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Journal of Anaesthesiology, Clinical... 2024The objective of the study was to evaluate the performances of qCON and qNOX indices in pediatric populations undergoing surgery under general anesthesia (GA), focusing...
BACKGROUND AND AIMS
The objective of the study was to evaluate the performances of qCON and qNOX indices in pediatric populations undergoing surgery under general anesthesia (GA), focusing on the induction and recovery periods. Both the indices are derived from electroencephalogram (EEG) and implemented in the CONOX monitor (Fresenius Kabi, Germany).
MATERIAL AND METHODS
After approval of the institutional ethics committee, this prospective observational study was conducted in pediatric patients of either sex in the age group of 1-12 years belonging to the American Society of Anesthesiology (ASA) grade I and II undergoing elective surgery under GA. Anesthetic technique was GA with or without regional analgesia (RA). All patients underwent inhalation induction and maintenance using sevoflurane. Patients were monitored with the use of a CONOX monitoring system (Fresenius Kabi, Germany), connected via a set of electrodes placed over the forehead. qCON and qNOX scores were recorded during awake (on operating table premedicated with oral midazolam 0.5 mg/kg), at induction, at loss of eyelash reflex, intubation/laryngeal mask airway (LMA) insertion, before and after regional anesthesia, surgical incision, at cessation of anesthesia, emergence, extubation, and eye-opening. Registered results were also analyzed compared with the minimum alveolar concentration of sevoflurane (MAC).
RESULTS
A total of 46 pediatric patients were enrolled in the study with a mean age of 5.6 years. All the patients were either ASA I or II. There was a simultaneous fall and rise of qCON and qNOX upon induction and recovery, respectively. There was a rise in qNOX with surgical incision irrespective of RA. However, there was a greater rise in qNOX following surgical incision in those who did not receive RA ( = 0.33) Also both qCON ( = 0.06) and qNOX ( = 0.41) were poorly correlated with MAC values of sevoflurane during GA in the pediatric population.
CONCLUSIONS
Both qCON and qNOX values change predictably with changes in the conscious level and with different noxious stimuli. Further studies are required to confirm the findings taking into account the postoperative assessment of delirium and recall of intraoperative events.
PubMed: 38919439
DOI: 10.4103/joacp.joacp_453_22 -
A qualitative study of geriatric specialist nurses' experiences to navigate delirium in the elderly.BMC Nursing Jun 2024The experiences and perceptions of geriatric specialist nurses are pivotal to understanding the complexities of managing delirium and to developing effective nursing...
BACKGROUND
The experiences and perceptions of geriatric specialist nurses are pivotal to understanding the complexities of managing delirium and to developing effective nursing interventions. This qualitative study aims to explore these experiences and perceptions to inform the enhancement of clinical geriatric nursing and care practices.
METHODS
Utilizing a qualitative exploratory design, this research engaged a convenience sample of geriatric specialist nurses at a tertiary hospital in Shanghai, China through focus groups and semi-structured interviews. Data were rigorously analyzed using Colaizzi's phenomenological method, which facilitated the identification of themes that emerged from the narratives of the geriatric specialist nurses.
RESULTS
The thematic analysis yielded three major themes that encapsulate the nurses' experiences and perceptions. Theme 1: Understanding of Delirium, highlighted the nurses' awareness of the condition's significance, yet it was often deprioritized due to the pressing demands of managing more acute and immediately life-threatening conditions. Theme 2: Barriers in Application, brought to light the multifaceted challenges faced by nurses, including language barriers, the frequency and consistency of delirium assessments, the social determinants of health, and the nurses' own competencies in assessment. Theme 3: Evolution of Nursing Approaches, detailed the adaptive strategies employed by nurses, such as managing nursing adverse events, improving communication with patients' families, and adopting a proactive stance towards long-term patient outcomes.
CONCLUSIONS
The findings suggest that while geriatric specialist nurses recognize the importance of delirium assessment, there are several barriers to effective application. The study underscores the imperative for the advancement of more refined delirium assessment and care protocols, tailored to address the unique requirements of geriatric nursing care.
PubMed: 38918789
DOI: 10.1186/s12912-024-02100-x -
BMJ Supportive & Palliative Care Jun 2024
PubMed: 38918049
DOI: 10.1136/spcare-2024-004996 -
Seminars in Neurology Jun 2024The care of a patient with neurologic disease at end-of-life requires expertise in addressing advance care planning, hospice, symptom management, and caregiver support....
The care of a patient with neurologic disease at end-of-life requires expertise in addressing advance care planning, hospice, symptom management, and caregiver support. Neurologists caring for patients with advanced neurologic disease often identify changes in disease trajectory, functional status, or goals of care that prompt discussions of advance care planning and hospice. Patients nearing end-of-life may develop symptoms such as dyspnea, secretions, delirium, pain, and seizures. Neurologists may be the primary clinicians managing these symptoms, particularly in the hospitalized patient, though they may also lend their expertise to non-neurologists about expected disease trajectories and symptoms in advanced neurologic disease. This article aims to help neurologists guide patients and caregivers through the end-of-life process by focusing on general knowledge that can be applied across diseases as well as specific considerations in severe stroke and traumatic brain injury, amyotrophic lateral sclerosis, Parkinson's disease, and dementia.
PubMed: 38917863
DOI: 10.1055/s-0044-1787809 -
Journal of Palliative Medicine Jun 2024Pain and symptom management at the end of life (EoL) can pose unique challenges, particularly when symptoms are refractory to conventional methods. Dexmedetomidine,...
Pain and symptom management at the end of life (EoL) can pose unique challenges, particularly when symptoms are refractory to conventional methods. Dexmedetomidine, originally approved for sedation in ventilated patients, has been demonstrated to be beneficial in pain management and palliative care settings by functioning as an alpha-2 agonist. A retrospective review of inpatient palliative care unit (IPU) records from January 2020 to December 2023 was conducted. Twenty-five adult patients receiving continuous dexmedetomidine for refractory pain at the EoL were identified. These patients were further evaluated for concurrent opioid, benzodiazepine, and chlorpromazine usage. Patients experienced predominantly cancer-related pain, and had a median infusion duration of 5 days. Dexmedetomidine's initial dosing differed between the intensive care unit (ICU) and IPU settings. There was a trend toward a decreased opioid requirement 24 hours after initiation. Patients transferred from the ICU showed a progressive increase in opioid use. This study contributes to understanding dexmedetomidine's role in managing refractory symptoms at the EoL in the palliative care setting.
PubMed: 38916782
DOI: 10.1089/jpm.2024.0016 -
GeroScience Jun 2024Since most of the precipitating factors of delirium are not due to neurological disorders, neurological diagnostic tests (NDTs) may be of limited value. We hypothesized...
Since most of the precipitating factors of delirium are not due to neurological disorders, neurological diagnostic tests (NDTs) may be of limited value. We hypothesized that delirium has a high burden of NDTs with a low diagnostic yield. All patients admitted to the internal medicine wards of a single secondary teaching hospital between November 2019 and January 2020 were eligible. Within the first 48 h of their admission, they had a formal evaluation by a neuropsychologist to screen for presence of delirium. NDTs (brain MRI, brain CT, electroencephalography (EEG), and lumbar puncture) performed during the hospital stay were compared between patients with and without delirium using a logistic regression model stratified by a propensity score. The proportions of diagnostic yield (acute anomalies that changed the treatment management) provided by each type of examination were compared. Of 217 patients included, 19/32 patients (61%) with delirium had one or more NDTs, compared to 48/185 (26%) without delirium (adjusted OR 2.7; 95%CI 1.1-6.7; p = 0.027). The proportions of NDT results affecting management for patients with and without delirium were 13 and 20% for brain CT scans (p = 0.71), 29 and 38% for brain MRI (p = 0.99), and 20 and 10% for EEGs (p = 0.99), respectively. The higher proportion of NDTs performed on patients with delirium was associated with a low diagnostic yield, although not statistically different from those performed among inpatients without delirium. There is a need for restrictive, evidence-based guidelines to help with the work-up for patients with delirium.
PubMed: 38916662
DOI: 10.1007/s11357-024-01246-5 -
European Journal of Anaesthesiology Jun 2024Preoperative anxiety (PA) is common in children and has detrimental effects on surgical outcome. Strategies based on virtual reality (VR) have recently been introduced...
BACKGROUND
Preoperative anxiety (PA) is common in children and has detrimental effects on surgical outcome. Strategies based on virtual reality (VR) have recently been introduced to address this problem.
OBJECTIVE
This study evaluated the usefulness of a virtual reality educational program (VREP) for reducing preoperative anxiety in elective low-complexity paediatric surgery.
DESIGN
Randomised clinical trial.
SETTING
Single tertiary centre in Barcelona, Spain. Between January 2019 and June 2022.
PATIENTS
Children aged 3-13 years of age, American Society of Anesthesiologists (ASA) I-II, scheduled for elective low-complexity surgery were enrolled in the study.
INTERVENTION
Children were randomised into a control group (received oral/written information about the anaesthetic-surgical process, and patients and their parents remained in a playroom waiting for the surgery) or VREP (viewed a VR-based educational video on the surgical process, 7-10 days prior to surgery) using the MATLAB application.
MAIN OUTCOME MEASURE
PA using the modified Yale Preoperative Anxiety Scale (mYPAS) during separation from parents.
RESULTS
In total, 241 children aged 3-12 years of age were studied (120 patients with VREP and 121 controls). Randomisation eliminated the differences between the groups, except for a greater male presence in the VREP group (83.3% vs. 71.1%; P = 0.023). The mYPAS yielded was lower in the VREP group (29.2% vs. 83.5%; P < 0.001). Sex did not influence VREP-mediated decrease in PA (P < 0.001). In turn, VREP patients were more cooperative (Induction Compliance Checklist [ICC] score 0 points vs. 2 points; P < 0.001) during anaesthesia induction, presented less delirium (Pediatric Anesthesia Emergence Delirium [PAED] score 1 point vs. 3 points; P = 0.001) on leaving the recovery room, and experienced less pain upon arrival in the hospital ward (Wong-Baker Faces Pain Rating Scale: 0-points vs. 1 point; P < 0.001).
CONCLUSIONS
The VREP-based prevention strategy reduced preoperative anxiety in children undergoing elective low-complexity surgery.
TRIAL REGISTRATION
NCT03578393.
PubMed: 38916221
DOI: 10.1097/EJA.0000000000002032 -
Journal of Palliative Medicine Jun 2024Delirium management is crucial in palliative care. Morphine effectively relieves dyspnea due to heart failure. However, the effect of morphine, which is used to relieve...
Delirium management is crucial in palliative care. Morphine effectively relieves dyspnea due to heart failure. However, the effect of morphine, which is used to relieve dyspnea due to heart failure, on the incidence of delirium has not been examined to date. To evaluate the effect of morphine, which is used to relieve dyspnea due to heart failure, on delirium. Retrospective observational study. Subjects were identified from Osaka University Hospital records, located in Japan, from January 1, 2010, to September 30, 2021. The case group consisted of admissions for heart failure or cardiomyopathy registered in electronic medical records. Morphine was administered to relieve dyspnea due to heart failure, and no surgeries or procedures were performed. The control group consisted of admissions for heart failure or cardiomyopathy in the Diagnosis Procedure Combination (DPC) database, which did not include administration of morphine, oxycodone, or fentanyl during the hospitalization period and patients did not undergo surgery or any other procedure. The incidence of delirium was assessed. The odds ratios for morphine in the multivariate logistic regression analysis with propensity score and univariate logistic regression analysis after propensity score matching were 1.406 (95% confidence interval (CI) [0.249-7.957]) and 1.034 (95% CI [0.902-1.185]), respectively. Morphine, which is used to relieve dyspnea due to heart failure, had minimal effect on the incidence of delirium. This information is likely to be beneficial for the future use of morphine in the management of dyspnea in patients with heart failure.
PubMed: 38916066
DOI: 10.1089/jpm.2023.0704 -
Ibrain 2024This review comprehensively assesses the epidemiology, interaction, and impact on patient outcomes of perioperative sleep disorders (SD) and perioperative neurocognitive... (Review)
Review
This review comprehensively assesses the epidemiology, interaction, and impact on patient outcomes of perioperative sleep disorders (SD) and perioperative neurocognitive disorders (PND) in the elderly. The incidence of SD and PND during the perioperative period in older adults is alarmingly high, with SD significantly contributing to the occurrence of postoperative delirium. However, the clinical evidence linking SD to PND remains insufficient, despite substantial preclinical data. Therefore, this study focuses on the underlying mechanisms between SD and PND, underscoring that potential mechanisms driving SD-induced PND include uncontrolled central nervous inflammation, blood-brain barrier disruption, circadian rhythm disturbances, glial cell dysfunction, neuronal and synaptic abnormalities, impaired central metabolic waste clearance, gut microbiome dysbiosis, hippocampal oxidative stress, and altered brain network connectivity. Additionally, the review also evaluates the effectiveness of various sleep interventions, both pharmacological and nonpharmacological, in mitigating PND. Strategies such as earplugs, eye masks, restoring circadian rhythms, physical exercise, noninvasive brain stimulation, dexmedetomidine, and melatonin receptor agonists have shown efficacy in reducing PND incidence. The impact of other sleep-improvement drugs (e.g., orexin receptor antagonists) and methods (e.g., cognitive-behavioral therapy for insomnia) on PND is still unclear. However, certain drugs used for treating SD (e.g., antidepressants and first-generation antihistamines) may potentially aggravate PND. By providing valuable insights and references, this review aimed to enhance the understanding and management of PND in older adults based on SD.
PubMed: 38915944
DOI: 10.1002/ibra.12167 -
Drug Design, Development and Therapy 2024The novel short-acting benzodiazepine drug, remimazolam tosilate, has been employed for sedation during endoscopic procedures. The optimal loading dosage of remimazolam... (Randomized Controlled Trial)
Randomized Controlled Trial Clinical Trial
BACKGROUND
The novel short-acting benzodiazepine drug, remimazolam tosilate, has been employed for sedation during endoscopic procedures. The optimal loading dosage of remimazolam tosilate in gastroscopy for elderly patients when co-administered with fentanyl remains unclear. Therefore, the primary objective of our research was to ascertain the median effective dose (ED50) and the 95% effective dose (ED95) of remimazolam tosilate in combination with various fentanyl dosages for elderly patients undergoing painless gastroscopy.
METHODS
Seventy-five patients aged ≥65 years and American Society of Anesthesiologists (ASA) class I-III were recruited to undergo elective painless gastroscopy. All patients were randomized assigned to group F, group F, and group F, and were injected intravenously with different doses of fentanyl (0.5 ug/kg, 1 ug/kg, and 1.5 ug/kg) 3 minutes prior to the administration of remimazolam tosilate, respectively. The initial preset dose of remimazolam tosilate was 0.3 mg/kg in group F, 0.2 mg/kg in group F, 0.15 mg/kg in group F. The dose gradient was 0.02 mg/kg per group according to the up-and-down sequential method. Probibt regression model was employed to determine the ED50 and ED95 of remimazolam tosilate.
RESULTS
The ED50 of remimazolam tosilate in group F was lower than that in group F and F (0.095 [0.088-0.108] mg/kg vs 0.162 [0.153-0.171] mg/kg; 0.258 [0.249-0.266] mg/kg, < 0.05). The ED95 of remimazolam tosilate was 0.272 mg/kg (95% CI: 0.264-0.295 mg/kg) in group F, 0.175 mg/kg (95% CI: 0.167-0.200 mg/kg) in group F and 0.109 mg/kg (95% CI: 0.101-0.135 mg/kg) in group F. The total dosage of remimazolam tosilate decreased gradually with the increasing of fentanyl ( < 0.001). The frequency of injection pain was higher in group F compared to groups F and F ( < 0.05). The patients in group F had a lower incidence of hypotension than in groups F and F ( < 0.05). There was no respiratory depression, intraoperative consciousness, dizziness or delirium in the three groups.
CONCLUSION
The concurrent use of fentanyl reduces the dosage of remimazolam tosilate required for sedative gastroscopy in elderly patients in a dose-dependent manner. Moreover, 1.5 ug/kg fentanyl combined with remimazolam tosilate may reduce the incidence of hypotension and injection pain. These findings should be confirmed in a large-scale study.
Topics: Humans; Aged; Benzodiazepines; Male; Female; Fentanyl; Gastroscopy; Dose-Response Relationship, Drug; Aged, 80 and over
PubMed: 38915865
DOI: 10.2147/DDDT.S462607