Time to epileptiform activity and EEG background recovery are independent predictors after cardiac arrest

Publication date: Available online 9 June 2018
Source:Clinical Neurophysiology
Author(s): E. Westhall, I. Rosén, M. Rundgren, J. Bro-Jeppesen, J. Kjaergaard, C. Hassager, H. Lindehammar, J. Horn, S. Ullén, N. Nielsen, H. Friberg, T. Cronberg
ObjectiveInvestigate the temporal development of EEG and prognosis.MethodsProspective observational substudy of the Target Temperature Management trial. Six sites performed simplified continuous EEG-monitoring (cEEG) on comatose patients after cardiac arrest, blinded to treating physicians. We determined time-points of recovery of a normal-voltage continuous background activity and the appearance of an epileptiform EEG, defined as abundant epileptiform discharges, periodic/rhythmic discharges or electrographic seizure activity.Results134 patients were included, 65 had a good outcome. Early recovery of continuous background activity (within 24 hours) occurred in 72 patients and predicted good outcome since 55 (76%) had good outcome, increasing the odds for a good outcome seven times compared to a late background recovery. Early appearance of an epileptiform EEG occurred in 38 patients and 34 (89%) had a poor outcome, increasing the odds for a poor outcome six times compared to a late debut. The time to background recovery and the time to epileptiform activity were highly associated with outcome and levels of neuron-specific enolase. Multiple regression analysis showed that both variables were independent predictors.ConclusionsTime to epileptiform activity and background recovery are independent prognostic indicators.SignificancePatients with early background recovery combined with late appearance of epileptiform activity may have a good outcome.



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Evaluation of two neck ultrasound measurements as predictors of difficult direct laryngoscopy: A prospective study

BACKGROUND Unpredictable difficult laryngoscopy remains a challenge for anaesthesiologists, especially if difficult ventilation occurs during standard laryngoscopy. Accurate airway assessment should always be performed, but the common clinical screening tests have shown low sensitivity and specificity with a limited predictive value. Ultrasound-based airway assessment has been proposed recently as a useful, simple, noninvasive bedside tool as an adjunct to clinical methods, but to date, few studies are available about the potential role of ultrasound in difficult airway evaluation, and these are mostly limited to specific groups of patients. OBJECTIVES The aim of this study was to determine the correlation between the sonographic measurements of anterior cervical soft tissues thickness and Cormack–Lehane grade view at direct laryngoscopy in patients with normal clinical screening tests. DESIGN Prospective, single blinded, observational study. SETTING Operating theatre of a teaching hospital from May 2017 to September 2017. PATIENTS A total of 301 patients at least 18 years of age undergoing elective surgery under general anaesthesia with tracheal intubation were included in the study. OUTCOME MEASURES Pre-operative evaluation was performed before surgery, demographic variables were collected and clinical screening tests to predict a difficult airway were performed. Patients with predicted difficult intubation were excluded. A 10 to 13-MHz linear ultrasound transducer was placed in the transverse plane and the thickness of the anterior cervical soft tissues was measured at two levels [thyrohyoid membrane (pre-epiglottic space) and vocal cords (laryngeal inlet)] with the patient's head in a neutral position. At each level, the distance from the skin in the median axis and the surrounding area was measured. The laryngoscopic view was graded by a different anaesthetist with more than 5 years of experience with direct laryngoscopy, blinded to the ultrasound assessments. RESULTS The 'pre-epiglottic space thickness' at the level of thyrohyoid membrane was measured as the median distance from skin to epiglottis (mDSE) and the pre-epiglottic area was calculated; the mDSE cut-off value of 2.54 cm (sensitivity 82%, specificity 91%) and the pre-epiglottic area cut-off value of 5.04 cm2 (sensitivity 85%, specificity 88%) were the best predictors of a Cormack–Lehane grade at least 2b at direct laryngoscopy and of difficult intubation. The cut-off value of mDSE showed greater sensitivity in female patients (94 vs. 86%) and greater specificity in male patients (92 vs. 83%). No correlation was found between difficult laryngoscopy and ultrasound assessments at the level of the vocal cords. CONCLUSION Airways ultrasounds might be considered as a predictor of restricted/difficult laryngoscopy and unpredicted difficult intubation. TRIAL REGISTRATION CERM 2016-0405. Correspondence to Stefano Falcetta, Clinic of Anaesthesia and Intensive Care Unit, Ospedali Riuniti Ancona, Via Conca 71, 60126 Ancona, Italy Tel: +39 3479639676; e-mail: falmed@libero.it © 2018 European Society of Anaesthesiology

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Postoperative Cognitive Dysfunction and Noncardiac Surgery

Postoperative cognitive dysfunction (POCD) is an objectively measured decline in cognition postoperatively compared with preoperative function. POCD has been considered in the anesthetic and surgical literature in isolation of cognitive decline which is common in the elderly within the community and where it is labeled as mild cognitive impairment, neurocognitive disorder, or dementia. This narrative review seeks to place POCD in the broad context of cognitive decline in the general population. Cognitive change after anesthesia and surgery was described over 100 years ago, initially as delirium and dementia. The term POCD was applied in the 1980s to refer to cognitive decline assessed purely on the basis of a change in neuropsychological test results, but the construct has been the subject of great heterogeneity. The cause of POCD remains unknown. Increasing age, baseline cognitive impairment, and fewer years of education are consistently associated with POCD. In geriatric medicine, cognitive disorders defined and classified as mild cognitive impairment, neurocognitive disorder, and dementia have definitive clinical features. To identify the clinical impact of cognitive impairment associated with the perioperative period, POCD has recently been redefined in terms of these geriatric medicine constructs so that the short-, medium-, and long-term clinical and functional impact can be elucidated. As the aging population present in ever increasing numbers for surgery, many individuals with overt or subclinical dementia require anesthesia. Anesthesiologists must be equipped to understand and manage these patients. Accepted for publication May 3, 2018. Funding: Institutional and/or departmental. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Lisbeth A. Evered, PhD, Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital, PO Box 2900 Fitzroy, Victoria 3065, Australia. Address e-mail to lis.evered@svha.org.au. © 2018 International Anesthesia Research Society

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A Prospective Observational Study of Anesthesia-Related Adverse Events and Postoperative Complications Occurring During a Surgical Mission in Madagascar

BACKGROUND: Two-thirds of the world's population lack access to safe anesthesia and surgical care. Nongovernmental organizations (NGOs) play an important role in bridging the gap, but surgical outcomes vary. After complex surgeries, up to 20-fold higher postoperative complication rates are reported and the reasons for poor outcomes are undefined. Little is known concerning the incidence of anesthesia complications. Mercy Ships uses fully trained staff, and infrastructure and equipment resources similar to that of high-income countries, allowing the influence of these factors to be disentangled from patient factors when evaluating anesthesia and surgical outcomes after NGO sponsored surgery. We aimed to estimate the incidence of anesthesia-related and postoperative complications during a 2-year surgical mission in Madagascar. METHODS: As part of quality assurance and participation in a new American Society of Anesthesiologists Anesthesia Quality Institute sponsored NGO Outcomes registry, Mercy Ships prospectively recorded anesthesia-related adverse events. Adverse events were grouped into 6 categories: airway, cardiac, medication, regional, neurological, and equipment. Postoperative complications were predefined as 16 adverse events and graded for patient impact using the Dindo-Clavien classification. RESULTS: Data were evaluated for 2037 episodes of surgical care. The overall anesthesia adverse event rate was 2.0% (confidence interval [CI], 1.4–2.6). The majority (85% CI, 74–96) of adverse events occurred intraoperatively with 15% (CI, 3–26) occurring in postanesthesia care unit. The most common intraoperative adverse event, occurring 7 times, was failed regional (spinal) anesthesia that was due to unexpectedly long surgery in 6 cases; bronchospasm and arrhythmias were the second most common, occurring 5 times each. There were 217 postoperative complications in 191 patients giving an overall complication rate of 10.7% (CI, 9.3–12.0) per surgery and 9.4% (CI, 8.1–10.7) per patient. The most common postoperative complication was unexpected return to the operating room and the second most common was surgical site infection (39.2%; CI, 37.0–41.3 and 33.2%; CI, 31.1–35.3 of all complications, respectively). The most common (42.9%; CI, 40.7–45.1) grade of complication was grade II. There was 1 death. CONCLUSIONS: This study adds to the scarce literature on anesthesia outcomes after mission surgery in low- and middle-income countries. We join others in calling for an international NGO anesthesia and surgical outcome registry and for all surgical NGOs to adopt international standards for the safe practice of anesthesia. Accepted for publication April 30, 2018. Funding: None. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website. Reprints will not be available from the authors. Address correspondence to Michelle C. White, MBChB, Department of Anesthesia, Great Ormond Street Hospital for Children, London WC1N 3JH, UK. Address e-mail to doctormcw@gmail.com. © 2018 International Anesthesia Research Society

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Adjusting the Ventilator? Not Only Size Matters!

No abstract available

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Miller’s Anesthesia Review

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Evidence Review Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery: Focus on Anesthesiology for Total Knee Arthroplasty

Enhanced recovery after surgery (ERAS) has rapidly gained popularity in a variety of surgical subspecialities. A large body of literature suggests that ERAS leads to superior outcomes, improved patient satisfaction, reduced length of hospital stay, and cost benefits, without affecting rates of readmission after surgery. These patterns have been described for patients undergoing elective total knee arthroplasty (TKA); however, adoption of ERAS to orthopedic surgery has lagged behind other surgical disciplines. The Agency for Healthcare Research and Quality, in partnership with the American College of Surgeons and the Johns Hopkins Medicine Armstrong Institute (AI) for Patient Safety and Quality, has developed the Safety Program for Improving Surgical Care and Recovery. The program comprises a national effort to incorporate best practice in perioperative care and improve patient safety, for over 750 hospitals and multiple procedures over the next 5 years, including orthopedic surgery. We have conducted a full evidence review of anesthetic interventions to derive anesthesiology-related components of an evidence-based ERAS pathway for TKA. A PubMed search was performed for each protocol component, focusing on the highest levels of evidence in the literature. Search findings are summarized in narrative format. Anesthesiology components of care were identified and evaluated across the pre-, intra-, and postoperative phases. A summary of the best available evidence, together with recommendations for inclusion in ERAS protocols for TKA, is provided. There is extensive evidence in the literature, and from society guidelines to support the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery goals for TKA. Accepted for publication March 22, 2018. Funding: This project was funded under contract number HHSP233201500020I from the Agency for Healthcare Research and Quality and the US Department of Health and Human Services. Conflicts of Interest: See Disclosures at the end of the article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website. The opinions expressed in this document are those of the authors and do not reflect the official position of Agency for Healthcare Research and Quality or the US Department of Health and Human Services. Reprints will not be available from the authors. Address correspondence to Christopher L. Wu, MD, Department of Anesthesiology, Hospital for Special Surgery/Weill Cornell Medical College, 535 E 70th St, New York, NY 10021. Address e-mail to wuch@hss.edu. © 2018 International Anesthesia Research Society

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In Response

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In Response

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Perioperative Care of the Elderly Patient

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The Future of Activated Clotting Time?

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