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PubMed1990

A retrospective study of compliance with recommended hematologic monitoring of carbamazepine.

Early case reports of fatal hematologic effects associated with carbamazepine (CBZ) resulted in manufacturer recommendations for extensive laboratory monitoring. Several alternative monitoring protocols have been published, indicating disagreement with those recommendations. The manufacturer has removed specific monitoring guidelines allowing physicians to monitor CBZ during treatment based on their clinical judgment. This study was designed to determine the frequency of CBZ hematologic monitoring in one academic setting. Data on complete blood counts (CBCs) were retrospectively obtained and were compared with 1975-88 Physicians' Desk Reference recommendations for weekly CBCs during the first three months of treatment. Eighty-three patients were identified: 32 psychiatry, 37 neurology, and 14 from other clinics. Only one patient met guidelines for monitoring during the entire first three months of treatment. Comparisons between clinics demonstrated no statistically significant differences in monitoring rates. Prospective studies in academic and private practice settings are needed to provide more information on actual monitoring practices. Due to the removal of specific manufacturer recommendations, a standard approach is needed to establish consistent and adequate monitoring and to provide legal support to prescribers.

Adult↗
PubMed1997

Value of molecular monitoring during the treatment of chronic myeloid leukemia: a Cancer and Leukemia Group B study.

PURPOSE: Disappearance of the Philadelphia chromosome during treatment for chronic myeloid leukemia (CML) has become an important therapeutic end point. To determine the additional value of molecular monitoring during treatment for CML, we performed a prospective, sequential analysis using quantitative Southern blot monitoring of BCR gene rearrangements of blood and marrow samples from Cancer and Leukemia Group B (CALGB) study 8761. PATIENTS AND METHODS: Sixty-four previously untreated adults with chronic-phase CML who were enrolled onto CALGB 8761, a molecular-monitoring companion study to a treatment study for adults with chronic-phase CML (CALGB 9013). Treatment consisted of repetitive cycles of interferon alfa and low-dose subcutaneous cytarabine. Blood and marrow Southern blot quantitation of BCR gene rearrangements was compared with marrow cytogenetic analysis before the initiation of treatment and of specified points during therapy. Reverse-transcriptase polymerase chain reaction (RT-PCR) analysis was performed to detect residual disease in patients who achieved a complete response by Southern blot or cytogenetic analysis. RESULTS: Quantitative molecular monitoring by Southern blot analysis of blood samples was found to be equivalent to marrow monitoring at all time points. Twelve of 62 (19%) follow-up samples studied by Southern blot analysis had a complete loss of BCR gene rearrangement in matched marrow and blood specimens. Southern blot monitoring of blood samples was also found to be highly correlated to marrow cytogenetic evaluation at all points, although there were four discordant cases in which Southern blot analysis of blood showed no BCR gene rearrangement, yet demonstrated from 12% to 20% Philadelphia chromosome-positive metaphase cells in the marrow. RT-PCR analysis detected residual disease in five of six patients in whom no malignant cells were detected using Southern blot or cytogenetic analyses. CONCLUSION: Quantitative Southern blot analysis of blood samples may be substituted for bone marrow to monitor the response to therapy in CML and results in the need for fewer bone marrow examinations. To avoid overestimating the degree of response, marrow cytogenetic analysis should be performed when patients achieve a complete response by Southern blot monitoring. This approach provides a rational, cost-effective strategy to monitor the effect of treatment of individual patients, as well as to analyze large clinical trials in CML.

Adult↗
PubMed2007

Construction of the electroencephalogram player: a device to present electroencephalogram data to electroencephalogram-based anesthesia monitors.

BACKGROUND: Recently, an increasing number of electroencephalogram (EEG)-based monitors of the hypnotic component of anesthesia has become available. Most of these monitors calculate a numerical index reflecting the hypnotic component of anesthesia. Most of the underlying algorithms are proprietary. Therefore, a quality check or comparison of different indices is very complex. METHODS: Because there is limited information about the algorithms used for index calculation of the different monitors, a reliable comparison or test of the monitors is possible only if the same set of EEG data are presented to each monitor. RESULTS: Parallel EEG monitoring during surgery is limited to two or three monitors because the space for electrode placement on the head is limited. This problem can be solved by using the EEG player to play back recorded EEG data to different monitors. CONCLUSIONS: The output of the player corresponds to the original EEG signal. A comparison of different indices based on identical EEGs is therefore possible. The index reproducibility can also be checked, if the same signal is presented to different monitors.

Anesthesia↗
PubMed2003

Lessons from the polybrominated diphenyl ethers (PBDEs): precautionary principle, primary prevention, and the value of community-based body-burden monitoring using breast milk.

Levels of chemicals in humans (body burdens) are useful indicators of environmental quality and of community health. Chemical body burdens are easily monitored using breast milk samples collected from first-time mothers (primiparae) with infants 2-8 weeks of age. Currently, there is no body-burden monitoring program using breast milk in the United States, although ad hoc systems operate successfully in several European countries. In this article we describe the value of such monitoring and important considerations of how it might be accomplished, drawing from our experiences with pilot monitoring projects. Breast milk has several advantages as a sampling matrix: It is simple and noninvasive, with samples collected by the mother. It monitors body burdens in reproductive-age women and it estimates in utero and nursing-infant exposures, all important to community health. Time-trend data from breast milk monitoring serve as a warning system that identifies chemicals whose body burdens and human exposures are increasing. Time trends also serve as a report card on how well past regulatory actions have reduced environmental chemical exposures. Body-burden monitoring using breast milk should include educational programs that encourage breast-feeding. Finally, and most important, clean breast milk matters to people and leads to primary prevention--the limiting of chemical exposures. We illustrate these advantages with polybrominated diphenyl ethers (PBDEs), a formerly obscure group of brominated flame retardants that rose to prominence and were regulated in Sweden when residue levels were found to be rapidly increasing in breast milk. A community-based body-burden monitoring program using breast milk could be set up in the United States in collaboration with the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). WIC has a large number of lactating first-time mothers: It has 6,000 clinics nationwide and serves almost half (47%) the infants born in the United States. Educational programs (e.g., those run by WIC) are needed that encourage breast-feeding, especially in lower-income communities where breast-feeding rates are low and where breast-feeding may help protect the infant from the effects of environmental chemical exposures. Education is also needed about reducing chemical body burdens. A body-burden monitoring program would provide valuable data on time trends, background levels, and community hot spots in need of mitigation and follow-up health studies; develop analytic methods for new chemicals of concern; and archive breast milk samples for future analyses of other agents.

Aid to Families with Dependent Children↗
PubMed2002

Self-monitoring of glucose levels for people with type 2 diabetes.

To determine the most effective way of monitoring glucose levels as an indicator of glycaemic control in people with type 2 diabetes in the community, we conducted a criteria-based review of randomized controlled trials and systematic reviews of randomized controlled trials that studied the efficacy of various glucose monitoring strategies. We searched the Cochrane Library, Medline, Embase, CINAHL and BNIPlus databases for relevant studies. The journals 'Diabetes', 'Diabetic Medicine', 'Diabetologica', 'Evidence-Based Medicine' and 'Evidence-Based Nursing' were hand searched. The outcome of interest was glycaemic control, as measured by glycated haemoglobin (HbA(1c)). A total of 642 titles were identified from the search; three studies answered the question criteria and only one study met all the quality criteria. The study that met the criteria was a systematic review of four trials measuring the efficacy of self-monitoring of glucose levels. The reduction in HbA(1c) in those who monitored glucose levels was estimated to be -0.25% (95% Cl -0.61 - +0.10). This result shows a small improvement, but it is not statistically significant. A meta-analysis was also performed on three studies (n=278) comparing HbA(1c) in subjects who performed blood glucose monitoring with those who performed urine monitoring. The reduction in HbA(1c) when monitoring blood glucose rather than urine glucose was -0.03% (95% Cl -0.52 - +0.47). This result is not statistically significant. The efficacy of blood and urine glucose monitoring testing, for people with type 2 diabetes, in improving glycaemic control as measured by HbA(1c) levels is still questionable. A rigorous randomized controlled trial is needed to establish these answers although there is no evidence of harm. Clinical protocols that make recommendations for glucose monitoring strategies for people with type 2 diabetes should acknowledge that the evidence is weak. There is no basis to recommend one method above another.

Blood Glucose Self-Monitoring↗
PubMed1999

Home blood glucose monitoring.

OBJECTIVE: To provide a review of self-monitoring blood glucose including home blood glucose meters and patient education. DATA SOURCES: A MEDLINE search (January 1966-January 1998) was conducted to identify original and review articles. Search terms included self-monitoring blood glucose and blood glucose monitoring. Owner's manuals and package inserts were reviewed to determine specific characteristics for each glucose meter. DATA EXTRACTION: All current original and review articles about self-monitoring blood glucose and home blood glucose meters were included if they contained information about benefits of self-monitoring blood glucose, technology and performance of blood glucose meters, quality control, selection characteristics of blood glucose meters, and patient education. DATA SYNTHESIS: Self-monitoring of blood glucose has become an increasingly vital component of the care of the diabetic patient. Many glucose monitors are available with various features that may be confusing to pharmacists. Pharmacists need to be able to aid patients in the selection of an appropriate glucose meter and provide the education necessary for proper use and follow-up. Patient education is a key component in optimizing the potential benefits of self-monitoring. CONCLUSIONS: Self-monitoring of blood glucose, if used properly, can have a positive effect by increasing patient involvement in overall diabetes care. Pharmacists are accessible and can teach patients necessary skills that will enhance their ability to self-manage blood glucose.

Blood Glucose Self-Monitoring↗
PubMed2006

Frequency of serum creatinine monitoring during allopurinol therapy in ambulatory patients.

BACKGROUND: Allopurinol dosage reduction is recommended in patients with renal dysfunction because drug toxicity risk is increased. Little information is available about serum creatinine (SCr) monitoring in ambulatory patients taking allopurinol. OBJECTIVE: To evaluate SCr monitoring among patients prescribed allopurinol, identify associated factors, and evaluate administrative data in assessing monitoring. METHODS: Information for this retrospective cohort study was drawn from a dataset of 2 020 037 individuals; approximately 200 000 members from each of 10 organizations. Study patients had received at least one year of ongoing allopurinol prescription dispensings. Patient variables analyzed included age, gender, chronic diseases, outpatient visits, hospitalizations, gout diagnosis, and SCr monitoring. A random sample of medical records was reviewed to assess the accuracy of the automated data. Statistical analysis included descriptive and logistic regression techniques. RESULTS: Overall, 1139 (26%) of 4357 patients did not have SCr monitoring. For individuals without recent hospitalization, factors protective against lack of monitoring were increasing age (OR 0.77 per 10 y; 95% CI 0.74 to 0.79), more chronic diseases (OR 0.81; 95% CI 0.78 to 0.83), more outpatient visits (OR 0.87 per 5 visits; 95% CI 0.83 to 0.91), and gout diagnosis (OR 0.74; 95% CI 0.65 to 0.85). The sensitivity and specificity of administrative data compared with medical records for SCr monitoring were 92% and 65%, respectively. CONCLUSIONS: More than one-fourth of patients dispensed allopurinol did not have SCr monitoring during one year of therapy. Lack of monitoring and lack of subsequent possible dosage adjustment put patients at increased risk of allopurinol toxicity.

Adolescent↗
PubMed2006

Variation in the use of intracranial-pressure monitoring and mortality in critically ill children with meningitis in the United States.

OBJECTIVE: Our goal was to describe patient and hospital characteristics associated with the use of intracranial pressure monitors and outcomes in critically ill children with meningitis. METHODS: This was a retrospective cohort study of children 0 to 17 years of age hospitalized with meningitis and requiring mechanical ventilation using the 1997 and 2000 Kids' Inpatient Database. We generated national estimates of rates of intracranial pressure monitoring and in-hospital mortality by patient and hospital characteristics, and compared in-hospital mortality, hospital length of stay, and total charges for children who received an intracranial pressure monitor with those who did not. RESULTS: There were an estimated 1067 and 1170 hospitalizations nationally for childhood meningitis requiring mechanical ventilation in 1997 and 2000, respectively. Most (79%) of the hospitalizations involved infants. Overall, intracranial-pressure monitors were used in 7% of hospitalizations for meningitis, with the highest rates in children aged 5 to 17 years and lowest rates in children <1 year. In-hospital mortality was 19.6%, highest in children aged 5 to 17 years and in children with pneumococcal infections. In multivariate regression analyses, intracranial pressure monitor use was positively associated with age, patient volume, and hospitals located in the West census region. In-hospital mortality was associated with increasing age, hospitalization in the year 2000, self-pay/other insurance status, and pneumococcal meningitis. There was no difference in hospital mortality associated with use of intracranial pressure monitors, but both length of stay and log-transformed total hospital charges were significantly higher in the group that received an intracranial-pressure monitor. CONCLUSION: Intracranial pressure monitoring for the treatment of critically ill children with meningitis varies by census region, the number of cases treated, and patient age. The use of intracranial pressure monitoring was not statistically associated with mortality in this national sample.

Adolescent↗
PubMed2005

Devices for ambulatory and home monitoring of blood pressure, lipids, coagulation, and weight management, part 1.

PURPOSE: The equipment and methods used for ambulatory and home monitoring of blood pressure, lipids, coagulation, and weight management are discussed. SUMMARY: Over 100 million people in the United States have one or more chronic diseases, such as diabetes, hypertension, and asthma. With the goal to improve health while reducing costs and the overall health care burden, ambulatory and home monitoring by pharmacists and patients are receiving more attention. Ambulatory and home monitoring of blood pressure, cholesterol, coagulation, and weight management (including devices for assessing overweight and obese patients, heart rate monitors, and pedometers) are convenient for clinicians and patients. Such monitoring provides pharmacists with an opportunity to differentiate their practices. Studies suggest that patients who are involved in ambulatory and home monitoring take a more active role in their health and may have better adherence to prescribed diet and medication regimens. Studies also show that ambulatory and home monitoring, if done correctly, provide clinicians with a large quantity of reliable readings for future therapeutic decisions. Devices are also a means for pharmacists to increase their provision of pharmacy services. Ambulatory monitoring is billable in many clinic settings, and the devices can be a profitable addition to prescription services. CONCLUSION: Many devices are available to assist patients and clinicians in monitoring blood pressure, lipids, coagulation, and weight management. Familiarity with the devices will help in their proper selection and use.

Ambulatory Care↗
PubMed1995

The role of therapeutic drug monitoring in improving the cost effectiveness of anticonvulsant therapy.

When monitoring of the plasma concentrations of anticonvulsant drugs first came into use 25 years ago, it appeared to have a major impact on improving the effectiveness and safety of anticonvulsant therapy. However, as time has passed, prescribers have absorbed many of the lessons to be learned from the monitoring, and now apply this knowledge without necessarily monitoring plasma anticonvulsant concentrations as frequently as in the past. Therefore, the effect of the drug concentration monitoring on the cost effectiveness of anticonvulsant therapy is probably not as significant now as it originally was. In theory, drug concentration monitoring is often unlikely to decrease the cost of contemporary anticonvulsant drug therapy, but it may enhance the efficacy of the therapy. Thus, monitoring may reveal unrecognised under- or overdosage, detect failure of compliance or drug-drug interactions, or indicate when there is little point in persisting with a particular anticonvulsant drug. Despite a good deal of anecdotal testimony, surprisingly little has been published demonstrating the benefits of anticonvulsant therapeutic drug monitoring in epileptic populations. However, one study did show better rates of seizure control rates in patients monitored in the first 6 months of their epileptic disorder; but not if the monitoring began later than this.(ABSTRACT TRUNCATED AT 250 WORDS)

Anticonvulsants↗
PubMed1996

Differences in orthostatic blood pressure changes measured with an oscillometric blood pressure monitor and a mercury sphygmomanometer.

AIMS: To compare orthostatic blood pressure (BP) changes recorded with the SpaceLabs 90207 BP monitor (SL) and the standard mercury sphygmomanometer (HgS). METHODS: 85 hospital in-patients aged 60-90 years had nine BP measurements recorded by both instruments using the same arm sequential measurement technique in supine and standing position by two observers. Supine BP was taken as the final set of three supine measurements, ie, one made with the SL, and the mean of the two HgS readings immediately before and after the monitor reading. From the SL supine reading was subtracted the three standing SL monitor readings and from the mean of the 2 supine HgS readings was subtracted the six standing measurements taken by the HgS. The orthostatic BP changes recorded by the HgS immediately before and after each SL monitor reading were averaged and compared with the corresponding orthostatic change recorded by the monitor. RESULTS: The monitor underestimated orthostatic SBP changes at all 3 comparisons compared to the HgS; i) -0.9 +/- 14.9 vs 2.7 +/- 10.3 mmHg, p < 0.05; ii) 0.3 +/- 15.4 vs 4.5 +/- 12.1 mmHg, p < 0.05; iii) 3.5 +/- 16.9 vs 7.5 +/- 14.9 mmHg, p < 0.05, respectively. These differences were more pronounced in males than females. Orthostatic hypotension (defined as SBP fall on standing of > or = 20 mmHg) was recorded in males by the monitor in four (8%) and by the HgS in 12 (25%), p < 0.05. Mean orthostatic DBP changes were similarly recorded by the monitor and HgS. On average only 60% and 77% of orthostatic SBP measurements taken by both instruments agreed within 10 and 15 mmHg respectively while 75% and 88% respectively of orthostatic DBP changes agreed within these limits. CONCLUSION: Orthostatic BP falls measured by an automatic oscillometric BP monitor may not be equivalent to those taken with a HgS and their use adds a further variable to the comparison of orthostatic BP changes between studies.

Aged↗
PubMed2005

[A comparative study between real time monitor KH-3000 and conventional Durham sampler measuring airborne pollen].

Real time monitoring of airborne pollen has gradually increased because monitoring is laborsaving and provides better real-time information. A problem arose, however, due to differences between the KH3000 (Yamato Co. Ltd) monitor and the conventional Durham sampler pointed out in results of airborne pollen monitoring in Wakayama in 2004. We compared the two monitors for airborne pollen in Wakayama in 2004, which less dispersed than usual. The peak monitored by the KH-3000 monitor was not consistent with the prime period of Japanese cedar and cypress pollen dispersion, especially in February and April, although they correlated highly in March. The inconsistency in February is thought to be caused by snow, and that in April by falsely monitoring beech-tree airborne pollen-which is similar in size-in addition to Japanese cedar and cypress pollen. This report points out the need to take these conditions (snow and other plants pollen) into account when a real time monitor is used for collecting pollen information.

Air Pollutants↗
PubMed2000

Intracranial pressure monitoring and outcomes after traumatic brain injury.

OBJECTIVE: Uncontrolled intracranial hypertension after traumatic brain injury (TBI) contributes significantly to the death rate and to poor functional outcome. There is no evidence that intracranial pressure (ICP) monitoring alters the outcome of TBI. The objective of this study was to test the hypothesis that insertion of ICP monitors in patients who have TBI is not associated with a decrease in the death rate. DESIGN: Study of case records. METHODS: The data files from the Ontario Trauma Registry from 1989 to 1995 were examined. Included were all cases with an Injury Severity Score (ISS) greater than 12 from the 14 trauma centres in Ontario. Cases identifying a Maximum Abbreviated Injury Scale score in the head region (MAIS head) greater than 3 were selected for further analysis. Logistic regression analyses were conducted to investigate the relationship between ICP and death. RESULTS: Of 9001 registered cases of TBI, an MAIS head greater than 3 was recorded in 5507. Of these patients, 541 (66.8% male, mean age 34.1 years) had an ICP monitor inserted. Their average ISS was 33.4 and 71.7% survived. There was wide variation among the institutions in the rate of insertion of ICP monitors in these patients (ranging from 0.4% to over 20%). Univariate logistic regression indicated that increased MAIS head, ISS, penetrating trauma and the insertion of an ICP monitor were each associated with an increased death rate. However, multivariate analyses controlling for MAIS head, ISS and injury mechanism indicated that ICP monitoring was associated with significantly improved survival (p < 0.015). CONCLUSIONS: ICP monitor insertion rates vary widely in Ontario's trauma hospitals. The insertion of an ICP monitor is associated with a statistically significant decrease in death rate among patients with severe TBI. This finding strongly supports the need for a prospective randomized trial of management protocols, including ICP monitoring, in patients with severe TBI.

Abbreviated Injury Scale↗
PubMed2002

Managing medication compliance of tuberculosis patients in Haiti with medication monitors.

SETTING: A tuberculosis clinic in Haiti using self-administered medication. OBJECTIVE: To determine if medication monitors could be used along with directly observed therapy in developing countries to help solve the problem of compliance with medication. DESIGN: Patients were randomized into three groups: Group A took medication from medication monitors and were given counseling based on the monitor record; Group B took medication from medication monitors, but the record was not available for counseling; and Group C took medication from simple containers. RESULTS: Good monitor records in the first 11 weeks predicted less default from treatment (P < 0.01), and better compliance (P < 0.01) in the last 9 months. Counseling based on the monitor record appeared to reduce treatment abandonment by about half. CONCLUSION: This study suggests that medication monitoring of self administered treatment would be useful in settings where directly observed therapy cannot be delivered for the entire duration of treatment, especially in rural areas, by 1) identifying poor compliance early in therapy, 2) reducing the frequency of clinic visits for patients with good monitor records who live excessive distances from the clinic, 3) counseling patients about their monitor record to improve treatment completion rates, and 4) lengthening the duration of therapy when poor compliance is found.

Adolescent↗
PubMed2002

[Monitoring serum levels of new antiepileptics].

AIM: Therapeutic monitoring of old antiepileptic drugs has been useful in improving their use in clinical practice. The new antiepileptic drugs have been developed with the idea that monitoring their serum levels was going to be unnecessary. We review the characteristics of the new antiepileptic drugs that can be relevant to their being monitored and their possible uses. DEVELOPMENT: After discussion of the evolution of the therapeutic monitoring of antiepileptic drugs in general, we take a more detailed look at the requirements needed for it to be useful, such as the indications, the procedure and a correct interpretation of the results. We point out the reasons why monitoring the new antiepileptic drugs can be worthwhile and we examine the characteristics of felbamate, gabapentin, lamotrigine, oxcarbazepine, tiagabine, topiramate, vigabatrin and zonisamide which may be relevant in their monitoring. These include the type of kinetics, the factors that have an influence on the relationship between dosage and serum levels, the concentration/dose ratio, data on the relationship between serum levels and effects, the factors that can influence this relationship, as well as the characteristics of sampling. CONCLUSION: The new antiepileptic drugs present a wide interindividual and intraindividual variability which leads us to believe that some of they may be suitable candidates for therapeutic monitoring, but at present no target ranges have been clearly defined for any of them. Therefore, routine monitoring cannot be recommended, but it may be useful to establish an individual reference level that allows control over compliance and dosage readjustment in the presence of factors that alter their pharmacokinetics. Specific prospective studies are needed to establish target ranges that allow to individualize dosage in the absence of clinical criteria and to resolve doubts about the efficacy and toxicity of these drugs. Quicker and simpler assays that make monitoring easier are also needed.

Anticonvulsants↗
PubMed2002

[Clinical application of the expert type terminal of remote electronic fetal heart rate home monitoring system].

OBJECTIVE: To investigate the clinical value of the expert type terminal of long-distance electronic fetal heart rate home monitoring system in the application to self-monitoring of pregnant woman at home in peripartum. METHODS: All the pregnant women (n = 284) were divided into two groups. Research group (n = 134) contained 73 high risk gravida. There were 78 high-risk gravida in control group (n = 150). In the research group, self-monitoring at home in 134 women was taken by the expert type terminal of long-distance electronic fetal heart rate monitoring system through telephone and fetal movement counting. The women were requested to auscultate and transfer fetal heart rate (FHR) to electronic FHR monitoring center in hospital. Non-stress test (NST) was made 1 approximately 2 times every week when fetal movement was active. When women felt any abnormality of baby, she should immediately test NST and then the photograph of NST was send to FHR monitoring center by telephone. Doctor would make a diagnosis and management in time according to the photograph of NST. In the control group, the way of fetal monitoring was fetal movement counting and regular NST test in the outpatient clinic. RESULTS: The incidence of abnormal NST was significantly higher in the research group than that in the control group (respectively 22.0% vs 13.5%, P < 0.05). The neonatal asphyxia was significantly lower in the research group than that in the control group (respectively 1.5% vs 4.0%, P < 0.05). The incidence of abnormal NST was not different between the high-risk women and non-high-risk women in the research group (respectively 22.3% vs 21.6%, P > 0.05). CONCLUSIONS: The expert type terminal of long-distance electronic FHR monitoring system through telephone is a new way of the FHR self-monitoring at home. The application of this method could ease mental press of the women, decrease significantly perinatal mortality, decrease incidence of neonatal asphyxia, and improve quality of obstetrics. Whatever there are high risk factors in any pregnant women, the system should be applied to all late pregnant women.

Asphyxia Neonatorum↗
PubMed1992

[Development of continuous monitoring of spontaneous respiration in the postoperative phase. 2. Cutaneous oxygen and carbon dioxide partial pressures following i.v. bolus application of fentanyl, buprenorphine, naloxone and amiphenazole in healthy adult subjects].

METHODS: In an attempt to develop a noninvasive monitoring technique for patients in the early postoperative period, cutaneous O2 and CO2 pressures (pctO2, pctCO2) were monitored in ten healthy adult volunteers of both sexes (5 male, 5 female, age 29 +/- 5 years, weight 68 +/- 11 kg) who received, in several sessions after a 60-min equilibration period, i.v. bolus doses of fentanyl (3 micrograms/kg and, 60 min later, another 1.5 micrograms/kg), buprenorphine (3 and 1.5 micrograms/kg), naloxone (1.8 and 0.9 micrograms/kg), and the respiratory analeptic amiphenazole (2 and 1 mg/kg) as well as combinations of fentanyl/amiphenazole or buprenorphine/naloxone in the aforementioned dosages. Data were collected and stored by a personal computer using the TCM3 system with a combination electrode for simultaneous measuring of pctO2 and pctCO2 (TINA, Radiometer) at 30-s intervals. The overall observation period was 240 min. Means, standard deviations, and ranges were calculated for individual data and data pooled for 15-min intervals. Groups were compared by means of Student's t-test and analysis of variance. RESULTS: Following i.v. fentanyl 3 micrograms/kg, pctO2 decreased and pctCO2 increased rapidly and statistically significantly. The changes were of similar intensity after the first and second doses (1.5 micrograms/kg) and normalized about 60 min after each injection. In contrast, following i.v. buprenorphine (3 and 1.5 micrograms/kg) the cutaneous partial pressures changed continuously and progressively during the observation period and did not reach the control values after 240 min. Naloxone and amiphenazole injections had no obvious influence on the time course of the blood gas tensions. If opiates and antagonists were combined, neither the fentanyl/amiphenazole group nor the buprenorphine/naloxone group differed significantly from the respective opiate groups. DISCUSSION AND CONCLUSION: As was discussed in detail in a previous communication, monitoring of opiate-induced respiratory depression must be nonstimulant and, preferably, noninvasive. Whereas the precision and/or limitations of monitoring partial oxygen saturations by pulse oximetry is well documented in the literature, knowledge of the value of cutaneous partial pressure monitoring is still limited and controversial for the adult patient population. The present study was performed to define the usefulness of cutaneous blood gas analysis in healthy volunteers receiving opiate dosages well known in recovery room patients. It is concluded that continuous monitoring of pctO2 and pctCO2 can indeed detect opiate-induced respiratory depression in adults. The well-known difference in respiratory pattern for fentanyl and buprenorphine could easily be determined. It was confirmed that naloxone and amiphenazole in the dosage range studied do not influence spontaneous respiration in healthy adults. Thus, the authors are convinced that continuous monitoring of cutaneous partial pressures of oxygen and carbon dioxide is sensitive enough to be used, in combination with pulse oximetry, in a monitoring concept for patients recovering from surgery and anaesthesia. Results in patients undergoing conventional pain management or patient-controlled analgesia with relatively high opiate dosages will be presented in following papers. Concerning the controversy about clinically relevant interactions between fentanyl and amiphenazole or buprenorphine and naloxone, the present study did not confirm any useful antagonism. Whether this is due to limitations of cutaneous monitoring, the difference between volunteers and patients, or pharmacological reasons must be evaluated in further investigations.

Adult↗
PubMed2003

Brain surgery in motor areas: the invaluable assistance of intraoperative neurophysiological monitoring.

AIM: Surgery for tumors in the central and precentral region, as much as for insular tumors, places at risk the functional integrity of the motor cortex and the subcortical motor pathways. These procedures may therefore benefit from the assistance of intraoperative neurophysiological monitoring (INM). INM consists of "mapping" and true "monitoring" (the continuous "on-line" assessment of the functional integrity of neural pathways) techniques. In spite of the large interest in mapping techniques, monitoring techniques have received less attention. We describe our experience with intraoperative neurophysiological mapping and monitoring of motor tracts during surgery for brain gliomas in or near motor areas, in order to support the feasibility and reliability of monitoring as an essential adjunct to mapping during surgery in these areas. METHODS: Between September 2000 and January 2002, 51 patients were surgically treated for brain gliomas located in the precentral gyrus (45.1%), the postcentral gyrus (23.5%), anterior to the precentral gyrus (15.6%), or in the insula (15.6%). INM of the motor system consisted of monitoring muscle motor evoked potentials (mMEPs) recorded via needle electrodes inserted into the controlateral upper and lower extremity muscles and elicited by transcranial multipulse electrical stimulation (TES). Once the dura was open and the central sulcus was identified using the phase reversal technique, mMEPs were elicited by direct stimulation of the motor cortex (DCS). Motor mapping was performed with a monopolar electrode using the same stimulation parameters as used for monitoring except for much lower intensity (up to 20 mA). RESULTS: Ninety-eight percent of the patients exhibited recordable baseline mMEPs. The success rate of the phase reversal technique was 95.8%. Eight patients presented disappearance of mMEPs during tumor removal. Using corrective measures, all intraoperative changes in mMEPs were reversed in time to prevent an irreversible complete injury to the motor system and no patient lost mMEPs at the end of the operation. At discharge, 66% of the patients remained at their preoperative status, 4% improved, and 24% had a mild worsening as compared to the preoperative status assessed using the Medical Research Council scale; 6% of the patients presented a moderate to severe supplementary motor area syndrome. CONCLUSION: Monitoring techniques significantly implement the reliability and effectiveness of INM since these provide: 1) continuous "on-line" assessment of the functional integrity of motor pathways with higher chance to early detect a progressive mechanical or vascular injury to the neural tissue, as compared to mapping techniques; 2) lower risk to induce intraoperative seizures and strong muscular twitches as compared to the single pulse mapping technique; 3) possibility to monitor motor pathways using TES also when there is no direct access to the motor cortex.

Adult↗