Adequacy Of Recovery Research Articles

The HERMESS model for addictive behaviors recovery

Abstract Background: Addictive behaviors treatment networks are composed of harm-reduction services and recovery-oriented programs. Recovery is a perspective in addictive behavior intervention based on the empowerment, competencies, and life skills of a person with addictive behaviors. Recovery-oriented programs have advanced from traditional therapeutic communities to actual integral services, which are integrated in social and health networks and developed by multidisciplinary professional staff. This evolution has not been systematic until XXIst century, with the beginning of “Science of Recovery”. Objective: to analyse the development of recovery programs, especially the theoretical models and good practices actually in development into European programs and to present the HERMESS Recovery model. Methods: This study draws on qualitative research methodology (with a complementary part of statistics), using an action research approach. It was included in the project “HOME/2014/JDRU/AG/DRUG/7092-Triple R: Rehabilitation for Recovery and Reinsertion”. Into the project, they have been analysed theoretical models and good practices about recovery. Results: As main result of the Triple R project, it was developed an intervention model based on peer learning and socioemotional development called the “Triple R HERMESS” model on rehabilitation and recovery. Conclusions: the “Science of Recovery” is advancing to validated, replicable and measurable models and programs. Recovery-oriented programs must be integrated and connected with harm reduction networks, social services, health systems, and employment services; recovery is based on empowerment and peer social support, so it´s necessary to develop structured programs for these topics; it´s also necessary to create specific actions for several collectives, as develop evaluation systems to validate efficiency and adequacy of recovery- oriented programs. As a main conclusion, the HERMESS recovery model was developed to be a reference for new recovery-oriented programs. Keywords: Addictive behaviors, Recovery, Good practices, Transference, Treatment network.

Sugammadex Is Not a Silver Bullet: Caveats Regarding Unmonitored Reversal.

Sugammadex Is Not a Silver Bullet: Caveats Regarding Unmonitored Reversal.

Neostigmine: Mechanism of Action, Dosing, and Factors Determining Adequacy of Recovery Following Administration

The endpoint of adequate neuromuscular recovery allowing for safe extubation has been revised several times. A train-of-four (TOF) ratio of at least 0.9 measured at the adductor polices muscle is required to exclude clinically relevant residual paralysis. In particular, upper airway muscle integrity, the hypoxic ventilatory response, and swallowing are still impaired at shallow degrees of residual paralysis. The aim of this review is to evaluate the efficacy of neostigmine in achieving this higher benchmark. Recent findings suggest that (a) the administration of neostigmine should be delayed until advanced degrees of pre-reversal recovery have occurred (i.e., T1 > 25% or the fourth response to TOF stimulation), or recovery intervals over 15 min have to be accepted; (b) small concentrations of neostigmine (i.e., 20–30 μg/kg) are effective in antagonizing shallow degrees of residual paralysis; and (c) the appropriate administration of neostigmine (i.e., dosing based on monitoring) reduces postoperative complications and improves neuromuscular recovery. When 40–70 μg/kg neostigmine are administered at the return of 1–4 TOF responses, a recovery interval over 20 min can be expected. Increasing the dose of neostigmine will not further accelerate this interval, but it may increase the risk of paradoxical effects (i.e., the reappearance of fade). A shorter recovery interval is obtained when neostigmine-based reversal is given at more advanced spontaneous pre-reversal neuromuscular recovery.

Comparative study between prophylactic single dose of fentanyl and dexmedetomidine in the management of agitation after sevoflurane anesthesia in children

ObjectiveThe higher incidence of post sevoflurane agitation presents a great dilemma. This controlled study was performed to test the hypothesis that the prophylactic single dose of either dexmedetomidine or fentanyl reduces the incidence of emergence agitation post sevoflurane anesthesia in children.Patients and methodsNinety pediatric patients were scheduled for elective surgical procedures under general anesthesia and caudal block. They were randomized to one of three groups (each one is 30 patients); fentanyl group (1 μg/kg), dexmedetomidine (DEX) group (0.15 μg/kg), and control group. Recovery was assessed by time until eye opening on command, pain was evaluated by the children’s and infants’ postoperative pain scale (CHIPPS) and adequacy of recovery was assessed using a Modified Aldert score. Both were recorded every 15 min. Behavior score was recorded in the pre- and postoperative periods.Main resultsPatients in control group obtained higher values (9.65 ± 0.34) in the modified Aldert score than patients who received fentanyl (9.58 ± 0.30) and dexmedetomidine (9.37 ± 0.37). There was significant difference between dexmedetomidine and fentanyl groups For pain assessment, patients in control group suffered from pain when measured by CHIPPS (0.93 ± 0.56) more than patients in dexmedetomidine group (0.48 ± 0.45) and fentanyl group (0.13 ± 0.35), with more significant pain in dexmedetomidine group when compared to fentanyl group (p < 0.05). As regard behavior during emergence, there were significant differences between the placebo with 40% agitation and both fentanyl group with 21.4% agitation (p = 0.002) and dexmedetomidine group with 16.7% agitation (p = 0.001), while there were no significant differences between fentanyl and dexmedetomidine group.ConclusionsIncidence of postoperative agitation in pediatric patients receiving sevoflurane was decreased from 40% with placebo to 16.7% with dexmedetomidine and 21.4% with fentanyl with no significant differences between dexmedetomidine and fentanyl groups.

Muscle relaxants: a clinical update

The doses of neuromuscular blocking agents must be chosen in such a way as to allow enough spontaneous recovery to occur before the end of the procedure so that anticholinesterase-assisted recovery is possible. Stimulation of the facial nerve and assessment of the response of the corrugator supercilii is useful to predict intubating conditions and as a guide to deep blockade. However, the adequacy of recovery is best assessed by adductor pollicis monitoring.

Does Perioperative Monitoring of the Train-of-Four Response Influence the Frequency of Postoperative Residual Curarization in Propofol Anesthesia?

Background : Sometimes hypoxemia occurs in the postoperative recovery room because of post- operative residual curarization (PORC). Some reports show that postoperative residual curarization is common. FORC occurs after the use of the long-acting muscle relaxants. It has been recommended to use intermediate-acting muscle relaxants and a TOF monitor to decrease PORC. The purpose of this study was to examine whether the use of the TOF monitor during propofol anesthesia affects the incidence of postoperative residual curarization. Methods : 38 ASA I or II patients were divided randomly into two groups of 19 each. They received propofol-fentanyl-nitrous oxide for anesthesia. Pancuronium (80 ― 100 μg/kg) was used to facilitate tracheal intubation and additional doses were used to maintain surgical relaxation. The requirement for incremental doses of pancuronium and adequacy of recovery following reversal were assessed, either with (control group: n = 19) or without (experimental group: n = 19) TOF monitoring. Fifteen minutes after the arrival at the recovery room, neuromuscular function was assessed clinically and by using TOF. Results : There were no statistical differences in body weight, age, or duration of operation between the two groups. There was no statistical difference in the total dose of pancuronium and total dose of pancuronium relative to body weight and duration of operation. There were statistical differences in TOF ratio in the recovery room (0.73 vs. 0.86). The incidence of PORC was 47% in the control group and 5% in the experimental group. Conclusions : Though the monitoring of TOF did not effect the dose of muscle relaxant, it may have reduced the incidence of PORC. However, the PORC had no clinical significance because the mean TOF ratio in the two groups was over 0.7 and there were no clinical signs of residual muscle weakness. (Korean J Anesthesiol 2000; 38: 783-788)

Simple and cost effective clinical methods for measuring neuromuscular fade responses with emphasis on "train of four" fade.

To evaluate different pressure transducers, available in the operating room for pressure measurements, interfaced with common monitoring equipment, for quantitation of the train of four (TOF) fade during clinical neuromuscular block (NMB). We determined evoked pressure changes produced by the thumb in response to TOF stimuli. We studied the responses of: a) a membrane disc device, and b) modified pressure transducers which were placed directly under the distal phalanx of the thumb of the clenched hand. The responses were displayed/recorded on OR monitors. The optimal positioning of these thumb pressure sensing (TPS) devices and their sensitivity and accuracy during onset, spontaneous (partial) recovery and pharmacologic reversal of NMB, were determined in anesthetized patients during muscle relaxation (Vecuronium) and reversal (Neostigmine). Simultaneous comparisons were made on twenty eight patients between the TOF fade responses obtained by the TPS devices and by conventional electromyographic and/or mechanomyographic methods. Comparisons were made either between pairs of data (e.g. "t" test, correlation coefficients, measuring agreement) or between several "treatment" groups (ANOVA of repeated measures). Correlations between the results of the TPS devices and the other methods were the closest (r- > 0.8) at higher TOF (T4/T1) ratios (e.g. during reversal. Measuring agreement was satisfactory and no significant differences were detected between the regression data (e.g. slope, residuals, x-axis of the regression lines) of the T4/T1 ratios vs. time when comparing EMG and TPS data during reversal of NMB. Measuring quantitatively the TOF fade by TPS devices is an economically feasible method for determining the adequacy of recovery from clinical non-depolarizing NMB.

Monitoring of neuromuscular function.

Monitoring neuromuscular transmission provides valuable information to the anesthesiologist. The acquisition of relevant data contributes to a more predictable and rational approach to the use of muscle relaxants and assures improved patient care during and in the immediate postoperative period. Clinical noninvasive criteria such as the presence or absence of diplopia and or ptosis, the ability to open the eyes widely, protrude the tongue or swallow, measurement of hand grip strength or head lift or assessment of the vital capacity are limited to awake and cooperative patients. Measurement of inspiratory force and tidal volume can be evaluated in anesthetized patients breathing spontaneously. Central depressant drugs tend to depress these respiratory parameters. Accordingly, the assumption that relaxants are responsible for respiratory depression at the end of an anesthetic can only be documented when impairment of neuromuscular transmission can be demonstrated. The most reliable method of measuring neuromuscular function is to stimulate an accessible peripheral motor nerve and measurement of the evoked response of the skeletal muscle or muscles innervated by the stimulated motor nerve. The evoked muscle response depends on the pattern of motor nerve stimulation: Single twitch stimuli at a defined frequency, tetanic stimulation, posttetanic single twitch stimulation or train-of-four stimulation. The response to these different modes of stimulation can be assessed either mechanically (evoked tension response) or electrically (evoked electromyography: EMG or integrated EMG). These response criteria can be employed either individually or combined to evaluate the response to muscle relaxants and to assess the adequacy of recovery from neuromuscular blockade.

Anatomical studies of the circle of Willis in normal brain.

Introduction The present study was undertaken in order to determine the anatomical structures of the circle of Willis, 27 with the purpose of learning its normal configuration, the frequency of deficient or incomplete circles, and, if possible, how these findings can be correlated with the clinical problems of vascular disease, such as infarcts, aneurysms, and vascular anomalies. There are many problems in vascular disease of the brain which make desirable an intimate knowledge of variants in the anatomy of the circle of Willis. The state of the circle becomes important in determining the adequacy of the brain circulation in operations for cerebral aneurysm and in ligation of the carotid artery. The possibility of bypassing or shunting effects in occlusion of one of the cerebral vessels and the adequacy of recovery or lack of recovery after vascular occlusion might be explained in part by variations in the anatomy of the circle