Background: Standardized volume dosing of 23.4% hypertonic saline (HTS) exists for adults, but the concentration, dosing and administration of HTS in pediatrics is variable. With emerging pediatric experience of 23.4% HTS, a standard volume dose approach may be helpful. Objective: To describe initial experience with a standardized 23.4% HTS weight-based volume dosing protocol of 10, 20, or 30 mL in the pediatric intensive care unit. Methods: Standard volume doses of 23.4% HTS were developed from weight dosing equivalents of 3% HTS. Pre and post sodium and intracranial pressure (ICP) measurements were compared with paired t-test or Wilcoxon rank-sum test. The site of administration and complications were noted. Results: A total of 16 pediatric patients received 37 doses of 23.4% HTS, with the smallest patient weighing 11 kg. For protocol compliance, 17 doses (46%) followed recommended dosing, 19 were less volume than recommended (51%), and 1 dose (3%) was more than recommended. Mean increase in sodium was 3.5 mEq/L (95% CI = 2-5 mEq/L); P < 0.0001. The median decrease in ICP was 10.5 mm Hg (interquartile range [IQR] 8.3-19.5) for a 37% (IQR 25%-64%) reduction. Most doses were administered through central venous access, although peripheral intravenous administrations occurred in 4 patients without complication. Conclusion and Relevance: Three standard-volume dose options of 23.4% HTS based on weight increases sodium and reduces ICP in pediatric patients. Standard-volume doses may simplify weight-based dosing, storage and administration for pediatric emergencies, although the optimum dose, and safety of 23.4% HTS in children remains unknown.
Purpose of review The current United States opioid epidemic resulted from the overprescribing of opioids by physicians and surgeons in response to deceptive and unlawful marketing campaigns by pharmaceutical companies seeking to profit from opioid sales. Surgeons have a moral obligation to employ evidence-based opioid-sparing analgesia protocols for management of perioperative pain. Recent findings Recent evidence strongly supports the use of NSAIDs in perioperative pain management, with large studies demonstrating no increased risk of postoperative hemorrhage or renal insult. Summary We present an evidence-based approach for opioid-sparing perioperative pain management, including multimodal analgesia guidelines used at our center for patients undergoing free flap facial reanimation procedures.
240 physicians 72% of them were Critical care physicians, 21% were neurologist and 7% were neurosurgeons. Results: 30% of the responders consider Non convulsive seizures as an underestimated problem in the ICU. When NCS is diagnosed in mechanically ventilated patients 70% of the responders will start loading phenytoin immediately while about 25% of the responders will start other medications via naso gastric route. 70% of the responders prefer propofol as the anesthetic drug of choice to control non convulsive status epileptics while 80% of the responses considered the levetiracitam as the first drug of choice for long term control. Conclusions: Although the advances in diagnosis still large number of physicians need more orientation about the diagnosis and the complications of non convulsive seizures and non convulsive status epileptics in the ICU. High variability in practice that require further investigations Learning Objectives: Neuro checks are necessary to detect neurologic events and deterioration in brain injured patients. Prolonged hourly checks over days may lead to profound sleep deprivation which could masquerade as a neurologic change necessitating workup. We aimed to identify the standard frequency of neuro checks in a variety of patient populations in neurocritical care and to evaluate recognition of serial neuro checks as a contributor to sleep deprivation and potential for subsequent neurologic deterioration. Methods: We conducted a survey of 10 questions to Mayo Clinic (Minnesota, Arizona and Florida) critical care nurses, advanced practice providers (APP) and physicians over 3 weeks to evaluate current practices of neurologic monitoring of brain injured patients. A categorical scale was developed to measure the frequencies of neuro checks in a variety of neurocritical care populations. Results: We received 103 responses from 518 invitations. RN's constituted 58% of respondents, physicians 28% and advanced practice providers 14%. The most common frequency (60/103) reported for neuro checks in high risk intracranial hemorrhage populations was q1hr. The majority of respondents (58/103) estimated that high risk patients were monitored for at least every 2 hr more than 5 days. The respondents (57/103) reported an observed relationship between neurologic deterioration and sleep deprivation that required evaluation including imaging. Only 1 physician noted delayed intervention as a result of less frequent checks. Conclusions: Sleep deprivation from ICU neuro checks may be an underappreciated phenomenon in neurocritical care, particularly in patients with prolonged ICU stays and may lead to unnecessary testing, including imaging. The data suggest respondents perceive an association between frequent neuro checks and neurologic deterioration caused by sleep deprivation. The survey underscores the need for studying the optimal frequency of neuromonitoring to detect secondary neurologic events and deterioration while counterbalancing potential for harm from sleep deprivation and unnecessary testing.
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