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)
If Cardiac Output is compromised than you will have low tissue/organ perfusion. Causing the patient to go into cardiac shock.
There is high risk of death and poor neurological function with unconscious survivors in out of hospital cardiac arrest. Trails were undertaken with the patients after awakening from cardiac arrest, which was compared with Ther...
Polderman, K. H. (2007). Screening methods for delirium: don't get confused! Intensive Care Med , 3-5.
A do not resuscitate order for patients who have emergency surgery is an “independent risk factor for poor surgical outcome and postoperative mortality” (Kelley , 2014 pg 1 para 3) and the probability of returning patients to their previous level of functioning is higher for CPR performed during the peri-operative period (Kelley , 2014).
Featherstone, P., Prytherch, D., Schmidt, P., Smith, G. (2010). ViEWS: towards a national early warning score for detecting adult inpatient deterioration. Resuscitation, 81(8), 932-937.
Keep the patient NPO, and establish two IV access sites with a large bore catheters running one IV with NS at KVO and morphine sulfate for pain. Initial laboratory testing including a complete blood cell count (CBC), basic metabolic panel (BMP), cardiac enzymes (creatine kinase, creatine kinase-MB, and cardiac Troponin) and repeat in 90 min. Administer antiplatelet ASA 324mg PO (Sen, B., McNab, A., & Burdess, C., 2009, p. 18). Before administering nitroglycerin 0.4 mg SL (every 5 minutes up to three doses) reassess blood pressure if systolic <90 mmHg, patient has used cocaine in the last 24 hours, or taking PDE-5 inhibitors do not administer. Thrombolytic therapy should be implemented within 30 minutes from the patient’s arrival to the emergency department, and if they are a candidate for cardiac catheterization it should be done within 90 minutes from the patient being admitted to the hospital. Delay on either therapy option increases the risk of mortality (Kosowsky, Yiadom, Hermann, & Jagoda, 2009, p. 10).
Cerebrovascular disease or the term stroke is used to describe the effects of an interruption of the blood supply to a localised area of the brain. It is characterized by rapid focal or global impairment of cerebral function lasting more than 24 hours or leading to death (Hatano, 1976). As such it is a clinically defined syndrome and should not be regarded as a single disease. Stroke affects 174-216 people per 10,000 population in the UK per year and accounts for 11% of all deaths in England and Wales (Mant et al, 2004). The risk of recurrent stroke within 5 years is between 30-43%. One problem is that the incidence of stroke rises steeply with age and the number of elderly people in the UK is on the increase. To date people who experience a stroke occupy around 20 per cent of all acute hospital beds and 25 per cent of long term beds (Stroke Association, 2004). The British Government now identifies stroke as a major economic burden on the National Health Service (DoH, 2002).
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,
This paper is designed to address the adverse effects of delirium associated with adult ICU patients with an emphasis on the elderly. Delirium is an acute state of confusion, attention, and perception. Though usually reversible, delirium is characterized by an inability to pay attention, disorientation, an inability to think clearly, and a fluctuation in ones level of consciousness (Aguirre, 2009). These changes develop over a short period of time and often result from and underlying medical condition, substance abuse or both (Fong, Tulebaev, and Inouye, 2009).
3a. There are several factors that make administering and accurately interpreting the results of neuropsychological tests difficult when dealing with stroke patients including visual neglect, aphasia, and hemiparesis. Visual neglect, or the loss of a section of one’s visual field often on one side, (right or left visual field), can occur in patients who have had a cerebrovascular accident (CVA) or a stroke. A stroke is caused by a clot that forms and occludes (blocks) an artery in the brain thus starving a portion of the brain of blood (which contains vital nutrients like glucose and oxygen). Although it is common for other blood vessels
Patients in the Intensive Care Unit are at a high risk to develop delirium. It is one of the most common conditions encountered by the staff in an Intensive Care Unit. Delirium can be hyperactive or hypo active according to the patients’ behavior. Disorientation, agitation, hallucinations, or delusions are characteristics that may be observed in the patient with hyperactive delirium. Apathy, quietly confused, withdrawal, lethargy, and even total lack of responsiveness are all symptoms of hypoactive delirium. Some or all of these symptoms may occur at any time.
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).
Paramedics are frequently presented with neurological emergencies in the pre-hospital environment. Neurological emergencies include conditions such as, strokes, head or spinal injuries. To ensure the effective management of neurological emergencies an appropriate and timely neurological assessment is essential. Several factors are associated with the effectiveness and appropriateness of neurological assessments within the pre-hospital setting. Some examples include, variable clinical presentations, difficulty undertaking investigations, and the requirement for rapid management and transportation decisions (Lima & Maranhão-Filho, 2012; Middleton et al., 2012; Minardi & Crocco, 2009; Stocchetti et al., 2004; Yanagawa & Miyawaki, 2012). Through a review of current literature, the applicability and transferability of a neurological assessment within the pre-hospital clinical environment is critiqued. Blumenfeld (2010) describes the neurological assessment as an important analytical tool that evaluates the functionality of an individual’s nervous system. Blumenfeld (2010) dissected and evaluated the neurological assessment into six functional components, mental status, cranial nerves, motor exam, reflexes, co-ordination and gait, and a sensory examination.
13. Steis, M.R. Acute delirium: differentiation and care. J. Psychosocial Nursing Ment Health Serv. 2012, Vol. 50, (7), 17-20.