Eye Opening Response Research Articles

MiR-221-5p regulates blood–brain barrier dysfunction through the angiopoietin-1/-2/Tie-2 signaling axis after subarachnoid hemorrhage

ABSTRACT Aim To explore the potential role of microRNA miR-221-5p on the angiopoietin-1 (Ang-1)/Ang-2/Tie-2 signaling axis after subarachnoid hemorrhage (SAH) in a rat model. Methods Aspects of the rat’s behavior were measured using the Kaoutzanis scoring system to test neurological responses. This included feeding behavior, body contraction, motor, and eye-opening responses. Brain sections were studied using transmission electron microscopy and Evans blue extravasation. Levels of Ang-1, Ang-2, and Tie-2 were determined by Western blot, while miR-221-5p was quantified using stem-loop real-time quantitative PCR (RT-qPCR). Results The SAH group responded worse to the neurological response test than the sham-operated group. The intercellular space was widened in the SAH group, but not in the sham-operated group. Evans blue dye leaked significantly more into brain tissue cells of the SAH group. Stem-loop qRT-PCR showed elevated miR-221-5p levels. Additionally, Ang-1 and Tie-2 were reduced but Ang-2 expression was increased after SAH. This led to a significant reduction of the Ang-1/Ang-2 ratio in the brain tissue, which was associated with the destruction of the blood-brain barrier. Conclusion The data indicate that miR-221-5p might regulate blood-brain barrier dysfunction through the Ang-1/Ang-2/Tie-2 signaling axis, suggesting that it should be further investigated as a potential novel biomarker.

Clinical Theragnostic Signature of Extracellular Vesicles in Traumatic Brain Injury (TBI).

Traumatic brain injury (TBI) is a common cause of disability and fatality worldwide. Depending on the clinical presentation, it is a type of acquired brain damage that can be mild, moderate, or severe. The degree of patient's discomfort, prognosis, therapeutic approach, survival rates, and recurrence can all be strongly impacted by an accurate diagnosis made early on. The Glasgow Coma Scale (GCS), along with neuroimaging (MRI (Magnetic Resonance Imaging) and CT scan), is a neurological assessment tools used to evaluate and categorize the severity of TBI based on the patient's level of consciousness, eye opening, and motor response. Extracellular vesicles (EVs) are a growing domain, explaining neurological complications in a more detailed manner. EVs, in general, play a role in cellular communication. Its molecular signature such as DNA, RNA, protein, etc. contributes to the status (health or pathological stage) of the parental cell. Brain-derived EVs support more specific screening (diagnostic and prognostic) in TBI research. Therapeutic impact of EVs are more promising for aiding in TBI healing. It is nontoxic, biocompatible, and capable of crossing the blood-brain barrier (BBB) to transport therapeutic molecules. This review has highlighted the relationships between EVs and TBI theranostics, EVs and TBI-related clinical trials, and related research domain-associated challenges and solutions. This review motivates further exploration of associations between EVs and TBI and develops a better approach to TBI management.

773 Diffusion-Weighted MRI Tractography of Midline Thalamic Subnuclei Characterizes the Return of Consciousness Following Severe Traumatic Brain Injury

INTRODUCTION: The prefrontal projections of the mediodorsal (MD) and central lateral (CL) thalamus have been implicated in the recovery of consciousness following severe traumatic brain injury (sTBI), but their specific roles are unknown. The CL has been proposed to modulate levels of arousal, while the MD modulates attention. METHODS: We generated tractograms in 25 patients with sTBI using DSI-Studio. The CL and MD were seeds and the orbitofrontal (OFC), dorsolateral prefrontal (dlPFC), medial prefrontal (mPFC), and anterior cingulate (ACC) cortices were targets. Fractional anisotropy (FA), a measure of tract integrity, and apparent diffusion coefficient (ADC), a proxy for neuronal injury, were computed for each tract and compared between the early (within 30 days post-injury) and late/no command followers. Spearman correlations were calculated between tract FA and ADC and final Glasgow Coma Scale (GCS) scores. RESULTS: Tractography revealed significantly increased MD-OFC tract FA in early compared late/no command followers (P = 0.0125). There was a statistically significant decrease in ADC in early compared late/no command followers in CL-dlPFC (P = 0.0281) and MD-dlPFC (P = 0.0454) tracts. GCS scores were significantly correlated with CL-ACC (P = 0.018) and CL-dlPFC (P = 0.0061) FA, and were not found to be significant in all MD tracts. CONCLUSIONS: The FA and ADC differences between early and late/no responders implicate tract integrity of the MD-OFC and dlPFC as key mediators in the return of command-following after TBI, respectively. The CL-ACC and CL-dlPFC tract FA were found to be associated with an increased final GCS score, which grades verbal, eye opening and motor responses. Our results corroborate the MD’s involvement in the content of consciousness, distinct from the CL’s in mediating the ascending arousal network.

Knowledge of the glasgow coma scale among physician interns in a Nigerian tertiary health facility

Background: The Glasgow coma scale (GCS) is the most utilized level of consciousness scale globally. Insufficient working knowledge of the GCS by physicians may contribute to poor outcomes in patients with altered levels of consciousness. Aim: This study aims to assess the knowledge of the GCS among the physician interns, also known as house officers, in a rural tertiary health facility in Nigeria. Materials and Methods: This was a questionnaire-based survey among physician interns in a rural tertiary hospital in Nigeria. Results: All the 77 respondents graduated from medical school within 2 years of the study. Seventy-two (93.5%) of the participants had been actively involved in the management of patients at the hospital's accident and emergency department within a month before the study, while 71.4% had been involved in emergency care outside the accident and emergency department within a month prior. Seventy-five (97.4%) conceded to having received didactic lectures on the GCS in the course of their medical training. About three-quarters (74.03%) of the respondents correctly defined GCS as GCS; about 85.7% were able to correctly identify all the clinical variables of the GCS, while only 15.6% could correctly describe and score all the parameters of the grading scale. The eye-opening response was the most correctly remembered (64.9%), followed by the verbal response (42.9%), while the motor response was remembered by 29.9% of the respondents (P = 0.04). Only 36 (46.8%) participants were aware of any subsequent modification to the original GCS score. Conclusion: The working knowledge of GCS is poor among physician interns surveyed in this study. The clinical variable of the GCS with the highest number of items, the motor response, was the least correctly remembered.

Glasgow Coma Scale: Linguistic-Cultural Adaptation of the Russian Version

INTRODUCTIONDetermination of the degree of depression of consciousness in patients with brain damage upon admission to the intensive care unit and intensive therapy is a primary task. In order to carry out a quick and at the same time sufficiently complete assessment of this kind, in 1974 neurosurgeons Graham Teasdale and Bryan Jennett from the University of Glasgow developed an algorithm consisting of a sequential series of tests in the form of eye opening, speech and motor responses, called Glasgow Coma Scale. This scale has received worldwide recognition and for many decades has been the main one for determining the state of consciousness in the most severe patients with brain damage. The absence of a validated version of this scale complicates its application in Russia, and the use of currently available versions that have not passed all the necessary stages of validation distorts the originally intended meaning of the scale and does not allow obtaining reliable clinical results when examining patients with acute impairment of consciousness.AIM OF STUDYDevelopment of the official Russian­language version of the Glasgow Coma Scale, taking into account linguistic and cultural characteristics (1st stage of the validation study).MATERIAL AND METHODSThe staff of Center for Validation of Health Status Questionnaires and Scales in Russia, Research Center of Neurology obtained consent from G. Teasdale to validate Glasgow Coma Scale in Russia. Two Russian­speaking professional certified translators in the field of medicine performed a direct translation of the original English­language scale, and a reverse translation was carried out by native speakers with a medical education. Pilot study was performed in 15 patients with acute impairment of consciousness, two meetings of the expert committee were held (before and after pilot study).RESULTSBased on the results of the first meeting of the expert commission, a linguistic and cultural adaptation of the text of the scale was carried out. During the pilot testing of the researchers did not have difficulties in understanding and interpreting instructions. As a result, the second meeting of the expert commission was held and the final Russian­language version was approved, which is presented in this article and is available on the website of Center for Validation of Health Status Questionnaires and Scales in Russia, Research Center of Neurology.CONCLUSIONFor the first time, the Russian language version of the Glasgow Coma Scale was officially presented and recommended for use both in clinical and research practice in Russia and other Russian speaking countries. The next publication will highlight the result of assessing the psychometric properties (reproducibility, inter­expert agreement and sensitivity) of the Russian­language version of the scale.

The factor structure of the Disability Rating Scale in individuals with traumatic brain injury

Purpose: To examine the factor structure of the Disability Rating Scale and the predictive validity of the scale’s factors among individuals with traumatic brain injury.Materials and methods: Five hundred and eight individuals with moderate-to-severe traumatic brain injury were administered the Disability Rating Scale. The sample was randomly divided into two groups. An exploratory factor analysis was conducted on Group 1, and a confirmatory factor analysis on Group 2. Regressions were performed to determine the predictive ability of the factors.Results: The exploratory factor analysis generated a three-factor structure, explaining 82.1% of the variance. Factor 1, comprising three disability items (feeding, toileting, and grooming), accounted for 58.4% of the variance. Factor 2, comprising three impairment items (eye opening, communication ability, and motor response), accounted for 14.8% of the variance. Factor 3, comprising two handicap items (level of functioning and employability), accounted for 8.9% of the variance. The three-factor solution was confirmed by confirmatory factor analysis. Regressions revealed the impairment factor at admission and the disability factor at discharge accounted for unique variance in predicting functional outcomes at one year post-injury.Conclusion: Each factor of the Disability Rating Scale may independently serve as a clinically useful outcome predictor after traumatic brain injury.Implications for rehabilitationThe Disability Rating Scale is a measure used in brain injury rehabilitation that generates a total score indicating level of disability.This study confirmed a three-factor structure and showed that the individual factor scores provide unique information in predicting rehabilitation outcomes at one year post-injury.

Effects of Afobazole on Postnatal Development of Rat Offspring.

Physical development, development of sensory and motor reflexes, behavioral and mnestic patterns were studied infantile and juvenile rat pups born by female rats receiving Afobazole during pregnancy. Physical development and development of sensory and motor reflexes in rats were completed without pathologies by the age of 2 months. During the infantile period, the rat pups demonstrated reduced body weight gain, delayed eye opening and pupillary response formation, decreased muscle force, and suppressed motor behavior. During the juvenile period, body weight gain and development of motor behavior were intensified. Females demonstrated later vagina opening and poorer mnestic responses. In males, the terms of sexual maturation were unchanged and processes of learning and memory retrieval were not impaired.

Modified Glasgow Coma Scale Score as an Early Indicator of Cerebral Vasospasm in Patients with Aneurysmal Subarachnoid Hemorrhage

Introduction Cerebral vasospasm (CV) is a delayed narrowing of cerebral arteries, occurring 4 to 14 days after subarachnoid hemorrhage (SAH). CV is a possible cause of delayed deterioration of patients after aneurysmal SAH (aSAH). Timely diagnostics and therapy of CV could reduce the morbidity and mortality after ruptured intracranial aneurysm (IA). Important diagnostic tool for the early detection of CV in conscious patients is neurological examination. The modified Glasgow Coma Scale score (mGCS) is derived from the Glasgow Coma Scale score (GCS) assessment of eye opening, verbal, and motor response. The mGCS score is calculated as the sum of the eye-opening response, the verbal response, and the worst motor response.

Does Rocuronium-Sugammadex Reduce Myalgia and Headache After Electroconvulsive Therapy in Patients With Major Depression?

We aimed to compare the effects of succinylcholine and rocuronium-sugammadex on development of myalgia and headache after electroconvulsive therapy (ECT). Forty-five patients undergoing ECT were enrolled in the study. Anesthesia induction was provided with propofol 1 mg/kg intravenously (IV) + succinylcholine 1 mg/kg IV in group S (n = 24) and propofol 1 mg/kg IV + rocuronium 0.3 mg/kg IV in group R (n = 21). Sugammadex 4 mg/kg IV was administered to group R after the motor seizure. The first 3 ECT sessions were evaluated on the basis of time to onset of spontaneous respiration following the induction, time to eye-opening response to verbal stimuli, and visual analog scale (VAS) scores for myalgia and headache at hours 2, 6, 12, and 24 following the ECT for all patients. The times to onset of spontaneous respiration and eye-opening response to verbal stimuli were significantly shorter in all the 3 sessions in group R compared with group S (P < 0.002). Myalgia VAS scores at hours 2, 6, and 12 and the headache VAS scores at hours 2 and 6 were significantly higher in group S versus group R (P < 0,015). We concluded that the rates of myalgia and headache after ECT were significantly lower in group R than in group S, and also the awakening time (spontaneous respiration and opening the eyes in response to verbal stimuli) was significantly shorter in group R compared with group S.

Traumatic brain injury: an evidence-based review of management

Traumatic brain injury (TBI) is the leading cause of death and disability in young adults in the developed world. In the UK about 1.4 million patients per year suffer head injuries. Although the majority of injuries are mild, around 10.9% are classified as moderate or severe and many patients are left with significant disability. The incidence is increasing in lower income countries, with the World Health Organization predicting that TBI and road traffic accidents will be the third greatest cause of disease and injury worldwide by 2020. In our ageing population the number of elderly patients presenting with TBI has increased and age appears to be an independent risk factor for poor outcome. Consequently TBI presents a major health and socioeconomic problem. TBI is a heterogeneous condition in terms of aetiology, severity, and outcome. The most useful classification of severity is based on the level of consciousness as assessed by the Glasgow Coma Scale (GCS) after resuscitation. The GCS comprises the sum score of the values from three components: eye, motor, and verbal scales (Table 1). TBI is classified as mild (GCS 15–13), moderate (GCS 13–9), and severe (GCS , 8). However, factors such as hypoxia, hypotension, and alcohol intoxication can all affect GCS, leading to diagnostic confusion. Therefore the patient should be resuscitated and reversible causes corrected before GCS assessment. The ability to assess eye opening and verbal response is influenced by sedative agents or tracheal intubation, leading some to suggest the use of the motor score alone. TBI can be divided into primary and secondary brain injury. The primary injury occurs as a consequence of the initial physical insult. The pattern and extent of damage will depend on the nature, intensity, and duration of the impact. Compression and shearing forces may result in skull fracture, contusions, intracranial haematoma, cerebral oedema, and diffuse brain injury. Microscopically there is cell wall disruption and increased membrane permeability disrupting ionic homeostasis. Axonal tissue is particularly susceptible to injury. Neurological injury progresses over hours and days, resulting in a secondary injury. Inflammatory and neurotoxic processes result in vasogenic fluid accumulation within the brain, contributing to raised intracranial pressure (ICP), hypoperfusion, and cerebral ischaemia. Much of this secondary injury may be amenable to intervention, as almost one-third of patients who die after a TBI will talk or obey commands before their death. Secondary injury also occurs as a result of further physiological insults. Hypoxia, hypotension, hyperor hypocapnia, hyperor hypoglycaemia have all been shown to increase the risk of secondary brain injury.

Deep coma and diffuse white matter abnormalities caused by sepsis-associated encephalopathy

In January, 2012, a 53-year-old woman with a history of progressive polyposis coli and hypertension was admitted to the intensive care unit (ICU) of our hospital because of septic shock 4 days after laparoscopic subtotal colectomy. She was intubated and mechanically ventilated, underwent emergent re-laparotomy for anastomotic leakage, and was treated with antibiotics. Blood cultures were positive for multiresistant Enterococcus faecium. After re-laparotomy the patient was sedated with midazolam for 2 days. The neurologist was consulted on the fourth postoperative day because of the patient’s persistent low level of consciousness. On neurological examination, we found no eye opening or motor response to a painful stimulus, intact brainstem refl exes, and generalised arefl exia of arms and legs with indiff erent plantar refl exes. We observed no signs indicative of minimally convulsive status epilepticus. During the period of septic shock and surgery, blood pressure had not been lower than 100/50 mm Hg and laboratory tests did not show abnormalities that could explain the patient’s coma. Non-contrast CT (NCCT) of the brain showed abnormal hypodensity of the complete white matter with swelling of the entire brain (fi gure); CT angiography was normal. Electromyography showed absence of motor unit potentials in arm and leg muscles without evidence for accompanying neuropathy. We made a diagnosis of sepsis-associated encephalopathy and critical illness myopathy. Because of the deep coma and the diff use and severely abnormal aspect of the white matter—both associated with poor outcome—dis continuation of treatment was discussed, but we recommended to continue treatment. On the ninth postoperative day the patient opened her eyes in response to painful stimuli, but there was still no motor response. Follow-up NCCT showed no improvement of the white matter abnormalities. In the following weeks the condition of the patient gradually improved and 4 weeks after the re-laparotomy she had regained full consciousness. When the patient was discharged from the ICU her muscle strength had gradually improved with movements against gravity now possible. At that time brain MRI was normal except for a small number of white matter lesions (fi gure). The patient was transferred to a rehabilitation centre 6 weeks after the initial onset of septic shock. At that point she was able to walk short distances. At last follow-up on Aug 19, 2012, she had regained independence in activities of daily living and was living at home. Sepsis-associated encephalopathy is a severe complication of sepsis and is associated with poor outcome. The reported incidence ranges from 9% to 71% because of variations in the defi nition. A recent study in an ICU showed that patients with sepsis secondary to intestinal infections are prone to develop septic encephalopathy, with Escherichia coli and Enterococcus faecium among the most frequently cultured bacteria. The exact pathogenesis of sepsis-associated encephalopathy remains unclear; disruption of the blood-brain barrier and mitochondrial dysfunction are probably involved. Imaging of the brain can show atrophy and periventricular white matter lesions. The diff use and severe white matter abnormalities like those we observed in our patient are rare and have been associated with poor outcome. This case shows that severe encephalopathy with extensive white matter lesions can be a reversible condition. Clinicians should realise that the fi rst signs of improvement of the clinical condition could still be observed beyond 7 days after onset.

Revisiting the eye opening response of the Glasgow Coma Scale

The Glasgow Coma Scale (GCS), introduced by Teasdale and Jenneth in 1974, has received tremendous acclaim from clinicians and has been extensively used in clinical practice for the evaluation of the level of consciousness. The author notes that some traumatic brain injury patients close eyes in response to painful stimuli as opposed to the eye opening response to pain of the GCS. A revision of the eye opening response subsection of the GCS is suggested.

Ingestion of gasoline in a suicide attempt: an uncommon cause of bilateral basal ganglia T1 hyperintensities

A 70-year-old man with a 27-year history of psychosis and hypertension was brought comatose to our Emergency Room following a suicide attempt with oral unleaded gasoline ingestion that was witnessed and described by his neighbors. His neurological examination disclosed a Glasgow Coma Scale Score of 8 (eye opening response 2 points, verbal response 2 points, motor response 2 points), with normal brainstem reflexes and spontaneous breathing. The subject was treated with a gastric lavage (gastric content, almost 2 l of gasoline) and activated charcoal. A baseline brain CT was unremarkable, while his liver function tests were normal. His neurological status did not improve and was transferred to the Intensive Care Unit of our institution where severe aspiration pneumonia was diagnosed. A brain MRI was performed at 16 days following his suicide attempt. Bilateral hyperintensities affecting the globus pallidus and the caudate nucleus were shown on axial T1, T2 and FLAIR sequences (Fig. 1). The patient expired 3 weeks later because of his aspiration pneumonia. Lesions with high signal intensity on spin-echo Tl-weighted MR images are unusual and are associated with relatively few entities, including lipids, calcification, high protein count, laminar necrosis in cerebral infarction, neoplasms and paramagnetic substances such as methemoglobin, melanin, copper and manganese [1]. Manganese, in particular, is considered a neurotoxic agent causing movement and psychological disorders characterized by rigidity, tremor and hypokinesia in workers involved in the alloy industry (miners, welders, smelters), in patients receiving long-term total parenteral nutrition and in hepatic encephalopathy patients with portal liver shunts [1–3]. Since the introduction of MRI in clinical practice, bilateral symmetric high signal intensities at the globus pallidus and substantia nigra have been well described in patients with manganese neurotoxicity. The most plausible explanation for the increased T1 signal intensity is a rise in manganese concentration that has paramagnetic properties in the central nervous system (CNS), with preferential deposition in the globus pallidus. Methylcyclopentadienyl manganese tricarbonyl (MMT) is an octane-improving additive to unleaded gasoline, which has recently attracted attention with regard to the prospect of worldwide manganese exposure as increases in environmental manganese concentrations have been recorded relative to traffic density [4]. We postulate that in the present case oral ingestion of large quantities of gasoline resulted in MMT absorption, which in turn resulted in increased CNS manganese concentrations leading to bilateral T1 basal ganglia hyperintensities. However, it should be noted that manganese concentrations were not measured in blood, while we have no neuropathological confirmation of manganese deposition in globus pallidus. In conclusion, the present case highlights bilateral T1 basal ganglia hyperintensities related to oral ingestion of gasoline in a suicide case and underscores manganese neurotoxicity as the potential underlying cause of this uncommon neuroimaging presentation. G. Tsivgoulis (&) I. Heliopoulos K. Vadikolias C. Piperidou Department of Neurology, Democritus University of Thrace, University Hospital of Alexandroupolis, Kapodistriou 3, Nea Xili, 68100 Alexandroupolis, Greece e-mail: tsivgoulisgiorg@yahoo.gr

Can Alcohol Intoxication be Excluded as the Cause of Confusion following Head Injury?

To assess whether there is a breath alcohol level (BrAC) below which confusion in the head injured patient should not be attributed solely to the acute effects of alcohol. Based in the Accident and Emergency Ward in Glasgow Royal Infirmary, a prospective observational study was carried out over a five month period. Patients admitted to the ward were recruited for the study if they had a primary diagnosis of head injury. The outcome measures recorded and analysed were sequential 2 hrly BrAC readings (mg/L) and Glasgow Coma Scale findings (Eye opening, motor and verbal responses). The relationship between these was investigated, which revealed additional relevant factors affecting level of consciousness. The breath alcohol analyser was found to be a useful non-invasive, quick and easy to use tool. The results obtained were consistent with the expected pattern of reducing BrAC levels over a 6 hour period. Within this group of patients, a poor correlation was found between each of the three responses of the Glasgow Coma Scale and BrAC readings. For those patients who remained confused, when their BrAC reading was less than 1 mg/L, other causes of a lowered level of consciousness were identified. Confusion in the head injured patient with a BrAC of less than 1 mg/L, should alert one to the likelihood of causes other than alcohol intoxication.

Development of Glasgow Coma and Outcome Scales

These scales were developed primarily to facilitate the assessment and recording of initial severity of brain dysfunction and of ultimate outcome in a multicenter study of outcome after severe brain damage. The aim was to use simple terms that could be readily understood by a wide range of observers, including doctors, nurses and others. Repeated observations of the coma scale displayed on a bedside chart give it a second use - the monitoring of improvement or deterioration in conscious level as an indication of recovery or of complications. Early sedation and ventilation can make assessment difficult but the motor score alone is still a good guide to severity. Giving numbers to the level of response in the three components of the coma scale (eye opening, motor and verbal responses) facilitates communication between different staff, including those consulted by telephone. Adding up these scores to give an overall coma score (from 3 to 15) results in some loss of information but is useful for triage and for epidemiological studies. Even among mild injuries (coma score 13-15) the score discriminates between those more or less likely to develop complications. The outcome scale describes overall social function rather than neurological deficits, and is useful in monitoring recovery. The outcomes so described at six months after injury correlate well with the early coma scale scores, which are therefore useful predictors of likely outcome. Nepal Journal of Neuroscience, Volume 2, Number 1, 2005, Page: 24-28

Interrater reliability of the Glasgow coma scale scoring among nurses in sub-specialties of critical care

The Glasgow Coma Scale (GCS) is used as an assessment tool to measure the levels of consciousness and coma in patients. This research investigated the reliability of scoring the GCS among registered nurses (RNs) working in five different sub-specialty clinical areas of critical care; general intensive care, neurosurgical intensive care, coronary care, emergency room and post anaesthetic recovery room. Seven video recordings were made of six patients (one patient was recorded twice) having their level of neurological response assessed utilising the GCS. Seventy five RNs (15 from each sub-specialty) viewed each of the GCS assessments on the videotape and rated each patient on the scoring sheet provided. Analysis was performed for all RN subjects as a single group as well as separately for each of the five groups under investigation. The ratings for the first six videos were used to test interrater reliability and the scores from videotape four and seven (same patient) were used to calculate intrarater reliability. Based on comparison with expert scores, of the 75 participants, 38 responded correctly to eye opening responses; only 26 responded correctly to the motor response ratings. However, a better accuracy was achieved in the verbal response category with 67 participants responding correctly. Education qualifications and previous neurosurgical experience were statistically significant with regard to the nurses' accuracy of GCS assessment with p values of 0.004 and 0.043 respectively. The results were consistent with previously published studies demonstrating the motor response rating is most problematic in relation to rater accuracy.

Propofol dosage achieving spontaneous breathing during balanced regional anesthesia with the laryngeal mask airway

Study Objective: To assess an anesthetic technique achieving spontaneous breathing through the laryngeal mask airway (LMA) during combined epidural block and propofol anesthesia. Design: Prospective, consecutive case series study. Setting: Operating room at a general hospital. Patients: 112 ASA physical status I and II adult surgery patients; 32 patients for lower extremity surgery are enrolled into study 1, and 30 patients for lower extremity surgery and 50 patients for lower abdominal gynecology surgery are enrolled into study 2. Interventions: In study 1, patients were given 1.5 to 2.0 mg/kg followed by a 3 mg/kg/h of infusion of propofol, after epidural block, and they were fitted with the LMA. Thirty minutes after induction, the dose of propofol was increased to 4, 5, 6, and 7 mg/kg/h every 15 minutes. In study 2, the patients were given 1.5 to 2.0 mg/kg and 5 mg/kg/h of propofol and the LMA insertion, after epidural block. Measurements and Main Results: PaO 2/FIO 2, PaCO 2, tidal volume or respiratory rate, blood pressure, heart rate, and eye opening and motor response scales in conformity with Glasgow coma scale were recorded. Study 1 suggested an induction dose of 1.5 to 2.0 mg/kg and an infusion of 5 mg/kg/h as an appropriate dose to preserve spontaneous breathing with the LMA and to maintain reasonable depth of anesthesia. Study 2 showed that respiratory and circulatory conditions, depth of anesthesia, and other data related to anesthesia were clinically acceptable. Conclusions: The best infusion dose of propofol to achieve spontaneous breathing with the LMA seems to be 5 mg/kg/h, and the present balanced regional anesthesia with the LMA, using propofol infusion at 1.5 to 2.0 mg/kg and 5 mg/kg/h combined with epidural block, may be useful in clinical practice for lower extremity and lower abdominal gynecologic operations.

Cardiovascular response and stress reaction to flumazenil injection in patients under infusion with midazolam

To evaluate the cardiovascular response and acute stress reaction after arousal induced by a benzodiazepine antagonist, flumazenil, in patients sedated with midazolam. Prospective study. Emergency center in a university hospital. A total of 12 patients were ventilated mechanically under sedation with midazolam. We monitored the consciousness level, heart rate, systemic blood pressure, pulmonary artery pressure, and pulmonary artery occlusion pressure before and after a bolus injection of 0.5 mg of flumazenil. The score for the consciousness level represents the sum of the scores for eye opening and best motor response, as determined by the Glasgow Coma Scale. We measured the cardiac output, concentrations of norepinephrine, epinephrine, and 3-methoxy-4-hydroxyphenylethyleneglycol in plasma, and concentration of cortisol in serum. We calculated the left ventricular ejection fraction, cardiac index, systemic vascular resistance index, pressure-rate product, systemic oxygen delivery, and systemic oxygen consumption at 0, 10, 30, and 60 mins after injection of flumazenil. The serum benzodiazepine's receptor binding activity in serum was in the range from 50 to 1000 ng/mL before injection of flumazenil. Flumazenil improved the consciousness level from 6.7+/-2.0 to 8.9+/-1.6 and induced transient elevations in heart rate, blood pressure, systolic pulmonary artery pressure, and pulmonary artery occlusion pressure. Left ventricular ejection fraction, oxygen delivery index, and pressure-rate product increased significantly, from 61%+/-8%, 640+/-170 mL/min/m2, and 13,300+/-2600 mm Hg/min at 0 mins to 67% +/-5%, 710+/-220 mL/min/m2, and 16,500+/-4400 mm Hg/min at 10 mins, respectively. Concentrations of norepinephrine and epinephrine in plasma increased significantly, from 890+/-840 pg/mL and 220+/-360 pg/mL, respectively, at 0 mins to 990+/-850 pg/mL and 270+/-300 pg/mL, respectively, at 10 mins. There were no significant changes in the plasma concentration of 3-methoxy-4-hydroxyphenylethyleneglycol, the serum concentration of cortisol after the administration of flumazenil. Flumazenil did not result in a significant acute stress reaction in midazolam-sedated patients, but it increased myocardial oxygen consumption by enhancing sympathetic nervous activity or antagonizing cardiovascular depression induced by midazolam.

Surgical outcome of hypertensive putaminal hemorrhage in patients older than 65 years.

There is no consensus of opinion on the treatment of hypertensive putaminal hemorrhage (HPH), especially in patients older than 65 years. The purpose of this study was to study the surgical outcome of HPH in patients older than 65 years while considering mortality and activity of daily life. Among eighty-three patients aged 65 or older with HPH, fifty-one patients received only medical treatment and 32 were operated upon to remove the hematoma. Each patient was measured by the intracerebral hemorrhage-intracranial hemorrhage grading scale (ICH Grade) which used the sum of eye opening and motor response scores derived from Glasgow Coma Scale. The cubic content of the HPH was calculated from measurement of maximum width (X), length (Y) and height (Z), and the hematoma volume taken as 1/2 that volume (X. Y. Z/2). The acute mortality in surgically treated group was 40.6% and three patients died during the follow-up period from one to six months after the operation. Determinant for the prognosis was the ICH grade and the volume of the hematoma. Patients who returned to ADL 1 and 2 (good recovery) after surgical treatment were 40.0% in ICH Grade I, 16.7% in ICH Grade II, and 20.0% in ICH Grade III. Among those patients who were in ICH Grade IV, none had good recovery. The acute mortality was zero in ICH Grade I, 16.7% in ICH Grade II, 40.0% in ICH Grade III, and 62.5% in ICH Grade IV. The crucial size was 60 ml with a mortality of 77.8% for hematomas larger and 39.1% for hematomas smaller than that. From our lim ited experience, we learned that operation in elderly patients with HPH was considered only in patients with hematomas between 20 to 60 ml, with a high operative mortality and only one-fourth having a good recovery postoperatively.

USEFULNESS OF ADVOCATED COMA SCALES

Recently several coma scales have been advocated in assessing impaired consciousness and have been parallely used with such traditional but ambiguous terms as coma, stupor, somnolence and so on. In this study the usefulness of Glasgow Coma Scale (GCS) was compared with that of Edinburgh Coma Scale (E2CS). The levels of E2CS was verified to have quite a good correlation with mortality and morbidity of the patients. On the other hand, correlation between outcome and the scores of GCS was apparently poorer exhibiting many parts of irregularity. The author showed that components of the GCS, namely the verbal, eye opening and motor response scales, if compared separately, did show a good correlation with the final outcome of the patients. It is futile, however, to depend on scoring system which simply add up numbers given to an order of each different functions. it is concluded that the E2CS is a clinically more convenient and useful scale in assessing impaired consciousness than the GCS.