This document summarizes research on brain oxygen monitoring after traumatic brain injury (TBI). It shows that:
1) Episodes of low brain tissue oxygen (PbtO2) levels below 15 mm Hg are common after TBI and can last from 30 minutes to over an hour.
2) Low PbtO2 levels are associated with worse neurological outcomes. Several studies found patients with PbtO2 levels below 10 mm Hg were 3-10 times more likely to have an unfavorable outcome.
3) Observational studies comparing TBI patients managed with intracranial pressure (ICP) monitoring alone versus ICP plus PbtO2 monitoring found those in the ICP+Pbt
Reducing Perioperative Cardiac Risk: Do Beta blockers Help?Terry Shaneyfelt
Review of the effect of beta blockers on perioperative cardiac events including updated recommendations by the ACC/AHA (August 2014. Watch my YouTube video (http://youtu.be/WPLXDm9Nzoc) describing these slides.
Reducing Perioperative Cardiac Risk: Do Beta blockers Help?Terry Shaneyfelt
Review of the effect of beta blockers on perioperative cardiac events including updated recommendations by the ACC/AHA (August 2014. Watch my YouTube video (http://youtu.be/WPLXDm9Nzoc) describing these slides.
Delaney shares insights into the mysterious world of statistics and trials. This 12 minute podcast is particularly useful for Registrars preparing for their exams and was recorded at BCC4. For similar podcasts and audio; head to www.intensivecarenetwork.com and to rego for BCC5 in Cairns, check out www.bedsidecriticalcare.com
BCC4: Michael Parr on ICU - Surviving Trauma GuidelinesSMACC Conference
Michael Parr, director of Liverpool ICU in Australia, speaks about "Surviving Trauma Guidelines". He does so through the use of an interesting case of a patient admitted to ICU following a MVA. This educational podcast was recorded at BCC4.
Does Type of Dialysis Affect BNP in Fluid Overload Patients?Premier Publishers
Brain Natriuretic Peptide (BNP) levels are important as predictors of heart failure in end-stage renal disease (ESRD) patients undergoing hemodialysis (HD) and continuous ambulatory peritoneal dialysis (PD). Twenty-four HD patients and 35 PD patients were included in the study. Each patient underwent an echocardiographic examination besides the determination of BNP, high-sensitivity C-reactive protein (hs-CRP) and homocysteine (Hcy). BNP, left ventricular mass (LVM), left ventricular mass index (LVMI) and Hcy levels were significantly higher in HD group (p<0.05); hs-CRP levels were significantly higher in PD group (p=0.029). Predialysis BNP was significantly higher than the postdialysis BNP (p=0.003). There was a significant correlation between LVMI and BNP in PD (r=0.527, p=0.009) and predialysis BNP in HD (r=0.417, p=0.043) groups. In conclusion, BNP levels were found to be significantly correlated with LVMI in HD and PD patients. Hemodialysis patients had higher BNP and LVMI levels. This may be due to the hemodynamic changes which occur with the hemodialysis.
Pre hospital reduced-dose fibrinolysis followed by pciVishwanath Hesarur
Extensive investigations of treatment strategies for patients with STEMIs have led to many improvements in care.
Yet optimal treatment strategies for patients aged ≥75 years with STEMIs are much less clear, and many knowledge gaps remain.
Age ≥75 years is an independent predictor of 30-day mortality in STEMI.
Although this higher mortality risk generally would dictate more aggressive treatments, recent data have shown, for example, that <1/2 of patients aged ≥80 years with STEMIs are treated with any reperfusion therapies at all.
DANISH is a major breakthrough trial published in NEJM on 29/09/2016 regarding Defibrillator Implantation in Patients with Nonischemic Systolic Heart Failure. All content of this slide is Copy right of NEJM.
Niklas Nielsen talks about the TTM trial as seen through a 2019 lens.
The video and references from the talk and all the rest of the goodness from The Big Sick 2019 in Zermatt is up at
https://scanfoam.org/
Delaney shares insights into the mysterious world of statistics and trials. This 12 minute podcast is particularly useful for Registrars preparing for their exams and was recorded at BCC4. For similar podcasts and audio; head to www.intensivecarenetwork.com and to rego for BCC5 in Cairns, check out www.bedsidecriticalcare.com
BCC4: Michael Parr on ICU - Surviving Trauma GuidelinesSMACC Conference
Michael Parr, director of Liverpool ICU in Australia, speaks about "Surviving Trauma Guidelines". He does so through the use of an interesting case of a patient admitted to ICU following a MVA. This educational podcast was recorded at BCC4.
Does Type of Dialysis Affect BNP in Fluid Overload Patients?Premier Publishers
Brain Natriuretic Peptide (BNP) levels are important as predictors of heart failure in end-stage renal disease (ESRD) patients undergoing hemodialysis (HD) and continuous ambulatory peritoneal dialysis (PD). Twenty-four HD patients and 35 PD patients were included in the study. Each patient underwent an echocardiographic examination besides the determination of BNP, high-sensitivity C-reactive protein (hs-CRP) and homocysteine (Hcy). BNP, left ventricular mass (LVM), left ventricular mass index (LVMI) and Hcy levels were significantly higher in HD group (p<0.05); hs-CRP levels were significantly higher in PD group (p=0.029). Predialysis BNP was significantly higher than the postdialysis BNP (p=0.003). There was a significant correlation between LVMI and BNP in PD (r=0.527, p=0.009) and predialysis BNP in HD (r=0.417, p=0.043) groups. In conclusion, BNP levels were found to be significantly correlated with LVMI in HD and PD patients. Hemodialysis patients had higher BNP and LVMI levels. This may be due to the hemodynamic changes which occur with the hemodialysis.
Pre hospital reduced-dose fibrinolysis followed by pciVishwanath Hesarur
Extensive investigations of treatment strategies for patients with STEMIs have led to many improvements in care.
Yet optimal treatment strategies for patients aged ≥75 years with STEMIs are much less clear, and many knowledge gaps remain.
Age ≥75 years is an independent predictor of 30-day mortality in STEMI.
Although this higher mortality risk generally would dictate more aggressive treatments, recent data have shown, for example, that <1/2 of patients aged ≥80 years with STEMIs are treated with any reperfusion therapies at all.
DANISH is a major breakthrough trial published in NEJM on 29/09/2016 regarding Defibrillator Implantation in Patients with Nonischemic Systolic Heart Failure. All content of this slide is Copy right of NEJM.
Niklas Nielsen talks about the TTM trial as seen through a 2019 lens.
The video and references from the talk and all the rest of the goodness from The Big Sick 2019 in Zermatt is up at
https://scanfoam.org/
Andrew Udy talks about Brain Tissue Oxygen Monitoring:
It’s Not What You’ve Got It’s What You Do With It
The BONANZA Trial
Andrew Udy talks about the ongoing BONANZA Trial which is assessing whether an algorithm that incorporates both ICP and brain tissue oxygen (PbTO2) can improve outcomes after traumatic brain injury (TBI). Like with all monitoring, how the PbTO2 is interpreted and managed is critical and the devil is in the detail!
More on BONANZA here
More on BOOST3 here
Stress & Strain during Lung Protective Ventilation Egypt Pulmonary Critical...Dr.Mahmoud Abbas
Stress & Strain During Lung Protective Ventilation. Presentation of Dr Lluis Blanch at Pulmonary Critical Care Egypt 2014 , the leading educational event and exhibition for Critical Care Medicine in Egypt. www.pccmegypt.com
Presentation of Dr. Lluis Blanch at 8th Pulmonary Medicine Update Course, February 2008, Cairo, Egypt. Pulmonary Medicine Update Course is organized by Scribe : www.scribeofegypt.com
Presented by D.Niall Ferguson at 9th Pulmonary Medicine Update Course held at Cairo, Egypt.
This course is the leading Pulmonary Critical Care event in Egypt. The course is organized by Scribe (www.scribeofegypt.com)
This presentation discusses the latest evidence for blood transfusion triggers in the intensive care unit of various clinical condition including severe sepsis, GI bleed, post surgical cases, and post cardiac surgery among other cnditions
Similar to Emerging neuromonitoring techniques in TBI by Professor Andrew Udy (20)
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
12. A. Normal condition. Oxygenated blood
delivers O2 to tissue. PaO2 and PtO2
equilibrated
B. Macrocirculatory ischemia (classical
ischemia). Hypotension or large vessel
stenosis reduces blood entering capillaries.
Tissue extracts higher fraction of O2 from
blood, but remains ischemic
C. Microcirculatory ischemia (diffusion hypoxia).
Patchy microvascular collapse or occlusion
results in increased gradient between blood
O2 and tissue O2
Menon et al, Crit Care Med 2004;32:1384-1390
13. Episodes of low PbtO2 are
common after TBI
– Van den Brink et al1 (2000)
• 101 patients monitored average 86 hours
• 57% had values < 15 mm Hg
• 42% had values < 10 mm Hg
• 22% had values < 5 mm Hg
– Longhi et al2 (2007)
• Episodes PbtO2 10 - 19 mm Hg in 23% of time
– Median duration 50 minutes
• Episodes PbtO2 < 10 mm Hg 11% of the time
– Median duration 39 minutes
1. van den Brink WA, et al, Neurosurgery 2000; 46:868-878.
2. Longhi L, et al, Intensive Care Med 2007; 33(12):2136-2142.
14. Low PbtO2 is associated with poor
neurological outcome
Study
(First Author,
# of patients
evaluable)
Hypoxia No Hypoxia
Odds Ratio
(95% C.I.)
Unfavorable
Outcome (n)
Favorable
Outcome (n)
Unfavorable
Outcome (n)
Favorable
Outcome (n)
Van den
Brink 2000 (n
= 99)
29 14 24 32
3.8
(1.6 – 8.4)
Bardt et al
1998 (n = 35)
18 5 3 9
10.8
(2.1 – 55.7)
Chang et al
2009 (n = 25)
6 1 7 11
9.43
(1.1 – 95.9)
1. van den Brink WA, et al Neurosurgery 2000; 46:868-878
2. Bardt TF, et al, Acta Neurochir 1998; Suppl. 71:153-156
3. Chang J, et al, Crit Care Med 2009;37:283-290
15. Chang et al, Crit Care Med 2009;37:283-290
1 0 1 5 2 0 2 5 3 0
0
1
2
3
4
5 *
P b tO 2 c u to ff (m m H g )
RRofGOSE1-4
16.
17. Uncontrolled, observational data
All used historical or concurrent (physician choice) controls
Study ICP + PbtO2 ICP/CPP Odds Ratio
Poor
Outcome
Good
Outcome
Poor
Outcome
Good
Outcome
(95% CI)
McCarthy 2009 34 29 32 16 1.7
Meixenberger 2003 18 34 18 21 1.6
Narotam 2009 44 83 22 17 2.4
Spiotta 2010 25 45 32 21 2.7
Pooled Odds Ratio 2.1 (1.4 – 3.1)
Nangunoori et al NeuroCrit Care 2012 17:131-138
18.
19.
20.
21. Scenario Tier Task# Task
ICP
Only
ICP+
PbtO2
C
1
1 Adjust head of bed to improve brain oxygenation 36
2 Ensure temperature < 38 41
3 Increase CPP to a maximum of 70mmHg with fluid bolus 27
4 Optimize hemodynamics 25
5 Increase PaO2 by increasing FiO2 to 60% 82
6 Increase PaO2 by adjusting PEEP 35
7 Add EEG monitoring 8
8 Add antiepileptic drug (AED) 7
2
1 Increase PaO2 by increasing FiO2 to 100% 26
2 Increase PaO2 by adjusting PEEP 13
3 Increase CPP to a maximum of 70mmHg with vasopressors 5
4 Adjust ventilation to increase PaCO2 to 45‐50 mmHg 6
5 Transfuse packed RBCs to reach Hgb > 10g/dL 4
6 Decrease ICP to < 10mmHg 11
22. Scenario Tier Task# Task
ICP
Only
ICP+
PbtO2
B
1
1 Adjust head of bed to lower ICP 61 44
2 Ensure temperature < 38 72 33
3 Adjust sedation and analgesia 324 181
4 Adjust ventilation to obtain PaCO2 between 35‐40 mmHg 38 10
5 CSF drainage 165 59
6 Standard dose mannitol (0.25 – 1.0 g/kg) 63 23
7 Hypertonic saline 70 26
2
1 Adjust ventilation to lower PaCO2 to 32‐35 mmHg. 9 5
2 High dose mannitol (>1g/kg), or higher frequency of standard dose 6 6
3 Repeat CT – look for increased size of intracranial mass lesions 14 7
4 Treat surgically remediable lesions with craniotomy 0 1
5 Adjust temperature to 35 – 37 °C 4 4
3
1 Pentobarbital coma 1 0
2 Decompressive craniectomy 3 0
3 Adjust Temperature to 32 – 34.5 °C 1 0
4 Neuromuscular paralysis 8 2
23.
24.
25. Brain Oxygen Optimization in Severe
TBI-Phase 3 (BOOST-3)
William Barsan, MD, Contact PI, CCC SIREN
Ramon Diaz-Arrastia, MD, PhD, Scientific PI
Lori Shutter, MD, Clinical PI
Sharon Yeatts, PhD, Statistical PI, DCC SIREN