深野 賢太朗

BACKGROUND: Tracking preload dependency non-invasively to maintain adequate tissue perfusion in the perioperative period can be challenging.The effect of phenylephrine on stroke volume is dependent upon preload. Changes in stroke volume induced by phenylephrine administration can be used to predict preload dependency. The change in the peripheral perfusion index derived from photoplethysmography signals reportedly corresponds with changes in stroke volume in situations such as body position changes in the operating room. Thus, the peripheral perfusion index can be used as a non-invasive potential alternative to stroke volume to predict preload dependency. Herein, we aimed to determine whether changes in perfusion index induced by the administration of phenylephrine could be used to predict preload dependency. METHODS: We conducted a prospective single-centre observational study. The haemodynamic parameters and perfusion index were recorded before and 1 and 2 min after administering 0.1 mg of phenylephrine during post-induction hypotension in patients scheduled to undergo surgery. Preload dependency was defined as a stroke volume variation of ≥ 12% before phenylephrine administration at a mean arterial pressure of < 65 mmHg. Patients were divided into four groups according to total peripheral resistance and preload dependency. RESULTS: Forty-two patients were included in this study. The stroke volume in patients with preload dependency (n = 23) increased after phenylephrine administration. However, phenylephrine administration did not impact the stroke volume in patients without preload dependency (n = 19). The perfusion index decreased regardless of preload dependency. The changes in the perfusion index after phenylephrine administration exhibited low accuracy for predicting preload dependency. Based on subgroup analysis, patients with high total peripheral resistance tended to exhibit increased stroke volume following phenylephrine administration, which was particularly prominent in patients with high total peripheral resistance and preload dependency. CONCLUSION: The findings of the current study revealed that changes in the perfusion index induced by administering 0.1 mg of phenylephrine could not predict preload dependency. This may be attributed to the different phenylephrine-induced stroke volume patterns observed in patients according to the degree of total peripheral resistance and preload dependency. TRIAL REGISTRATION: University Hospital Medical Information Network (UMIN000049994 on 9/01/2023).

<jats:title>Abstract</jats:title><jats:sec> <jats:title>Background</jats:title> <jats:p>It has been 50 years since the pulmonary artery catheter was introduced, but the actual use of pulmonary artery catheters in recent years is unknown. Some randomized controlled trials have reported no causality with mortality, but some observational studies have been published showing an association with mortality for patients with cardiogenic shock, and the association with a pulmonary artery catheter and mortality is unknown. The aim of this study was to investigate the utilization of pulmonary artery catheters (PACs) in the intensive care unit (ICU) and to examine their association with mortality, taking into account differences between hospitals.</jats:p> </jats:sec><jats:sec> <jats:title>Methods</jats:title> <jats:p>This is a retrospective analysis using the Japanese Intensive care PAtient Database, a multicenter, prospective, observational registry in Japanese ICUs. We included patients aged 16 years or older who were admitted to the ICU for reasons other than procedures. We excluded patients who were discharged within 24 h or had missing values. We compared the prognosis of patients with and without PAC. The primary outcome was hospital mortality. We performed propensity score analysis to adjust for baseline characteristics and hospital characteristics.</jats:p> </jats:sec><jats:sec> <jats:title>Results</jats:title> <jats:p>Among 184,705 patients in this registry from April 2015 to December 2020, 59,922 patients were included in the analysis. Most patients (94.0%) with a PAC in place had cardiovascular disease. There was a wide variation in the frequency of PAC use between hospitals, from 0 to 60.3% (median 14.4%, interquartile range 2.2–28.6%). Hospital mortality was not significantly different between the PAC use group and the non-PAC use group in patients after adjustment for propensity score analysis (3.9% vs 4.3%; difference, − 0.4%; 95% CI − 1.1 to 0.3; <jats:italic>p</jats:italic> = 0.32). Among patients with cardiac disease, those with post-open-heart surgery and those in shock, hospital mortality was also not significantly different between the two groups (3.4% vs 3.7%, <jats:italic>p</jats:italic> = 0.45, 1.7% vs 1.7%, <jats:italic>p</jats:italic> = 0.93, 4.8% vs 4.9%, <jats:italic>p</jats:italic> = 0.87).</jats:p> </jats:sec><jats:sec> <jats:title>Conclusions</jats:title> <jats:p>The frequency of PAC use varied among hospitals. PAC use for ICU patients was not associated with lower hospital mortality after adjusting for differences between hospitals.</jats:p> </jats:sec>

<h4>Background</h4>Procedural sedation is increasingly used for elderly patients, but there is no established ideal method for elderly patients who are prone to respiratory and circulatory depression. This study aims to investigate the association of respiratory complications and the combination of ketamine-propofol versus fentanyl-propofol in elderly patients undergoing prostate biopsy requiring deep sedation.<h4>Methods</h4>This was a single-center, retrospective, observational study conducted from April 2020 to March 2021. We included male patients aged 65 years and older scheduled for prostate biopsy under procedural sedation. Ketamine-propofol and fentanyl-propofol were administered at the discretion of the anesthesiologist. The primary outcome was the need for assisted ventilation. The secondary outcome was the duration of oxygen saturation (SpO₂) below 90%.<h4>Results</h4>We enrolled 120 patients over 65 years, and 92 patients were included in the final analysis. The anesthesiologist administered an initial dose of ketamine and propofol of 1:1 to 1:4 of 1.0 mg kg^-1 (interquartile range: 0.98 to 1.17) or administered an initial dose of fentanyl of 0.05 to 0.1 mg and a target-controlled infusion of propofol of 2.8 μg ml^-1 (interquartile range: 2.0 to 3.0) followed by additional doses at the discretion of the anesthesiologist. Ketamine-propofol was associated with a reduced need for assisted ventilation and a shorter duration of SpO2 below 90% than propofol-fentanyl (95.7% vs. 4.3%, P < 0.05; 0.64 minutes vs. 0.17 minutes, P = 0.26).<h4>Conclusions</h4>Ketamine-propofol is associated with a significantly reduced need for assisted ventilation compared to propofol-fentanyl during procedural sedation and analgesia for procedures requiring deep sedation for the elderly.

硫酸マグネシウム(以下Mg)静注療法は,破傷風の筋痙攣・強直や自律神経障害への有効性が報告されている。しかし,その投与量の調整方法は確立されていない。本邦で破傷風患者は稀であるが,我々は異なる指標で硫酸Mgの投与量を調整した2名の破傷風患者を経験した。患者1では臨床所見にもとづいて調整したところ,筋痙攣・強直や自律神経障害のコントロールは良好であったものの重篤な高Mg血症を生じ,経過中にQT延長と気管内出血の合併症を来した。患者2では血清Mg濃度で投与量を調整したところ,患者1よりも血圧変動が目立ったものの,有害事象を生じることなく良好な転帰を得ることができた。破傷風に対して硫酸Mg静注を行う際には,ある程度の自律神経障害が残存したとしても,重篤な高Mg血症を来さないように血中濃度をもとに投与量を調整するほうが好ましい可能性が示唆された。(著者抄録)

Migraine is a common disease seen in the emergency department (ED). Triptans, which are recommended in therapeutic guidelines for migraine, have some contraindications and possible severe side effects. Metoclopramide, which is commonly used as an antiemetic, also seems to have pain-relieving effects for migraine. In this article, we will introduce a study in progress, which investigates whether metoclopramide 10 mg intravenously (IV) is non-inferior to sumatriptan 3 mg subcutaneously (SQ) as migraine treatment in the ED. This study is a single-center, open-label, cluster-randomized controlled trial of 80 patients with migraine attacks to investigate the non-inferiority of metoclopramide to sumatriptan. The patients will be cluster-randomized monthly into metoclopramide 10 mg IV and sumatriptan 3 mg SQ arms. The primary outcome will be change in Numerical Rating Scale score for headache at 1 h after baseline. In discussion, if our hypothesis is confirmed, metoclopramide can be considered as first-line medication for migraine attacks in ED settings.

処置時の鎮静・鎮痛(procedural sedation and analgesia:PSA)は日本の救急外来でも広く行われているが、その実態のデータはきわめて乏しい。本研究では、2015年4月から2016年3月の仙台市立病院救命救急センター受診者で、PSAを受けた18歳以上の症例を後ろ向きに検討した。延べ173症例が対象となり、年齢の中央値は66.5歳であった。適用となった処置は同期電気ショックがもっとも多く(120症例、69.4%)、骨折・脱臼の整復が11症例(6.4%)とそれに続いた。短時間の呼吸抑制は79症例(45.7%)で見られたが、肺炎、侵襲的な気道確保の実施、PSAが原因の死亡など、重篤な合併症は認めなかった。救急外来でのPSAは、おおむね安全と考えられた。(著者抄録)

PurposeProcedural sedation and analgesia (PSA) is widely performed outside of the operating theater, often in emergency departments (EDs). The practice and safety of PSA in the ED in an aging society such as in Japan have not been well described. We aimed to characterize the practice pattern of PSA including indications, pharmacology and incidence of adverse events (AEs) in Japan.MethodsWe formed the Japanese Procedural Sedation and Analgesia Registry, a multicenter prospective observation registry of ED patients undergoing PSA. We included all patients who received PSA in the ED. PSA was defined as any systemic pharmacological intervention intended to facilitate a painful or uncomfortable procedure. The main variables in this study were patients' demographics, American Society of Anesthesiologists (ASA) physical status, indication of PSA, medication choices, and AEs. The primary outcome measure was overall AEs from PSA.ResultsWe enrolled 332 patients in four EDs during the 12-month period. The median age was 67years (IQR, 46-78). In terms of ASA physical status, 79 (23.8%), 172 (51.8%), and 81 (24.4%) patients were class 1, 2, 3 or higher, respectively. The most common indication was cardioversion (44.0%). The most common sedative used was thiopental (38.9%), followed by midazolam (34.0%) and propofol (19.6%). Among all patients, 72 (21.7%, 95% confidence interval, 17-26) patients experienced one or more AEs. The most common AE was hypoxia (9.9%), followed by apnea (7.2%) and hypotension (3.5%). All of the AEs were transient and no patient had a serious AE.ConclusionIn a multicenter prospective registry in Japan, PSA in the ED appears safe particularly since the patients who underwent PSA were older and had a higher risk profile compared to patients in previous studies in different countries.

74歳男。受診7日前から全身倦怠感を自覚し、4日前から仕事を休んでいた。受診当日、同僚が様子を見に行ったところ全身黄色で朦朧としていたため救急要請し、当院に搬送された。自宅がネズミで汚染されているという生活歴と、全身性黄疸、下腿優位の下肢痛、肝機能障害、腎機能障害、血小板減少、低血圧などの所見から、レプトスピラ症による敗血症を疑った。急速大量輸液を行い、循環動態はいったん安定したが、抗菌薬投与後に発熱と血圧低下を認めた。ヤーリッシュヘルクスハイマー反応を疑ってアドレナリン投与を開始し、14時間後にアドレナリンから離脱することができた。レプトスピラの血清PCRは陰性であったが、尿中PCR陽性であり、血清抗体価検査でL.interrogans serovar Copenhageniの抗体価が4倍以上を示した。症状は徐々に改善し、第19病日に退院となった。