論文

＜Point＞●深在性真菌症の多くは,免疫力が低下している患者に発生する.確定診断のための組織生検が実施できない全身状態の患者では,臨床所見や画像所見から総合的に診断し,早期の治療介入を行う.●侵襲性カンジダ症に対しては,まずはアゾール系抗真菌薬を検討し,効果が乏しい場合はエキノキャンディン系を考慮する.●侵襲性肺アスペルギルス症に対しては,VRCZやL-AMBを使用し,症例に応じて投与期間を検討する.●クリプトコッカス症に対しては,L-AMBと5-FCの併用療法をまずは行う.L-AMBの治療期間を完遂するため,有害事象への対応に注力する.(著者抄録)

日本版敗血症診療ガイドライン2020特別委員会COVID-19対策タスクフォースは、非営利団体であるMAGIC Evidence Ecosystem Foundationが運営するガイドライン公開プラットフォームMAGICappを用いて、COVID-19薬物療法に関するRapid/Living recommendationsのデジタル版ガイドラインを公表している。MAGICappを利用してガイドラインを公開することは、ガイドライン作成者、使用者、患者のそれぞれにとって有益であり、ガイドラインに高い利便性を持たせることができる。例えば、living systematic reviewによって数ヵ月ごとにアップデートするガイドラインでは、ガイドライン使用者にとって最新版へ追随していく能動的作業は容易ではないが、MAGICappによるデジタル版ガイドラインではアップデートした内容へ容易にアクセスすることができる。ここではMAGICappについて解説する。(著者抄録)

＜ここがポイント!＞▼多発外傷患者の救急外来による初期輸液としては,可能な限り輸血製剤を準備し,晶質液(crystalloid)を用いる.▼輸液投与に用いる点滴ラインはなるべく径が太いものを選択するが,耐圧ラインの使用タイミングについてあらかじめ考えておく.▼循環動態が不安定なときは迅速に止血・輸血投与を実施するが,それまでは急速輸液を行う.▼循環動態が不安定な多発外傷患者に対する急速輸液は,一時的な処置にすぎないことを理解する.▼循環動態が安定した後は,患者の状況を評価し至適輸液量へ調整する.これは,ほかの集中治療を要する患者と同様である.(著者抄録)

© 2017 Association of Program Directors in Surgery Objective: Focused transthoracic echocardiography (FTTE) is an emerging tool in the management of critically ill patients, but the lack of adequate training models has limited the expansion of this technology. Although basic FTTE training courses have been shown to be sufficient in developing echocardiography skills, limited data exist regarding skill retention. In an effort to develop an adequate FTTE training model, we sought to determine the degree of skill retention after FTTE training. Design: A prospective, observational study. Setting: An academic center. Participants: Surgical residents and medical students: 31 subjects were enrolled from February to June 2016. Results: Participants underwent a 2-hour FTTE course including didactics and a hands-on session measuring ejection fraction of left ventricle (LV) and inferior vena cava (IVC) diameter. Written knowledge and performance examinations applying FTTE were conducted before the course, immediately after, and at 1- and 3-month intervals, which were evaluated on a 0 to 9 scale and analyzed with paired t-tests. Performance examination scores obtaining the LV and IVC views preinitial and postinitial training increased from 1.7 to 6.5 (LV) and from 2.0 to 6.8 (IVC) (p < 0.01), decreased to 5.0 and 4.8, respectively, at 1 month (posttraining vs 1 month, p < 0.01), and did not significantly change at 3 months (5.4 and 5.0, respectively). Written examination scores increased from 42% to 62% (pretraining vs posttraining, p < 0.01), decreased to 48% in 1 month (posttraining vs 1 month, p < 0.01), and further decreased to 34% at 3 months (1 month vs 3 month, p < 0.01). Conclusions: Although a short training course appears sufficient to impart basic FTTE skills and knowledge, skills are significantly decayed at 1 month and knowledge continually decreases at 1 and 3 months. Future FTTE training models should consider the rapid degradation of knowledge and skills in determining frequency of refresher training and ongoing evaluation.

© 2019 Elsevier Inc. Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a technique for temporary control of arterial hemorrhage. However, its effectiveness and clinical outcomes are unclear. Methods: Using a nationwide database (2004–2016) in Japan, trauma patients with survival data were identified. Patients were divided between REBOA and non-REBOA groups, and a propensity score was developed using multivariate logistic regression. Survival to discharge was compared between the groups after propensity score matching. Results: Among 82,371 patients included in this study, 385 were treated with REBOA. After propensity score matching, 117 pairs were selected. Survival to discharge was significantly higher among patients treated with REBOA than among those treated without REBOA (53 [45.3%] vs. 38 [32.5%]; odds ratio = 1.72; 95% CI = 1.01–2.93; p = 0.04). Conclusions: REBOA use was associated with improved survival to discharge and should therefore be considered during the management of severely injured trauma patients.

Background: Unnecessary whole-body computed tomography (CT) may lead to excess radiation exposure. Serum D-dimer levels have been reported to correlate with injury severity. We examined the predictive value of serum D-dimer level for identifying patients with isolated injury that can be diagnosed with selected-region CT rather than whole-body CT. Methods: This single-center retrospective cohort study included patients with blunt trauma (2014–2017). We included patients whose serum D-dimer levels were measured before they underwent whole-body CT. “Isolated” injury was defined as injury with Abbreviated Injury Scale (AIS) score ≤ 5 to any of five regions of interest or with AIS score ≤ 1 to other regions, as revealed by a CT scan. A receiver operating characteristic curve (ROC) was drawn for D-dimer levels corresponding to isolated injury; the area under the ROC (AUROC) was evaluated. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated for several candidate cut-off values for serum D-dimer levels. Results: Isolated injury was detected in 212 patients. AUROC was 0.861 (95% confidence interval [CI]: 0.815–0.907) for isolated injury prediction. Serum D-dimer level ≤ 2.5 μg/mL was an optimal cutoff value for predicting isolated injury with high specificity (100.0%) and positive predictive value (100.0%). Approximately 30% of patients had serum D-dimer levels below this cutoff value. Conclusion: D-dimer level ≤ 2.5 μg/mL had high specificity and high positive predictive value in cases of isolated injury, which could be diagnosed with selected-region CT, reducing exposure to radiation associated with whole-body CT.

Background Rapid deterioration of oxygenation occurs in novel coronavirus disease 2019 (COVID-19), and prediction of mechanical ventilation (MV) is needed for allocation of patients to intensive care unit. Since intubation is usually decided based on varying clinical conditions, such as required oxygen changes, we aimed to elucidate thresholds of increase in oxygen demand to predict MV use within 12 h. Methods A single-center retrospective cohort study using data between January 2020 and January 2021was conducted. Data were retrieved from the hospital data warehouse. Adult patients diagnosed with COVID-19 with a positive polymerase chain reaction (PCR) who needed oxygen during admission were included. Hourly increments in oxygen demand were calculated using two consecutive oxygen values. Covariates were selected from measurements at the closest time points of oxygen data. Prediction of MV use within 12 h by required oxygen changes was evaluated with the area under the receiver operating curves (AUCs). A threshold for increased MV use risk was obtained from restricted cubic spline curves. Results Among 66 eligible patients, 1835 oxygen data were analyzed. The AUC was 0.756 for predicting MV by oxygen demand changes, 0.888 by both amounts and changes in oxygen, and 0.933 by the model adjusted with respiratory rate, PCR quantification cycle (Ct), and days from PCR. The threshold of increments of required oxygen was identified as 0.44 L/ min/h and the probability of MV use linearly increased afterward. In subgroup analyses, the threshold was lower (0.25 L/min/h) when tachypnea or frequent respiratory distress existed, whereas it was higher (1.00 L/min/h) when viral load is low (Ct ≥20 or days from PCR >7 days). Conclusions Hourly changes in oxygen demand predicted MV use within 12 h, with a threshold of 0.44 L/ min/h. This threshold was lower with an unstable respiratory condition and higher with a low viral load.