Postoperative Cognitive Dysfunction and the Change of Regional Cerebral Oxygen Saturation in Elderly Patients Undergoing Spinal Surgery.

BACKGROUND: In this study, we examined the relationship between postoperative cognitive dysfunction (POCD) and intraoperative regional cerebral oxygen saturation (rSO2) in elderly patients undergoing spinal surgery. METHODS: We enrolled 87 patients older than 65 years. All patients were tested using a battery of cognitive function tests (Korean Mini-Mental State Examination and visuomotor test of Dynamic Lowenstein Occupational Therapy Cognitive Assessment-Geriatric Version) the day before their surgical operation and on the seventh postoperative day. Our threshold for defining POCD for a given patient was a Reliable Change Index score of <-1.96 occurring on 2 tests. RESULTS: POCD was detected in 20 patients (23%) at the seventh postoperative day. Between-patient baseline characteristics, surgical data, and baseline cognitive function were similar for both those who developed POCD and those who did not. A univariate analysis that included age, female sex, education level, presence of diabetes, and duration of intraoperative decline in rSO2 to a level of <60% of baseline revealed that only diabetes and duration of rSO2 <60% (odds ratio, 1.01; 95% confidence interval [CI], 1.005-1.010) were found to be risk factors for POCD. After multivariate logistic regression analysis of these 2 variables, only the duration of rSO2 <60% (odds ratio, 1.006; 95% CI, 1.00-1.01, P = 0.014) remained as an independent risk factor for POCD. The area under the receiver operation characteristic of the duration of rSO2 <60% was 0.70 (95% CI, 0.57-0.82; P = 0.008). The optimal cutoff value was 157 minutes with a sensitivity of 75% and specificity of 72%. CONCLUSIONS: This study showed that the duration of decline in rSO2 <60% during lumbar spinal surgery was correlated with the development of POCD at the seventh postoperative day in elderly patients.

Dexmedetomidine added to an opioid-based analgesic regimen for the prevention of postoperative nausea and vomiting in highly susceptible patients: A randomised controlled trial.

BACKGROUND: Dexmedetomidine, an α2 adrenergic receptor agonist, has analgesic, sedative and sympatholytic properties, with a lack of respiratory depression. It is licensed only for intensive care sedation. OBJECTIVE: The objective of this study is to investigate whether intravenous (i.v.) patient-controlled analgesia (PCA) with dexmedetomidine added to a fentanyl-based drug mixture could reduce postoperative nausea and vomiting (PONV) in highly susceptible patients undergoing lumbar spinal surgery. DESIGN: A randomised, double-blinded study. SETTING: At a tertiary university hospital between September 2012 and September 2013. PATIENTS: One hundred and eight patients undergoing level 1 or 2 posterior lumbar spinal fusion who had at least three risk factors for PONV (female, nonsmoker, use of postoperative opioids) were randomised into two groups. Three patients were excluded from analysis and 105 patients completed the study. METHODS: Patients received either dexmedetomidine 0.5 µg kg⁻¹ i.v. (dexmedetomidine group) or 0.9% normal saline (control group) 30 min before the completion of surgery followed by fentanyl 0.5 µg kg⁻¹ and 4 mg ondansetron. Postoperatively, the PCA (fentanyl 10 µg kg⁻¹ with 120 mg ketorolac, with or without dexmedetomidine 10 µg kg⁻¹ made up to a total volume of 100 ml) was programmed to deliver 1 ml bolus (lockout 15 min) with a continuous background infusion of 2 ml h⁻¹. The PCA was used for the first 48 h postoperatively. MAIN OUTCOME MEASURES: The incidence and severity of PONV, cumulative dose of PCA fentanyl consumed and pain scores were assessed for 48 h. RESULTS: The dexmedetomidine group experienced less nausea during the time interval 1 to 3 h postoperatively compared with the control group [odds ratio (OR) 0.32; 95% confidence interval (CI) 0.13 to 0.77; P = 0.019]. The intensity of nausea between the groups during the first 48 h was comparable, but the dexmedetomidine group had a lower incidence of moderate to severe nausea (OR 0.28; 95% CI 0.12 to 0.67; P < 0.003). Pain scores were not significantly different between the groups, but patients in the dexmedetomidine group required less fentanyl and less rescue analgesia in the first 12 h. Compared with the control group, patients in the dexmedetomidine group experienced almost twice as many episodes of hypotension and bradycardia, but this failed to reach statistical significance. CONCLUSION: Adding dexmedetomidine to a fentanyl-based PCA drug mixture reduces the frequency and severity of acute postoperative nausea in highly susceptible patients. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT01840254.

Association of carotid arterial circumferential strain with left ventricular function and hemodynamic compromise during off-pump coronary artery bypass surgery.

BACKGROUND: Considering the importance of ventricular-vascular coupling, a measure of arterial stiffness may reflect global myocardial performance. We evaluated the predictive value of common carotid arterial circumferential strain (CCA CirS), measured with ultrasound speckle tracking, for hemodynamic deterioration during off-pump coronary artery bypass (OPCAB) and assessed its association with echocardiographic indices of myocardial function. METHODS AND RESULTS: Patients with left ventricular ejection fraction (LVEF) ≥50% were enrolled. Intraoperative hemodynamic variables were compared in relation to CCA CirS tertiles. A total of 96 patients were analyzed. Mixed venous oxygen saturation (SvO2) during left circumflex artery grafting and sternum closure were lower in the first tertile than in the third tertile. On univariate logistic regression female gender, ratio of early transmitral velocity to annular velocity, pulse pressure, and CCA CirS were predictors of hemodynamic deterioration (defined as decrease in SvO2≥20%), while only CCA CirS remained as an independent predictor after multivariate analysis (OR, 0.27; 95% CI: 0.11-0.68). Area under the curve of CCA CirS for its prediction was 0.730 (95% CI: 0.608-0.852). CCA CirS was strongly associated with tissue Doppler-derived parameters of LV function. CONCLUSIONS: CCA CirS is a comprehensive marker reflecting LV function, and a predictor for hemodynamic deterioration during OPCAB in patients with preserved LVEF.

Impact of preoperative fibrinogen concentration on postoperative outcome in patients who received dual antiplatelet therapy in proximity to off-pump coronary bypass surgery.

BACKGROUND: Preoperative fibrinogen concentration is associated with increased blood loss at the lower end, and with hypercoagulability-related ischemic event at the higher end in cardiac patients. We evaluated the influence of preoperative fibrinogen concentration on blood loss and outcome in patients who received clopidogrel in proximity to off-pump coronary artery bypass surgery (OPCAB). METHODS AND RESULTS: Medical records of 538 patients who received clopidogrel within 5 days of OPCAB (April 2007 to March 2012) were retrospectively reviewed. Perioperative bleeding and composite of morbidity endpoints including myocardial infarction were compared in relation to the tertile distribution of the fibrinogen concentration. The amount of blood loss was significantly larger in the first tertile, whereas the incidence of composite of morbidity endpoints was significantly higher in the third tertile. In multivariate analysis for risk factors of perioperative blood loss, body mass index and duration of surgery were identified as independent risk factors but not the fibrinogen level. And hypertension and preoperative fibrinogen level were identified as independent risk factors about composite of morbidity. The third tertile was associated with a 2-fold increased risk of developing composite of morbidity endpoints. CONCLUSIONS: In patients who received dual antiplatelet therapy in proximity to OPCAB, increased preoperative fibrinogen concentration could serve as a valuable predictor for composite of morbidity endpoints, whereas low fibrinogen concentration was not found to be a risk factor of bleeding.

Exploring Chinese and Korean American Teachers' Perceptions of Their Cultural Identity as Assets and Barriers.

The representation of Asian American teachers in schools is a unique asset in promoting diversity and advocating for social justice. However, they also face various barriers that negatively affect their work experiences. The diverse nature of the Asian American population is likely to yield different assets and barriers among teachers from different ethnic groups. To gain insight into how Chinese and Korean American teachers perceive their cultural identity in their teaching practices, we utilized a qualitative approach by conducting semi-structured interviews with nine teachers who identified as Chinese and/or Korean American in K-12 public schools in California. Findings based on thematic analyses of the interview data revealed several assets, including empathy and understanding towards minority groups, more exposure to diversity, increased representation, and shared language skills. However, there were also identified barriers, including internalized model minority beliefs, cultural expectations of being passive observers, internalized racism, an overemphasis on education, and a savior complex. Based on our findings, we provide practical suggestions for recruiting and retaining Chinese and Korean American teachers in schools.

Training to Work with Interpreters in US School Psychology Graduate Programs.

Despite rapidly increasing cultural and linguistic diversity in US schools, the majority of psychoeducational evaluations will be conducted by monolingual, English-speaking school psychologists. As such, the appropriate use of interpreters has been identified as a critical skill in working with emergent bilinguals and their families. Surveys of practicing school psychologists conducting assessments with emergent bilinguals indicate a lack of knowledge and training in the use of interpreters; however, few studies have examined the extent to which school psychology graduate students are trained in the appropriate use of interpreters. Utilizing survey methodology, this study examined school psychology graduate students' training in and preparedness to work with interpreters, as well as their knowledge of best practices in the use of interpreters. Current graduate students and interns enrolled in school psychology master's, specialist, and doctoral programs in 36 states throughout the USA (n = 364) responded to the survey. The majority of participants were White (61.5%), monolingual (70.3%), and seeking a master's or specialist degree (71.2%). Survey responses suggest that graduate students and interns' training, knowledge, and preparedness to work with interpreters is lacking. A qualitative analysis of the open-ended question revealed that first-hand experience working with interpreters was among the most beneficial types of training experiences for graduate students and interns. Implications for how program directors and graduate-level faculty can provide better training for their students in the use of interpreters are discussed.