Capillary Oxygen Saturation Research Articles

How Well Do Children with Cystic Fibrosis Sleep? An Actigraphic and Questionnaire-Based Study

To measure sleep patterns and quality, objectively and subjectively, in clinically stable children with cystic fibrosis (CF) and healthy control children, and to examine the relationship between sleep quality and disease severity. Clinically stable children with CF and healthy control children (7-18 years of age) were recruited. Sleep patterns and quality were measured at home with actigraphy (14 days). Overnight peripheral capillary oxygen saturation was measured via the use of pulse oximetry. Daytime sleepiness was evaluated by the Pediatric Daytime Sleepiness Scale (PDSS) and subjective sleep quality by the Sleep Disturbance Scale for Children and Obstructive Sleep Apnea-18. A total of 87 children with CF and 55 control children were recruited with no differences in age or sex. Children with CF had significantly lower total sleep time and sleep efficiency than control children due to frequent awakenings and more wake after sleep onset. In children with CF, forced expiratory volume in 1 second and overnight peripheral capillary oxygen saturation nadir correlated positively with total sleep time and sleep efficiency and negatively with frequency of awakenings and wake after sleep onset. Patients with CF had significantly greater Sleep Disturbance Scale for Children (45 vs 35; P < .001), Obstructive Sleep Apnea-18 (35 vs 24; P < .001), and PDSS scores (14 vs 11; P < .001). There was a negative correlation between PDSS and forced expiratory volume in 1 second (r = -0.23; P < .05). Even in periods of clinical stability, children with CF get less sleep than their peers due to more time in wakefulness during the night rather than less time spent in bed. Objective measures of sleep disturbance and subjective daytime sleepiness were related to disease severity. In contrast, parents of children with CF report high levels of sleep disturbance unrelated to disease severity.

Association of Microcirculation, Macrocirculation, and Severity of Illness in Septic Shock: A Prospective Observational Study to Identify Microcirculatory Targets Potentially Suitable for Guidance of Hemodynamic Therapy.

Clinically unapparent microcirculatory impairment is common and has a negative impact on septic shock, but specific therapy is not established so far. This prospective observational study aimed at identifying candidate parameters for microcirculatory-guided hemodynamic therapy. ClinicalTrials.gov : NCT01530932. Microcirculatory flow and postcapillary venous oxygen saturation were detected during vaso-occlusive testing (VOT) on days 1 (T0), 2 (T24), and 4 (T72) in 20 patients with septic shock at a surgical intensive care unit using a laser Doppler spectrophotometry system (O2C). Reperfusional maximal venous capillary oxygen saturation (SvcO2max) showed negative correlations with Simplified Acute Physiology Score II (SAPSII)/Sequential Organ Failure Assessment (SOFA) score, norepinephrine dosage, and lactate concentration and showed positive correlations with cardiac index (CI). At T24 and T72, SvcO2max was also inversely linked to fluid balance. With respect to any predictive value, SvcO2max and CI determined on day 1 (T0) were negatively correlated with SAPS II/SOFA on day 4 (T72). Moreover, SvcO2max measured on day 1 or day 2 was negatively correlated with cumulated fluid balance on day 4 ( r= -.472, P < .05 and r = -.829, P < .001). By contrast, CI neither on day 1 nor on day 2 was correlated with cumulated fluid balance on day 4 ( r = -.343, P = .17 and r = -.365, P = .15). In patients with septic shock, microcirculatory reserve as assessed by SvcO2max following VOT was impaired and negatively correlated with severity of illness and fluid balance. In contrast to CI, SvcO2max determined on day 1 or day 2 was significantly negatively correlated with cumulative fluid balance on day 4. Therefore, early microcirculatory measurement of SvcO2max might be superior to CI in guidance of sepsis therapy to avoid fluid overload. This has to be addressed in future clinical studies.

BPS 02–22 THE ACCURACY OF THE NEW CUFF-LESS BLOOD PRESSURE MONITORING SYSTEM

Objective: The present study aimed to evaluate the accuracy of the J-1 (Huinno) cuff-less blood pressure monitor system by invasive intra-arterial pressure monitoring. Design and Method: Studies were carried out in post-operation patients (n = 31, F = 17), with no history of cardiovascular disease. After operation, intra-arterial pressure monitoring was used for all blood pressure measurements. And we also measured ECG, peripheral capillary oxygen saturation (SpO2) and photoplethysmography (PPG) using GE Datex-ohmeda (S/5 FM) and the J-1 (Huinno). All parameters were collected for 10 minutes by 300 Hz. Finally, 29 patients were analysed to create the formula for cuff-less blood pressure. Results: The accuracy of ECG, heart rate and SpO2 by the J-1 (Huinno) was 96.5%, 99.5% and 99.9% respectively compared to medical device (GE Datex-ohmeda). The Goodness-Of-Fit (GOF) of the formula of systolic and diastolic blood pressure was 0.74 and 0.62 (adjusted-R2). The number of absolute differences between the J-1 (Huinno) and medical device within 5, 10, and 15 mmHg was for 52.06%, 83.23%, and 96.08%, respectively, for systolic blood pressure, and 46.87%, 87.53%, and 98.6%, respectively, for diastolic blood pressure. Conclusions: The J-1 (Huinno) cuff-less blood pressure monitor system is the new cuff-less device and might be useful as medical device according to BHS protocol.

Seizure-related modulation of systemic arterial blood pressure in focal epilepsy.

Cardiorespiratory function alterations are commonly observed with epileptic seizures and may lead to syncope and sudden unexpected death in epilepsy (SUDEP). Although most previous research has focused on controlling heart rate (HR) and respiration, little is known about seizure-related regulation of systemic blood pressure (BP). Herein, we have investigated whether the periictal modulation of systemic BP and HR depends on seizure characteristics. Systemic arterial BP, HR, and peripheral capillary oxygen saturation (SPO2 ) were continuously and noninvasively monitored using the ccNexfin device in those epilepsy patients undergoing video-electroencephalography (EEG) telemetry. Data are given as mean ± standard deviation (SD). Forty-five seizures in 37 patients were included. In focal seizures (FS, n = 35), the mean arterial BP (MAP) increased by 33 ± 35% and the HR by 53 ± 44%, whereas the SPO2 remained unaltered. The MAP and HR increases were significantly greater in FS with alterations in consciousness than in those without. For those FS that evolved to bilateral convulsive seizures (BCS, n = 10), all of the ictal recordings were compromised by artifacts. However, 2 min after seizure cessation, the MAP was enhanced by only 16 ± 14% and returned to a baseline slightly below preictal levels after 5 min, whereas the HR was increased by 77 ± 33% and remained elevated throughout the postictal phase. Periictal regulation of systemic BP and HR displays distinct patterns depending on the type of seizure with focal onset. These changes were unrelated to alterations in SPO2 . The potential clinical implications of these findings are discussed in the article.

Prevalence, Severity, and Prognostic Value of Sleep Apnea Syndromes in Cardiac Amyloidosis.

To assess prevalence, severity, and prognostic value of sleep-disordered breathing (SDB), in the three main cardiac amyloidosis (CA) types, i.e., light-chain (AL), transthyretin-related familial (m-TTR), or senile (WT-TTR). Patients consecutively referred for CA diagnosis work-up underwent cardiac assessment and nocturnal polygraphy. SDB was defined as apnea-hypopnea index (AHI) ≥ 5/h. Multivariate analysis was used to identify predictors of a major adverse cardiac event (MACE) defined as death, heart transplantation and acute heart failure. Seventy CA patients were included (31 AL, 22 m-TTR, 17 WT-TTR). The mean ± standard deviation age and left ventricular ejection fraction were 71 ± 12 years and 49% ± 13% and median (interquartile range) N terminal pro brain natriuretic peptide (NT-proBNP) was 3,932 (1,607; 7,028) pg/mL. The prevalence of SDB was 90% without difference between amyloidosis types. SDB was central in 27% and obstructive in 73%. AL had less frequent severe SDB compared to m-TTR and WT-TTR (P = 0.015) but longer time with peripheral capillary oxygen saturation (SpO2) < 90% (P = 0.037). After a median follow-up of 7.5 (2.8; 14.9) months, 49% patients experienced MACE. Time with nocturnal SpO2 < 90% was the only independent predictor of MACE. The best-identified threshold was 30 min. Values > 30 min were associated with bad prognosis (Log-rank χ(2): 8.01, P value = 0.005). Using binomial logistic regression, determinants of time with nocturnal SpO2 < 90% were New York Heart Association class (P = 0.011), and log-NT-proBNP (P = 0.04) but not AHI. In CA population, prevalence of SDB is high (90%) and dominated by the obstructive pattern. Bad prognosis in this population was driven by nocturnal desaturation, reflecting heart failure severity and respiratory involvement.

Yoga-based pulmonary rehabilitation for the management of dyspnea in coal miners with chronic obstructive pulmonary disease: A randomized controlled trial

BackgroundCoal mine dust exposure causes chronic airflow limitation in coal miners resulting in dyspnea, fatigue, and eventually chronic obstructive pulmonary disease (COPD). Yoga can alleviate dyspnea in COPD by improving ventilatory mechanics, reducing central neural drive, and partially restoring neuromechanical coupling of the respiratory system. ObjectivesTo evaluate the effectiveness of Integrated Approach of Yoga Therapy (IAYT) in the management of dyspnea and fatigue in coal miners with COPD. Materials and methodsRandomized, waitlist controlled, single-blind clinical trial. Eighty-one coal miners (36–60 years) with stable Stages II and III COPD were recruited. The yoga group received an IAYT module for COPD that included asanas, loosening exercises, breathing practices, pranayama, cyclic meditation, yogic counseling and lectures 90 min/day, 6 days/week for 12 weeks. Measurements of dyspnea and fatigue on the Borg scale, exercise capacity by the 6 min walk test, peripheral capillary oxygen saturation (SpO2%), and pulse rate (PR) using pulse oximetry were made before and after the intervention. ResultsStatistically significant within group reductions in dyspnea (P < 0.001), fatigue (P < 0.001) scores, PR (P < 0.001), and significant improvements in SpO2% (P < 0.001) and 6 min walk distance (P < 0.001) were observed in the yoga group; all except the last were significant compared to controls (P < 0.001). ConclusionsFindings indicate that IAYT benefits coal miners with COPD, reducing dyspnea; fatigue and PR, and improving functional performance and peripheral capillary SpO2%. Yoga can now be included as an adjunct to conventional therapy for pulmonary rehabilitation programs for COPD patients.

Growth Outcomes of Preterm Infants Exposed to Different Oxygen Saturation Target Ranges from Birth

To test whether infants randomized to a lower oxygen saturation (peripheral capillary oxygen saturation [SpO2]) target range while on supplemental oxygen from birth will have better growth velocity from birth to 36weeks postmenstrual age (PMA) and less growth failure at 36weeks PMA and 18-22months corrected age. We evaluated a subgroup of 810 preterm infants from the Surfactant, Positive Pressure, and Oxygenation Randomized Trial, randomized at birth to lower (85%-89%, n=402, PMA 26±1weeks, birth weight 839±186g) or higher (91%-95%, n=408, PMA 26±1weeks, birth weight 840±191g) SpO2 target ranges. Anthropometric measures were obtained at birth, postnatal days 7, 14, 21, and 28; then at 32 and 36weeks PMA; and 18-22months corrected age. Growth velocities were estimated with the exponential method and analyzed with linear mixed models. Poor growth outcome, defined as weight <10th percentile at 36weeks PMA and 18-22months corrected age, was compared across the 2 treatment groups by the use of robust Poisson regression. Growth outcomes including growth at 36weeks PMA and 18-22months corrected age, as well as growth velocity were similar in the lower and higher SpO2 target groups. Targeting different oxygen saturation ranges between 85% and 95% from birth did not impact growth velocity or reduce growth failure in preterm infants.

Effects of cryotherapy methods on circulatory, metabolic, inflammatory and neural properties: a systematic review

Abstract Introduction: The cooling therapy (cryotherapy) is commonly used in clinical environmental for the injuries treatment according to its beneficial effects on pain, local inflammation and the recovery time of patients. However, there is no consensus in the literature about the effects of cryotherapy in the physiological reactions of affected tissues after an injury. Objective: To realize a systematic review to analyze the cryotherapy effects on circulatory, metabolic, inflammatory and neural parameters. Materials and methods: A search was performed in PubMed, SciELO, PEDro and Scopus databases following the eligibility criteria. Included studies were methodologically assessed by PEDro scale. Results: 13 original studies were selected and presented high methodological quality. Discussion: The cryotherapy promotes a significant decrease in blood flow, in venous capillary pressure, oxygen saturation and hemoglobin (only for superficial tissues) and nerve conduction velocity. However, the effect of cryotherapy on the concentration of inflammatory substances induced by exercise, as the creatine kinase enzyme and myoglobin, remains unclear. Conclusion: The physiological reactions to the cryotherapy application are favorable to the use of this therapeutic tool in inflammatory treatment and pain decrease, and demonstrate its importance in the neuromuscular system injuries rehabilitation.

Butorphanol suppresses fentanyl-induced cough during general anesthesia induction: A randomized, double-blinded, placebo-controlled clinical trial.

Fentanyl-induced cough (FIC) is unwanted in the patients requiring stable induction of general anesthesia. This study was designed to evaluate the suppressive effects of butorphanol pretreatment on the incidence and severity of FIC during the induction of general anesthesia. A total of 315 patients of American Society of Anesthesiologists physical status I and II, scheduled for elective surgery under general anesthesia were randomized into 3 equally sized groups (n = 0105). Two minutes before fentanyl bolus, group I received intravenously 5 mL normal saline, groups II and III received butorphanol 0.015 and 0.03 mg/kg (diluted with saline to 5 mL), respectively. Patients were then administrated with fentanyl 2.5 μg/kg within 5 s. The incidence and severity of FIC was recorded for 2 minutes after fentanyl bolus. During experimental period, the mean arterial pressure, heart rate, and peripheral capillary oxygen saturation (SpO2) were recorded before the administration of butorphanol or normal saline (T0), 2 minutes (T1) after butorphanol injection, and 2 minutes (T2) after fentanyl injection. The incidence of FIC was 31.4% in group I, 11.4% in group II, and 3.8% in group III. Group III had a lowest incidence of FIC among 3 groups (P < 0.001, vs group I; P < 0.05, vs group II). The severe FIC was not observed in groups II and III, but was recoded from 6 patients in group I. At 2 minutes after fentanyl injection (T2), the mean arterial pressure was significantly higher in group I than that in groups II and III (P < 0.01, vs group II; P < 0.05, vs group III), but the values remained within safe limits. In conclusion, pretreatment with butorphanol could effectively and safely suppress FIC during anesthesia induction.

Considerations in the management of hypoxemic respiratory failure and persistent pulmonary hypertension in term and late preterm neonates.

Recent advances in our understanding of neonatal pulmonary circulation and the underlying pathophysiology of hypoxemic respiratory failure (HRF)/persistent pulmonary hypertension of the newborn (PPHN) have resulted in more effective management strategies. Results from animal studies demonstrate that low alveolar oxygen tension (PAO2) causes hypoxic pulmonary vasoconstriction, whereas an increase in oxygen tension to normoxic levels (preductal arterial partial pressure of oxygen (PaO2) between 60 and 80 mm Hg and/or preductal peripheral capillary oxygen saturation between 90% and 97%) results in effective pulmonary vasodilation. Hyperoxia (preductal PaO2 >80 mm Hg) does not cause further pulmonary vasodilation, and oxygen toxicity may occur when high concentrations of inspired oxygen are used. It is therefore important to avoid both hypoxemia and hyperoxemia in the management of PPHN. In addition to oxygen supplementation, therapeutic strategies used to manage HRF/PPHN in term and late preterm neonates may include lung recruitment with optimal mean airway pressure and surfactant, inhaled and intravenous vasodilators and 'inodilators'. Clinical evidence suggests that administration of surfactant or inhaled nitric oxide (iNO) therapy at a lower acuity of illness can decrease the risk of extracorporeal membrane oxygenation/death, progression of HRF and duration of hospital stay. Milrinone may be beneficial as an inodilator and may have specific benefits following prolonged exposure to iNO plus oxygen owing to inhibition of phosphodiesterase (PDE)-3A. Additionally, sildenafil, and, in selected cases, hydrocortisone may be appropriate options after hyperoxia and oxidative stress owing to their effects on PDE-5 activity and expression. Continued investigation into these and other interventions is needed to optimize treatment and improve outcomes.

Low-positive pressure ventilation improves non-hypoxaemic apnoea tolerance during ear, nose and throat pan-endoscopy: A randomised controlled trial.

It has been suggested that oxygenation using pressure support ventilation (PSV) before general anaesthesia can reduce the duration of non-hypoxaemic apnoea. The objective was to determine whether or not pre-oxygenation with PSV increases the duration of non-hypoxaemic apnoea in non-obese patients during pan-endoscopy. A randomised, controlled trial. Amiens University Hospital, France. Fifty patients scheduled for ENT pan-endoscopy with a BMI lower than 35 kg m(-2). Patients scheduled for pan-endoscopy were enrolled to receive either 100% oxygen at neutral pressure (the control group) or 100% oxygen with positive-pressure ventilation (a positive inspiratory pressure of 4 cmH2O and a positive end-expiratory pressure of 4 cmH2O; the PSV group) during spontaneous ventilation with a face mask. The goal of pre-oxygenation was to obtain an end-tidal oxygen concentration of more than 90% prior to induction of anaesthesia. The primary efficacy criterion was the duration of non-hypoxaemic apnoea (i.e. before the peripheral capillary oxygen saturation fell to 90%). Secondary outcomes were duration of pre-oxygenation, pre-oxygenation failure and tolerance. The mean (interquartile range) duration of non-hypoxaemic apnoea was longer in the PSV group [598 (447 to 717) s] than in the control group [310 (217 to 451) s] (P < 0.001). Oxygenation time was shorter in the PSV group [190 (159 to 225) s] than in the control group [245 (151 to 435) s] (P = 0.037). Pre-oxygenation was unsuccessful (i.e. end-tidal oxygen concentration was < 90%) in 20% of the patients in the control group but none in the PSV group. The intergroup difference in the duration of pan-endoscopy was not significant. Tolerance was good or very good in all patients. Our results show that pre-oxygenation with PSV is associated with a longer duration of non-hypoxaemic apnoea and a lower frequency of manual reventilation during ENT pan-endoscopy. CLINICALTRIALS. NCT02167334.

Accuracy of Pulse Oximeters Intended for Hypoxemic Pediatric Patients.

Prior studies have shown inaccuracies in pulse oximetry readings at saturations less than 85%; however, no large studies have evaluated new sensors marketed for these low saturations. This study's purpose was to evaluate two sensors with claims of improved accuracy in children with saturations less than 85%. Prospective observational study. Single institution; cardiac catheterization laboratory, and operating room. Fifty patients weighing 3-20 kg with baseline saturations less than 90% undergoing surgical or catheterization procedure. Data collected included demographics, diagnosis, continuous saturations from three different pulse oximeters (Masimo LNCS [Masimo, Irvine, CA], Masimo Blue [Masimo], and Nellcor Max-I [Medtronic, Dublin, Ireland]) and up to four blood samples for co-oximetry as the gold-standard arterial oxygen saturation. Analysis included scatter plots, smoothed regression estimates of mean continuous saturation levels plotted against corresponding arterial oxygen saturation values, and Bland-Altman plots. Bland-Altman analysis indicated increasing levels of bias and variability for decreasing arterial oxygen saturation levels for all three sensors, with a statistically significant increase in mean difference observed for decreasing arterial oxygen saturation level. The Masimo Blue sensor had the lowest mean difference, SD and Bland-Altman limits in patients with saturations less than or equal to 85%. At saturation range of less than or equal to 85% and greater than 75%, 14% of the samples obtained from Masimo Blue, 24% of the readings from the Nellcor, and 31% from the Masimo Standard sensors were greater than or equal to 5% points difference. All three sensors had a further increase in these differences for arterial oxygen saturation values less than 75%. The Masimo Blue sensor has improved accuracy at saturations 75-85% versus the Nellcor and Masimo Standard sensors. The accuracy of peripheral capillary oxygen saturation of the Masimo Blue sensor was within 5% points of the arterial oxygen saturation the majority of the time. Currently, at saturations less than or equal to 85%, pulse oximetry alone should not be relied on in making clinical decisions.

Hypoxaemia on arrival in a multidisciplinary intensive care unit.

Transport of the critically ill patient poses the risk of numerous complications. Hypoxaemia is one such serious adverse event and is associated with potential morbidity and mortality. It is, however, potentially preventable. To determine the incidence of hypoxaemia on arrival in a tertiary multidisciplinary intensive care unit (ICU) and to identify risk factors for this complication. A retrospective observational study was conducted at King Edward VIII Hospital, Durban, South Africa, from May 2013 to February 2014. Hypoxaemia occurred in 15.5% of admissions sampled. Statistically significant risk factors for hypoxaemia on univariate analysis (p&lt;0.05) included lack of peripheral capillary oxygen saturation (SpO2) monitoring, transfer by an intern as opposed to other medical/paramedical staff, and transfer from internal medicine. Use of neuromuscular blockers and transfer from theatre were protective. Binary logistic regression analysis revealed lack of SpO2 monitoring to be the only significant independent predictor of hypoxaemia (odds ratio 6.1; 95% confidence interval 1.5 - 24.5; p=0.02). Hypoxaemia is common on admission to the ICU and may be prevented by simple interventions such as appropriate transport monitoring.

Enhanced recovery after giant ventral hernia repair.

Giant ventral hernia repair is associated with a high risk of postoperative morbidity and prolonged length of stay (LOS). Enhanced recovery (ERAS) measures have proved to lead to decreased morbidity and LOS after various surgical procedures, but never after giant hernia repair. The current study prospectively examined the results of implementation of an ERAS pathway including high-dose preoperative glucocorticoid, and compared the outcome with patients previously treated according to standard care (SC). Consecutive patients who underwent giant ventral hernia repair were included. Pain, nausea and fatigue were registered prospectively in all patients treated according to ERAS, as well as continuous measurement of transcutaneous capillary oxygen saturation. Postoperative morbidity and LOS were compared between patients treated according to ERAS and a historic group treated with SC. A total of 32 patients were included. Postoperative LOS was decreased after the introduction of the ERAS pathway compared with SC (median 3.0 vs. 5.5days, P=0.003). Scores of pain, nausea and fatigue were low, while mean oxygen saturation during the first three postoperative days was 0.92. There were no differences when comparing readmission (5 vs. 2, P=0.394), postoperative complications (7 vs. 4, P=0. 458), or reoperation (5 vs. 1, P=0.172) in ERAS versus controls. The current study suggests that an ERAS pathway including preoperative high-dose glucocorticoid may lead to low scores of pain, fatigue and nausea after giant ventral hernia repair with reduced LOS compared with patients treated according to SC.

Sleep-disordered breathing in children with Down syndrome: Usefulness of home polysomnography

ObjectiveTo investigate the technical feasibility of unattended home polysomnography (HPSG) in children with Down syndrome. MethodsData from children with Down syndrome under 10 years of age referred to a diagnostic sleep study was analyzed. A full sleep-lab based polysomnography (PSG) or a HPSG with a portable device was performed. Uninterpretable HPSGs were defined as: recordings with (i) loss of ≥2 of the following channels: nasal flow, or thoracoabdominal sensors, or (ii) HPSG with less than 4h of artifact-free recording time or (iii) less than 4h SpO2 (peripheral capillary oxygen saturation) signal. ResultsA total of 44 children (68% males) were included in the study, with a mean age of 3.6 (0.1–10) years. PSG was performed in 8 cases and HPSG in 36 cases. Six HPSG recordings were classified as uninterpretable and had to be repeated. Age, gender and BMI were no significant predictors of uninterpretability of the HPSG. Obstructive sleep apnea (OSA) was present in 61% (n=27) of all subjects, and classified as mild, moderate, and severe in 43% (n=19), 11% (n=5), and 7% (n=3) of cases, respectively. Interpretable and technically acceptable HPSGs were obtained in 30 subjects (83%). Age, gender and BMI were no significant predictors for interpretability of the HPSG. DiscussionThis study demonstrates that a portable polysomnographic home device may be helpful for diagnosing OSA in children with Down syndrome. Considering the potential consequences of untreated OSA, this screening test may be helpful for early diagnosis of OSA in children with Down syndrome.

Abstract 34: Low SpO 2 and Lack of Heparin are Associated With Cardiac Catheterization-related Stroke in Children With Congenital Heart Disease

Introduction: Stroke is an uncommon yet serious complication associated with cardiac catheterization in children with congenital heart disease. Our objective was to estimate the frequency and predictors of arterial ischemic stroke (AIS) in this specific setting. Methods: We performed a case-control study of children with congenital heart disease, who developed stroke in relation to cardiac catheterization performed at the Hospital for Sick Children between 1 January, 1992 and 1 January, 2014. Cases had new AIS (either symptomatic or silent) within 72 hours of cardiac catheterization and controls had cardiac catheterization but no new stroke within this time window. We estimated the frequency of AIS in children who underwent cardiac catheterization in this study period. Predictors of stroke that were tested include age, nature of intra-cardiac shunt, pre-procedural peripheral capillary oxygen saturation (SpO 2 ), type of catheterization (diagnostic versus interventional), duration of procedure, right versus left heart protocol, procedural anticoagulation and major/minor complications. Pediatric Stroke Outcome Measure was used to assess the neurological outcome of cases. Results: Twenty eight children (mean age1.66years; 64% males) developed stroke among 19414 children who underwent cardiac catheterization during the study period. The frequency of cardiac catheterization related-stroke in children is 1.44/1000 cardiac catheterizations. Univariate analysis revealed that younger age (OR 1.22; 95% CI (1.02,1.45); p=0.030), low SpO 2 pre-catheterization (OR 1.08; 95% CI (1.03,1.12); p=0.004), lack of procedural anticoagulation with heparin (OR 3.57; 95% CI (1.04,11.76); p=0.044), and minor complications during catheterization (OR 7.15; 95% CI (1.51,33.79); p=0.013) were associated with stroke. Low SpO 2 pre-catheterization and lack of procedural anticoagulation remained significant in multivariate analysis. Conclusion: The frequency of stroke after cardiac catheterization in children with congenital heart disease is 1.44/1000 cardiac catheterizations. Low SpO 2 pre-catheterization and lack of procedural anticoagulation appear to be associated with a higher risk of stroke.

Changes in Default Alarm Settings and Standard In-Service are Insufficient to Improve Alarm Fatigue in an Intensive Care Unit: A Pilot Project.

BackgroundClinical alarm systems safety is a national concern, specifically in intensive care units (ICUs) where alarm rates are known to be the highest. Interventional projects that examined the effect of changing default alarm settings on overall alarm rate and on clinicians’ attitudes and practices toward clinical alarms and alarm fatigue are scarce.ObjectiveTo examine if (1) a change in default alarm settings of the cardiac monitors and (2) in-service nursing education on cardiac monitor use in an ICU would result in reducing alarm rate and in improving nurses’ attitudes and practices toward clinical alarms.MethodsThis quality improvement project took place in a 20-bed transplant/cardiac ICU with a total of 39 nurses. We implemented a unit-wide change of default alarm settings involving 17 parameters of the cardiac monitors. All nurses received an in-service education on monitor use. Alarm data were collected from the audit log of the cardiac monitors 10 weeks before and 10 weeks after the change in monitors’ parameters. Nurses’ attitudes and practices toward clinical alarms were measured using the Healthcare Technology Foundation National Clinical Alarms Survey, pre- and postintervention.ResultsAlarm rate was 87.86 alarms/patient day (a total of 64,500 alarms) at the preintervention period compared to 59.18 alarms/patient day (49,319 alarms) postintervention (P=.01). At baseline, Arterial Blood Pressure (ABP), Pair Premature Ventricular Contractions (PVCs), and Peripheral Capillary Oxygen Saturation (SpO2) alarms were the highest. ABP and SpO2 alarms remained among the top three at the postproject period. Out of the 39 ICU nurses, 24 (62%) provided complete pre- and postproject survey questionnaires. Compared to the preintervention survey, no remarkable changes in the postproject period were reported in nurses’ attitudes. Themes in the narrative data were related to poor usability of cardiac monitors and the frequent alarms. The data showed great variation among nurses in terms of changing alarm parameters and frequency of replacing patients' electrodes. Despite the in-service, 50% (12/24) of the nurses specified their need for more training on cardiac monitors in the postproject period.ConclusionsChanging default alarm settings and standard in-service education on cardiac monitor use are insufficient to improve alarm systems safety. Alarm management in ICUs is very complex, involving alarm management practices by clinicians, availability of unit policies and procedures, unit layout, complexity and usability of monitoring devices, and adequacy of training on system use. The complexity of the newer monitoring systems requires urgent usability testing and multidimensional interventions to improve alarm systems safety and to attain the Joint Commission National Patient Safety Goal on alarm systems safety in critical care units.

The Effect of an Inspiratory Muscle Training Period at High Altitude on Arterial Oxygen Saturation and Performance of Iran’s National Team Endurance Runners

The aim of this study was to investigate the effect of inspiratory muscle training at high altitude on peripheral capillary oxygen saturation and performance among endurance runners. Twelve endurance male runners (age: 24 yrs ± 3 yrs, height: 180.5 cm ± 4.2 cm, weight: 66.7 kg ± 3 kg, Body mass index: 20.5 ± 1.0) among Iranian national team were randomly divided into case and control group in hypoxic condition. Exhaustive testing free 1500 m, strength Index and arterial oxygen saturation tests were taken before and 24 h after training period. Training program include same continues, interval, aerobic and resistance training for two groups. Runners performed 16 training session per week in high altitude within four weeks. Data were analyzed by analysis of variance (P ≤ 0.05). Inspiratory muscle training at hypoxia due to significant decrease in 1500 m running performance, inspiratory muscle strength and peak inspiratory flow in both group, but the differences in volume and peripheral capillary oxygen saturation were not significant (P ≤ 0.05). This study suggests that using inspiratory muscle training along with specified training in hypoxia increases inspiratory muscle strength and peak inspiratory flow pressure meanwhile it decreases ventilation and 1500 m running time in lower altitude.

Hemodynamic and respiratory conditions of patients with obstetric fistulae operated under spinal anesthesia at the Regional Reference Hospital in Manakara, Madagascar

L'objectif était d'évaluer les états hémodynamiques et respiratoires des opérées de fistules obstétricales et rapporter nos expériences sur la prise en charge de ces malades. Il s'agit d'une étude transversale descriptive effectuée au Bloc opératoire et Réanimation du CHRR Manakara allant du 20 au 30 aout 2013. Etaient incluses les patientes opérées de fistules obstétricales sous rachianesthésie. Nous avons exclu les patientes classées ASA >2 et celles ayant des tares cardio-vasculaires ou respiratoires. Après consultations préanesthésiques, et bilans préopératoires, nous avons administré chez les patientes 12,5mg de bupivacaïne adrénalinée 0,5% isobare en intrathécal. Elles étaient mises en position de Trendelenburg 5 minutes après l'injection du produit anesthésique et durant toute l'intervention. Le niveau sensitif, la pression artérielle, la fréquence cardiaque, la fréquence respiratoire et la saturation pulsée en oxygène (SpO2) étaient enregistrés pendant l'intervention. Nous avons retenues 57 malades. Le bloc sensitivomoteur était excellent pour toutes les malades. Un niveau métamérique supérieur à T6 était atteint chez 56,36% des malades. A part quelques épisodes d'hypertension artérielle et tachycardie, nous n'avons trouvé aucune difficulté respiratoire ni cardiovasculaire en rapport avec la position. Seuls, le niveau sensitif et la fréquence respiratoire présentaient une corrélation (p=0,01). Cette étude suggère que la position de Trendelenburg est réalisable au cours de la rachianesthésie en utilisant un produit anesthésique approprié, en faisant attention, notamment aux changements de position et en tenant compte de l'examen préanesthésique.

Severe Hypotension, Hypoxia, and Subcutaneous Erythema Induced by Indigo Carmine Administration during Open Prostatectomy.

Indigo carmine (also known as 5,5′-indigodisulfonic acid sodium salt or indigotine) is a blue dye that is administered intravenously to examine the urinary tract and usually is biologically safe and inert. Indigo carmine rarely may cause adverse reactions. We treated a 66-year-old man who had general anesthesia and radical retropubic prostatectomy for prostate cancer. He had a previous history of allergy to bee sting with nausea, vomiting, and dizziness. Within 1 minute after injection of indigo carmine for evaluation of the ureters, the patient developed hypotension to 40 mmHg, severe hypoxia (the value of SpO2 (peripheral capillary oxygen saturation) was 75% on 40% inspired oxygen concentration), poor air movement and bilateral diffuse wheezing on auscultation, and marked subcutaneous erythema at the upper extremities. After treatment with 100% oxygen, epinephrine (total, 1.5 mg), hydrocortisone (100 mg), diphenhydramine (50 mg), albuterol nebulizer (0.083%), and continuous infusion of epinephrine (0.15 μg/kg/min), the vital signs became stable, and he recovered completely. In summary, indigo carmine rarely may cause life-threatening anaphylactic or anaphylactoid reaction that may necessitate rapid treatment to stabilize cardiovascular, hemodynamic, and pulmonary function.