Japanese Clinical Practice Guidelines for Rehabilitation in Critically Ill Patients 2023 (J-ReCIP 2023).

Providing standardized, high-quality rehabilitation for critically ill patients is a crucial issue. In 2017, the Japanese Society of Intensive Care Medicine (JSICM) promulgated the "Evidence-Based Expert Consensus for Early Rehabilitation in the Intensive Care Unit" to advocate for the early initiation of rehabilitations in Japanese intensive care settings. Building upon this seminal work, JSICM has recently conducted a rigorous systematic review utilizing the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. This endeavor resulted in the formulation of Clinical Practice Guidelines (CPGs), designed to elucidate best practices in early ICU rehabilitation. The primary objective of this guideline is to augment clinical understanding and thereby facilitate evidence-based decision-making, ultimately contributing to the enhancement of patient outcomes in critical care settings. No previous CPGs in the world has focused specifically on rehabilitation of critically ill patients, using the GRADE approach. Multidisciplinary collaboration is extremely important in rehabilitation. Thus, the CPGs were developed by 73 members of a Guideline Development Group consisting of a working group, a systematic review group, and an academic guideline promotion group, with the Committee for the Clinical Practice Guidelines of Early Mobilization and Rehabilitation in Intensive Care of the JSICM at its core. Many members contributed to the development of the guideline, including physicians and healthcare professionals with multiple and diverse specialties, as well as a person who had been patients in ICU. Based on discussions among the group members, eight important clinical areas of focus for this CPG were identified. Fourteen important clinical questions (CQs) were then developed for each area. The public was invited to comment twice, and the answers to the CQs were presented in the form of 10 GRADE recommendations and commentary on the four background questions. In addition, information for each CQ has been created as a visual clinical flow to ensure that the positioning of each CQ can be easily understood. We hope that the CPGs will be a useful tool in the rehabilitation of critically ill patients for multiple professions.

Verifying the Japanese version of the Healthy Aging Brain Care Monitor self-report tool for evaluating post-intensive care syndrome.

BACKGROUND: Post-intensive care syndrome (PICS) requires the use of multiple assessment tools because it affects multiple domains: Cognitive, Functional, and Behavioural/Psychological. Therefore, this study translated the self-report (SR) version of the Healthy Aging Brain Care Monitor (HABC-M), spanning multiple domains, into Japanese and analysed its reliability and validity in a post-intensive care setting. METHODS: Patients aged 20 years or older and admitted to the adult intensive care unit from August 2019 to January 2021 were included and surveyed by questionnaire. The 21-item Dementia Assessment Sheet for the Regional Comprehensive Care System was used to validate cognitive and physical aspects, and the Patient Health Questionnaire-9, the Generalized Anxiety Disorder-7, and the Post Traumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders 5th edition were used to validate emotional aspects. Reliability was assessed by Cronbach's alpha, and congruent validity by correlation analysis. Multivariate linear regression models were used to identify potential factors for PICS. RESULTS: A total of 104 patients (mean age: 64 ± 14 years) with 3 median mechanical ventilation days (interquartile range: 2-5) were enrolled. The Cognitive domain of the HABC-M SR was highly correlated with memory and disorientation (r = 0.77 for each), while the Functional domain was highly correlated with Instrumental Activities of Daily Living Scale (r = 0.75-0.79). The Behavioural/Psychological domain highly correlated with the Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, and Post Traumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders 5th edition (r = 0.75-0.76). Multivariate analysis revealed longer ICU stays associated with lower Cognitive and Functional (p = 0.03 for each) domains and longer mechanical ventilation days with a lower Behavioural/Psychological domain (p < 0.01). CONCLUSION: The translated Japanese HABC-M SR showed high validity for assessment of the Cognitive, Functional, and Behavioural/Psychological domains of PICS. Therefore, we recommend that the Japanese version of the HABC-M SR be routinely used in the assessment of PICS.

Coagulopathy correlates with muscle titin injury in critically ill patients.

PURPOSE: We hypothesized that coagulopathy independently contributes to muscle injury focusing to titin fragmentation, and investigated their correlations. MATERIAL AND METHODS: We conducted a post-hoc analysis of an observational study, in which we evaluated muscle injury with the biomarker titin. Coagulopathy was assessed on the first day using the Japanese diagnostic criteria of acute-phase disseminated intravascular coagulopathy (JAAM-DIC). Mean N-titin/Cre measured on days 1, 3, 5, and 7 was assigned as the primary outcome. RESULTS: Overall, 111 eligible patients were included. Mean N-titin/Cre were significantly higher in the JAAM-DIC group. A multivariable analysis identified JAAM-DIC as independent risk factors for mean N-titin/Cre while other severity scores were not. CONCLUSIONS: Coagulopathy correlated with muscle titin fragmentation, as an independent risk factor. TRIAL REGISTRATION NUMBER: The present study is registered at the University Hospital Medical Information Network-clinical trials registry (UMIN000040290, Registration date: May 7, 2020).

Endogenous and exogenous protection from surgically induced reactive oxygen and nitrogen species.

Surgical intervention creates reactive oxygen species through diverse molecular mechanisms, including direct stimulation of immune-mediated inflammation necessary for wound healing. However, dysregulation of redox homeostasis in surgical patients overwhelms the endogenous defense system, slowing the healing process and damaging organs. We broadly surveyed reactive oxygen species that result from surgical interventions and the endogenous and/or exogenous antioxidants that control them. This study assimilates current reports on surgical sources of reactive oxygen and nitrogen species along with literature reports on the effects of endogenous and exogenous antioxidants in human, animal, and clinical settings. Although exogenous antioxidants are generally beneficial, endogenous antioxidant systems account for over 80% of total activity, varying based on patient age, sex, and health or co-morbidity status, especially in smokers, the diabetic, and the obese. Supplementation of exogenous compounds for support in surgical patients is thus theoretically beneficial, but a lack of persuasive clinical evidence has left this potential patient support strategy without clear guidelines. A more thorough understanding of the mechanisms of exogenous antioxidants in patients with compromised health statuses and pharmacokinetic profiling may increase the utility of such support in both the operating and recovery rooms.

Pediatric delirium is associated with increased brain injury marker levels in cardiac surgery patients.

Despite global consensus on the importance of screening pediatric delirium, correlations between pediatric delirium during acute brain injury and adult delirium are unclear. Therefore, we hypothesized that similar pediatric biomarkers reflect acute brain injury as in adult delirium. We observed pediatric cardiac surgery patients from neonatal age to 18 years, who were admitted to our pediatric intensive care unit after cardiovascular operations between October 2019 to June 2020, up to post-operative day 3 (4 days total). We recorded age, sex, risk score (Risk Adjustment in Congenital Heart Surgery [RACHS-1]), midazolam/dexmedetomidine/fentanyl dosage, and pediatric Sequential Organ Failure Assessment (pSOFA). Richmond Agitation-Sedation Scale (RASS), Cornell Assessment of Pediatric Delirium (CAPD), Face, Leg, Activity, Consolability (FLACC) behavioral scale, and Withdrawal Assessment Tool (WAT-1) scales were used and serum sampling for neuron specific enolase (NSE) was conducted. Consciousness status was considered hierarchical (coma > delirium > normal) and associations between conscious status and NSE were conducted by hierarchical Bayesian modeling. We analyzed 134 data points from 40 patients (median age 12 months). In the multi-regression model, NSE was positively associated with coma [posterior odds ratio (OR) = 1.1, 95% credible interval (CrI) 1.01-1.19] while pSOFA [posterior OR = 1.63, 95% CrI 1.17-2.5], midazolam [posterior OR = 1.02, 95% CrI 1.01-1.04], and dexmedetomidine [posterior OR = 9.52, 95% CrI 1.02-108.85] were also associated. We also evaluated consciousness state probability at each NSE concentration and confirmed both that consciousness was hierarchically sorted and CAPD scores were also associated with NSE [posterior OR = 1.32, 95% CrI 1.09-1.58]. "Eye contact" (r = 0.55) was the most correlated component with NSE within the pain, withdrawal syndrome, and PD items. PD within the hierarchy of consciousness (coma, delirium, normal) and CAPD scores are associated with brain injury marker levels. Using pediatric delirium assessment tools for monitoring brain injury, especially eye contact, is a reliable method for observing PD.

Pediatric Critical Care Nursing Research Priorities in Asia: An eDelphi Study.

OBJECTIVES: To identify nursing research priorities in pediatric critical care in Asia. DESIGN: We conducted a modified three-round eDelphi survey with pediatric critical care nurses in Asia. The eDelphi technique has been extensively used within health research to achieve a common viewpoint from experts using questionnaires to gather research priorities. In round 1, participants were asked to list three to five research topics that they deemed important. These topics were thematically analyzed and categorized into a questionnaire. Participants rated the research topics in round 2 on a 6-point scale (1 = not important to 6 = extremely important). In round 3, the same questionnaire was used with addition of the calculated mean scores from round 2 for each topic. Research topics ranked among the top 10 were considered extremely important. SETTINGS: Twenty-two PICUs in eight Asian countries. SUBJECTS: Clinical nurses, managers, educators, and researchers. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In round 1, 146 PICU nurses across eight countries provided 520 research topics. Topics from round 1 were categorized into seven domains with 52 research topics. Prioritized research topics included early recognition of patient deterioration (mean 5.58 ± 0.61), prevention of healthcare-associated infections (mean 5.47 ± 0.70), and interventions to reduce compassion fatigue (mean 5.45 ± 0.80). The top three research domains were end-of-life care (mean 5.34 ± 0.68), professionalism (mean 5.34 ± 0.69), and management of pain, sedation, and delirium (5.32 ± 0.72). CONCLUSIONS: This first PICU nursing research prioritization exercise within Asia identified key nursing research themes that should be prioritized and provide a framework for future collaborative studies.

Development and initial validation of the Japanese healthy work environment assessment tool for critical care settings.

AIM: This study aims to translate the Healthy Work Environment Assessment Tool (HWE-AT) into Japanese and evaluate its validity and reliability. DESIGN AND METHODS: The authors followed the guidelines for scale translation, adaptation, and validation in cross-cultural healthcare research. After translation and back-translation, a series of pilot studies were conducted to assess comprehensibility. Subsequently, an expert panel established the content validity. Content validity was calculated using the content validity index (CVI). Finally, we verified the construct validity and calculated the test-retest reliability. RESULTS: The updated HWE-AT achieved sufficient comprehensibility after conducting the two pilot tests. Content validity was calculated using the scale-level CVI/average and all the items were 1.00. The content validity indices CFI and RMSEA were 0.918 and 0.082, respectively. Intraclass correlation coefficients for all dimensions ranged from 0.618 to 0.903, indicating acceptable test-retest reliability. Our findings suggest that the Japanese version of the HWE-AT has good validity and reliability.

PERSonality, Ehical, and PROfessional quality of life in Pediatric/Adult Intensive Nurses study: PERSEPRO PAIN study.

BACKGROUND: The World Health Organization included burnout syndrome criteria that reduce both professional quality of life and work satisfaction in its 11th Revision of the International Classification of Diseases in 2019 while nursing bodies have issued action calls to prevent burnout syndrome. Despite this, the effect of social factors, personality traits and cross-interaction on professional quality of life is still unclear. AIM: To reveal the association between ethical climate, personal trait and professional quality of life. METHOD: An online survey of registered nurses working in adult, pediatric or both ICUs. We used the ten-item personality measure based on The Big Five theory and Type-D personality Scale-14 then measured the ethical climate with the Hospital Ethical Climate Survey and the professional domains of burnout syndrome, secondary traumatic stress and compassion satisfaction by the Professional Quality of Life Scale Version 5 simultaneously. Multivariate analysis confirmed the triangular association of hospital ethical climate, personality traits and professional quality of life. RESULT: We enrolled 310 participants from September 2019 to February 2020. Mean age was 33.1 years (± 5.9) and about 70% were female. In the multivariate analysis, neuroticism (p = 0.03, p = 0.01) and Type D personality (both of p<0.01) were associated with burnout syndrome and secondary traumatic stress while agreeableness (p<0.01) was associated with secondary traumatic stress. Conversely, extraversion (p = 0.01), agreeableness (p<0.01) and openness (p<0.01) were associated with compassion satisfaction. We also observed interactions between hospital ethical climate and conscientiousness (p = 0.01) for burnout syndrome and secondary traumatic stress. Neuroticism was related to (p<0.01) BOS and compassion satisfaction while Type D personality (p<0.01) correlated with burnout syndrome and secondary traumatic stress. CONCLUSION: Hospital ethical climate strongly affects professional quality of life in nurses with specific personality traits. Therefore, it is important to maintain an ethical hospital climate, considering individual personalities to prevent burnout syndrome.

Novel protocol combining physical and nutrition therapies, Intensive Goal-directed REhabilitation with Electrical muscle stimulation and Nutrition (IGREEN) care bundle.

BACKGROUND: Although the combination of rehabilitation and nutrition may be important for the prevention of intensive care unit (ICU)-acquired weakness, a protocolized intervention of this combination has not yet been reported. We herein developed an original combined protocol and evaluated its efficacy. METHODS: In this single-center historical control study, we enrolled adult patients admitted to the ICU. Patients in the control group received standard care, while those in the intervention group received the protocol-based intervention. The ICU mobility scale was used to set goals for early mobilization and a neuromuscular electrical stimulation was employed when patients were unable to stand. The nutritional status was assessed for nutritional therapy, and target calorie delivery was set at 20 or 30 kcal/kg/day and target protein delivery at 1.8 g/kg/day in the intervention group. The primary endpoint was a decrease in femoral muscle volume in 10 days assessed by computed tomography. RESULTS: Forty-five patients in the control group and 56 in the intervention group were included in the analysis. Femoral muscle volume loss was significantly lower in the intervention group (11.6 vs 14.5%, p = 0.03). The absolute risk difference was 2.9% (95% CI 0.1-5.6%). Early mobilization to a sitting position by day 10 was achieved earlier (p = 0.03), and mean calorie delivery (20.1 vs. 16.8 kcal/kg/day, p = 0.01) and mean protein delivery (1.4 vs. 0.8 g/kg/day, p < 0.01) were higher in the intervention group. CONCLUSION: The protocolized intervention, combining early mobilization and high-protein nutrition, contributed to the achievement of treatment goals and prevention of femoral muscle volume loss. TRIAL REGISTRATION NUMBER: The present study is registered at the University Hospital Medical Information Network-clinical trials registry (UMIN000040290, Registration date: May 7, 2020).

Severity and prevalence of burnout syndrome in paediatric intensive care nurses: A systematic review.

OBJECTIVES: The aim of this study is to identify burnout syndrome severity and prevalence in paediatric intensive care unit nurses. DESIGN: Systematic review. SETTING: Paediatric intensive care unit. MAIN OUTCOME MEASURES: A librarian was consulted on methodology before the search process. MEDLINE (via PubMed), EMBASE, the Cochrane Library, CINAHL, and PsycINFO were searched for full-text studies published before September 2019 in any language. Only those observational studies exploring burnout syndrome, including paediatric intensive care unit nurses, were included. Two authors independently screened studies. We assessed the risk of bias within each study based on the Office of Health Assessment and Translation tool. RESULT: After screening 1238 articles, we identified six studies which met the systematic review criteria. All studies included were published after 2012 and participant sample sizes were between 35 and 195 nurses. Three studies were conducted in the United States of America while the others were from the United Kingdom, Turkey and Taiwan. Prevalence of burnout syndrome in pediatric intensive care unit nurses was reported in these studies as between 42% and 77%. The assessment tools used in these studies were the (abbreviated) Maslach Burnout Inventory, Abbreviated Maslach Burnout Inventory, Occupational Burnout Inventory, and Professional Quality of Life Scale Version 5. We could not conduct a meta-analysis due to the lack of studies. CONCLUSION: Our systematic review identifies that a low number (6 total) of relevant studies focused on burnout syndrome for pediatric intensive care unit nurses with a prevalence of burnout syndrome in paediatric intensive care unit nurses of between 42% and 77%.

Physical Restraints in Critically Ill Children: A Multicenter Longitudinal Point Prevalence Study.

OBJECTIVES: We elucidate to investigate the prevalence of and factors associated with the use of physical restraints among critically ill or injured children in PICUs. DESIGN: This was a multicenter, longitudinal point prevalence study. SETTING: We included 26 PICUs in Japan. PATIENTS: Included children were 1 month to 10 years old. We screened all admitted patients in the PICUs on three study dates (in March, June, and September 2019). INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: We collected prevalence and demographic characteristics of critically ill or injured children with physical restraints, as well as details of physical restraints, including indications and treatments provided. A total of 398 children were screened in the participating PICUs on the three data collection dates. The prevalence of children with physical restraints was 53% (211/398). Wrist restraint bands were the most frequently used means (55%, 117/211) for potential contingent events. The adjusted odds of using physical restraint in patients 1-2 years old was 2.3 (95% CI, 1.3-4.0) compared with children less than 1 year old. When looking at the individual hospital effect, units without a prespecified practice policy for physical restraints management or those with more than 10 beds were more likely to use physical restraints. CONCLUSIONS: The prevalence of physical restraints in critically ill or injured children was high, and significant variation was observed among PICUs. Our study findings suggested that patient age, unit size, and practice policy of physical restraint could be associated with more frequent use of physical restraints.

Severe COVID-19 Infection Associated with Endothelial Dysfunction Induces Multiple Organ Dysfunction: A Review of Therapeutic Interventions.

Since December 2019, the SARS-CoV-2 (COVID-19) pandemic has transfixed the medical world. COVID-19 symptoms vary from mild to severe and underlying chronic conditions such as pulmonary/cardiovascular disease and diabetes induce excessive inflammatory responses to COVID-19 and these underlying chronic diseases are mediated by endothelial dysfunction. Acute respiratory distress syndrome (ARDS) is the most common cause of death in COVID-19 patients, but coagulation induced by excessive inflammation, thrombosis, and disseminated intravascular coagulation (DIC) also induce death by multiple-organ dysfunction syndrome. These associations imply that maintaining endothelial integrity is crucial for favorable prognoses with COVID-19 and therapeutic intervention to support this may be beneficial. Here, we summarize the extent of heart injuries, ischemic stroke and hemorrhage, acute kidney injury, and liver injury caused by immune-mediated endothelial dysfunction that result in the phenomenon of multi-organ dysfunction seen in COVID-19 patients. Moreover, the potential therapeutic effect of angiotensin receptor blockers and angiotensin-converting enzyme inhibitors that improve endothelial dysfunction as well as the bradykinin storm are discussed.

Urinary Titin N-Fragment Evaluation in a Randomized Controlled Trial of Beta-Hydroxy-Beta-Methylbutyrate for Acute Mild Trauma in Older Adults.

The effects of beta-hydroxy-beta-methylbutyrate (HMB) complex administration and the significance of titin, a biomarker of muscle injury, in elderly minor trauma patients in acute phase has not been established. In this single-center, randomized controlled study, trauma patients aged ≥ 70 years with an injury severity score < 16 were included. Titin values on days 1 and 3 were measured and the intervention group received HMB complex (2.4 g of HMB + 14 g of glutamine + 14 g of arginine) and the control group received glutamine complex (7.2 g of protein including 6 g of glutamine). The cross-sectional area of the rectus femoris (RFCSA) on ultrasound, grip strength, and the Barthel Index were assessed on the first day of rehabilitation and after 2 weeks. We analyzed 24 HMB and 25 control participants. Titin values on day 3 correlated with grip strength (r = -0.34, p = 0.03) and the Barthel Index (r = -0.39, p = 0.01) at follow-up. HMB complex supplementation had no effect on the RFCSA (2.41 vs. 2.45 cm2, p = 0.887), grip strength (13.3 vs. 13.1 kg, p = 0.946), or the Barthel Index (20.0 vs. 50.0, p = 0.404) at follow-up. Titin values might associate with subsequent physical function. Short-term HMB complex supplementation from acute phase did not ameliorate muscle injury.

Association between intensive care unit delirium and delusional memory after critical care in mechanically ventilated patients.

AIM: To determine the relationship between the delirium of patients with mechanical ventilation during intensive care unit (ICU) stay and delusional memory after ICU discharge. DESIGN: Prospective cohort study. METHODS: Delirium in adult patients who received mechanical ventilation for more than 24 hr was assessed twice daily using the Confusion Assessment Method for the ICU. Delusional memories were evaluated using the ICU Memory Tool 5-10 days after ICU discharge. The associations between the presence of delirium during the ICU stay and delusional memories were evaluated. RESULTS: Of 60 enrolled patients, 62% had delirium during their ICU stay, and 68% experienced delusional memories 5-10 days after discharge. Delirium during ICU stay was an independent factor to experience delusional memories following discharge. Preventing delirium during ICU stay might reduce delusional memory. We recommend that patients with delirium during their ICU stay should be carefully followed up after discharge from the ICU.

Translation, reliability and validity of Japanese version the TeamSTEPPS® teamwork perceptions questionnaire.

Aim: This study aimed to translate the TeamSTEPPS® Teamwork Perceptions Questionnaire (T-TPQ) into Japanese and assess its validity and reliability. Design: Translation of the T-TPQ and a cross-sectional survey. Methods: Following a forward and back translation of the questionnaire, content validity was assessed by an expert panel using item-level content validity index. Construct validity was assessed by a confirmatory factor analysis. Further, intraclass correlation coefficient was estimated by test-retest methods. Results: A total of 587 healthcare professionals responded to the translated T-TPQ. The item-level content validity index ranged between 0.8 and 1.0, indicating an acceptable content validity. The multiple fit indices showed an acceptable fitting model. Fifty-one healthcare professionals participated in the test-retest method. Intraclass correlation coefficients for all dimensions ranged from 0.838 to 0.957, indicating acceptable test-retest reliability. Our findings suggest that the Japanese version of the T-TPQ has acceptable validity and reliability.

Association between fluid overload and delirium/coma in mechanically ventilated patients.

AIM: Several studies have shown an association between fluid overload (FO) and mortality or duration of mechanical ventilation in critically ill patients. However, the association between FO and delirium duration remains unclear. METHODS: This retrospective observational cohort study was undertaken at University of Tsukuba Hospital (Tsukuba, Japan) from April 2015 to March 2017. Mechanically ventilated patients who stayed in the intensive care unit for more than 7 days were eligible for inclusion. Univariate analysis was carried out with the Mann-Whitney U-test for continuous variables and Fisher's exact test for categorical variables. A multivariate proportional odds logistic regression model was used to evaluate the association between FO and delirium/coma days (DCDs) during the 7-day study period. RESULTS: A total of 118 patients were included and divided into FO and non-FO groups. Fluid overload occurred in 40% of patients. The FO group had a higher APACHE II score than the non-FO group (19 [16-26] versus 23 [20-29], P = 0.017). Cumulative fluid balance at day 3 was higher in the FO group (3,238 [281-6,530] versus 7,886 [4,106-10,631], P < 0.001). Delirium days within 7 days was longer in the FO group (1 [0-3] versus 2 [1-3], P = 0.048) and DCDs was longer in the FO group (4 [1-5] versus 6 [3-7], P = 0.002). After adjusting for covariates, there were significant associations between FO and DCDs (odds ratio, 2.16; 95% confidence interval, 1.05-4.47). CONCLUSIONS: Our findings suggest that FO is associated with increased DCDs in mechanically ventilated patients.

Evaluating the Therapeutic Efficacy and Safety of Landiolol Hydrochloride for Management of Arrhythmia in Critical Settings: Review of the Literature.

BACKGROUND: Landiolol hydrochloride, a highly cardio-selective beta-1 blocker with an ultra-short-acting half-life of 4 minutes, was originally approved by Japan for treatment of intraoperative tachyarrhythmias. This review aims to provide an integrated overview of the current state of knowledge of landiolol hydrochloride in the management of arrhythmia in critical settings. METHODS: We searched MEDLINE, EMBASE, and the Cochrane Library to retrieve relevant articles with a total of 65 records identified. RESULTS: The high ß1 selectivity (ß1/ß2 ratio of 255:1) of landiolol causes a more rapid heart rate (HR) decrease compared to esmolol while avoiding decreases in mean arterial blood pressure. Recently, it has been found useful in left ventricular dysfunction patients and fatal arrhythmia requiring emergency treatment. Recent random clinical trials (RCT) have revealed therapeutic and prophylactic effects on arrhythmia, and very low-dose landiolol might be effective for preventing postoperative atrial fibrillation (POAF) and sinus tachycardia. Likewise, landiolol is an optimal choice for perioperative tachycardia treatment during cardiac surgery. The high ß1 selectivity of landiolol is useful in heart failure patients as a first-line therapy for tachycardia and arrhythmia as it avoids the typical depression of cardiac function seen in other ß-blockers. Application in cardiac injury after percutaneous coronary intervention (PCI), protection for vital organs (lung, kidney, etc.) during sepsis, and stabilizing hemodynamics in pediatric patients are becoming the new frontier of landiolol use. CONCLUSION: Landiolol is useful as a first-line therapy for the prevention of POAF after cardiac/non-cardiac surgery, fatal arrhythmias in heart failure patients and during PCI. Moreover, the potential therapeutic effect of landiolol for sepsis in pediatric patients is currently being explored. As positive RCT results continue to be published, new clinical uses and further clinical studies in various settings by cardiologists, intensivists and pediatric cardiologists are being conducted.

The Validity and Reliability of the Japanese Version of the Cornell Assessment of Pediatric Delirium.

OBJECTIVES: To examine validity and reliability of the Japanese version of the Cornell Assessment of Pediatric Delirium. DESIGN: Prospective double-blinded observational cohort study. SETTING: Eight-bed mixed PICU (post-surgical and internal medicine) from May 2017 to June 2018. PATIENTS: All children between the ages of 0-13 years who were admitted to the PICU for at least 24 hours were eligible for inclusion, as long as the child was arousable to verbal stimulation. INTERVENTIONS: Two nurses simultaneously and independently assessed each patient for pediatric delirium with the Japanese version of the Cornell Assessment of Pediatric Delirium; this was compared to the gold standard of psychiatric diagnosis based on Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition standards. MEASUREMENTS AND MAIN RESULTS: Forty-one children were enrolled and 92 assessments (ranging from one to four per subject) were completed. Congenital heart disease patients accounted for 73 enrollees (79%). Forty-three percent of observations were performed in children on invasive mechanical ventilation. Pediatric delirium prevalence (as determined by psychiatric diagnosis) was 53%. The Japanese version of the Cornell Assessment of Pediatric Delirium demonstrated an optimal scoring cutpoint of 9. Overall, area under the curve was 92%, sensitivity 90% (95% CI, 79-97%), specificity 88% (95% CI, 75-96%), positive predictive value of 90% (95% CI, 79-97%), negative predictive value of 91% (95% CI, 80-97%), and a Cohen's κ of 0.89 (95% CI, 0.8-0.98). In children on invasive mechanical ventilation, the Japanese version of the Cornell Assessment of Pediatric Delirium maintained an area under the curve 87%, sensitivity 97%, and specificity 64%. CONCLUSIONS: The Japanese version of the Cornell Assessment of Pediatric Delirium is a valid and reliable tool for use in Japanese PICUs. This will allow for detection of delirium in real-time and may lead to better identification of the population and risk factors for appropriate management and therapeutic and preventative interventions.

Down Syndrome Reduces the Sedative Effect of Midazolam in Pediatric Cardiovascular Surgical Patients.

Down syndrome (DS) is frequently comorbid with congenital heart disease and has recently been shown to reduce the sedative effect of benzodiazepine (BDZ)-class anesthesia but this effect in a clinical setting has not been studied. Therefore, this study compared midazolam sedation after heart surgery in DS and normal children. We retrospectively reviewed patient records in our pediatric intensive care unit (PICU) of pediatric cardiovascular operations between March 2015 and March 2018. We selected five days of continuous post-operative data just after termination of muscle relaxants. Midazolam sedation was estimated by Bayesian inference for generalized linear mixed models. We enrolled 104 patients (average age 26 weeks) of which 16 (15%) had DS. DS patients had a high probability of receiving a higher midazolam dosage and dexmedetomidine dosage over the study period (probability = 0.99, probability = 0.97) while depth of sedation was not different in DS patients (probability = 0.35). Multi regression modeling included severity scores and demographic data showed DS decreases midazolam sedation compared with controls (posterior OR = 1.32, 95% CrI = 1.01-1.75). In conclusion, midazolam dosages should be carefully adjusted as DS significantly decreases midazolam sedative effect in pediatric heart surgery patients.