西山 聖也

BACKGROUND: The aim of this study was to assess in-hospital mortality and identify its predictors in adult patients with hematological malignancies admitted to intensive care units (ICUs) in Japan. METHODS: We conducted a retrospective cohort study of adult patients with hematological malignancies admitted to ICUs participating in the Japanese Intensive care PAtient Database from 2015 to 2020. The primary outcome was in-hospital mortality. We compared survivors and non-survivors based on their characteristics at ICU admission and ICU treatments. We also assessed the relationship between institutional characteristics and in-hospital mortality. RESULTS: A total of 1,700 patients from 69 institutions were included. In-hospital mortality was 46.2%. The most common reason for ICU admission was respiratory failure (28.2%). Mechanical ventilation and continuous renal replacement therapy were used in 49.0% and 24.6% of patients, respectively. In multivariable logistic regression analysis, a higher in-hospital mortality was independently associated with type of neoplasm, Acute Physiological Assessment and Chronic Health Evaluation III score, invasive mechanical ventilation (OR 1.64, 95% CI 1.30-2.08), noninvasive ventilation (OR 1.71, 95% CI 1.22-2.41), and continuous renal replacement therapy (OR 1.98, 95% CI 1.51-2.61), whereas other patient characteristics (e.g., age, comorbidities, ICU admission source, reason for ICU admission) were not associated. There was also no association between institutional characteristics and in-hospital mortality. CONCLUSIONS: In-hospital mortality of adult patients with hematological malignancies admitted to ICUs remains high. Factors associated with in-hospital mortality in these patients differed from those in the general ICU population. Institutional characteristics were not significantly associated with in-hospital mortality.

BACKGROUND: The optimal strategy for discontinuing arginine vasopressin and norepinephrine in patients recovering from shock remains uncertain. Although prior studies have suggested a higher risk of hypotension when arginine vasopressin is discontinued first, these findings may have been influenced by baseline imbalances and tapering practices. We conducted a retrospective study to evaluate whether the order of discontinuation between arginine vasopressin and norepinephrine was associated with the incidence of hypotension during the recovery phase of shock, with vasopressor end doses converted to norepinephrine equivalents for analysis. METHODS: This was a single-center retrospective cohort study of intensive care unit patients with shock who received both arginine vasopressin and norepinephrine from August 2017 to March 2024. Patients were categorized based on whether arginine vasopressin or norepinephrine was discontinued first. The primary outcome was the incidence of hypotension within 24 h of vasopressor cessation, defined as mean arterial pressure < 60 mmHg requiring a ≥ 25% increase in the remaining vasopressor, reinstitution of the stopped agent, or a bolus of ≥ 500 mL crystalloid or 25 g albumin. Overlap weighting using propensity scores was applied to adjust for baseline imbalances both in the overall cohort and in the septic shock subgroup. Propensity scores were estimated using logistic model, including baseline characteristics, hemodynamic parameters, and vasopressor end doses in norepinephrine equivalents. RESULTS: A total of 524 patients were analyzed, with 293 discontinuing AVP first and 231 discontinuing NE first. In the unadjusted cohorts, hypotension occurred in 19% of the AVP-first group and 26% of the NE-first group. After overlap weighting, all baseline covariates were balanced between the groups, and the incidence of hypotension was not significantly different (19% vs 21%, P = 0.59). In the septic shock subgroup (n = 267), the weighted analysis showed no significant difference in the incidence of hypotension between groups. CONCLUSIONS: In patients recovering from shock who received both arginine vasopressin and norepinephrine, discontinuing arginine vasopressin first was not associated with a higher risk of hypotension.

BACKGROUND: Cerebrospinal fluid (CSF) levels of orexin show a cyclic diurnal variation in healthy subjects, which is diminished in patients with certain diseases. However, possible circadian variations in orexin levels in critically ill patients remain unknown. In this study, we evaluated the orexin concentrations in the CSF and their diurnal variation in patients undergoing thoracic aortic aneurysm repair with lumbar intrathecal catheterization for CSF drainage after non-neurosurgery. METHODS: Eligible patients with a lumbar intrathecal catheter placed for CSF drainage following aortic surgery at a single-center ICU between September 2019 and February 2020 were included. Catheters were placed before anesthesia induction, and CSF was collected at the time of catheter placement, ICU admission, and daily at 6:00, 12:00, 18:00, and 24:00 until the catheter was removed or for up to 5 days after admission to the ICU. RESULTS: Three patients (Patients A, B, and C) who underwent thoracic aortic aneurysm repair were included. Patients B and C received sedatives or hypnotics during the orexin measurement period. The baseline orexin levels for Patients A, B, and C were 219.9, 312.3, and 403.8 pg/mL, while the mean orexin levels were 319.4 ± 82.6, 372.4 ± 56.0, and 306.3 ± 48.3 pg/mL, respectively. For all three patients, orexin levels showed diurnal variations, but no consistent periodic changes. CONCLUSION: CSF orexin concentrations for patients undergoing thoracic aortic aneurysm repair in the ICU were within the reported range compared to those of previously reported healthy subjects; however, consistent periodic diurnal variations were not observed.