Characterization of end-of-life electroencephalographic surges in critically ill patients.

Neuromonitoring devices to assess level of sedation are now used commonly in many hospital settings. The authors previously reported that electroencephalicgraphic (EEG) spikes frequently occurred after the time of death in patients being neuromonitored at the time of cessation of circulation. In addition to the initial report, end-of-life electrical surges (ELES) have been subsequently documented in animal and human studies by other investigators. The frequency, character, intensity, and significance of ELES are unknown. Some have proposed that patients should not be declared dead for purposes of organ donation prior to the occurrence of an ELES. If clinical practice were altered to await the presence of an ELES, there could be detrimental consequences to donated organs and their recipients. To better characterize ELES, the authors retrospectively assessed the frequency and nature of ELES in serial patients. To better document ELES, they collected neuromonitoring, demographic, and clinical data on consecutive patients who expired while being actively monitored as part of their standard palliative care. These data were retrospectively collected when available as a convenience sample. The authors assessed 35 patients of which 7 were clinically confirmed as brain dead. None of the brain-dead patients displayed an ELES. Thirteen of the 28 remaining patients (46.4%) exhibited an ELES. The ELES observed were demonstrated to have high frequency EEG signal. The mean peak amplitude of ELES as measured by Patient State IndexTM (PSI) was 58.5 ± 25.7. In this preliminary assessment, the authors found that ELES are common in critically ill patients who succumb. The exact cause and significance of ELES remain unknown; further study is warranted.

Estimation of right atrial and ventricular hemodynamics by CT coronary angiography.

BACKGROUND: Computed tomography coronary angiography (CTCA) provides an accurate noninvasive alternative to the invasive assessment of coronary artery disease. However, a specific limitation of CTCA is inability to assess hemodynamic data. OBJECTIVE: We hypothesized that CTCA-derived measurements of contrast within the superior vena cava (SVC) and inferior vena cava (IVC) would correlate to echocardiographic estimations of right atrial and right ventricular pressures. METHODS: Medical records of all patients who underwent both echocardiography and CTCA in our center were reviewed (n = 32). Standard CTCA was performed with a 64-detector CT using test-bolus method for image acquisition timing and iso-osmolar contrast injection through upper extremity vein. The length of the column of contrast reflux into the inferior vena cava (IVC) was correlated to echocardiographically determine tricuspid regurgitation jet velocity (TRV). SVC area change with contrast injection at the level of the bifurcation of the pulmonary artery was also correlated with IVC sniff response by echocardiogram. RESULTS: The reflux column length was interpretable in 27 of 32 patients with a mean length of 10.1 ± 1.1 mm, and a significant bivariate correlation was observed between reflux column length and the tricuspid regurgitant jet velocity (r = 0.84; P < .0001). Mean SVC distensibility ratio was 0.63 ± 0.03; mean IVC sniff response ratio was 0.53 ± 0.03. SVC distensibility correlated to IVC sniff response with a Pearson r of 0.57 (P = .04). CONCLUSION: Quantification of IVC and SVC contrast characteristics during CTCA provides a feasible and potentially accurate method of estimating right atrial and ventricular pressure.

Effects of bariatric surgery on inflammatory, functional and structural markers of coronary atherosclerosis.

This study was designed to assess the effects of bariatric weight loss surgery on structural, functional, and inflammatory markers of coronary atherosclerosis. Obesity is a worldwide epidemic and an independent risk factor for coronary atherosclerosis. It remains unclear whether surgically induced weight loss reduces cardiovascular risk. This prospective study enrolled 50 consecutive subjects with morbid obesity who underwent Roux-en-Y gastric bypass surgery (GBS) after failed attempts at medical weight loss. Subjects were recruited through a comprehensive weight loss center affiliated with an academic tertiary care hospital. All subjects had body mass indexes > or =40 kg/m(2) or body mass indexes of 35 to 40 kg/m(2) with > or =2 co-morbid obesity-related conditions. Markers of coronary atherosclerosis, including brachial artery flow-mediated dilation, carotid intima-media thickness, and high-sensitivity C-reactive protein, were measured before GBS and 6, 12, and 24 months after GBS. There were statistically significant improvements in all measured markers of coronary atherosclerosis after GBS. The mean body mass index decreased from 47 to 29.5 kg/m(2) at 24 months (p <0.001), the mean carotid intima-media thickness regressed from 0.84 to 0.50 mm at 24 months (p <0.001), mean flow-mediated dilation improved from 6.0% to 14.9% at 24 months (p <0.05), and mean high-sensitivity C-reactive protein decreased from 1.23 to 0.65 mg/dl at 6 months (p <0.001) and to 0.35 mg/dl at 24 months (p <0.001). In conclusion, GBS results in significant improvements in inflammatory, structural, and functional markers of coronary atherosclerosis.