Neurocritical care
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Osmotic agents such as mannitol remain a mainstay in the management of cerebral edema and raised intracranial pressure. Some patients do not respond to sustained mannitol administration with the expected rise in serum osmolality, and this may correlate with lack of therapeutic efficacy. ⋯ A substantial proportion of patients receiving sustained mannitol do not manifest the expected osmotic response. This lack of response may correlate with the failure of clinical efficacy seen in a subgroup of patients, who then require alternate agents such as hypertonic saline. This association merits further exploration.
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Cerebral edema is a potential life-threatening complication in patients with acute liver failure who progress to grade III/IV encephalopathy. The incidence is variably reported but appears to be most prevalent in those patients with hyperacute liver failure as opposed to subacute forms of liver failure. In those patients who are deemed at risk of cerebral edema and raised intracranial pressure, insertion of an intra-cranial pressure monitoring device may be considered to optimize treatment and interventions. ⋯ Sustained elevation of intracranial pressure may be responsive to mannitol or hypertonic saline bolus, and in those with hyperemia indomethacin has been reported as beneficial in case series. Recently, interest has developed into the use of cooling in the management of patients with acute liver failure and raised intracranial pressure. Animal studies support this treatment option as do case series, although randomized trials are still awaited.
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Randomized Controlled Trial
Rapid blood pressure reduction in acute intracerebral hemorrhage: feasibility and safety.
The optimal blood pressure (BP) for treating acute intracerebral hemorrhage remains (ICH) uncertain. High BP may contribute to hematoma growth while excessive BP reduction might precipitate peri-hemorrhage ischemia. We examine here the feasibility and safety of reducing BP to lower than presently recommended levels in patients with acute ICH. ⋯ A more aggressive reduction of acute hypertension after ICH does not increase the rate of neurological deterioration even when treatment is initiated within hours of symptom onset. Lowering BP aggressively did not affect hematoma and edema expansion but this possibility deserves further study.
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In patients with severe head trauma, endotracheal suctioning can result in adverse reactions including cough, systemic hypertension, increased intracranial pressure, and reduced cerebral perfusion pressure. The aim of this prospective, blinded clinical trial in mechanically ventilated patients with severe head trauma whose cough reflexes were still intact was to assess the effectiveness of endotracheally instilled lidocaine in preventing endotracheal suctioning-induced changes in cerebral hemodynamics (increase in intracranial pressure and reduced cerebral perfusion pressure) after a single endotracheal suctioning. ⋯ In mechanically ventilated patients with severe head trauma endotracheal lidocaine instillation effectively and dose-dependently prevents the endotracheal suctioning-induced intracranial pressure increase and cerebral perfusion pressure reduction.
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Comparative Study Clinical Trial
A prospective, observational clinical trial of fever reduction to reduce systemic oxygen consumption in the setting of acute brain injury.
Fever after acute brain injury appears to be a detrimental factor, associated with impaired neurological outcomes. This study assessed physiological changes in systemic oxygen consumption (VO2) during cutaneous cooling after severe brain injury. ⋯ Fever reduction in acute brain injury appears to significantly reduce systemic VO2, but is highly dependent on shivering control.