Early quantitative CT perfusion parameters variation for prediction of delayed cerebral ischemia following aneurysmal subarachnoid hemorrhage.

OBJECTIVES: To prospectively evaluate the predictive value of cerebral perfusion-computerized tomography (CTP) parameters variation between day0 and day4 after aneurysmal subarachnoid haemorrhage (aSAH). METHODS: Mean transit time (MTT) and cerebral blood flow (CBF) values were compared between patients with delayed cerebral ischemia (DCI+ group) and patients without DCI (DCI- group) for previously published optimal cutoff values and for variations of MTT (ΔMTT) and of CBF (ΔCBF) values between day0 and day4. DCI+ was defined as a cerebral infarction on 3-months follow-up MRI. RESULTS: Among 47 included patients, 10 suffered DCI+. Published optimal cutoff values did not predict DCI, either at day0 or at day4. Conversely, ΔMTT and ΔCBF significantly differed between the DCI+ and DCI- groups, with optimal ΔMTT and ΔCBF values of 0.91 seconds (83.9 % sensitivity, 79.5 % specificity, AUC 0.84) and -7.6 mL/100 g/min (100 % sensitivity, 71.4 % specificity, AUC 0.86), respectively. In multivariate analysis, ΔCBF (OR = 1.91, IC95% 1.13-3.23 per each 20 % decrease of ΔCBF) and ΔMTT values (OR = 14.70, IC95% 4.85-44.52 per each 20 % increase of ΔMTT) were independent predictors of DCI. CONCLUSIONS: Assessment of MTT and CBF value variations between day0 and day4 may serve as an early imaging surrogate for prediction of DCI in aSAH. KEY POINTS: • CT perfusion values are an imaging surrogate for prediction of DCI. • Early variations (day0-day4) after aneurysmal subarachnoid haemorrhage predicted DCI. • A CBF decrease of 7.6 mL/min/100 g predicted DCI with 100 % sensitivity. • An MTT increase of 0.91 seconds predicted DCI with 83.9 % sensitivity. • DCI risk multiplied by 2 per 20 % ΔCBF decrease and by 15 per 20 % ΔMTT increase.

Comparison of the time to extubation after use of remifentanil or sufentanil in combination with propofol as anesthesia in adults undergoing nonemergency intracranial surgery: a prospective, randomized, double-blind trial.

BACKGROUND: Anesthetics with a short context-sensitive half-time (ie, the time required for the effect-site concentration of an IV drug to decrease by 50% at steady state), such as the opioids remifentanil and sufentanil, are suitable for anesthesia when early neurologic assessment is desired to detect postoperative complications. OBJECTIVE: This study compared the efficacy and safety profile of remifentanil and sufentanil in combination with propofol for anesthesia in adult patients undergoing nonemergency intracranial surgery. METHODS: This was a prospective, randomized, double-blind study in adults aged 18 to 75 years who were scheduled to undergo a supratentorial neurosurgical procedure with a maximum anticipated duration of 480 minutes. Eligible patients had no incapacitating severe systemic disease (American Society of Anesthesiologists physical status class 1-3), and only those in whom immediate postoperative extubation was planned were included. Anesthesia was induced with propofol and either remifentanil 1 microg/kg or sufentanil 0.25 microg/kg. Propofol was continued using a target-controlled infusion (TCI) system. Maintenance infusion rates for remifentanil and sufentanil were 0.25 and 0.0025 microg.kg-1.min-1, respectively. The opioid and propofol infusions were adjusted based on hemodynamic parameters (mean arterial blood pressure, heart rate). The primary end point was the time to extubation. Secondary end points were hemodynamic stability (defined as the number of anesthetic adjustments required to maintain intraoperative hemodynamic parameters within 20% of preinduction values), postoperative IV morphine requirement, postoperative nausea/vomiting (PONV), and intraoperative anesthetic costs. RESULTS: Sixty adults (29 remifentanil, 31 sufentanil) were included in the study. The 2 groups were similar with respect to sex, weight, indication for surgery, and duration of anesthesia. The sufentanil group was significantly older than the remifentanil group (55.3 vs 45.7 years, respectively; P=0.001). The median extubation time was similar in the remifentanil and sufentanil groups (10 minutes [interquartile range, 5-19 minutes] and 16 minutes [interquartile range, 10-30 minutes], respectively). Remifentanil was associated with the need for significantly fewer adjustments to maintain hemodynamic stability compared with sufentanil (0.8 vs 2.1; P=0.037), greater use of postoperative morphine (44.8% vs 22.6% of patients, P=0.01; mean IV morphine dose per patient: 4 vs 1.3 mg, P=0.016), and higher intraoperative opioid costs per patient euro vs euro P<0.001). The incidence of PONV did not differ significantly between groups. The total cost of intraoperative anesthetics per patient was similar in the 2 groups euro and euro as was the cost of propofol euro vs euro CONCLUSION: In these adults undergoing nonemergency intracranial surgery, there was no significant difference in extubation time between those receiving remifentanil and sufentanil infusions adjusted based on hemodynamic parameters in combination with propofol administered by TCI.

Family participation in care to the critically ill: opinions of families and staff.

BACKGROUND: Allowing family members to participate in the care of patients in intensive care units (ICUs) may improve the quality of their experience. No previous study has investigated opinions about family participation in ICUs. METHODS: Prospective multicenter survey in 78 ICUs (1,184 beds) in France involving 2,754 ICU caregivers and 544 family members of 357 consecutive patients. We determined opinions and experience about family participation in care; comprehension (of diagnosis, prognosis, and treatment) and satisfaction (Critical Care Family Needs Inventory) scores to assess the effectiveness of information to families and the Hospital Anxiety and Depression score for family members. RESULTS: Among caregivers 88.2% felt that participation in care should be offered to families. Only 33.4% of family members wanted to participate in care. Independent predictors of this desire fell into three groups: patient-related (SAPS II at ICU admission, OR 0.984); ICU stay length, OR 1.021), family-related (family member age, OR 0.97/year); family not of European descent, OR 0.294); previous ICU experience in the family, OR 1.59), and those related to emotional burden and effectiveness of information provided to family members (symptoms of depression in family members, OR 1.58); more time wanted for information, OR 1.06). CONCLUSIONS: Most ICU caregivers are willing to invite family members to participate in patient care, but most family members would decline.