Neurocritical care
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The noise produced by oscillatory movements of secretions in the oropharynx, hypopharynx, and trachea during inspiration and expiration in unconscious terminal patients is often described as "the death rattle." The secretions are produced by the salivary glands and bronchial mucosa. These patients are usually too weak to expectorate or swallow the migrating secretions. Sputum usually only accumulates in these areas if there is a significant impairment of the cough reflex, as in deep coma or near death. ⋯ Death rattle was most commonly reported in patients dying from pulmonary malignancies, primary brain tumors, or brain metastases, and predicts death within 48 hours in 75% of the patients. After withdrawal of artificial ventilation from the intensive care unit, excessive respiratory secretion resulting in a rattling breathing during the last hours of life is not uncommon, especially not in pulmonary and neurological patients. The distressing experience and negative influence in the bereavement process indicates an ethical demand to treat this symptom from the perspective of others merely than that of the patient.
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The use of continuous electroencephalogram (cEEG) monitoring in the intensive care unit is becoming more widespread, with improvements in data storage capability and networking and the increasing awareness of nonconvulsive seizures. Current and potential uses for this technology include seizure detection, ischemia detection, and prognostication. ⋯ The implications of some of the electrographical patterns observed in critically ill patients are not yet clear. This article discusses findings with cEEG to date, pitfalls in performing and interpreting these studies, and where we should turn our attention with this underutilized brain monitoring technique.
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Tuberculous meningitis (TBM) remains a common serious neurological emergency especially in the developing world. Elevated intracranial pressure (ICP) is often a feature of severe TBM and is associated with high morbidity and mortality. The pathology associated with TBM, such as cerebral edema, hydrocephalus, tuberculoma(s), and infarcts related to arthritis, contribute to increase in intracranial volume and, therefore, elevated ICP. ⋯ Use of steroids reduces not only cerebral edema but also the production of cytokines and other chemicals involved in the immunopathogenesis of TBM. Fever associated with TBM should be aggressively treated, because fever can worsen the impact of elevated ICP. Hyponatremia may complicate TBM and requires appropriate correction because it can aggravate cerebral edema.
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Clinical Trial
Frameless stereotactic aspiration and thrombolysis of spontaneous intracerebral hemorrhage.
To test the feasibility and safety of a minimally invasive technique, we report our experience in treating spontaneous intracerebral hemorrhage (ICH) patients by using frameless stereotactic clot aspiration-thrombolysis and its effects on their 30-day survival. We compared the observed cohort mortality with its predicted 30-day ICH mortality, by using previously validated methods. ⋯ In this selected cohort of patients with ICH, stereotactic aspiration and thrombolytic washout seemed to be feasible and to have a trend towards improved 30-day survival, when using their predicted mortality data as "historical control." Complications did not exceed expected incidence rates. Based on the experience presented here as well as previous similar reports, a larger, randomized study addressing dose escalation, patient selection, and best therapeutic window is needed.
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A national shortage of organs for transplantation has led to a renewed interest in an old concept of using nonheart-beating organ donors as a source of organs for transplantation. Nonheart-beating donors are patients who have organ procurement obtained after death has been declared by cardiopulmonary criteria as opposed to the traditional heart-beating donor who has been declared dead by neurological criteria. The practice seems promising to increase the available organ supply. This article reviews the history, classification, protocols, and ethical issues involved with nonheart-beating organ donation.