Anaesthesia in septic patients: good preparation and making the right choice?

Septic patients may require anaesthesia for surgery or to facilitate endotracheal intubation for respiratory failure. These patients frequently start with a deranged haemodynamic state, including vasodilation with hypotension, and cardiomyopathy, making induction of anaesthesia a potentially hazardous task. Anaesthetic agents are well known to decrease contractility and to cause vasodilation - in part from direct effect of the drugs, and in part due to the state of anaesthesia, that causes reduced sympathetic tone. Before induction, the physician should understand the haemodynamic state (especially using echocardiography), should restore cardiovascular reserve with inotropes and vasopressors, and should induce anaesthesia with the smallest dose of the safest drug. In the previous issue of Critical Care, Zausig and colleagues show that propofol may not be the safest choice of induction agent in septic patients

A stratigraphic and sedimentologic analysis of the Tongue River and Sentinel Butte Formations (Paleocene), western North Dakota

The Tongue River-Sentirel Butte contact has been regarded by many workers as a vague color boundary of minor extent within a relatively homogeneous sequence of Paleocene strata. Consequently, the Sentinel Butte has come to be regarded as a subordinate unit of the ”Tongue River Formation. As defined in report, the contact is a distinctive horizon between two discrete lithogenetic units. It characterized by three criteria: a horizon (HT Butte bad) &t the top of the Tongue River sequence; a. basal sandy unit in the Sentinel Butte sequence, and a marked change in color between buff yellow Tongue River sediments below and somber gray Sentinel Butte sediments above. This contact has been mapped on a scale of 1:250,000 throughout the badlands of the Little Missouri River, and along the Missouri River from the Montana-North Dakota border to the mouth of the Little Missouri River. The contact is concealed in the central part of the Williston basin, but crops out on the eastern flank of the basin about 60 to 80 miles east of the area mapped. The extent of the contact along the eastern margin of\u27 the basin has not been determined, but outcrops in Marton County display lithologic relationships similar to those which distinguish the contact farther west. No evidence was found in support of the Tongue River-Sentinel Butte facies relationship postulated by previous investigators. Recognition of distinctive stratigraphic relationships at the Tongue River-Sentinel Butte contact and documentation of their regional persistence demonstrate that the Sentinel Butte sequence is a mappable lithostratigraphic unit. It is therefore recommended that in western North Dakota and adjacent areas the Sentinel Butte sequence be assigned formational rank. The name Tongue River Formation should be applied only to beds underlying the Sentinel Butte Formation. Granulometric analysis of nearly 500 sediment samples from 11 stratigraphic sections show that Tongue River sediments are finer grained and less well sorted than those of the Sentinel Butte For mation. Median diameter and skewness are environmentally sensitive particle-size statistics. CM patter-as illustrate the fluvial origin of these Paleocene deposits and are used to differentiate sediment transport types and depositional environments; channel, floodplain, and backswamp facies are recognized. Significant differences in fluvial regimes are indicated by the relative abundances of .flood plain and backswamp sediments deposited by Tongue River and Sentinel Butte streams. CM patterns give values for maximum suspended-load and minimum bed-load particle sizes which can be used with Hjulstrom type diagrams to approximate paleocurrent velocities. Sentinel Butte streams had higher velocities than those of Tongue River time, but the magnitude of both was small and maximum and mid-depth velocities of 40 to 50 centimeters per second are estimated. Evaluation of stratigraphic, lithologic, and sedimentologic relationships, types and occurrences of\u27 primary sedimentary structures, and carbonate contents o:f Tongue River and Sentinel Butte strata permit formulation of a sedimentation model for each sequence. Tongue River strata were dispersed eastward across the North Dakota portion of the Williston basin by slow moving streams which drained a low-lying source area to the west. The gradient of the paleoslope was low and sediments were transported primarily in suspension. The fluvial system was stable and protected backswamps developed in which extensive deposits of locally derived organic material accumulated. Basinal subsidence was uniform and controlled the rate of sedimentation during most of the episode. Sediment characteristics indicate that western North Dakota was near base level during Tongue River time. Near the close of the episode, the elevation of the source area was reduced, basinal subsidence exceeded sedimentation, and swamp conditions prevailed throughout much of Western North Dakota. The episode of Sentinel Butte deposition was initiated by an influx of coarse, basal sediment which spread eastward and south eastward across the late Tongue River swamp. Streams had slightly greater energies than those which previously crossed the basin, but sediment transport was still primarily by suspension. The paleoslope appears to have been variable, both in magnitude and direction, and may reflect changing or multiple sediment source areas created by late Iarmide activity to the west and northwest. The elevation of western North Dakota above base-level increased during Sentinel Butte time, probably as a result of rapid deposition (in excess of basinal subsidence), vertical accretion, and eastward overstepping of the Sentinel Butte sequence

The Effect of a Hyperdynamic Circulation on Tissue Doppler Values: A Simulation in Young Adults during Exercise

Left ventricular tissue Doppler imaging (TDI) velocities are used to monitor systolic and diastolic function, but it is not known how these may change in a hyperdynamic circulation, as often occurs in anesthesia and critical care medicine. Twenty-six healthy young volunteers were recruited and left ventricular systolic and diastolic tissue Doppler velocities measured at rest, light exercise, strenuous exercise, and recovery (10 minutes after exercise). At rest, TDI velocities significantly decreased from base to apex (P < .001). Within basal, mid, and apical sections, systolic and diastolic peak velocities differed between segments (P < .05), except for systolic middle (P = .094) and late diastolic apical velocities (P = .257). Basal septal velocities differed from basal lateral, for systolic (P = .041) but not diastolic peak values. Inferobasal radial values differed from basal lateral values for both systolic and diastolic velocities (P < .05). Both systolic and diastolic TDI velocities increased significantly in all segments in a proportionate manner with a hyperdynamic circulation

Validation of the cognitive recovery assessments with the Postoperative Quality of Recovery Scale in patients with low-baseline cognition

Patients with pre-surgery cognitive impairment cannot currently be assessed for cognitive recovery after surgery using the Postoperative Quality of Recovery Scale (PostopQRS),as they would mathematically be scored as recovered. The group nonetheless represent a frail cohort at high risk of recovering poorly. We aimed to validate a novel method to score cognitive recovery in patients with low baseline cognition, using the number of low-score tests rather than their numerical values. Face validity was demonstrated in 86 participants in whom both PostopQRS and an 11-item neuropsychological battery were performed. The PostopQRS agreed with neuropsychological categorization of low versus normal cognition 74% of the time, with all but 5 incorrectly coded participants deviating by only 1 neurocognitive test. Cognitive recovery over time was comparable for groups with differing baseline cognitive function, irrespective of whether PostopQRS or neuropsychological methods were used. Discriminant validation was demonstrated in a post hoc analysis of the Steroids in Cardiac Surgery (SIRS) substudy by allocating groups to normal (n=246) or low baseline cognition (n=231) stratified by cognitive recovery on day 1. Recovery was similar for participants with low and normal baseline cognition. Postoperative length of stay was longer in patients with failed cognitive recovery whether they had normal (10.4±10.0 vs. 8.0±5.9 days, P=0.02) or low baseline cognition (12.0±11.1 vs. 8.2±4.7 days, P<0.01). Overall quality of recovery, as well as cognitive, emotive, and physiological recovery in those who recovered was independent of baseline cognition. The modified scoring method for the PostopQRS cognitive domain therefore demonstrates acceptable face and discriminant validity

A human volunteer study to identify variability in performance in the cognitive domain of the postoperative quality of recovery scale

Background: The Postoperative Quality of Recovery Scale found lower than anticipated recovery in the cognitive domain. The definition of cognitive recovery did not allow for performance variability, and may have been too sensitive. This study aimed to examine variability in cognitive performance in volunteers. Methods: One hundred forty-three volunteers completed the cognitive domain questions at baseline, after 15 min and 40 min, and on days 1 and 3. Delivery via face-to-face interview was conducted for the first three measurements,and then randomized for day 1 and 3 measurements (faceto-face only, telephone only, telephone then face-to-face, face-to-face then telephone)

Predictors of patient satisfaction with anaesthesia and surgery care: a cohort study using the Postoperative Quality of Recovery Scale

Context Previous research has shown that most patients are satisfied with their anaesthetic care. For those who are not the causes may be multifactorial including dissatisfaction with surgical outcomes. Objectives We aimed to identify whether quality of recovery after anaesthesia and surgery measured in multiple domains affects patient satisfaction. Design Sub-group analysis of previously published observational cohort study of quality of recovery after surgery (using the Postoperative Quality of Recovery Scale) was used to identify predictors of incomplete satisfaction 3 days after surgery. Setting Multicentre perioperative surgery. Patients Patients !6 years old, undergoing a variety of operation types and all receiving general anaesthesia. Observations Of 701 patients, 573 completed the satisfaction question on day 3. Satisfaction was rated by a single fivepoint rating question. Patients were divided into two groups: 477 (83%) were completely satisfied and 96 (17%) were not completely satisfied. Multivariable logistic regression analysis was performed on preoperative and patient characteristics and recovery in five domains as follows: physiological, nociceptive (pain and nausea), emotive (anxiety and depression), activities of daily living and cognition. Recovery was defined as return to baseline values or better for all questions within each domain. Results Incomplete satisfaction was predicted by persistent pain or nausea at day 3 [OR 8.2 (95% CI 2.5 to 27), P &lt; 0.01] and incomplete satisfaction at day 1 [OR 28 (95% CI 10 to 77), P &lt; 0.01]. Paradoxically, incomplete satisfaction was less likely to occur if pain or nausea was present 15 min after surgery [OR 0.34 (95% CI 0.11 to 0.99), P &lt; 0.05] or at day 1 [OR 0.30 (95% CI 0.10 to 0.91), P ¼ 0.03]. Incomplete recovery in the other domains did not influence satisfaction. Conclusion Of the recovery domains measured using the Postoperative Quality of Recovery Scale, only nociception (pain or nausea) contributed to incomplete satisfaction. Eur J Anaesthesiol 2012; 29:000-00

Validation of the Portuguese Version of the Postoperative Quality Recovery Scale (PostopQRS)

Introduction: The Postoperative Quality Recovery Scale is a brief instrument of six domains designed to assess quality of recovery from early to long term after surgery. This study aims to validate the Portuguese version of the Postoperative Quality Recovery Scale. Material and Methods: In this observational study 101 adult patients undergoing elective surgery completed the Postoperative Quality Recovery Scale at 15 minutes and 40 minutes, one and three days after surgery. Three constructs were assessed for validity: increased recovery over time; effect of gender and recovery association with muscle strength. Reliability, responsiveness, feasibility and acceptability were also assessed. Results: Construct validity was shown by increased recovery over time; worse recovery for female patients in emotive, nociceptive, activities of daily living and overall recovery; improved muscle strength in recovered patients. Internal consistency for activities of daily living was acceptable at all-time points (Cronbach’s α value of 0.772 or higher), indicating scale reliability. The scale was able to detect differences in postoperative quality of recovery between the neuromuscular blockade reversal agents, neostigmine and sugammadex, indicating scale responsiveness. The time to conduct the Portuguese version at baseline was 95 - 581 seconds (median 319 seconds) and it was reduced with subsequent assessments. The proportion of patients completing all scale items was 87%, 75%, 65% and 94% for the four time periods evaluated, indicating scale feasibility and acceptability. Discussion: This study shows that the Portuguese version of the Postoperative Quality Recovery Scale, demonstrates construct validity, reliability, responsiveness, feasibility and acceptability. Conclusions: This study allowed validation of the Portuguese version of the Postoperative Quality Recovery Scale

Anomalous buried hollows in London: development of a hazard susceptibility map

Engineering works carried out in central London over many decades have revealed a number of buried hollows that exhibit curious characteristics. Some extend deep into the bedrock geology and are in-filled with disturbed superficial deposits and reworked bedrock. Others are contained within the superficial deposits. They can be up to 500 m wide and more than 60 m in depth. As the infill material often has different behavioural characteristics from the surrounding deposits failure to identify them during an initial site investigation can prove costly. This paper considers their common characteristics and describes the method used to develop a buried hollow hazard susceptibility map. This map provides planners with a broader awareness of the potential location of difficult ground conditions associated with them, thereby reducing the potential for unforeseen ground conditions through effective site investigation design. The paper continues with a discussion of some of the likely processes associated with their formation, which are attributed to cryogenic processes, and concludes with potential future research directions

Keeping it Real : An Evaluation Audit of Five Years of Youth-led Program Evaluation

Youth are increasingly seen as competent in participating in research and program evaluation, two activities previously reserved for adults. This paper is a report of the findings from an evaluation audit of Stand Up! Help Out!, a participatory action after-school youth leadership development program for disadvantaged urban youth that utilized youth evaluations to develop a best practices service model. The youths’ feedback assisted providers in improving services so that youth engagement in the program was 99% (by comparison with national highs of 79%). Here, we describe an important aspect of the process of youth-led program evaluation leading to such high youth engagement: How youth interviewed each other so as to optimize the authenticity of their program evaluations and contributions to program design. Drawing from over five years of program evaluation data collected by youth, the authors report on the youths’ experiences as informants and co-researchers, consider strategies used to help youth best describe their experiences in the program, and describe implications for other settings looking to incorporate youth-led program evaluation. Youth-led program evaluation has considerable promise for helping service providers make programs more meaningful for disadvantaged youth