Early Cardiac Evaluation, Abnormal Test Results, and Associations with Outcomes in Patients with Acute Brain Injury Admitted to a Neurocritical Care Unit.

Background: to examine factors associated with cardiac evaluation and associations between cardiac test abnormalities and clinical outcomes in patients with acute brain injury (ABI) due to acute ischemic stroke (AIS), spontaneous subarachnoid hemorrhage (SAH), spontaneous intracerebral hemorrhage (sICH), and traumatic brain injury (TBI) requiring neurocritical care. Methods: In a cohort of patients ≥18 years, we examined the utilization of electrocardiography (ECG), beta-natriuretic peptide (BNP), cardiac troponin (cTnI), and transthoracic echocardiography (TTE). We investigated the association between cTnI, BNP, sex-adjusted prolonged QTc interval, low ejection fraction (EF < 40%), all-cause mortality, death by neurologic criteria (DNC), transition to comfort measures only (CMO), and hospital discharge to home using univariable and multivariable analysis (adjusted for age, sex, race/ethnicity, insurance carrier, pre-admission cardiac disorder, ABI type, admission Glasgow Coma Scale Score, mechanical ventilation, and intracranial pressure [ICP] monitoring). Results: The final sample comprised 11,822 patients: AIS (46.7%), sICH (18.5%), SAH (14.8%), and TBI (20.0%). A total of 63% (n = 7472) received cardiac workup, which increased over nine years (p < 0.001). A cardiac investigation was associated with increased age, male sex (aOR 1.16 [1.07, 1.27]), non-white ethnicity (aOR), non-commercial insurance (aOR 1.21 [1.09, 1.33]), pre-admission cardiac disorder (aOR 1.21 [1.09, 1.34]), mechanical ventilation (aOR1.78 [1.57, 2.02]) and ICP monitoring (aOR1.68 [1.49, 1.89]). Compared to AIS, sICH (aOR 0.25 [0.22, 0.29]), SAH (aOR 0.36 [0.30, 0.43]), and TBI (aOR 0.19 [0.17, 0.24]) patients were less likely to receive cardiac investigation. Patients with troponin 25th-50th quartile (aOR 1.65 [1.10-2.47]), troponin 50th-75th quartile (aOR 1.79 [1.22-2.63]), troponin >75th quartile (aOR 2.18 [1.49-3.17]), BNP 50th-75th quartile (aOR 2.86 [1.28-6.40]), BNP >75th quartile (aOR 4.54 [2.09-9.85]), prolonged QTc (aOR 3.41 [2.28; 5.30]), and EF < 40% (aOR 2.47 [1.07; 5.14]) were more likely to be DNC. Patients with troponin 50th-75th quartile (aOR 1.77 [1.14-2.73]), troponin >75th quartile (aOR 1.81 [1.18-2.78]), and prolonged QTc (aOR 1.71 [1.39; 2.12]) were more likely to be associated with a transition to CMO. Patients with prolonged QTc (aOR 0.66 [0.58; 0.76]) were less likely to be discharged home. Conclusions: This large, single-center study demonstrates low rates of cardiac evaluations in TBI, SAH, and sICH compared to AIS. However, there are strong associations between electrocardiography, biomarkers of cardiac injury and heart failure, and echocardiography findings on clinical outcomes in patients with ABI. Findings need validation in a multicenter cohort.

Characteristics of lower airway parameters in an adult Asian population related to endotracheal tube design: a cadaveric study.

The risk of endotracheal tube (ETT) placement includes endobronchial intubation and subglottic injury. This study aimed to describe the lengths of lower airway parameters related to cuff location and vocal cord markings in different adult-sized ETTs. Eighty cadavers were examined for the lengths of the lower airway, including their correlations and linear regressions with height. Thirty adult-sized ETTs from seven different brands were examined for Mark-Cuff and Mark-Tip distances. The depth of ETT placement was simulated for each brand using vocal cord marking. The mean (standard deviation) lengths from the subglottis, trachea, vocal cord to mid- trachea, and vocal cord to carina were 24.2 (3.5), 97.9 (8.6), 73.2 (5.3), and 122.1 (9.0) mm, respectively. Airway lengths were estimated as: (1) subglottis (mm) = 0.173 * (height in cm) - 3.547; (2) vocal cord to mid-trachea (mm) = 0.28 * (height in cm) + 28.391. There were variations in the Mark-Cuff and Mark-Tip distances among different ETTs. In the simulation, endobronchial intubation ranged between 2.5 and 5% and the cuff in the subglottis ranged between 2.5 and 97.5%. In summary, the lower airway parameters were height-related. ETT placement using vocal cord marking puts the patient at a high risk of cuff placement in the subglottis.

First anesthesia exposure effects on short-term neurocognitive function among 1- to 36-month-old children: a case-control pilot study.

Background: Multiple human studies have shown no significant long-term results of anesthesia exposure during early childhood compared to the general population; however, reports on short-term neurodevelopmental assessment before and after anesthesia exposure are limited. This study aimed to evaluate the short-term characteristics of neurocognitive function post-anesthesia in noncardiac surgery compared with baseline. Methods: This prospective case-control pilot study recruited healthy participants in the control group and hospitalized children in the anesthesia group. Children aged 1-36 months without previous anesthesia were included. Neurocognitive function was assessed at baseline and seven days after anesthesia administration using a cognitive scale of the Bayley Scales of Infant and Toddler Development, third edition. The control group received only a baseline assessment. The cognitive composite score had a mean of 100 and a standard deviation (SD) of 15, with a difference of score >1/3 SD (5 points) defined as clinically significant. Results: Twenty and 39 participants in the control and anesthesia groups, respectively, were included in the final analysis. The baseline cognitive scale score of the anesthesia group was statistically and clinically lower than that of the control group. The mean (SD) cognitive composite scores in the control and anesthesia group were 111.50 (11.71) and 97.13 (9.88), P<0.001. The mean difference [95% confidence interval (CI)] was -14.37 (-8.28 to -20.47). In the anesthesia group, the post-anesthesia cognitive composite score was statistically higher than that at baseline, but without clinical significance. The mean (SD) of baseline and post-anesthesia cognitive composite scores were 97.05 (9.85) and 101.28 (10.87), P=0.039, respectively. The mean difference (95% CI) was 4.23 (0.23-8.23). However, 7 (17.9%) participants had decreased cognitive composite scores after anesthesia exposure. Conclusions: Children in the anesthesia group had lower baseline cognitive composite scores than those in the control group. The post-anesthesia cognitive score did not decrease compared with the baseline assessment. Anesthetic exposure resulted in a decline in the cognitive composite score in 17.9% of the participants.

Incidences and outcomes of intra-operative vs. postoperative paediatric cardiac arrest: A retrospective cohort study of 42 776 anaesthetics in children who underwent noncardiac surgery in a Thai tertiary care hospital.

BACKGROUND: The reported incidence of paediatric perioperative cardiac arrest (PPOCA) in most developing countries ranges from 2.7 to 22.9 per 10 000 anaesthetics, resulting in mortality rates of 2.0 to 10.7 per 10 000 anaesthetics. The definitions of 'peri-operative' cardiac arrest often include the intra-operative period and extends from 60 min to 48 h after anaesthesia completion. However, the characteristics of cardiac arrests, care settings, and resuscitation quality may differ between intra-operative and early postoperative cardiac arrests. OBJECTIVE: To compare the mortality rates between intraoperative and early postoperative cardiac arrests (<24 h) following anaesthesia for paediatric noncardiac surgery. DESIGN: A retrospective cohort study. SETTING: In a tertiary care centre in Thailand during 2014 to 2019, the peri-operative period was defined as from the beginning of anaesthesia care until 24 h after anaesthesia completion. PATIENTS: Paediatric patients aged 0 to 17 years who underwent anaesthesia for noncardiac surgery. MAIN OUTCOME MEASURES: Mortality rates. RESULTS: A total of 42 776 anaesthetics were identified, with 63 PPOCAs and 23 deaths (36.5%). The incidence (95% confidence interval) of PPOCAs and mortality were 14.7 (11.5 to 18.8) and 5.4 (3.6 to 8.1) per 10 000 anaesthetics, respectively. Among 63 PPOCAs, 41 (65%) and 22 (35%) occurred during the intra-operative and postoperative periods, respectively. The median [min to max] time of postoperative cardiac arrest was 3.84 [0.05 to 19.47] h after anaesthesia completion. Mortalities (mortality rate) of postoperative cardiac arrest were significantly higher than that of intra-operative cardiac arrest at 14 (63.6%) vs. 9 (22.0%, P = 0.001). Multivariate analysis of risk factors for mortality included emergency status and duration of cardiopulmonary resuscitation with adjusted odds ratio 5.388 (95% confidence interval (1.031 to 28.160) and 1.067 (1.016 to 1.120). CONCLUSIONS: Postoperative cardiac arrest resulted in a higher mortality rate than intra-operative cardiac arrest. A high level of care should be provided for at least 24 h after the completion of anaesthesia. TRIAL REGISTRATION: None. CLINICAL TRIAL NUMBER AND REGISTRY URL: NA.

The actual duration of preoperative fasting in pediatric patients, and its effects on hunger and thirst: a prospective observational study.

Background: Preoperative fasting time for food and clear liquid was recommended as 2 and 6 h to prevent pulmonary aspiration. Prolonged fasting led to ketosis, hypotension, and patient discomfort. This study aimed to investigate the actual duration of preoperative fasting in pediatric patients, its effects on hunger and thirst, and factors that influence hunger and thirst. Methods: This prospective observational study recruited participants aged 0-15 years who were scheduled for elective surgery or for other procedures to be performed under general anesthesia in a tertiary care center. All parents or participants were asked to report the fasting time for food and clear liquid. Participants aged 7-15 years self-rated their degree of hunger and thirst using a 0-10 scale. For participants aged less than 7 years, parents were asked to rate their child's degree of hunger based on the child's behavior. Dextrose-containing intravenous fluid administration and anesthesia start time were collected. Results: Three hundred and nine participants were included. The overall median [interquartile range; IQR] fasting duration for food and clear liquid was 11.1 h [IQR: 8.0, 14.0] and 10.0 h [IQR: 7.2, 12.5], respectively. The overall median hunger and thirst score was 7 [IQR: 5, 9] and 5 [IQR: 0, 7.5], respectively. High hunger score was reported in 76.4% of participants. There was no correlation between fasting time for food and hunger score [Spearman's rank correlation coefficient (Rho): -0.150, P=0.008], or between fasting time for clear liquid and thirst score (Rho: 0.007, P=0.955). Zero to 2-year-old participants had a significantly higher hunger score compared to older participants (P<0.001) and a higher proportion (80-90%) of high hunger score regardless of anesthesia start time. Although dextrose-containing fluid was administered ≥10 mL/kg, 85.7% of this group still reported high hunger score (P=0.008). Ninety percent of participants who had anesthesia start time after 12:00 PM reported high hunger score (P=0.044). Conclusions: The actual duration of preoperative fasting was found to be longer than the recommendation for both food and liquid in pediatric surgical population. Younger age group and anesthesia start time in the afternoon were factors associated with high hunger score.

Incidence of Myocardial Injury and Cardiac Dysfunction After Adult Traumatic Brain Injury: A Systematic Review and Meta-analysis.

Myocardial injury and cardiac dysfunction after traumatic brain injury (TBI) have been reported in observational studies, but there is no robust estimate of their incidences. We conducted a systematic review and meta-analysis to estimate the pooled incidence of myocardial injury and cardiac dysfunction among adult patients with TBI. A literature search was conducted using MEDLINE and EMBASE databases from inception to November 2022. Observational studies were included if they reported at least one abnormal electrocardiographic finding, elevated cardiac troponin level, or echocardiographic evaluation of systolic function or left ventricular wall motion in adult patients with TBI. Myocardial injury was defined as elevated cardiac troponin level according to the original studies and cardiac dysfunction was defined as the presence of left ventricular ejection fraction <50% or regional wall motion abnormalities assessed by echocardiography. The meta-analysis of the pooled incidence of myocardial injury and cardiac dysfunction was performed using random-effect models. The pooled estimated incidence of myocardial injury after TBI (17 studies, 3,773 participants) was 33% (95% CI: 27%-39%, I2:s 93%), and the pooled estimated incidence of cardiac dysfunction after TBI (9 studies, 557 participants) was 16.% (95% CI: 9%-25.%, I2: 84%). Although there was significant heterogeneity between studies and potential overestimation of the incidence of myocardial injury and cardiac dysfunction, our findings suggest that myocardial injury occurs in approximately one-third of adults after TBI, and cardiac dysfunction occurs in approximately one-sixth of patients with TBI.

Apneic oxygenation with low-flow oxygen cannula for rapid sequence induction and intubation in pediatric patients: a randomized-controlled trial.

Background: Classical rapid sequence induction and intubation (RSII) is used to reduce pulmonary aspiration, but it increases the risk of hypoxemia. Apneic oxygenation (ApOx) has been studied to prolong safe apneic time, and to decrease the incidence of hypoxemia in adults. The aim of this study was to investigate the effectiveness of ApOx via low-flow nasal cannula to reduce the incidence of hypoxemia in pediatric rapid sequence induction. Methods: This prospective single-blind randomized controlled trial included patients aged 0-7 years, American Society of Anesthesiologists (ASA) physical status 1 to 3, who underwent elective or emergency surgery under general anesthesia with rapid sequence induction during February 2020 to March 2021. Participants were randomized to the ApOx group or the classical rapid sequence induction group. The ApOx group received oxygen flow via regular nasal cannula, as follows: 1 liter per minute (LPM) in age 0-1 month, 2 LPM in age 1-12 months, and 4 LPM in age 1-7 years. The classical group did not receive oxygen supplementation during intubation. The primary outcome was the incidence of hypoxemia, defined as oxygen saturation (SpO2) ≤92%. Results: Sixty-four participants were recruited. The incidence of hypoxemia in both groups was 8 of 32 participants (25%) (P=1.000). Among desaturated patients, the median time to desaturation was 29.5 and 35 seconds in the ApOx and classical groups, respectively (P=0.527). The median lowest SpO2 was 91% and 88.5% in the ApOx and classical groups, respectively (P=0.079). In non-desaturated patients, the median time to successful intubation was 40.5 and 35.5 seconds in the ApOx and classical groups, respectively (P=0.069). Conclusions: In this small sample study, ApOx using age-adjusted low-flow nasal cannula was ineffective for reducing the incidence of hypoxemia in pediatric RSII. Trial Registration: Thai Clinical Trials Registry TCTR20210802002.

Feasibility and indicator outcomes using computerized clinical decision support in pediatric traumatic brain injury anesthesia care.

BACKGROUND: Traumatic brain injury anesthesia care is complex. The use of clinical decision support to improve pediatric trauma care has not been examined. AIMS: The aim of this study was to examine feasibility, reliability, and key performance indicators for traumatic brain injury anesthesia care using clinical decision support. METHODS: Clinical decision support was activated for patients under 19 years undergoing craniotomy for suspected traumatic brain injury. Anesthesia providers were prompted to adhere to process measures via on-screen alerts and notified in real time of abnormal monitor data or laboratory results (unwanted key performance indicator events). Process measures pertained to arterial line placement and blood gas draws, neuromuscular blockade, hypotension, anemia, coagulopathy, hyperglycemia, and intracranial hypertension. Unwanted key performance indicators were: hypotension, hypoxia, hypocarbia, hypercarbia, hypothermia, hyperthermia, anesthetic agent overdose; hypoxemia, coagulopathy, anemia, and hyperglycemia. Anesthesia records, vital signs, and alert logs were reviewed for 39 anesthetic cases (19 without clinical decision support and 20 with clinical decision support). RESULTS: Data from 35 patients aged 11 months to 17 years and 77% males were examined. Clinical decision support reliably identified 39/46 eligible anesthetic cases, with 85% sensitivity and 100% specificity, and was highly sensitive, detecting 89% of monitor key performance indicator events and 100% of reported lab key performance indicator events. There were no false positive alerts. Median event duration was lower in the "with clinical decision support" group for 4/7 key performance indicators. Second insult duration was lower for duration of hypocarbia (by 44%), hypotension (29%), hypothermia (12%), and hyperthermia (15%). CONCLUSION: Use of clinical decision support in pediatric traumatic brain injury anesthesia care is feasible, reliable, and may have the potential to improve key performance indicator outcomes. This observational study suggests the possibility of clinical decision support as a strategy to reduce second insults and improve traumatic brain injury guideline adherence during pediatric anesthesia care.

Effects of pregabalin on postoperative pain after hysterectomy under spinal anesthesia with intrathecal morphine: a randomized controlled trial.

PURPOSE: To determine if preoperative pregabalin could decrease 24-h postoperative morphine consumption after spinal anesthesia with intrathecal morphine compared with placebo. METHODS: A randomized, double-blind, controlled trial was performed in the tertiary care center. Patients aged between 18 and 65 years who were American Society of Anesthesiologists class I-II and scheduled for abdominal hysterectomy with or without salpingo-oophorectomy were randomly allocated to a placebo or a pregabalin group. Patients received pregabalin 150 mg or placebo 1 h prior to anesthesia. Spinal anesthesia was achieved with 0.5% hyperbaric bupivacaine with morphine 0.2 mg. Intravenous patient-controlled analgesia morphine was provided postoperatively. Postoperative morphine consumption at 6, 12, and 24 h, time to first analgesic rescue, pain scores, adverse effects, and patient satisfaction were evaluated at 24 h after the operation. RESULTS: One hundred twenty-five patients were recruited and 119 patients (placebo N = 58, pregabalin N = 61) were included in the analysis. Forty-seven (81.0%) patients in the placebo group and 53 (86.9%) patients in the pregabalin group required morphine in the first 24 h. Median [IQR] 24-h morphine consumption was 4.0 [1.8, 10.0] mg in the placebo group and 5.0 [2.0, 11.0] mg in the prebagalin group, p = 0.60. There were no differences in cumulative morphine consumption at 6, 12, and 24 h postoperatively. The two groups also did not differ in time to first analgesic rescue, pain scores at rest and on movement, and side effects. CONCLUSION: A single preoperative dose of pregabalin 150 mg did not reduce 24-h postoperative morphine consumption or pain scores or prolong the time to first analgesic rescue in spinal anesthesia with intrathecal morphine.

Targeted areas for improving health literacy after traumatic brain injury.

OBJECTIVE: To develop a framework to identify targeted areas for improving health literacy for caregivers after traumatic brain injury (TBI). METHOD: Qualitative study using inductive and deductive qualitative content analysis was conducted in a large, urban, level I trauma centre. Interviews were conducted with 23 caregivers of persons with TBI. Participants' perspectives on communication and preparation for discharge were explored and understanding of commonly used words and discharge instructions were assessed. RESULTS: Four types of communication patterns were identified: formal, informal, indirect and caregiver-initiated. Informal and caregiver-initiated communication were the most common. All caregivers reported confusion about their family member's condition, care plan or discharge plan. Caregivers were not able to define commonly used terms in discharge instructions, and were confused by formatting and medical language. Caregivers were not aware of expected caregiving roles upon discharge. Conceptualizing findings within a family-centred care model, we offer specific strategies to improve health communication and caregiver capacity building to enhance health literacy. CONCLUSIONS: Health literacy and caregiver capacity to care for loved ones with TBI after hospital discharge is low. We offer specific target areas for improvement in verbal and written communication and capacity building that take into account provider, patient and family characteristics.

Early Systolic Dysfunction Following Traumatic Brain Injury: A Cohort Study.

OBJECTIVE: Prior studies have suggested that traumatic brain injury may affect cardiac function. Our study aims were to determine the frequency, longitudinal course, and admission risk factors for systolic dysfunction in patients with moderate-severe traumatic brain injury. DESIGN: Prospective cohort study. SETTING: Level 1 trauma center. MEASUREMENTS: Transthoracic echocardiogram within 1 day and over the first week after moderate-severe traumatic brain injury; transthoracic echocardiogram within 1 day after mild traumatic brain injury (comparison group). MEASUREMENTS AND MAIN RESULTS: Systolic function was assessed by transthoracic echocardiogram, and systolic dysfunction was defined as fractional shortening less than 25%. Multivariable Poisson regression models examined admission risk factors for systolic dysfunction. Systolic function in 32 patients with isolated moderate-severe traumatic brain injury and 32 patients with isolated mild traumatic brain injury (comparison group) was assessed with transthoracic echocardiogram. Seven (22%) moderate-severe traumatic brain injury and 0 (0%) mild traumatic brain injury patients had systolic dysfunction within the first day after injury (p < 0.01). All patients with early systolic dysfunction recovered in 1 week. Younger age (relative risk, 0.87; 95% CI, 0.79-0.94; for 1 yr increase in age) and lower admission Glasgow Coma Scale score (relative risk, 0.34; 95% CI, 0.20-0.58; for one unit increase in Glasgow Coma Scale) were independently associated with the development of systolic dysfunction among moderate-severe traumatic brain injury patients. CONCLUSIONS: Early systolic dysfunction can occur in previously healthy patients with moderate-severe traumatic brain injury, and it is reversible over the first week of hospitalization. Younger age and lower admission Glasgow Coma Scale score are independently associated with the development of systolic dysfunction after moderate-severe traumatic brain injury.

Development and Feasibility of a Real-Time Clinical Decision Support System for Traumatic Brain Injury Anesthesia Care.

BACKGROUND: Real-time clinical decision support (CDS) integrated with anesthesia information management systems (AIMS) can generate point of care reminders to improve quality of care. OBJECTIVE: To develop, implement and evaluate a real-time clinical decision support system for anesthetic management of pediatric traumatic brain injury (TBI) patients undergoing urgent neurosurgery. METHODS: We iteratively developed a CDS system for pediatric TBI patients undergoing urgent neurosurgery. The system automatically detects eligible cases and evidence-based key performance indicators (KPIs). Unwanted clinical events trigger and display real-time messages on the AIMS computer screen. Main outcomes were feasibility of detecting eligible cases and KPIs, and user acceptance. RESULTS: The CDS system was triggered in 22 out of 28 (79%) patients. The sensitivity of detecting continuously sampled KPIs reached 93.8%. For intermittently sampled KPIs, sensitivity and specificity reached 90.9% and 100%, respectively. 88% of providers reported that CDS helped with TBI anesthesia care. CONCLUSIONS: CDS implementation is feasible and acceptable with a high rate of case capture and appropriate generation of alert and guidance messages for TBI anesthesia care.

Hypertension After Severe Traumatic Brain Injury: Friend or Foe?

Traumatic brain injury (TBI) is a major public health problem, with severe TBI contributing to a large number of deaths and disability worldwide. Early hypotension has been linked with poor outcomes following severe TBI, and guidelines suggest early and aggressive management of hypotension after TBI. Despite these recommendations, no guidelines exist for the management of hypertension after severe TBI, although observational data suggests that early hypertension is also associated with an increased risk of mortality after severe TBI. The purpose of this review is to discuss the underlying pathophysiology of hypertension after TBI, provide an overview of the current clinical data on early hypertension after TBI, and discuss future research that should test the benefits and harms of treating high blood pressure in TBI patients.

Prevalence and Characteristics of Abnormal Pre-Operative Chest X-Rays in Patients Undergoing Elective Surgery.

OBJECTIVE: To determine the prevalence of pre-operative abnormal chest x-rays (CX Rs) in patients undergoing elective surgery, and to describe the management of the patients with abnormal CXRs. In addition, we question whether the healthy patients aged more than 45 years really needs pre-operative chest radiographs. MATERIAL AND METHOD: Patients undergoing elective surgery between June 2013 and May 2014 were recruited, and medical records were retrospectively reviewed. RESULTS: Data for 960 patients was included CX Rs were abnormal in 485 patients (50.5%), with cardiomegaly being the most common abnormality. Among patients who had pre-operative abnormal CXRs, 91 patients (18.8%) required consultation or other investigation pre-operatively, and three patients (0.6%) had their treatment plans altered. Comparing between age groups, there was no different of abnormal results (p-value = 0.606). CONCLUSION: Prevalence of pre-operative abnormal CXRs was high; however, the abnormalities seldom led to changes in case management.