Severe Shivering on Venoarterial Extracorporeal Membrane Oxygenation-Raising the Circuit Temperature to Stop Rhabdomyolysis: A Case Report.

We report a case of severe shivering resulting in rhabdomyolysis while on venoarterial extracorporeal membrane oxygenation (ECMO) that resolved after hyperthermia was induced using the ECMO circuit. The patient developed shivering approximately 24 hours after venoarterial ECMO cannulation for refractory ventricular tachycardia. The shivering caused rhabdomyolysis and necessitated cisatracurium infusion. The shivering failed to resolve after the patient was diagnosed and treated for ventilator-associated pneumonia. Suspecting sepsis as the etiology of shivering, the ECMO circuit temperature was increased to 38 °C, and the shivering was resolved. This case demonstrates therapeutic hyperthermia to treat infection-induced severe shivering and rhabdomyolysis while on ECMO.

The Clinical Significance of Patient Specimen Transport Modality: Pneumatic Tube System Impact on Blood Gas Analytes.

INTRODUCTION: A pneumatic tube system (PTS) is a cost-effective, rapid transport modality that utilizes induced pressure changes. We evaluated the clinical importance of 2 transport modalities, human courier and PTS, for blood gas specimens. METHODS: Following open heart surgery, 35 simultaneous pairs of arterial and venous blood gas specimens were analyzed from 20 subjects. Of each pair, one specimen was transported to the blood gas laboratory via a human courier and the other via a SwissLog PTS. Transport modalities were compared using the Bland-Altman limits of agreement method. RESULTS: Compared with the walked specimen, the bias for PaO2 was -8.0 mm Hg (95% CI, -40.0 to 24.5 mm Hg); PaCO2 , -0.94 mm Hg (95% CI, -3.76 to 1.86 mm Hg); PvO2 , -0.60 mm Hg (95% CI, -6.90 to 5.70 mm Hg); PvCO2 , -0.58 mm Hg (95% CI, -3.12 to 1.92 mm Hg) for the PTS specimen. CONCLUSION: The difference in the PO2 and PCO2 of paired (walked vs tubed) arterial and venous blood gas specimens demonstrated a slight bias. PaO2 values demonstrated the greatest bias, however not clinically important. Thus, PTS transport does not impact clinical interpretations of blood gas values.

A comparison of hemoglobin measured by co-oximetry and central laboratory during major spine fusion surgery.

BACKGROUND: Many factors affect the accuracy of hemoglobin concentration values. In this study, we evaluated whether the hemoglobin concentration obtained by means of arterial blood gas (ABG) co-oximetry and complete blood count (CBC) central laboratory techniques clinically correlate when using simultaneous measurements of hemoglobin concentration obtained during complex spine fusion surgery. METHODS: Three hundred forty-eight patients who underwent spinal fusion of >3 bony levels between September 2006 and September 2010, with concurrent ABG and CBC samples, were identified. The mean difference between pairs of measured hemoglobin values was determined using limits of agreement analysis. Error grid analysis was used to delineate correlation of samples in relation to hemoglobin values within the range considered for transfusion. RESULTS: The median difference (ABG-CBC) between the measured hemoglobin values was 0.4 g/dL (95% confidence interval [CI], 0.35-0.40 g/dL; P < 0.0001). Limits of agreement analysis correcting for repeated observations in multiple patients demonstrated that the mean difference between measured hemoglobin values (i.e., bias) was 0.4 g/dL (95% CI, 0.36-0.41 g/dL), and the 95% limits of agreement of the difference between paired measurements were -0.70 to 1.47 g/dL. The magnitude of the difference between the measured hemoglobin values was >0.5 g/dL in 44.5% of patients (95% CI, 42.2%-46.8%); however, 6.8% (95% CI, 5.8%-8.1%) of paired measurements had a difference of >1.0 g/dL. There was only fair-to-moderate agreement between the CBC and ABG values within the clinically significant range of hemoglobin values of 7 to 10 g/dL (Cohen κ = 0.39; 95% CI, 0.33-0.45). CONCLUSIONS: The hemoglobin values obtained from ABG and CBC cannot be used interchangeably when verifying accuracy of novel point-of-care hemoglobin measurement modalities or when managing a patient with critical blood loss.

United States practice patterns in the use of transesophageal echocardiography during adult liver transplantation.

OBJECTIVE: To characterize contemporary practice patterns in the use of transesophageal echocardiography during adult liver transplantation and to identify factors preventing more frequent use. DESIGN: Online questionnaire. SETTING: Liver transplantation centers in the United States performing 12 or more adult liver transplants in 2011. PARTICIPANTS: One representative from each qualifying center: The transplant anesthesiology director, a transplant anesthesiologist personally known to the authors, or the department of anesthesiology chair. INTERVENTIONS: Three e-mail attempts were made to solicit participation in the study between June and August 2012. MEASUREMENTS AND MAIN RESULTS: Of the 97 institutions identified, an anesthesiologist from each of 79 (81.4%) centers completed the questionnaire; 38.0% of centers reported routine use and 57.0% for special circumstances or rescue situations, yielding an overall use rate of 94.9%. This distribution was consistent regardless of operative volume, practice size, or academic affiliation. The sole factor predictive of routine transesophageal echocardiography use was an overlap between an institution's cardiac and transplant anesthesiology teams. In practices not routinely employing the technology, the most compelling reason was a sense that it was not necessary. Although 69.9% of transplant anesthesiologists reportedly were proficient in echocardiography, inadequate anesthesiologist training was also a strongly cited hindrance. CONCLUSIONS: Transesophageal echocardiography during adult liver transplantation in the United States has become widely prevalent, with notable growth in its use as a routine diagnostic and monitoring modality. Almost all institutions now use the technology at least occasionally, with the participation of cardiac anesthesiologists being predictive of a center's routine use.

Intracerebral hemorrhage and delirium symptoms. Length of stay, function, and quality of life in a 114-patient cohort.

RATIONALE: The prognostic significance of delirium symptoms in intensive care unit (ICU) patients with focal neurologic injury is unclear. OBJECTIVES: To determine the relationship between delirium symptoms and subsequent functional outcomes and quality of life (QOL) after intracerebral hemorrhage. METHODS: We prospectively enrolled 114 patients. Delirium symptoms were routinely assessed twice daily using the Confusion Assessment Method for the ICU by trained nurses. Functional outcomes were recorded with modified Rankin Scale (scored from 0 [no symptoms] to 6 [dead]), and QOL outcomes with Neuro-QOL at 28 days, 3 months, and 12 months. MEASUREMENTS AND MAIN RESULTS: Thirty-one (27%) patients had delirium symptoms ("ever delirious"), 67 (59%) were never delirious, and the remainder (14%) had persistent coma. Delirium symptoms were nearly always hypoactive, were detected mean 6 days after intracerebral hemorrhage presentation, and were associated with longer ICU length of stay (mean 3.5 d longer in ever vs. never delirious patients; 95% confidence interval, 1.5-8.3; P = 0.004) after correction for age, admit National Institutes of Health (NIH) Stroke Scale, and any benzodiazepine exposure. Delirium symptoms were associated with increased odds of poor outcome at 28 days (odds ratio, 8.7; 95% confidence interval, 1.4-52.5; P = 0.018) after correction for admission NIH Stroke Scale and age, and with worse QOL in the domains of applied cognition-executive function and fatigue after correcting for the NIH Stroke Scale, age, benzodiazepine exposure, and time of follow-up. CONCLUSIONS: After focal neurologic injury, delirium symptoms were common despite low rates of infection and sedation exposure, and were predictive of subsequent worse functional outcomes and lower QOL.

Moderate Hypoglycemia is associated with vasospasm, cerebral infarction, and 3-month disability after subarachnoid hemorrhage.

BACKGROUND: Many ICUs have implemented protocols for tight glucose control, but there are few data on hypoglycemia and neurologic outcomes in patients with subarachnoid hemorrhage (SAH). METHODS: We prospectively ascertained 172 patients with SAH, who were treated according to a standard protocol for target glucose 80-110 mg/dl. Outcomes were assessed with the modified Rankin scale (mRS) at 14 days, 28 days, and 3 months. RESULTS: Worse neurologic injury at admission (P < 0.001) and a history of diabetes (P = 0.002) were associated with increased glucose variance. There was lower nadir glucose in patients with radiographic cerebral infarction (81 +/- 15 vs. 87 +/- 16 mg/dl, P = 0.02), symptomatic vasospasm (78 +/- 12 vs. 84 +/- 16 mg/dl, P = 0.04) and angiographic vasospasm (79 +/- 14 vs. 86 +/- 16 mg/dl, P = 0.01), but maximum and mean glucose values were not different. Glucose < 80 mg/dl was earlier and more frequent in patients with worse functional outcome at 3 months (P < 0.001). Progressive reductions in nadir glucose were associated with increasing functional disability at 3 months (P = 0.001) after accounting for neurologic grade and mean glucose. Severe hypoglycemia (<40 mg/dl) occurred in one patient. CONCLUSIONS: In patients with SAH, nadir glucose < 80 mg/dl is associated with cerebral infarction, vasospasm, and worse functional outcomes in multivariate models. Protocols for target glucose 80-110 mg/dl effectively control hyperglycemia, but may place patients with SAH at risk for vasospasm, cerebral infarction, and poor outcome even when severe hypoglycemia does not occur.

Cardiac troponin I and acute lung injury after subarachnoid hemorrhage.

INTRODUCTION: There are few predictors of acute lung injury (ALI) or the acute respiratory distress syndrome (ARDS) after subarachnoid hemorrhage (SAH). We hypothesized that cardiac troponin I, which is associated with cardiovascular morbidity, would also predict ALI. METHODS: We prospectively enrolled 171 consecutive patients with SAH. Troponin was routinely measured on admission and the next day and subsequently if abnormal. We prospectively recorded the maximum troponin, in-hospital events, and clinical endpoints. ALI and ARDS were defined by standard criteria. RESULTS: Acute lung injury was found in 10 patients (6%), ARDS in an additional 14 (8%), and pulmonary edema without lung injury in 9 (5%). Maximum troponin was different in patients without lung injury or pulmonary edema (0.03 [0.02-0.12] mcg/l), ALI (0.17 [0.04-1.4]), or ARDS (0.31 [0.9-1.8], P < 0.001). In ROC analysis, a cutoff of 0.04 mcg/l had 91% sensitivity and 42% specificity for ALI or ARDS (AUC = 0.75, P < 0.001). Troponin was associated with ALI or ARDS after accounting for neurologic grade in multivariate models without further contribution from pneumonia, packed red cell transfusion, gender, tobacco use, coronary artery disease, vasospasm, depressed ejection fraction on echocardiography, or CT grade. Lung injury was associated with worse functional outcome at 14 days, but not at 28 days or 3 months. CONCLUSION: Troponin I is associated with the development of ALI after SAH.

Monitoring with the Somanetics INVOS 5100C after aneurysmal subarachnoid hemorrhage.

INTRODUCTION: Vasospasm is a major cause of morbidity after subarachnoid hemorrhage (SAH), and current screening techniques (angiography, transcranial Doppler [TCD], and clinical examination) have serious limitations. Brain oximetry is a promising noninvasive tool to detect reduced brain oxygenation from vasospasm. METHODS: Consecutive SAH patients at high risk for vasospasm were monitored with the INVOS (Somanetics, IL, USA) 5100C cerebral oximeter. We prospectively collected oximeter readings (rO2) with concurrent values for vital signs, intracerebral pressure (ICP), arterial blood gas measurement, and hemoglobin (HGB). Data were prospectively collected every 12 h and at clinical events (angiography, transfusion, etc.). We prospectively recorded clinical history, clinical events, radiology results, and outcomes. RESULTS: Six patients were measured 123 times. rO2 values were correlated with the contralateral side, HGB, blood pressure, and PaO2, but not with ICP or perfusion pressure. There were no measured effects of angiography or transfusion. Patterns relating rO2 readings to clinical, angiographic, or TCD evidence of vasospasm were unclear, and there were no associations with the outcome (cerebral infarction, NIH Stroke Scale, or modified Rankin Scale). CONCLUSION: INVOS rO2 readings are associated with other factors that relate to cerebral oxygen delivery but seem to be of limited use as a screening tool for vasospasm or cerebral infarction after SAH.

Higher hemoglobin is associated with less cerebral infarction, poor outcome, and death after subarachnoid hemorrhage.

OBJECTIVE: Higher-goal hemoglobin (hgb) and more packed red blood cell transfusions lead to worse outcomes in general critical care patients. There are few data on hgb, transfusion, and outcomes after aneurysmal subarachnoid hemorrhage (SAH). METHODS: We reviewed the daily hgb levels of 103 patients with aneurysmal SAH. Cerebral infarction was diagnosed by computed tomographic scan. We corrected for Hunt and Hess grade, age, and angiographic vasospasm in multivariate models. RESULTS: Of 103 patients, the mean age was 55.3 +/- 14.5 years, 63% were women, and 29% were Hunt and Hess Grades 4 and 5; hgb values steadily declined from 12.6 +/- 1.7 g/dl the day of SAH to 10.4 +/- 1.2 g/dl by Day 14. Patients who died had lower hgb than survivors on Days 0, 1, 2, 4, 6, 10, 11, and 12 (P < or = 0.05). Higher mean hgb was associated with reduced odds of poor outcome (odds ratio, 0.57 per g/dl; 95% confidence interval [CI], 0.38-0.87; P = 0.008) after correcting for Hunt and Hess grade, age, and vasospasm; results for hgb on Days 0 and 1 were similar. Higher Day 0 (odds ratio, 0.7 per g/dl; 95% CI, 0.5-0.99; P = 0.05) and mean hgb (odds ratio, 0.57 per g/dl; 95% CI, 0.38-0.87; P = 0.009) predicted a lower risk of cerebral infarction independent of vasospasm. There were no associations between hgb and other prognostic variables. CONCLUSION: We found that SAH patients with higher initial and mean hgb values had improved outcomes. Higher hgb in SAH patients may be beneficial. The efficacy and safety of blood transfusions to increase hgb in patients with SAH may warrant further study.