Safety and efficacy of target-controlled infusion versus intermittent bolus administration of propofol for sedation in colonoscopy: a randomized controlled trial

Abstract Background: Our objective was to compare the safety and efficacy of Target-Controlled Infusion (TCI) versus intermittent bolus of propofol for colonoscopy sedation. Methods: We conducted a randomized (1:1), single-blind, parallel-group superiority trial with fifty ASA I or II patients, both sexes, aged 18 to 65 years, Body Mass Index ≤ 30 kg.mr-2, undergoing colonoscopy, allocated to receive propofol by TCI (effect-site, 2 μg.mL-1 plus 0.5 μg.mL-1 until unconsciousness and as necessary for agitation) or intermittent bolus (1 mg.kg-1 plus 0.5 mg.kg-1 every 5 minutes or as above). The primary safety outcome was the need for airway maneuvers and the primary efficacy outcome was the need for interventions to adjust the level of sedation. Secondary outcomes included incidence of agitation, propofol dose, and time to recovery. Results: The median (IQR) number of airway maneuvers and interventions needed to adjust sedation was 0 (0-0) vs. 0 (0-0) (p = 0.239) and 1 (0-1) vs. 3 (1-4) (p < 0.001) in the TCI and control groups, respectively. Agitation was more common in the intermittent bolus group - 2 (0-2) vs. 1 (0-1), p < 0.001. The mean ± SD time to recovery was 4.9 ± 1.4 minutes in the TCI group vs. 2.3 ± 1.6 minutes in the control group (p < 0.001). The total propofol dose was higher in the TCI group (234 ± 46 μg.kg-1.min-1 vs. 195 ± 44 μg.kg-1.min-1 (p = 0.040)). Conclusions: During colonoscopy, TCI is as safe as intermittent bolus of propofol while reducing the incidence of agitation and the need for dose adjustments. However, intermittent bolus administration was associated with lower total propofol dose and earlier recovery.

P-l Assoun and the irony inherent in the unconscious / P-l assoun e a ironia inerente ao inconsciente

RESUMO: Figura polissêmica e polimorfa, de expressiva abrangência, a ironia é objeto de sucessivas análises de múltiplas áreas de estudos, o que contrasta com a quantidade de estudos psicanalíticos dedicados a ela. Este trabalho busca circunscrever e discutir a ideia de uma ironia inerente ao inconsciente proposta por Assoun e mostrar que comentários temáticos e críticos de textos elementares podem fornecer subsídios para a abordagem da ironia pela psicanálise, mesmo se comportarem um viés retrospectivo e comparativo.

ABSTRACT: A polysemic and polymorphic figure, of expressive scope, irony is the subject of successive analyses of multiple study areas, which contrasts with the amount of psychoanalytical studies dedicated to it. This work seeks to circumscribe and discuss the idea of an irony inherent to the unconscious proposed by Assoun and to show that thematic and critical comments of elementary texts can provide subsidies to the approach of irony by psychoanalysis, even if they have a retrospective and comparative bias.

Contribuições da clínica de linguagem para uma discussão psicanalítica sobre a contradição nos dizeres / Contributions of the language clinic for a psychoanalytic discussion on contradiction in speech

RESUMO: A partir da constatação de contradições cotidianas e de sua recepção na lógica clássica, onde não são admitidas, este trabalho teórico interroga, junto a outros campos, fenômenos linguageiros considerados indesejáveis e, consequentemente, descartáveis em descrições e análises. A discussão reconhece na Lógica paraconsistente avanços importantes para a abordagem das contradições em sistemas lógicos. Na Clínica de Linguagem, tropeços e embaraços são tratados como dados de subjetividade relevantes para elaborações teórico-clínicas; ali encontramos contribuições para discutir a contradição na Psicanálise. Resta dizer que o interesse pela questão decorre da afirmação de Freud de que a vida psíquica é composta de contradições.

ABSTRACT: Based on the observation of everyday contradictions and their reception in classical logic, where they are not admitted, this theoretical work interrogates, together with other fields, linguistic phenomena considered undesirable and disposable in descriptions and analyses. The discussion recognizes in Paraconsistent Logic important advances for the approach of contradictions in logical systems. At the Language Clinic, stumbling blocks and embarrassments are treated as relevant subjectivity data for theoretical-clinical elaborations; there we find contributions to discuss the contradiction in Psychoanalysis. It remains to be said that the interest in the question stems from Freud's assertion that psychic life is made up of contradictions.

L'inconscient est politique / O inconsciente é a política: sobre as distopias na sociedade brasileira contemporânea / The unconscious is politics: about dystopias in contemporary brazilian society

RESUMO. A intenção deste ensaio é circunscrever na tradição social brasileira recente a problemática do populismo de extrema direita, em uma retomada e repetição do que se passou nos tempos nefastos da ditadura militar. Para isso, vamos destacar a dívida estabelecida pela sociedade brasileira para com os mortos, na medida em que os crimes realizados pela ditadura não foram julgados. Além disso, tal dívida remete a outras dívidas existentes na sociedade brasileira, referentes à tradição escravocrata, assim como as relações patriarcais no registro do gênero.

RESUME: L'intention de cet essai est de circonscrire dans la récente tradition sociale brésilienne la problématique du populisme d'extrême droite, dans une reprise et une répétition de ce qui s'est passé dans les temps néfastes de la dictature militaire. Pour cela, nous soulignerons la dette établie par la société brésilienne envers les morts, dans la mesure où les crimes perpétrés par la dictature n'ont pas été jugés. En outre, cette dette fait référence à d'autres dettes existant dans la société brésilienne, se référant à la tradition esclavagiste, ainsi qu'aux relations patriarcales dans le registre des sexes.

ABSTRACT. This essay intends to circumscribe in the recent Brazilian social tradition the problem of far right-wing populism, in a resumption and repetition of what happened in the nefarious times of the military dictatorship. For this, we analyzed the debt established by Brazilian society towards the dead, insofar as the crimes committed by the dictatorship were not judged. In addition, this debt refers to other existing debts in Brazilian society, referring to the slavery tradition, as well as gender related patriarchal relations.

Situação-limite: por outro olhar sobre a violência em um Caps AD / Limit-situation: for another look on the violence in a CAPS AD / Situación límite: otra mirada sobre la violencia en un Caps AD

Este relato de experiência, situado no campo do cuidado a pessoas usuárias de álcool e outras drogas em contextos marcados por violência, tem como objetivo explorar os limites, desafios e caminhos possíveis, em um Centro de Atenção Psicossocial Álcool e Drogas (Caps AD III), para a sustentação de um cuidado orientado pela compreensão das pessoas usuárias do Caps a partir da sua existência, sofrimento e relação com o corpo social, mesmo diante de comportamentos tidos como violentos. De caráter qualitativo, o percurso de pesquisa foi conduzido por meio de dois recursos metodológicos: o relato de experiência, referente à trajetória de uma das autoras no Programa de Residência Multiprofissional em Saúde Mental do Instituto de Psiquiatria da Universidade Federal do Rio de Janeiro (IPUB/UFRJ), e a metodologia caso traçador ou usuário-guia. O trabalho de cuidar de pessoas expostas à necropolítica exige um posicionamento ético dos trabalhadores de saúde mental de engendrar processos de resistências e produção de vida. Pela radicalidade que é vivenciá-la, a violência comparece como um elemento dificultador desse trabalho para os profissionais, fazendo com que, diante do desamparo, por vezes utilizem lógicas disciplinares para conseguir lidar com esse fenômeno. Propõe-se abordar as cenas nomeadas como violentas nos Caps com base na noção de situação-limite, retirando a situação da malha de sentidos que acompanha a palavra e remete a práticas disciplinares e ao contexto da violência urbana. Essa mudança de paradigma abre a possibilidade de que os trabalhadores se incluam nas situações, as entendam como relacionadas à complexidade e à singularidade da existência das pessoas envolvidas e, assim, proponham soluções produtoras de vida.(AU)

This experience report, situated in the field of care for people who use alcohol and other drugs in contexts marked by violence, aims to explore the limits, challenges, and possible paths, at a Psychosocial Care Center for Alcohol and Drugs (CAPS AD III), to support care guided by the knowledge of CAPS users based on their existence, suffering, and relationship with the social body, even in the face of behaviors considered to be violent. The path of this qualitative research was conducted with two methodological resources: the experience report, referring to the trajectory of one of the authors at the Multiprofessional Residency Program in Mental Health at the Institute of Psychiatry at the Federal University of Rio de Janeiro (IPUB/UFRJ), and the methodology of case tracer or user-guide. The work of caring for people exposed to necropolitics requires an ethical positioning of mental health workers to build resistance processes and life production. Due to it is radical to experience, violence appears as a complicating element of this work for the professionals, forcing them to, due to the lack of support, occasionally use disciplinary reasoning to deal with this phenomenon. This study proposes to approach violent scenarios in the CAPS under the guise of limit-situation, withdrawing the situation from the web of meanings that accompany the word and refer to disciplinary actions and the context of urban violence. This paradigmatic change opens the path for workers to include themselves in these situations, to understand their relationship with the complexity and singularity of the existence of the implicated people, and thus offer solutions that produce life.(AU)

Este reporte de experiencia se sitúa en el área de la atención a las personas que consumen alcohol y otras drogas en contexto de violencia y tiene por objetivo explorar los límites, desafíos y caminos posibles en un Centro de Atención Psicosocial Alcohol y Drogas (Caps AD III), para ofrecer un cuidado a los usuarios basado en la comprensión de las personas usuarias del Caps considerando su existencia, sufrimiento y relación con el cuerpo social, incluso ante situaciones violentas. Esta es una investigación cualitativa que se basó en dos recursos metodológicos: el reporte de experiencia sobre la trayectoria de una de las autoras en el Programa de Residencia Multiprofesional en Salud Mental de la Universidad Federal de Río de Janeiro (IPUB/UFRJ) y de la metodología del caso trazador o usuario guía. La labor de asistir a las personas expuestas a la necropolítica requiere un posicionamiento ético de los profesionales de la salud mental de producir vida y procesos de resistencia. Por la radicalidad de la experiencia, la violencia es un obstáculo para el trabajo de los profesionales, lo que los llevan a actuar de forma disciplinaria para hacer frente a este fenómeno. Se propone aquí abordar las escenas violentas bajo la noción de situación límite en el Caps, sacando del contexto la red semántica que acompaña la palabra y alude a las prácticas disciplinarias y la violencia urbana. Este cambio de paradigma permite que los trabajadores se incluyan en las situaciones, las comprendan en relación con la complejidad y la singularidad de la existencia de las personas y propongan soluciones que produzcan vida.(AU)

Troubles de la conscience au service de réanimation polyvalente du Centre Hospitalier Universitaire Analakininina, Toamasina, Madagascar / Impaired consciousness in the intensive care unit at Analankininina Teaching Hospital of Toamasina, Madagascar

La survenue d'un coma ou de troubles de la conscience en réanimation est très fréquemment observée et leur présence est associée à un pronostic sévère. Nos objectifs étaient de décrire le profil épidémio-clinique des patients admis pour coma et trouble de la conscience ainsi que les principales étiologies de ces manifestations cliniques. Méthodes : Il s'agissait d'une étude prospective, descriptive, longitudinale de Juin à Novembre 2019. Le cadre de notre étude était le service de réanimation polyvalente du centre hospitalier universitaire (CHU) Analakininina Toamasina. Résultats : Nous avions recensé 77 patients dont 37 femmes et 40 hommes (sex ratio de 1,081). La moyenne d'âge était de 39 +/-17 ans. La majorité des patients soit 67% présentait un trouble de la conscience, le reste (31%) était comateux. La principale étiologie des troubles rencontrés était l'AVC (53%) dont 61% était hémorragiques, 17% ischémiques, et 22% non étiquetés. Plus de la moitié des patients avaient évolué vers le décès (61%). Conclusion : Pour l'amélioration du pronostic des patients, il serait nécessaire de connaitre les étiologies fréquentes afin d'adapter la prise en charge

What is there in chinese writing that can guide us about the instance of the letter in the unconscious? / O que há na escrita chinesa que possa nos orientar acerca da instância da letra no inconsciente?

RESUMO: Este artigo versa sobre as relações entre o sistema de escrita chinês e a instância da letra no inconsciente. Para isso, revisamos teoricamente uma rede de conceitos imbricados que suportam essa questão na Linguística, com Saussure e Peirce, e na Psicanálise lacaniana: escrita, letra, signo e significante, lidos a partir da experiência de aprendizado do Mandarim e de recortes clínicos de situação de análise. Tal percurso nos apontou que, ao escutar um sujeito em análise, além da escuta de seus significantes, devemos nos atentar à dimensão do que é letra, inclusive na sua dimensão visual, para então, quiçá, transpor algo disso para o simbólico.

Abstract: This article discusses the relation between the Chinese writing system and the instance of the letter in the unconscious. We review theoretically a network of interwoven concepts that support this issue in Saussure and Lacan: writing, signifier and letter rethought from the learning experience of Mandarin and from clinical clippings of analysis situation. This way showed us that while listening to a subject in analysis, in addition to listening to its significant, we must be aware of the dimension of what the letter is, including its visual dimension, so then, perhaps, transpose something from it to the symbolic.

Contributions of René Kaës to the epistemology of psychoanalysis / Contribuições de rené kaës para a epistemologia da psicanálise

RESUMO: O objetivo deste artigo é discutir os efeitos das alianças inconscientes na restrição à extensão da psicanálise no que se refere à construção do conhecimento psicanalítico sobre os grupos. Cinquenta e cinco textos publicados na Revista Brasileira de Psicanálise RBP, entre 1967 e 1976, foram analisados a partir do referencial teórico-metodológico proposto por René Kaës. Numa breve reconstrução histórica, operou-se com o conceito de alianças inconscientes com o propósito de investigar as bases narcísicas presentes desde as origens da psicanálise; que restringiram a capacidade de pensar o grupo no campo da psicanálise. Benefícios narcísicos foram extraídos destas resistências que ainda hoje dificultam a extensão da psicanálise no que diz respeito à inclusão do grupo como objeto teórico.

Abstract: Contributions of René Kaës to the epistemology of psychoanalysis. The objective of this article is to discuss the effects of the unconscious alliances on extension of psychoanalysis. 55 texts published in the Revista Brasileira de Psicanálise between 1967 and 1976 were analyzed under the theoretical framework of René Kaës. A brief historical reconstruction with the concept of unconscious alliances in order to investigate the narcissistic bases present since the origins of psychoanalysis; that restricted the capacity to think in the group in the field of psychoanalysis. Narcissistic benefits were extracted of this resistance, that still today difficult the extension of the psychoanalysis for the inclusion of the group as a theoretical object.

Embolismo cerebral durante vuelo comercial: reporte de caso / Cerebral embolism during commercial flight: case report

RESUMEN Presentamos el caso de un varón de 25 años con antecedentes de consumo de marihuana y tabaco, que durante viaje en vuelo comercial a Cusco presentó disnea, pérdida de conciencia y estado epiléptico. Arribó a esta ciudad presentando hipotensión arterial, murmullo pulmonar abolido, sin recuperación de conciencia. La tomografía de tórax reveló bullas pulmonares y la tomografía mostró neumoencéfalo, diagnosticándose embolia gaseosa cerebral. La hipoxemia asociada a convulsiones y pérdida de conciencia en una persona joven durante el vuelo no es un evento común. La pérdida de la presión en la cabina durante el ascenso parece ser el evento desencadenante en pacientes con enfermedad pulmonar.

ABSTRACT We present the case of a 25-year old man with a history of marijuana and tobacco consumption who, during a commercial flight to Cusco, presented dyspnea, loss of consciousness, and epileptic condition. He arrived in this city presenting arterial hypotension, abolished pulmonary murmur, with no recovery of consciousness. The thorax tomography revealed lung bullae and the tomography showed pneumocephalus. He was diagnosed with cerebral gas embolism. Hypoxemia associated with seizures and loss of consciousness in a young person during a flight is not a common event. Loss of cabin pressure during climb appears to be the triggering event in patients with lung disease.

Intermittent loss of consciousness during cesarean section under spinal anesthesia: a case report / Perda intermitente de consciência durante cesariana sob raquianestesia: relato de caso

Abstract Loss of consciousness during spinal anesthesia is a rare but scary complication. This complication is generally related to severe hypotension and bradycardia, but in this case, the loss of consciousness occurred in a hemodynamically stable parturient patient. We present a 31 years-old patient who underwent an emergency cesarean section. She lost consciousness and had apnea that started 10 minutes after successful spinal anesthesia and repeated three times for a total of 25 minutes, despite the stable hemodynamics of the patient. The case was considered a subdural block, and the patient was provided with respiratory support. The subdural block is expected to start slowly (approximately 15-20 minutes), but in this case, after about 10 minutes of receiving anesthesia, the patient suddenly had a loss of consciousness. After the recovery of consciousness and return of spontaneous respiration, the level of a sensory block of the patient, who was cooperative and oriented, was T4. There were motor blocks in both lower extremities. Four hours after intrathecal injection, both the sensory and motor blocks ended, and she was discharged two days later with no complications. Hence, patients who receive spinal anesthesia should be closely observed for any such undesirable complications.

Resumo A perda de consciência durante a raquianestesia é uma complicação rara, mas assustadora. Essa complicação geralmente está relacionada à grave hipotensão e bradicardia, mas, neste caso, a perda de consciência ocorreu em uma paciente parturiente hemodinamicamente estável. Apresentamos o caso de uma paciente de 31 anos, submetida a uma cesariana de emergência. A paciente perdeu a consciência e apresentou apneia que teve início 10 minutos após a raquianestesia bem-sucedida e repetiu o episódio três vezes por 25 minutos, a despeito de sua hemodinâmica estável. O caso foi considerado como um bloqueio subdural e a paciente recebeu suporte respiratório. Espera-se que o bloqueio subdural inicie lentamente (aproximadamente 15-20 minutos), mas, neste caso, cerca de 10 minutos após a anestesia, a paciente repentinamente perdeu a consciência. Após a recuperação da consciência e o retorno da respiração espontânea, a paciente que estava orientada e cooperativa apresentou nível de bloqueio sensorial em T4. Havia bloqueio motor em ambas as extremidades inferiores. O bloqueio sensório-motor terminou quatro horas após a injeção intratecal e a paciente recebeu alta hospitalar dois dias depois, sem complicações. Considerando o exposto, os pacientes que recebem raquianestesia devem ser atentamente observados para quaisquer complicações indesejáveis.

O vivo incomensurável: entre ciência e inconsciente / The incommendable living: between science and the unconscious

Pensar o laço entre neurociências e psicanálise obriga a pensar no incomensurável: pensar a partir do "nada em comum", para além de toda tradução, superposição, analogia redutora ou relação causa-efeito simplista. Senão permaneceremos nos pulos da pulga. Se pegarmos uma pulga, batermos uma palma: ela salta. Se lhe tirarmos uma pata, depois duas, depois três, ela salta cada vez menos longe. Se lhe tirarmos todas as patas, ela não salta de modo algum tal como quando batemos palma. Conclusão: a audição está nas patas! Há, com efeito, sempre o mesmo risco na interpretação das funções do cérebro: de ser tomado em uma relação estrutura-função simplista, linear, contínua, sem resto culminando em um falso raciocínio malgrado suas roupagens de evidência.

¿El siglo de las luces? / The lights century?

El siglo de las luces es una reflexión sobre el excesivo racionalismo de la medicina actual frente a los problemas del inconsciente dejando de lado el análisis del inconsciente del sujeto y la posibilidad del sujeto de mirarse así mismo.

This paper is a reflection about the excessive rationalism of current medici-ne against the unconscious problems leaving aside the analysis of the un-conscious of the person and the possibility of the person to look at himself.

O inconsciente e a lógica a partir de freud e lacan / The unconscious and the logic from freud and lacan

RESUMO: Nós propomos, neste artigo, uma interpretação da seguinte passagem do Abriss der Psychoanalyse de Freud: "As regras decisivas da lógica não têm validade no inconsciente, pode-se dizer que ele é o reino do ilógico". Para tanto, procederemos em quatro etapas: 1) Delimitar o conceito de lógica a partir do Organon de Aristóteles. 2) Identificar quais são as regras decisivas da lógica e seu conteúdo. 3) Examinar em que sentido tais regras não possuem validade no inconsciente. 4) Problematizar a tese freudiana de que o inconsciente seria o reino do ilógico. A ideia de que esta tese freudiana é problemática surge de uma tese que Lacan apresenta no seminário XIV sobre a lógica da fantasia, a saber, que o inconsciente "está instalado no campo da lógica e que ele articula proposições". Esta tese lacaniana nos permitirá chegar à conclusão de que o inconsciente não é totalmente o reino do ilógico.

Abstract: We propose, in this paper, an interpretation of this passage in Freud's Abriss der Psychoanalyse: "The decisive rules of logic don't apply in the unconscious, we could call it the Empire of the illogical". To do this, we are going to follow these steps: 1) Define the concept of logic through Aristotle's Organon. 2) Identify the decisive rules of logic and their contents. 3) Examine in what sense these rules don't apply in the unconscious. 4) Call into question Freud's thesis that unconscious would be the Empire of the illogical. The idea that this Freudian thesis is problematic comes from a thesis which Lacan presents in the seminar XIV on the logic of phantasy, namely that the unconscious "is installed in the field of logic and that it articulates propositions". This thesis will allow us to conclude that the unconscious is not completely the Empire of the illogical.

Costo-efectividad de la reanimación cardiopulmonar con el uso del desfibrilador externo automático, comparado con reanimación cardiopulmonar básica, para personas con pérdida de conciencia en espacios de afluencia masiva de público / Cost-effectiveness of cardiopulmonary resuscitation using an automated external defibrillator compared with a basic defibrillator in unconscious patients in crowded public spaces in Colombia

Resumen Objetivo: Estimar la razón de costo-efectividad de la reanimación cardiopulmonar con el uso del desfibrilador externo automático (DEA), comparado con la reanimación cardiopulmonar básica, para la reanimación de personas con pérdida de conciencia en espacios de afluencia masiva de público en Colombia. Métodos: Para estimar los costos y desenlaces de las dos alternativas de comparación, se diseñó un árbol de decisiones en el cual se reflejan los principales desenlaces posterior a la pérdida de conciencia y la reanimación con cualquiera de las dos alternativas. Se asumió la perspectiva del sistema de salud colombiano en un horizonte temporal comprendido entre el momento de la pérdida de conciencia de la persona hasta el ingreso al hospital. Las probabilidades de los eventos se obtuvieron de un meta-análisis de ensayos clínicos y la información de costos de fuentes oficiales y consulta directa a proveedores de DEA en Colombia. Los costos fueron expresados en pesos colombianos de 2016 y la efectividad en muertes evitadas. Se realizaron análisis de sensibilidad determinísticos y probabilísticos para estimar el impacto de la incertidumbre sobre las conclusiones. Resultados: La razón de costo-efectividad de la reanimación cardiopulmonar con DEA fue de $3.267.777 por muerte evitada. La probabilidad de que esta intervención sea costo-efectiva es superior al 90% para un umbral de costo-efectividad superior a 10 millones de pesos. Conclusión: Un programa de reanimación cardiopulmonar con desfibrilación temprana mediante el uso de DEA, en espacios de afluencia masiva de público, es una alternativa costo-efectiva para el sistema de salud colombiano.

Abstract Objective: To estimate the cost-effectiveness of cardiopulmonary resuscitation using an automated external defibrillator (AED) compared with basic cardiopulmonary resuscitation, for the resuscitation of unconscious patients in crowded public spaces in Colombia. Methods: A decision tree was designed in order to estimate the costs and outcomes of the two alternatives. This included the main outcomes after the loss of consciousness and resuscitation by any of the two alternatives. The perspective of the Colombian Health System was adopted in a time scale consisting of the time of loss of consciousness until hospital admission. The probabilities of the events were obtained from a meta-analysis of clinical trials, and the information on costs from official sources and direct consultations with AED providers in Colombia. The costs were expressed in Colombian pesos of 2016, and the effectiveness in deaths prevented. Deterministic and probabilistic sensitivity analyses were performed to estimate the impact of uncertainty on the conclusions. Results: The cost-effectiveness of cardiopulmonary resuscitation with AED was COP $3,267,777 per death avoided. The probability that this intervention would be cost-effective is greater than 90% for cost-effectiveness threshold greater than 10 million Colombian pesos. Conclusion: A cardiopulmonary resuscitation program with early defibrillation using an AED in crowded public spaces is a cost-effective alternative for the Colombian Health System.

Path Analysis for Delirium on Patient Prognosis in Intensive Care Units / 간호학회지

PURPOSE: This study was conducted to investigate relationship between delirium, risk factors on delirium, and patient prognosis based on Donabedian's structure-process-outcome model.METHODS: This study utilized a path analysis design. We extracted data from the electronic medical records containing delirium screening data. Each five hundred data in a delirium and a non-delirium group were randomly selected from electronic medical records of medical and surgical intensive care patients. Data were analyzed using SPSS 20 and AMOS 24.RESULTS: In the final model, admission via emergency department (B=.06, p=.019), age over 65 years (B=.11, p=.001), unconsciousness (B=.18, p=.001), dependent activities (B=.12, p=.001), abnormal vital signs (B=.12, p=.001), pressure ulcer risk (B=.12, p=.001), enteral nutrition (B=.12, p=.001), and use of restraint (B=.30, p=.001) directly affecting delirium accounted for 56.0% of delirium cases. Delirium had a direct effect on hospital mortality (B=.06, p=.038), hospital length of stay (B=5.06, p=.010), and discharge to another facility (not home) (B=.12, p=.001), also risk factors on delirium indirectly affected patient prognosis through delirium.CONCLUSION: The use of interventions to reduce delirium may improve patient prognosis. To improve the dependency activities and risk of pressure ulcers that directly affect delirium, early ambulation is encouraged, and treatment and nursing interventions to remove the ventilator and drainage tube quickly must be provided to minimize the application of restraint. Further, delirium can be prevented and patient prognosis improved through continuous intervention to stimulate cognitive awareness and monitoring of the onset of delirium. This study also discussed the effects of delirium intervention on the prognosis of patients with delirium and future research in this area.

Dexmedetomidine as a non-triggering anesthetic agent in a patient with MELAS syndrome and systemic sepsis: A case report

BACKGROUND: The selection of anesthetic agents is important in mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) syndrome patient because serious and unexpected complications can occur after anesthetic exposure.CASE: A 30-year-old man with MELAS syndrome and sepsis underwent colectomy. Propofol was administered by step-wise until target effect-site concentration (Ce) 1.0 µg/ml and stopped for the loss of consciousness and to avoid hemodynamic instability. After the loss of consciousness, total intravenous anesthesia (TIVA) using dexmedetomidine (1.0 µg/ml/h) and remifentanil (1–4 ng/ml of Ce) was performed for the maintenance of anesthesia to avoid malignant hyperthermia and mitochondrial dysfunction. During the surgery, the bispectral index score stayed between 26 and 44, and increased to 97 after the end of anesthesia.CONCLUSIONS: TIVA with dexmedetomidine and remifentanil as non-triggering anesthetic agents in patients with MELAS syndrome and systemic sepsis may have advantages to decrease damages associated with mitochondrial stress and metabolic burden.

Cognitive Decline in Korean Patients with Neurocognitive Disorder due to Traumatic Brain Injury: A Control for Premorbid Intelligence

OBJECTIVE: Previous studies of cognitive decline in patients with neurocognitive disorder due to traumatic brain injury (NCD-TBI) have often failed to control for baseline factors such as premorbid intelligence. The purpose of the current study was to estimate and compare cognitive function among three groups (controls, complicated mild/moderate TBI, and severe TBI) after controlling for premorbid intelligence.METHODS: Severity of TBI was classified as complicated mild/moderate or severe based on duration of loss of consciousness and brain neuroimaging results. Premorbid intelligence quotients (IQs) were estimated with the Oklahoma Premorbid Intelligence Estimate. There were no differences in premorbid intelligence between the groups, which were also matched for age and education. Current cognitive function was evaluated with the Wechsler Adult Intelligence Scale-Fourth Edition.RESULTS: Comparison of current cognitive function among the three groups indicated significant group differences for all indexes and subtest scores. Processing speed showed the highest effect size. However, only working memory differed significantly between the two NCD-TBI groups.CONCLUSION: The present findings suggest that mental memory manipulation processes seem to be more sensitive to TBI severity than are perceptual-motor processes. Specifically, both auditory rehearsal/discrimination and mental alertness/manipulation will be most strongly influenced by TBI severity.

Lipid emulsion therapy of local anesthetic systemic toxicity due to dental anesthesia

Local anesthetic systemic toxicity (LAST) refers to the complication affecting the central nervous system (CNS) and cardiovascular system (CVS) due to the overdose of local anesthesia. Its reported prevalence is 0.27/1000, and the representative symptoms range from dizziness to unconsciousness in the CNS and from arrhythmias to cardiac arrest in the CVS. Predisposing factors of LAST include extremes of age, pregnancy, renal disease, cardiac disease, hepatic dysfunction, and drug-associated factors. To prevent the LAST, it is necessary to recognize the risk factors for each patient, choose a safe drug and dose of local anesthesia, use vasoconstrictor , confirm aspiration and use incremental injection techniques. According to the treatment guidelines for LAST, immediate application of lipid emulsion plays an important role. Although lipid emulsion is commonly used for parenteral nutrition, it has recently been widely used as a non-specific antidote for various types of drug toxicity, such as LAST treatment. According to the recently published guidelines, 20% lipid emulsion is to be intravenously injected at 1.5 mL/kg. After bolus injection, 15 mL/kg/h of lipid emulsion is to be continuously injected for LAST. However, caution must be observed for >1000 mL of injection, which is the maximum dose. We reviewed the incidence, mechanism, prevention, and treatment guidelines, and a serious complication of LAST occurring due to dental anesthesia. Furthermore, we introduced lipid emulsion that has recently been in the spotlight as the therapeutic strategy for LAST.

Distinct Topographical Patterns of Spike-Wave Discharge in Transgenic and Pharmacologically Induced Absence Seizure Models

Absence seizures (AS) are generalized non-convulsive seizures characterized by a brief loss of consciousness and spike-and-wave discharges (SWD) in an electroencephalogram (EEG). A number of animal models have been developed to explain the mechanisms of AS, and thalamo-cortical networks are considered to be involved. However, the cortical foci have not been well described in mouse models of AS. This study aims to use a high density EEG in pathophysiologically different AS models to compare the spatiotemporal patterns of SWDs. We used two AS models: a pharmacologically induced model (gamma-hydroxybutyric acid, GHB model) and a transgenic model (phospholipase beta4 knock-out, PLCβ4 model). The occurrences of SWDs were confirmed by thalamic recordings. The topographical analysis of SWDs showed that the onset and propagation patterns were markedly distinguishable between the two models. In the PLCβ4 model, the foci were located within the somatosensory cortex followed by propagation to the frontal cortex, whereas in the GHB model, a majority of SWDs was initiated in the prefrontal cortex followed by propagation to the posterior cortex. In addition, in the GHB model, foci were also observed in other cortical areas. This observation indicates that different cortical networks are involved in the generation of SWDs across the two models.

A case of acute organic solvent poisoning during epoxy coating

BACKGROUND: In the construction industry, maintaining health and safety of workers often challenging. Among the workers at construction sites, painters are at particular risk of respiratory diseases and neurotoxicity. However, in Korea there is weak enforcement of workers' health and safety practices in the construction industry in Korea. Poisonings frequently occur at (semi)closed construction sites. In this study, we report a case of acute organic solvent poisoning during construction site painting. CASE PRESENTATION: A 71-year-old man was found unconscious at a construction site and immediately transferred to the emergency room. The consciousness level was 'stupor state' and the body temperature was hypothermic, at 32 degrees (Celsius). There were no acute brain or cardiac lesions that would have accounted for the faintness. In addition, blood and urine tests did not indicate a cause of loss of consciousness. He had been painting epoxy to waterproof the basement floor before fainting. According to exposure simulation, the patient was overexposed to various organic solvents, such as approximately 316–624 ppm toluene during the work before fainting. Considering the ventilation status of the workplace and the status of no protection, it is considered that exposure through the respiratory tract was considerable. CONCLUSIONS: The patient in this case lost consciousness during the epoxy coating in a semi-enclosed space. It can be judged as a result of acute poisoning caused by organic solvent exposure and considered to be highly related to work environment.