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PubMed1989

Incidence, physiologic description, compensatory mechanisms, and therapeutic implications of monitored events.

We described 663 unanticipated monitored circulatory events in 247 high-risk surgical patients by simultaneous invasive and noninvasive hemodynamic and oxygen transport monitoring systems. Unanticipated monitored events were defined as sudden reductions (greater than 20%) in cardiac index (CI), PaO2, SaO2, transcutaneous PO2 (PtcO2), and PtcO2/PaO2 index, or decreases to the lower limits of satisfactory values, specifically: PaO2 less than 70 torr, SaO2 less than 95%, PtcO2 less than 50 torr, and PtcO2/PaO2 less than 0.6. Essentially, monitored events are the small variations superimposed on the overall physiologic patterns that describe the entire course of critical illnesses. Monitored events are described by their baseline values just before each event, at the nadir of the event, and at the recovery from the event. To simplify presentation of complex changes in many variables, the circulatory changes were evaluated in terms of cardiac, pulmonary, and peripheral perfusion functions. Common patterns of these monitored events and the incidence of these patterns in high-risk surgical patients were described. Before the unanticipated monitored event, there were normal or increased heart, lung, and perfusion functions in about three fourths of the events. At the nadir, cardiac functions decreased in about two thirds, perfusion decreased in over half, and lung function fell in only one quarter of the events. Recovery occurred with increased cardiac function in two thirds, improved perfusion in over half, and increased lung function in less than one fifth of these monitored events. Noninvasive and invasive hemodynamic and oxygen transport variables were measured simultaneously to evaluate compensatory and decompensatory patterns.(ABSTRACT TRUNCATED AT 250 WORDS)

Blood Gas Analysis↗

PubMed1993

Clinical performance of a blood gas monitor: a prospective, multicenter trial.

OBJECTIVE: To prospectively assess the clinical performance of a fluorescent optode-based blood gas monitoring system that is designed to perform arterial pH, PCO2, and PO2 measurements as frequently as clinically required without violating the integrity of the arterial catheter tubing system or permanently removing blood from the patient. DESIGN: A prospective, multicenter study to compare modern blood gas analyzer measurements with the coinciding measurements of the blood gas monitoring system. SETTING: Four intensive care units (ICUs) in academic centers with varying patient populations, blood gas measurement routines, and blood gas laboratory facilities. PATIENTS: Adult ICU patients (n = 117), with appropriately functioning radial arterial catheters in place, who were assessed as likely to require multiple arterial blood gas measurements for > or = 2 days. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 117 patients had 1,341 concurrent blood gas analyzer and monitor measurements of arterial pH, PCO2, and PO2 over a 1- to 4-day period. The range of values were 7.14 to 7.64 for arterial pH, 19 to 98 torr (2.5 to 13.0 kPa) for PaCO2, and 38 to 413 torr (5.1 to 54.9 kPa) for PaO2. Linear regression analysis of the optode-based monitor compared with the electrode-based blood gas analyzer demonstrated r2 values of .85 for pH, .92 for PCO2, and .94 for PO2. Comparative statistical analyses for bias (mean difference between analyzer and monitor) and precision (standard deviation of the mean difference [+/- SD] between analyzer and monitor) were respectively:-0.004 and +/- 0.027 for pH; -0.8 torr (-0.11 kPa) and +/- 2.4 torr (0.32 kPa) for PCO2; -2.2 torr (-0.31 kPa) and +/- 8.7 torr (1.2 kPa) for PO2. CONCLUSIONS: Clinical performance of this fluorescent, optode-based blood gas monitoring system demonstrates stability, consistency, and accuracy comparable to modern blood gas analyzers. This system withstood the normal abuse and rigors of clinical conditions common to the ICU while reliably performing in critically ill patients for up to 80 hrs. Use of the device did not significantly alter the function or longevity normally expected from a 20-gauge radial artery catheter. We submit that this blood gas monitoring system can replace the use of blood gas analyzers for ICU patients with indwelling arterial catheters.

Adolescent↗

PubMed1995

Accuracy and reproducibility of the measurement of actively circulating blood volume with an integrated fiberoptic monitoring system.

OBJECTIVE: Bedside monitoring of circulating blood volume has become possible with the introduction of an integrated fiberoptic monitoring system that calculates blood volume from the changes in blood concentration of indocyanine green dye 4 mins after injection. The aim of this investigation was to compare the blood volume estimate of the integrated fiberoptic monitoring system (group 1) with the standard methods of blood volume measurement using Evans blue (group 2), and indocyanine green measured photometrically (group 3). DESIGN: Prospective laboratory study. SETTING: Animal laboratory of a University's institute for experimental surgery. SUBJECTS: Eleven anesthetized, paralyzed, and mechanically ventilated piglets. INTERVENTIONS: A central venous catheter was used for the injection of the indicator dyes (Evans blue and indocyanine green). A fiberoptic thermistor catheter was advanced into the thoracic aorta. The fiberoptic catheter detects indocyanine green by reflection densitometry for the estimation of blood volume of the integrated fiberoptic monitoring system. Samples for the determination of Evans blue and indocyanine green concentrations were drawn from an arterial catheter in the femoral artery over a period of 17 mins after injection. MEASUREMENTS AND MAIN RESULTS: Measurements were performed during normovolemia, hypovolemia (blood withdrawal of < or = 30 mL/kg), and hypervolemia (retransfusion of the withdrawn blood plus an infusion of 10% hydroxyethyl starch [45 mL/kg]). Linear regression, correlation, and bias were calculated for the comparison of the blood volume estimates by the fiberoptic monitoring system (group 1) vs. the total blood volume estimates using Evans blue (group 2) and indocyanine green (group 3): group 1 = 0.82.group 2-26 mL; r2 = 82.71%; r = .91; n = 40; group 1-group 2 +/- 1 SD = -435 +/- 368 mL; group 1 = 0.79.group 3 + 50 mL; r2 = 74.81%; r = .87; n = 28; group 1-group 3 +/- 1 SD = -506 +/- 374 mL. CONCLUSIONS: The results demonstrate that the blood volume estimate of the fiberoptic monitoring system (group 1) correlates closely with the total blood volume measurement using Evans blue (group 2) and indocyanine green (group 3). Trapped indicator in the packed red cell column after centrifugation of the blood samples may account for an overestimation of group 2 and group 3 of approximately 10% to 14%, but there still remains a proportional difference of 10% between group 1 vs. group 2 and vs. group 3. This difference is due to the longer mixing times of group 3 (16 mins) and group 2 (17 mins), during which they are distributed in slowly exchanging blood pools. It seems that the blood volume estimate of the fiberoptic monitoring system (group 1) represents the actively circulating blood volume and may be useful for bedside monitoring.

Animals↗

PubMed1996

Accuracy and reliability of disposable pressure transducers coupled with modern pressure monitors.

OBJECTIVE: To determine the bedside accuracy of direct patient pressure monitoring when used with new and clinically used disposable blood pressure (BP) transducers. DESIGN: Prospective study. SETTING: Laboratory bench and critical care units in an adult and children's hospital. SUBJECTS: Seventy-five bedside patient monitors (25 Marquette Electronics, 25 Spacelab Medical, and 25 Hewlett-Packard), and 100 disposable transducers (50 from Utah Medical Products and 50 from Abbott Critical Care Systems [25 new, 25 clinically used of each manufacturer]) were tested. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A +/- 2% accuracy requirement for bedside monitors and the +/- 3% American National Standards Institute accuracy standard for disposable BP transducers were used. To test the accuracy of the bedside monitors, a certified transducer simulator was used to apply 100 mm Hg to each bedside monitor. To test the accuracy of the disposable BP transducers, a very accurate (+/- 0.05%) pneumatic dead weight tester was used to apply pressures to the transducer. A digital power supply and a 6 1/2 digit voltmeter were used. The average output of the bedside monitors when 100 mm Hg was applied was 99.90 +/- 0.83 mm Hg, with the worst cases being 98 and 103 mm Hg. For all 100 disposable pressure transducers, the average output was 100.03 +/- 0.55 mm Hg, with the worst cases being 98.53 and 101.36 when 100 mm Hg was applied. There was no important difference in the accuracy of the transducers obtained from the two vendors nor whether the transducers had been used clinically. CONCLUSIONS: All disposable BP transducers tested were much more accurate than the American National Standards Institute standard for accuracy. Even the worst case transducers were twice as accurate as required by the American National Standards Institute standard. Only one bedside monitor was outside the +/- 2% accuracy range (103 mm Hg). Based on these findings, this author recommends that fixed calibration disposable transducers and fixed calibration bedside pressure monitoring systems be used. The clinical risks of air embolism and infection from the calibrating mercury manometer and the complexity of the calibration task are the overriding factors for making these recommendations.

Adult↗

PubMed1998

The first decade of continuous monitoring of jugular bulb oxyhemoglobinsaturation: management strategies and clinical outcome.

OBJECTIVE: To comparatively assess outcome of patients undergoing monitoring and management of cerebral extraction of oxygen along with cerebral perfusion pressure vs. outcome of patients undergoing monitoring and management of cerebral perfusion pressure alone in severe acute brain trauma. DESIGN: Prospective, interventional study. SETTING: Intensive care unit of a university hospital. PATIENTS: Adults (n = 353) with severe acute brain trauma. A group of 178 patients underwent continuous monitoring and management of cerebral extraction of oxygen and cerebral perfusion pressure, while a control group of 175 patients underwent monitoring and management of cerebral perfusion pressure only. INTERVENTIONS: Routine neuroemergency procedures. MEASUREMENTS AND MAIN RESULTS: The two groups of patients were matched with regard to age, postresuscitation Glasgow Coma Scale scores, rates of acute surgical intracranial hematomas and brain swelling, pupillary abnormalities, early hypotensive events (before intensive care monitoring), as well as initial levels of intracranial pressure and cerebral perfusion pressure. Outcome at 6 months post injury was significantly better (p < .00005) in the 178 patients undergoing monitoring and management of cerebral extraction of oxygen along with cerebral perfusion pressure, than in the control group of 175 patients undergoing monitoring and management of cerebral perfusion pressure alone. CONCLUSION: In patients with severe acute brain trauma and intracranial hypertension associated with compromised cerebrospinal fluid spaces, monitoring and managing cerebral extraction of oxygen in conjunction with cerebral perfusion pressure result in better outcome than when cerebral perfusion pressure is managed alone.

Acute Disease↗

PubMed1999

Pediatric electroencephalographic video monitoring.

Pediatric EEG video monitoring is based on methodology that is similar to that used for monitoring of adults, although there are important differences. In addition, the range of clinical events suspected of being seizures in the pediatric population is quite different from those in adults and, within childhood, is age-specific. Thus, the clinical utility of monitoring in neonates, infants, and children is based on an understanding of the full range of normal and abnormal epileptic and nonepileptic events that may occur in this age group. Similarly, the findings of the EEG are age-dependent and must be considered when they are interpreted as part of the monitoring study and when they are correlated with clinical events captured on video. Monitoring can be utilized in the detection, characterization, and quantification of various types of seizure disorders in children. The most effective application of monitoring, which can ensure the greatest chance for clinically useful information, occurs when monitoring is well-planned; utilizes appropriate EEG and polygraphic-physiologic parameters; incorporates optimal video recording techniques; maintains age-appropriate recording environments within the context of medical necessity; and is conducted in a laboratory with adequate support staff. Pediatric monitoring has been effective in the clinical management of neonatal seizures, infantile spasms, other seizure types in infancy, epilepsy in late childhood, and in the evaluation of pediatric patients of all ages for epilepsy surgery.

Age Factors↗

PubMed2002

Outpatient EEG monitoring in the presurgical evaluation of patients with refractory temporal lobe epilepsy.

Most epilepsy centers obtain ictal EEG recordings to localize the epileptogenic zone during presurgical evaluations. Inpatient monitoring is standard practice but is expensive and can be inconvenient. The authors sought to determine whether outpatient monitoring can be safe and effective as the sole method of recording seizures in the presurgical evaluation of patients with refractory temporal lobe epilepsy. They reviewed the data of seven temporal lobectomy patients whose presurgical monitoring was performed entirely outside the hospital. Mean baseline seizure frequency was at least 9.1 seizures per week. An average of 7.4 seizures was recorded over 9.4 days of monitoring. Only one patient had any antiepileptic drug taper; none suffered any complications. After temporal lobectomy on the side of demonstrated ictal onset, postoperative follow-up averaged 5.5 years. At the most recent follow-up, all patients were either seizure free or had only rare disabling or nocturnal seizures (four patients had outcomes in Engel's class I and three patients in Engel's class II). A comparison group who underwent standard inpatient monitoring was similar in average seizure frequency, monitoring duration, number of seizures recorded, and postoperative outcome, although all but one had antiepileptic drugs tapered during monitoring. The authors conclude that there is a subset of patients for whom solely outpatient presurgical EEG monitoring can be used to help plan successful temporal lobectomy.

Adult↗

PubMed1989

Clinical evaluation of the Colin ABPM 630 at rest and during exercise: an ambulatory blood pressure monitor with gas-powered cuff inflation.

The Colin ABPM 630 is a silent, gas-powered (CO2) ambulatory blood pressure monitor which uses both ausculatory and/or oscillometric methods to measure blood pressure. We compared simultaneous, same-arm blood pressures obtained with the monitor with those made by two blinded, skilled clinicians using a mercury column and teaching stethoscope. In a second study, the monitor readings were also compared with opposite-arm intra-arterial recordings of blood pressure. The group mean systolic blood pressures obtained by the Colin monitor via the Korotkoff mode were almost identical to the mercury column readings (127.8 +/- 19.4 versus 128.1 +/- 19.3 mmHg, P = NS) and the limit of agreement (2 standard deviations) for the differences in the two methods was +/- 9 mmHg. The diastolic blood pressure obtained by the Colin monitor was significantly lower than the clinician's readings (-6.0 +/- 5.9 mmHg, P less than 0.0001). Similar findings were obtained with the oscillometric mode, however, the mean systolic blood pressure given by the monitor was slightly higher than that given by the mercury column (1.9 +/- 4.5 mmHg, P less than 0.001). In contrast to the mercury column comparisons, the mean diastolic blood pressure obtained with the monitor was nearly the same as the mean intra-arterial diastolic blood pressure for both the Korotkoff (0.1 +/- 5.6 mmHg) and the oscillometric modes (1.2 +/- 6.3 mmHg). During 100-watt bicycle exercise, there was a considerably greater scatter in the individual comparisons of the monitor and intra-arterial blood pressure than that seen in the measurements at rest, but the group means were again similar.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed2001

Evaluation of various evoked potential techniques for spinal cord monitoring during scoliosis surgery.

STUDY DESIGN: This prospective study compared the outcomes of different evoked potential (EP) techniques for intraoperative spinal cord monitoring. OBJECTIVES: To evaluate the reliability of different EP techniques administered during scoliosis surgery. SUMMARY OF BACKGROUND DATA: A number of different methods of intraoperative spinal cord monitoring are available. Because each has its own advantages and limitations, multimodal spinal cord monitoring has been proposed to improve monitoring reliability. MATERIALS AND METHODS: Cortical somatosensory-evoked potential (CSEP), cortical motor-evoked potential (CMEP), spinal somatosensory-evoked potential (SSEP), and spinal cord-evoked potential (SCEP) were applied simultaneously to 30 patients undergoing surgical correction for spinal deformity. The presence of the EP waveforms and their reproducibilities over separate tests were compared. In addition, the monitoring outcomes were evaluated with the clinical results. RESULTS: Of the 30 patients, CSEP waveforms were successfully recorded in 28 cases (93%), SCEP in 25 cases (83%), CMEP in 24 cases (80%), and SSEP in 21 cases (70%). Latencies of each EP technique showed no significant variability. However, amplitudes showed significant differences between different techniques. SCEP and CMEP showed clearer waveforms of greater amplitude that could be detected faster than CSEP and SSEP waveforms. SCEP and SSEP waveforms were more easily influenced by the surgical procedure. CONCLUSION: CSEP and CMEP are recommended for routine monitoring, so that both ascending and descending tracts are monitored. If adequate signals for either of these proposed monitoring methods cannot be easily obtained, SSEP can substitute for CSEP, whereas SCEP can substitute for CMEP.

Adolescent↗

PubMed2003

Monitoring during cardiac arrest: are we there yet?

Advancements in electronic data acquisition have translated into improved monitoring of victims of cardiac arrest, but initial techniques remain direct observation of pulses and respirations. The most essential monitor continues to be the electrocardiogram. However, monitoring diastolic blood pressure, myocardial perfusion pressure, and end-tidal carbon dioxide are extremely useful. Most of the current research on monitoring during cardiopulmonary resuscitation focuses on methods for analyzing ventricular fibrillation waveforms. By analyzing the waveform, defibrillation shocks may be delivered at the time when the chance of success is optimal. Low-amplitude and low-frequency fibrillation waveforms are associated with increased rates of asystole and pulseless electrical activity after defibrillation. Methods of analyzing the ventricular fibrillation waveform include measuring the amplitude and frequency and combining the contributions of amplitude and frequency by various methods to improve discrimination. Other types of monitoring being studied for their usefulness during cardiac arrests include sonography, Bispectral Index monitoring, tissue carbon dioxide monitors, and pupil observation. The test of these monitoring techniques is ultimately their ability to improve patient survival to hospital discharge, which is a major challenge for resuscitation researchers.

Animals↗

PubMed2003

Validation of the TONOPORT V ambulatory blood pressure monitor according to the European Society of Hypertension International Protocol for Validation of Blood Pressure Measuring Devices in Adults.

BACKGROUND: It is now accepted that blood pressure measuring devices should be subjected to an independent evaluation of their accuracy before they are marketed for clinical use. The results of validation of the TONOPORT V blood pressure monitor for the measurement of ambulatory blood pressure according to the European Society of Hypertension International Protocol for Validation of Blood Pressure Measuring Devices in Adults are presented in this paper. POPULATION: Thirty-three subjects were recruited from among staff and patients at Beaumont Hospital, Dublin, Ireland. METHODS: The TONOPORT V monitor was connected to the Sphygmocorder, an audiovisual system for validation, which records blood pressure on tape and video for later analysis. Nine sequential same-arm measurements between the device and a standard mercury sphygmomanometer were recorded using the Sphygmocorder. RESULTS: In phase 1, the TONOPORT V monitor produced 28 measurements within 5 mmHg, 37 within 10 mmHg and 40 within 15 mmHg for systolic blood pressure (SBP), and 26 within 5 mmHg, 38 within 10 mmHg and 44 within 15 mmHg for diastolic blood pressure (DBP). The mean differences were -2.2 (8.6) [mean (SD)] mmHg for SBP and +0.5 (7.2) mmHg for DBP. The TONOPORT V monitor passed all the criteria for both SBP and DBP. In phase 2.1, the TONOPORT V monitor had 56 measurements within 5 mmHg, 78 within 10 mmHg and 88 within 15 mmHg for SBP, and 60 measurements within 5 mmHg, 83 within 10 mmHg and 97 within 15 mmHg for DBP. The mean differences were -1.4 (8.7) mmHg for SBP and -0.2 (6.8) mmHg for DBP. The TONOPORT V monitor passed the criteria for DBP but failed to meet any of the criteria for SBP. In phase 2.2, 19 subjects had at least two of the differences within 5 mmHg and six subjects had no differences within 5 mmHg for SBP, and 22 subjects had at least two of the differences within 5 mmHg and six subjects no differences within 5 mmHg for DBP. The TONOPORT V monitor failed to meet the criteria for SBP and for DBP. CONCLUSIONS: The TONOPORT V monitor cannot be recommended for clinical use in an adult population because it records SBP inaccurately and because it records DBP inaccurately in an unacceptably high proportion of people.

Adult↗

PubMed2003

Intracranial pressure monitoring and case mix-adjusted mortality in intracranial hemorrhage.

OBJECTIVE: Intracranial pressure (ICP) monitoring is frequently used in intensive care treatment of patients with intracranial hemorrhage. Data demonstrating an improved outcome from this intervention are lacking. We analyzed standardized mortality ratios in patients with and without ICP monitoring to determine its efficacy. DESIGN: A nonrandomized study of case records of consecutively admitted intensive care unit (ICU) patients with intracranial hemorrhage. SETTING: General and medical ICU of a 900-bed tertiary-care hospital. PATIENTS: A total of 225 patients with intracranial hemorrhage (mainly nontraumatic) admitted consecutively between April 1997 and March 2000. MEASUREMENTS: Simplified Acute Physiology Score (SAPS) II, diagnosis, age, sex, use of ICP monitoring, and in-hospital mortality rates were collected from the hospital's ICU database. Expected mortality was provided by means of SAPS II. Standardized mortality ratios were calculated and compared in 119 patients with ICP monitoring and 106 patients without ICP monitoring. MAIN RESULTS: The case mix-adjusted hospital mortality in the group with ICP monitoring was in the expected range (standardized mortality ratio, 1.09 [95% confidence interval (CI), 0.87-1.31]). Patients without ICP monitoring had a significantly higher standardized mortality ratio than expected (1.26 [95% CI, 1.06-1.46]). CONCLUSIONS: A beneficial effect of ICP monitoring in patients with intracranial hemorrhage may be reflected in an improved standardized mortality ratio.

APACHE↗

PubMed2005

Differences in oscillometric non-invasive blood pressure measurements recorded by different revisions of the Philips Component Monitoring System.

OBJECTIVE: To investigate whether a simulator can detect differences in oscillometric noninvasive blood pressure measurements in different revisions of the Philips Component Monitoring System. Philips revised the intraarterial-based algorithm with software revision C.0, and added an auscultation-based algorithm in revision C.1. METHODS: Three methods were adopted. Firstly, differences were assessed using the Dynatech Nevada CuffLink simulator. Five noninvasive blood pressure modules were tested on monitors with software revision C (software revision prior to C.0) and revision C.0. Monitor C.1 allows the selection of the original intraarterial algorithm (as for revision C), the improved intraarterial (revision C.0) or auscultation; two noninvasive blood pressure modules were tested on it.Secondly, pressures were recorded simultaneously from a participant's left and right arms by monitors C and C.0. The monitors were then swapped between arms and a second set of six pressures were recorded. The two sets were subtracted to calculate the differences between monitors, removing interarm differences. The experiment was carried out on two participants.Thirdly, pressures were recorded from three participants with a simultaneous reference auscultatory measurement. Six sets of simultaneous oscillometric and auscultatory determinations were recorded from monitors C and C.0. RESULTS AND CONCLUSIONS: All three methods revealed that the 'original' intraarterial-based algorithm in revision C recorded lower systolic, diastolic and mean arterial pressures than revision C.0, with the difference in diastolic pressure being the greatest. The difference in diastolic pressures between C and C.0 was up to 15 mmHg. The simulator evaluation finding of higher systolic and diastolic pressures recorded by the revised intraarterial algorithm (C.1 option 3) than by the auscultation-based algorithm (C.1 option 2) is in qualitative agreement with the regression equations of the clinical validation studies. The results suggest that simulators can identify the existence of differing algorithms used to measure blood pressure by the CMS monitor. Philips has continued to develop the algorithms used to determine the pressure by the oscillometric method. While significantly different pressures were recorded by the different revisions, it is interesting that each revision passed clinical validation studies.

Algorithms↗

PubMed2005

Continuous facial nerve monitoring during pleomorphic adenoma recurrence surgery.

OBJECTIVES: Surgery of recurrent pleomorphic adenoma (RPA) is known to lead to a high facial nerve complication rate. The efficacy of the continuous facial nerve monitoring (CFNM) technique remains to be proven in RPA surgery. The goal was thus to evaluate facial nerve palsy rates and the recovery period after parotidectomy for RPA using CFNM by way of continuous electromyography and to compare these rates and the operation time with those of patients who had undergone surgery without facial nerve monitoring. DESIGN: Cohort study. PATIENTS: Forty-seven patients were referred for RPA (1981-2003). Among them, 32 (18 unmonitored and 14 monitored) patients displayed no preoperative facial palsy, and histologic analyses revealed evidence of recurrence. The operation time and the extent and duration of postoperative facial nerve palsy were examined in both groups (monitored vs. unmonitored). Both groups had a similar clinical appearance distribution. RESULTS: Facial nerve paralysis was estimated using the House-Brackmann grading scale. CFNM reduced the intensity of facial nerve paralysis independently of the kind of surgery performed. The complete deficit rates were 0% for the monitored group and 5.6% for the unmonitored group. Postoperative facial nerve paralysis was significantly lower (P = .01) in the monitored group than in the unmonitored group. CFNM improved the duration of facial paralysis (P = .001) in the monitored group. The operation time was significantly lower in the monitored group than in the unmonitored group (P = .001). CONCLUSIONS: Routine use of CFNM during RPA surgery improves the surgical outcome. The facial nerve deficit can be reduced, and the recovery of facial nerve function is faster.

Adenoma, Pleomorphic↗

PubMed2005

Multimodal monitoring in the neurological intensive care unit.

BACKGROUND: Neurocritical care is a specialty that focuses on the critical care management of patients with catastrophic neurologic diseases. Brain ischemia and hypoxia are often central causes of brain damage in these patients. Until recently, the only methods widely accepted for monitoring in the neurological intensive care unit have been intracranial pressure and cerebral perfusion pressure monitoring. Recent developments in technology have resulted in several new monitoring techniques that can provide the neurointensivist with information, at the cellular level, that can help guide management. REVIEW SUMMARY: The brain requires a continuous blood-borne supply of oxygen and glucose for normal metabolism. Ischemia occurs when supply is insufficient to meet the metabolic demand. Cerebral blood flow can now be directly monitored using laser Doppler or thermal diffusion techniques. Transcranial cerebral oximetry can estimate regional cerebral oxygen saturation, although the reliability is questionable. Jugular bulb oximetry can provide a global assessment of oxygen delivery, and consumption and brain tissue oxygen tension monitoring can provide a focal measurement of cerebral oxygenation. Intracerebral microdialysis can provide information about glucose metabolism and the overall health of the neuron. CONCLUSIONS: New monitoring techniques can provide the neurointensivist with crucial information about brain physiology and metabolism. Combining these techniques ("multimodal monitoring") can produce a more accurate overall picture. This approach, along with new computer systems for integrating data at the bedside, may change the way patients with brain injury are monitored and treated in the future.

Brain↗

PubMed2004

Impact of late conversion from C0 to C2 monitoring of microemulsified cyclosporine in pediatric living donor liver transplant recipients.

The efficacy and feasibility of 2-h post-dose level (C2) monitoring of cyclosporine in long-term living donor liver transplantation (LDLT) is not clear. The aim of this study was to investigate the impact of late conversion from conventional trough-level (C0) monitoring to C2 monitoring of a microemulsion form of cyclosporine (Neoral) in pediatric LDLT recipients. From June 1994 to August 2002, we performed 116 LDLTs in 115 patients. Initially, we adapted conventional C0 monitoring of Neoral, which was converted to C2 monitoring starting in January 2002. The 60 patients who were enrolled in the study had the following characteristics: they were younger than or equal to 15 yr at transplantation, and they had survived LDLT, and they had received a Neoral-based immunosuppression regimen, and they underwent conversion to C2 more than 1 month after transplantation. We evaluated the impact of conversion on doses, blood levels, rejection, adverse effects, and patient/graft outcome. In the long-term patients, the mean C2 levels immediately after conversion were higher than the target levels at any time point selected after transplantation; thus, 34 patients (57%) finally required a dose reduction of Neoral. The current mean C2 level was significantly lower than that observed immediately after conversion (584.6 +/- 262.8 ng/ml vs. 893.1 +/- 260.2 ng/ml, mean +/- SD, p < 0.0001) with a mean follow-up period of 7.4 +/- 0.6 months (range: 5-8 months) after conversion. Only one patient encountered rejection after conversion (1.7%), and no de novo infection or adverse effects were observed. Traditional C0 monitoring of Neoral was safely replaced by C2 monitoring without an increase in the rejection rate or any adverse effects in pediatric LDLT patients. C2 monitoring contributed to the dose reduction of Neoral, which may lead to the avoidance of long-term complications due to immunosuppression.

Adolescent↗

PubMed2004

Reduction in the incidence of awareness using BIS monitoring.

BACKGROUND: Explicit recall (ER) is evident in approximately 0.2% of patients given general anaesthesia including muscle relaxants. This prospective study was performed to evaluate if cerebral monitoring using BIS to guide the conduction of anaesthesia could reduce this incidence significantly. PATIENTS AND METHODS: A prospective cohort of 4945 consecutive surgical patients requiring muscle relaxants and/or intubation were monitored with BIS and subsequently interviewed for ER on three occasions. BIS values between 40 and 60 were recommended. The results from the BIS-monitored group of patients was compared with a historical group of 7826 similar cases in a previous study when no cerebral monitoring was used. RESULTS: Two patients in the BIS-monitored group, 0.04%, had ER as compared with 0.18% in the control group (P < 0.038). Both BIS-monitored patients with ER were aware during intubation when they had high BIS values (> 60) for 4 min and more than 10 min, respectively. However, periods with high BIS = 4 min were also evident in other patients with no ER. Episodes with high BIS, 4 min or more, were found in 19% of the monitored patients during induction, and in 8% of cases during maintenance. CONCLUSIONS: The use of BIS monitoring during general anaesthesia requiring endotracheal intubation and/or muscle relaxants was associated with a significantly reduced incidence of awareness as compared with a historical control population.

Adolescent↗

PubMed2005

Baseline laboratory monitoring of cardiovascular medications in elderly health maintenance organization enrollees.

OBJECTIVES: To identify correlates of laboratory monitoring errors in elderly health maintenance organization (HMO) members at the initiation of therapy with cardiovascular medications. DESIGN: Cross-sectional study in 10 HMOs. SETTING: United States. PARTICIPANTS: From a 2 million-member sample, individuals aged 65 and older who received one of seven cardiovascular medications (angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), amiodarone, digoxin, diuretics, potassium supplements, and statins) and did not have recommended baseline monitoring performed during the 180 days before or 14 days after the index dispensing. MEASUREMENTS: The proportion of members receiving each drug for whom recommended laboratory monitoring was not performed. Laboratory monitoring error rates stratified by sex, age group, chronic disease score, and HMO site were examined, and logistic regression was used to identify predictors of laboratory monitoring errors. RESULTS: Error rates varied by medication class, ranging from 23% of patients receiving potassium supplementation without serum potassium and serum creatinine monitoring to 58% of patients receiving amiodarone who did not have recommended monitoring for thyroid and liver function. Highest error rates occurred in the youngest elderly for ACE inhibitors, ARBs, digoxin, diuretics, and potassium supplements, although in patients receiving amiodarone and statins, errors were most frequent in the oldest elderly. Errors occurred more frequently in patients with less comorbidity. CONCLUSION: Laboratory monitoring errors occurred frequently in elderly HMO members at the initiation of therapy with cardiovascular medications. Further study must examine the association between these errors and adverse outcomes.

Aged↗