Measurements of adequacy of anesthesia and level of consciousness during surgery and intensive care

The adequacy of anesthesia has been studied since the introduction of balanced general anesthesia. Commercial monitors based on electroencephalographic (EEG) signal analysis have been available for monitoring the hypnotic component of anesthesia from the beginning of the 1990s. Monitors measuring the depth of anesthesia assess the cortical function of the brain, and have gained acceptance during surgical anesthesia with most of the anesthetic agents used. However, due to frequent artifacts, they are considered unsuitable for monitoring consciousness in intensive care patients. The assessment of analgesia is one of the cornerstones of general anesthesia. Prolonged surgical stress may lead to increased morbidity and delayed postoperative recovery. However, no validated monitoring method is currently available for evaluating analgesia during general anesthesia. Awareness during anesthesia is caused by an inadequate level of hypnosis. This rare but severe complication of general anesthesia may lead to marked emotional stress and possibly posttraumatic stress disorder. In the present series of studies, the incidence of awareness and recall during outpatient anesthesia was evaluated and compared with that of in inpatient anesthesia. A total of 1500 outpatients and 2343 inpatients underwent a structured interview. Clear intraoperative recollections were rare the incidence being 0.07% in outpatients and 0.13% in inpatients. No significant differences emerged between outpatients and inpatients. However, significantly smaller doses of sevoflurane were administered to outpatients with awareness than those without recollections (p<0.05). EEG artifacts in 16 brain-dead organ donors were evaluated during organ harvest surgery in a prospective, open, nonselective study. The source of the frontotemporal biosignals in brain-dead subjects was studied, and the resistance of bispectral index (BIS) and Entropy to the signal artifacts was compared. The hypothesis was that in brain-dead subjects, most of the biosignals recorded from the forehead would consist of artifacts. The original EEG was recorded and State Entropy (SE), Response Entropy (RE), and BIS were calculated and monitored during solid organ harvest. SE differed from zero (inactive EEG) in 28%, RE in 29%, and BIS in 68% of the total recording time (p<0.0001 for all). The median values during the operation were SE 0.0, RE 0.0, and BIS 3.0. In four of the 16 organ donors, EEG was not inactive, and unphysiologically distributed, nonreactive rhythmic theta activity was present in the original EEG signal. After the results from subjects with persistent residual EEG activity were excluded, SE, RE, and BIS differed from zero in 17%, 18%, and 62% of the recorded time, respectively (p<0.0001 for all). Due to various artifacts, the highest readings in all indices were recorded without neuromuscular blockade. The main sources of artifacts were electrocauterization, electromyography (EMG), 50-Hz artifact, handling of the donor, ballistocardiography, and electrocardiography. In a prospective, randomized study of 26 patients, the ability of Surgical Stress Index (SSI) to differentiate patients with two clinically different analgesic levels during shoulder surgery was evaluated. SSI values were lower in patients with an interscalene brachial plexus block than in patients without an additional plexus block. In all patients, anesthesia was maintained with desflurane, the concentration of which was targeted to maintain SE at 50. Increased blood pressure or heart rate (HR), movement, and coughing were considered signs of intraoperative nociception and treated with alfentanil. Photoplethysmographic waveforms were collected from the contralateral arm to the operated side, and SSI was calculated offline. Two minutes after skin incision, SSI was not increased in the brachial plexus block group and was lower (38 ± 13) than in the control group (58 ± 13, p<0.005). Among the controls, one minute prior to alfentanil administration, SSI value was higher than during periods of adequate antinociception, 59 ± 11 vs. 39 ± 12 (p<0.01). The total cumulative need for alfentanil was higher in controls (2.7 ± 1.2 mg) than in the brachial plexus block group (1.6 ± 0.5 mg, p=0.008). Tetanic stimulation to the ulnar region of the hand increased SSI significantly only among patients with a brachial plexus block not covering the site of stimulation. Prognostic value of EEG-derived indices was evaluated and compared with Transcranial Doppler Ultrasonography (TCD), serum neuron-specific enolase (NSE) and S-100B after cardiac arrest. Thirty patients resuscitated from out-of-hospital arrest and treated with induced mild hypothermia for 24 h were included. Original EEG signal was recorded, and burst suppression ratio (BSR), RE, SE, and wavelet subband entropy (WSE) were calculated. Neurological outcome during the six-month period after arrest was assessed with the Glasgow-Pittsburgh Cerebral Performance Categories (CPC). Twenty patients had a CPC of 1-2, one patient had a CPC of 3, and nine patients died (CPC 5). BSR, RE, and SE differed between good (CPC 1-2) and poor (CPC 3-5) outcome groups (p=0.011, p=0.011, p=0.008, respectively) during the first 24 h after arrest. WSE was borderline higher in the good outcome group between 24 and 48 h after arrest (p=0.050). All patients with status epilepticus died, and their WSE values were lower (p=0.022). S-100B was lower in the good outcome group upon arrival at the intensive care unit (p=0.010). After hypothermia treatment, NSE and S-100B values were lower (p=0.002 for both) in the good outcome group. The pulsatile index was also lower in the good outcome group (p=0.004). In conclusion, the incidence of awareness in outpatient anesthesia did not differ from that in inpatient anesthesia. Outpatients are not at increased risk for intraoperative awareness relative to inpatients undergoing general anesthesia. SE, RE, and BIS showed non-zero values that normally indicate cortical neuronal function, but were in these subjects mostly due to artifacts after clinical brain death diagnosis. Entropy was more resistant to artifacts than BIS. During general anesthesia and surgery, SSI values were lower in patients with interscalene brachial plexus block covering the sites of nociceptive stimuli. In detecting nociceptive stimuli, SSI performed better than HR, blood pressure, or RE. BSR, RE, and SE differed between the good and poor neurological outcome groups during the first 24 h after cardiac arrest, and they may be an aid in differentiating patients with good neurological outcomes from those with poor outcomes after out-of-hospital cardiac arrest.

But consciousness isn't everything.

Comments on an article entitled `No Good News for DATA,' by Norman Lillegard in the Spring 1994 issue of `Cross Currents' magazine. Lillegard's stand that the android Commander Data in `Star Trek' fails to satisfy the biblical conception of persons; Lillegard's presentation of models that espouse functionalist theories of mind; Views of the essence of the human person.

Linking Attention to Learning, Expectation, Competition, and Consciousness

The concept of attention has been used in many senses, often without clarifying how or why attention works as it does. Attention, like consciousness, is often described in a disembodied way. The present article summarizes neural models and supportive data and how attention is linked to processes of learning, expectation, competition, and consciousness. A key them is that attention modulates cortical self-organization and stability. Perceptual and cognitive neocortex is organized into six main cell layers, with characteristic sub-lamina. Attention is part of unified design of bottom-up, horizontal, and top-down interactions among indentified cells in laminar cortical circuits. Neural models clarify how attention may be allocated during processes of visual perception, learning and search; auditory streaming and speech perception; movement target selection during sensory-motor control; mental imagery and fantasy; and hallucination during mental disorders, among other processes.

Consciousness CLEARS the Mind

A full understanding of consciouness requires that we identify the brain processes from which conscious experiences emerge. What are these processes, and what is their utility in supporting successful adaptive behaviors? Adaptive Resonance Theory (ART) predicted a functional link between processes of Consciousness, Learning, Expectation, Attention, Resonance, and Synchrony (CLEARS), includes the prediction that "all conscious states are resonant states." This connection clarifies how brain dynamics enable a behaving individual to autonomously adapt in real time to a rapidly changing world. The present article reviews theoretical considerations that predicted these functional links, how they work, and some of the rapidly growing body of behavioral and brain data that have provided support for these predictions. The article also summarizes ART models that predict functional roles for identified cells in laminar thalamocortical circuits, including the six layered neocortical circuits and their interactions with specific primary and higher-order specific thalamic nuclei and nonspecific nuclei. These prediction include explanations of how slow perceptual learning can occur more frequently in superficial cortical layers. ART traces these properties to the existence of intracortical feedback loops, and to reset mechanisms whereby thalamocortical mismatches use circuits such as the one from specific thalamic nuclei to nonspecific thalamic nuclei and then to layer 4 of neocortical areas via layers 1-to-5-to-6-to-4.

“Fiction makes a better job of the truth”: dialogism, oppositional consciousness and re-membering in the novels of Helena María Viramontes

This thesis comprises close textual analyses of Chicana author Helena María Viramontes' two published novels, Under the Feet of Jesus (1995) and Their Dogs Came With Them (2007). These analyses fall under three broad frameworks: space, time and body. Chapter One engages with the first of these frameworks, space, and explores concepts of cognitive mapping and heteroptopias. Chapter Two, which looks at time, employs theories of intertextuality and the palimpsest, while Chapter Three looks at the interrrelationship between mythology and images of the body in the texts. This study emerges five years after the publication of Viramontes' last novel, Their Dogs Came With Them, but offers fresh insight into the contribution of the author to both the Chicano literary tradition and also the U.S. canon through her critique of hegemonic power structures that suppress not only the voices of lower class ethnic citizens but also of ethnic writers. In particular, her work chastises the paucity of attention given to ethnic women writers in the U.S. This thesis reaffirms Viramontes' position as one of the most important writers living and writing in the U.S. today. It corroborates her work as a contestation against ethnic and gender suppression, and applauds the craftsmanship of her narrative style that delicately but decisively exposes the socio-political wrongs that occur in ocntemporary U.S. society.

Measuring the state of consciousness in a free-living diving sea turtle

We report on results from two types of data-logger attached to hawksbill turtles (Eretmochelys coriacea) in the breeding season at the Seychelles, Indian Ocean. Conventional time-depth recorders (TDRs) showed prolonged bouts of long dives to the seabed, consistent with benthic resting. This behaviour has been widely reported in sea turtles and appears to be a common feature for energy conservation. An Inter-Mandibular Angle Sensor (IMASEN) recorded mouth opening and buccal pumping by one turtle for 2.5 days. Buccal pumping occurred widely while the turtle was submerged, consistent with a function of olfactory sensory perception of the turtle's environment. However, buccal pumping stopped during the middle of long benthic dives consistent with the turtle entering a phase of sleep. It therefore appears that by recording buccal oscillations, it is possible to assess the state of consciousness of turtles allowing the eco-physiology of diving to be more fully explored. (C) 2007 Elsevier B.V. All rights reserved.

An Exploration of Political Consciousness Amongst Final Year Nursing Students in Northern Ireland

Context and background
Historically nurses perceive politics and nursing as being at odds with the caring image, synonymous with nurses (Salvage, 1985). Furthermore the concept of the ‘politics of nursing’ lacks clear conceptual clarity (Hewison, 1994). This concept ranges across a continuum from political interest to participation or engagement (Rains et al, 2001). It is often argued political interest tends to be equated with knowledge/ involvement in health policy development and nurse education can foster political consciousness, through political socialization (Brown, 1996). But despite the World Health Organization (WHO, 2002) urging this involvement, nurses globally are largely absent from the political and policy making arena. What influences nurse’s political socialization and the development of a political consciousness is not clearly identified or known, although many commentators suggest the undergraduate educational environment, plays an important role (Hanley, 1987, Winter, 1991).     

AIM
The aim of this study was to explore third year nursing student’s perceptions of politics in nursing, in the context of Northern Ireland. A number of hypotheses were tested examining the relationship between age, prior educational attainment and political interest and attitudes.  

Research methodology
A cross sectional research design was used and the data was collected using a short anonymous self-completion web survey (Bryman, 2012). The sample was a convenience sample of one cohort of final year adult nursing students (n154) in one Northern Irish university, with a 42% response rate. Data was analyzed using SPSS.

Key findings and conclusions
The results revealed 55% of students were very/fairly interested in politics, with 6% reporting no interest in politics. 85% of students were registered to vote, but only 48% voted in the 2010 N Ireland Assembly election.   
Recommend inclusion of a unit of study incorporating innovative teaching methods related to politics and health related policy, in the undergraduate nursing programme.