Neurocritical care
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Advances in intensive care medicine have increased survival rates of patients with critical neurological conditions. The focus of prognostication for such patients is therefore shifting from predicting chances of survival to meaningful neurological recovery. This study assessed the variability in long-term outcome predictions among physicians and aimed to identify factors that may account for this variability. ⋯ Various prognostication profiles exist among intensivists. These may be dictated by factors such as physicians' age and clinical experience. Awareness of these associations may be a first step to more uniform prognostication.
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Intracranial hypertension (ICH) remains the single most difficult therapeutic challenge for the acute management of severe traumatic brain injury (TBI). We reviewed the published trials of therapeutic moderate hypothermia to determine its effect on ICH and compared its efficacy to other commonly used therapies for ICH. ⋯ Therapeutic moderate hypothermia is as effective, or more effective, than most other treatments for ICH. If used for 2-3 days or less there is no evidence that it causes clinically significant adverse events. The lack of consistent evidence that hypothermia improves long-term neurologic outcome should not preclude consideration of its use for the primary treatment of ICH since no other ICP therapy is held to this standard.
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Clinical Trial
Seizure detection with a commercially available bedside EEG monitor and the subhairline montage.
Availability of standard, continuous electroencephalography (cEEG) monitoring in ICU is very limited, although commercially available 4-channel modules are present in many ICUs. We investigated the sensitivity of such modules compared with the more complete monitoring with a standard EEG system. ⋯ The 4-channel EEG module has limited but practical usefulness for seizure detection when standard cEEG monitoring is not available.
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Anti-platelet medication and reduced platelet activity are associated with an increased risk of death after intracerebral hemorrhage (ICH). The optimal assay for assessing platelet activity is not defined. We hypothesized that reduced platelet activity would be common after ICH. ⋯ A medication history does not reliably identify patients with reduced platelet activity after ICH, and this may explain studies that found no association between known aspirin use and outcomes. Future studies should screen for unknown use of anti-platelet medications after ICH. Neither assay perfectly identified patients who reportedly used anti-platelet medication before ICH.
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Percutaneous dilatational tracheostomy (PDT) continues to gain in popularity as a bedside method for tracheostomy placement in the intensive care unit. Here, we present a description of ultrasound technique and two case examples to show the utility of bedside ultrasound screening to select patients with appropriate anatomy for PDT. ⋯ Bedside ultrasound screening allows for easy identification of pretracheal vascular structures that might pose a hemorrhage risk during PDT.