Maintaining adequate levels of cerebral perfusion during cardiac surgical procedures is of utmost importance in achieving positive neurologic outcomes and minimizing length of hospital stay. Because cardiac surgical interventions ranging from major aortic arch reconstruction to coronary artery bypass grafting (CABG) each carry their own inherent risk for developing perioperative strokes, transcranial near-infrared spectroscopy (NIRS) is an interesting technique that may shed light on hypoperfusion events and decrease the overall incidence of stroke (4, 13). The use of transcranial near-infrared spectroscopy (NIRS) to monitor cerebral oxygenation levels was first developed over thirty years ago (1). Recent studies over the past fifteen years have created much excitement about its potential applications and overall clinical value. Although NIRS is currently being used to noninvasively measure cerebral oxygen saturation (ScO2) during many cardiac and vascular surgeries, there remain many questions about its true therapeutic value (1). This literature review will offer a brief description of the NIRS technique as well as an overall assessment of current available studies highlighting the use of cerebral oximetry during cardiac surgical interventions.
Cerebral Complications Associated With Cardiac Surgery – change title?
Adequate cerebral perfusion is necessary to maintain proper oxygenation and meet aerobic metabolic demands (4). However, brain ischemia associated with cardiac surgical intervention can have many etiologies and can be hard to identify (1,4). While cerebral emboli is a major cause of perioperative strokes, more serious consideration is being placed on the influence of cerebral hypoperfusion resulting in perioperative n...
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...erative baseline values and resulted in a decrease in POD from 13.3% in 2009 to 7.3% in 2010 (p=0.019), but no significant change in average ICU LOS, going from 2.11 days in 2009 to 1.83 days in 2010 (p=0.228). Although the new HBCS improved POD rate, there is no way to confidently attribute the decrease in delirium rate to either the use of TCD or NIRS. Not every patient in 2010 received TCD, NIRS, or both, with only 49.1% of patients receiving NIRS monitoring, and 34.0% receiving both. In addition, without a set protocol, intervention was dependent on anesthesiologist discretion allowing for bias and human error. The author also states that simply the awareness among anesthesiologists about the importance of maintaining adequate cerebral blood flow in addition to preserving blood pressure may have contributed to the decline in POD rate among intervention patients.
Inadvertent perioperative hypothermia is a common anesthesia-related complication with reported prevalence ranging from 50% to 90%.(ref 3,4 of 4) The clinical consequences of perioperative hypothermia include tripling the risk of morbid myocardial outcomes and surgical wound infections, increased blood loss and transfusion requirements, and prolonged recovery and hospitalization.(ref 5)
Lippincott, W. (2013). Management of Patients with Cerebrovascular Disorders. Brunner and suddarth's textbook of medical -surgical nursing 12th ed. + nursing diagnosis, (p. 1895). S.l.: Wolters Kluwer Health.
Delirium in the Intensive Care Unit (ICU) has become a genuine phenomenon and can be problematic for the patient and the staff caring for them. Delirium occurs when a patient is placed in an unfamiliar environment and has to endure the stress of not just the hospitalization but the stimuli of the environment, which can cause disturbances in consciousness. Patients can become confused, anxious, and agitated; making this difficult for the staff to correctly diagnosis and care for them. Sleep deprivation and environmental factors along with neurotransmitters are strongly related to the occurrence of ICU delirium. ICU staff needs to become more educated on prevention, detection, and proper treatment for the patient experiencing this condition.
Kothari, R., Jaunch, E., Broderick, J., Brott, T., Sauerbeck, L., Khoury, J. & Liu, T. (1998). Acute stroke: Delays to presentation and emergency department evaluation. Annals of Emergency Medicine, 33, 3−8. doi:10.1016/S0196-0644(99)70431-2
Stroke is the third leading cause of death and the brain injuries caused by stroke are a huge cause of disability in older adults. There are over 1.2 million stroke survivors in the UK and half of all stroke survivors have a disability following their stroke. A person’s age increases their risk of having a stroke. Most strokes occur between the ages of 65 and 75. There are three main types of strokes. 85% of strokes are ischaemic and occur when a blood clot forms in an artery leading to the brain, stopping the blood supply causing a neurological defect lasting more than 24 hours (Alexander et al., 2011). 15% of strokes are haemorrhagic and result from a weakened blood vessel that has ruptured and bleeds into the surrounding brain. It can be
Prevention of ICU psychosis should occur as soon as the patient has been in the ICU for a few hours. Review visiting policies for the facilities, provide great periods of sleep, by reducing the disturbing and noise levels in the patient room, also try to minimize shift change in nursing staff caring for the patient, assess the patient alertness for the place, date and time on every shift(Welker, M. MSN, 2016). ICU psychosis can be increase by health care professional awareness of early clinical signs of delirium during patients assessment(Arend, E., Christensen, M. 2009). ICU psychosis is affecting the majority of the patient admitted to the ICU. Evidence base shows that the ICU environment is contributed to it’s development. Delirium is increased with morbidity and mortality as well as increased with length of stay in the intensive care unit(Arend, E., Christensen,
13. Steis, M.R. Acute delirium: differentiation and care. J. Psychosocial Nursing Ment Health Serv. 2012, Vol. 50, (7), 17-20.
Delirium is a sudden, fluctuating, and usually reversible disturbance of mental function (Fan, Guo, Li, & Zhu, 2012). Delirium has been identified in several hospital settings, however occurs more frequently in an Intensive Care setting. Risk factors are not limited to a certain age, race, or gender. There are several long and short term adverse effects associated with Delirium, and may even leave the patient in a decreased mental state after discharge. It is important to use the proper assessment tools to identify delirium in patients. More so, it is imperative that the medical and nursing staff be aware of all risk factors, signs and symptoms, and interventions to minimize and properly treat delirium in the ICU setting.
The World Health Organisation (2013) explains that an Ischaemic stroke occurs as a result of a blood vessel becoming blocked by a clot, reducing the supply of oxygen to the brain and, therefore, damaging tissue. The rationale for selecting Mary for this discussion is; the author wishes to expand her evidenced based knowledge of stroke since it is the principal cause of disability and the third leading cause of mortality within the Scottish population (Scottish Intercollegiate Guidelines Network (SIGN), 2008) and, therefore, a national priority. In response to this priority, the Scottish Government (2009) produced their ‘Better Heart Disease and Stroke Care Action Plan’. Additionally, they have introduced a HEAT target to ensure 90% of stroke patients get transferred to a specialised stroke unit on the day of admission to hospital (Scottish Government, 2012).
American Association of Nurse Anesthetists. Professional Aspects of Nurse Anesthesia Practice. Philadelphia: F. A. Davis Company, 1994. Print.
...., & Jr, L. H. (1992). Release of vasoactive substances during cardiopulmonary bypass. Annals of Thoracic Surgery. doi:10.1016/0003-4975(92)90113-I-6
Brott, T., et al., Measurements of acute cerebral infarction: a clinical examination scale. Stroke, 1989. 20(7): p. 864-70.
Stroke can be thrombotic (local formation of a clot), embolic a clot traveling from a remote place in the body), or hemorrhagic (bleeding into the brain). Ischemic stroke is characterized by the sudden loss of blood circulation to an area of the brain, reacting in a corresponding loss of neurologic function. Acute ischemic stroke is more common than hemorrhagic stroke, and is caused by thrombotic or embolic occlusion of a cerebral artery.” Hemorrhagic stroke is less common than ischemic stroke and epidemiologic studies indicate that only 8-18% of strokes are hemorrhagic. However, hemorrhagic stroke is more associated with high mortality rates than mortality in ischemic stroke is.” (Broderick, 2007)
So that, the diagnostic and therapeutic course of management should have been commenced sooner. Contacting other therapeutic members and explaining the situations to different people including nurse manager, consultant, senior registrar and anaesthetists have delayed the management. However, I believe that my action benefitted the patient and his family by avoiding further delay in the management. And also, ensuring the presence of a staff member with Michael’s wife should have assisted her to go through the unforeseen situation. I understand the neurological deterioration of GCS >8 and respiratory distress are indications of intubation of neuroscience patients. However, intubation is also indicated for therapeutic and diagnostic procedures in aggressive and uncooperative patients (Souter & Manno 2013). This scenario highlights the importance of the person-centred approach to clinical judgement and decision
Webster CS, Merry AF, Larsson L, McGrath KA, Weller J. The frequency and nature of drug administration error during anaesthesia. Anaesth Intensive Care 2001; 29: 494-500.