Mannitol and HS cause an increase in cerebrospinal fluid osmolality, and are associated with similar brain relaxation scores and arteriovenous oxygen and lactate difference during craniotomy.

There is little information on gender differences in cerebral autoregulation. The purpose of this study was to compare autoregulation of the anterior and posterior circulations using the tilt test method in healthy boys and girls who were 10 -16 y of age. Transcranial Doppler was used to measure middle cerebral artery and basilar artery flow velocities (Vmca and Vbas). Cerebral autoregulation (ARI) of the middle cerebral (ARImca) and basilar arteries (ARIbas) was examined using the tilt test method. An ARI Ͻ0.4 indicates impaired autoregulation. Among the 13 boys and 13 girls, Vmca and Vbas were higher in girls. All children demonstrated intact autoregulation, but boys had higher ARImca than girls, whereas girls had higher ARIbas than boys. Girls demonstrated greater autoregulation in the basilar artery, whereas boys demonstrated greater autoregulation in the middle cerebral artery. Girls had higher flow velocities in both vessels. This study provides normative data on cerebral autoregulation of the poste- Autoregulation of cerebral blood flow (CBF) is a physiologic and homeostatic process that maintains nearly constant CBF over a range of mean arterial pressures (MAPs). Disease states, including traumatic brain injury, can impair cerebral autoregulation, rendering the brain susceptible to inadequate (cerebral ischemia) or excessive (cerebral hyperemia) CBF (1). Despite its critical role in maintaining CBF, there is limited information on cerebral autoregulation in healthy children.Little has been published on pediatric cerebral autoregulation in children outside the clinical arena of neurogenic syncope (2-4). In one study that examined dynamic cerebral autoregulation in awake adolescent study participants, the time to return of middle cerebral artery flow velocity (Vmca) to normal after a transient hypotensive stimulus was reported to be more in healthy adolescents compared with their healthy adult counterparts (5). However, in a subsequent evaluation of cerebral autoregulation in children versus adults during general anesthesia using static autoregulation testing, the investigators reported no age-related differences in autoregulatory capacity and no difference in cerebral autoregulation compared with adults (6). Because both of these studies examined cerebral autoregulation of the anterior circulation only, differences in cerebral autoregulation between the anterior and posterior circulation in children could not be evaluated. In addition, to our knowledge, there is no information regarding cerebral autoregulation of the posterior circulation in children, no information on gender differences in cerebral autoregulation in children, and finally no normative data on cerebral autoregulation using the tilt test method. Therefore, the purpose of this study was to 1) provide normative data on cerebral autoregulation using the tilt test method, 2) describe cerebral autoregulation of the posterior cerebral circulation, and 3) examine gender-related differences in autoregulatory capacity in healthy, awake boys and girl...

Repeat head computed tomography imaging is frequently used. About 30% of repeated computed tomographies showed new or worsening brain injury. However, worsening brain injury on repeat computed tomography rarely resulted in neurosurgical intervention. Patients with moderate or severe head injury and intraparenchymal injuries were more likely to show worsening brain injury and undergo neurosurgical intervention.

The pharmacologic profile of the alpha-2 agonist dexmedetomidine (Dex) suggests that it may be an ideal sedative drug for deep brain stimulator (DBS) implantation. We performed a retrospective chart review of anesthesia records of patients who underwent DBS implantation from 2001 to 2004. In 2003, a clinical protocol with Dex sedation for DBS implantation was initiated. Demographic data, use of antihypertensive medication, and duration of mapping were compared between patients who received Dex (11 patients/13 procedures) and patients who did not receive any sedation (controls: 8 patients/9 procedures). There were no differences in severity of illness between the two groups. Dex provided patient comfort and surgical satisfaction with mapping in all cases, and significantly reduced the use of antihypertensive medication (54% in the Dex group, versus 100% in controls, P = 0.048). In DBS implantation, sedation with Dex did not interfere with electrophysiologic mapping, and provided hemodynamic stability and patient comfort. Routine use of Dex in these procedures may be indicated.

Similar to older children and adults, girls between 4 and 8 years of age had higher middle cerebral and basilar artery flow velocity than age-matched boys. This difference may reflect inherent differences in cerebral metabolic rate and/or estimated cerebrovascular resistance between the genders.

Silver sulfadiazine has been used as a topical burn wound treatment for many years. Pain associated with dressing changes is a common problem in burn wounds. Aquacel Ag, a hydrofiber dressing coated with ionic silver has been reported to reduce burn wound infection and promote antimicrobial activity. The purpose of this study was to show the benefits of Aquacel Ag for the treatment of partial thickness burns. This prospective randomized study was conducted in 70 patients who had partial thickness burns less than 15% of total body surface area and were treated at Siriraj outpatient burn clinic during December 2006-February 2008. Patients were divided into two groups: Aquacel Ag-treated group with dressing changes every 3 days (35 patients) and 1% silver sulfadiazine-treated group, with daily dressing changes (35 patients). There was no difference in demographic data including age, gender, burn percentage between groups. Time-to-wound healing pain score during dressing change and cost of treatment were compared between both groups. Time-to-wound closure was significantly shorter in the Aquacel Ag-treated group (10 +/- 3 versus 13.7 +/- 4 days, P < 0.02) as well as pain scores at days 1, 3 and 7 (4.1 +/- 2.1, 2.1 +/- 1.8, 0.9 +/- 1.4 versus 6.1 +/- 2.3, 5.2 +/- 2.1, 3.3 +/- 1.9, respectively, P < 0.02). Total cost of treatment was 52 +/- 29 US dollars for the Aquacel Ag-treated group versus 93 +/- 36 US dollars for the silver sulfadiazine-treated group. This study showed that Aquacel Ag increased time to healing, decreased pain symptoms and increased patient convenience because of limiting the frequency of replacement of the dressing at lower total cost. This study confirms the efficacy of Aquacel Ag for the treatment of partial thickness burns at an outpatient clinic.

The objective of this study was to describe the incidence of impaired cerebral autoregulation and to describe the relationship between impaired cerebral autoregulation and outcome after severe pediatric traumatic brain injury (TBI). We prospectively examined cerebral autoregulation in 28 children ≤17 (10 ± 5) years with a Glasgow coma scale score <9 within the first 72 h of pediatric intensive care unit admission. Children with isolated focal TBI were excluded. Glasgow outcome scores (GOS) were collected at hospital discharge, as well as 3 and 6 months after severe TBI. GOS <4 reflected poor outcome. Cerebral autoregulation was impaired in 12/28 children. An autoregulatory index <0.4 was associated with GOS <4 at 6 months (p = 0.005). Impaired cerebral autoregulation, early after severe pediatric TBI, was associated with a poor 6-month outcome.

Objective-To examine the influence of definition and location (field, emergency department [ED] or Pediatric Intensive Care Unit [PICU]) of hypotension on outcome following severe pediatric Traumatic Brain Injury (TBI). Participants-93 children < 14 years of age with TBI following injury, head abbreviated injury score (AIS) ≥ 3, and PICU admission Glasgow Coma Sale (GCS) score < 9 formed the analytic sample. Data sources included the Harborview Trauma Registry and Hospital Records. Design-Retrospective Cohort study. Setting-HarborviewOutcome Measures-The relationship between hypotension and outcome was examined comparing two definitions of hypotension: 1) systolic blood pressure (SBP) < 5 th percentile for age and 2) SBP < 90 mmHg. Hospital discharge Glasgow Outcome score (GOS) < 4, or disposition of either death or discharge to a skilled nursing facility were considered poor outcomes. PICU and hospital length of stay (LOS) were also examined.Results-SBP < 5 th percentile for age was more highly associated with poor hospital discharge GOS (p = 0.001), poor disposition (p = 0.02), PICU LOS (RR 9.5; 95% CI 6.7-12.3) and hospital LOS (RR 18.8;) than SBP < 90mmHg. Hypotension occurring in either the field or ED, but not in the PICU, was associated with poor GOS (p = 0.008), poor disposition (p= 0.03) and hospital LOS (RR 18.7; 95% CI 13.1-24.2).Conclusions-Early hypotension, defined as SBP < 5 th percentile for age in the field and/or ED, was a better predictor of poor outcome than delayed hypotension or the use of SBP < 90 mmHg.