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Goal-Directed Resuscitative Interventions During Pediatric Interfacility Transport.

ABSTRACT: This article reports results of the first National Institutes of Health-funded prospective interfacility transport study to determine the effect of goal-directed therapy administered by a specialized pediatric team to critically ill children with the systemic inflammatory response syndrome. We hypothesized that goal-directed therapy during interfacility transport would decrease hospital length of stay, prevent multiple organ dysfunction, and reduce subsequent ICU interventions.Before-and-after intervention trial.During interfacility transport of critically ill patients by a specialized pediatric transport team, back to a tertiary care children's hospital.Before-and-after intervention trial.Interfacility pediatric transport patients, age 1 month to 17 years, with systemic inflammatory response syndrome.Prospective data were collected on all pediatric interfacility transport patients with systemic inflammatory response syndrome transported by the Angel One Transport team at Arkansas Children's Hospital. A 10-month data collection period was followed by institution of a goal-directed resuscitation protocol. Data were subsequently collected for 10 additional months followed by comparison of pre- and postintervention groups. All transport personnel underwent training with didactics and high-fidelity simulation until mastery with goal-directed resuscitation was achieved.All transport patients were screened for systemic inflammatory response syndrome using established variables and 235 (123 preintervention and 112 postintervention) were enrolled. Univariate analysis revealed shorter hospital stay (11 ± 15 d vs 7 ± 10 d; p = 0.02) and fewer required therapeutic ICU interventions in the postintervention group (Therapeutic Intervention Scoring System-28 Scores, 19.4 ± 6.8 vs 17.3 ± 6.6; p = 0.04). ICU stay and prevalence of organ dysfunction were not statistically different. Multivariable analysis showed a 1.6-day (95% CI, 1.3-2.03; p = 0.02) decrease in hospital stay in the postintervention group.This study suggests that goal-directed therapy administered by a specialized pediatric transport team has the potential to impact the outcomes of critically ill children. Findings from this study should be confirmed across multiple institutions, but have the potential to impact the clinical outcomes of critically ill children with systemic inflammatory response syndrome.

SUBMITTER: Stroud MH

PROVIDER: S-EPMC4506208 | biostudies-literature | 2015 Aug

REPOSITORIES: biostudies-literature

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Project description:Distracted eating can lead to increased food intake, but it is unclear how. We aimed to assess how distraction affects motivated, goal-directed responses for food reward after satiation. Thirty-eight healthy normal-weight participants (28F; 10M) performed a visual detection task varying in attentional load (high vs. low distraction) during fMRI. Simultaneously, they exerted effort for sweet and savory food rewards by repeated button presses. Two fMRI runs were separated by sensory-specific satiation (outcome devaluation) of one of the (sweet or savory) reward outcomes, to assess outcome-sensitive, goal-directed, responses (valued vs. devalued reward, post vs. pre satiation). We could not verify our primary hypothesis that more distraction leads to less activation in ventromedial prefrontal cortex (vmPFC) during goal-directed effort. Behaviorally, distraction also did not affect effort for food reward following satiation across subjects. For our secondary hypothesis, we assessed whether distraction affected other fronto-striatal regions during goal-directed effort. We did not obtain such effects at our whole-brain corrected threshold, but at an exploratory uncorrected threshold (p?<?0.001), distraction decreased goal-directed responses (devalued vs. valued) in the right inferior frontal gyrus (rIFG). We continued with this rIFG region for the next secondary hypothesis; specifically, that distraction would reduce functional connectivity with the fronto-striatal regions found in the previous analyses. Indeed, distraction decreased functional connectivity between the rIFG and left putamen for valued versus devalued food rewards (pFWE(cluster)?<?0.05). In an exploratory brain-behavior analysis, we showed that distraction-sensitive rIFG-responses correlated negatively (r?=?- 0.40; p?=?0.014) with the effect of distraction on effort. Specifically, decreased distraction-related rIFG-responses were associated with increased effort for food reward after satiation. We discuss the absence of distraction effects on goal-directed responses in vmPFC and in behavior across participants. Moreover, based on our significant functional connectivity and brain-behavior results, we suggest that distraction might attenuate the ability to inhibit responses for food reward after satiation by affecting the rIFG and its connection to the putamen.

Project description:IntroductionTotal hip replacement is one of the most commonly performed major orthopaedic operations. Goal-directed therapy (GDT) using haemodynamic monitoring has previously demonstrated outcome benefits in high-risk surgical patients under general anaesthesia. GDT has never been formally assessed during regional anaesthesia.MethodsPatients undergoing total hip replacement while under regional anaesthesia were randomised to either the control group (CTRL) or the protocol group (GDT). Patients in the GDT group, in addition to standard monitoring, were connected to the FloTrac sensor/Vigileo monitor haemodynamic monitoring system, and a GDT protocol was used to maximise the stroke volume and target the oxygen delivery index to > 600 mL/minute/m2.ResultsPatients randomised to the GDT group were given a greater volume of intravenous fluids during the intraoperative period (means ± standard deviation (SD): 6,032 ± 1,388 mL vs. 2,635 ± 346 mL; P < 0.0001), and more of the GDT patients received dobutamine (0 of 20 CTRL patients vs. 11 of 20 GDT patients; P < 0.0003). The GDT patients also received more blood transfused during the intraoperative period (means ± SD: 595 ± 316 mL vs. 0 ± 0 mL; P < 0.0001), although the CTRL group received greater volumes of blood replacement postoperatively (CTRL patients 658 ± 68 mL vs. GDT patients 198 ± 292 mL; P < 0.001). Overall blood consumption (intraoperatively and postoperatively) was not different between the two groups. There were an increased number of complications in the CTRL group (20 of 20 CTRL patients (100%) vs. 16 of 20 GDT patients (80%); P = 0.05). These outcomes were predominantly due to a difference in minor complications (20 of 20 CTRL patients (100%) vs. 15 of 20 GDT patients (75%); P = 0.047).ConclusionsGDT applied during regional anaesthesia in patients undergoing elective total hip replacement changes intraoperative fluid management and may improve patient outcomes by decreasing postoperative complications. Larger trials are required to confirm our findings.

Project description:Recent research has shown that perceptual processing of stimuli previously associated with high-value rewards is automatically prioritized even when rewards are no longer available. It has been hypothesized that such reward-related modulation of stimulus salience is conceptually similar to an "attentional habit." Recording event-related potentials in humans during a reinforcement learning task, we show strong evidence in favor of this hypothesis. Resistance to outcome devaluation (the defining feature of a habit) was shown by the stimulus-locked P1 component, reflecting activity in the extrastriate visual cortex. Analysis at longer latencies revealed a positive component (corresponding to the P3b, from 550-700 ms) sensitive to outcome devaluation. Therefore, distinct spatiotemporal patterns of brain activity were observed corresponding to habitual and goal-directed processes. These results demonstrate that reinforcement learning engages both attentional habits and goal-directed processes in parallel. Consequences for brain and computational models of reinforcement learning are discussed.SIGNIFICANCE STATEMENT The human attentional network adapts to detect stimuli that predict important rewards. A recent hypothesis suggests that the visual cortex automatically prioritizes reward-related stimuli, driven by cached representations of reward value; that is, stimulus-response habits. Alternatively, the neural system may track the current value of the predicted outcome. Our results demonstrate for the first time that visual cortex activity is increased for reward-related stimuli even when the rewarding event is temporarily devalued. In contrast, longer-latency brain activity was specifically sensitive to transient changes in reward value. Therefore, we show that both habit-like attention and goal-directed processes occur in the same learning episode at different latencies. This result has important consequences for computational models of reinforcement learning.

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Goal-Directed Resuscitative Interventions During Pediatric Interfacility Transport.

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