abdominal pain. Following contrast-enhanced computed tomography, both patients were diagnosed with massive PVT extending to the splenic and superior mesenteric veins. Hybrid treatment (simultaneous necrotic bowel resection and EVT) was performed in a hybrid operating room (OR). EVTs, including aspiration thrombectomy, catheter-directed thrombolysis (CDT), and continuous CDT, were performed via the ileocolic vein under laparotomy. The portal veins were patent 4 and 6 mo posttreatment in the 22-year-old and 48-year-old patients, respectively. CONCLUSION: Hybrid necrotic bowel resection and transileocolic EVT performed in a hybrid OR is effective and safe.

The impact of blood type on the mortality of patients with severe abdominal trauma: a multicenter observational study.

Few studies have investigated the relationship between blood type and trauma outcomes according to the type of injury. We conducted a retrospective multicenter observational study in twelve emergency hospitals in Japan. Patients with isolated severe abdominal injury (abbreviated injury scale for the abdomen ≥ 3 and that for other organs < 3) that occurred between 2008 and 2018 were divided into four groups according to blood type. The association between blood type and mortality, ventilator-free days (VFD), and total transfusion volume were evaluated using univariate and multivariate regression models. A total of 920 patients were included, and were divided based on their blood type: O, 288 (31%); A, 345 (38%); B, 186 (20%); and AB, 101 (11%). Patients with type O had a higher in-hospital mortality rate than those of other blood types (22% vs. 13%, p < 0.001). This association was observed in multivariate analysis (adjusted odds ratio [95% confidence interval] = 1.48 [1.25-2.26], p = 0.012). Furthermore, type O was associated with significantly higher cause-specific mortalities, fewer VFD, and larger transfusion volumes. Blood type O was associated with significantly higher mortality and larger transfusion volumes in patients with isolated severe abdominal trauma.

Nonocclusive mesenteric ischemia associated with a hyperosmolar hyperglycemic state: Hepatic portal venous gas as an indicator of mesenteric ischemia.

BACKGROUND: The diagnosis of nonocclusive mesenteric ischemia (NOMI) is always challenging in critically ill patients. Herein, we aimed to report a case of NOMI associated with a hyperosmolar hyperglycemic state (HHS). A small amount of hepatic portal venous gas (HPVG) triggered the diagnosis of NOMI. CASE PRESENTATION: A 77-year-old man was transferred due to shock and disorder of consciousness. He was diagnosed with an HHS. We suspected intestinal ischemia due to a small amount of HPVG revealed by computed tomography (CT). Peritoneal signs were revealed after treatment for the HHS. Computed tomography was carried out again 5 h after admission, which showed a large amount of HPVG, remarkable bowel dilatation, and pneumatosis intestinalis. We performed an emergency laparotomy and resected the small bowel necrosis resulting from NOMI. CONCLUSION: An HHS can cause NOMI, and the presence of HPVG on CT is an important finding that suggests mesenteric ischemia, even in small amounts.

Revision of the Protocol of the Telephone Triage System in Tokyo, Japan.

INTRODUCTION: The Emergency Telephone Consultation Center in Tokyo (#7119) was the first telephone triage system in Japan and has operated since 2007. This study examined the revision of the #7119 protocol by referring the linked data to each code of the triage protocol. METHODS: We selected candidates based on the medical codes targeted by the revision, linking data from the nurses' decisions in triage and the patients' condition severity when the ambulance arrived at the hospital, gathering data from June 1, 2016, to December 31, 2017. Then, several emergency physicians evaluated the cases and decided whether the code should be moved to the more or less urgent category or if new protocols and codes would be established. RESULTS: In this revision, 371 codes were moved to the less urgent category, 35 codes were moved to the more urgent category, and 128 codes were newly established. In all, 59 red codes (transfer to the ambulance dispatcher) were reduced, while 254 orange codes (attendance at hospital within 1 hour) and yellow codes (within 6 hours) were moved to less urgent, and 12 yellow and green codes (within 24 hours) were moved to more urgent. CONCLUSION: We adjusted the triage codes for the revision by linking the call data with the case data. This revision should decrease the inappropriate use of ambulances and reduce the primary care workload. To achieve a more accurate revision, we need to refine the process of evaluating the validity of patients' acuity over the telephone during triage.

Planned Versus On-Demand Relaparotomy Strategy in Initial Surgery for Non-occlusive Mesenteric Ischemia.

BACKGROUND: There has been insufficient evidence regarding a treatment strategy for patients with non-occlusive mesenteric ischemia (NOMI) due to the lack of large-scale studies. We aimed to evaluate the clinical benefit of strategic planned relaparotomy in patients with NOMI using detailed perioperative information. METHODS: We conducted a multicenter retrospective cohort study that included NOMI patients who underwent laparotomy. In-hospital mortality, 28-day mortality, incidence of total adverse events, ventilator-free days, and intensive care unit (ICU)-free days were compared between groups experiencing the planned and on-demand relaparotomy strategies. Analyses were performed using a multivariate mixed effects model and a propensity score matching model after adjusting for pre-operative, intra-operative, and hospital-related confounders. RESULTS: A total of 181 patients from 17 hospitals were included, of whom 107 (59.1%) were treated using the planned relaparotomy strategy. The multivariate mixed effects regression model indicated no significant differences for in-hospital mortality (61 patients [57.0%] in the planned relaparotomy group vs. 28 patients [37.8%] in the on-demand relaparotomy group; adjusted odds ratio [95% confidence interval] = 1.94 [0.78-4.80]), as well as in 28-day mortality, adverse events, and ICU-free days. Significant reduction in ventilator-free days was observed in the planned relaparotomy group. Propensity score matching analysis of 61 matched pairs with comparable patient severity did not show superiority of the planned relaparotomy strategy. CONCLUSIONS: The planned relaparotomy strategy, compared with on-demand relaparotomy strategy, did not show clinical benefits after the initial surgery of patients with NOMI. Further studies estimating potential subpopulations who may benefit from this strategy are required.

Portal Venous Gas in Adults: Clinical Significance, Management, and Outcomes of 25 Consecutive Patients.

BACKGROUND: Portal venous gas (PVG) is a rare finding and has a grave prognosis. The most common and critical underlying pathology of PVG is bowel necrosis. However, bowel necrosis is sometimes difficult to accurately diagnose. We retrospectively analyzed data from patients that contributed to the decision to perform emergency surgery and bowel resection. METHODS: Between 2009 and 2019, 25 consecutive adult patients with PVG were identified retrospectively and divided into the Operation and Non-operation groups. The Operation group was further subdivided into the Bowel resection and Non-resection groups. Clinical, laboratory, and radiographic variables were analyzed. RESULTS: Conservative management was successful for 32% (8/25) of patients (Non-operation group: mortality 0%); 68% (17/25) were treated surgically (Operation group: mortality 35.3%). In the Operation group, 52.9% (9/17) underwent bowel resection (Bowel resection group: mortality 55.6%); however, bowel resection was unnecessary in 47.1% (8/17) of cases (Non-resection group: mortality 12.5%). Univariate analysis revealed significant differences between the Operation and Non-operation groups in GCS, APACHE II, abdominal distention, CRP, lactate, and CT findings of bowel dilatation, pneumatosis intestinalis, and attenuation of contrast effects of the bowel wall. However, with the exception of GCS, there was no significant difference between the Bowel resection and Non-resection groups. CONCLUSIONS: Analysis of clinical, laboratory, and radiographic variables can inform decisions on conservative management. However, 47.1% of the present patients who underwent surgery for suspected bowel necrosis did not require bowel resection, suggesting that this approach alone may not be sufficient to avoid non-therapeutic laparotomy. A new approach should be developed to improve this situation.

Vasodilator Therapy and Mortality in Nonocclusive Mesenteric Ischemia: A Nationwide Observational Study.

OBJECTIVES: Previous studies have suggested that vasodilator therapy may be beneficial for patients with nonocclusive mesenteric ischemia. However, robust evidence supporting this contention is lacking. We examined the hypothesis that vasodilator therapy may be effective in patients diagnosed with nonocclusive mesenteric ischemia. DESIGN: Retrospective cohort study. SETTING: The Japanese Diagnosis Procedure Combination inpatient database. PATIENTS: A total of 1,837 patients with nonocclusive mesenteric ischemia from July 2010 to March 2018. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We compared patients who received vasodilator therapy (vasodilator group; n = 161) and those who did not (control group; n = 1,676) using one-to-four propensity score matching. Vasodilator therapy was defined as papaverine and/or prostaglandin E1 administered via venous and/or arterial routes within 2 days of admission. Only patients who did not receive abdominal surgery within 2 days of admission were analyzed. The main outcomes were in-hospital mortality and abdominal surgery performed greater than or equal to 3 days after admission. After propensity score matching, in-hospital mortality was significantly lower in the vasodilator group (risk difference, -11.6%; p = 0.005). The proportion of patients who received abdominal surgery at greater than or equal to 3 days after admission was also significantly lower in the vasodilator group (risk difference, -10.2%; p = 0.002). CONCLUSIONS: Vasodilator therapy with papaverine and/or prostaglandin E1 is associated with lower in-hospital mortality and prevalence of abdominal surgery in patients with nonocclusive mesenteric ischemia.

Delayed development of portal vein thrombosis in a patient initially detected with portal venous gas and pneumatosis intestinalis: a case report.

BACKGROUND: Portal venous gas (PVG) and pneumatosis intestinalis (PI) are rare pathologic findings, and a delayed appearance of portal vein thrombosis (PVT) in such patients is extremely rare. CASE PRESENTATION: A 51-year-old man complaining of epigastric pain was referred to our hospital. Computed tomography (CT) at admission revealed massive PVG and extensive PI, but no PVT. Emergency laparotomy was carried out, but bowel resection was unnecessary. On follow-up CT on postoperative day 5, thrombosis was noted in the portal venous system, and anticoagulant was started immediately. This patient was discharged and continued to take the anticoagulant. Seven months after discharge, PVT had disappeared on CT without any thromboembolic complications. CONCLUSION: If acute PVT is detected, anticoagulant is needed to prevent bowel ischemia and/or portal hypertension due to the growth of the thrombus. Clinicians should be aware of the potential for such a complication, and make their best efforts to exclude this entity using CT or sonography.

Advanced cadaver-based educational seminar for trauma surgery using saturated salt solution-embalmed cadavers.

AIM: Senior surgeons in Japan who participated in "cadaver-based educational seminar for trauma surgery (CESTS)" subsequently stated their interest in seminars for more difficult procedures. Therefore, we held a 1-day advanced-CESTS with saturated salt solution (SSS)-embalmed cadavers and assessed its effectiveness for surgical skills training (SST). METHODS: Data were collected from three seminars carried out from September 2015 to January 2018, including a 10-point self-assessment of confidence levels (SACL) questionnaire on nine advanced surgical skills, and evaluation of seminar content before, just after, and half a year after the seminar. Participants assessed the suitability of the two embalming methods (formalin solution [FAS] and SSS) for SST, just after the seminar. Statistical analysis resulted in P < 0.0167 comparing SACL results from seminar evaluations at the three time points and P < 0.05 comparing FAS to SSS. RESULTS: Forty-three participants carried out surgical procedures of the lung, liver, abdominal aorta, and pelvis and extremity. The SACL scores increased in all skills between before and just after the seminar, but were decreased by half a year after. However, SACL scores of each skill did not change significantly, except for external fixation for pelvic fracture at just after and half a year after. The SSS-embalmed cadavers were evaluated as being more suitable than FAS-embalmed cadavers for each procedure. CONCLUSIONS: Advanced-CESTS using SSS-embalmed cadavers increased the participants' self-confidence just after the seminar, which was maintained after half a year in each skill, except external fixation for pelvic fracture. Therefore, SSS-embalmed cadavers are useful for SST, particularly for surgical repairs.

The long-term outcomes of early abdominal wall reconstruction by bilateral anterior rectus abdominis sheath turnover flap method in critically ill patients requiring open abdomen.

Background: In a previous study, we reported the usefulness of early abdominal wall reconstruction using bilateral anterior rectus abdominis sheath turnover flap method (turnover flap method) in open abdomen (OA) patients in whom early primary fascial closure was difficult to achieve. However, the long-term outcomes have not been elucidated. In the present study, we aimed to evaluate the procedure, particularly in terms of ventral hernia, pain, and daily activities. Methods: Between 2001 and 2013, 15 consecutive patients requiring OA after emergency laparotomy and in whom turnover flap method was applied were retrospectively identified. The long-term outcomes were evaluated based on medical records, physical examinations, CT imaging, and a ventral hernia pain questionnaire (VHPQ). Results: The turnover flap method was applied in 2 trauma and 13 non-trauma patients.In most of cases, primary fascial closure could not be achieved due to massive visceral edema. The turnover flap method was performed for abdominal wall reconstruction at the end of OA. The median duration of OA was 6 (range 1-42) days. One of the 15 patients died of multiple organ failure during initial hospitalization after the performance of the turnover flap method. Fourteen patients survived, and although wound infection was observed in 3 patients, none showed enteric fistula, abdominal abscess, graft infection, or ventral hernia during hospitalization. However, it was found that 1 patient developed ventral hernia during follow-up at an outpatient visit. Nine of 14 patients were alive and able to be evaluated with a VHPQ (follow-up period: median 10 years; range 3-15 years). Seven out of nine patients were satisfied with this procedure, and none complained of pain or were limited in their daily activities. Conclusions: Based on the results of this study, early abdominal reconstruction using the turnover flap method can be considered to be safe and effective as an alternative technique for OA patients in whom primary fascial closure is considered difficult to achieve.

Staged Strategy for Early Abdominal Wall Closure in a Case Involving Ruptured Abdominal Aortic Aneurysm Requiring Open Abdomen in Which Primary Fascial Closure was Difficult to Achieve: A Case Report.

Open abdomen is sometimes necessary to save lives after ruptured abdominal aortic aneurysm repair. We report a case in which a staged strategy for early abdominal wall closure was applied to prevent the severe complications due to the extended period of open abdomen. An 81-year-old man with ruptured abdominal aortic aneurysm was transported to our hospital. After the first operation, which required open abdomen, prolonged visceral edema and retroperitoneal hematoma made primary fascial closure difficult. Mesh mediated fascial traction was undergone to reduce the gap in fascial dehiscence under negative pressure wound therapy. However, primary fascial closure could not be accomplished, and abdominal wall reconstruction was performed using bilateral anterior rectus abdominis sheath turnover flap method. Moreover, the skin along the abdominal wall was too tight to be closed primarily. Thus, a bipedicled skin flap was applied. The patient was transferred to another hospital without any remarkable complications. In the present case, the application of a staged closure strategy, which was based on the duration of open abdomenand the condition of the fascia and skin was considered to be important for achieving definitive abdominal closure and preventing the severe complications.

Recent trends in 30-day mortality in patients with blunt splenic injury: A nationwide trauma database study in Japan.

BACKGROUND: Splenic injury frequently occurs after blunt abdominal trauma; however, limited epidemiological data regarding mortality are available. We aimed to investigate mortality rate trends after blunt splenic injury in Japan. METHODS: We retrospectively identified 1,721 adults with blunt splenic injury (American Association for the Surgery of Trauma splenic injury scale grades III-V) from the 2004-2014 Japan Trauma Data Bank. We grouped the records of these patients into 3 time phases: phase I (2004-2008), phase II (2009-2012), and phase III (2013-2014). Over the 3 phases, we analysed 30-day mortality rates and investigated their association with the prevalence of certain initial interventions (Mantel-Haenszel trend test). We further performed multiple imputation and multivariable analyses for comparing the characteristics and outcomes of patients who underwent TAE or splenectomy/splenorrhaphy, adjusting for known potential confounders and for within-hospital clustering using generalised estimating equation. RESULTS: Over time, there was a significant decrease in 30-day mortality after splenic injury (p < 0.01). Logistic regression analysis revealed that mortality significantly decreased over time (from phase I to phase II, odds ratio: 0.39, 95% confidence interval: 0.22-0.67; from phase I to phase III, odds ratio: 0.34, 95% confidence interval: 0.19-0.62) for the overall cohort. While the 30-day mortality for splenectomy/splenorrhaphy diminished significantly over time (p = 0.01), there were no significant differences regarding mortality for non-operative management, with or without transcatheter arterial embolisation (p = 0.43, p = 0.29, respectively). CONCLUSIONS: In Japan, in-hospital 30-day mortality rates decreased significantly after splenic injury between 2004 and 2014, even after adjustment for within-hospital clustering and other factors independently associated with mortality. Over time, mortality rates decreased significantly after splenectomy/splenorrhaphy, but not after non-operative management. This information is useful for clinicians when making decisions about treatments for patients with blunt splenic injury.

Hyperfibrinolysis in severe isolated traumatic brain injury may occur without tissue hypoperfusion: a retrospective observational multicentre study.

BACKGROUND: Hyperfibrinolysis is a critical complication in severe trauma. Hyperfibrinolysis is traditionally diagnosed via elevated D-dimer or fibrin/fibrinogen degradation product levels, and recently, using thromboelastometry. Although hyperfibrinolysis is observed in patients with severe isolated traumatic brain injury (TBI) on arrival at the emergency department (ED), it is unclear which factors induce hyperfibrinolysis. The present study aimed to investigate the factors associated with hyperfibrinolysis in patients with isolated severe TBI. METHODS: We conducted a multicentre retrospective review of data for adult trauma patients with an injury severity score ≥ 16, and selected patients with isolated TBI (TBI group) and extra-cranial trauma (non-TBI group). The TBI group included patients with an abbreviated injury score (AIS) for the head ≥ 4 and an extra-cranial AIS < 2. The non-TBI group included patients with an extra-cranial AIS ≥ 3 and head AIS < 2. Hyperfibrinolysis was defined as a D-dimer level ≥ 38 mg/L on arrival at the ED. We evaluated the relationships between hyperfibrinolysis and injury severity/tissue injury/tissue perfusion in TBI patients by comparing them with non-TBI patients. RESULTS: We enrolled 111 patients in the TBI group and 126 in the non-TBI group. In both groups, patients with hyperfibrinolysis had more severe injuries and received transfusion more frequently than patients without hyperfibrinolysis. Tissue injury, evaluated on the basis of lactate dehydrogenase and creatine kinase levels, was associated with hyperfibrinolysis in both groups. Among patients with TBI, the mortality rate was higher in those with hyperfibrinolysis than in those without hyperfibrinolysis. Tissue hypoperfusion, evaluated on the basis of lactate level, was associated with hyperfibrinolysis in only the non-TBI group. Although the increase in lactate level was correlated with the deterioration of coagulofibrinolytic variables (prolonged prothrombin time and activated partial thromboplastin time, decreased fibrinogen levels, and increased D-dimer levels) in the non-TBI group, no such correlation was observed in the TBI group. CONCLUSIONS: Hyperfibrinolysis is associated with tissue injury and trauma severity in TBI and non-TBI patients. However, tissue hypoperfusion is associated with hyperfibrinolysis in non-TBI patients, but not in TBI patients. Tissue hypoperfusion may not be a prerequisite for the occurrence of hyperfibrinolysis in patients with isolated TBI.

Fibrinogen level on admission is a predictor for massive transfusion in patients with severe blunt trauma: Analyses of a retrospective multicentre observational study.

INTRODUCTION: In the early phase of trauma, fibrinogen (Fbg) plays an important role in clot formation. However, to the best of our knowledge, few studies have analysed methods of predicting the need for massive transfusion (MT) based on Fbg levels using multiple logistic regression. Therefore, the present study aimed to evaluate whether Fbg levels on admission can be used to predict the need for MT in patients with trauma. METHODS: We conducted a retrospective multicentre observational study. Patients with blunt trauma with ISS ≥16 who were admitted to 15 tertiary emergency and critical care centres in Japan participating in the J-OCTET were enrolled in the present study. MT was defined as the transfusion of packed red blood cells (PRBC) ≥10 units or death caused by bleeding within 24h after admission. Patients were divided into non-MT and MT groups. Multiple logistic-regression analysis was used to assess the predictive value of the variables age, sex, vital signs, Glasgow Coma Scale (GCS) score, and Fbg levels for MT. We also evaluated the discrimination threshold of MT prediction via receiver operating characteristic curve (ROC) analysis for each variable. RESULTS: Higher heart rate (HR; per 10 beats per minutes [bpm]), systolic blood pressure (SBP; per 10mm Hg), GCS, and Fbg levels (per 10mg/dL) were independent predictors of MT (odds ratio [OR] 1.480, 95% confidence interval [CI] 1.326-1.668; OR 0.851, 95% CI 0.789-0.914; OR 0.907, 95% CI 0.855-0.962; and OR 0.931, 95% CI 0.898-0.963, respectively). The optimal cut-off values for HR, SBP, GCS, and Fbg levels were ≥100 bpm (sensitivity 62.4%, specificity 79.8%), ≤120mm Hg (sensitivity 61.5%, specificity 70.5%), ≤12 points (sensitivity 63.3%, specificity 63.6%), and ≤190mg/dL (sensitivity 55.1%, specificity 78.6%), respectively. CONCLUSIONS: Our findings suggest that vital signs, GCS, and decreased Fbg levels can be regarded as predictors of MT. Therefore, future studies should consider Fbg levels when devising models for the prediction of MT.

Development of Novel Criteria of the "Lethal Triad" as an Indicator of Decision Making in Current Trauma Care: A Retrospective Multicenter Observational Study in Japan.

OBJECTIVES: To evaluate the utility of the conventional lethal triad in current trauma care practice and to develop novel criteria as indicators of treatment strategy. DESIGN: Retrospective observational study. SETTINGS: Fifteen acute critical care medical centers in Japan. PATIENTS: In total, 796 consecutive trauma patients who were admitted to emergency departments with an injury severity score of greater than or equal to 16 from January 2012 to December 2012. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: All data were retrospectively collected, including laboratory data on arrival. Sensitivities to predict trauma death within 28 days of prothrombin time international normalized ratio greater than 1.50, pH less than 7.2, and body temperature less than 35°C were 15.7%, 17.5%, and 15.9%, respectively, and corresponding specificities of these were 96.4%, 96.6%, and 93.6%, respectively. The best predictors associated with hemostatic disorder and acidosis were fibrin/fibrinogen degradation product and base excess (the cutoff values were 88.8 µg/mL and -3.05 mmol/L). The optimal cutoff value of hypothermia was 36.0°C. The impact of the fibrin/fibrinogen degradation product and base excess abnormality on the outcome were approximately three- and two-folds compared with those of hypothermia. Using these variables, if the patient had a hemostatic disorder alone or a combined disorder with acidosis and hypothermia, the sensitivity and specificity were 80.7% and 66.8%. CONCLUSIONS: Because of the low sensitivity and high specificity, conventional criteria were unsuitable as prognostic indicators. Our revised criteria are assumed to be useful for predicting trauma death and have the potential to be the objective indicators for activating the damage control strategy in early trauma care.