飯塚 悠祐

INTRODUCTION: With the rapid increase in the ageing population, the use of procedural sedation and analgesia (PSA) for diagnostic procedures such as prostate biopsy in older adults is increasing. However, elderly patients are particularly susceptible to respiratory depression during PSA testing and have a significantly higher risk of hypoxaemia during procedures requiring deep sedation. Although propofol combined with fentanyl is commonly used, it frequently causes hypoxaemia and apnoea. Remimazolam, a novel ultrashort-acting benzodiazepine, may be a safer alternative with less respiratory compromise; however, the supporting evidence remains limited. This study aims to assess whether remimazolam combined with fentanyl reduces the incidence of respiratory depression compared with propofol combined with fentanyl in elderly patients undergoing prostate biopsy under deep sedation requiring immobility. METHODS AND ANALYSIS: This is a single-centre, participant and assessor-blinded (with pragmatic blinding of participants), parallel-group, superiority randomised controlled trial conducted at the Jichi Medical University Saitama Medical Centre, Japan. Eligible participants are men aged ≥70 years who are scheduled to undergo prostate biopsy under intravenous sedation. Participants will be randomised in a 1:1 ratio to receive either remimazolam or propofol, each administered in combination with fentanyl at a fixed effect-site concentration. The primary outcome is the incidence of severe apnoea (≥1 min). The primary analysis will follow the intention-to-treat principle, implemented practically as a full analysis set analysed using a complete case approach. Sensitivity analyses will include a per-protocol analysis and multiple imputations of missing data. A subgroup analysis of patients aged ≥75 years was performed. ETHICS AND DISSEMINATION: This study was approved by the Jichi Medical University Central Clinical Research Ethics Committee (approval number: 24JMU001S-2) and was registered with the Japan Registry of Clinical Trials on 11 November 2024. Written informed consent was obtained from all participants before enrolment. These findings will be disseminated through publications in peer-reviewed journals and presentations at scientific conferences. TRIAL REGISTRATION NUMBER: jRCTs031240478.

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.

BACKGROUND: One-lung ventilation (OLV) is an essential technique in thoracic surgery, and double-lumen endobronchial tubes (DLTs) are commonly used. While right-sided DLTs are useful in specific situations, few studies have investigated the prevalence of their use. This study aimed to investigate the current practice of OLV and right-sided DLT usage among anesthesiologists in Japan. METHODS: A nationwide cross-sectional survey was conducted in September 2024, targeting 1444 hospitals certified by the Japanese Society of Anesthesiologists. Questionnaires were mailed to anesthesiology departments, inquiring about OLV practices, right-sided DLT usage, challenges, and desired improvements. Responses were collected via postal mail or web, and data were analyzed using descriptive statistics and Chi-square tests. RESULTS: A total of 768 institutions responded (response rate: 53.2%). Among 761 valid responses, 74.9% performed OLV, and DLTs were the most frequently used device (94.7%). Approximately half (45.8%) of the institutions performing OLV reported never using right-sided DLTs. Frequently recognized challenges included insertion difficulty, positioning difficulty, and unfamiliarity, and 42.1% of institutions expressed a willingness to increase the use of right-sided DLTs if these challenges were resolved. Institutions with a higher annual volume of OLV cases tended to use right-sided DLTs more frequently, but the proportion of institutions unfamiliar with right-sided DLTs was not associated with the number of OLV cases performed. CONCLUSION: OLV is widely practiced in Japan, primarily using DLTs, while the use of right-sided DLTs is limited. Concerns over technical difficulties and complications may hinder the use of right-sided DLTs.

BACKGROUND: Clinically important gastrointestinal bleeding (CIGIB) is a serious complication in critically ill patients, contributing to prolonged ICU stays and increased mortality. Despite efforts to identify high-risk patients, no previous studies have employed machine learning models to predict CIGIB during ICU stay or identify key predictors in this context. METHODS: This single-center retrospective study included ICU patients aged 18 years or older admitted between 2017 and 2024. Patients with ICU stays of less than 24 hours or GIB within 24 hours of admission were excluded. Machine learning models, including XGBoost, Random Forest, and L1-regularized logistic regression, were trained using patient data from the first 24 hours of ICU admission. Model performance was assessed using AUROC, precision, recall, and F1 scores. Shapley Additive Explanations (SHAP) were employed to evaluate key predictors. RESULTS: A total of 7,357 ICU patients were included, of whom 171 (2.3%) experienced CIGIB. The XGBoost model demonstrated the highest predictive performance with an AUROC of 0.84. Key predictors included APACHE III scores, hematocrit levels, APTT, creatinine and respiratory rate, while invasive mechanical ventilation and stress ulcer prophylaxis within the first 24 hours of ICU admission did not rank among the top 20 predictors based on SHAP values. CONCLUSIONS: This study represents the first application of machine learning for predicting CIGIB in ICU patients, providing valuable insights into risk stratification. The model demonstrated high predictive accuracy and interpretability, highlighting its potential to guide early intervention and prophylaxis. Further multi-center studies and interventional trials are needed to validate these findings and refine clinical risk prediction strategies.

An endotracheal tube (ETT) cuff leakage has serious consequences. Anatomical abnormalities are rare but are possible causes. We report the case of a patient having a robot-assisted laparoscopic prostatectomy. Endotracheal intubation was performed successfully. However, a cuff leak occurred, and persisted despite standard management efforts. The ETT was carefully advanced until one-lung ventilation was established and then gradually withdrawn until bilateral lung ventilation was restored. Chest computed tomography revealed a tracheal diverticulum immediately below the vocal cords as the underlying cause. If standard troubleshooting fails to resolve a cuff leak, unusual causes should be considered.

BACKGROUND: Patients with end-stage renal disease on hemodialysis (HD) undergoing cardiac surgery face increased risks. Mixed venous saturation (SvO2) is an important parameter representing the systemic oxygen supply-demand balance. However, interpreting SvO2 in HD patients may be challenging due to arteriovenous fistulas. The literature on these issues is lacking. This study aimed to investigate the change in SvO2 in HD patients by comparing those in non-HD patients perioperatively. METHODOLOGY: From April 1, 2019, to March 31, 2020, 39 patients undergoing cardiac surgery with pulmonary artery catheters, 18 with and 21 without HD, were identified. The cardiac index (CI) and SvO2 were extracted from patient records, and the oxygen delivery index (DO2I) was calculated before surgery (T0), on intensive care unit (ICU) admission (T1), 24 hours (T2), and 48 hours (T3) after ICU admission. A linear mixed effects model was applied for repeated measures analyses. RESULTS: T0 CI was significantly higher in the HD group (2.5 ± 0.5 vs. 2.0 ± 0.5 L/minute/m2, mean ± SD, P = 0.003) and increased significantly over time in both groups, without an interaction effect (P for interaction = 0.12). T0 SvO2 did not differ between groups (72 ± 10% vs. 72 ± 5%, P = 0.97) and decreased over time, more evidently in the non-HD group (P for interaction = 0.016). DO2I was similar in both groups perioperatively. CONCLUSIONS: SvO2 tended to be higher in the HD group perioperatively. If SvO2 in HD patients is similar to that in non-HD patients, this may mean that the oxygen supply-demand balance is disturbed.

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.

PURPOSE: The purpose of this study is to describe the implementation of life-supporting interventions and the short-term outcomes of older patients in ICUs in Japan. METHODS: All adult patients admitted to ICUs participating in the Japanese Intensive Care Patient Database (JIPAD) from April 1, 2015, to March 31, 2022, were eligible for inclusion. Information, including life-supporting interventions, was retrieved from the database. Patients were divided into six age groups. The primary outcome of interest was the proportion of receiving a composite of the following interventions: mechanical ventilation, continuous renal replacement therapy, and veno-venous or veno-arterial extracorporeal membrane oxygenation. RESULTS: Data of a total of 233,093 patients were analyzed. The median age was 71 years, with 18.2% of the patients in their 80s, 5303 patients in their 90s (2.3%), and 67 patients in their 100s. Many life-supporting interventions were provided to older patients. The proportion of patients older than 90 years who received the composite interventions decreased from 40.4% in 18-59 to 27.6% in 90-99. Non-invasive ventilation (NIV) use increased with age, resulting in a consistent proportion of patients receiving either NIV or mechanical ventilation until their 90s. ICU mortality for patients aged 80 years or older was 5.6%, and hospital mortality for this age group was 12.9%. Approximately half of the patients in their 80s and 60% of those older than 90 years did not return home. CONCLUSION: Although life-supporting interventions tended to decrease with age, a considerable number of patients of advanced age still received these interventions.

BACKGROUND: Interatrial right-to-left shunt flow through a patent foramen ovale (PFO) can be caused by changes in heart position for anastomosis during off-pump coronary artery bypass (OPCAB). We herein present a case in which the direction of PFO shunt flow changed with heart position during OPCAB and the ventilation settings after sternal closure. CASE PRESENTATION: A 66-year-old man with interstitial pneumonia underwent OPCAB. Preoperative transesophageal echocardiography revealed right-to-left shunt flow through a PFO induced by the Valsalva maneuver. During OPCAB, heart displacement resulted in right-to-left shunting and acute hypoxemia, which quickly improved with increase of inspired oxygen fraction. After chest closure, bidirectional shunt flow developed under increased airway pressure. CONCLUSIONS: Vigilant intraoperative monitoring with TEE and postoperative airway pressure management are important to address shunt flow and hypoxemia due to PFO.

Introduction Remifentanil is an opioid with rapid onset and elimination. Theoretically, reducing sedation using high-dose remifentanil may contribute to early emergence and prevention of postanesthetic complications related to residual anesthesia. However, there have been few reports of high-dose remifentanil anesthesia in neonatal surgery. This study aims to describe the techniques of high-dose remifentanil anesthesia in neonates and their safety outcomes. Methods This is a single-center, retrospective observational study from January 2016 to February 2022. Medical records from neonatal surgical procedures performed using high-dose remifentanil anesthesia were reviewed. "High dose" was defined as 0.5 mcg/kg/min or more. Patient profiles, anesthetic drugs used, and intra- and post-operative adverse events, including cardiopulmonary complications, were abstracted. Results There were 15 neonatal abdominal operations performed under high-dose (>0.5 mcg/kg/min) remifentanil anesthesia during the study period. The average remifentanil infusion rate was 1.9 (0.68-3.1) mcg/kg/min. Hypotension occurred in two patients (13%). Bradycardia was not observed in any patients. The mean time for tracheal extubation was 16 minutes. Five patients (33%) received naloxone administration before extubation, and two patients (13%) experienced hypoxemia immediately after extubation. No patient had cardiorespiratory complications after leaving the operating room. Conclusions High-dose remifentanil can be used without impairing hemodynamic stability in neonatal surgery, although there is concern about respiratory depression. Further research is needed on its potential impact on long-term outcomes.

OBJECTIVE: Systemic heparinization during cardiopulmonary bypass (CPB) can significantly affect thromboelastography (TEG). This study investigated the feasibility of adding protamine in vitro to allow assessment of coagulation status using the TEG 6s system during CPB. METHODS: In this prospective observational study, 21 patients undergoing elective cardiac valve surgery were evaluated. During CPB, protamine was added in vitro to the heparinized blood of these patients at a concentration of 0.05 mg/mL and analyzed with the TEG 6s (Pre). The TEG parameters were compared to those analyzed after CPB withdrawal and systemic protamine administration (Post). RESULTS: The citrated kaolin maximal amplitude (CK-MA) and the citrated functional fibrinogen maximal amplitude (CFF-MA) exhibited strong correlations between Pre and Post measurements (r = 0.790 and 0.974, respectively, P < 0.001 for both), despite significant mean differences (-2.23 mm for CK-MA and -0.68 mm for CFF-MA). Bland-Altman analysis showed a clinically acceptable agreement between Pre and Post measurement of CK-MA and CFF-MA (the percentage error was 10.6% and 12.2%, respectively). In contrast, the citrated kaolin reaction time (CK-R) showed no significant correlation between Pre and Post measurements (r = 0.328, P = 0.146), with a mean difference of 1.42 min (95% CI: -0.45 to 3.29). CONCLUSIONS: In vitro protamine addition allows assessment of coagulation status during CPB using the TEG 6s system. CK-MA and CFF-MA measured during CPB using this method revealed a strong correlation and agreement with post-CPB measurements, suggesting that our method potentially facilitates early prediction of post-CPB coagulation status and decision-making on transfusion strategies. CLINICAL TRIAL REGISTRATION: The study was registered in the University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR, registration number: UMIN000041097, date of registration: July 13, 2020, https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000046925 ) before the recruitment of participants.

BACKGROUND: Masks are well accepted in Japan, where they were already part of daily life even before the COVID-19 pandemic. Unlike many other countries where mask mandates were lifted as soon as the pandemic was under control, Japan was one of the last countries to ease mask-wearing guidelines. Even after the formal announcement to allow masks-off in mid-March 2023, many Japanese still voluntarily wear masks. In this work, possible reasons for this extreme "mask-affinity" of Japanese people were studied by exploring various information sources including tweets (now known as X posts) and subsequent text-analysis, online news, and medical literature. METHODS: An observational study was conducted based on tweets prospectively collected during 5 months from June 26th, 2022 to November 26th, 2022. Tweets with the hashtag "mask (in Japanese)" were collected weekly via the Twitter application programming interface by using R version 4.0.3 to gauge public opinions. The word clouds to allow intuitive understanding of the key words were drawn from the tokenized text. RESULTS: The data collection period included the 7th flareups of the newly infected cases i.e. "the 7th surge". In total, 161,592 tweets were collected. Word clouds for 1) before the 7th surge based on 18,000 tweets on June 26th and 2) during/after the 7th surge based on 143,592 tweets between July-November were created with the R package "wordcloud2". The results indicated that the people wanted to take off masks due to the heat in summer, then shifted again toward mask-wearing along with the 7th surge but with a certainly growing "no-mask" sentiment. CONCLUSIONS: Subsequent review of domestic information sources suggested that various factors, not only well-known peer pressure, may have contributed the public's mask affinity in Japan. This work revealed an aspect of Japanese struggle toward adaptation to life in an unexpected pandemic by focusing on masks as our closest daily adjunct over the past 3 years of isolation.Trial registration: not applicable.

Andexanet alfa neutralizes factor Xa inhibitors in critical bleeding situations. However, in cardiac surgery with cardiopulmonary bypass (CPB), heparin resistance induced by andexanet alfa should be a concern, and the lack of point-of-care monitoring of plasma concentration of factor Xa inhibitors makes it difficult to decide when to administer andexanet alfa. A 69-year-old man underwent emergency surgery for acute pulmonary thromboembolism. The patient had been on edoxaban until the day before the surgery. Withdrawal from CPB required venoarterial extracorporeal membrane oxygenation due to right heart failure, followed by severe bleeding that required massive transfusion. Despite adequate coagulation factor replacement, bleeding persisted and citrated kaolin-reaction time (CK-R) on thromboelastography (TEG) was prolonged. Administering andexanet alfa achieved excellent hemostasis without any thrombosis and normalized the prolonged CK-R of TEG. This is the first report of a change in TEG findings before and after administration of andexanet alfa in a cardiac surgery patient taking factor Xa inhibitor. Monitoring CK-R in TEG may help evaluate the anticoagulant effect of factor Xa inhibitors and the reversal effect of andexanet alfa.

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).

BACKGROUND: 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. METHODS: 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. RESULTS: 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; p = 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%, p = 0.45, 1.7% vs 1.7%, p = 0.93, 4.8% vs 4.9%, p = 0.87). CONCLUSIONS: 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.

BACKGROUND: The incidence of delirium is high in older patients undergoing cardiovascular surgery with cardiopulmonary bypass (CPB). Intraoperative tissue hypoperfusion and re-reperfusion injury, which generate reactive oxygen species (ROS), are suggested to induce delirium. Ascorbic acid is an excellent antioxidant and may reduce organ damage by inhibiting the production of ROS. This prospective observational study aimed to measure pre- and postoperative plasma ascorbic acid levels and examine their association with delirium. METHODS: Patients older than 70 years of age scheduled for elective cardiovascular surgery using CPB were enrolled. From September 2020 to December 2021, we enrolled 100 patients, and the data of 98 patients were analyzed. RESULTS: In total, 31 patients developed delirium, while 67 did not. Preoperative plasma ascorbic acid levels did not differ between the non-delirium and delirium groups (6.0 ± 2.2 vs. 5.5 ± 2.4 µg/mL, p = 0.3). Postoperative plasma ascorbic acid levels were significantly different between the groups (2.8 [2.3-3.5] vs. 2.3 [1.6-3.3] µg/mL, p = 0.037). CONCLUSIONS: In patients who undergo cardiovascular surgery with CPB, lower postoperative plasma ascorbic acid levels may be associated with the development of delirium.

BACKGROUND: 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. METHODS: 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%. RESULTS: 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). CONCLUSIONS: 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.

PURPOSE: Retained foreign bodies (RFBs) are a major complication of surgical procedures. However, the efficacy of preventive measures is not well defined. This study investigates the characteristics of potential (near miss) and actual RFBs, and the contributions of routine practice for the prevention of RFB events. METHODS: We conducted a retrospective review of incident reports regarding near-miss and RFB events in patients who underwent surgery under general anesthesia in our institution between October 2008 and November 2018. RESULTS: Among 49,831 operations under general anesthesia, there were 106 (2.13/1000) near-miss events and 24 (0.48/1000) RFB events. Counting surgical materials and intraoperative X-rays detected the remaining items before completion of surgery in 59 (56%) and 15 (14%) cases, respectively. The operator or staff noticed the surgical materials in the remaining 32 (30%) near-miss events. RFBs included 4 sponges (17%), 4 instruments (17%), 4 needles (17%), and 12 miscellaneous items (50%). Of these, 12 (50%) RFBs were discovered on postoperative X-rays and 16 (67%) patients required operative removal. Four incidents (17%) with RFBs were attributable to ignoring count discrepancies during surgery. CONCLUSION: The actual incidence of RFB events is higher than previously reported. A standardized counting protocol, communication among staff, and intra- and postoperative X-rays may contribute to the prevention and detection of RFBs.

BACKGROUND: Capillary refill time (CRT) is the gold standard for evaluating peripheral organ perfusion; however, intraoperative CRT measurement is rarely used because it cannot be conducted continuously, and it is difficult to perform during general anesthesia. The peripheral perfusion index (PI) is another noninvasive method for evaluating peripheral perfusion. The PI can easily and continuously evaluate peripheral perfusion and could be an alternative to CRT for use during general anesthesia. This study aimed to determine the cutoff PI value for low peripheral perfusion status (prolonged CRT) by exploring the relationship between CRT and the PI during general anesthesia. METHODS: We enrolled 127 surgical patients. CRT and the PI were measured in a hemodynamically stable state during general anesthesia. A CRT >3 s indicated a low perfusion status. RESULTS: Prolonged CRT was observed in 27 patients. The median PI values in the non-prolonged and prolonged CRT groups were 5.0 (3.3-7.9) and 1.5 (1.2-1.9), respectively. There was a strong negative correlation between the PI and CRT (r = -0.706). The area under the receiver operating characteristic curve generated for the PI was 0.989 (95% confidence interval, 0.976-1.0). The cutoff PI value for detecting a prolonged CRT was 1.8. CONCLUSION: A PI <1.8 could accurately predict a low perfusion status during general anesthesia in the operating room. A PI <1.8 could be used to alert the possibility of a low perfusion status in the operating room. TRIAL REGISTRATION: University Hospital Medical Information Network (UMIN000043707; retrospectively registered on March 22, 2021, https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno = R000049905).

BACKGROUND: The joint committee of the Japanese Society of Intensive Care Medicine/Japanese Respiratory Society/Japanese Society of Respiratory Care Medicine on ARDS Clinical Practice Guideline has created and released the ARDS Clinical Practice Guideline 2021. METHODS: The 2016 edition of the Clinical Practice Guideline covered clinical questions (CQs) that targeted only adults, but the present guideline includes 15 CQs for children in addition to 46 CQs for adults. As with the previous edition, we used a systematic review method with the Grading of Recommendations Assessment Development and Evaluation (GRADE) system as well as a degree of recommendation determination method. We also conducted systematic reviews that used meta-analyses of diagnostic accuracy and network meta-analyses as a new method. RESULTS: Recommendations for adult patients with ARDS are described: we suggest against using serum C-reactive protein and procalcitonin levels to identify bacterial pneumonia as the underlying disease (GRADE 2D); we recommend limiting tidal volume to 4-8 mL/kg for mechanical ventilation (GRADE 1D); we recommend against managements targeting an excessively low SpO2 (PaO2) (GRADE 2D); we suggest against using transpulmonary pressure as a routine basis in positive end-expiratory pressure settings (GRADE 2B); we suggest implementing extracorporeal membrane oxygenation for those with severe ARDS (GRADE 2B); we suggest against using high-dose steroids (GRADE 2C); and we recommend using low-dose steroids (GRADE 1B). The recommendations for pediatric patients with ARDS are as follows: we suggest against using non-invasive respiratory support (non-invasive positive pressure ventilation/high-flow nasal cannula oxygen therapy) (GRADE 2D), we suggest placing pediatric patients with moderate ARDS in the prone position (GRADE 2D), we suggest against routinely implementing NO inhalation therapy (GRADE 2C), and we suggest against implementing daily sedation interruption for pediatric patients with respiratory failure (GRADE 2D). CONCLUSIONS: This article is a translated summary of the full version of the ARDS Clinical Practice Guideline 2021 published in Japanese (URL: https://www.jsicm.org/publication/guideline.html ). The original text, which was written for Japanese healthcare professionals, may include different perspectives from healthcare professionals of other countries.

BACKGROUND: The joint committee of the Japanese Society of Intensive Care Medicine/Japanese Respiratory Society/Japanese Society of Respiratory Care Medicine on ARDS Clinical Practice Guideline has created and released the ARDS Clinical Practice Guideline 2021. METHODS: The 2016 edition of the Clinical Practice Guideline covered clinical questions (CQs) that targeted only adults, but the present guideline includes 15 CQs for children in addition to 46 CQs for adults. As with the previous edition, we used a systematic review method with the Grading of Recommendations Assessment Development and Evaluation (GRADE) system as well as a degree of recommendation determination method. We also conducted systematic reviews that used meta-analyses of diagnostic accuracy and network meta-analyses as a new method. RESULTS: Recommendations for adult patients with ARDS are described: we suggest against using serum C-reactive protein and procalcitonin levels to identify bacterial pneumonia as the underlying disease (GRADE 2D); we recommend limiting tidal volume to 4-8 mL/kg for mechanical ventilation (GRADE 1D); we recommend against managements targeting an excessively low SpO2 (PaO2) (GRADE 2D); we suggest against using transpulmonary pressure as a routine basis in positive end-expiratory pressure settings (GRADE 2B); we suggest implementing extracorporeal membrane oxygenation for those with severe ARDS (GRADE 2B); we suggest against using high-dose steroids (GRADE 2C); and we recommend using low-dose steroids (GRADE 1B). The recommendations for pediatric patients with ARDS are as follows: we suggest against using non-invasive respiratory support (non-invasive positive pressure ventilation/high-flow nasal cannula oxygen therapy) (GRADE 2D); we suggest placing pediatric patients with moderate ARDS in the prone position (GRADE 2D); we suggest against routinely implementing NO inhalation therapy (GRADE 2C); and we suggest against implementing daily sedation interruption for pediatric patients with respiratory failure (GRADE 2D). CONCLUSIONS: This article is a translated summary of the full version of the ARDS Clinical Practice Guideline 2021 published in Japanese (URL: https://www.jrs.or.jp/publication/jrs_guidelines/). The original text, which was written for Japanese healthcare professionals, may include different perspectives from healthcare professionals of other countries.

To assess the general Japanese population's thoughts on coronavirus disease of 2019 related discrimination by Tweets.Tweets were retrieved from search queries using the keywords "health care providers and discrimination (no hashtags)" and "corona and rural area (no hashtags)" via the Twitter application programming interface. Subsequently, a text-mining analysis was conducted on tokenized text data. R version 4.0.2 was used for the analysis.In total, 51,906 tweets for "corona and health care providers", 59,560 tweets for "corona and rural" were obtained between the search period of July 29, 2020 and September 30, 2020. The most common 20 words from the tokenized text data were translated to English. Word clouds with the original Japanese words are presented.Tweets for corona and health care providers did not suggest significant evidence of discrimination toward health care providers on Twitter. Results for corona and rural area, however, showed the unexpected word "murahachibu" (an outmoded word meaning ostracism), suggesting persistent strong social pressure to prevent bringing the disease to the community. This kind of pressure may not be supported by scientific facts. These results demonstrate the need for continued educational efforts to disseminate factual information to the public.

PURPOSE: Thoracentesis and chest tube insertion are procedures commonly performed in routine clinical practice and are considered mandatory skills for all physicians. Adverse events secondary to these procedures have been widely reported; however, epidemiology data concerning life-threatening events associated with these procedures are lacking. METHODS: We retrospectively analyzed data from the Japan Council for Quality Health Care open database regarding subject safety incidents involving thoracentesis and chest tube insertion. The adverse events extracted from the database included only events associated with thoracentesis and chest tube insertion reported between January 2010 and April 2020. RESULTS: We identified 137 adverse events due to thoracentesis or chest tube insertion. Our analysis also revealed at least 15 fatal adverse events and 17 cases of left/right misalignment. Not only resident doctors but also physicians with 10 years or more of clinical experience had been mentioned in these reports. The most common complications due to adverse events were lung injury (55%), thoracic vascular injury (21%), and liver injury (10%). Surgical treatment was required for 43 (31%) of the 137 cases, and the mortality risk was significantly higher for thoracic vascular injury than for other complications (p = 0.02). CONCLUSION: We identified at least 15 fatal adverse events and 17 cases of left/right misalignment over a 10-year period in the Japan Council for Quality Health Care open database. Our findings also suggest that care should be taken to avoid thoracic vascular injury during chest tube insertion and that immediate intervention is required should such an injury occur.

Background: The aim of this study was to evaluate the utility of collapsibility of the internal jugular veins (IJVs) and subclavian veins (SCVs) in comparison with collapsibility of the inferior vena cava (IVC) in patients receiving pressure support ventilation. Methods: Patients receiving pressure support ventilation were prospectively enrolled when fluid bolus administration was clinically indicated. The antero-posterior diameters of IJVs, SCVs and IVC were measured. Fluid responsiveness was defined as an 8% increase in stroke volume calculated with arterial pulse contour analysis after a passive leg raising maneuver. Results: Twenty-seven patients (34 measurements) were included. Eighteen measurements were deemed fluid responsive. The area under the receiver operating characteristic curve of collapsibility of the right IJV antero-posterior diameter was 0.88 (95% confidence interval (CI): 0.75 - 0.99), while the area under the ROC curves for the antero-posterior diameter of the left IJV, right SCV, left SCV and the IVC were 0.57 (95% CI: 0.37 - 0.77), 0.61 (95% CI: 0.41 - 0.80), 0.55 (95% CI: 0.35 - 0.76) and 0.57 (95% CI: 0.37 - 0.77), respectively. Conclusions: These results suggest that collapsibility of the right IJV is a useful predictor of fluid responsiveness in patients receiving pressure support ventilation. Collapsibility of the IVC did not predict fluid responsiveness in these patients.

Background: Considering the adverse effects of sleep disturbance in critical care settings, accurate assessment could aid therapy; however, methodological inadequacies mean that no viable option is currently available. Research in healthy population has recently shown that a non-wearable sleep measurement device placed under the mattress of the bed could be beneficial in intensive care settings. Therefore, we aimed to validate this device compared with polysomnography (PSG) and to assess how it related to subjective sleep evaluations. Methods: This observational study measured the sleep of critically ill adult patients. The primary goal was to validate the Nemuri SCAN (NSCAN; Paramount Bed Co., Ltd., Tokyo, Japan) against the reference standard PSG for 24 h. The secondary goal was to evaluate the association between the objective parameters obtained from NSCAN and PSG and the subjective report data obtained using the Richards-Campbell Sleep Questionnaire (RCSQ) for the nighttime. Results: Eleven participants were evaluated. The median of the total sleep time scored by PSG was 456.0 (353.0-517.5) min during the nighttime and 305.0 (186.2-542.5) min during the daytime. PSG over 24 h revealed significant decreases in restorative sleep, with excessive daytime sleep, but with a normal quantity of nighttime sleep. The agreement, sensitivity, and specificity rates (with 95% confidence intervals) for the NSCAN compared with PSG were 68.4% (67.9-69.0%), 90.1% (89.7-90.6%), and 38.7% (37.9-39.7%), respectively. The median RCSQ value when subjectively evaluating nighttime sleep was 68.0 (26.3-83.5); this showed no correlation with the NSCAN sleep parameters, despite a positive correlation with the ratio of the stage N2 isolated or combined with restorative sleep in the PSG assessment. Conclusions: NSCAN had moderate agreement, high sensitivity, and poor specificity in intensive care settings, which is most likely due to its inability to identify immobile wakefulness often observed in critically ill patients or sleep depth. This remains a barrier to its use in the assessment of subjective sleep quality. Trial registration: This investigation was part of an interventional trial registered with the University Hospital Medical Information Network Individual Clinical Trials Registry (UMIN000026350, http://www.umin.ac.jp/icdr/index-j.html) on March 1, 2017.

PURPOSE: We investigated the epidemiology and outcome of disseminated intravascular coagulation (DIC) in patients with sepsis. MATERIALS AND METHODS: We analyzed data from a multicenter observational study (Japan Septic Disseminated Intravascular Coagulation [JSEPTIC-DIC] study) conducted in 42 intensive care units in Japan. DIC scores were calculated using two scoring systems: the International Society on Thrombosis and Haemostasis (ISTH) and Japanese Association for Acute Medicine (JAAM) criteria. We compared demographics and clinical characteristics of patients with and without DIC, and performed multivariable logistic regression analyses to assess the association of diagnosis and scores for DIC with in-hospital mortality. RESULTS: Of 1895 eligible patients, 1162 (61%) and 554 patients (29%) were diagnosed as having DIC by the JAAM and ISTH criteria, respectively. Patients with DIC had higher in-hospital mortality compared with those without DIC (33% vs. 20% in JAAM and 38% vs. 24% in ISTH). However, in multivariable analysis, the JAAM score (odds ratio 1.026, 95% confidence interval 0.958-1.097; p = 0.465) and the ISTH score (odds ratio 1.049, 95% confidence interval 0.969-1.135; p = 0.238) did not have an independent association with in-hospital mortality. CONCLUSIONS: Patients with sepsis and DIC have high mortality. However, the DIC are not independently associated with in-hospital mortality.

We examined the institutional variations in anticoagulation therapy for sepsis-induced disseminated intravascular coagulation (DIC) and their effects on patient outcomes. This post hoc analysis of a cohort study included 3195 patients with severe sepsis across 42 intensive care units. To evaluate differences in the intensity of anticoagulation therapy, the proportion of patients receiving anticoagulation therapy and the total number of patients with sepsis-induced DIC were compared. Predicted in-hospital mortality for each patient was calculated using logistic regression analysis. To evaluate survival outcomes, the actual/mean predicted in-hospital mortality ratio in each institution was calculated. Thirty-eight institutions with 2897 patients were included. Twenty-five institutions treated 60% to 100% (high-intensity institutions), while the rest treated 0% to 50% (low-intensity institutions) of patients with sepsis-induced DIC having anticoagulant therapy. Every 10-unit increase in the intensity of anticoagulant therapy was associated with lower in-hospital mortality (odds ratio: 0.904). A higher number of high-intensity institutions (compared to low-intensity institutions) had lower in-hospital mortality and fewer bleeding events than predicted. In conclusion, institutional variations existed in the use of anticoagulation therapy in patients with sepsis-induced DIC. High-intensity anticoagulation therapy was associated with better outcomes.

Sepsis is a syndrome with physiologic, pathologic, and biochemical abnormalities induced by infection. Sepsis can induce the dysregulation of systemic coagulation and fibrinolytic systems, resulting in disseminated intravascular coagulation (DIC), which is associated with a high mortality rate. Although there is no international consensus on available treatments for sepsis-induced DIC, DIC diagnosis and treatment are commonly performed in Japanese clinical settings. Therefore, clinical data related to sepsis-induced DIC diagnosis and treatment can be obtained from Japanese clinical settings. We performed a retrospective nationwide observational study (Japan Septic Disseminated Intravascular Coagulation [J-SEPTIC DIC] study) to collect data regarding characteristics of sepsis patients in Japan, with a focus on coagulofibrinolytic dysregulation and DIC treatment received by each patient. The J-SEPTIC DIC study collected information for a total of 3,195 patients with severe sepsis and septic shock and is the largest data set in Japan on DIC diagnosis and treatment in clinical settings.

BACKGROUND: Benzodiazepine use is a risk factor for the development of delirium in adult intensive care unit (ICU) patients. Suvorexant is an alternative to benzodiazepines to induce sleep, but the incidence of delirium in critically ill patients is unknown. We undertook this retrospective study to investigate the incidence of delirium in patients who receive suvorexant in the ICU. METHODS: This retrospective cohort study was conducted in a closed 12-bed ICU at a tertiary teaching hospital. Patients admitted to the ICU for 72 h or longer between January and June 2015 were evaluated for delirium using the Confusion Assessment Method for the Intensive Care Unit tool. We evaluated the incidence of delirium in patients who received suvorexant and those who did not. To adjust for confounding factors, multivariable logistic regression analysis was conducted. RESULTS: Study subjects included 118 patients, with a median age of 72 years and a median Acute Physiology and Chronic Health Evaluation II score of 18 points. Eighty-two patients (69.5%) were admitted after cardiovascular surgery. In the suvorexant group, there were fewer post-cardiovascular surgical patients and more medical patients. The duration of mechanical ventilation during ICU stay was longer in the suvorexant group, and sedatives and sleep inducers other than suvorexant were used more frequently in the suvorexant group. The incidence of delirium was 43.8% in the suvorexant group and 58.8% in the non-suvorexant group (P = 0.149). After adjustment for risk factors using multivariable logistic regression analysis, suvorexant was associated with a lower incidence of delirium (odds ratio = 0.23, 95% confidence interval: 0.07-0.73; P = 0.012). CONCLUSIONS: Suvorexant was associated with decreased odds of transitioning to delirium in critically ill patients. The use of suvorexant may lower the incidence of delirium in ICU patients. Future prospective studies are warranted.

Purpose: The lack of recognition of respiratory distress may result in emergency tracheal intubation in the general ward. However, few studies have examined the differences in the frequency of vital sign measurement between patients with and without emergency tracheal intubation in the general ward. Thus, this study aimed to investigate the differences in the frequency of vital sign measurements between patients with and without emergency tracheal intubation. Patients and methods: This is a single-center, retrospective, observational study of unplanned intensive care unit (ICU) admissions from the general wards between December 2015 and February 2017. This study included patients with emergency medical intubations in the general ward who were then transferred to the ICU. Vital signs measured within 24 hours prior to ICU admission were compared between patients who did and did not require emergency tracheal intubation in the general ward. A survey was also conducted to explore the nurses' attitudes toward vital sign measurements. Results: Compared with other vital signs, the respiratory rate was significantly less frequently measured. Moreover, the frequency of respiratory rate measurement was lower in the 38 patients who were intubated than in the 102 patients who were not intubated in the general ward (P=0.07). The survey revealed that 54% of the participating nurses considered assessment of the respiratory rate as the most troublesome nursing task and ~15% of nurses did not routinely measure respiratory rates. Conclusion: Respiratory rate was less frequently assessed in deteriorating patients in the general ward, possibly because it was considered a troublesome task.