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.