Anesthesia practice for Cesarean delivery in Japan: a retrospective cohort study.

PURPOSE: General anesthesia for Cesarean delivery affects maternal and neonatal outcomes. We aimed to evaluate temporal trends in anesthesia management for Cesarean deliveries over 16 years and analyze interinstitutional variations in general anesthesia use in Japan. METHODS: In this retrospective cohort study, we obtained patient data from the nationwide health insurance claims database containing data for ten million individuals. We included patients who underwent Cesarean delivery between 1 January 2005 and 31 August 2021. The primary outcome was the use of general anesthesia. We evaluated institutional variations in general anesthesia use in medical facilities using two-level hierarchical logistic regression analyses with median odds ratios and intraclass correlation coefficients. RESULTS: The cohort included 86,793 patients who underwent 102,617 Cesarean deliveries at 2,496 institutions. General anesthesia was used in 3.7% (95% confidence interval [CI], 3.6 to 3.9) of all Cesarean deliveries. The temporal trend in the use of general anesthesia decreased gradually from 10.8% in 2005 to 2.9% in 2021 (P for trend < 0.001). The adjusted median odds ratio for medical facilities was 6.1 (95% CI, 5.9 to 6.7), and the intraclass correlation coefficient was 0.52 (95% CI, 0.51 to 0.55). CONCLUSION: Although the rate of general anesthesia use for Cesarean delivery in Japan decreased gradually from 2005 to 2021, general anesthesia was used in 3.7% of all Cesarean deliveries. The use of general anesthesia varied significantly across institutions, and 52% of the overall variations in general anesthesia practice can be explained by differences between facilities.

RéSUMé: OBJECTIF: L'anesthésie générale pour l'accouchement par césarienne affecte les issues maternelles et néonatales. Notre objectif était d'évaluer les tendances temporelles de la prise en charge anesthésique pour les accouchements par césarienne sur 16 ans et d'analyser les variations interinstitutionnelles dans l'utilisation de l'anesthésie générale au Japon. MéTHODE: Dans cette étude de cohorte rétrospective, nous avons obtenu des données sur les patient·es à partir de la base de données nationale des réclamations d'assurance maladie contenant des données pour dix millions de personnes. Nous avons inclus les personnes ayant bénéficié d'un accouchement par césarienne entre le 1er janvier 2005 et le 31 août 2021. Le critère d'évaluation principal était le taux d'utilisation de l'anesthésie générale. Nous avons évalué les variations institutionnelles dans l'utilisation de l'anesthésie générale dans les établissements médicaux à l'aide d'analyses de régression logistique hiérarchique à deux niveaux avec des rapports de cotes médians et des coefficients de corrélation intraclasse. RéSULTATS: La cohorte comprenait 86 793 patient·es ayant bénéficié de 102 617 accouchements par césarienne dans 2496 établissements. L'anesthésie générale a été utilisée dans 3,7 % (intervalle de confiance [IC] à 95 %, 3,6 à 3,9) de tous les accouchements par césarienne. La tendance temporelle de l'utilisation de l'anesthésie générale a diminué graduellement, passant de 10,8 % en 2005 à 2,9 % en 2021 (P pour la tendance < 0,001). Le rapport de cotes médian ajusté pour les établissements médicaux était de 6,1 (IC 95 %, 5,9 à 6,7), et le coefficient de corrélation intraclasse était de 0,52 (IC 95 %, 0,51 à 0,55).

The association between intraoperative anesthesia methods used during gastric cancer surgery and long-term mortality: A retrospective observational study using a Japanese claims database.

PURPOSE: Various basic and clinical studies have investigated the association between the types of anesthetic agents and prognosis. However, the results have varied among studies and remain controversial. In the present study, we aimed to investigate whether the risk of all-cause mortality differs between inhaled or intravenous anesthetics in patients with gastric cancer undergoing gastrectomy. METHODS: Using a Japanese nationwide insurance claims database, we analyzed patients who underwent gastrectomy under general anesthesia for gastric cancer between January 2005 and September 2019. Postoperative outcomes were compared between two groups: those who received inhaled anesthetics (Sevoflurane, Isoflurane, or Desflurane) and those who received intravenous anesthetics (propofol), using a multivariable Cox proportional hazards model. The primary outcome was overall survival. RESULTS: Among 2671 eligible patients, 2105 were in the inhaled anesthetic group, and 566 were in the intravenous anesthetic group. The median (interquartile range) age was 58 (51-63) years, and 1979 (74.1%) were men. The median follow-up period was 795 days. We identified 56 (2.7%) and 16 (2.8%) deaths during the follow-up period in the inhaled and intravenous anesthetic use groups, respectively. There was no difference in postoperative overall survival between the two groups (hazard ratio, 0.97; 95% confidence interval, 0.56-1.70; P = 0.93). CONCLUSIONS: We found no significant difference in the postoperative risks of overall survival between inhaled and intravenous anesthesia in patients with gastric cancer undergoing gastrectomy.

Impact of Energy and Protein Delivery to Critically Ill Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Optimal energy and protein delivery goals for critically ill patients remain unknown. The purpose of this systematic review and meta-analysis was to compare the impact of energy and protein delivery during the first 4 to 10 days of an ICU stay on physical impairments. We performed a systematic literature search of MEDLINE, CENTRAL, and ICHUSHI to identify randomized controlled trials (RCTs) that compared energy delivery at a cut-off of 20 kcal/kg/day or 70% of estimated energy expenditure or protein delivery at 1 g/kg/day achieved within 4 to 10 days after admission to the ICU. The primary outcome was activities of daily living (ADL). Secondary outcomes were physical functions, changes in muscle mass, quality of life, mortality, length of hospital stay, and adverse events. Fifteen RCTs on energy delivery and 14 on protein were included in the analysis. No significant differences were observed in any of the outcomes included for energy delivery. However, regarding protein delivery, there was a slight improvement in ADL (odds ratio 21.55, 95% confidence interval (CI) −1.30 to 44.40, p = 0.06) and significantly attenuated muscle loss (mean difference 0.47, 95% CI 0.24 to 0.71, p < 0.0001). Limited numbers of RCTs were available to analyze the effects of physical impairments. In contrast to energy delivery, protein delivery ≥1 g/kg/day achieved within 4 to 10 days after admission to the ICU significantly attenuated muscle loss and slightly improved ADL in critically ill patients. Further RCTs are needed to investigate their effects on physical impairments.

Trend in neuraxial morphine use and postoperative analgesia after cesarean delivery in Japan from 2005 to 2020.

The increasing rate of cesarean deliveries warrants obstetric anesthesiologists to deliver high-quality post-cesarean delivery analgesia. The aim of this study was to evaluate the temporal trends in the use of neuraxial morphine for cesarean deliveries and to describe the current postoperative analgesia practices. A retrospective cohort study using nationwide health insurance claims databases was conducted from 2005 to 2020 in Japan. Pregnant women who had undergone cesarean deliveries were included. The annual rate of neuraxial morphine use was extracted and analyzed. Additionally, we explored the patient- and facility-level factors associated with neuraxial morphine use through a multilevel logistic regression analysis. The cohort included 65,208 cesarean delivery cases from 2275 institutions. The prevalence of neuraxial morphine use was 16.0% (95% confidence interval [CI], 15.8-16.3) in the overall cohort. Intrathecal morphine was used in 20.6% (95% CI, 20.2-21.0) of spinal anesthesia cases. The trend in neuraxial morphine use steadily increased from 2005 to 2020. The significant predictors of neuraxial morphine use included spinal anesthesia, recent surgery, large medical facilities, and academic hospitals. Variations in the utilization of postoperative analgesia were observed. Our study described the current trend of neuraxial morphine use and the variation in postoperative analgesia practice in Japan.

Consensus statement on smoking cessation in patients with pain.

Smoking is closely associated with the development of various cancers and tobacco-related illnesses such as cardiovascular and respiratory disorders. However, data are scarce on the relationship between smoking and both acute and chronic pain. In addition to nicotine, tobacco smoke contains more than 4000 different compounds. Although nicotine is not the sole cause of smoking-induced diseases, it plays a critical role in pain-related pathophysiology. Despite the acute analgesic effects of nicotine, long-term exposure leads to tolerance and increased pain sensitivity due to nicotinic acetylcholine receptor desensitization and neuronal plastic changes. The purpose of smoking cessation interventions in smoking patients with pain is primarily not only to reduce their pain and associated limitations in activities of daily living, but also to improve the outcomes of underlying pain-causing conditions and reduce the risks of tobacco-related disorders. This statement aims to summarize the available evidence on the impact of smoking on pain and to inform medical professionals of the significance of smoking cessation in patients with pain.

Current Epidemiology of the General Anesthesia Practice for Cesarean Delivery Using a Nationwide Claims Database in Japan: A Descriptive Study.

The current status of general anesthesia practice for cesarean delivery in Japan remains unknown. Therefore, using a nationwide claims database, we aimed to investigate general anesthesia use for cesarean delivery over a period of 15 years, and to analyze the general anesthesia practice in Japan. Patients who claimed the Japanese general anesthesia claim code (L008) for cesarean delivery between 1 January 2005, and 31 March 2020, were analyzed. Primary endpoint was the prevalence of general anesthesia use. We used two definitions of general anesthesia: L008 code only (insurance definition) and combination of the L008 code with muscle relaxant use (clinical definition). The general anesthesia claim cohort (L008) included 10,972 cesarean deliveries at 1111 institutions from 2005 to 2020. Muscle relaxants were used in 27.3% of L008 claims cases. The rate of general anesthesia use for cesarean delivery ranged from 3.9% in clinical definition to 14.4% in insurance definition of all cesarean deliveries. We observed a temporal trend of gradual decrease in general anesthesia use, regardless of its definition (p for trend < 0.001). We recommend the clinical definition of general anesthesia as the combination of L008 code and muscle relaxant use in a claims-based approach.

A practical guide for perioperative smoking cessation.

The perioperative management of patients who are smokers presents anesthesiologists with various challenges related to respiratory, circulatory, and other clinical problems. Regarding 30-day postoperative outcomes, smokers have higher risks of mortality and complications than non-smokers, including death, pneumonia, unplanned tracheal intubation, mechanical ventilation, cardiac arrest, myocardial infarction, and stroke. Given the benefits of smoking cessation and the adverse effects of smoking on perioperative patient management, patients should quit smoking long before surgery. However, anesthesiologists cannot address these issues alone. The Japanese Society of Anesthesiologists established guidelines in 2015 (published in a medical journal in 2017) to enlighten surgical staff members and patients regarding perioperative tobacco cessation. The primary objective of perioperative smoking cessation is to reduce the risks of adverse cardiovascular and respiratory events, wound infection, and other perioperative complications. Perioperative preparations constitute a powerful teachable moment, a "golden opportunity" for smoking cessation to achieve improved primary disease outcomes and prevent the occurrence of tobacco-related conditions. This review updates the aforementioned guidelines as a practical guide to cover the nuts and bolts of perioperative smoking cessation. Its goal is to assist surgeons, anesthesiologists, and other medical professionals and to increase patients' awareness of smoking risks before elective surgery.

ARDS Clinical Practice Guideline 2021.

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.

ARDS clinical practice guideline 2021.

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.

Incidence, clinical characteristics and long-term prognosis of postoperative symptomatic venous thromboembolism: a retrospective cohort study.

OBJECTIVES: The purpose of this study was to evaluate the incidence, clinical characteristics and prognosis of postoperative symptomatic venous thromboembolism (VTE) in Japan. DESIGN: Retrospective observational study. Two data sets, Contemporary ManageMent AND outcomes in patients with Venous ThromboEmbolism (COMMAND VTE) Registry and Japanese Society of Anesthesiologists (JSA) annual report, were used for current analyses. SETTING: Eighteen of 29 centres participated in the COMMAND VTE Registry. PARTICIPANTS: Acute symptomatic patients with VTE who had undergone surgery 2 months prior to the diagnosis at 18 centres from January 2010 to December 2013 were identified in the COMMAND VTE Registry. From each centre's JSA annual report, the overall population that had received anaesthetic management during this period was retrieved. INTERVENTIONS: None. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was the incidences and clinical characteristics of postoperative symptomatic VTE. The secondary outcomes were recurrent VTE, major bleeding and all-cause death. RESULTS: We identified 137 patients with postoperative symptomatic VTE, including 57 patients with pulmonary embolism. The incidences of postoperative symptomatic VTE and pulmonary embolism were 0.067% and 0.028%, respectively, based on data from 2 03 943 patients who underwent surgery, managed by anaesthesiologists, during the study period. The incidences of postoperative symptomatic VTE varied widely, depending on surgical and anaesthetic characteristics. Postoperative symptomatic VTE occurred at a median of 8 days after surgery, with 58 patients (42%) diagnosed within 7 days. The cumulative incidence, 30 days after VTE, of recurrent VTE, major bleeding, and all-cause death was 3.0%, 5.2%, and 3.7%, respectively. CONCLUSION: This study, combining the large real-world VTE and anaesthesiology databases in Japan revealed the incidence, clinical features and prognosis of postoperative symptomatic VTE, providing useful insights for all healthcare providers involved in various surgeries. TRIAL REGISTRATION: Not applicable.

Safety of sugammadex for myasthaenia gravis patients undergoing general anaesthesia: a retrospective database study.

Background: Using neuromuscular blocking drugs (NMBDs) for patients with myasthaenia gravis remains a challenge in perioperative management. Sugammadex has enabled the safe use of NMBDs. We investigated whether the adverse outcomes, and the treatment used for myasthaenic crises and tracheotomy, are affected by NMBD use in patients with myasthaenia gravis under general anaesthesia. Methods: Patients with myasthaenia gravis who underwent general anaesthesia were retrieved from the Diagnostic Procedure Combination/Per-Diem Payment systems in Japan between 1 January 2010 and 30 November 2020. This database did not contain information on the severity of myasthaenia gravis (Osserman classification). Patients who received rocuronium and sugammadex were compared with those who did not receive NMBDs after propensity-score matching. We excluded patients who underwent emergency or cardiac surgery or tracheal intubation before anaesthesia. The primary outcome was receipt of postoperative treatment used for myasthaenic crises. Results: Among 2304 surgical patients with comorbid myasthaenia gravis, propensity-score matching identified 788 patients administered rocuronium and sugammadex and 449 not administered NMBDs. On comparing the treatment used for myasthaenic crises, we found no significant difference between the two groups (6.2% vs 5.3%; hazard ratio, 1.14; 95% confidence interval, 0.70-1.85). Conclusions: Use of rocuronium and sugammadex in patients with myasthaenia gravis did not significantly affect the receipt of postoperative treatment used for myasthaenic crises compared with no use of NMBDs. As well as the severity of myasthaenia gravis was not fully adjusted, it is unclear whether intraoperative administration of rocuronium with the use of sugammadex postoperatively is acceptable and further investigations are needed.

Hemodynamic Monitoring Using a Pulmonary Artery Catheter Versus the Vigileo/FloTrac System during Elective Cardiac Surgery Based on Real-world Data in Japan.

BACKGROUND: The controversy concerning the benefits of pulmonary artery catheter (PAC)-based hemodynamic monitoring in cardiac surgeries has not been adequately addressed. This study aims to compare the all-cause mortality between the PAC with venous oxygen saturation monitoring and the Vigileo/FloTrac (FloTrac) system with central venous oxygen saturation monitoring in cardiac surgeries. METHODS: This nationwide retrospective study includes adult patients who underwent elective cardiac surgeries between April 2010 and October 2014, based on the Japanese health insurance claims database. The main outcome was 30-day all-cause mortality. Propensity scores (PS) were used to adjust for the confounding factors. Treatment effects were estimated using multivariable logistic regression analysis, including PS. RESULTS: A total of 5,838 patients were included in this study. The crude 30-day mortality rates were 2.4% (8/334) and 1.7% (96/5,504) in the FloTrac and PAC groups, respectively. After PS matching, the ORs for 30-day all-cause mortality, in-hospital mortality after PAC placement (vs. FloTrac) were 0.36 (95% CI: 0.05-2.37; p = 0.28) and 0.59 (95% CI: 0.16-2.20; p = 0.43), respectively. The amount of dobutamine was larger in the PAC group (281 ± 31 mg vs 155 ± 19 mg; p < 0.001). There were no significant differences in the amounts of other inotropes, the volume of fluids, or blood transfusions. CONCLUSIONS: The association between PAC (with venous oxygen saturation monitoring) and mortality in patients who underwent elective cardiac surgeries was unclear compared to FloTrac (with central venous oxygen saturation monitoring). Additional investigation is needed to evaluate the benefits of PAC-specific hemodynamic parameters in this population.

Cardiovascular Safety of Celecoxib after Cardiac Surgery with Cardiopulmonary Bypass: A Retrospective Cohort Study.

BACKGROUND: Cardiac surgery is a highly invasive procedure resulting in hypercoagulability due to thoracotomy and cardiopulmonary bypass (CPB). The long-term use of selective cyclooxygenase-2 inhibitors has been shown to increase the risk of adverse cardiovascular (CV) events such as myocardial infarction. This study aimed to determine whether short-term prescription of celecoxib increases CV events in patients who have undergone cardiac surgery with CPB. METHODS: This retrospective observational study included 16,141 patients (≥20 years) who had undergone cardiac surgery with CPB between April 1, 2008 and March 31, 2016. Patients who underwent coronary artery bypass grafting were excluded. Patients who received celecoxib (n = 904) and acetaminophen (n = 5,002) from postoperative day 0 to 30 were extracted and matched by propensity score (PS). The primary outcomes were all-cause death and CV events, defined as coronary artery disease, ischemic stroke, pulmonary embolism, and venous thrombosis, coded using International Classification of Diseases-10 within 30 days after the first postoperative prescription of either medication. Results were assessed using Kaplan-Meier survival analysis and multivariate Cox regression analysis. RESULTS: PS matching created 885 pairs. Multivariate Cox regression analysis showed that prescription of celecoxib after cardiac surgery was not associated with an increase in the primary outcomes when compared with prescription of acetaminophen (hazard ratio, 0.76; 95% confidence interval, 0.35-1.65). CONCLUSIONS: The prescription of celecoxib in patients who had undergone cardiac surgery with cardiopulmonary bypass was not statistically different from the prescription of acetaminophen in the incidence of CV events and death.

The association between arterial pulse waveform analysis device and in-hospital mortality in high-risk non-cardiac surgeries.

BACKGROUND: Perioperative goal-directed fluid therapy is used for haemodynamic optimization in high-risk surgeries. Cardiac output monitoring can be performed by a specialized pressure transducer for arterial pulse waveform analysis (S-APWA). No study has assessed whether real-world use of S-APWA is associated with post-operative outcomes; therefore, using a Japanese administrative claims database, we retrospectively investigated whether S-APWA use is associated with in-hospital mortality among patients undergoing high-risk surgery under general anaesthesia. METHODS: Adult patients who underwent high-risk surgery under general anaesthesia and arterial catheterization between 2014 and 2016 were divided into S-APWA and conventional arterial pressure transducer groups, then compared regarding baseline factors and outcomes. Logistic regression analysis was performed to compare in-hospital mortality. Subgroup analyses evaluated S-APWA efficacy and outcomes based on the type of surgery and patients' comorbidity. RESULTS: S-APWA was used in 6859 of 23 655 (29.0%) patients; the crude in-hospital mortality rate was 3.5%. Adjusted analysis showed no significant association between S-APWA use and in-hospital mortality rate (adjusted odds ratio [aOR] = 0.91; 95% confidence interval [CI]: 0.76-1.07; P = .25). S-APWA use was associated with significantly lower in-hospital mortality in patients undergoing vascular surgery (aOR = 0.67; 95% CI: 0.49-0.94), and significantly higher in-hospital mortality in patients undergoing lower limb amputation (aOR = 2.63; 95% CI: 1.32-5.22). S-APWA use and in-hospital mortality were not significantly associated with other subgroups. CONCLUSION: S-APWA use was not associated with in-hospital mortality in the entire study population. However, S-APWA was associated with decreased in-hospital mortality among vascular surgery and increased in-hospital mortality among lower limb amputation.