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To establish the experts consensus on the management of delirium in critically ill patients.A special committee was set up by 15 experts from the Chinese Critical Hypothermia-Sedation Therapy Study Group.Each statement was assessed based on the GRADE (Grading of Recommendations Assessment,Development,and Evaluation) principle.Then the Delphi method was adopted by 36 experts to reassess all the statements.(1) Delirium is not only a mental change,but also a clinical syndrome with multiple pathophysiological changes.(2) Delirium is a form of disturbance of consciousness and a manifestation of abnormal brain function.(3) Pain is a common cause of delirium in critically ill patients.Analgesia can reduce the occurrence and development of delirium.(4) Anxiety or depression are important factors for delirium in critically ill patients.(5) The correlation between sedative and analgesic drugs and delirium is uncertain.(6) Pay attention to the relationship between delirium and withdrawal reactions.(7) Pay attention to the relationship between delirium and drug dependence/ withdrawal reactions.(8) Sleep disruption can induce delirium.(9) We should be vigilant against potential risk factors for persistent or recurrent delirium.(10) Critically illness related delirium can affect the diagnosis and treatment of primary diseases,and can also be alleviated with the improvement of primary diseases.(11) Acute change of consciousness and attention deficit are necessary for delirium diagnosis.(12) The combined assessment of confusion assessment method for the intensive care unit and intensive care delirium screening checklist can improve the sensitivity of delirium,especially subclinical delirium.(13) Early identification and intervention of subclinical delirium can reduce its risk of clinical delirium.(14) Daily assessment is helpful for early detection of delirium.(15) Hopoactive delirium and mixed delirium are common and should be emphasized.(16) Delirium may be accompanied by changes in electroencephalogram.Bedside electroencephalogram monitoring should be used in the ICU if conditions warrant.(17) Pay attention to differential diagnosis of delirium and dementia/depression.(18) Pay attention to the role of rapid delirium screening method in delirium management.(19) Assessment of the severity of delirium is an essential part of the diagnosis of delirium.(20) The key to the management of delirium is etiological treatment.(21) Improving environmental factors and making patient comfort can help reduce delirium.(22) Early exercise can reduce the incidence of delirium and shorten the duration of delirium.(23) Communication with patients should be emphasized and strengthened.Family members participation can help reduce the incidence of delirium and promote the recovery of delirium.(24) Pay attention to the role of sleep management in the prevention and treatment of delirium.(25) Dexmedetomidine can shorten the duration of hyperactive delirium or prevent delirium.(26) When using antipsychotics to treat delirium,we should be alert to its effect on the heart rhythm.(27) Delirium management should pay attention to brain functional exercise.(28) Compared with non-critically illness related delirium,the relief of critically illness related delirium will not accomplished at one stroke.(29) Multiple management strategies such as ABCDEF,eCASH and ESCAPE are helpful to prevent and treat delirium and improve the prognosis of critically ill patients.(30) Shortening the duration of delirium can reduce the occurrence of long-term cognitive impairment.(31) Multidisciplinary cooperation and continuous quality improvement can improve delirium management.Consensus can promote delirium management in critically ill patients,optimize analgesia and sedation therapy,and even affect prognosis.
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Objective To explore the application value of short latency somatosensory evoked potentials (SLSEP) as a tool for preoperative assessment of surgical or interventional treatment in patients with severe aneurysmal subarachnoid hemorrhage (aSAH). Methods A prospective observational cohort study was conducted. The patients with severe aSAH with a WFNS grade of Ⅳ or Ⅴ admitted to intensive care unit (ICU) of Beijing Tiantan Hospital of Capital Medical University from November 2016 to April 2017 were enrolled. The patients received SLSEP monitoring within 12 hours after onset, and the monitoring results were classified according to the Judson scale. Meanwhile, the findings on cerebral CT scans at admission were evaluated by the modified Fisher classification. The follow-up was performed at 3 months after aSAH ictus based on the modified Rankin scale (mRS), and a mRS score 0-3 was defined as favorable outcome, 4-6 was defined as unfavorable outcome. For statistical evaluation, demographic, clinical, neuroimaging and SLSEP data were evaluated by univariate analysis to identify the risk factors associated with prognosis;afterwards, those factors were analyzed by multivariate Logistic regression; also the validity was assessed by calculating the respective sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). Results A total of 41 patients with aSAH were selected, of which 7 were excluded because of the interference of the SLSEP monitoring results, 34 patients with aSAH were enrolled finally. Among them, 21 were classified in the unfavorable outcome group, while the rest (n = 13) were allocated into the favorable outcome group. No significant difference was found in gender, age, body mass index (BMI), time delay from ictus to treatment or the options for therapeutic methods between the two groups. The findings of univariate analysis, however, showed statistically differences in WFNS grade, the modified Fisher scale and Judson scale of SLSEP between the two groups. Yet, the further validity evaluation for these predictors demonstrated that the sensitivity, specificity, PPV and NPV of WFNS grade of Ⅴ and modified Fisher scale of Ⅳ were all less than 85%, whereas the results for SLSEP Judson scale of Ⅲ were much better (sensitivity: 90.5% vs. 71.4% and 71.4%, specificity: 84.6% vs. 69.2% and 76.9%, PPV: 90.5% vs. 79.0% and 83.3%). In the following multivariate Logistic analysis, only Judson scale of Ⅲ was identified to be the independent risk factor for poor outcome [odds ratio (OR) = 45.73, 95% confidence interval (95%CI) = 4.25-499.31, P = 0.002], while the WFNS grade of Ⅴ (OR = 1.14, 95%CI = 0.12-13.06, P = 0.912) and the modified Fisher scale of Ⅳ (OR = 7.22, 95%CI = 0.51-113.20, P = 0.160) were merely associated with poor outcomes without significant independence. Conclusion In comparison with WFNS grade and the modified Fisher scale, SLSEP seems more accurate in the prediction of long-term outcome of severe aSAH prior to surgical or interventional treatment, and thus may be applied as an effective aid in preoperative assessment.
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Objective To evaluate the effects of different positions on cerebral blood flow in patients undergoing laparoscopic surgery.Methods Thirty patients of both sexes,aged 23-64 yr,of American Society of Anesthesiologists physical status Ⅰ or Ⅱ,scheduled for elective laparoscopic surgery,were included.Patients' position was changed using a random number table after induction of anesthesia.Patients were placed in the supine position and tilted 15° head-up or 15° head-down,and the parameters of the middle cerebral artery were monitored using the transcranial Doppler ultrasound.After admission to the operating room (baseline),after induction of anesthesia and before pneumoperitoneum,in the supine position,at head-up tilt and at head-down tilt,the mean blood flow velocity,pulsatility index,resistance index,mean arterial blood pressure (MAP) and heart rate were recorded.Results Compared with the baseline in the supine position,the MAP and bilateral mean blood flow velocity were significantly decreased at head-up tilt,and the MAP and bilateral pulsatility and resistance indices were significantly increased at head-down tilt (P＜0.05).Conclusion During laparoscopic surgery,head-up tilt can lead to a decrease in cerebral blood flow,and head-down tilt exerts no effect on cerebral blood flow.
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Objective To evaluate the diagnostic validity of application of brainstem auditory evoked potential (BAEP) as an ancillary test in patients with brain death.Methods A prospective observational study was conducted. Adult patients (≥ 18 years) with brain death were consecutively admitted to the Department of Intensive Care Unit (ICU) of Beijing Tiantan Hospital Affiliated to Capital Medical University from July 2015 to June 2017, and they further underwent BAEP monitoring. The following findings: absence of all waveforms at bilateral sides, absence of all waveforms except wave-Ⅰonly present at bilateral orunilateral side were set as the positive criteria of BAEP for the diagnosis of brain death, and its diagnostic sensitivity (SEN), positive predictive value (PPV) and false negative rate (FNR) were further assessed.Results A total of 47 patients were enrolled in the study, and the 43 complete BAEP results were analyzed. The SEN, PPV and FNR of the above 3 types of diagnostic criteria (absence of all waveforms, and unilateral or bilateral presence of wave-Ⅰ only) were 100% [95% confidence interval (95%CI) 90-100], 100% (95%CI 89-100), and 0% (95%CI 0-9), respectively.Conclusion As an ancillary test, BAEP has extremely high validity for the diagnosis of patients with brain death, thus it should be used more extensively in clinical practice.
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OBJECTIVE:To establish the method for the determination of tigecycline (TGC) in human plasma. METHODS:After precipitated by acetonitrile,the plasma sample was determined by LC-MS/MS. Using d9-TGC as internal standard,Kromasil C18 column was used with mobile phase consisted of water (containing 0.05% TFA)-acetonitrile (gradient elution) at flow rate of 0.6 ml/min,column temperature of 40 ℃. The ion transitions were performed under ESI positive MRM model at m/z 586.3→513.2 and m/z 595.3→514.3 for TGC and internal standard,respectively. RESULTS:The linear range of TGC was 25-2 000 ng/ml (r=0.999 8),and lowest quantification limit was 25 ng/ml;intra-day and inter-day RSD was 3.15%-7.23%,and relative error was-4.53%-10.48%. Plasma sample kept stable after 3 times of freezing and thawing cycle,at room temperature for 24 h,in automat-ic sample injector for 24 h and freezing for 42 d (RSD<15%). Plasma concentration of TGC was 0-438.0 ng/ml in one patient with pan-drug resistant bacteria infection(0-12 h after administration). CONCLUSIONS:The developed method is accurate,sensi-tive and specific,and can be used for plasma concentration determination of TGC and pharmacokinetic study.
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Objective To compare the difference in pharmacokinetics characteristics of vancomycin in cerebrospinal fluid between administration by continuous infusion and interim infusion.Methods Twenty postoperative patients in the Department of Neurosurgery of Beijing Tiantan Hospital, Capital Medical University admitted into intensive care unit (ICU) to receive vancomycin for prophylaxis of intracranial infection were enrolled, and they were randomly distributed to a continuous intravenous infusion group and a interim intravenous infusion group, each group 10 cases. In continuous intravenous infusion group, the patients received a loading dose of vancomycin (15 mg/kg) by continuous intravenous pump infusion for 1 - 2 hours followed by 30 mg/kg vancomycin in a constant pump infusion rate for 24 hours; while in interim intravenous infusion group, the patients received 15 mg/kg vancomycin administered by intravenous pump infusion for 1 - 2 hours, once every 12 hours. The concentration of vancomycin in the cerebrospinal fluid at different time points was measured by two-dimensional liquid chromatography (2D-LC) method, the parameters of pharmacokinetics were calculated in the two groups, and the adverse reaction was observed.Results The comparison between the ratio of areas under the concentration-time curves (AUC) and minimum inhibitory concentration (MIC) of the continuous and interim groups showed no significant difference (19.7±14.0 vs. 16.1±6.4,P > 0.05). However, in the continuous intravenous infusion group, the drug concentration reached the peak value (0.96± 0.77)μg/mL at 12 hours, and later revealed a plateau concentration 0.91-0.93μg/mL for 12 hours; while in the intravenous infusion interim group, the drug concentration reached the peak value (0.92±0.47)μg/mL at 16 hours, in the later 2 hours declined to (0.84±0.45)μg/mL, and afterwards still had a tendency of persistent declination. In all the patients, no any adverse reaction related to the drug occurred.Conclusion Continuous intravenous infusion and interim intravenous infusion of vancomycin for the postoperative neurosurgical patients without intracranial infection have the similar efficacy of medication, but the former can achieve the peak concentration faster and later the fluctuation of drug concentration in cerebrospinal fluid is smaller than those in the latter.
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<p><b>OBJECTIVE</b>To investigate pre- and postoperative changes of regional cerebral cortical blood flow in patients with cerebral arteriovenous malformation.</p><p><b>METHOD</b>Twenty-two adult patients with arteriovenous malformation (AVM) were recruited into this study at Beijing Tiantan Hospital from September 2001 to May 2002. Eight patients had giant cerebral AVM and the other 14 had a small one. Cortical cerebral blood flow (CBF) was measured by laser Doppler flowmetry (LDF) before and after AVM resections. After surgery, the probe of LDF was implanted adjacent to the area of AVM and monitored for 24 hours.</p><p><b>RESULTS</b>CBF increased significantly after the resection in all patients regardless of AVM size. In patients with small AVM, CBF returned to the baseline level within 4 hours, but in patients with giant AVM, CBF remained high even after 24 hours.</p><p><b>CONCLUSIONS</b>Monitoring CBF is helpful to understand pre- and postoperative changes of regional cortical CBF in patients with cerebral AVM.</p>