Introduction and utility of resuscitative endovascular balloon occlusion of the aorta for cases with a potential high risk of postpartum hemorrhage: A single tertiary care center experience of two cases

Postpartum hemorrhage is an important obstetric complication and the leading cause of maternal mortality worldwide. Occasionally, we encounter unexpected massive postpartum hemorrhage diagnosed for the first time after delivery. Therefore, it is essential to pay attention to patients with a high risk of postpartum hemorrhage. The authors report two cases of patients at high risk of postpartum hemorrhage that were successfully managed by resuscitative endovascular balloon occlusion of the aorta before cesarean section. Case 1: A 32-year-old woman with a history of cesarean section and who conceived using assisted reproductive technology was diagnosed with partial placenta previa at 25 weeks of gestation. Because of tocolysis failure, emergent cesarean section with resuscitative endovascular balloon occlusion of the aorta was performed at 36 weeks of gestation. Natural placental resorption was observed. She was discharged at 5 days after delivery without significant hemorrhage. Case 2: A 41-year-old woman with suspected placenta accreta spectrum due to a cesarean scar pregnancy was referred to our hospital at 33 weeks of gestation. A planned cesarean section with resuscitative endovascular balloon occlusion of the aorta was conducted at 37 weeks of gestation. There was no visual evidence of abnormal placental invasion of the myometrium, and natural placental resorption was observed. She was discharged at 5 days after delivery without significant hemorrhage

Presence of periaortic gas in Clostridium septicum-infected aortic aneurysm aids in early diagnosis: a case report and systematic review of the literature

Abstract Background Clostridium septicum-infected aortic aneurysm is a fatal and rare disease. We present a fatal case of C. septicum-infected aortic aneurysm and a pertinent literature review with treatment suggestions for reducing mortality rates. Case presentation A 58-year-old Japanese man with an unremarkable medical history presented with a 3-day history of mild weakness in both legs, and experienced paraplegia and paresthesia a day before admission. Upon recognition of signs of an abdominal aortic aneurysm and paraplegia, we suspected an occluded Adamkiewicz artery and performed a contrast-enhanced computed tomography scan, which revealed an aortic aneurysm with periaortic gas extending from his chest to his abdomen and both kidneys. Antibiotics were initiated followed by emergency surgery for source control of the infection. However, owing to his poor condition and septic shock, aortic repair was not possible. We performed bilateral nephrectomy as a possible source control, after which we initiated mechanical ventilation, continuous hemodialysis, and hemoperfusion. A culture of the samples taken from the infected region and four consecutive blood cultures yielded C. septicum. His condition gradually improved postoperatively; however, on postoperative day 10, massive hemorrhage due to aortic rupture resulted in his death. Conclusions In this patient, C. septicum was thought to have entered his blood through a gastrointestinal tumor, infected the aorta, and spread to his kidneys. However, we were uncertain whether there was an associated malignancy. A literature review of C. septicum-related aneurysms revealed the following: 6-month mortality, 79.5%; periaortic gas present in 92.6% of cases; no standard operative procedure and no guidelines for antimicrobial administration established; and C. septicum was associated with cancer in 82.5% of cases. Thus, we advocate for early diagnosis via the identification of periaortic gas, as an aortic aneurysm progresses rapidly. To reduce the risk of reinfection as well as infection of other sites, there is the need for concurrent surgical management of the aneurysm and any associated malignancy. We recommend debridement of the infectious focus and in situ vascular graft with omental coverage. Postoperatively, orally administered antibiotics must be continued indefinitely (chronic suppression therapy). We believe that these treatments will decrease mortality due to C. septicum-infected aortic aneurysms

The off-hour effect on trauma patients requiring subspecialty intervention at a community hospital in Japan: a retrospective cohort study

Background: Because most community hospitals in Japan do not maintain 24-h availability of in-house anesthesiologists, surgeons, and interventional radiologists, staffing dramatically declines during off hours. It is unclear whether, in such under-resourced hospitals, trauma patients presenting during off hours and requiring subspecialty intervention have worse outcomes than those who present during business hours. Methods: This was a retrospective cohort study at a community hospital in Japan. Participants were all injured patients requiring emergency trauma surgery or transarterial embolization who presented from January 2002 to December 2013. We investigated whether outcomes of these patients differed between business hours (8:01 AM to 6:00 PM weekdays) and off hours (6:01 PM to 8:00 AM weekdays plus all weekend hours). The primary outcome measure was mortality rate, and the secondary outcome measures were duration of emergency room (ER) stay; unexpected death (death/probability of survival > 0.5); and adverse events occurring in the ER. We adjusted for potential confounders of age, sex, Injury Severity Score (ISS), Revised Trauma Score, presentation phase (2002–2005, 2006–2009, and 2010–2013), Charlson Comorbidity Index, and injury type (blunt or penetrating) using logistic regression models. Results: Of the 805 patients included, 379 (47.1%) presented during business hours and 426 (52.9%) during off hours. Off-hours presentation was associated with longer ER stays for patients with systolic blood pressure 15 (p = 0.047), and pelvic fracture requiring transarterial embolization (p < 0.001). Off-hours presentation was also associated with increased risk of adverse events in the ER (odds ratio [OR] 1.7, 95% confidence interval [CI] 1.1–2.7, p = 0.020). After adjustment for confounders, an increased risk of adverse events (OR 1.6, 95% CI 1.1–2.7, p = 0.049) persisted, but no differences were detected in mortality (p = 0.80) and unexpected death (p = 0.44) between off hours and business hours. Conclusions: At a community hospital in Japan, presentation during off hours was associated with a longer ER stay for severely injured patients and increased risk of adverse events in the ER. However, these disadvantages did not impact mortality or unexpected outcome