Neurocritical care
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Brain tissue oxygen (PbrO2) monitoring is an emerging technique for detection of secondary brain injury in neurocritical care. Although it has been extensively reported in traumatic brain injury and aneurysmal subarachnoid hemorrhage, its use in nontraumatic intracerebral hemorrhage (ICH) has not been well described. We report complementary preliminary studies in a large animal model and in patients that demonstrate the feasibility of PbrO2 monitoring after ICH. ⋯ Brain tissue oxygen monitoring is feasible in ICH patients, as well as in a swine model of ICH. Translational research that emphasizes complementary information derived from human and animal studies may yield additional insights not available from either alone.
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Paradoxical embolus should be suspected in young patients with cerebrovascular events who do not have any vascular risk factors. There is significant controversy as to how best to treat his phenomenon. ⋯ This case emphasizes the potential complications of the use of central lines in ICUs, particularly in patients with diabetic ketoacidosis in whom sluggish blood flow may predispose to a procoagulant state.
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Weaning patients with myasthenic crisis (MC) from mechanical ventilation is often difficult, and the ideal time for extubation is often uncertain. However, little is known about the risk of extubation failure and the factors that may affect its occurrence. The goals of this study were to assess the risk of extubation failure in patients with MC and to determine which clinical variables may predict unsuccessful extubation. ⋯ Extubation failure may often complicate MC. Older age and development of pulmonary complications during mechanical ventilation increase the risk of extubation failure.
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Comparative Study
Percutaneous dilational tracheostomy in neurosurgical patients.
Tracheostomy is often performed in patients requiring long-term mechanical ventilation after severe neurological injury. Percutaneous dilational tracheostomy (PDT) is an alternative to traditional surgical tracheostomy (TST) for creating a tracheostomy. We compared these techniques in neurosurgical patients and assessed the impact on cost and clinical course. ⋯ PDT appears to have a low incidence of complications in neurosurgical patients and may shorten the length of hospitalization and the overall cost compared with TST.
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Numerous systems are reported for grading the clinical condition of patients following subarachnoid hemorrhage (SAH). The literature was reviewed for articles pertaining to the grading of such patients, including publications on the Hunt and Hess Scale, Fisher Scale, Glasgow Coma Score (GCS), and World Federation of Neurological Surgeons Scale. This article reviews the advantages and limitations of these scales as well as more recent proposals for other grading systems based on these scales with or without addition of other factors known to be prognostic for outcome after SAH. ⋯ Most grading scales were derived retrospectively, and the intra- and interobserver variability has seldom been assessed. Inclusion of additional factors increases the complexity of the scale, possibly making it less likely to be adopted for routine usage and increasing (only marginally in some cases) the ability to predict prognosis. Until further data are available, it is recommended that publications on patients with SAH report at least the admission GCS as well as factors commonly known to influence prognosis, such as age, pre-existing hypertension, the amount of blood present on admission computed tomography, time of admission after SAH, aneurysm location and size, presence of intracerebral or intraventricular hemorrhage, and blood pressure at admission.