The purpose of this update of the European Society of Anaesthesiology (ESA) guidelines on the pre-operative evaluation of the adult undergoing noncardiac surgery is to present recommendations based on the available relevant clinical evidence. Well performed randomised studies on the topic are limite

Pre-operative evaluation of adults undergoing elective noncardiac surgery: Updated guideline from the European Society of Anaesthesiology.

Background Dehydration appears prevalent, costly and associated with adverse outcomes. We sought to generate consensus on such key issues and elucidate need for further scientific enquiry. Materials and methods: A modified Delphi process combined expert opinion and evidence appraisal. Twelve relevant experts addressed dehydration’s definition, objective markers and impact on physiology and outcome. Results: Fifteen consensus statements and seven research recommendations were generated. Key findings, evidenced in detail, were that there is no universally accepted definition for dehydration; hydration assessment is complex and requires combining physiological and laboratory variables; “dehydration” and “hypovolaemia” are incorrectly used interchangeably; abnormal hydration status includes relative and/or absolute abnormalities in body water and serum/plasma osmolality (pOsm); raised pOsm usually indicates dehydration; direct measurement of pOsm is the gold standard for determining dehydration; pOsm >300 and ≤280 mOsm/kg classifies a person as hyper or hypo-osmolar; outside extremes, signs of adult dehydration are subtle and unreliable; dehydration is common in hospitals and care homes and associated with poorer outcomes. Discussion: Dehydration poses risk to public health. Dehydration is under-recognized and poorly managed in hospital and community-based care. Further research is required to improve assessment and management of dehydration and the authors have made recommendations to focus academic endeavours. •Key messages •Dehydration assessment is a major clinical challenge due to a complex, varying pathophysiology, non-specific clinical presentations and the lack of international consensus on definition and diagnosis. •Plasma osmolality represents a valuable, objective surrogate marker of hypertonic dehydration which is underutilized in clinical practice. •Dehydration is prevalent within the healthcare setting and in the community, and appears associated with increased morbidity and mortality.

/pdf/a-multidisciplinary-consensus-on-dehydration-definitions-12az4oq9jb.pdf

A Multidisciplinary Consensus on Dehydration: definitions, diagnostic methods and clinical implications

We aimed to investigate the correlation between the Glasgow Coma Scale (GCS), the injury severity score (ISS) and serum levels of trace elements (TE) in severe trauma patients to analyze alteration of the levels of trace elements and serum biochemical indexes in the period of admission from 126 adult cases of severe brain trauma with traffic accidents. Multi-trace elements for patients in the trauma-TE groups were used. The results indicated that all patients presented an acute trace elements deficiency syndrome (ATEDs) after severe trauma, and the correlation between ISS and serum levels of Fe, Zn, and Mg was significant. Compared to the normal control group, levels of the trace elements in serum were significantly decreased after trauma, suggesting that enhancement of immunity to infection and multiple organ failure (MOF) via the monitoring and supplement of trace elements will be a good strategy to severe traumatic patients in clinics.

Analysis of Blood Trace Elements and Biochemical Indexes Levels in Severe Craniocerebral Trauma Adults with Glasgow Coma Scale and Injury Severity Score

Objective We aimed to determine if abnormal laboratory values which may indicate volume depletion are associated with increased odds of experiencing a hospital-acquired fall. Design Matched case–control study. Setting Four hospitals located in the Southeast USA. Participants Data from 699 adult fallers and 1189 matched controls (non-fallers) were collected via chart review from 2005 to 2010. Controls were matched to cases by nursing unit, time of fall and length of stay. Outcome measures The primary exposures included serum sodium, blood urea nitrogen (BUN), creatinine, BUN/creatinine ratio and haematocrit. Conditional logistic regression with m:n matching was used to determine adjusted and unadjusted ORs. Results Serum sodium levels were strongly associated with falls. In models controlling for demographic and other fall risk factors, patients with serum sodium levels of 125 mEq/L or less were associated with increased odds of experiencing a fall as compared with those with serum sodium levels of greater than 134 mEq/L (adjusted OR (aOR)=5.08, 95% CI 1.43 to 18.08). Conversely, elevated BUN, creatinine and elevated BUN/creatinine ratios were not associated with increased odds of experiencing a fall (aOR=0.64, 95% CI 0.49 to 0.84; aOR=0.70, 95% CI 0.54 to 0.92 and aOR=0.77, 95% CI 0.58 to 1.04, respectively.) Conclusions Laboratory indices that may indicate volume depletion appear to be unrelated to falls. However, hyponatraemia does appear to be a risk factor for falls, and those with serum sodium levels below 126 mEq/L are at especially high risk. It may be that other deficits associated with hyponatraemia, like altered mental status, are associated with risk of experiencing a hospital-acquired fall. These results indicate that abnormal laboratory values, like low sodium, can be useful for identifying hospitalised patients at risk of falling. Therefore, further investigation into abnormal laboratory values as predictors of hospital-acquired falls is warranted.

https://bmjopen.bmj.com/content/bmjopen/7/8/e017045.full.pdf

Associations between hyponatraemia, volume depletion and the risk of falls in US hospitalised patients: a case-control study.

Endovascular mechanical thrombectomy is a new standard of care for acute ischemic stroke (AIS). The majority of these patients receive mechanical ventilation (MV), which has been associated with poor outcomes. The implication of this is significant, as most neurointerventionalists prefer general compared to local anesthesia during the procedure. Consequences of hemodynamic and respiratory perturbations during general anesthesia and MV are thought to contribute significantly to the poor outcomes that are encountered. In this review, we first describe the unique risks associated with MV in the specific context of AIS and then discuss evidence of brain goal-directed approaches that may mitigate these risks. These strategies include an individualized approach to hemodynamic parameters (eg, adherence to a minimum blood pressure goal and adequate volume resuscitation), respiratory parameters (eg, arterial carbon dioxide optimization), and the use of ventilator settings that optimize neurological outcomes (eg, arterial oxygen optimization).

Optimizing Outcomes for Mechanically Ventilated Patients in an Era of Endovascular Acute Ischemic Stroke Therapy

BACKGROUND: Dehydration is a frequent clinical problem. No single laboratory val- ue has been found to be accurate; however, the BUN/Creatinine Ratio appears the most sensitive parameter. The respiratory variation (Caval Index, CIn) in the diameter of the inferior vena cava has been investigated as a non-invasive marker for the intravascularvolumestatus. AIM : The present study is performed with the aim to explore the relationship between CIn and BUN/creatinine ratio. PATIENTS AND METHODS: This prospective, observational study was conducted at Emergency Department (ED) of San Paolo Hospital (Savona, Italy), in October 2011. RESULTS: 113 patients were considered eligible (mean age of 63 years). We found a good correla - tion between CIn and BUN/Cr Ratio (Pearson Index 0.76, p < 0.001). Receiver operator characteristic curve (ROC) analyses indicated that the maximum value was 0.884 ( p < 0.0001) and corresponded to CIn 60.7%, (sensitivity 79%, specificity 89%). CIn was a good predictor for patients with BUN/Cr ratio greater than 20, and was particularly strong in de - termining patients with lower BUN/Cr ratio. DISCUSSION: Our study suggests that inferior vena cava could provide indications on the state of hydration of the patients: we found that a caval in - dex greater than or equal to 60% was associated with a BUN/Cr Ratio over 20, which is considered an important marker for dehydration. Therefore, bedside sonography can give emergency physi - cians immediate information on patient volume status long before obtaining laboratory findings. CONCLUSIONS: Our study seems to support the hypothesis that CIn can be a useful bedside mark - er to predict dehydration in Emergency Depart - ment (ED) patients.

/pdf/identification-of-the-hydration-state-in-emergency-patients-28zt7oks53.pdf

Identification of the hydration state in emergency patients: correlation between caval index and BUN/creatinine ratio.

The appropriate management of minor head injury (MHI) in patients receiving oral anticoagulant (OAC) is unclear. In this retrospective study, we focused on elderly patients (>65 years) treated with OAC, presented to our emergency department with MHI between 2004 and 2010. Three hundred and six patients with MHI were taking OAC: we documented 7.19% hemorrhages at the first computed tomography (C); 18.19% deaths; 50.1% spontaneous reabsorptions; 22.73% deteriorations of intracranial bleeding without surgical intervention (for clinical comorbidity), and 4.55% neurosurgical interventions. We documented a second positive CT scan in 2 patients (1.51%) who had no symptoms and remained asymptomatic during observation. In both cases, intracranial bleeding resolved spontaneously. The mean international normalized ratio (INR) value was 2.26, higher in the group of patients with bleeding (2.74) than in the group without bleeding (2.19). We found a significant increased risk in patients with posttraumatic loss of consciousness [odds ratio (OR) 28.3], diffuse headache (OR 14.79), vomiting (OR 14.2) and neurological signs (OR 5.27). We did not reach significance in patients with post-traumatic amnesia. Our data confirm the need for a CT scan of any patients on OAC with MHI. None of our patients developed any symptoms or signs during observation, and only 2 patients developed an intracranial hemorrhage in the second CT scan with a favorable evolution. Our data need to be confirmed with an observational study, but we suggest that the second CT could be reserved for patients developing symptoms and signs during observation. We also underline the role of the INR in the stratification of risk.

/pdf/minor-head-injury-in-anticoagulated-patients-a-6-year-1jzjgoiupn.pdf

Minor head injury in anticoagulated patients: a 6-year retrospective analysis in an emergency department

The authors analyze the major trauma recorded in a couple of years in the Emergency Room of the San Paolo Hospital of Savona after the setting, in the same district, of the trauma center at the Santa Corona Hospital of Pietra Ligure. Despite the policy of centralization adopted the amount of major trauma seen at the San Paolo Hospital remained unchanged over time and the number of patients who are not rescued by medicalized ambulance is still significant. These observations underline the importance of periodically reviewing the protocols and make training on trauma also in hospitals that are not recognized as trauma center.

/pdf/evaluation-of-severe-trauma-at-the-emergency-department-of-45jdibozwo.pdf

Evaluation of severe trauma at the Emergency Department of the San Paolo Hospital of Savona: two years of experience

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Identification of the hydration state in emergency patients: correlation between caval index and BUN/creatinine ratio.

Minor head injury in anticoagulated patients: a 6-year retrospective analysis in an emergency department

Evaluation of severe trauma at the Emergency Department of the San Paolo Hospital of Savona: two years of experience