Identifying behaviors that characterize emergence delirium: An observational study.

BACKGROUND: Diagnostic criteria for emergence agitation are sensitive but not specific; they misclassify patients who are angry or upset as having emergence delirium. AIMS: The aim of this three-phase study was to determine expert agreement on the behaviors that differentiate children with emergence delirium from those without. METHODS: In the first phase of this observational study, pediatric dental patients were video recorded while awakening from anesthesia. In the second phase, salient 10 s segments of the recordings showing patient activity were shown to an expert audience of pediatric dentists, anesthesiologists and Post Anesthetic Care nurses, who scored the recordings as showing or not showing "true emergence delirium." In phase 3, the video segments were assessed by three research assistants using a behavior checklist for features that discriminate between those scored "true emergence delirium" and those scored "NOT true emergence delirium" by the experts. RESULTS: One hundred and fifty-four pediatric dental patients were included. Subsequently, an expert audience consisting of 10 anesthesiologists, 12 anesthesiology residents, 3 pediatric dentists, and 4 experienced Post Anesthesia Care Unit nurses rated each 10-second video segment. This resulted in three groups of patients: a group for whom all experts agreed was "True emergence delirium" (n = 33; CI 21 to 45), a group for whom all agreed was "Not True emergence delirium" (n = 120; CI 107 to 133), and a group where experts disagreed (n = 11; CI 4 to 18). Three research assistants then completed a behavior checklist for each of the 33 "True emergence delirium" video segments and matched "Not True" controls. Twenty-four behaviors were identified as significantly different between videos scored True emergence delirium and those scored Not True emergence delirium. Research assistants reached almost perfect agreement (0.81-1.00) on one behavior, and substantial agreement (0.61-0.80) on seven behaviors that characterized "True emergence delirium." CONCLUSIONS: Eight behaviors that differentiate pediatric dental patients with emergence delirium from those without were found. These discriminators may be used to develop a scale that will lead to better diagnosis and treatment of emergence delirium.

Resting mechanomyography before and after resistance exercise.

A number of mechanisms have been proposed to explain the elevation in oxygen consumption following exercise. Biochemical processes that return muscle to its pre-exercise state do not account for all of the extra oxygen consumed after exercise (excess post-exercise oxygen consumption, EPOC). Muscle at rest after aerobic exercise produces mechanomyographic (MMG) activity of increased amplitude, compared to the pre-exercise state, which declines exponentially with the same time constant as EPOC. The purpose of this study was to determine how the resting MMG is affected by resistance exercise, and whether any change is related to oxygen consumption (VO(2)). Ten young male subjects (22.9 years) performed 30 min of resistance exercise consisting of one set of 10 repetitions at 50% 1-repetition maximum (1-RM) followed by five sets of eight repetitions at 75% of 1-RM for leg press and leg (knee) extension, with 1 min rest between sets. Oxygen consumption was measured by indirect calorimetry, MMG by an accelerometer placed over the rectus femoris, and surface electromyogram (EMG) with electrodes placed distal to the accelerometer. Recordings were made before exercise and for 5.5 h after exercise. MMG activity, expressed as mean absolute acceleration, was significantly elevated after exercise (P = 0.0006), as was EMG activity expressed as root-mean-square voltage (P = 0.03). MMG and VO(2) demonstrated exponential decay after exercise with similar time constants of 7.5 +/- 2.2 and 7.2 +/- 1.0 min, respectively. We conclude that resting muscle is more mechanically active following resistance exercise and that this may contribute to an elevated VO(2).

Peripheral venous pressure predicts central venous pressure poorly in pediatric patients.

PURPOSE: Using peripheral venous pressure (PVP) instead of central venous pressure (CVP) as a volume monitor decreases patient risks and costs, and is convenient. This study was undertaken to determine if PVP predicts CVP in pediatric patients. METHODS: With ethical approval and informed consent, 30 pediatric patients aged neonate to 12 yr requiring a central venous line were studied prospectively in a tertiary care teaching hospital. In the supine position, PVP and CVP were simultaneously transduced. Ninety-six paired recordings of CVP and PVP were made. Correlation and Bland-Altman analysis of agreement of end-expiratory measurements were performed. RESULTS: The mean (SD; range) CVP was 10.0 mmHg (6.0; -1.0 to 27.0); the mean PVP was 13.7 mmHg (6.3; 0.0 to 33.0); offset (bias) of PVP > CVP was 3.7 mmHg with SD 2.6. The 95% confidence intervals (CI) for the bias were 3.2 to 4.1 mmHg. In the Bland-Altman analysis, lower and upper limits of agreement (LOA; CI in parentheses) were -1.5 (-2.3 to -0.7) and 8.8 (8.1 to 9.6) mmHg. Eight of 96 points were outside the limits of agreement. The correlation of PVP on CVP was r = 0.92, P < 0.0001. For a subset of ten patients (20 simultaneous recordings) with iv catheters proximal to the hand, limits of agreement were better - offset: 3.8 mmHg (+/- 1.4); lower LOA: 1.2 mmHg (0.25 to 2.1); upper LOA: 6.6 mmHg (5.7 to 7.5). CONCLUSION: Peripheral venous pressure measured from an iv catheter in the hand predicts CVP poorly in pediatric patients.

Effects of graded levels of exercise on ipsilateral and contralateral post-exercise resting rectus femoris mechanomyography.

Mechanomyography has shown that "resting" muscle is mechanically active, with greater activity after vigorous exercise. This experiment studied the post-exercise resting mechanomyography activity that results from different levels of exercise; the effects of exercise levels on the contralateral non-exercised limb; and the effects of resting muscle length on post-exercise resting mechanomyographic activity. Ten healthy volunteers had mechanomyography recordings over both mid-rectus femoris, at rest, before and after sets (1, 5, 10, 20, and 30 repetitions) of right leg extensions on an isokinetic dynamometer at 60 s(-1). Sets were performed a week apart, after only sedentary activity during the previous two hours. No definite threshold effect was shown. There was a linear correlation between mechanomyography and work done (R = 0.61, P < 0.01). There was a positive correlation of change of activity between the two thighs (R = 0.62, P < 0.01), with the non-exercised thigh demonstrating about half the activity of the exercised thigh. Finally, we observed that mechanomyographic activity was greater when rectus femoris muscle length was shorter (i.e. when the leg was extended versus flexed). We conclude that resting mechanomyography increases with increasing work and that there is a cross-over for increase in mechanomyography in the non-exercised leg, suggesting a neural mechanism. The greater mechanomyographic activity at shorter muscle lengths suggests that muscle that is less stretched could more freely oscillate, producing higher MMG amplitudes. Altered activity of the muscle spindle gamma loop or Golgi tendon apparatus may also play a role in altered activity with different muscle length.

Reactive hyperemia increases forearm vein area.

PURPOSE: To determine the effect of reactive hyperemia on human forearm vein area. METHODS: After obtaining ethics approval and informed consent, an automatic tourniquet was applied to the forearms of 20 healthy subjects for one, two, and three minutes, at pressures of 25 mmHg, 200 mmHg, then 25 mmHg. A blinded radiographer measured the cross-sectional area of the cephalic vein at the wrist using ultrasonography. Measurements were recorded prior to tourniquet application and every minute thereafter for ten minutes, at each pressure setting and each time interval. RESULTS: The mean vein cross-sectional area (mm2) increased from 8.22 +/- 3.09 to 10.77 +/- 3.50 after one minute of ischemia, from 8.31 +/- 2.78 to 10.61 +/- 2.77 after two minutes of ischemia, and from 8.39 +/- 3.34 to 10.94 +/- 3.46 after three minutes of ischemia (P < 0.05 for all). A tourniquet inflated to 25 mmHg for 13 min produced a mean vein cross-sectional area of 10.71 +/- 3.25 mm2. CONCLUSIONS: Reactive hyperemia causes human forearm vein cross-sectional area to increase. A low pressure tourniquet will also increase forearm vein area, but veins dilate more quickly during reactive hyperemia. This may have important clinical implications for attempting venous cannulation in patients with difficult venous access.

Resting mechanomyography after aerobic exercise.

A number of mechanisms have been proposed for the elevation in oxygen consumption following exercise. Biochemical processes that return muscle to its preexercise state do not account for all the oxygen consumed after exercise. It is possible that mechanical activity in resting muscle, which produces low frequency vibrations (i.e., muscle sounds: mechano-myographic [MMG] activity), could contribute to the excess postexercise oxygen consumption. Therefore the purpose of this study was to determine whether the resting MMG amplitude changes after exercise, and whether the change is related to the elevation in oxygen consumption (VO2). Ten young male subjects (22.9 yrs) performed 30 minutes of exercise on a cycle ergometer at an intensity corresponding to 70% peak VO2. Oxygen consumption was measured by indirect calorimetry, and MMG by an accelerometer placed over the mid-quadriceps before exercise and for 5.5 hours after exercise. MMG activity, expressed as mean absolute acceleration, was significantly elevated for the 5.5 hours of measurement after exercise (p < 0.05). MMG and VO2 decayed exponentially after exercise with time constants of 7.2 minutes and 7.4 minutes, respectively. We conclude that muscle is mechanically active following exercise and that this may contribute to an elevated VO2.