Background: There is some evidence that electroencephalography guidance of general anesthesia can decrease postoperative delirium after non-cardiac surgery. There is limited evidence in this regard ...for cardiac surgery. A suppressed electroencephalogram pattern, occurring with deep anesthesia, is associated with increased incidence of postoperative delirium (POD) and death. However, it is not yet clear whether this electroencephalographic pattern reflects an underlying vulnerability associated with increased incidence of delirium and mortality, or whether it is a modifiable risk factor for these adverse outcomes.
Methods: The
Electroe
ncephalography
Guidance of
Anesthesia to Alleviate
Geriatric
Syndromes (
ENGAGES-Canada) is an ongoing pragmatic 1200 patient trial at four Canadian sites. The study compares the effect of two anesthetic management approaches on the incidence of POD after cardiac surgery. One approach is based on current standard anesthetic practice and the other on electroencephalography guidance to reduce POD. In the guided arm, clinicians are encouraged to decrease anesthetic administration, primarily if there is electroencephalogram suppression and secondarily if the EEG index is lower than the manufacturers recommended value (bispectral index (BIS) or WAVcns below 40 or Patient State Index below 25). The aim in the guided group is to administer the minimum concentration of anesthetic considered safe for individual patients. The primary outcome of the study is the incidence of POD, detected using the confusion assessment method or the confusion assessment method for the intensive care unit; coupled with structured delirium chart review. Secondary outcomes include unexpected intraoperative movement, awareness, length of intensive care unit and hospital stay, delirium severity and duration, quality of life, falls, and predictors and outcomes of perioperative distress and dissociation.
Discussion: The ENGAGES-Canada trial will help to clarify whether or not using the electroencephalogram to guide anesthetic administration during cardiac surgery decreases the incidence, severity, and duration of POD.
Registration: ClinicalTrials.gov (
NCT02692300) 26/02/2016
Background: There is some evidence that electroencephalography guidance of general anesthesia can decrease postoperative delirium after non-cardiac surgery. There is limited evidence in this regard ...for cardiac surgery. A suppressed electroencephalogram pattern, occurring with deep anesthesia, is associated with increased incidence of postoperative delirium (POD) and death. However, it is not yet clear whether this electroencephalographic pattern reflects an underlying vulnerability associated with increased incidence of delirium and mortality, or whether it is a modifiable risk factor for these adverse outcomes.
Methods: The
Electroe
ncephalography
Guidance of
Anesthesia to Alleviate
Geriatric
Syndromes (
ENGAGES-Canada) is an ongoing pragmatic 1200 patient trial at four Canadian sites. The study compares the effect of two anesthetic management approaches on the incidence of POD after cardiac surgery. One approach is based on current standard anesthetic practice and the other on electroencephalography guidance to reduce POD. In the guided arm, clinicians are encouraged to decrease anesthetic administration, primarily if there is electroencephalogram suppression and secondarily if the EEG index is lower than the manufacturers recommended value (bispectral index (BIS) or WAVcns below 40 or Patient State Index below 25). The aim in the guided group is to administer the minimum concentration of anesthetic considered safe for individual patients. The primary outcome of the study is the incidence of POD, detected using the confusion assessment method or the confusion assessment method for the intensive care unit; coupled with structured delirium chart review. Secondary outcomes include unexpected intraoperative movement, awareness, length of intensive care unit and hospital stay, delirium severity and duration, quality of life, falls, and predictors and outcomes of perioperative distress and dissociation.
Discussion: The ENGAGES-Canada trial will help to clarify whether or not using the electroencephalogram to guide anesthetic administration during cardiac surgery decreases the incidence, severity, and duration of POD.
Registration: ClinicalTrials.gov (
NCT02692300) 26/02/2016
Background
Ultrasound (US) examination of the eye can be used to detect and monitor elevated intracranial pressure (ICP) and its consequences. Elevated ICP is transmitted to the contiguous optic ...nerve and its sheath (dura mater), thus underlying the development of papilledema and a widened sheath diameter. The US measurement of the optic nerve sheath diameter (ONSD) has previously been validated to diagnose and monitor raised ICP. The occurrence of vitreous hemorrhage in association with subarachnoid hemorrhage (SAH)—i.e., Terson syndrome—can also be easily diagnosed using ophthalmic US. Because of its relevance in anesthesia and critical care, we describe how to perform the technique illustrated by two cases.
Case presentations
A 72-yr-old man with hydrocephalus secondary to a SAH developed raised ICP following the removal of an external ventricular drainage (EVD) system. Daily ONSD measurements using handheld US allowed us to diagnose and monitor the progression and resolution of the intracranial hypertension following the placement of a second EVD system. We also describe the steps used to obtain ONSD measurements during the ophthalmic US examination of a 53-yr-old woman who presented with a stage IV SAH with concomitant bilateral vitreous hemorrhages or Terson syndrome.
Conclusion
Ophthalmic US using a handheld device to measure and monitor ONSD at the bedside is useful in diagnosing and monitoring the progression of intracranial hypertension following EVD removal in a patient with hydrocephalus secondary to SAH. Ophthalmic US can also be used to identify concomitant vitreous hemorrhage that is associated with a worse prognosis.
Crystal Lake is a small (0.02 km2), alpine lake in the San Gabriel Mountains. This hydrologically closed lake is one of the very few permanent, freshwater lakes in the range. As a result, it is ideal ...for recording coastal southwestern US hydrologic variability. This study presents a 1300 year sub-decadally resolved reconstruction of extreme hydrologic events (i.e., floods). Regional records of late Holocene floods are scarce and largely limited to marine sediment archives, making this research integral to better prepare the highly-urbanized area for, and to mitigate the effects of, excess water. Sediment cores were obtained in May 2014 from the lake’s depocenter. Magnetic susceptibility, LOI 550°C and 950°C, and grain size were measured at 1 cm contiguous intervals; Corg:Ntotal ratios and bulk δ13Corg were measured every 2 cm. An age model was generated by linear regression of 8 AMS 14C dates of discrete organic matter. Age control for the past 200 years is based on correlation to Rothenberg et al. (2010) core ages. Fourteen storm-induced, rapidly deposited layers are distinguished and characterized from ambient sediments. Regionally, these rapidly deposited event layers occur during both wet and dry climate states. Forcings related to Pacific Ocean-atmosphere interactions are explored as potential drivers of these hydrologic events. Ultimately, the Crystal Lake record shows that large flood-producing storm events, likely caused by atmospheric rivers, have occurred in the late Holocene and will occur in the future, regardless of the background climate state.
Abbott Lake (Monterey County, California) is one of only a few natural, permanent lakes located in coastal central California. As a result, it represents an important site for assessing ...spatiotemporal patterns of past hydroclimatic variability. Combined sedimentologic and isotopic analyses are used to describe 1400 years of hydrologic variability within the lake and its drainage basin. Specifically, changes in sand content, percent total organic matter, and δ
18
O
(
G. parvus
)
values suggest changes in paleo-runoff, depositional environment, and relative δ
18
O
(lake water)
values, respectively. Nine AMS
14
C dates on discrete organic material provide age control with a basal age estimate of ~2400 cal years BP. However, we focus on the most recent 1400 years where the age model is most robust. The results indicate that coastal central California was relatively dry (less runoff) during the Medieval Climatic Anomaly (MCA) and variably wet (more runoff) during the Little Ice Age (LIA). These results are compared to Zaca Lake (Kirby et al.
2014
) and Lake Elsinore (Kirby et al.
2010
), both located south of Abbott Lake, and to flood event layers from Santa Barbara Basin (Hendy et al.
2013
). All three sites, including SBB’s flood event history, indicate a variably wet LIA and dry MCA; however, the absolute timing of wet and dry episodes is more congruent between Zaca and Elsinore than to Abbott Lake suggesting real spatiotemporal variability along the southern to central California coast. Finally, Abbott Lake is compared to Pacific Decadal Oscillation and Pacific sea surface temperature reconstructions. These comparisons suggest a Pacific-sourced control on late Holocene hydroclimates along coastal central California.
Continuous versus bolus dosing of furosemide has been a longstanding debate for clinicians treating patients with acute decompensated heart failure. This article discusses the efficacy and safety of ...both options, and reviews several meta-analyses examining this topic.
Acute kidney injury occurs early in PICU admission and increases risks for poor outcomes. We evaluated the feasibility of a multicenter acute kidney injury biomarker urine collection protocol and ...measured diagnostic characteristics of urine neutrophil gelatinase-associated lipocalin, interleukin-18, and liver fatty acid binding protein to predict acute kidney injury and prolonged acute kidney injury.
Prospective observational pilot cohort study.
Four Canadian tertiary healthcare PICUs.
Eighty-one children 1 month to 18 years old. Exclusion criteria were as follows: cardiac surgery, baseline severe kidney disease, and inadequate urine or serum for PICU days 1-3.
PICUs performed standardized urine collection protocol to obtain early PICU admission urine samples, with deferred consent.
Study barriers and facilitators were recorded. Acute kidney injury was defined based on Kidney Disease: Improving Global Outcomes serum creatinine criteria (acute kidney injuryserum creatinine) and by serum creatinine and urine output criteria (acute kidney injuryserum creatinine+urine output) Prolonged acute kidney injury was defined as acute kidney injury duration of 48 hours or more. PICU days 1-3 neutrophil gelatinase-associated lipocalin, interleukin-18, and liver fatty acid binding protein were evaluated for acute kidney injury prediction (area under the curve). Biomarkers on the first day of acute kidney injury attainment (day 1 acute kidney injury) were evaluated for predicting prolonged acute kidney injury. Eighty-two to 95% of subjects had urine collected from PICU days 1-3. Acute kidney injuryserum creatinine developed in 16 subjects (20%); acute kidney injuryserum creatinine+urine output developed in 38 (47%). On PICU day 1, interleukin-18 predicted acute kidney injuryserum creatinine with area under the curve=0.82, but neutrophil gelatinase-associated lipocalin and liver fatty acid binding protein predicted acute kidney injuryserum creatinine with area under the curve of less than or equal to 0.69; on PICU day 2, area under the curve was higher (not shown). Interleukin-18 and liver fatty acid binding protein on day 1 acute kidney injury predicted prolonged acute kidney injuryserum creatinine (area under the curve=0.74 and 0.83, respectively). When acute kidney injuryserum creatinine+urine output was used to define acute kidney injury, biomarker area under the curves were globally lower.
Protocol urine collection to procure early admission samples is feasible. Individual biomarker acute kidney injury prediction performance is highly variable and modest. Larger studies should evaluate utility and cost effectiveness of using early acute kidney injury biomarkers.
Letters to the Editor Fee, Jean L; Intili, Henry; Palermo, Jennifer
Journal for nurse practitioners,
07/2008, Letnik:
4, Številka:
7
Journal Article
Recenzirano
After 50 years of nursing in a variety of settings but always dealing with whole families, I agree that, once explained, the option of palliative care fits the wishes of many, if not most, patients ...dealing with a terminal or severely chronic illness. No medication is entirely without risk; that goes for vaccines as well. Since 2001, all vaccines made for children under age 6 in the United States have been thimerosal-free or have contained only trace amounts (this doesn't include the flu vaccine).
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