OBJECTIVE:Therapeutic hypothermia in the ICU requires mechanical ventilation and sedation. Hypothermia reduces the metabolism of commonly used IV sedatives. The use of long-acting sedative agents may ...confound neurologic assessment. Volatile anesthetics have been reported to provide protection against ischemia-reperfusion injury and have been safely used in the ICU to provide sedation in trials with shorter wake-up times. There are no clinical studies in this setting. We describe a case series and discuss potential benefits.
DESIGN:Retrospective study.
SETTINGS:Ten-bed ICU, university hospital.
PATIENTS:Twelve patients resuscitated from cardiac arrest with Glasgow Coma Scale score less than or equal to 4.
INTERVENTION:Isoflurane sedation with the AnaConDa during 24 hours therapeutic hypothermia, until rewarming.
MEASUREMENTS AND MAIN RESULTS:Data were extracted from the computerized ICU chart/monitors, hospital and prehospital charts, and the national death index. Patients were 49–76 years old. Median return of spontaneous circulation was 14 minutes. Glasgow Coma Scale scores were assessed within 24 hours from reaching normal body temperature and compared with outcomes at 6 monthssix patients had poor Glasgow Coma Scale scores (< 8) that remained low and all died before 6-month follow-up, whereas another six patients had high scores (> 8) and survived to 6 months with good Cerebral Performance Category. In the ICU, four of the survivors were directly extubated after rewarming while two were once more sedated due to pneumonia requiring invasive ventilator therapy. All patients required norepinephrine to maintain adequate mean arterial pressure. Isoflurane sedation was changed to midazolam in two nonsurviving patients because of hemodynamic instability, which persisted despite the change.
CONCLUSIONS:Sedation with volatile anesthetics during therapeutic hypothermia may be a feasible short-acting option with potential postconditioning effects protecting vital organs from ischemia-reperfusion injury. Its measurability and insignificant drug accumulation could facilitate early neurologic assessment. Prospective clinical trials are warranted.
Background: Studies of volatile anesthetic administration during coronary artery bypass grafting (CABG) report reduced serum levels of post‐operative cardiac troponin‐T (cTnT). Our primary objective ...was to evaluate whether short‐term sedation with sevoflurane in the intensive care unit (ICU) – after CABG – could affect the release of cTnT, compared with propofol sedation.
Methods: Following isolated CABG with cardiopulmonary bypass, 100 patients were randomized to either sevoflurane via the Anesthetic Conserving Device (AnaConDa®) or propofol for ICU sedation. Study drugs were administered for 2 h during mechanical ventilation and thereafter until extubation criteria were met. The primary endpoint was cTnT 12 h post‐operatively. Crude cTnT data were not normally distributed and therefore compared with the Mann–Whitney U‐test. Because of the skewed pre‐operative and post‐operative cTnT data, we performed a post hoc analysis of the change in cTnT between pre‐operative values and 12 h post‐operatively.
Results: There was no statistically significant difference between groups in the primary endpoint cTnT values at 12 h post‐operatively, cardiac events or the need for hemodynamic support. In the post hoc analysis, the cTnT increase from pre‐operative values to 12 h post‐operatively was less pronounced in the sevoflurane group (P=0.008).
Conclusion: Post‐operative short‐term sevoflurane sedation following CABG, in comparison with propofol, did not affect the cTnT values at 12 h post‐operatively and clinical outcome was equal between groups. The result from the post hoc analysis, with less cTnT change over time, is nevertheless hypothesis‐generating and warrants a larger study.
Abstract
Objectives. Intravenous sedation in the intensive care unit (ICU) may contribute to altered consciousness and prolonged mechanical ventilation. We tested the hypothesis that replacing ...intravenous propofol with inhaled sevoflurane for sedation after cardiac surgery would lead to shorter wake-up times, quicker patient cooperation, and less delusional memories. Design. Following coronary artery bypass surgery with cardiopulmonary bypass, 100 patients were randomized to sedation with sevoflurane via the anesthetic conserving device or propofol. Study drugs were administered for a minimum of 2 hours until criteria for extubation were met. Primary endpoints were time from drug stop to extubation and to adequate verbal response. Secondary endpoints were adverse recovery events, memories reported in the ICU Memory Tool test, and ICU/hospital stay. Results. Median time from drug stop to extubation (interquartile range/total range) was shorter after sevoflurane compared to propofol sedation; 10 (10/100) minutes versus 25 (21/240) minutes (p <0.001). Time from extubation to adequate verbal response was shorter (p =0.036). No differences were found in secondary endpoints. Conclusions. Sevoflurane sedation after cardiac surgery leads to shorter wake-up times and quicker cooperation compared to propofol. No differences were seen in ICU-stay, adverse memories or recovery events in our short-term sedation.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
Objective:
To assess improvement of soft-tissue facial symmetry in children surgically treated for unicoronal synostosis (UCS) in infancy, to correlate pre- and postsurgical facial asymmetry and to ...evaluate whether the improvement was visually recognizable.
Design:
Case–controlled follow-up.
Patients/Settings:
Eleven Danish children diagnosed with UCS were included, 3 of whom had tested positive for Muenke mutation. Preoperative computed tomography scans and postoperative 3dMD surfaces were available for measurements. A control group of healthy children matched for age and sex was employed.
Main Outcome Measures:
Pre- and postsurgical facial asymmetry was analyzed using a computerized method capable of objective and spatially detailed quantification in 3-dimension (transverse, vertical, and sagittal directions). Asymmetry was evaluated in the facial region and 6 subregions (forehead, mouth, eyes, nose, cheek, and chin).
Results:
The largest significant improvement was seen in the sagittal direction of the facial (1.9 mm), forehead (2.0 mm), and cheek (3.4 mm) regions. Small but significant improvements were also seen in the mouth, chin, and eye regions. No significant improvement was seen in the nose region. Significant correlations were found between the pre- and postsurgically calculated facial asymmetry and between calculated asymmetry and clinical validation scores.
Conclusions:
All patients presented with improved facial symmetry after surgery and the improvements were visually recognizable. However, only 1 (9.1%) of the 11 patients reached a level of facial asymmetry as low as that seen in the control group. The best outcome was, in general, seen in cases with mild facial asymmetry presurgically.
Objective:
To quantify soft tissue facial asymmetry (FA) in children with nonsyndromic and Muenke syndrome–associated unicoronal synostosis (NS-UCS and MS-UCS), hypothesizing that MS-UCS presents ...with significantly larger FA than NS-UCS.
Design:
Retrospective cohort study.
Patients and Methods:
Twenty-one children (mean age: 0.6 years; range: 0.1-1.4 years) were included in the study (NS-UCS = 14; MS-UCS = 7). From presurgical computed tomography scans, facial surfaces were constructed for analysis. A landmark guided atlas was deformed to match each patient’s surface, obtaining spatially detailed left-right point correspondence. Facial asymmetry was calculated in each surface point across the face, as the length (mm) of an asymmetry vector, with its Cartesian components providing 3 directions. Mean FA was calculated for the full face, and the forehead, eye, nose, cheek, mouth, and chin regions.
Results:
For the full face, a significant difference of 2.4 mm (P = .001) was calculated between the 2 groups, predominately in the transverse direction (1.5 mm; P < .001). The forehead and chin regions presented with the largest significant difference, 3.5 mm (P = .002) and 3.2 mm (P < .001), respectively; followed by the eye (2.4 mm; P = .004), cheek (2.2 mm; P = .004), nose (1.7 mm; P = .001), and mouth (1.4 mm; P = .009) regions. The transverse direction presented with the largest significant difference in the forehead, chin, mouth, and nose regions, the sagittal direction in the cheek region, and the vertical direction in the eye region.
Conclusions:
Muenke syndrome–associated unicoronal synostosis presented with significantly larger FA in all regions compared to NS-UCS. The largest significant differences were found in the forehead and chin regions, predominantly in the transverse direction.
Muenke syndrome is a craniosynostosis syndrome associated with the p.Pro250Arg mutation in FGFR3. An increasing number of individuals with this mutation are reported to not have craniosynostosis. The ...purpose of this report is to increase awareness of the high phenotypic variability seen in Muenke syndrome. DNA testing for the p.Pro250Arg mutation is routinely performed in Denmark, in children presenting with isolated coronal synostosis. Verified diagnosis entails detailed family history, drawing of family pedigree, DNA testing of the parents, genetic counseling, skull radiographs, clinical photographs, and follow-up. Sixteen individuals from 5 Danish families with Muenke syndrome are presented. Large phenotypic variation was seen both within and across families. The most striking observations were that 6/16 (38%) cases did not have craniosynostosis and one individual presented with a normal phenotype. In addition, 3 unrelated cases had incomplete cleft palate, submucous cleft palate, and bifid uvula, respectively. There is strong evidence for reduced penetrance of the craniosynostosis trait in Muenke syndrome. We argue that many studies on Muenke syndrome have been influenced by ascertainment bias in regard to craniosynostosis. In addition, it is suggested that oral clefting might be part of the clinical spectrum seen in Muenke syndrome.
Objective
Quantitatively assess 3D spatially detailed soft-tissue facial asymmetry in children who had undergone craniofacial reconstruction for Unicoronal Synostosis (UCS), and compare the facial ...asymmetry to control patients. It was hypothesized that there would be no significant differences in the facial asymmetry between the groups.
Design
Clinical, retrospective follow-up study. Methodological study.
Setting
Primary care center.
Patients/Participants
Twenty-two children with UCS were selected after review of records. Inclusion criteria: isolated UCS; surgically treated for UCS within the first 19 months of life, without secondary reconstruction; and DNA analysis for the Muenke mutation. An age- and sex-matched control group was employed.
Interventions
The UCS group had undergone bilateral craniotomy of the frontal bone with unilateral supraorbital rim advancement.
Main outcome Measure(s)
Using 3D surface scanning, a detailed map of 3D asymmetry presenting the amount of asymmetry in the sagittal, vertical, and transverse directions was calculated for six facial subregions.
Results
The facial asymmetry in the UCS group was significantly larger than in the control group for all regions, to the largest extent in the sagittal direction (level of significance: 5%). The regions with the most pronounced asymmetry were cheeks (mean: 5.45 mm; SD: 1.83 mm), forehead (mean: 5.00 mm; SD: 1.57 mm), and eyes (mean: 4.26 mm; SD: 1.44 mm).
Conclusions
Ninety percent of the UCS patients in the study had significant facial asymmetry throughout the facial area. The study demonstrates a methodology of facial asymmetry quantification well suited for soft-tissue surgical outcome evaluations and long-term follow-up studies in patients with craniofacial anomalies.
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