Establishing normal Lindegaard Ratio in healthy children 10-16 years of age.

PURPOSE: Transcranial doppler based diagnostic criteria for cerebral vasospasm are not well established in the pediatric population because there is no published normative data to support the diagnosis. Studies have relied on expert consensus, but the definitions have not been validated in children diagnosed with angiographic evidence of vasospasm. Obtaining normative data is a prerequisite to defining pediatric cerebral vasospasm and the Lindegaard Ratio (LR). In this study, we obtained normative data and calculation of the normal LR from healthy children aged 10-16 years. METHODS: TCD and carotid ultrasonography was used to measure steady state velocities of both the middle cerebral artery (VMCA) and the extracranial internal cerebral artery (VEICA) in healthy children aged 10-16 years. Demographic information, hemodynamic characteristics and the calculated LR (VMCA/VEICA) was determined for each subject using descriptive statistics. RESULTS: Of the 26 healthy children, 13 were male and 13 were female. VMCA ranged between 53 and 93 cm/sec. LR ranged between 1 and 2.2 for the cohort. VMCA for both males and females were within 2 standard deviations (SD) of the normal mean flow velocity. As the VMCA velocities approached 2 SD above the mean, LR did not exceed 2.2. CONCLUSION: Our results help define a threshold for LR which can be used to establish radiographic criteria for cerebral vasospasm in children. Our data suggests that using VMCA criteria alone would overestimate cerebral vasospasm and raises question of whether an LR threshold other than 3 is more appropriate for the cut off between hyperemia versus vasospasm in children.

A Comparison of Perioperative Complications and Outcomes in Patients Undergoing Cerebral Aneurysm Clipping Performed Ultra-Early (≤ 24 hours) versus Late (> 24 hours): A 7-Year Retrospective Study of 302 Patients.

Objectives The intracerebral aneurysm with subarachnoid hemorrhage (SAH) has a high morbidity and mortality rate. This study aimed to compare the incidences of perioperative complications in ultra-early surgery (within 24 hours) with those in late surgery (> 24 hours). Methods Retrospective data were reviewed for 302 patients who underwent craniotomies with aneurysm clipping between January 2014 and December 2020. Perioperative data were obtained from the medical records and reviewed by the investigators. The complications were compared between ultra-early and late operations. We were interested in major complications such as delayed ischemic neurologic deficit (DIND), intraoperative aneurysm rupture (IAR), and anesthesia-related complications. The short-term (in hospital) and long-term (1 year) outcomes in patients with or without DIND and IAR were compared. The collected data was statistically analyzed. Results Three hundred and two patients were analyzed, and 264 patients had completed follow-up. The ultra-early cases (150 patients) had a higher American Society of Anesthesiologists physical status, a lower Glasgow Coma Scale, and higher Hunt and Hess scales. The surgeons operated on more cases of the anterior cerebral artery as ultra-early operations. The incidence rates of DIND, IAR, severe hemodynamic instability, and cardiac arrest were 5.6, 8.3, 6.3, and 0.3%, respectively, which were not different between groups. However, the reintubation rate was higher in the ultra-early surgery cases (0 vs. 3.3%, p = 0.023). The DIND and IAR patients had poorer short-term (in hospital) outcomes. Conclusions There were no differences in major complications between ultra-early and late craniotomy with aneurysm clipping. However, the reintubation rate was strikingly higher in the ultra-early group. Patients with major complications had early, unfavorable outcomes.

Long-term multiple metabolic abnormalities among healthy and high-risk people following nonsevere COVID-19.

Few studies have identified the metabolic consequences of the post-acute phase of nonsevere COVID-19. This prospective study examined metabolic outcomes and associated factors in nonsevere, RT-PCR-confirmed COVID-19. The participants' metabolic parameters, the prevalence of long-term multiple metabolic abnormalities (≥ 2 components), and factors influencing the prevalence were assessed at 1, 3, and 6 months post-onset. Six hundred individuals (mean age 45.5 ± 14.5 years, 61.7% female, 38% high-risk individuals) with nonsevere COVID-19 attended at least one follow-up visit. The prevalence of worsening metabolic abnormalities was 26.0% for BMI, 43.2% for glucose, 40.5% for LDL-c, 19.1% for liver, and 14.8% for C-reactive protein. Except for lipids, metabolic-component abnormalities were more prevalent in high-risk hosts than in healthy individuals. The prevalence of multiple metabolic abnormalities at the 6-month follow-up was 41.3% and significantly higher in high-risk than healthy hosts (49.2% vs 36.5%; P = 0.007). Factors independently associated with a lower risk of these abnormalities were being female, having dyslipidemia, and receiving at least 3 doses of the COVID-19 vaccine. These findings suggest that multiple metabolic abnormalities are the long-term consequences of COVID-19. For both high-risk and healthy individuals with nonsevere COVID-19, healthcare providers should monitor metabolic profiles, encourage healthy behaviors, and ensure complete vaccination.

Dynamics of Antibody Responses after Asymptomatic and Mild to Moderate SARS-CoV-2 Infections: Real-World Data in a Resource-Limited Country.

The dynamics of humoral immune responses of patients after SARS-CoV-2 infection is unclear. This study prospectively observed changes in anti-receptor binding domain immunoglobulin G (anti-RBD IgG) and neutralizing antibodies against the Wuhan and Delta strains at 1, 3, and 6 months postinfection between October 2021 and May 2022. Demographic data, clinical characteristics, baseline parameters, and blood samples of participants were collected. Of 5059 SARS-CoV-2 infected adult patients, only 600 underwent assessment at least once between 3 and 6 months after symptom onset. Patients were categorized as immunocompetent (n = 566), immunocompromised (n = 14), or reinfected (n = 20). A booster dose of a COVID-19 vaccine was strongly associated with maintained or increased COVID-19 antibody levels. The booster dose was also more strongly associated with antibody responses than the primary vaccination series. Among patients receiving a booster dose of a mRNA vaccine or a heterologous regimen, antibody levels remained steady or even increased for 3 to 6 months after symptom onset compared with inactivated or viral vector vaccines. There was a strong correlation between anti-RBD IgG and neutralizing antibodies against the Delta variant. This study is relevant to resource-limited countries for administering COVID-19 vaccines 3 to 6 months after infection.

Early antiviral and supervisory dexamethasone treatment improve clinical outcomes of nonsevere COVID-19 patients.

This study aimed to evaluate the efficacy of early antiviral treatment in preventing clinical deterioration in asymptomatic or mildly symptomatic severe acute respiratory syndrome coronavirus 2 infected (COVID-19) patients in home isolation and to share our experiences with the ambulatory management of nonsevere COVID-19 patients. This retrospective study included mild COVID-19 adult patients confirmed by real-time reverse transcription-polymerase chain reaction. They received care via an ambulatory management strategy between July 2021 and November 2021. Demographic data, clinical progression, and outcomes were collected. Both descriptive and inferential statistics were performed to illustrate the cohort's characteristic and outcomes of the study. Univariable and multivariable logistic regression models were employed to investigate the associations between clinical factors and disease progression. A total of 1940 patients in the Siriraj home isolation system met the inclusion criteria. Their mean age was 42.1 ±â€…14.9 years, with 14.2% older than 60 years, 54.3% female, and 7.1% with a body weight ≥ 90 kg. Only 115 patients (5.9%) had deterioration of clinical symptoms. Two-thirds of these could be managed at home by dexamethasone treatment under physician supervision; however, 38 of the 115 patients (2.0% of the study cohort) needed hospitalization. Early favipiravir outpatient treatment (≤ 5 days from onset of symptoms) in nonsevere COVID-19 patients was significantly associated with a lower rate of symptom deterioration than late favipiravir treatment (50 [4.6%] vs 65 [7.5%] patients, respectively; P = .008; odds ratio 1.669; 95% confidence interval, 1.141-2.441). The unfavorable prognostic factors for symptom deterioration were advanced age, body weight ≥ 90 kg, unvaccinated status, higher reverse transcription-polymerase chain reaction cycle threshold, and late favipiravir treatment. The early delivery of essential treatment, including antiviral and supervisory dexamethasone, to ambulatory nonsevere COVID-19 patients yielded favorable outcomes during the COVID-19 pandemic in Thailand.

Early diagnosis by antigen test kit and early treatment by antiviral therapy: An ambulatory management strategy during COVID-19 crisis in Thailand.

This study aimed to assess the clinical characteristics of patients who registered at the Siriraj Favipiravir Clinic and to share our experiences in this comparatively unique clinical setting. This retrospective study included patients who registered at the Siriraj Favipiravir Clinic during August 11, 2021 to September 14, 2021. Included adult patients were those with severe acute respiratory syndrome coronavirus 2 (coronavirus disease 2019 [COVID-19]) infection confirmed by antigen test kit (ATK) or real-time reverse transcription-polymerase chain reaction, no favipiravir contraindication, no prior COVID-19 treatment, and not receiving care from another medical facility. Demographic data and outcomes were collected and analyzed. Of the 1168 patients (mean age: 44.8 ± 16.4 years, 55.7% female) who registered at the clinic, 117 (10%) did not meet the treatment criteria, and 141 (12%) patients did not pick up their medication. One-third of patients had at least 1 symptom that indicated severe disease. Higher proportion of unvaccinated status (56.7% vs 47.5%, P = .005), higher proportion of persons with risk factors for disease progression (37.7% vs 31.3%, P = .028), and longer duration between the date of clinic registration and the date of positive diagnostic test (3 vs 2 days, P = .004) were significantly more commonly observed in the severe disease group compared to the nonsevere disease group. The duration between symptom onset and the date of clinic registration was significantly longer in the real-time reverse transcription-polymerase chain reaction group than in the ATK group (6 vs 4 days, P < .001). Most patients (90.0%) had completed favipiravir treatment regimen. The improvement and mortality rates were 86.7% and 1.2%, respectively. COVID-19 severity is associated with vaccination status, baseline risk factors, and timing between disease detection and treatment. The use of ATK influences patients to seek treatment significantly earlier in ambulatory setting. Our early diagnosis and antiviral treatment strategy yielded favorable results in an outpatient setting during a COVID-19 outbreak in Thailand.

SARS-CoV-2 Antibody Response against Mild-to-Moderate Breakthrough COVID-19 in Home Isolation Setting in Thailand.

Background: In December 2021, Omicron replaced Delta as the dominant coronavirus disease 2019 (COVID-19) variant in Thailand. Both variants embody diverse epidemiological trends and immunogenicity. We investigated whether Delta and Omicron patients' biological and clinical characteristics and immunogenicity differed post-COVID-19 infection. Methods: This retrospective cohort study investigated the clinical outcomes and laboratory data of 5181 patients with mild-to-moderate COVID-19 (Delta, 2704; Omicron, 2477) under home isolation. We evaluated anti-receptor-binding domain immunoglobulin G (anti-RBD IgG) and surrogate viral neutralizing (sVNT) activity in 495 individuals post-COVID-19 infection during the Delta pandemic. Results: Approximately 84% of all patients received favipiravir. The median cycle threshold (Ct) values were lower for Omicron patients than Delta patients (19 vs. 21; p < 0.001), regardless of vaccination status. Upper respiratory tract symptoms were more frequent with Omicron patients than Delta patients. There were no significant associations between Ct and Omicron symptoms (95% confidence interval 0.98−1.02). A two-dose vaccine regimen reduced hospital readmission by 10% to 30% and death by under 1%. Anti-RBD IgG and sVNT against Delta were higher among older individuals post-COVID-19 infection. Older individuals expressed anti-RBD IgG and sVNT for a more extended period after two-dose vaccination than other age groups. Conclusions: After a full vaccination course, breakthrough mild-to-moderate Delta and Omicron infections have limited immunogenicity. Prior infections exert reduced protection against later reinfection or infection from novel variants. However, this protection may be sufficient to prevent hospitalization and death, particularly in countries where vaccine supplies are limited.

Incidence and Risk Factors of Hypoxemia During Interventional Rigid Bronchoscopy Under Spontaneous-assisted Ventilation.

BACKGROUND: Interventional rigid bronchoscopy for tracheobronchial stenosis can be performed under total intravenous anesthesia and spontaneous-assisted ventilation. Intraoperative hypoxemia can occur during this procedure, but the incidence and risk factors have not yet been determined. METHODS: Medical records of patients who underwent rigid bronchoscopy for the treatment of tracheobronchial stenosis under total intravenous anesthesia and spontaneous-assisted ventilation during the study period from January 2011 to December 2012 were retrospectively reviewed. RESULTS: There were 126 patients who underwent 263 procedures. The 2 main causes of tracheobronchial stenosis were tuberculosis (41.3%) and malignancy (35.7%). The 2 main locations of stenotic area were the trachea (58.6%) and the left main bronchus (46.4%). Tracheobronchial dilatation and stent insertion were performed in 78.7% and 21.3% of patients, respectively. The incidence of intraoperative hypoxemia was 25.5%. Independent risk factors for intraoperative hypoxemia were a degree of tracheal stenosis ≥75% (odds ratio: 2.48; 95% confidence interval, 1.19-5.17) and tumor removal procedure (odds ratio: 2.9; 95% confidence interval, 1.13-7.41). CONCLUSIONS: Incidence of intraoperative hypoxemia during interventional rigid bronchoscopy for tracheobronchial stenosis under spontaneous-assisted ventilation was 25.5%. Risk factors for hypoxemia were a degree of tracheal stenosis ≥75% and tumor removal procedure.

Severe Venous Air Embolism Related to Positioning in Posterior Cranial Fossa Surgery in Siriraj Hospital.

BACKGROUND: Posterior cranial fossa surgery is commonly performed under sitting and horizontal position in our institution. Venous air embolism is a potentially serious complication of neurosurgery especially in the sitting position. OBJECTIVE: We aim to compare the incidence of severe venous air embolism and other complications of both positions. MATERIAL AND METHOD: A retrospective analysis of medical record was performed in 192 patients undergoing posterior cranial fossa craniotomy from January 2010 to December 2013. Data collected from the records included demographic profile, patient position, hemodynamic changes, venous air embolism (VAE), blood loss/transfusion, duration of surgery, postoperative complications, duration of ICU stay, and postoperative discharge status. The definition of severe air embolism was identified as suspected VAE with decreased systolic blood pressure greater than 20%. RESULTS: There were 92 patients in sitting position (SP) group and 100 patients in horizontal position (HP) group. The incidence of severe venous air embolism was signficantly higher in SP group compared with HP group (41.3% vs. 11.0%, p<0. 001). SP group had more complications than HP group in both central nervous system (71% vs. 34.0%, p = 0.001), and cardiovascular system (17% vs. 6%, p = 0.001). Although postoperative ventilator time in SP group was less than HP group (1.24 vs. 1.60 days, p = 0.029), ICU and hospital stay were not different in either group. CONCLUSION: The incidence of severe venous air embolism detected by end tidal CO2 was significantly higher in SP group. However, 11% of HP group were suspected of severe air embolism.

Lidocaine for reducing propofol-induced pain on induction of anaesthesia in adults.

BACKGROUND: Pain on propofol injection is an untoward effect and this condition can reduce patient satisfaction. Intravenous lidocaine injection has been commonly used to attenuate pain on propofol injection. Although many studies have reported that lidocaine was effective in reducing the incidence and severity of pain, nevertheless, no systematic review focusing on lidocaine for preventing high-intensity pain has been published. OBJECTIVES: The objective of this review was to determine the efficacy and adverse effects of lidocaine in preventing high-intensity pain on propofol injection. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 10), Ovid MEDLINE (1950 To October 2014), Ovid EMBASE (1988 to October 2014), LILACS (1992 to October 2014) and searched reference lists of articles.We reran the search in November 2015. We found 11potential studies of interest, those studies were added to the list of 'Studies awaiting classification' and will be fully incorporated into the formal review findings when we update the review. SELECTION CRITERIA: We included randomized controlled trials (RCTs) using intravenous lidocaine injection as an intervention to decrease pain on propofol injection in adults. We excluded studies without a placebo or control group. DATA COLLECTION AND ANALYSIS: We collected selected studies with relevant criteria. We identified risk of bias in five domains according to the following criteria: random sequence generation, allocation concealment, adequacy of blinding, completeness of outcome data and selective reporting. We performed meta-analysis by direct comparisons of intervention versus control. We estimated the summary odds ratios (ORs) and 95% confidence intervals using the random-effects Mantel-Haenszel method in RevMan 5.3. We used the I(2) statistic to assess statistical heterogeneity. We assessed overall quality of evidence using the GRADE approach. MAIN RESULTS: We included 87 studies, 84 of which (10,460 participants) were eligible for quantitative analysis in the review. All participants, aged 13 years to 89 years, were American Society of Anesthesiologists (ASA) I-III patients undergoing elective surgery. Each study was conducted in a single centre in high- , middle- and low-income countries worldwide. According to the risk of bias assessment, all except five studies were identified as being of satisfactory methodological quality, allowing 84 studies to be combined in the meta-analysis. Five of the 84 studies were assessed as high risk of bias: one for participant and personnel blinding, one for incomplete outcome data, and three for other potential sources of bias.The overall incidence of pain and high-intensity pain following propofol injection in the control group were 64% (95% CI 60% to 67.9%) and 38.1% (95% CI 33.4% to 43.1%), respectively while those in the lidocaine group were 30.2% (95% CI 26.7% to 33.7%) and 11.8% (95% CI 9.7% to 13.8%). Both lidocaine admixture and pretreatment were effective in reducing pain on propofol injection (lidocaine admixture OR 0.19, 95% CI 0.15 to 0.25, 31 studies, 4927 participants, high-quality evidence; lidocaine pretreatment OR 0.13, 95% CI 0.10 to 0.18, 43 RCTs, 4028 participants, high-quality evidence). Similarly, lidocaine administration could considerably decrease the incidence of pain when premixed with the propofol (OR 0.19, 95% CI 0.15 to 0.24, 36 studies, 5628 participants, high-quality evidence) or pretreated prior to propofol injection (OR 0.14, 95% CI 0.11 to 0.18, 52 studies, 4832 participants, high-quality evidence). Adverse effects of lidocaine administration were rare. Thrombophlebitis was reported in only two studies (OR not estimated, low-quality evidence). No studies reported patient satisfaction. AUTHORS' CONCLUSIONS: Overall, the quality of the evidence was high. Currently available data from RCTs are sufficient to confirm that both lidocaine admixture and pretreatment were effective in reducing pain on propofol injection. Furthermore, there were no significant differences of effect between the two techniques.

Comparison of age-based and height-based formula for tracheal tube size in cardiac children.

OBJECTIVE: To compare the effectiveness of age-based formula (ABF) and height-based formula (HBF) for pediatric cardiac patients, including patients with failure to thrive (FTT). MATERIAL AND METHOD: In a retrospective study of 260 cardiac patients that included those with failure to thrive, aged 2 to 7 years was done. The actual uncuffed endotracheal tube (ETT) size was compared with the predicted one, using both the ABF [ID (mm) = age (years)/4 + 4] and the HBF [ID (mm) = height (cm)/30 + 2]. RESULTS: ABF and HBF correctly predicted 50.8% and 50.4% of ETT sizes (p = 1.0), whereas three sizes of tubes (one above and one below the predicted size) cover 95.8% and 93.5% of the patients, respectively (p = 0.24). In patients with FTT, both the ABF and HBF correctly predicted 56.6% of ETT sizes. CONCLUSION: Age- and height-based formula for estimating tube size in cardio-surgical children is equivalent and independent of physical development. Age-based formula as the simple method can be recommended. The availability of three tube sizes (one smaller one larger than estimated) should be ensured.

A prospective, randomized trial of silver containing hydrofiber dressing versus 1% silver sulfadiazine for the treatment of partial thickness burns.

Silver sulfadiazine has been used as a topical burn wound treatment for many years. Pain associated with dressing changes is a common problem in burn wounds. Aquacel Ag, a hydrofiber dressing coated with ionic silver has been reported to reduce burn wound infection and promote antimicrobial activity. The purpose of this study was to show the benefits of Aquacel Ag for the treatment of partial thickness burns. This prospective randomized study was conducted in 70 patients who had partial thickness burns less than 15% of total body surface area and were treated at Siriraj outpatient burn clinic during December 2006-February 2008. Patients were divided into two groups: Aquacel Ag-treated group with dressing changes every 3 days (35 patients) and 1% silver sulfadiazine-treated group, with daily dressing changes (35 patients). There was no difference in demographic data including age, gender, burn percentage between groups. Time-to-wound healing pain score during dressing change and cost of treatment were compared between both groups. Time-to-wound closure was significantly shorter in the Aquacel Ag-treated group (10 +/- 3 versus 13.7 +/- 4 days, P < 0.02) as well as pain scores at days 1, 3 and 7 (4.1 +/- 2.1, 2.1 +/- 1.8, 0.9 +/- 1.4 versus 6.1 +/- 2.3, 5.2 +/- 2.1, 3.3 +/- 1.9, respectively, P < 0.02). Total cost of treatment was 52 +/- 29 US dollars for the Aquacel Ag-treated group versus 93 +/- 36 US dollars for the silver sulfadiazine-treated group. This study showed that Aquacel Ag increased time to healing, decreased pain symptoms and increased patient convenience because of limiting the frequency of replacement of the dressing at lower total cost. This study confirms the efficacy of Aquacel Ag for the treatment of partial thickness burns at an outpatient clinic.

Benefit of hydrocolloid SSD dressing in the outpatient management of partial thickness burns.

Silver sulfadiazine has been used as topical medication in the treatment of partial-thickness burns or secondary degree burns for many years. Pain during daily wound cleansing is the main problem. Urgotul SSD, a hydrocolloid dressing with silver sulfadiazine (SSD) has been reported to reduce infection and exhibit antimicrobial activity in burn wounds. The purpose of the present study was to compare the efficacy of Urgotul SSD and 1% silver sulfadiazine for treatment of partial thickness burn wounds. The authors reviewed 68 patients who had partial thickness burn wound less than 15% total body surface area (TBSA%) and were treated at Siriraj outpatient burn clinic during July 2005-December 2006. All patients were divided into two groups: Urgotul SSD treated group (34 patients) and 1% silver sulfadiazine treated group (34 patients). The two groups were compared by the demographic data including age, gender, % total body surface area (TBSA) burn, % TBSA deep burn, type of burn as well as percent of wound infection, total cost of wound dressing, pain medication, level of pain and time of wound healing. There were no differences in demographic data of age, % TBSA burn, % wound infection, total treatment cost of burn wound care (52 +/- 38 US$ for Urgotul SSD versus 45 +/- 34 US$ for silver sulfadiazine treated group). Time of wound closure was significantly shorter in the Urgotul SSD treated group (10 +/- 4 days in Urgotul SSD versus 12 +/- 6 in 1% silver sulfadiazine treated group) between both groups (p < 0.05). Average pain scores and pain medication in Urgotul SSD treated group was significantly lower than 1% silver sulfadiazine treated group (3 +/- 1 versus 6 +/- 2 and respectively, p < 0.05). All of the patients who developed wound infection responded well to targeted topical and oral antibiotic treatment. The authors conclude that Urgotul SSD has advantages of reducing pain symptom, pain medication requirement, increased patient convenience due to decreased time of follow-up at outpatient burn clinic, limiting the frequency of replacement of the dressing at comparable total cost and incidence of burn wound infection. The present study confirms the efficacy of Urgotul SSD in the treatment of partial thickness or secondary degree burn wound at the outpatient clinic.

Iatrogenic chylothorax in major burn patient: case report and literature review.

Chylothorax is a potentially life-threatening form of pleural effusion containing lymphatic fluid. Its etiology may be either traumatic (either post-operative or a direct result of injury), a congenital abnormality of the thoracic duct, or non-traumatic. This is a case report of a left iatrogenic chylothorax, which developed 2 days after internal jugular vein catheterization, in a patient with 50% total body surface area (TBSA) burns. This complication was treated successfully by tube thoracostomy and oral supplementation with a low fat, high carbohydrate, high protein diet. Further the authors review the etiology, pathogenesis, clinical presentation and recommended management of catheter-related chylothorax.

Effect of equiosmolar solutions of mannitol versus hypertonic saline on intraoperative brain relaxation and electrolyte balance.

BACKGROUND: The purpose of the study was to compare the effect of equiosmolar solutions of mannitol and hypertonic saline (HS) on brain relaxation and electrolyte balance. METHODS: After institutional review board approval and informed consent, patients with American Society of Anesthesiologists physical status II-IV, scheduled to undergo craniotomy for various brain pathologies, were enrolled into this prospective, randomized, double-blind study. Patients received 5 ml/kg 20% mannitol (n = 20) or 3% HS (n = 20). Partial pressure of carbon dioxide in arterial blood was maintained at 35-40 mmHg, and central venous pressure was maintained at 5 mmHg or greater. Hemodynamic variables, fluid balance, blood gases, electrolytes, lactate, and osmolality (blood, cerebrospinal fluid, urine) were measured at 0, 15, 30, and 60 min and 6 h after infusion; arteriovenous difference of oxygen, glucose, and lactate were calculated. The surgeon assessed brain relaxation on a four-point scale (1 = relaxed, 2 = satisfactory, 3 = firm, 4 = bulging). Appropriate statistical tests were used for comparison; P < 0.05 was considered significant. RESULTS: There was no difference in brain relaxation (mannitol = 2, HS = 2 points; P = 0.8) or cerebral arteriovenous oxygen and lactate difference between HS and mannitol groups. Urine output with mannitol was higher than with HS (P < 0.03) and was associated with higher blood lactate over time (P < 0.001, compared with HS). Cerebrospinal fluid osmolality increased at 6 h in both groups (P < 0.05, compared with baseline). HS caused an increase in sodium in cerebrospinal fluid over time (P < 0.001, compared with mannitol). CONCLUSION: Mannitol and HS cause an increase in cerebrospinal fluid osmolality, and are associated with similar brain relaxation scores and arteriovenous oxygen and lactate difference during craniotomy.

The use of repeated head computed tomography in pediatric blunt head trauma: factors predicting new and worsening brain injury.

OBJECTIVE: Opinion is divided on the value of repeat head computed tomography for guiding clinical management of pediatric patients with blunt head trauma. This study describes the prevalence of worsening brain injury on repeat computed tomography, predictors of worsening computed tomography findings, and the frequency of neurosurgical intervention after the repeat computed tomography. DESIGN: Retrospective cohort study. SETTING: All patients were admitted to a level I pediatric trauma center between 1994 and 2003. PATIENTS: Children <15 yrs old with two or more head computed tomographies following hospital admission for blunt head trauma. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We reviewed the imaging reports to determine injury progression. Potential predictors of worsening computed tomography findings and neurosurgical intervention were recorded by chart review. Logistic regression and recursive partitioning were used to identify predictors. Twenty percent (50 of 257) of patients with mild head injury had worsening computed tomography findings, and three patients (1%) had subsequent neurosurgical intervention. Patients with moderate and severe head injuries were more likely to have worsening computed tomography findings (107 of 248; 43%) and to have neurosurgical intervention (15 of 248; 6%). In most surgical patients, repeat computed tomography was preceded by rapid decline in neurologic status or elevated intracranial pressure. Stratification based on four clinical factors (initial head injury severity, any intraparenchymal finding on initial computed tomography, normal findings on initial computed tomography, coagulopathy) identified 100% of the surgical patients and 89% of patients with worsening brain injuries on the repeat computed tomography. CONCLUSIONS: Repeat head computed tomography imaging is frequently used. About 30% of repeated computed tomographies showed new or worsening brain injury. However, worsening brain injury on repeat computed tomography rarely resulted in neurosurgical intervention. Patients with moderate or severe head injury and intraparenchymal injuries were more likely to show worsening brain injury and undergo neurosurgical intervention.

Abdominal compartment syndrome monitoring in major burn patients with Siriraj device catheter.

Abdominal compartment syndrome (ACS) is consistently reported to have significant morbidity and mortality. Major burn patients who receive massive fluid resuscitation are at high-risk for this condition. Close monitoring of ACS is necessary for these patients. Prolonged unrelieved intra-abdominal pressure (IAP) at greater than 20 mmHg can produce significant morbidity and mortality. The most widely accepted and feasible way to measure IAP is via the draining port of a standard urinary catheter Siriraj burn unit developed its own device from simple equipment that can be found easily in the hospital. It proved to be useful, cheap, and effective in monitoring intra-abdominal pressure. The present study described techniques of using this device for monitoring and early detection of ACS. Five major burn patients > or = 40% Total body surface area (TBSA) was measured by IAP measurement via foley catheter using the Siriraj device catheter compared to direct measurement via peritoneal catheter. There was no difference of IAP between the two methods (p = 0.48). This suggested that Siriraj device catheter was useful, not invasive, and effective in reflection of actually IAP Siriraj burn unit suggested IAP measurement in all major burns > or = 40% TBSA to early recognize and treat intra-abdominal hypertension(IAH) that can lead to ACS. Early detection of this syndrome might decrease the adverse effects after increasing abdominal pressure that can cause organ dysfunction.

Neurointensive care; impaired cerebral autoregulation in infants and young children early after inflicted traumatic brain injury: a preliminary report.

The objective of this report is to describe cerebral autoregulation after severe inflicted pediatric traumatic brain injury (iTBI). We examined cerebral autoregulation of both cerebral hemispheres (mean autoregulatory index; ARI) in children <5 years with Glasgow Coma Scale (GCS) score of <9 and no evidence of brain death within the first 48 h of pediatric intensive care unit (PICU) admission. Discharge and 6-month Glasgow Outcome Scale (GOS) scores were collected. GOS of <4 reflected poor outcome. All three iTBI and all seven noninflicted TBI (nTBI) patients had admission GCS score of <9. Eight of 10 patients had Autoregulatory Index (ARI) of <0.4 (impaired cerebral autoregulation) of at least one hemisphere. All children with iTBI had poor outcome, and none had intact cerebral autoregulation in both hemispheres. Children with nTBI had better overall outcome than those with iTBI. Two of the children with nTBI had intact autoregulation in both hemispheres and good outcome. Two of the three children with iTBI had differential effects on autoregulation between hemispheres despite bilateral injury. These are, to our knowledge, the first data on cerebral blood flow autoregulation in the unique setting of iTBI and provide a rationale for further study of their relationship to outcome and effects of therapy.

Early childhood gender differences in anterior and posterior cerebral blood flow velocity and autoregulation.

OBJECTIVE: We aimed to describe gender differences in blood flow velocity and autoregulation of the anterior and posterior cerebral circulations in prepubertal children. METHODS: A prospective observational cohort study was performed at Harborview Medical Center's Cerebrovascular Laboratory after institutional review board approval, consent, and assent procedures. Children underwent measurement of middle cerebral and basilar artery flow velocities and cerebral autoregulation testing of the middle cerebral and basilar arteries. Cerebral autoregulation was quantified using the autoregulatory index, and estimated cerebrovascular resistance was calculated. Autoregulatory index <0.4 reflects impaired cerebral autoregulation. Data are presented as mean +/- SD. Patients were healthy 4- to 8-year-old children. RESULTS: Forty-eight children (24 boys and 24 girls) 4 to 8 years of age (mean: 6 +/- 2 years) were enrolled. Middle cerebral artery flow velocity was higher than basilar artery flow velocity (96 +/- 13 vs 65 +/- 11 cm/s). Girls had higher middle cerebral artery flow velocity (99 +/- 11 vs 91 +/- 13 cm/s) and basilar artery flow velocity (70 +/- 10 vs 61 +/- 9 cm/s) than boys. Cerebral autoregulation was intact in all children. There was no gender difference in autoregulation between the middle cerebral artery (boys: 0.97 +/- 0.07; girls: 0.94 +/- 0.11) or basilar artery (boys: 0.94 +/- 0.13; girls: 0.94 +/- 0.11). CONCLUSIONS: Similar to older children and adults, girls between 4 and 8 years of age had higher middle cerebral and basilar artery flow velocity than age-matched boys. This difference may reflect inherent differences in cerebral metabolic rate and/or estimated cerebrovascular resistance between the genders.

Clinical experience with dexmedetomidine for implantation of deep brain stimulators in Parkinson's disease.

The pharmacologic profile of the alpha-2 agonist dexmedetomidine (Dex) suggests that it may be an ideal sedative drug for deep brain stimulator (DBS) implantation. We performed a retrospective chart review of anesthesia records of patients who underwent DBS implantation from 2001 to 2004. In 2003, a clinical protocol with Dex sedation for DBS implantation was initiated. Demographic data, use of antihypertensive medication, and duration of mapping were compared between patients who received Dex (11 patients/13 procedures) and patients who did not receive any sedation (controls: 8 patients/9 procedures). There were no differences in severity of illness between the two groups. Dex provided patient comfort and surgical satisfaction with mapping in all cases, and significantly reduced the use of antihypertensive medication (54% in the Dex group, versus 100% in controls, P = 0.048). In DBS implantation, sedation with Dex did not interfere with electrophysiologic mapping, and provided hemodynamic stability and patient comfort. Routine use of Dex in these procedures may be indicated.