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Sutures or staples should not be removed until the incision has healed fully to prevent dehiscence. Staff education is an important element of any prevention program—ideally covering many of the issues listed earlier. Finally, patient and family education is essential to allow the patient to partner with the surgeon to achieve the best outcomes.
In the postoperative period, careful fluid management is essential for a good outcome. It may prove difficult to determine whether the patient is normovolemic, dehydrated, or fluid overloaded. The experienced medical consultant following the patient regularly is usually in the best position to provide advice on this issue.
It is generally best to use an isotonic saline solution to assure volume adequacy while monitoring serum electrolyte laboratory values for hypokalemia, hyponatremia, or bicarbonate changes. It has been shown that properly hydrated patients have better survival rates.
Increasing evidence suggests that allogeneic blood transfusions may be harmful to patients and may contribute to infections. Pressure sores have a very negative impact on the recovery of the elderly patient with a fracture. Pressure sores take months to heal and often become infected, which may result in wound infection, readmission to hospital, additional surgery, or death. Regions to be checked include the buttocks, hips, heels, and elbows at least daily for the development of redness or blister, which indicate a beginning pressure sore.
The most commonly used prediction tools are the Norton and Braden scales. The Braden scale assesses risk level based on a point system for sensory perception, moisture level, activity level, mobility, nutrition, friction, and shear using scores from one to three or four. The Norton scale uses a 1 to 4 scoring system and rating patients in each of 5 subscales, namely, physical condition, mental condition, activity, mobility, and incontinence.
A score of less than 14 indicates a high risk of pressure ulcer development. The Norton scale generally identifies more patients at high risk than the Braden scale. A pressure sore can be staged , by determining whether it has partial or full thickness skin loss or by grading it on a 1 to 4 Braden scale: stage 1, non-blanching erythema of the skin; stage 2, partial-thickness skin loss, such as a blister or shallow ulcer; stage 3, a deep ulcer not penetrating the fascia and with no undermining; and stage 4, extensive soft-tissue loss with exposure of tendon, muscle, or bone and undermining of the skin.
Treatment of the pressure sore is based on stage and involves relief of pressure and shearing stresses on the skin, debridement of any necrotic tissues, and dressing changes. Rarely, surgical coverage with a muscle flap is required.
Avoiding the pressure sore is the best approach. Pressure-reducing mattresses and surfaces have not been shown to reduce development of pressure ulcers in a recent study. Avoiding or minimizing delirium see earlier discussion will reduce the likelihood of developing a pressure sore. The development of a perioperative thrombosis is a common event in the elderly patient with a fracture.
One study has shown a higher risk of developing VTE in patients with intertrochanteric and subtrochanteric fractures when compared with femoral neck fractures. It has become a standard of care in most hospitals in the United States to use a prophylactic strategy for hospitalized patients with a lower extremity fracture.
For example, mechanical means include sequential pneumatic compression devices and foot pumps placed on the legs; these devices are somewhat effective in the reduction in thrombosis. To avoid the development of a pressure sore, such stockings should not be left on the elderly patient with a fracture while in bed. Mechanical devices may also serve to tether the patient to the bed and thus increase the risk of falls and delirium.
Early surgery and early mobilization have been shown to reduce the likelihood of thrombosis and should be instituted whenever possible. Pharmacologic means commonly used to prevent VTE include unfractionated heparin, low-molecular weight heparin, warfarin, and factor XA inhibitors.
Heparins significantly reduce the risk of venous thrombosis and embolism, but they also increase the incidence of bleeding into the wound and at other sites. Considerations for use of the low-molecular weight heparins include its high cost and the need to inject the medication subcutaneously.
Weekly platelet counts are required to check for the development of heparin-induced thrombocytopenia. Low-molecular weight heparins such as dalteparin and enoxaparin have been shown to be very effective as prophylaxis of VTE after hip fractures.
It is also effective as a prophylactic agent, particularly in the inpatient setting where the twice daily administration is less problematic. It also carries the risk of heparin-induced thrombocytopenia. Warfarin inhibits the production of vitamin-K-dependent coagulation factors in the liver. It has a long half-life, and dosing is often troublesome in the elderly patients. Effects of the dose are not seen until 48 hours after the dose is taken orally.
Although warfarin is inexpensive and easy for the patient to take, it requires frequent, often inconvenient, and in the aggregate expensive laboratory testing INR to monitor and adjust dosage. It may cause bleeding complications, particularly if the INR values are greater than 3. The effects of warfarin are reversible with the administration of vitamin K orally or parenterally. This newer class of medications inhibits activated factor X and thereby anticoagulates the patient.
Fondaparinux sodium is very effective for thromboprophylaxis, but it also can result in bleeding complications. It is not approved for this use in the United States at this time for VTE prophylaxis in patients with hip or lower extremity fracture. They are in concordance on the use of aspirin. Aspirin is not an appropriate sole option for prevention of VTE after hip fracture but can be considered as an option if part of a multimodal approach to prevention including other means such as mechanical compression devices.
Pharmacologic prophylaxis for VTE should be undertaken postoperatively for all patients with a hip fracture. Fondaparinux or low-molecular weight heparin for 28 to 35 days after surgery seems to be the best evidence-based recommendation at this time. All patients with a major lower extremity fracture should receive prophylactic anticoagulation for pharmacologic postoperative prophylaxis—unless strongly contraindicated.
Nutrition is an essential part of care of the elderly patient with a fracture. The patient who is unable to eat postoperatively has a very poor prognosis. Screening for malnutrition has been studied. Screening tools while quick and easy do not perform as well as a complete nutritional assessment in correctly diagnosing malnutrition. Generally, patients with fragility fracture should be fed orally.
Nasogastric feeding is uncomfortable, likely a precipitant of delirium, is associated with aspiration pneumonia, and should be avoided. Parenteral feeding should also be avoided if at all possible, as it has a risk of sepsis, metabolic abnormalities, and delirium.
The diet should consist of small portions with high-caloric content. Foods should be easily chewable because many elderly patients have impaired dentition. Nutritional supplementation consisting of liquid oral supplements between or with meals may be useful for decreasing complications, improving rehabilitation, reducing pressure sores, and improving muscle strength.
Some high-caloric drinks or shakes may not be well tolerated by the elderly patients, and assistance from a dietician is often very useful. A recent study of a multidisciplinary nutritional approach to patients with hip fracture showed improved nutritional intake and better outcomes for the patients.
The goal of rehabilitation after fracture is to restore the patient to the preinjury activity status. This is a difficult goal to achieve, as many patients lose functional status and independence after hip fracture. In most cases, rehabilitation should begin immediately after surgery. The patient should be mobilized to stand and then walk with a walker as soon as possible after surgery but always within 24 hours.
The preinjury functional status is the therapeutic target and should be the basis of planning of the rehabilitation program. In the United States, patients are typically transitioned to an acute rehabilitation center or a subacute nursing facility depending on their ability to perform 3 hours of rehabilitation per day. In some limited cases, patients with very high functional status may be discharged home with home services.
Overall, long-term differences in outcomes between these different approaches have not been seen. Weight bearing as tolerated should be recommended for patients with hip fractures.
In addition, most elderly patients cannot comply with limited weight bearing restrictions. Appropriate pain control will allow the patient to participate effectively in his or her rehabilitation. There is some evidence that scheduled dosing of pain medicine may improve results of rehabilitation.
Delirium should be prevented to allow rehabilitation to progress. Dementia frequently gives care providers problems in the rehabilitation process and slows rehabilitation.
The length and intensity of rehabilitation after hip fracture is a topic of great importance. Studies have shown that long periods of rehabilitation improve function. Improved results were seen using this approach.
Currently, there is no consensus on the best method for the rehabilitation of the patient with a fragility fracture, and this area requires additional study. There are several different models of care in current use in the United States, and there is some evidence to suggest that improvements in the system of care will improve patient outcomes and costs of care. The common models in use in the United States are traditional care, closed panel-health maintenance organization HMO , and comanaged Rochester model.
In this model of care, the patient with a fragility fracture enters through the ED and is evaluated. This evaluation is often delayed because elderly patients tend to suffer quietly and are perceived as low acuity problems to assess.
The diagnosis may be quite apparent to the nurse triaging the elderly patient, but they are frequently placed in the hallway or back of the ED. When a decision is being made to admit the patient to the hospital, there is frequently a dispute that occurs between the medical and the surgical physicians as to who should accept the patient onto their hospital service.
Such a situation must be avoided. The result is a delay in surgical intervention that can be especially detrimental for an elderly patient. When the patient has been cleared for surgery, the anesthesiologist becomes involved.
An unclear clearance note or a perceived lack of diagnostic testing may result in surgery being delayed or canceled. In most cases, postoperative care is dependent on the surgeon. The comorbid conditions may present substantial challenges medically in the postoperative period.
Discharge to a SNF is common, and the patient may or may not recover from the injury. In most cases, there is no treatment prescribed for osteoporosis upon discharge nor is there a referral made for treatment of the osteoporosis. The patient is admitted to a designated facility for care or transferred there if originally admitted to a nonparticipating hospital.
The patient is usually admitted to the hospitalist and assessed medically. Surgery is typically mandated within 24 hours of admission. Postoperative care is provided primarily by the hospitalist, with the orthopedic surgeon as the consultant.
At the hour point, the stable patient is transferred to inpatient rehabilitation, which is also operated by the HMO. This procedure results in a very short length of stay and very orderly care.
Follow-up care is arranged by the closed-panel HMO and may not be with the operating surgeon. This model of care has resulted in a very successful rate of post-fracture osteoporosis management. In this model of care, an emphasis is placed on the rapid admission of the patient through the ED or as a direct admission to the floor from other facilities. A fast-track approach is undertaken in the ED, with rapid admission after assessment of medical stability. The patient is admitted by agreement to the orthopedic surgery service.
The emphasis of this consultation is to ensure medical optimization for early surgery. A detailed assessment of the comorbid conditions and medications is also obtained. The patient is risk stratified for the appropriate operative risk level. Additional consultations and diagnostic testing are rarely obtained. Early surgery, typically in less than 24 hours, is provided for all optimized patients. The risk stratification and comprehensive assessment is reassuring to the anesthesia physician, and thus cancelation of surgery is a rare event.
Postoperatively, all patients are comanaged by medicine and surgical services, and care is by standard protocol. Patients are advised to bear weight as tolerated so they may participate effectively in their rehabilitation. The stable patient is discharged on the third hospital day. This model of care has been shown to result in reduced length of stay, reduced complication rates, and lower costs than that of usual care.
The system or model of care used has a profound impact on the quality of care and outcomes for the patient with a fragility fracture. Standardizing care will provide better care to such patients. Attention to details and avoidance of adverse events should be important goals when instituting such a system. Physician leadership and collaborative interdisciplinary care are fundamental concepts in such a system.
Improvements in quality will directly result in improvement in costs of care. An organized and standardized system of care for the patient with a fragility fracture will afford a better outcome for that patient and be of benefit to the health care system. Costs have become a hotly debated topic in political, economic, and business forums. Several public groups have run educational events on ways to reduce health care costs and improve health care economics.
Hip fracture is the third most costly diagnosis in American medicine. Typically, costs of care are inversely proportional to quality of care. Why is hip fracture care so costly? High charges are incurred from skilled nursing facilities, home care services as well as lesser charges for durable medical equipment, prescription drug charges, and physician charges. Adding to this problem is that It is clear that our present system of care for the patients with hip fracture and fragility fractures in general is expensive and is not providing acceptable value of care high mortality, large number of readmissions, and frequent poor outcomes.
It is unlikely that specific surgical improvements will have any effect on improving the situation. Additionally, simply changing the payment model will be unlikely to have significant impact on improving the value of care.
A complete retooling of the present system of care for fragility fractures is needed to achieve double-digit impact on outcomes and costs. The misaligned incentives in particular work against significant cost improvements. Each provider in the present system is incentivized to maximize profitability rather than reduce costs of care. This will, no doubt, be a subject of great debate and intense effort over the ensuing decade. Some methods to improve costs of care for fragility fractures include utilization of the lean business model when designing the system of care.
Some methods of inpatient cost reduction are already well described. The goal of this text is to enable the clinician to use the best available evidence to guide clinical care of the geriatric patient with low-energy fractures. Reaching this goal is dependent upon the availability of robust outcome data in this patient population. The area of outcomes assessment has also grown rapidly in the past decade.
Increasingly, research into outcomes is segregating into 2 major areas, namely, clinical outcomes and quality improvement. Most clinicians are familiar with this type of research. Research into clinical outcomes seeks to understand what diagnostic or treatment modality leads to improvement in patients outcomes, whereas quality improvement research examines the processes and defect rates in the delivery of health care.
This type of research has been traditionally the focus of hospital administrators and is relatively new to many clinicians. Research in quality improvement seeks to understand how well treatment is delivered to the patient. Whereas the denominator requires critical evaluation of the resources we use to deliver health care through techniques like cost-effectiveness analysis.
Robert Kaplan and Michael Porter of Harvard Business School have highlighted the need for improvement in measuring costs before when can expect to effectively control them Clinical data may also be gathered to gain new, generalizable knowledge for research.
Data gathered for purposes of answering a research question will need to be carefully collected and should be of the highest quality. Obtaining research data requires expertise in data collection and database management, which are often best done by a dedicated data manager or research associate.
An operational definition for each data point is central to maintaining reliability of data. Because database integrity is of the utmost importance, integrity and validity checks need to be performed routinely. There are many important areas of fragility fracture care that need active ongoing research. Some aspects of clinical practice are studied because of a short-term outcome. An example a short-term outcome is pain control in the perioperative period for patients with hip fracture.
Strong clinical evidence indicates that regional analgesia techniques improve preoperative pain control.
Research into the effect of regional analgesia techniques in overall opioid medication use, incidence of delirium, or length of stay is needed. An improvement in any of these parameters would provide a means to add the resources required to provide this treatment in the initial care as well as identifying which patients benefit from these techniques. Additional needed research can be identified throughout the continuum of care delivery for patients with fragility fractures. Research examining the geriatric patients with hip fracture will require a range of different clinical outcome parameters.
These will include basic information such as patient demographics age, gender, pre-injury living situation, etc and fracture outcomes union rates, time to union, hip range of motion, etc. Outcomes scores are sorted into the types of outcomes that are measured. Quality-of-life measures will assess the overall function of a patient using a SF, or EuroQol as a measures. Some of these measures such as the EuroQol allow the investigator to calculate a quality of life-year measure that is useful for cost-effectiveness analysis.
In addition, in the geriatric population with hip fracture, a measure of mental status function may be necessary to validate these other measures. Fragility fracture programs typically have 2 distinct components;, a clinical pathway for management of acute orthopedic injuries and related medical comorbidities and a clinical pathway to ensure that osteoporosis treatment is started and appropriate follow-up treatment is arranged after discharge.
These programs typically involve at least 3 or more medical specialties, namely, Orthopaedic Surgery, Hospital Medicine, Anesthesiology, Geriatrics, Endocrinology, or Emergency Medicine. Performance and outcome data are critical in gaining and subsequently maintaining administrative support for special orthopedic care programs. It is helpful for the clinician to have an understanding of how hospital administrators perceive value created by an efficient orthopedic surgery practice.
Other important data points to consider include time to operation, percentage of patients discharged on osteoporosis treatment, and so on. This information should be compared with available benchmarks from national, international, or other regional medical centers providing care to such patients. Organizations such as University Hospital Consortium or American Association of Medical Colleges provide bench mark data for a variety of medical conditions.
Data collection should address the areas of opportunity along with major national bench mark data points. Assessment of the yearly volume of admissions, types of procedures, costs, and reimbursement allows for financial planning and sets the stage for developing a realistic business plan. Documentation of changes over time provides evidence of program efficacy and sustainability. Data are also important for compliance and billing purposes.
Medical quality of care can be improved by evaluation of individual cases, individual incidents, and trends. Regular morbidity and mortality review is important to identify clinical issues and to reinforce best practices. Review of the cost of care by treating surgeon or medical provider can help identify differences in practices, implant use as well as complications.
Most surgeons are very competitive by nature—making appropriate comparison data available within a physician group can drive change in an individual physicians practice. Study of care delivery data allows the physician and hospital leaders to identify opportunities for improvement in the day-to-day delivery of care.
Data collected on process measures such as time spent in the ED, pain assessment and management, completion of falls prevention education, time to start of physical therapy, intensity of medical comanagement, and time to indwelling urinary catheter removal can be tracked and compared with benchmarks. Data provide the foundation for process improvement.
The IOM defined medical errors as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. The IOM outlined 4 goals. Goals 2 and 3 require the development and use of performance measures. In the United States, The National Quality Forum NQF was developed to provide a forum to develop and implement quality measurement, data collection, and reporting standards throughout the health care community.
This group has membership that spans the public and private sector to include patients, providers, nursing and allied health, employers, insurers, and industrial producers and suppliers in health care. The NQF promotes quality in medicine by evaluating and endorsing standardized performance measurements.
Endorsements are re-evaluated every 3 years. Four primary criteria are utilized in the endorsement process:. The AHRQ maintains a clearing house of recognized performance measures for a variety of medical conditions from the US and international community.
As of January this site listed 25 performance measures for patients with hip fractures created in the United States, Canada, the United Kingdom, and Australia. Through the use of registries and other large data sets, we can identify other aspects of care that will be the basis of additional performance measures.
The AHRQ gives several reasons to consider establishing a registry. Several countries have developed national databases concerning fragility fractures, but such an entity is not available in the United States at this time. The core data set includes elements of case mix, process, and outcomes. They collect data points that address matters of 6 key areas of review for every patient including :. The hospitals in the United Kingdom are compelled to participate in the national registry.
The availability of this large, national database will enable important clinical questions, such as surgical timing, anesthetic choices, implant issues, and postfracture osteoporosis care to be answered in the future. In the United States, registries have been successfully constructed on a more limited basis. For example, the Kaiser Permanente Healthy Bones Program has permitted high-quality fracture follow-up care of osteoporosis by use of a computer registry.
The availability of this registry has permitted clinicians to improve patient safety, quality of care, and cost-effectiveness. It is increasingly clear that outcomes data should be used to drive decision making for fragility fracture care at the hospital level and national level.
In summary, outcomes information is critical to the success of fragility fracture programs. Tracking of data allows for quality assurance both locally and nationally through the use of registries. By following outcomes data, fracture programs can prove their value to hospital systems and society. Mid-level practitioners include physician assistants and nurse practitioners. A physician assistant can provide a broad range of health care services under the supervision of a physician.
Nurse practitioners may or may not work under the supervision of a physician. The exact definition of these delegations is state dependent. The work of the mid-level practitioner can reduce the clinical and nonclinical tasks for the physician. The decrease in resident work hours has led to many of the duties of the orthopedic resident staff now being performed by the mid-level practitioner in most academic centers. Community hospitals often employ mid-level practitioners to perform the daily inpatient medical care of patients.
Duties include obtaining complete medical history and physical examination, ordering and interpreting laboratory test and X-rays, prescribing medications, daily rounds, admitting and discharging patients, and coordination of other medical consult services. Disease and patient characteristics in NP-C patients: findings from an international disease registry.
Niemann-Pick type C disease in a year-old patient. J Neurol Neurosurg Psychiatry. Niemann-Pick disease type C clinical database: cognitive and coordination deficits are early disease indicators. The national Niemann-Pick C1 disease database: report of clinical features and health problems. Clinical experience with miglustat therapy in pediatric patients with Niemann-Pick disease type C: a case series. Mol Genet Metab. Niemann-Pick type C is frequent in adult ataxia with cognitive decline and vertical gaze palsy.
Early co-occurrence of a neurologic-psychiatric disease pattern in Niemann-Pick type C disease: a retrospective Swiss cohort study. The adult form of Niemann-Pick disease type C. Niemann-Pick disease type C symptomatology: an expert-based clinical description. The neuropsychiatry of Niemann-Pick type C disease in adulthood. J Neuropsychiatry Clin Neurosci. Niemann-Pick type C: a potentially treatable disorder?
Pract Neurol. Development of a suspicion index to aid diagnosis of Niemann-Pick disease type C. Linear clinical progression, independent of age of onset, in Niemann-Pick disease, type C. Saccades in adult Niemann-Pick disease type C reflect frontal, brainstem, and biochemical deficits. Saccadic eye movement characteristics in adult Niemann-Pick type C disease: relationships with disease severity and brain structural measures. PLoS One. Recommendations for the detection and diagnosis of Niemann-Pick disease type C.
Neurol Clin Pract. Cholesterol oxidation products are sensitive and specific blood-based biomarkers for Niemann-Pick C1 disease. Sci Transl Med. J Lipid Res. Plasma lysosphingomyelin demonstrates great potential as a diagnostic biomarker for Niemann-Pick disease type C in a retrospective study. A novel, highly sensitive and specific biomarker for Niemann-Pick type C1 disease. Anal Biochem. Clin Chem Lab Med. Rapid screening for lipid storage disorders using biochemical markers.
Expert center data and review of the literature. Development of a bile acid-based newborn screen for Niemann-Pick disease type C. Identification of novel bile acids as biomarkers for the early diagnosis of Niemann-Pick C disease. FEBS Lett. Recommendations for the diagnosis and management of Niemann-Pick disease type C: an update. Niemann-Pick C1 disease: the IT substitution is a frequent mutant allele in patients of western European descent and correlates with a classic juvenile phenotype.
Niemann-Pick type C1 IT mutant encodes a functional protein that is selected for endoplasmic reticulum-associated degradation due to protein misfolding. Niemann-Pick C1 disease: correlations between NPC1 mutations, levels of NPC1 protein, and phenotypes emphasize the functional significance of the putative sterol-sensing domain and of the cysteine-rich luminal loop. Vanier MT, Latour P. Laboratory diagnosis of Niemann-Pick disease type C: the filipin staining test.
Methods Cell Biol. Rapid diagnosis of 83 patients with Niemann-Pick type C disease and related cholesterol transport disorders by Cholestantriol screening. Comprehensive evaluation of plasma 7-ketocholesterol and cholestan-3beta,5alpha,6beta-triol in an Italian cohort of patients affected by Niemann-Pick disease due to NPC1 and SMPD1 mutations. Clin Chim Acta. Cerebellar volume correlates with saccadic gain and ataxia in adult Niemann-Pick type C. Subcortical volumetric reductions in adult Niemann-Pick disease type C: a cross-sectional study.
White and gray matter alterations in adults with Niemann-Pick disease type C: a cross-sectional study. Size and shape of the corpus callosum in adult Niemann-Pick type C reflects state and trait illness variables. Pontine-to-midbrain ratio indexes ocular-motor function and illness stage in adult Niemann-Pick disease type C. Eur J Neurol. Article Google Scholar.
Niemann-Pick disease type C1 predominantly involving the frontotemporal region, with cortical and brainstem Lewy bodies: An autopsy case.
Stable or improved neurological manifestations during miglustat therapy in patients from the international disease registry for Niemann-Pick disease type C: an observational cohort study. Miglustat for treatment of Niemann-Pick C disease: a randomised controlled study. Lancet Neurol. Natural history of Niemann-Pick disease type C in a multicentre observational retrospective cohort study.
Miglustat in adult and juvenile patients with Niemann-Pick disease type C: long-term data from a clinical trial. Miglustat therapy in the French cohort of paediatric patients with Niemann-Pick disease type C. Recommendations for initiation and cessation of enzyme replacement therapy in patients with Fabry disease: the European Fabry working group consensus document. Intrathecal 2-hydroxypropyl-beta-cyclodextrin decreases neurological disease progression in Niemann-Pick disease, type C1: a non-randomised, open-label, phase trial.
The effect of cholesterol-lowering agents on hepatic and plasma cholesterol in Niemann-Pick disease type C. Schiffmann R. From bench to bedside. Type C Niemann-Pick disease: biochemical aspects and phenotypic heterogeneity. Dev Neurosci. Identification of 25 new mutations in 40 unrelated Spanish Niemann-Pick type C patients: genotype-phenotype correlations. Clin Genet. Molecular analysis of 30 Niemann-Pick type C patients from Spain. Niemann-Pick type C disease: mutations of NPC1 gene and evidence of abnormal expression of some mutant alleles in fibroblasts.
Recommendations on the diagnosis and management of Niemann-Pick disease type C. Niemann-Pick disease type C: implications for sedation and anesthesia for diagnostic procedures. J Child Neurol. Defining natural history: assessment of the ability of college students to aid in characterizing clinical progression of Niemann-Pick disease, type C. Diagnostic and treatment implications of psychosis secondary to treatable metabolic disorders in adults: a systematic review. Auditory phenotype of Niemann-Pick disease, type C1.
Ear Hear. The videofluoroscopic swallowing study shows a sustained improvement of dysphagia in children with Niemann-Pick disease type C after therapy with miglustat. Eye movement and diffusion tensor imaging analysis of treatment effects in a Niemann-Pick Type C patient.
Normalisation of brain spectroscopy findings in Niemann-Pick disease type C patients treated with miglustat. J Neurol.
Download references. Data sharing not applicable to this article as no datasets were generated or analysed during the current study. You can also search for this author in PubMed Google Scholar. All authors have contributed to the guidelines development process of planning, writing and revising of the manuscript. All authors read and approved the final manuscript.
Correspondence to Tarekegn Geberhiwot. Alexion has provided funding to SS and MP. SS has received funding from Biomarin and Pfizer. MP has received funding from Agio, Amicus and Novartis.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Reprints and Permissions. Geberhiwot, T. Consensus clinical management guidelines for Niemann-Pick disease type C. Orphanet J Rare Dis 13 , 50 Download citation. Received : 24 November Accepted : 13 March Published : 06 April Anyone you share the following link with will be able to read this content:.
Sorry, a shareable link is not currently available for this article. Provided by the Springer Nature SharedIt content-sharing initiative. Additional CAFG recommendations for tracheal extubation are as follows:. Supplemental oxygen delivery should occur during transportation of all recently extubated patients to high-dependency nursing units including postanesthesia care units. Pulse oximetry monitoring should also be used.
Handover should routinely detail the type and ease of airway management. If tracheal intubation was or might now be challenging, short-term use of an AEC can be considered at extubation to assist re-intubation should it be required. Appropriately positioned and secured above the carina e. Although AECs can support oxygen insufflation and even jet ventilation, barotrauma and fatalities have been reported in these scenarios.
An AEC can be left in situ after extubation of the difficult airway patient until the need for tracheal re-intubation becomes unlikely. Although case specific, in one published ICU series, most patients requiring tracheal re-intubation over an AEC underwent the procedure within two to ten hours after extubation.
Although infrequently required, tracheal re-intubation over an AEC will be facilitated by the use of VL to both retract the tongue and enable monitoring of tracheal tube passage through the glottis. Therefore, leaving an AEC in situ for retaining airway access following extubation, though widely practiced, is technically an off-label application.
The NAP4 study 1 and published closed legal claims 2 , 3 have indicated that airway management misadventure was often associated with inadequate evaluation and lack of a pre-determined airway strategy. That is, airway managers simply did not anticipate difficulty or failed to modify their strategy appropriately despite predicted difficulty. The airway manager must be self-aware of potential human factor pitfalls to avoid.
Table 13 presents some issues together with suggested mitigating strategies. Informed by publications of airway-related morbidity, 1 , 2 , 3 guidelines should not only address management techniques for the difficult airway when encountered in the unconscious patient but also emphasize the need for detailed patient evaluation, planning, and communication.
In this way, safe airway management decision-making and implementation can occur. Briefly summarized, our guiding principles and recommendations are as follows:. Airway evaluation of the patient should always occur before embarking on airway management;.
Review of previous airway management records, databases, and imaging studies will contribute to a complete evaluation. Nasopharyngoscopy or VL under local anesthesia can add useful information about the patient with known or suspected glottic or supraglottic pathology;.
Information gleaned from the airway evaluation must be synthesized into the safest decision on how to proceed with airway management. It is also useful if difficulty is predicted with more than one mode of airway management e. Awake tracheal intubation can proceed via oral, nasal, or front of neck routes. In some cases, oral or nasal ATI can be facilitated by a variety of devices e.
A second airway manager should be sourced, the team briefed, and the required equipment brought to the room. Attention should be paid to patient positioning, pre-oxygenation, and apneic oxygenation;. Regardless of the chosen approach when difficulty is predicted, the airway manager must clearly communicate the planned management strategy to the team, including the triggers for moving from one technique to the next;.
Extra care should be used in the planning and implementation of care for the patient with head and neck pathology, obesity, or increased aspiration risk;. Tracheal extubation of the at-risk patient must be carefully planned in terms of assessing whether the patient can tolerate extubation and whether re-intubation might be difficult;.
As unanticipated difficulty with airway management can occur despite none being predicted, the airway manager must be ready with a strategy for difficulty occurring in every patient, and the institution must make difficult airway equipment readily available and easily accessible;.
As pandemic conditions add complexity to both routine and difficult airway decision-making and management, individual and institutional preparedness should be mandated. Management of difficulty with airway management occurring in the already-unconscious patient is addressed in the part 1 companion article.
Major complications of airway management in the United Kingdom. London: The Royal College of Anaesthetists; Management of difficult tracheal intubation: a closed claims analysis. Anesthesiology ; PubMed Google Scholar. Anesthesiology airway-related medicolegal cases from the Canadian Medical Protection Association. Can J Anesth ; Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation.
Canadian Airway Focus Group consensus-based recommendations for management of the difficult airway: part 1. Difficult airway management encountered in an unconscious patient. Article PubMed Google Scholar.
Difficult Airway Society guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth ; Guidelines for the management of tracheal intubation in critically ill adults. Anaesthesist ; 64 Suppl 1 : All India Difficult Airway Association guidelines for the management of unanticipated difficult tracheal intubation in adults.
Indian J Anaesth ; Cook TM. Strategies for the prevention of airway complications – a narrative review. Anaesthesia ; Will this patient be difficult to intubate? JAMA ; Predictors of a difficult intubation in the bariatric patient: does preoperative body mass index matter? Surg Obes Relat Dis ; 9: Lundstrom LH. Detection of risk factors for difficult tracheal intubation. Dan Med J ; B Neck circumference to thyromental distance ratio: a new predictor of difficult intubation in obese patients.
Prediction of difficult tracheal intubations in thyroid surgery. Predictive value of neck circumference to thyromental distance ratio. Bedside tests for predicting difficult airways: an abridged Cochrane diagnostic test accuracy systematic review.
Pandit JJ , Heidegger T. Croskerry P. Cognitive forcing strategies in clinical decisionmaking. Ann Emerg Med ; Preoperative endoscopic airway examination PEAE provides superior airway information and may reduce the use of unnecessary awake intubation.
Anesth Analg ; The effect of virtual endoscopy on diagnostic accuracy and airway management strategies in patients with head and neck pathology: a prospective cohort study.
The difficult airway refocused. Br J Anaesth ; e Ultrasound identification of the cricothyroid membrane: the new standard in preparing for front-of-neck airway access.
Ultrasonographic identification of the cricothyroid membrane: best evidence, techniques, and clinical impact. Br J Anaesth ; Suppl 1 : i A marking of the cricothyroid membrane with extended neck returns to correct position after neck manipulation and repositioning. Acta Anaesthesiol Scand ; The influence of morbid obesity on difficult intubation and difficult mask ventilation. J Anesth ; Comparison of the Mallampati classification in sitting and supine position to predict difficult tracheal intubation: a prospective observational cohort study.
Determination of the diagnostic value of the Modified Mallampati score, Upper Lip Bite Test and Facial Angle in predicting difficult intubation: a prospective descriptive study. J Clin Anesth ; Neck circumference as a predictor of difficult intubation and difficult mask ventilation in morbidly obese patients: a prospective observational study.
Eur J Anaesthesiol ; A comparison of the Mallampati test in supine and upright positions with and without phonation in predicting difficult laryngoscopy and intubation: a prospective study. J Anaesthesiol Clin Pharmacol ; Incidences and predictors of difficult laryngoscopy in adult patients undergoing general anesthesia : a single-center analysis of , cases.
Incidence and predictors of difficult nasotracheal intubation with airway scope. Routine clinical practice effectiveness of the Glidescope in difficult airway management: an analysis of 2, Glidescope intubations, complications, and failures from two institutions. Standard clinical risk factors for difficult laryngoscopy are not independent predictors of intubation success with the GlideScope.
Poor visualization during direct laryngoscopy and high upper lip bite test score are predictors of difficult intubation with the GlideScope videolaryngoscope. Predictors of difficult intubation with the Bonfils rigid fiberscope. Patient factors associated with difficult flexible bronchoscopic intubation under general anesthesia: a prospective observational study.
Shah PN , Sundaram V. Incidence and predictors of difficult mask ventilation and intubation. Difficult mask ventilation in general surgical population: observation of risk factors and predictors. Difficult mask ventilation in obese patients: analysis of predictive factors. Minerva Anestesiol ; Predictive factors for difficult mask ventilation in the obese surgical population. Prediction and outcomes of impossible mask ventilation: a review of 50, anesthetics.
Incidence, predictors, and outcome of difficult mask ventilation combined with difficult laryngoscopy: a report from the multicenter perioperative outcomes group. Incidence and predictors of difficult and impossible mask ventilation. Prediction of difficult mask ventilation. The incidence and risk factors of difficult mask ventilation.
Laryngeal mask placement in a teaching institution: analysis of difficult placements. FRes ; 4: Modifiable and nonmodifiable factors associated with perioperative failure of extraglottic airway devices. Article Google Scholar. The physiologically difficult airway. West J Emerg Med ; Evaluation and management of the physiologically difficult airway: consensus recommendations from Society for Airway Management.
Complications and failure of airway management. The Australian Incident Monitoring Study. Difficult intubation: an analysis of incident reports. Anaesth Intensive Care ; Mosier JM.
Physiologically difficult airway in critically ill patients: winning the race between haemoglobin desaturation and tracheal intubation. The incidence, success rate, and complications of awake tracheal intubation in 1, patients over 12 years: an historical cohort study.
A retrospective study of success, failure, and time needed to perform awake intubation. A prospective cohort study of awake fibreoptic intubation practice at a tertiary centre. Awake intubation creates feelings of being in a vulnerable situation but cared for in safe hands: a qualitative study.
Effective nonanatomical endoscopy training produces clinical airway endoscopy proficiency. Conscious sedation for awake fibreoptic intubation: a review of the literature. Safety and efficacy of dexmedetomidine as a sedative agent for performing awake intubation: a meta-analysis.
Am J Ther ; e Heidegger T , Schnider TW. McGuire G, el-Beheiry H. Complete upper airway obstruction during awake fibreoptic intubation in patients with unstable cervical spine fractures. Dexmedetomidine for the management of awake fibreoptic intubation. Awake fiberoptic or awake video laryngoscopic tracheal intubation in patients with anticipated difficult airway management: a randomized clinical trial.
Videolaryngoscopy vs. Videolaryngoscopy versus fiberoptic bronchoscope for awake intubation – a systematic review and meta-analysis of randomized controlled trials.
Ther Clin Risk Manag ; From variance to guidance for awake tracheal intubation. The emerging role of awake videolaryngoscopy in airway management. Lim WY , Wong P. Awake supraglottic airway guided flexible bronchoscopic intubation in patients with anticipated difficult airways: a case series and narrative review.
Korean J Anesthesiol ; A clinical evaluation of the intubating laryngeal airway as a conduit for tracheal intubation in children. Jagannathan N , Truong CT. A simple method to deliver pharyngeal anesthesia in syndromic infants prior to awake insertion of the intubating laryngeal airway.
Johnson CM , Sims C. Management of the difficult airway: a closed claims analysis. Total airway obstruction during local anesthesia in a non-sedated patient with a compromised airway. Complete airway obstruction during awake fibreoptic intubation. The obstructed airway in head and neck surgery. Upper airway anesthesia induces airflow limitation in awake humans.
Am Rev Respir Dis ; The use of extracorporeal membrane oxygenation in the anticipated difficult airway: a case report and systematic review.
Elective use of veno-venous extracorporeal membrane oxygenation and high-flow nasal oxygen for resection of subtotal malignant distal airway obstruction. Awake extracorporeal membrane oxygenation for management of critical distal tracheal obstruction. Otolaryngol Head Neck Surg ; Anesthetic management of a patient with tracheal dehiscence post-tracheal resection surgery. Semin Cardiothorac Vasc Anesth ; Pre-intubation veno-venous extracorporeal membrane oxygenation in patients at risk for respiratory decompensation.
J Extra Corpor Technol ; Comparison of ease of intubation in sniffing position and further neck flexion. Head and neck position for direct laryngoscopy. Head elevation improves laryngeal exposure with direct laryngoscopy. Changes in airway configuration with different head and neck positions using magnetic resonance imaging of normal airways: a new concept with possible clinical applications.
Shoulder and head elevation improves laryngoscopic view for tracheal intubation in nonobese as well as obese individuals. Obes Surg ; Comparison of glottic views and intubation times in the supine and 25 degree back-up positions.
Inclined position is associated with improved first pass success and laryngoscopic view in prehospital endotracheal intubations. Am J Emerg Med ; Head-elevated patient positioning decreases complications of emergent tracheal intubation in the ward and intensive care unit.
Feasibility of upright patient positioning and intubation success rates at two academic EDs. A multicenter, randomized trial of ramped position vs sniffing position during endotracheal intubation of critically ill adults. Chest ; Laryngeal exposure during laryngoscopy is better in the 25 degrees back-up position than in the supine position.
Effectiveness of intubation devices in patients with cervical spine immobilisation: a systematic review and network meta-analysis. Sniffing position improves pharyngeal airway patency in anesthetized patients with obstructive sleep apnea. Head position angles to open the upper airway differ less with the head positioned on a support.
The Laryngeal Mask Company Limited. Influence of head and neck position on the performance of supraglottic airway devices: a systematic review and meta-analysis. Petrosillo G. Free Radic Biol Med. Mandel I. Journal of Cardiothoracic and Vascular Anesthesia. Introduction: Cardiac arrest carries a poor prognosis. The average cardiac arrest patient is comorbid and retrospective studies suggest that diabetes mellitus is an independent risk factor for increased mortality after cardiac arrest.
Despite this, cardiac arrest animal studies are conducted on healthy young animals, limiting our knowledge regarding the post-cardiac arrest organ dysfunction and the impact of type 2 diabetes mellitus T2DM. We hypothesize that T2DM, in a rat model of cardiac arrest, is associated with increased brain injury and reduced left ventricular function following resuscitation.
Brain injury was evaluated by neuron specific enolase NSE and left ventricular function was measured as fractional shortening FS by echocardiography both measured at baseline and min. At baseline lactate was 1.
At the end of experiment lactate concentration in the ZDF group was at 8. Conclusions: Cardiac arrest in an animal model of T2DM results in increased brain injury, while in contrast left ventricular function was increased when compared to non-diabetic animals. Introduction: We hypothesized the amount of energy required by the surface device to reach target temperature Ttarget in post-cardiac arrest patients treated with therapeutic hypothermia TH may be associated with outcomes by serving as a proxy for patient thermoregulatory ability and may modify the relationship between the time to Ttarget and outcomes.
Some studies have shown that TH-treated post-arrest patients who reach Ttarget quickly have worse outcomes than those who cool more slowly. However, the ischemia-reperfusion insult of cardiac arrest may cause temperature derangements that affect the time trajectory of TH independent of external cooling factors.
Methods: Adult patients with sustained return of spontaneous circulation treated with TH between with serial temperature data were included. Primary outcome was neurologic status measured by Cerebral Performance Category [CPC] score ; secondary outcome was survival, both at hospital discharge.
Univariate analyses were performed using Wilcoxon rank-sum tests; multivariate analyses used logistic regression. Results: Of patients included, those with CPC required less energy to reach Ttarget median 8. Patients who did not survive required less energy than survivors median 8. Controlling for average water temperature between initiation and Ttarget, the relationship between outcomes and time to Ttarget was no longer significant.
Controlling for location, witnessed arrest, age, initial rhythm, and neuromuscular blockade use, increased energy was associated with better neurologic aOR: 1. Conclusions: Increased energy requirement during TH initiation is associated with better outcomes at hospital discharge and may affect the relationship between time to Ttarget and outcomes.
Introduction: We aimed for clinical assessment of cardiopulmonary resuscitation CPR procedures of witnessed cardiac arrests inside the intensive care units ICU and follow up of patients surviving to discharge.
Resuscitation protocol was done according to the latest recommendation of the European society of cardiology. Clinical data were recorded and surviving patients were clinically followed daily until hospital discharge. Long term survival decreased with Asystole p 0.
Conclusions: CPR in the ICU may achieve variable rates of short and long term survival depending on the associated comorbidities. Introduction: To look at the outcomes of patients who suffered a non-traumatic OHCA, witnessed by layperson. Methods: This is a retrospective case record review. Exclusion criteria included traumatic OHCA and all patients declared dead at scene. Data of patients admitted were extracted from inpatient electronic case records.
Patient discharged from hospital were followed up for 30 days. Among witnessed, by family, by layperson, 76 by EMS, and 40 by healthcare providers.
None was shockable. Some of these arrests were witnessed by laypersons, however, none survived when CPR was not started.
This warrants further study to find out the reasons for not initiating CPR. There should be more efforts directed at community CPR programs. Introduction: Early intervention and prevention of psychological disorders could help to significantly reduce costs to the NHS. Relatives who experience the sudden and unexpected death of a relative following OOHCA may be at high risk of developing both psychological and physical health problems.
As many of these deaths occur within the Emergency Department ED , it is important to understand the support needs of relatives to help minimise risk of a poor outcome.
Twelve male and female participants who experienced the death of a relative following an OOHCA and who had either i witnessed the event and provided CPR, ii witnessed the event and did not provide CPR, and iii those who did not witness the event completed audio-recorded interviews lasting up to 90 minutes.
Audio-recordings were transcribed verbatim and subjected to inductive thematic analysis. Results: Three major themes were identified. Flashbacks, recurring traumatic images, and experiencing physical symptoms associated with the heart were common. Intimations of mortality were associated with hyperarousal symptoms and health anxieties. Coping techniques included avoidance behaviours and emotional numbing, often masking their distress and support needs.
Relatives blamed themselves for not noticing sooner that something was wrong, particularly when an underlying heart condition was identified as cause of death. Seeking information was important for relatives to help both try to make sense of what happened and exonerate feelings of guilt and self-blame. Conclusions: Findings suggest that the psychological impact of experiencing the sudden death of a relative following an OOHCA may be profound.
Information provision is crucial to help relatives make sense of their experience and exonerate feelings of guilt and self-blame. Support of relatives needs to be a more serious consideration to help minimise risk of poor psychological outcome and reduce the health economic burden this may pose.
Introduction: Bispectral index BIS monitoring has been considered as a promising electrophysiological tool for early prognostication after out-of-hospital cardiac arrest OHCA. In recent years, a broad range of BIS thresholds has been put forward at diverse time points to predict neurological outcome in OHCA patients.
This study aimed to reach consensus about the optimal time point and threshold for predicting poor neurological outcome after OHCA using the BIS monitor. Norwood, USA. BIS and SR values were continuously recorded during the hypothermic and rewarming phase. Receiver operator characteristics curves were constructed to determine the best cut-off value and time point to predict poor neurological outcome. There were no patients with a CPC 3 or 4. Using a mean BIS value below With a cut-off value of SR above 2.
Conclusions: This prospective, observational study confirmed that mean BIS values at hour 12 can be used to predict poor neurological outcome. In addition, we showed that the predictive ability of the SR might be even higher as compared to the one of BIS. Debate is ongoing regarding the optimal antiplatelet strategy for survivors of OHCA, given the concerns of both bleeding and clotting complications in this population.
To understand why OHCA survivors are at risk of bleeding and whether this impacts survival to hospital discharge, we retrospectively analysed laboratory parameters of coagulation PT and APTT , platelet count, and haemoglobin then stratified these by survival to hospital discharge, over the period January to August Methods: Routinely collected electronic data was used to identify patients for this study.
Parameters of; status at hospital discharge, platelet count, APTT and haemoglobin within 24 hours of admission were extracted from the database. However, absolute values do not give an indication as to the function of platelets or of the coagulation cascade. An analysis of platelet function and the coagulation cascade as a whole may provide better insights into the risks of bleeding in this population.
We therefore propose to carry out a prospective analysis of thromoelastometric coagulation assessment and platelet inhibition, and correlate this with bleeding events and administration of antiplatelet therapy. Nolan JP et al. Increasing survival after admission to UK critical care units following cardiopulmonary resuscitation. Critical Care. Introduction: Cardiac arrest CA is a catastrophic event with a high rate of mortality, often resulting in devastating brain injury that might evolve to brain death BD [1].
Methods: We retrospectively enrolled all patients admitted to our hospital between January and September after refractory CA treated with eCPR. Deads vs. Tab1 shows characteristics of eligible patients at the time of donation.
Conclusions: eCPR patients might become BD and be considered potential resource for organ donation with a similar success rate as organs retrieved from patients deceased from other causes. Introduction: Therapeutic exercise is an integral component of the rehabilitation of patients with stroke.
The objective of the present study was to investigate effects of post-ischemic exercise on neuronal damage or death and gliosis in the aged gerbil hippocampus after transient cerebral ischemia using immunohistochemistry.
Methods: Aged gerbils male, 22 to 24 months induced by ischemia were subjected to treadmill exercise for 1 or 4 weeks. Neuronal death was apparently found in the stratum pyramidale of the hippocampal CA1 region and in the polymorphic layer PoL of the dentate gyrus DG using cresyl violet and Fluoro-Jade B histofluorescence staining.
Results: In addition, no significant difference in neuronal death was found after 1 or 4 weeks of post-ischemic treadmill exercise. However, post-ischemic treadmill exercise apparently affected gliosis activation of astrocytes and microglia.
However, 4 weeks after treadmill exercise significantly alleviated ischemia-induced astrocyte and microglia activation, although the gliosis was not alleviated in the animals with 1-week exercise. Conclusions: These findings suggest that long-term post-ischemic treadmill exercise after transient cerebral ischemia could not influence neuronal protection, however, it could effectively alleviate astrocyte and microglial activation in the aged hippocampus induced by 5 min of transient cerebral ischemia.
Introduction: One of the most promising interventions for acute ischemic strokes is intravenous thrombolysis IVT. The aim of the study was to evaluate which factors can predict the need for critical care support after thrombolysis. They all fulfilled the international inclusion criteria [2] and received IVT with alteplase. Comparison amongst the two groups was performed with application of proper statistical tests.
Introduction: To describe comorbidities, clinical presentation, diagnostic method, treatment and outcome of 6 patients with Posterior Reversible Encephalopathy Syndrome PRES. Radiological findings on computed tomography CT and magnetic resonance imaging MRI include abnormalities of white and grey matter, predominantly affecting parietal and occipital lobes.
The treatment is based on the removal of the underlying cause. Results: Four patients had lupus, 2 were solid-organ transplant patients 1 kidney and 1 liver. Immunosuppression and headache were found in all patients, 5 presented hypertensive emergencies, 4 had seizures, 3 showed decreased level of consciousness and nausea and vomiting, 1 had status epilepticus. Treatment was performed with intravenous blood pressure lowering agents and antiepileptic drugs.
The length of stay ranged from 22 days to 66 days. Five patients showed full recovery, and 1 died of intracranial hemorrhage. Conclusions: Autoimmune disease, use of immunosuppressant and hypertension are important risk factors for PRES. Patients usually have a good recovery after prolonged stay in hospital, but death and neurological disability may occur. Symptoms include diplopia and gait ataxia.
Pontine lesions are a commonly seen on magnetic resonance imaging. Patients display a favourable response to glucocorticosteroid therapy. Methods: A 54 year-old man with no significant past medical history presented to the emergency department with a day history of vomiting and feeling generally unwell.
He suffered from dizziness, ataxia, diplopia, bilateral nystagmus, taste and hearing disturbances. Within 24 hours of admission he developed right sided weakness. GCS dropped to 8 and he required intubation. He had downgoing plantar reflexes, myoclonic jerks, tonic-clonic movements of lower limbs and spasticity of both upper and lower limbs.
Seizures occurred daily and were terminated with lorazepam. Two weeks after admission, the patient developed pyrexia of 42 0 C and required cooling for 7 days. Results: The patient was treated for infective encephalitis with amoxicillin, ceftriaxone and acyclovir. All cultures, viral PCR and cryptococcal antigens were negative. The first MR head showed high T2 signal and swelling in the pons, which extended into the cerebral peduncle on the left.
There was restricted diffusion within the pons and middle cerebellar peduncle. High-dose methylprednisolone was commenced intravenously.
He was alert and followed commands within days. Nystagmus persisted, but he had no further spasticity. A third MR after five days of steroid treatment described significant improvement in the pontine lesions, but a small focus of high signal remained. Midbrain oedema present on previous scans had resolved. Central pyrexia is common in neurological conditions. An infective cause was not identified, however, with no response to antimicrobials in the absence of positive cultures, central pyrexia is likely.
Introduction: Lumbar puncture LP is the main procedure to obtain the diagnosis of meningitis and subarachnoid hemorrhage. However the success rate could be compromised in difficult LP patients such as patients with obesity or scoliosis. Methods: This is a prospective randomized controlled trail from August to July Primary outcome was the success rate of first LP attempt.
Secondary outcome included number of attempts, time to complete the procedure, and post-procedure complication. There were 20 patients in each group. Introduction: The pathophysiology of the acid-base equilibrium of the cerebrospinal fluid CSF is important, as it influences respiration [1]. Aim of the present study was to describe CSF acid-base of patients with subarachnoid hemorrhage SAH and compare them with control subjects.
A similar procedure was performed in patients without significant comorbidities undergoing spinal anesthesia for elective surgery. Comparison between groups was performed via t-test or Rank Sum Test, as appropriate. Acid-base results are summarized in Table.
Introduction: Natriuresis and polyuria are common events after aneurysmal subarachnoid haemorrhage aSAH. A relationship has been found between polyuria, cerebral salt wasting syndrome CSWS and vasospasm [1]. The aim of this study is to determine the relationship between creatinine clearance and natriuresis, and to identify variables related to natriuresis.
Methods: During 2 years 29 patients with aSAH and polyuria were identified. The tomographic characteristics and neurological clinical scores were considered. Symptomatic vasospasm was defined as clinical deterioration confirmed with cerebral angiography.
Results: 29 patients were included, eight of them No patient presented hyponatremia. Neither sodium in 24 hours AUC: 0. Conclusions: We found no relationship between polyuria, natriuresis and symptomatic vasospasm.
Brown RJ et al. Polyuria and cerebral vasospasm after aneurysmal subarachnoid hemorrhage. BMC Neurology. Introduction: Unconscious young patients are admitted to hospitals in Amsterdam nearly on a daily basis, mostly due to intoxications. However, the following case underscores that routine laboratory and imaging investigations do not replace a detailed interrogation.
Methods: A year old woman was found unconscious in the early morning. Her family mentions she had complained about headaches, but no other complaints or fever. She was unresponsive and had uncontrolled jerking movements, without signs of lateralisation and with normal stem reflexes. Cerebral computer tomography and analysis of cerebrospinal fluid were unremarkable. Empiric therapy with broad-spectrum antibiotics, acyclovir and dexamethasone were started.
Further interrogation of the parents reported a visit to Ghana for 2 weeks 3 months before. She had taken mefloquine prophylactically. On follow up she had minor concentration problems. Conclusions: Cerebral malaria is a diffuse symmetric encephalopathy. Children are at a higher risk than adults. Focal signs are unusual. CT scans and cerebrospinal fluid analysis are usually unremarkable. It is important to note that cerebral malaria may have a prolonged incubation time, especially in patients using malaria prophylaxis, like in the current case, and may be lethal even at a low parasitemia.
Early treatment is vital. The authors confirm they have received informed consent to publish from the patient. Characteristic abnormalities in cerebrospinal fluid biochemistry in children with cerebral malaria compared to viral encephalitis.
Cerebrospinal Fluid Res. Cerebral malaria is frequently associated with latent parasitemia among the semi-immune population of eastern Sudan.
Microbes Infect. Introduction: To report incidence rates, pathogens distribution, and patient related outcomes of healthcare-associated infections HAIs in a neurological intensive care unit Neuro-ICU patient population over a 6-year period. Methods: We are presenting a prospective cohort study of all patients admitted in a 14 bed Neuro-ICU part of a highly-specialized referral center from April 1, to March 31, Surveillance for HAIs was carried by infection control professionals who reviewed laboratory results and targeted specific clinical indicators to match National Healthcare Safety Network infection criteria.
Rates were calculated per 1, patient days and per 1, device days. Differences in infection rates were analyzed by emergency neurocritical care diagnostic categories. We studied the association between: i primary diagnosis and infection using Cox proportional hazards model, ii infection and length of stay using linear regression, and iii infection and mortality using Cox proportional hazards model. Yearly objectives were set to reduce HAIs with implementation of targeted infection control measures.
A total of HAIs were identified. Pooled mean HAI incidence rates were pneumonia For device-associated infections, which accounted for Pathogen frequencies were S.
Among patients with HAIs, all-cause day case mortality proportion was 9. Introduction: IV nicardipine is commonly used for blood pressure reduction. Few studies have described its effects on cerebrovascular hemodynamics as measured by transcranial Doppler TCD waveform analysis and pulsatility index PI. Methods: The data presented are from patients who underwent TCD monitoring before, after, or during nicardipine administration.
Results: TCD waveforms during nicardipine infusion are characterized by a prominent systolic peak and dicrotic notch. Conclusions: This study provides first evidence of paradoxical intracranial vasoconstriction associated with nicardipine.
This is a consistent finding in patients treated with IV nicardipine and is contradictory to what is expected from a vasodilator and anti-hypertensive. Introduction: Cerebral venous thrombosis CVT is a rare neurovascular disorder with a highly variable presentation that accounts for only 0. It can lead to neurologic impairment. There have been some studies and case reports about CVT; however, there is a lack of information on the incidence and clinical features of CVT due to its rarity.
We, therefore, conducted this study to clarify important aspects of the epidemiology, diagnosis, and prognosis of CVT. Methods: We carried out a retrospective observational study of all patients with a diagnosis of CVT in our hospital between January and October We also performed a systemic review of the literature for CVT using a multiple web research platform PubMed from to Results: Four patients were diagnosed with CVT in our hospital during the study period.
The mean age of the patients was The most frequent symptom was headache cases, The use of an oral contraceptive was one of the most frequent predisposing risk factors patients, The most frequent site of involvement was the superior sagittal sinus cases, The hospital mortality rate was 5. There was no association between hospital mortality and location of thrombosis. Conclusions: Patients presenting with headache, especially patients taking an oral contraceptive, should be examined carefully.
Although there is no typical red flag symptomatology, recognition of CVT is important. Introduction: Absence of respiratory control reflexes in the brainstem in response to hypercapnic stimulation through the observation of the thoracic and abdominal movements, positive apnea testing AT , is a key component in the clinical assessment of brain death BD.
False negative results of AT may occur due to ventilatory auto-triggering which could hamper and delay BD determination.
Electrical activity of the diaphragm EAdi reflects the neural respiratory drive. We hypothesized that EAdi monitoring would add accuracy and safety to AT procedure. Methods: We performed a single centre prospective observational study of adult patients admitted to the ICU with devastating acute brain injury and clinical examination consistent with BD.
Stable patients on ventilator control mode were switched to Pressure Support during the period of apnea. Respiratory movements, arterial pressure, hearth rhythm and SpO2 were continuously monitored and airway pressure, airflow and EADi were also saved using a Ventilation Record Card for later analysis.
AT duration and complications during the procedure were recorded. Results: We included 8 patients in the study. EADi signals recorded during AT were tonic and with very low voltage. Sensitive auto-triggering was observed in a case. The AT was positive and completed in all patients and no severe complications were noted. Conclusions: We found that EADi monitoring and analysis is a safe and effective tool for diagnosing apnea during BD confirmation, avoiding false negative diagnosis based on direct observation.
This strategy of rapid implementation, operator-independent, minimally invasive and low cost, may be introduced in the AT protocols. All current methods of AT have as main purpose to elevate CO2 and observe the patient for any spontaneous effort by close observation of respiratory movements that may sometimes be subtle and doubtful.
Moreover, commonly AT practice involve disconnection of ventilator circuit, adding an adjustable CPAP valve to the distal extremity of the T-piece extension in order to try to preserve oxygenation.
This study was aimed to evaluate an alternative AT method that allows the patient to stay connected to the mechanical ventilator circuit during AT procedure and avoid the disadvantages of the current methods. Patients were closely monitored throughout the procedure by clinical observation. Airway pressure, airflow and volume waveforms were displayed on the ventilator screen. Patient and screen data were saved to a Ventilation Record Card for later analysis.
Duration of AT, invasive arterial pressure, heart rate and SpO2 were recorded. Physiologic, ventilatory mode and settings, respiratory mechanics and arterial blood gases were collected at 3 time points: basal T1 , start of AT T2 , end of AT T3.
After AT ventilator was switched to prior settings. Results: Nine patients were studied. Main data collected are showed in the table.
Analysis of pressure and flow waveform tracings showed absence of airflow and maintenance of PEEP at stable levels. A case of sensitive auto-triggering was clearly observed due to the selected PS level but the procedure did not have to be aborted. There were no complications or discontinued procedures. We speculate that these findings could have a significant impact if the strategy used really contributes to increase numbers of organ procurements and under the best possible conditions.
Introduction: Detection and management of delayed cerebral ischemia DCI after severe subarachnoid hemorrhage SAH is difficult, and tools are lacking to guide the therapy.
– Recommended
CVC insertion puts the patient at risk from a number of complications and unintended outcomes, at the time of insertion, after insertion, and upon removal. Niemann-Pick Type C (NPC) is a progressive and life limiting autosomal recessive disorder caused by mutations in either the NPC1 or NPC2. Health, Vancouver Coastal Health, and Vancouver Island Health) as well as Resident care tasks account for 60% of care aides’ daily workload, and are.
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Each of these levels of approval requires a concise business style presentation to a group of administrators. Co-authored a textbook: Management of the Difficult and Failed Airway. NPC disease is not yet curable but is an eminently treatable condition. Disclaimer These recommendations seek to reflect the перейти на страницу published evidence regarding airway management. Attention to mental status including dementia and delirium is important. Scandinavian journal of trauma, resuscitation and emergency medicine.
