A physician-staffed ground emergency medical service does not significantly shorten door-to-balloon time in patients with STEMI: an observational study in a single emergency center in Japan.

AIM: Current guidelines recommend a door-to-balloon time (DTBT) of <90 min for reperfusion treatment of patients with ST-segment elevation myocardial infarction (STEMI). A physician-staffed ground emergency medical service (GEMS) using a rapid response car (RRC) system was implemented at our hospital in April 2015. The medical team, including a physician and nurse, is dispatched to assess the patient and expedite the start of treatment by emergency physicians and cardiologists after arrival at the hospital. The study aimed to determine whether the RRC system shortened the DTBT. METHODS: This retrospective observational study was carried out in a tertiary emergency center in Japan. Those STEMI patients with primary percutaneous intervention between January 2016 and December 2018 were evaluated. The DTBTs of patients transported by the RRC system, the emergency medical service (EMS), and transferred from other hospitals after STEMI diagnosis (TRANS group) were compared. RESULTS: A total of 121 patients were included, 33 in the RCC, 20 in the EMS, and 68 in the TRANS groups. The median DTBT was 51 min (interquartile range [IQR], 43-67) in the RRC, 61 min (IQR, 52-85) in the EMS, and 59 min (IQR, 48-72) in the TRANS groups (P = 0.13). The DTBT was not significantly shorter in the RRC than in the other groups. CONCLUSION: An RRC physician-staffed GEMS did not significantly shorten the DTBT of patients with STEMI compared with other transport systems.

A rapid response-type doctor car system shortened time to intravenous thrombolytic therapy for patients with ischemic stroke: an observational study at a single emergency center in Japan.

BACKGROUND: For patients with ischemic stroke, rapid reperfusion therapy is extremely important. In April 2015, our medical center introduced a rapid response-type doctor car (RRC) system. Here, an emergency medical team, including a physician, is dispatched to the patient's prehospital location. The team then assesses the patient and, if necessary, initiates infusion therapy, excluding thrombolytic therapy. Before arriving at the hospital, a prehospital physician orders the preparation of diagnostic tools and conducts an early consultation to a neurologist in order to begin thrombolytic therapy more swiftly. This study aimed to determine whether the RRC system shortened the time to commence intravenous reperfusion therapy in patients with ischemic stroke. This was a retrospective observational study conducted at a tertiary emergency center in Japan. Cases of patients with ischemic stroke who underwent intravenous thrombolytic therapy from January 2015 to December 2018 were enrolled. They were divided into two groups: RRC group (intervened by RRC system) and non-RRC group (not intervened by RRC system). The groups' door-to-needle (DTN) time was compared. RESULTS: During the study period, 140 patients received intravenous thrombolytic therapy. Among those, 28 were in the RRC group and 28 received the usual prehospital care. Of 56 patients, the median age was 82 years old, and 42.9% of patients were male. The median NIHSS was 14 (IQR 10-21). As for demographics, there were no significant differences between the two groups. Median DTN time was 67 min (IQR 55-79) in RRC group vs. 81 min (IQR 69-107) in usual care group, respectively (P < 0.05). CONCLUSION: In this study, patients with ischemic stroke in RRC group received intravenous thrombolytic therapy in a shorter time compared to the group that received usual care.

Association between contrast extravasation on computed tomography scans and pseudoaneurysm formation in pediatric blunt splenic and hepatic injury: A multi-institutional observational study.

PURPOSE: We aimed to examine the association between contrast extravasation (CE) on initial computed tomography (CT) scan and pseudoaneurysm (PSA) development in pediatric blunt splenic and/or liver injury. METHODS: We conducted a multi-institutional retrospective study in cases of blunt splenic and/or hepatic injury who underwent an initial attempt of nonoperative management. A logistic regression model was used to compare PSA formation and CE on initial CT scan, and the area under the receiver operating characteristic curve (AUC) with and without CE was used to assess the predictive performance of CE for PSA formation. RESULTS: Of 236 cases enrolled from 10 institutions, PSA formation was observed in 17 (7.2%). Multivariate analysis showed a significant association between CE on initial CT scan and increased incidence of PSA formation (odds ratio, 4.96; 95% confidence interval, 1.37-18.0). There was no statistically significant association between the grade of injury and PSA formation. The AUC improved from 0.75 (0.64-0.87) to 0.80 (0.70-0.91) with CE. CONCLUSION: Active CE on initial CT scan was an independent predictor of PSA formation. Selective use of follow-up CT in children who showed CE on initial CT may provide early identification of PSA formation, regardless of injury grade. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III.

Impact of polymyxin B hemoperfusion in the treatment of patients with sepsis and septic shock: a meta-analysis of randomized controlled trials.

BACKGROUND: Polymyxin B hemoperfusion is a strategy to remove circulating endotoxin in patients with sepsis. Previous systematic reviews derived from randomized and non-randomized studies suggested that use of polymyxin B hemoperfusion reduced mortality, based on the pooled data from various time points in the clinical course of sepsis. We conducted a meta-analysis of randomized controlled trials to assess the impact of polymyxin B hemoperfusion specifically on 28-day mortality in patients with sepsis and septic shock. METHODS: PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for eligible trials from inception through July 30, 2017. All randomized controlled trials were eligible if they examined the impact of polymyxin B hemoperfusion on 28-day mortality in patients with sepsis and septic shock. Risk of bias was evaluated with the Cochrane risk of bias assessment tool. Data were pooled using the DerSimonian and Laird random-effects model. RESULTS: Seven trials involving 586 participants were identified for the analysis. Use of polymyxin B hemoperfusion was not associated with a reduced risk of 28-day mortality [risk ratio (RR), 0.76; 95% CI, 0.54-1.07] compared with usual care. One unpublished trial also showed no significant 28-day survival benefit. CONCLUSIONS: There is no evidence to support the use of polymyxin B hemoperfusion for patients with sepsis and septic shock with respect to 28-day mortality.

Impact of rapid response car system on ECMO in out-of-hospital cardiac arrest: A retrospective cohort study.

INTRODUCTION: Extracorporeal life support (ECLS) has been reported to be more effective than conventional cardiopulmonary resuscitation (CPR). In ECLS, a shorter time from arrival to implantation of extracorporeal membrane oxygenation (ECMO; door-to-ECMO) time was predicted to be associated with better survival rates. This study aimed to examine the impact of the physician-based emergency medical services (P-EMS) using a rapid response car (RRC) on door-to-ECMO time in patients with out-of-hospital cardiac arrest (OHCA). METHODS: In this retrospective cohort study, adult patients with OHCA who were admitted to a Japanese tertiary care hospital from April 2012 to December 2016 and underwent venoarterial ECMO were included. Patients were either transferred by emergency medical service (EMS only group) or RRC (RRC group). Primary outcome was door-to-ECMO time. Wilcoxon rank-sum test was used to compare the outcome between the two groups. RESULTS: A total of 34 patients were included in this study, and outcome data were available for all patients. The door-to-ECMO time was significantly shorter in the RRC group than in the EMS only group (median, 23min vs. 36min; P=0.006). Additionally, the RRC was also associated with earlier successful intubation and intravenous adrenaline administration. CONCLUSION: The physician-based RRC system was associated with a shorter door-to-ECMO time and successful advanced procedures in prehospital settings. Combination of the RRC system with ECLS may lead to better outcomes in patients with OHCA.

Prevalence and Appropriateness of Urinary Catheters in Japanese Intensive Care Units: Results From a Multicenter Point Prevalence Study.

BACKGROUND: Catheter-associated urinary tract infection is a common and costly problem throughout the world. As limited data from Asia exist regarding the prevalence and appropriateness of urinary catheters in critically ill patients, we sought to assess both prevalence and appropriateness of urinary catheters in Japan. METHODS: Using independent observers, we evaluated the prevalence and clinical necessity of indwelling urinary catheters in 7 Japanese intensive care units. RESULTS: Data were collected on 1289 catheter-days and 1706 patient days in the 7 participating intensive care units between August 2015 and May 2016. Urinary catheter prevalence was 76% (range, 49%-94%). The observers deemed that only 54% of the catheters met an appropriate indication for use (range, 40%-74%). The most common appropriate indications for urinary catheter use were (1) the need for accurate input and output monitoring in critically ill patients; (2) perioperative use; and (3) prolonged immobilization. The use of monitoring accurate input and output in critically ill patients, however, may be overused as bedside nurses used this indication in 27% more patients than the objective observer deemed necessary. CONCLUSIONS: Urinary catheters were frequently used in the 7 participating Japanese intensive care units and almost half did not meet an appropriate indication for use. Overusing catheters for monitoring accurate input and output was especially notable. Multimodal interventions may be needed to limit inappropriate urinary catheter use.

Prevalence and risk factors of sepsis-induced cardiomyopathy: A retrospective cohort study.

The aim of the study is to evaluate the epidemiology and clinical features of sepsis-induced cardiomyopathy (SICM).A retrospective cohort study was conducted.A total of 210 adult patients with sepsis or septic shock admitted to a Japanese tertiary care hospital from January 1, 2013, to December 31, 2015, who underwent transthoracic echocardiography (TTE) on admission.The definition of SICM was ejection fraction (EF) < 50% and a ≥10% decrease compared to the baseline EF which recovered within 2 weeks, in sepsis or septic shock patients.Our primary outcome was the incidence rate of SICM. Our secondary outcomes were the in-hospital mortality rate and length of intensive care unit (ICU) stay according to the presence or absence of SICM. In total, 29 patients (13.8%) were diagnosed with SICM. The prevalence rate of SICM was significantly higher in male than in female (P = 0.02). Multivariate logistic regression analyses revealed that the incidence of SICM was associated with younger age (odds ratio [OR], 0.97; 95% confidence interval [CI], 0.95-0.99), higher lactate level on admission (OR, 1.18; 95% CI, 1.05-1.32) and history of heart failure (HF) (OR, 3.77; 95% CI, 1.37-10.40). There were no significant differences in the in-hospital and 30-day mortality between patients with and without SICM (24.1% vs 12.7%, P = 0.15; 20.7% vs 12.1%, P = 0.23). Lengths of hospital and ICU stay were significantly longer in patients with SICM than in those without SICM (median, 43 vs 26 days, P = 0.04; 9 vs 5 days, P < 0.01).SICM developed in 13.8% of patients with sepsis and septic shock. A younger age, higher lactate levels on admission and history of HF were risk factors.

Impact of closed versus open tracheal suctioning systems for mechanically ventilated adults: a systematic review and meta-analysis.

PURPOSE: Whether closed tracheal suctioning systems (CTSS) reduce the incidence of ventilator-associated pneumonia (VAP) compared with open tracheal suctioning systems (OTSS) is inconclusive. We conducted a systematic review and meta-analysis of randomized controlled trials that compared CTSS and OTSS. METHODS: PubMed, the Cochrane Central Register of Controlled Trials, the Web of Science, Google Scholar, and a clinical trial registry from inception to October 2014 were searched without language restrictions. Randomized controlled trials of CTSS and OTSS that compared VAP in mechanically ventilated adult patients were included. The primary outcome was the incidence of VAP. Secondary outcomes were mortality and length of mechanical ventilation. Data were pooled using the random effects model. RESULTS: Sixteen trials with 1,929 participants were included. Compared with OTSS, CTSS was associated with a reduced incidence of VAP (RR 0.69; 95 % CI 0.54-0.87; Q = 26.14; I (2) = 46.4 %). Compared with OTSS, CTSS was not associated with reduction of mortality (RR 0.96; 95 % CI 0.83-1.12; Q = 2.27; I (2) = 0.0 %) or reduced length of mechanical ventilation (WMD -0.45 days; 95 % CI -1.25 to 0.36; Q = 6.37; I (2) = 5.8 %). Trial sequential analysis suggested a lack of firm evidence for 20 % RR reduction in the incidence of VAP. The limitations of this review included underreporting and low quality of the included trials, as well as variations in study procedures and characteristics. CONCLUSIONS: Based on current, albeit limited evidence, it is unlikely that CTSS is inferior to OTSS regarding VAP prevention; however, further trials at low risk of bias are needed to confirm or refute this finding.