Michael H. Wall

Delirium: Past, present, and future

Delirium was described by Hippocrates over 2500 years ago and it remains an important clinical problem today. Work continues to improve definition, prevention, diagnosis, and treatment, but relatively young science remains. Delirium affects 12,500,000 patients and costs

Assessing the predictive value of the bispectral index vs patient state index on clinical assessment of sedation in postoperative cardiac surgery patients

152,000,000,000 every year. Up to 80% of mechanically ventilated patients experience delirium, which exists as a spectrum of acute brain organ dysfunction. Multiple theories exist, including contribution from baseline pathology, medications, surgical inflammation, and environment. Biochemical models point to pathophysiology. Delirium remains largely preventable through planning and subgroup identification. Validated objective assessment models aid diagnosis, whereas protocolized multimodal intervention remains best practice. Pharmacotherapy, as chemical restraint, is reserved for cases of potential harm to self or others. Observation obviates mechanical restraint. The contribution of delirium to cognitive decline remains controversial and concerning. As dollars shrink and cost does not, delirium becomes increasingly important. In an aging population of increasing frailty, delirium will contribute increasingly to long-term morbidity and even mortality.

Rocuronium-induced coronary vasospasm — “Kounis syndrome”

PURPOSE To compare the depth of sedation determined by Ramsay sedation scale (RSS) with electroencephalogram-based bispectral index (BIS) and patient state index (PSI). MATERIALS AND METHODS Fifty mechanically ventilated cardiac surgical patients undergoing propofol and morphine sedation were assessed hourly for up to 6 hours or until tracheal extubation using the BIS, PSI, and RSS. Correlation between RSS, BIS, and PSI was determined, as well as the interrater reliability of RSS, BIS, and PSI. kappa statistics was used to further evaluate the agreement between BIS and PSI. RESULTS There was positive correlation between BIS and PSI values (rho = 0.731, P < .001). The average weighted kappa coefficient was .40 between the BIS and PSI, 0.28 between the RSS and BIS, and 0.16 between the RSS and PSI. Intraclass correlation was consistently higher between the BIS and PSI at all time intervals during the study. Logistic regression modeling over study duration showed that the BIS was consistently better at predicting oversedation (area under the curve, 0.92) than the PSI (area under the curve, 0.78). A comparison of BIS and PSI receiver operating characteristic curves showed that the BIS monitor was a better predictor of oversedation compared with the PSI (P = .02). CONCLUSIONS There is significant positive correlation between the BIS and PSI but poor correlation and poor test agreement between the RSS and BIS as well as RSS and PSI. The BIS is a better predictor of oversedation compared with the PSI. There was no significant difference between the BIS and PSI with respect to the prediction of undersedation.

Endpoints of resuscitation: What are they anyway?

A 49-year-old male became hypotensive, bradycardic, and suffered myocardial injury during induction of anesthesia with lidocaine, propofol, and rocuronium in the operating room. Coronary arteriography revealed coronary vasospasm in coronary arteries otherwise free of disease. In the ICU, the patient was again administered rocuronium for a procedure with subsequent hypotension, bradycardia, and ST elevation on telemetry that resolved with administration of diphenhydramine and hydrocortisone. An allergic reaction to rocuronium with coronary vasospasm is suspected, suggestive of the Type 1 variant of Kounis syndrome. This is the first report to describe a case of rocuronium-induced Type 1 Kounis syndrome.

Advances in Transfusion Medicine

Hemodynamic optimization of surgical patients during and after surgery in the Surgical Intensive Care Unit is meant to improve outcomes. These outcomes have been measured by Length Of Stay (LOS), rate of infection, days on ventilator, etc. Unfortunately, the adaptation of modern technology to accomplish this has been slow in coming. Ever since Shoemaker described in 1988 using a pulmonary artery catheter (PAC) to guide fluid and inotropic administration to deliver supranormal tissue oxygenation, many authors have written about different techniques to achieve this “hemodynamic optimization”. Since the PAC and CVC have both gone out of favor for utilization to monitor and improve hemodynamics, many clinicians have resorted using the easy to use static measurements of blood pressure (BP), heart rate (HR), and urine output. In this paper, the authors will review why these static measurements are no longer adequate and review some of the newer technology that have been studied and proven useful. This review of newer technologies combined with laboratory measurements that have also proven to help guide the clinician, may provide the impetus to adopt new strategies in the operating rooms (OR) and SICU.

Con: Hct >25% is better

Transfusion medicine has developed as a specialty by linking rapidly evolving knowledge in areas of physiology and immunology to the vastly expanded clinical requirements for blood products resulting from advances in medicine and surgery. This article covers major developments in transfusion medicine related to anesthesiology and surgery. It will familiarize the anesthesia practitioner with evolving concepts in basic science as they relate to innovations in clinical care in three areas: (1) red cell transfusion, (2) other blood components, and (3) recently introduced massive transfusion protocols. RED BLOOD CELL TRANSFUSION Blood component therapy is a limited resource that contributes to overall health care expense. In the United States, four million patients will receive 12 million units of packed red blood cells this year. The estimated hospital cost for a unit of autologous blood ranges from

Dexmedetomidine Infusion Decreases Cerebral Blood Flow in Humans

250 to

Perioperative Considerations and Management in Patients with Intravascular Stents

750. Actual costs of transfusion therapy, alternatives to transfusion therapy, complications associated with transfusion therapy, and complications associated with anemia are unknown [1]. The Transfusion Requirement in Critical Care trial has shown that a conservative strategy of red blood cell transfusion (transfusion for a hemoglobin of less than 7 g/dL) is as effective, if not superior to, a liberal transfusion strategy (transfusion for a hemoglobin less than 9 g/dL) in normovolemic critically ill patients [2]. Following a conservative transfusion strategy, institutions may decrease costs by limiting perioperative erythrocyte transfusions and their complications [2]. Erythrocytes compose an estimated 25 trillion of the 100 trillion cells that are found in the human body [3]. The major function of the erythrocyte is to transport hemoglobin, which in turn carries oxygen from the lungs to the tissues. Along with oxygen transporting capacity, hemoglobin acts as an acid–base buffer. The buffering capacity of hemoglobin provides about 70% of the buffering capacity of whole blood. Red blood cells also remove carbon dioxide from the body by using carbonic anhydrase, an enzyme that catalyzes