Takayuki Ogura

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Objectives: To investigate the prevalence of long-term mental disorders in caregivers of ICU sepsis survivors and examine associations with post-intensive care syndrome (PICS) in patients. Design: Prospective observational study. Setting: Twenty-one mixed ICUs. Patients: Caregivers (the next of kin) of the patients diagnosed with sepsis between November 2020 and April 2022. Interventions: None. Measurements and Main Results: Caregivers and patients were assessed at 3, 6, and 12 months after hospital discharge by telephone and mail. The primary outcome was caregiver mental disorders (mental post-intensive care syndrome-family [PICS-F]). Mixed-effects logistic regression analyses were performed to evaluate the association between caregiver PICS-F and patient PICS. Ninety-four caregiver-patient dyads were analyzed. Caregivers were a median of 67 years old (55–79 yr old), 31 (33.0%) were male, and 41 (43.6%) were spouses. Patients were a median of 74 years old (69–82 yr old), and 54 (57.4%) were male. The prevalence of mental PICS-F did not decrease from 3 to 12 months (43% vs. 42%, respectively), whereas the presence of PICS symptoms in patients decreased from 82% to 62%. In mixed-effects logistic regression, the presence of PICS symptoms in patients was significantly associated with PICS-F (adjusted odds ratio, 3.00; 95% CI, 1.54–5.88; p < 0.01). Among the individual patient PICS domains, only mental PICS was significantly associated with PICS-F (3.71; 2.03–6.77; p < 0.01), whereas physical and cognitive impairments in patients were not. Conclusions: The prevalence of mental PICS-F in caregivers of ICU sepsis survivors was frequent and long-lasting over the first year after hospital discharge. Since it was most strongly associated with patients’ mental disorders rather than physical or cognitive impairments, the mental PICS domain in patients may be an important indicator of PICS-F and should be considered in future studies.

The COVID-19 pandemic has placed unprecedented pressure on global healthcare systems, severely affecting the intensive care unit (ICU) capacity. Therefore, this study explored the association between prefecture-level ICU congestion and COVID-19 mortality in each prefecture of Japan. This retrospective study analyzed data from the CRoss Icu Searchable Information System, covering all patients with COVID-19 who underwent mechanical ventilation with clearly documented initiation and cessation dates between January 1, 2020, and March 31, 2023. Prefecture-level ICU congestion was calculated as the total ventilator days over 2 weeks for severely ill patients with COVID-19, divided by the maximum potential ventilator days in the prefecture. Prefecture-level ICU congestion in each region was visualized by plotting time-series graphs capturing the temporal progression of congestion levels. Continuous variables were standardized, and missing data were imputed into 20 datasets by chained equations, assuming data missing at random. A mixed-effects logistic regression model was separately applied to each of the 20 multiply-imputed datasets generated during the imputation procedure to evaluate the association between prefecture-level ICU congestion and mortality. Estimates and standard errors from each model were pooled using Rubin’s rules to obtain final combined results. A sensitivity analysis was performed using the same mixed-effects model, replacing the continuous congestion level with a categorical variable. A total number of 10,427 patients were included in this study, and the mortality rate was 22.7% in the original cohort, with 226 (1.9%) cases having missing data. Congestion levels varied by time and prefecture, ranging from 0 to over 1.5, indicating a strain beyond capacity. Median congestion level (interquartile range [IQR]) at admission was 0.3 (0.1, 0.7), and increased congestion level was statistically associated with increased mortality (odds ratio: 1.14; 95% confidential interval: 1.07–1.22). Sensitivity analysis showed consistent results, indicating the robustness of our findings. Increased prefecture-level ICU congestion may be associated with increased COVID-19 mortality, warranting further investigation.

Background: The Traumatic Bleeding Severity Score (TBSS), developed in Japan, has shown high predictive accuracy in internal validation; however, external validation has still not been performed. We conducted the first external validation of the TBSS in Japan and compared it with other massive transfusion (MT) prediction scores. Methods: This multicenter retrospective study included severe trauma patients (aged ≥ 18 years, Injury Severity Score [ISS] ≥ 16) from 25 tertiary critical care centers (April 2018–March 2019), excluding those with isolated head injury or cardiac arrest on arrival. TBSS's accuracy for predicting MT was analyzed using the area under the curve (AUC). A complete case was the primary approach, with sensitivity analysis using multiple imputed datasets. The Trauma‐Associated Severe Hemorrhage (TASH) score and Assessment of Blood Consumption (ABC) score were also evaluated for comparison. Results: Of 1193 patients, 873 were eligible, and 365 patients were included in the complete case analysis. The median age was 63 (interquartile range [IQR]: 45–75) years, the median ISS was 25 (IQR: 20–34), 69.3% were male individuals, 98.1% experienced blunt trauma, and 24.7% received MT. TBSS' AUC was 0.86 (sensitivity: 70.1%; specificity: 88.4%). The TASH score showed a comparable AUC of 0.88 ( p = 0.850), whereas the ABC score had a significantly lower AUC of 0.80 ( p = 0.024). Sensitivity analysis confirmed these findings. Conclusion: TBSS' accuracy for predicting MT was comparable to that of the TASH score and superior to that of the ABC score. Further research is needed to determine its clinical utility and broader applicability in trauma care.

Recently, patients with out-of-hospital cardiac arrest (OHCA) refractory to conventional resuscitation have started undergoing extracorporeal cardiopulmonary resuscitation (ECPR). However, the mortality rate of these patients remains high. This study aimed to clarify whether a center ECPR volume was associated with the survival rates of adult patients with OHCA resuscitated using ECPR. This was a secondary analysis of a retrospective multicenter registry study, the SAVE-J II study, involving 36 participating institutions in Japan. Centers were divided into three groups according to the tertiles of the annual average number of patients undergoing ECPR: high-volume (≥ 21 sessions per year), medium-volume (11–20 sessions per year), or low-volume (< 11 sessions per year). The primary outcome was survival rate at the time of discharge. Patient characteristics and outcomes were compared among the three groups. Moreover, a multivariable-adjusted logistic regression model was applied to study the impact of center ECPR volume. A total of 1740 patients were included in this study. The center ECPR volume was strongly associated with survival rate at the time of discharge; furthermore, survival rate was best in high-volume compared with medium- and low-volume centers (33.4%, 24.1%, and 26.8%, respectively; P = 0.001). After adjusting for patient characteristics, undergoing ECPR at high-volume centers was associated with an increased likelihood of survival compared to middle- (adjusted odds ratio 0.657; P = 0.003) and low-volume centers (adjusted odds ratio 0.983; P = 0.006). The annual number of ECPR sessions was associated with favorable survival rates and lower complication rates of the ECPR procedure.Clinical trial registration: https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000041577 (unique identifier: UMIN000036490).

Background: Risk stratification is important in patients with post–cardiac arrest syndrome. The Post‐Cardiac Arrest Syndrome for Therapeutic Hypothermia (CAST) and revised CAST (rCAST) scores have been well validated for predicting neurological outcomes, particularly for conventionally resuscitated patients with post–cardiac arrest syndrome. However, no studies have evaluated patients undergoing extracorporeal cardiopulmonary resuscitation. Methods and Results: Adult patients with out‐of‐hospital cardiac arrest who underwent extracorporeal cardiopulmonary resuscitation were analyzed in this retrospective observational multicenter cohort study. We validated the accuracy of the CAST/rCAST scores for predicting neurological outcomes at 30 days. Moreover, we compared the predictive performance of these scores with the TiPS65 risk score derived from patients with out‐of‐hospital cardiac arrest who were resuscitated using extracorporeal cardiopulmonary resuscitation. A total of 1135 patients were analyzed. The proportion of patients with favorable neurological outcomes was 16.6%. In the external validation, the area under the receiver operating characteristic curve of the CAST score was significantly higher than that of the rCAST score (area under the receiver operating characteristic curve 0.677 versus 0.603; P P =0.154). Both CAST/rCAST risk scores showed good calibration (Hosmer–Lemeshow test: P =0.726 and 0.674), and the CAST score showed significantly better predictability in net reclassification compared with the rCAST ( P P =0.001). Conclusions: The prognostic accuracy of the CAST score was significantly better than that of other risk scores in net reclassification. The CAST score may help to predict neurological outcomes in patients with out‐of‐hospital cardiac arrest who undergo extracorporeal cardiopulmonary resuscitation. However, the predictive value of the CAST score was not sufficiently high for clinical application. Registration: URL: https://center6.umin.ac.jp/cgi‐open‐bin/ctr_e/ctr_view.cgi?recptno=R000041577 ; Unique identifier: UMIN000036490.

Background:Recently, patients with out-of-hospital cardiac arrest (OHCA) refractory to conventional resuscitation have started undergoing extracorporeal cardiopulmonary resuscitation (ECPR). However, the mortality rate of these patients remains high. This study aimed to clarify whether a center ECPR volume was associated with the survival rates of adult patients with OHCA resuscitated using ECPR. Methods: This was a secondary analysis of a retrospective multicenter registry study, the SAVE-J II study, involving 36 participating institutions in Japan. The centers were divided into three groups according to the tertiles of the annual average number of patients undergoing ECPR: high-volume (≥21 sessions per year), medium-volume (11–20 sessions per year), or low-volume (Results: A total of 1,740 patients were included in this study. The center ECPR volume was strongly associated with survival rate at the time of discharge; furthermore, survival rate was best in high-volume compared with medium- and low-volume centers (33.4%, 24.1%, and 26.8%, respectively; P=0.001). After adjusting for patient characteristics, undergoing ECPR at high-volume centers was associated with an increased likelihood of survival compared to middle- (adjusted odds ratio 0.657; P=0.003) and low-volume centers (adjusted odds ratio 0.983; P=0.006). Conclusion: The annual number of ECPR sessions was associated with favorable survival rates and lower complication rates of the ECPR procedure. IRB information: The present study was approved by the institutional review board of Kagawa University (approval number: 2018-110) Clinical trial registration: https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000041577 (unique identifier: UMIN000036490, Registered 15 April 2019, retrospectively registered)

Sepsis leads to organ dysfunction. Acute kidney injury, a common type of organ dysfunction, is associated with a high mortality rate in patients with sepsis. Kidney replacement therapy can correct the metabolic, electrolyte, and fluid imbalances caused by acute kidney injury. While this therapy can improve outcomes, evidence of its beneficial effects is lacking. Herein, we review the indications for blood purification therapy, including kidney replacement therapy, and the current knowledge regarding acute kidney injury in terms of renal and non-renal indications. While renal indications have been well-documented, indications for blood purification therapy in sepsis (non-renal indications) remain controversial. Excessive inflammation is an important factor in the development of sepsis; blood purification therapy has been shown to reduce inflammatory mediators and improve hemodynamic instability. Given the pathophysiology of sepsis, blood purification therapy may decrease mortality rates in these patients. Further trials are needed in order to establish the effectiveness of blood purification therapy for sepsis.

Background: Calcium channel blockers and angiotensin II receptor blockers are commonly prescribed to treat hypertension. Massive overdoses can cause both distributive and cardiogenic shock because of their effects on vascular smooth muscles and severe myocardial depression.Case Presentation: We present the case of a 46‐year‐old man who was brought to our emergency department after ingesting 1210 mg amlodipine and 936 mg candesartan. The patient's hemodynamic status deteriorated despite treatment with vasopressors, calcium gluconate, and hyperinsulinemia‐euglycemia therapy with mechanical ventilation. Venoarterial extracorporeal membrane oxygenation was initiated for refractory shock. The patient was weaned off extracorporeal membrane oxygenation on day 5 and discharged on day 18 of hospitalization.Conclusion: When medical therapies are ineffective, aggressive venoarterial extracorporeal membrane oxygenation should be considered for the management of refractory shock in the setting of calcium channel blocker with angiotensin II receptor blocker overdose.