深野 賢太朗

Procedural sedation and analgesia (PSA) is generally considered safe, yet fatal events remain poorly characterised across procedures and specialties. We retrospectively reviewed the Japan Council for Quality Health Care nationwide adverse-event database (2012-2021), searching narrative reports with 40 Japanese keywords for sedation terms and drug names. Only reports in which PSA was deemed the primary cause of death were included; non-procedural sedation, planned general anaesthesia and procedure-induced injuries were excluded. Among 10 011 reports identified via keyword search, 805 described deaths and 23 were attributed to PSA. Fatalities clustered in gastroenterology (73.9%), particularly endoscopic retrograde cholangiopancreatography (ERCP; 34.8%). Most cases were high-risk patients aged 70-89 years (65.2%) and retrospectively classified as American Society of Anesthesiologists Physical Status III/IV (87%), yet no anaesthetist involvement was documented. Oxygen desaturation was the earliest sign of deterioration (56.5%), and capnography was not documented in any case. When PSA fatalities in Japan are examined across procedures and specialties, gastrointestinal interventions-especially ERCP-predominate in our cohort; however, the absence of procedure-specific denominators warrants cautious interpretation. Targeted safety measures, in line with current national sedation guidelines, including enhanced presedation evaluation, anaesthetist involvement for high-risk patients and routine capnography, may help to reduce PSA-related mortality.

BACKGROUND: Postoperative delirium is a common complication associated with prolonged hospitalization, cognitive decline, and increased mortality. Intraoperative hypotension (IOH) is a potential modifiable risk factor for postoperative delirium, but previous studies have shown inconsistent results due to methodological limitations. High-risk surgical patients, particularly those with comorbidities or advanced age, may be especially vulnerable. We evaluated the association between IOH and postoperative ICU delirium within 48 h. METHODS: We conducted a single-center retrospective study of high-risk adult patients who underwent surgery under general anesthesia without cardiopulmonary bypass and were admitted to the ICU between 2017 and 2024. IOH exposure was quantified using the cumulative area where mean arterial pressure (MAP) was below 65 mmHg (hypotension area) and total time under this threshold (hypotension time). Multivariable logistic regression was used to assess the association between IOH and postoperative ICU delirium, adjusting for preoperative comorbidities, intraoperative medications, and anesthetic depth. Subgroup and interaction analyses explored effect modifiers. RESULTS: Among 4798 patients, both hypotension area (OR 1.16, 95% CI 1.05-1.29, P = 0.003) and hypotension time (OR 3.42, 95% CI 1.21-9.65, P = 0.02) were significantly associated with postoperative ICU delirium within 48 h. Subgroup analyses suggested stronger associations in patients with advanced age, higher ASA-PS, inhalational anesthesia, neurosurgery, and intubation at ICU admission. CONCLUSIONS: IOH was significantly associated with postoperative ICU delirium. These findings underscore the importance of vigilant blood pressure management during surgery, particularly in high-risk patients. Interventional studies are needed to confirm these results and guide preventive strategies.

BACKGROUND: The optimal strategy for acute type A aortic dissection (ATAAD) with coronary malperfusion remains unclear. This study aimed to compare in-hospital mortality between coronary angiography followed by aortic repair and direct aortic repair without coronary angiography in patients with ATAAD and coronary malperfusion. METHODS: We conducted a retrospective cohort study using the Japanese Diagnosis Procedure Combination database, a nationwide inpatient database, from July 2010 to March 2022. We included patients who were admitted emergently and underwent surgery for ATAAD on the day of admission. Patients were defined as having preoperative coronary malperfusion if they had a diagnosis of acute myocardial infarction present on admission or underwent coronary angiography or percutaneous coronary intervention on the day of surgery. The primary outcome was in-hospital mortality. Patients were categorized as coronary angiography followed by aortic repair (CAG group) or direct aortic repair (DAR group). A multivariable Cox regression model was used to compare the time to in-hospital death between groups. RESULTS: We identified 1167 patients with ATAAD with coronary malperfusion. Of these, 508 (43.5 %) were in the CAG group and 659 (56.5 %) were in the DAR group. Cox regression analysis revealed no significant differences in the in-hospital mortality between the groups (hazard ratio, 1.05; 95 % confidence interval, 0.83 to 1.34, p = 0.661). CONCLUSIONS: Among patients with ATAAD with coronary malperfusion, in-hospital mortality did not differ significantly between those who underwent coronary angiography followed by aortic repair and those who underwent direct aortic repair.

UNLABELLED: Purpose To evaluate the effect of reducing tidal volume from 8 mL/kg predicted body weight (PBW) to 6 mL/kg PBW on dynamic arterial elastance (Eadyn) in patients scheduled for laparoscopic surgery. METHOD: After the start of intra-abdominal insufflation, if MAP became < 65 mmHg and SVV > 10%, then the tidal volume was reduced from 8 mL/kg PBW to 6 mL/kg PBW. One min later, 250 mL of lactate Ringer's solution was administered over 10 min. MAP responsiveness was defined as a > 10% increase in MAP following a fluid challenge. RESULTS: This study included 46 patients, 11 MAP non-responders and 35 MAP responders. Both PPV and SVV decreased significantly (- 19.4 ± 11% and - 19.7 ± 9.9%, respectively) following tidal volume reduction. However, the magnitude of the decrease differed. As a result, the change in Eadyn was minimal on average, although inter-individual variability was observed. Bland-Altman analysis revealed a mean difference of - 0.004, with 95% limits of agreement ranging from - 0.285 to + 0.278. Eadyn values before and after tidal volume reduction failed to predict MAP responsiveness (at 8 mL/kg PBW: area under the ROC curve [AUC] 0.514, at 6 mL/kg PBW: AUC 0.508). CONCLUSION: The reduction in tidal volume had a clinically negligible effect on Eadyn. Neither Eadyn values at tidal volume of 8 mL/kg PBW and 6 mL/kg PBW could not predict MAP increase after a fluid challenge during laparoscopic surgery. TRIAL REGISTRATION: This study was registered in the UMIN-CTR Clinical Database (ID: UMIN000054061) on April 4th, 2024. https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi? recptno=R000061722.

BACKGROUND: The use of supplemental oxygen (SO) for procedural sedation and analgesia (PSA) is recommended in many guidelines, but the evidence of SO for the elderly is limited. OBJECTIVES: This study aimed to compare the incidence of hypoxia with or without SO in PSA for the elderly patients. METHODS: We prospectively collected data on all patients undergoing PSA in the emergency department (ED) from May 2017 through December 2021. These data are from the Japanese Procedural SedaTion and Analgesia Registry. We included all elderly patients (65 years and older) who received PSA in the ED. We performed propensity score analysis for inverse probability of treatment weighting (IPTW) to balance the baseline characteristics. The primary outcome was the incidence of hypoxia (SpO2 < 90%), and the secondary outcome was the incidence of bag-valve mask ventilation. RESULTS: Among 1465 patients in the registry, we included 816 (55.7%) patients in the analysis. After propensity score method for IPTW, the distributions of confounders were closely balanced between the two groups. The incidence of hypoxia was significantly lower in the SO group compared with the non-SO group (6.2% vs. 19.3%; difference -13.1%; 95% confidence interval [CI] -9.8 to -16.4; p < 0.001). SO was also associated with a lower incidence of bag-valve mask ventilation (5.2% vs. 15.4%; difference -10.2%; 95% CI -7.1 to -13.2; p < 0.001). CONCLUSIONS: In a propensity-matched analysis, SO was associated with a lower incidence of hypoxia in elderly patients during ED PSA.

BACKGROUND: Intercostal nerve block (ICNB) plus intravenous (IV) patient-controlled analgesia (PCA) could be an alternative method of perioperative pain management in patients undergoing video-assisted thoracic surgery (VATS). However, the efficacy of this strategy has not been established. METHODS: A retrospective observational study was conducted at an acute care hospital in Japan. Among patients who underwent VATS under general anesthesia from January 1, 2012, to December 31, 2022, we included those who received ICNB or thoracic epidural anesthesia (TEA). The ICNB group had postoperative IV PCA, and the TEA group had postoperative epidural PCA. VATS indicated for pneumothorax or biopsy was excluded. The primary outcome was the maximum pain score measured by the numerical rating scale on postoperative day 1. Secondary outcomes included the times rescue analgesics were used and the use of antiemetics. Propensity score matching was performed to minimize bias from nonrandomized assignment of anesthesia methods. RESULTS: Among 1,641 patients who met the criteria, 590 underwent ICNB and IV PCA, while 1,051 received TEA. After 1:1 propensity score-matching, 456 were in each group. The median (interquartile range) pain score on postoperative day 1 was higher in the ICNB group than in the TEA group, with values of 5 (4-7) vs. 3 (2-5) (p < 0.0001). Patients in the ICNB group more frequently used rescue analgesics on postoperative day 0, with values of 2 (1-2) vs. 1 (1-2) (p < 0.0001), and had a higher proportion of receiving antiemetics on postoperative day 1 (13.4% vs. 6.1%, p = 0.0004), compared to the patients in the TEA group. CONCLUSIONS: ICNB plus IV PCA was inferior to TEA for postoperative pain management of VATS in the study population. Protocol-based prospective studies are needed to determine the efficacy of this strategy.

BACKGROUND: Ascorbic acid is a strong antioxidant that prevents postoperative delirium by inhibiting reactive oxygen species production. This pilot study was designed to investigate the prevalence of postoperative delirium among older patients undergoing cardiovascular surgery, who received perioperative ascorbic acid administration, to estimate an appropriate sample size for further randomized controlled trials. METHODS: This single-arm prospective interventional study enrolled patients aged > 70 years scheduled to undergo elective cardiovascular surgery using cardiopulmonary bypass. Ascorbic acid (500 mg) was administered intravenously every 6 h for a total of eight times following the induction of general anesthesia. The incidence of postoperative delirium was evaluated until discharge using the Confusion Assessment Method for the Intensive Care Unit. RESULTS: Data from 48 patients were analyzed. Of the 48 patients, 16 developed postoperative delirium (33.3%). Patients in the delirium group had more severe heart failure (New York Heart Association Classification), higher European System for Cardiac Operative Risk Evaluation scores, lower intraoperative Bispectral Index, longer duration of cardiopulmonary bypass and surgery, incidence of postoperative cerebral infarction, longer intubation time, and length of intensive care unit stay. CONCLUSIONS: The incidence of postoperative delirium among older patients undergoing cardiovascular surgery who received ascorbic acid perioperatively (2 g/day for 2 days) was 33%. This incidence was comparable to that observed in a previous observational study, suggesting that ascorbic acid administration may not be effective in preventing the incidence of postoperative delirium.

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>

BACKGROUND: The use of supplemental oxygen (SO) for procedural sedation and analgesia (PSA) is recommended in many guidelines, but the evidence of SO for the elderly is limited. OBJECTIVES: This study aimed to compare the incidence of hypoxia with or without SO in PSA for the elderly patients. METHODS: We prospectively collected data on all patients undergoing PSA in the emergency department (ED) from May 2017 through December 2021. These data are from the Japanese Procedural SedaTion and Analgesia Registry. We included all elderly patients (65 years and older) who received PSA in the ED. We performed propensity score analysis for inverse probability of treatment weighting (IPTW) to balance the baseline characteristics. The primary outcome was the incidence of hypoxia (SpO2 < 90%), and the secondary outcome was the incidence of bag-valve mask ventilation. RESULTS: Among 1465 patients in the registry, we included 816 (55.7%) patients in the analysis. After propensity score method for IPTW, the distributions of confounders were closely balanced between the two groups. The incidence of hypoxia was significantly lower in the SO group compared with the non-SO group (6.2% vs. 19.3%; difference -13.1%; 95% confidence interval [CI] -9.8 to -16.4; p < 0.001). SO was also associated with a lower incidence of bag-valve mask ventilation (5.2% vs. 15.4%; difference -10.2%; 95% CI -7.1 to -13.2; p < 0.001). CONCLUSIONS: In a propensity-matched analysis, SO was associated with a lower incidence of hypoxia in elderly patients during ED PSA.

<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.

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.

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。