Sedation and neurodevelopmental outcomes in PICU: identification of study groups

Abstract

Background/Aims

As little as 30 minutes of exposure to anesthetic and sedative agents may adversely affect the developing brain. Safe, humane management of critically ill infants requires the use of sedative agents, often for prolonged periods. We sought to identify two comparable groups of critical care patients who did or did not receive sedatives, with the aim of designing a long‐term neuro‐development follow‐up study. This feasibility study aimed to determine if two comparable groups could be found.

Methods

Infants with respiratory diagnoses having non‐invasive ventilation without sedation (Group C) or intubation and ventilation with sedation (Group S) were identified by chart review. Charts of patients fulfilling the above inclusion criteria were searched for exclusion criteria including neurological disease, extreme prematurity, congenital cardiac disease, genetic anomalies. Data was extracted to score pediatric severity of illness scores (PRISM and PELOD) for each patient. These scores were then compared using the absolute scores and by risk strata.

Results

Group S included 33 patients and Group C had 39. The absolute PRISM and PELOD scores were different between groups, Comparing the groups in 3 risk strata (PRISM greater or less than 5 or 10) there were no significant differences between groups

Conclusions

It is not possible to randomise infants to sedation or no sedation to investigate neurodevelopmental outcomes. This phase of the project aimed to determine the comparability of 2 groups of PICU patients.

These findings indicate that these groups could be enrolled as exposed and control subjects in an outcomes study.

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Physico‐chemical stability of Plasma‐Lyte 148 ® and Plasma‐Lyte 148 ® + 5% Glucose with eight common intravenous medications

Abstract

Background

Plasma‐Lyte 148 ^® is a balanced, crystalloid intravenous (IV) fluid which is both calcium‐free and isotonic. It prevents the hyperchloraemic metabolic acidosis and iatrogenic hyponatraemia seen with use of 0.9% sodium chloride and hypotonic solutions respectively. However, data on compatibility with commonly used drugs is lacking.

Aim

To investigate the stability of Plasma‐Lyte 148 ^® and Plasma‐Lyte 148 ^® + 5% Glucose with eight commonly used therapeutic agents when compared with 5% Glucose and 0.9% Sodium Chloride as diluents. We aimed to provide vital data which may facilitate the introduction of what appears to be a safer and more economic fluid.

Method

Plasma‐Lyte 148 ^® and Plasma‐Lyte 148 ^® + 5% Glucose were mixed with morphine, midazolam, fentanyl, ketamine, clonidine, aminophylline, salbutamol and furosemide at set concentrations. Comparisons were made to 0.9% Sodium Chloride and 5% Glucose fluid controls. Six repeats of each IV fluid and drug admixture were analysed through high performance liquid chromatography (HPLC), at three time points: 0, 2 and 24 hours. A concentration change of < 5% was defined as chemically stable. Physical stability was assessed by observation of precipitate formation or colour change. pH changes were measured using a Fisherbrand Hydrus 300 pH meter.

Results

Relative to starting concentration, all drugs except midazolam were stable to +/‐ 3%. All examined therapeutic agents were chemically stable at 2 and 24 hours relative to control solutions. No precipitate formed in any of the samples. All Plasma‐Lyte 148 ^® and Plasma‐Lyte 148 ^® + 5% Glucose drug admixtures remained in a safe, peripheral administration pH range of 5‐9 and were closer to the pH of blood than standard fluid‐drug admixtures.

Conclusion

Morphine, fentanyl, ketamine, salbutamol, aminophylline, and clonidine are stable for 24 hours when mixed with Plasma‐Lyte 148 ^® and Plasma‐Lyte 148 ^®+5% Glucose for administration at concentrations equivalent to those found at a typical Y site with maintenance fluid. Furosemide is stable at lower concentrations than those seen at a Y‐site, but midazolam displayed instability.

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Sips for little lips‐ letter to the editor

Abstract

We write to you in relation to your recent important publication of the consensus statement on clear fluid fasting for elective paediatric general anaesthesia, that emphasises improving fasting times from two hours to one hour prior to surgery^[1].

In order to determine the volume of clear fluid to be given, one of the practical interventions advised by the author was to use an age‐based banded calculator. This eliminates the need to weigh the child prior to fluid administration.

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A Follow‐up Survey of Total Intravenous Anesthesia Usage in Children in the U.K. and Ireland

Abstract

Background

Total intravenous anesthesia usage in children remains relatively unpopular in the UK and Ireland. A postal survey by Hill et al in 2008 indicated that only 26% of Consultants used a propofol infusion at least once a month.

Aim

Following an increase in teaching and training opportunities in pediatric total intravenous anesthesia in the UK, we repeated the survey amongst Consultant members of Association of Paediatric Anaesthetists of Great Britain and Ireland and Society for Intravenous Anaesthesia, to see if this had affected total intravenous anesthesia usage in children and how practice may have changed.

Methods

We used an anonymous online survey sent to APAGBI and SIVA members.

Results

A total of 291 responses were analysed. Total intravenous anesthesia was the default method of anesthesia in 8% of respondents and a further 46% used total intravenous anesthesia at least monthly. Overall total intravenous anesthesia usage had increased in the past year in 53%. The main indications were malignant hyperthermia susceptibility, and postoperative nausea and vomiting. ENT Surgery was the most popular surgical specialty. The main reasons for not using total intravenous anesthesia were that it was too 'fiddly' and lack of confidence in the user. Most respondents used propofol in combination with remifentanil. Over 80% used propofol target‐controlled infusion. The potential for propofol‐related infusion syndrome concerned many, with 74% limiting infusion duration as a result. Bispectral Index was not used routinely by the majority of anesthetists. Even though most anesthetists did not use total intravenous anesthesia routinely, 98% felt they would be confident to anesthetize an MH positive patient using the technique.

Conclusion

This survey has shown that although total intravenous anesthesia is not the default anesthetic technique for most anesthetists, overall usage in children has more than doubled in the past 10 years, with many happy to use it in a wide variety of patients and procedures.

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Preoperative parafunctional or dysfunctional oral habits are associated with the temporomandibular disorders after orthognathic surgery An observational cohort study

Abstract

Background

Temporomandibular disorders (TMDs) are frequent and disabling, and hence, preventing them is an important health issue. Combining orthodontic and surgical treatments for malocclusions has been shown to affect temporomandibular joint (TMJ) health. However, publications regarding the risk factors that predict negative TMJ outcomes after orthognathic surgery are scarce.

Objective

Present prospective cohort study was conducted to identify an association between preoperative dysfunctional/parafunctional oral habits and presence of TMD symptoms after orthognathic surgery.

Method

We included 237 patients undergoing orthodontics and surgical treatment for malocclusions associated with dento‐facial deformities within the Department of Oral and Maxillofacial Surgery of the University of Lille. Their parafunctional and dysfunctional oral habits were recorded through clinical examination along with presence of TMD symptoms before and after the surgery. According to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) classification, the TMD symptoms studied were myalgia, arthralgia, disc displacement with or without reduction.

Results

Multivariate analysis revealed significant associations among bruxism (odds ratio [OR] 3.17 [1.066; 9.432]), lingual interposition (OR 4.241 [1.351; 13.313]), as well as primary swallowing (OR 3.54 [1.225; 10.234]) and presence of postoperative symptoms of myalgia. Moreover, a significant association was observed between presence of any dysfunctional oral habit and postoperative disc displacement with reduction (OR 4.611 [1.249; 17.021]).

Conclusion

Bruxism and dysfunctional oral habits were shown to be risk factors for presence of TMD symptoms also after combined orthodontic and surgical treatment. Treating such habits before orthognathic surgery should help prevent TMD.

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Motor Unit Number Index (MUNIX) of hand muscles is a disease biomarker for adult spinal muscular atrophy

Publication date: Available online 24 November 2018

Source: Clinical Neurophysiology

Author(s): René Günther, Christoph Neuwirth, Jan Christoph Koch, Paul Lingor, Nathalie Braun, Robert Untucht, Daniel Petzold, Markus Weber, Andreas Hermann

Abstract

Objective

There is still insufficient knowledge about natural history in adult spinal muscular atrophy, thus valid markers for treatment and disease monitoring are urgently needed.

Methods

We studied hand muscle innervation pattern of 38 adult genetically confirmed 5q spinal muscular atrophy (SMA) patients by the motor unit number index (MUNIX) method. Data were compared to healthy controls and amyotrophic lateral sclerosis (ALS) patients and systematically correlated to typical disease-relevant scores and other clinical as well as demographic characteristics.

Results

Denervation of hand muscles in adult SMA was not evenly distributed. By calculation of the MUNIX ratios, we identified a specific hand muscle wasting pattern for SMA which is different to the split hand in ALS. Furthermore, MUNIX parameters strongly correlated with established disease course parameters independent of disease stages.

Conclusion

We found a pathophysiological remarkable denervation pattern of hand muscles, a 'reversed split hand'. MUNIX of single hand muscles correlated well with disease severity and thus represents an easily available biomarker for adult SMA.

Significance

Our data show the power of the MUNIX method as a biomarker for upcoming questions in adult SMA.

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Alexithymia and Temporomandibular Joint and Facial Pain in the General Population

Abstract

Background

Associations of alexithymia with temporomandibular pain disorders (TMD), facial pain, head pain and migraine have been described, but the role of the different dimensions of alexithymia in pain development remained incompletely understood.

Objectives

We sought to investigate the associations of alexithymia and its subfactors with signs of TMD and with facial pain, head pain, and migraine in the general population.

Methods

1,494 subjects from the general population completed the Toronto Alexithymia Scale‐20 (TAS‐20) and underwent a clinical functional examination with palpation of the temporomandibular joint and masticatory muscles. Facial pain, migraine and head pain were defined by questionnaire. A set of logistic regression analyses was applied with adjustment for age, sex, education, number of traumatic events, depressive symptoms, and anxiety.

Results

Alexithymia was associated with TMD joint pain (Odds Ratio 2.63; 95% confidence interval 1.60‐4.32 for 61 TAS‐20 points versus the median of the TAS‐20 score) and with facial pain severity (Odds Ratio 3.22; 95% confidence interval 1.79‐5.79). Differential effects of the subfactors were discovered with difficulties in identifying feelings as main predictor for joint, facial, and head pain, and externally oriented thinking (EOT) as U‐shaped and strongest predictor for migraine.

Conclusion

Alexithymia was moderately to strongly associated with signs and symptoms of TMD. These results should encourage dental practioners using the TAS‐20 in clinical practice, to screen TMD, facial or head pain patients for alexithymia and could also help treating alexithymic TMD, facial or head pain patients.

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