Adenosine-induced cardiac arrest in complex cerebral aneurysms surgery: an Italian single-center experience.

AIM: Even if endovascular techniques are improving, treatment of complex intracranial aneurysms still remains a neurosurgeon challenge. Adenosine administration, producing a brief and profound systemic hypotension, seems to improve surgical aneurysm visualization facilitating its exclusion with less risks of rupture. In our retrospective study we confirmed that adenosine advantages could be determinant for an optimal surgical result. METHODS: We retrospectively reviewed all unruptured complex cerebral aneurysms surgically treated in our institution between August 2009 and April 2012. Treatment of those aneurysms was surgical, with proximal temporary artery occlusion or adenosine induced flow arrest. We compared the two different techniques, evaluating intra- and postoperative data; a three-month follow-up including a neurological assessment, cerebral angiography and echocardiography for the adenosine group was performed. RESULTS: Twenty-four patients were collected in our study. Eleven patients underwent traditional temporary proximal clipping while in 13 patients intraoperative adenosine was used. Most common location was paraclinoid region. We did not observe any complication in the adenosine group. Adenosine was well tolerated, spontaneous recovery of sinusal cardiac rhythm was observed even at high and subsequent doses. The Intensive Care Unit and Hospital length of stay were shorter in adenosine group. A three-month follow-up did not show cardiac abnormalities with good angiographic aneurysms exclusion. CONCLUSION: We observed that adenosine administration allowed an easier clipping thanks to a reduced wall tension in a clearer surgical field without cardiological adverse events. In our opinion adenosine induced arrest technique could be an efficacious, harmless and reliable alternative strategy for surgical treatment of complex cerebral aneurysms.

Understanding international differences in terminology for delirium and other types of acute brain dysfunction in critically ill patients.

BACKGROUND: Delirium (acute brain dysfunction) is a potentially life threatening disturbance in brain function that frequently occurs in critically ill patients. While this area of brain dysfunction in critical care is rapidly advancing, striking limitations in use of terminology related to delirium internationally are hindering cross-talk and collaborative research. In the English literature, synonyms of delirium such as the Intensive Care Unit syndrome, acute brain dysfunction, acute brain failure, psychosis, confusion, and encephalopathy are widely used. This often leads to scientific "confusion" regarding published data and methodology within studies, which is further exacerbated by organizational, cultural and language barriers. OBJECTIVE: We undertook this multinational effort to identify conflicts in terminology and phenomenology of delirium to facilitate communication across medical disciplines and languages. METHODS: The evaluation of the terminology used for acute brain dysfunction was determined conducting communications with 24 authors from academic communities throughout countries/regions that speak the 13 variants of the Romanic languages included into this manuscript. RESULTS: In the 13 languages utilizing Romanic characters, included in this report, we identified the following terms used to define major types of acute brain dysfunction: coma, delirium, delirio, delirium tremens, délire, confusion mentale, delir, delier, Durchgangs-Syndrom, acute verwardheid, intensiv-psykose, IVA-psykos, IVA-syndrom, akutt konfusion/forvirring. Interestingly two terms are very consistent: 100 % of the selected languages use the term coma or koma to describe patients unresponsive to verbal and/or physical stimuli, and 100% use delirium tremens to define delirium due to alcohol withdrawal. Conversely, only 54% use the term delirium to indicate the disorder as defined by the DSM-IV as an acute change in mental status, inattention, disorganized thinking and altered level of consciousness. CONCLUSIONS: Attempts towards standardization in terminology, or at least awareness of differences across languages and specialties, will help cross-talk among clinicians and researchers.

Sleep disturbances in the critically ill patients: role of delirium and sedative agents.

BACKGROUND: Impairment of sleep quality and quantity has been described in critically ill patients. Delirium, an organ dysfunction that affects outcome of the critically ill patients, is characterized by an acute onset of impaired cognitive function, visual hallucinations, delusions, and illusions. These symptoms resemble the hypnagogic hallucinations and wakeful dreams seen in patients with neurological degenerative disorders and suffering of disorders of rapid eye movement (REM) sleep. We assessed the characteristics of sleep disruption in a cohort of surgical critically ill patients examining the hypothesis that severe impairments of rapid eyes movement (REM) sleep are associated to delirium. METHODS: Surgical patients admitted to the intensive care units of the San G. Battista Hospital (University of Turin) were enrolled. Once weaning was initiated, sleep was recorded for one night utilizing standard polysomnography. Clinical status, laboratory data on admission, co-morbidities and duration of mechanical ventilation were recorded. Patients were a priori classified as having a "severe REM reduction" or "REM reduction" if REM was higher or lower than 6% of the total sleep time (TST), respectively. Occurrence of delirium during intensive care unit (ICU) stay was identified by CAM-ICU twice a day. Multivariate forward stepwise logistic regression analysis was performed with sleep ("severe REM reduction" vs. "REM reduction") as the a priori dependent factor. RESULTS: REM sleep amounted to 44 (16-72) minutes [11 (8-55) % of the TST] in 14 patients ("REM reduction") and to 2.5 (0-36) minutes [1 (0-6) % of the TST] in the remaining 15 patients ("severe REM reduction") (P = 0.0004). SAPS II on admission was higher in " severely REM deprived" then in "REM deprived" patients. Delirium was present in 11 patients (73.3%) of the patients with "severe REM reduction" and lasted for a median of 3 (0-11) days before sleep assessment, while only one patient having "REM reduction" developed delirium that lasted for 1 day. The factors independently associated with a higher risk of developing "severe REM reduction" were delirium and daily dosage of lorazepam. CONCLUSION: The present study shows that while all critically ill patients present a profound fragmentation of sleep with a high frequency of arousals and awakenings and a reduction of REM sleep, a percentage of patients present an extremely severe reduction of REM sleep. Delirium and daily dosage of lorazepam are the factors independently associated to extremely severe REM sleep reduction.