Neurocritical care
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Clinical Trial
The prediction of extubation success of postoperative neurosurgical patients using frequency-tidal volume ratios.
The process of discontinuing neurological patients from mechanical ventilation is still controversial. The aim of this study was to report the outcome from extubating patients undergoing elective craniotomy and correlate the result with the measured f/V (t) ratio. ⋯ The f/V (t) ratio does not predict extubation failure in patients who have undergone elective craniotomy. Patients who fail extubation present higher incidence of pneumonia, tracheostomy and higher mortality rate.
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Decompressive Craniectomy (DC) is used to treat elevated intracranial pressure that is unresponsive to conventional treatment modalities. The underlying cause of intracranial hypertension may vary and consequently there is a broad range of literature on the uses of this procedure. Traumatic brain injury (TBI), middle cerebral artery (MCA) infarction, and aneurysmal subarachnoid hemorrhage (SAH) are three conditions for which DC has been predominantly used in the past. ⋯ We conclude that at the time of this review, there still remains insufficient data to support the routine use of DC in TBI, stroke or SAH. There is evidence that early and aggressive use of DC in good-grade patients may improve outcome, but the notion that DC is indicated in these patients is contentious. At this point, the indication for DC should be individualized and its potential implications on long-term outcomes should be comprehensively discussed with the caregivers.
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Comparative Study
Acute Hypothalamic-pituitary-adrenal response in traumatic brain injury with and without extracerebral trauma.
Endocrine disturbances are common after traumatic brain injury (TBI). Hypothalamic-pituitary-adrenal (HPA) axis response in TBI patients may be related with hemodynamic status. However, its relationship with outcome is unclear. Our objective was to evaluate HPA axis response in the acute phase after TBI in patients with or without extracerebral trauma (ECT), and to investigate the impact of systemic injury and the mechanisms underlying HPA response. ⋯ Patients with TBI presenting with or without associated ECT present similar acute HPA response. AI is present in 23.6% of patients. Risk is increased in patients with low plasma ACTH levels and in patients with hemorrhagic shock. Both primary and secondary mechanisms of HPA failure were found. However, AI did not affect outcome.
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Mechanical ventilation in neurologically injured patients presents a number of unique challenges. Patients who are intubated due to a primary neurologic injury often experience respiratory phenomena secondary to that injury, including elevation of intracranial pressure (ICP) in response to mechanical ventilation and variations in respiratory patterns. ⋯ Balancing the need to maintain brain oxygenation and control of ICP can be complicated by the effects of ventilator management on ICP. We will examine the consequences of ventilator management as they relate to parameters that affect ICP and brain oxygenation in patients who have neurologic injury.
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No proven treatments exist for intracerebral hemorrhage (ICH). Carefully selected patients may benefit from surgery, and an international multicenter trial is ongoing. We sought to determine how many patients in a population-based ICH cohort would have been eligible for surgery using the Surgical Trial in Intracerebral Hemorrhage II (STICH II) criteria. ⋯ In this population-based ICH cohort, 7.7% (22 of 286) of ICH patients would have qualified for STICH II enrollment. Other treatment options need to be explored for most ICH patients.