Benchmarking Hospital Practices and Policies on Intrahospital Neurocritical Care Transport: The Safe-Neuro-Transport Study.

An electronic survey was administered to multidisciplinary neurocritical care providers at 365 hospitals in 32 countries to describe intrahospital transport (IHT) practices of neurocritically ill patients at their institutions. The reported IHT practices were stratified by World Bank country income level. Variability between high-income (HIC) and low/middle-income (LMIC) groups, as well as variability between hospitals within countries, were expressed as counts/percentages and intracluster correlation coefficients (ICCs) with a 95% confidence interval (CI). A total of 246 hospitals (67% response rate; n = 103, 42% HIC and n = 143, 58% LMIC) participated. LMIC hospitals were less likely to report a portable CT scanner (RR 0.39, 95% CI [0.23; 0.67]), more likely to report a pre-IHT checklist (RR 2.18, 95% CI [1.53; 3.11]), and more likely to report that intensive care unit (ICU) physicians routinely participated in IHTs (RR 1.33, 95% CI [1.02; 1.72]). Between- and across-country variation were highest for pre-IHT external ventricular drain clamp tolerance (reported by 40% of the hospitals, ICC 0.22, 95% CI 0.00-0.46) and end-tidal carbon dioxide monitoring during IHT (reported by 29% of the hospitals, ICC 0.46, 95% CI 0.07-0.71). Brain tissue oxygenation monitoring during IHT was reported by only 9% of the participating hospitals. An IHT standard operating procedure (SOP)/hospital policy (HP) was reported by 37% (n = 90); HIC: 43% (n= 44) vs. LMIC: 32% (n = 46), p = 0.56. Amongst the IHT SOP/HPs reviewed (n = 13), 90% did not address the continuation of hemodynamic and neurophysiological monitoring during IHT. In conclusion, the development of a neurocritical-care-specific IHT SOP/HP as well as the alignment of practices related to the IHT of neurocritically ill patients are urgent unmet needs. Inconsistent standards related to neurophysiological monitoring during IHT warrant in-depth scrutiny across hospitals and suggest a need for international guidelines for neurocritical care IHT.

Implementation of an Online External Ventricular Drain Training Module-An Educational Initiative to Improve Proficiency of Perioperative Health Care Providers: Results of a Retrospective Study.

BACKGROUND: An external ventricular drain (EVD) training module may improve the knowledge and proficiency of perioperative health care providers (HCPs). METHODS: We examined knowledge gaps, self-reported comfort in managing EVDs, and improvement in self-assessment scores among HCPs from 7 academic medical centers based on an online EVD training module. RESULTS: Of the 326 HCPs who completed the module, 207 (70.6%) reported being uncomfortable managing EVDs. The median pretest scores were 6 (interquartile range=2), and posttest scores were 8 (interquartile range=1), out of a maximum possible score of 9. The most frequent incorrectly answered questions were: (a) maximum allowed hourly cerebrospinal fluid volume drainage (51%), (b) the components of a normal intracranial pressure waveform (41%), and (c) identifying the correct position of the stopcock for accurate measurement of intracranial pressure (41%). The overall gain in scores was 2 (interquartile range=2) and highest among HCPs who had managed 1 to 25 EVDs (2.51, 95% confidence interval: 2.23-2.80), and without self-reported comfort in managing EVDs (2.26, 95% confidence interval: 1.96-2.33, P <0.0001). The majority of participants (312, 95.7%) reported that the training module helped them understand how to manage EVDs, and 276 (84.7%) rated the module 8 or more out of 10 in recommending it to their colleagues. CONCLUSIONS: This online EVD training module was well-received by participants. Overall, improved scores reflect enhanced knowledge among HCPs following completion of the module. The greatest benefit was observed in those reporting less experience and feeling uncomfortable in managing EVDs. The impact on the reduction in EVD-associated adverse events deserves further examination.

Surgical Field Visualization during Functional Endoscopic Sinus Surgery: Comparison of Propofol- vs Desflurane-Based Anesthesia.

OBJECTIVE: To assess if the type of general anesthetic affects bleeding and field visualization during endoscopic sinus surgery. STUDY DESIGN: Prospective, randomized, controlled trial. SETTING: Academic teaching hospital and Veterans Affairs hospital in the United States. SUBJECTS AND METHODS: Seventy patients were randomized to 1 of 3 anesthetic regimens: (1) the volatile anesthetic desflurane (n = 22), (2) intravenous anesthesia with propofol (n = 25), or (3) a combination of propofol and desflurane (n = 23). Intravenous remifentanil was titrated to decrease the mean arterial pressure to 60 to 70 mm Hg but not ≥30% from baseline. Surgical bleeding scores were recorded along with bleeding rates and hemodynamic parameters, including cardiac output and systemic vascular resistance through pulse contour analysis from a radial arterial line. Statistics: multiple comparison tests and regression analyses; α = .05. RESULTS: There were no differences in bleeding rate (median, 0.58, 0.85, 0.57 mL min-1), bleeding score (2.1, 2.0, 2.0), surgery duration (79, 81, 86 minutes), extubation time (9, 7, 8 minutes), recovery room time (65, 61, 61 minutes), or any hemodynamic parameters among groups 1 through 3, respectively. Group 1 required lower remifentanil infusions than group 2 (0.11 vs 0.26 µg kg-1 min-1; P = .01). The bleeding score correlated positively with height (P = .014) and the Lund-MacKay score (P = .013). Bilateral vs unilateral surgery led to longer surgery duration (P = .001) and recovery room time (P = .004). CONCLUSION: When remifentanil is used for controlled hypotension, propofol has no advantage over desflurane to improve surgical field visualization during functional endoscopic sinus surgery.

Propofol Sedation Alters Perceptual and Cognitive Functions in Healthy Volunteers as Revealed by Functional Magnetic Resonance Imaging.

BACKGROUND: Elucidating networks underlying conscious perception is important to understanding the mechanisms of anesthesia and consciousness. Previous studies have observed changes associated with loss of consciousness primarily using resting paradigms. The authors focused on the effects of sedation on specific cognitive systems using task-based functional magnetic resonance imaging. The authors hypothesized deepening sedation would degrade semantic more than perceptual discrimination. METHODS: Discrimination of pure tones and familiar names were studied in 13 volunteers during wakefulness and propofol sedation targeted to light and deep sedation. Contrasts highlighted specific cognitive systems: auditory/motor (tones vs. fixation), phonology (unfamiliar names vs. tones), and semantics (familiar vs. unfamiliar names), and were performed across sedation conditions, followed by region of interest analysis on representative regions. RESULTS: During light sedation, the spatial extent of auditory/motor activation was similar, becoming restricted to the superior temporal gyrus during deep sedation. Region of interest analysis revealed significant activation in the superior temporal gyrus during light (t [17] = 9.71, P < 0.001) and deep sedation (t [19] = 3.73, P = 0.001). Spatial extent of the phonologic contrast decreased progressively with sedation, with significant activation in the inferior frontal gyrus maintained during light sedation (t [35] = 5.17, P < 0.001), which didn't meet criteria for significance in deep sedation (t [38] = 2.57, P = 0.014). The semantic contrast showed a similar pattern, with activation in the angular gyrus during light sedation (t [16] = 4.76, P = 0.002), which disappeared in deep sedation (t [18] = 0.35, P = 0.731). CONCLUSIONS: Results illustrate broad impairment in cognitive cortex during sedation, with activation in primary sensory cortex beyond loss of consciousness. These results agree with clinical experience: a dose-dependent reduction of higher cognitive functions during light sedation, despite partial preservation of sensory processes through deep sedation.

Regional entropy of functional imaging signals varies differently in sensory and cognitive systems during propofol-modulated loss and return of behavioral responsiveness.

The level and richness of consciousness depend on information integration in the brain. Altered interregional functional interactions may indicate disrupted information integration during anesthetic-induced unconsciousness. How anesthetics modulate the amount of information in various brain regions has received less attention. Here, we propose a novel approach to quantify regional information content in the brain by the entropy of the principal components of regional blood oxygen-dependent imaging signals during graded propofol sedation. Fifteen healthy individuals underwent resting-state scans in wakeful baseline, light sedation (conscious), deep sedation (unconscious), and recovery (conscious). Light sedation characterized by lethargic behavioral responses was associated with global reduction of entropy in the brain. Deep sedation with completely suppressed overt responsiveness was associated with further reductions of entropy in sensory (primary and higher sensory plus orbital prefrontal cortices) but not high-order cognitive (dorsal and medial prefrontal, cingulate, parietotemporal cortices and hippocampal areas) systems. Upon recovery of responsiveness, entropy was restored in the sensory but not in high-order cognitive systems. These findings provide novel evidence for a reduction of information content of the brain as a potential systems-level mechanism of reduced consciousness during propofol anesthesia. The differential changes of entropy in the sensory and high-order cognitive systems associated with losing and regaining overt responsiveness are consistent with the notion of "disconnected consciousness", in which a complete sensory-motor disconnection from the environment occurs with preserved internal mentation.

Total intravenous versus inhaled anesthesia in transsphenoidal tumor surgery.

PURPOSE: Visualization of the surgical field is essential for patient safety during endoscopic transsphenoidal tumor surgery. In this retrospective chart review and data analysis of patients undergoing endoscopic transsphenoidal resection of pituitary tumors under general anesthesia we sought to determine if total intravenous anesthesia with propofol and remifentanil leads to decreased bleeding, surgical duration, time to extubation and/or length of stay in the recovery room compared to inhaled anesthesia with sevoflurane or desflurane. METHODS: After IRB approval, chart reviews of 193 American Society of Anesthesiologists class 1 to 3 patients were conducted who had undergone transsphenoidal, endonasal resections of pituitary tumors under total intravenous or inhaled anesthesia at an academic teaching hospital in the United States over a seven-year time period. One hundred four patients fulfilled the inclusion criteria and were further reviewed. Primary outcome was intraoperative blood loss; secondary outcomes were surgical duration, time to extubation and length of stay in the recovery room. RESULTS: Gender, age, and Lund-Mackay-Scores were equally distributed between the two anesthetic groups. We found no significant effect of the anesthetic technique, age, gender, or Lund Mackay score on any of the primary or secondary outcomes. The only significant predictor for recovery room length of stay was intraoperative blood loss. CONCLUSION: Our study shows no evidence that total intravenous anesthesia is superior to inhaled anesthesia or vice versa during endoscopic transsphenoidal sinus surgery with regard to relevant clinical outcome parameters.

Persistent Hypotension and Cerebral Swelling Resulting From Mesenteric Traction Syndrome After Omental-to-Pial Pedicle Flap Transfer in a Young Woman With Refractory Moyamoya Disease: A Case Report.

Superficial temporal arterial to middle cerebral arterial anastomosis is often the initial surgical treatment of Moyamoya disease. In refractory cases, placing a pedicle flap of omentum over the ischemic brain has resulted in clinical improvement or stabilization of symptoms. We present a case of persistent mesenteric traction syndrome manifested by hypotension unresponsive to conventional doses of vasopressors during and after pulling the omentum to the brain. As prostacyclin is a major mediator of hypotension from mesenteric traction syndrome and also a cerebral vasodilator, we discuss the possibility that brain swelling may be a manifestation of mesenteric traction syndrome.

Fine-Grained Parcellation of Brain Connectivity Improves Differentiation of States of Consciousness During Graded Propofol Sedation.

Conscious perception relies on interactions between spatially and functionally distinct modules of the brain at various spatiotemporal scales. These interactions are altered by anesthesia, an intervention that leads to fading consciousness. Relatively little is known about brain functional connectivity and its anesthetic modulation at a fine spatial scale. Here, we used functional imaging to examine propofol-induced changes in functional connectivity in brain networks defined at a fine-grained parcellation based on a combination of anatomical and functional features. Fifteen healthy volunteers underwent resting-state functional imaging in wakeful baseline, mild sedation, deep sedation, and recovery of consciousness. Compared with wakeful baseline, propofol produced widespread, dose-dependent functional connectivity changes that scaled with the extent to which consciousness was altered. The dominant changes in connectivity were associated with the frontal lobes. By examining node pairs that demonstrated a trend of functional connectivity change between wakefulness and deep sedation, quadratic discriminant analysis differentiated the states of consciousness in individual participants more accurately at a fine-grained parcellation (e.g., 2000 nodes) than at a coarse-grained parcellation (e.g., 116 anatomical nodes). Our study suggests that defining brain networks at a high granularity may provide a superior imaging-based distinction of the graded effect of anesthesia on consciousness.

Propofol attenuates low-frequency fluctuations of resting-state fMRI BOLD signal in the anterior frontal cortex upon loss of consciousness.

Recent studies indicate that spontaneous low-frequency fluctuations (LFFs) of resting-state functional magnetic resonance imaging (rs-fMRI) blood oxygen level-dependent (BOLD) signals are driven by the slow (<0.1Hz) modulation of ongoing neuronal activity synchronized locally and across remote brain regions. How regional LFFs of the BOLD fMRI signal are altered during anesthetic-induced alteration of consciousness is not well understood. Using rs-fMRI in 15 healthy participants, we show that during administration of propofol to achieve loss of behavioral responsiveness indexing unconsciousness, the fractional amplitude of LFF (fALFF index) was reduced in comparison to wakeful baseline in the anterior frontal regions, temporal pole, hippocampus, parahippocampal gyrus, and amygdala. Such changes were absent in large areas of the motor, parietal, and sensory cortices. During light sedation characterized by the preservation of overt responsiveness and therefore consciousness, fALFF was reduced in the subcortical areas, temporal pole, medial orbital frontal cortex, cingulate cortex, and cerebellum. Between light sedation and deep sedation, fALFF was reduced primarily in the medial and dorsolateral frontal areas. The preferential reduction of LFFs in the anterior frontal regions is consistent with frontal to sensory-motor cortical disconnection and may contribute to the suppression of consciousness during general anesthesia.

Anesthetic Considerations of Sporadic Inclusion Body Myositis in an Elderly Man With Orthopedic Trauma.

INTRODUCTION: Sporadic inclusion body myositis (IBM) is an inflammatory myopathy characterized by progressive asymmetric extremity weakness, oropharyngeal dysphagia, and the potential for exaggerated sensitivity to neuromuscular blockers and respiratory compromise. The authors describe their management of a patient with IBM undergoing urgent orthopedic surgery. CASE PRESENTATION: An 81-year-old man with IBM suffered a left intertrochanteric femoral fracture after falling down stairs. His IBM caused progressive left proximal lower extremity, bilateral distal upper extremity weakness (left > right), and oropharyngeal dysphagia (solid food, pills). He denied dyspnea, exercise intolerance, and a history of aspiration. Because respiratory insufficiency resulting from diaphragmatic dysfunction and prolonged duration of action of neuromuscular blockers may occur in IBM, the authors avoided using a neuromuscular blocker. After applying cricoid pressure, anesthesia was induced using intravenous lidocaine, propofol, remifentanil followed by manual ventilation with inhaled sevoflurane in oxygen. Endotracheal intubation was accomplished without difficulty; anesthesia was then maintained using remifentanil and sevoflurane. The fracture was repaired with a trochanteric femoral nail. The patient was extubated without difficulty and made an uneventful recovery. CONCLUSIONS: In summary, there is a lack of consensus about the use of neuromuscular blockers in patients with IBM. The authors avoided these drugs and were able to easily secure the patient's airway and maintain adequate muscle relaxation using a balanced sevoflurane-remifentanil anesthetic. Clinical trials are necessary to define the pharmacology of neuromuscular blockers in patients with IBM and determine whether use of these drugs contributes to postoperative respiratory insufficiency in these vulnerable patients.

Quality of surgical field during endoscopic sinus surgery: a systematic literature review of the effect of total intravenous compared to inhalational anesthesia.

BACKGROUND: Adequate surgical field visualization is imperative for successful outcomes in endoscopic sinus surgery (ESS). The type of anesthetic administered can alter a patient's hemodynamics and impact endoscopic visualization during surgery. We review the current evidence regarding the effect of total intravenous anesthesia (TIVA) compared to inhalational anesthesia (INA) on visualization of the surgical field during ESS. METHODS: A systematic review of the literature was performed. Ovid MEDLINE, Scopus, and Cochrane databases were searched from 1946 to January 2012. Citations from the primary search were reviewed and filtered to identify all relevant abstracts in English. Articles meriting full review included prospective controlled trials enrolling adult patients undergoing ESS that were randomized to a group receiving INA or TIVA with outcome measures focused on surgical field visualization. RESULTS: Seven eligible trials fulfilled inclusion criteria. Four of the 7 demonstrated a statistically significant improvement in surgical field grade during ESS when receiving TIVA compared with INA. However, detailed INA concentrations were often not provided. High levels of INA may have been administered; therefore, side effects of INA rather than effects of an ideal INA administration were possibly represented. Analgesic administration also varied widely among the anesthetic groups, further complicating interpretation of study results. The lack of power and the heterogeneity of the studies precluded a formal meta-analysis. CONCLUSION: Although several studies reported that TIVA improves surgical conditions in ESS, there are significant limitations. These findings prevent any definite recommendation at this point, emphasizing the need for further high-quality studies.