Neurocritical care
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Ventilator-associated pneumonia (VAP) is the most common nosocomial infection among medical intensive care unit (ICU) patients and is associated with increased mortality and length of stay (LOS). Neurologic disease is a risk factor for VAP development, but the relationship between VAP and outcomes in patients admitted to the ICU for neurologic reasons remains largely unknown. ⋯ VAP in neurocritical care patients is associated with increased LOS and ventilator hours, but is not associated with increased mortality, contrary to prior studies in medical ICU patients.
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Venous thrombo-embolism (VTE) is frequently encountered in critically ill neurological and neurosurgical patients admitted to intensive care units. This patient population includes those with brain neoplasm, intracranial hemorrhage, ischemic stroke, subarachnoid hemorrhage, pre- and post-operative patients undergoing neurosurgical procedures and those with traumatic brain injury, and acute spinal cord injury (SCI). There is a wide variability in clinical practice for thromboprophylaxis in these patients, in part due to paucity of data based on randomized clinical trials. ⋯ Inferior vena cava filters may play a role in thromboprophylaxis in selected cases. Without clear guidelines that can be universally applied to this diverse group of patients, prophylaxis for VTE should be tailored to the individual patient with cautious assessment of benefits versus risks. There is a need for higher level evidence to guide VTE prophylaxis in certain subgroups of this patient population.
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Randomized Controlled Trial
Prospective, randomized, single-blinded comparative trial of intravenous levetiracetam versus phenytoin for seizure prophylaxis.
Anti-epileptic drugs are commonly used for seizure prophylaxis after neurological injury. We performed a study comparing intravenous (IV) levetiracetam (LEV) to IV phenytoin (PHT) for seizure prophylaxis after neurological injury. ⋯ This study of LEV versus PHT for seizure prevention in the NSICU showed improved long-term outcomes of LEV-treated patients vis-à-vis PHT-treated patients. LEV appears to be an alternative to PHT for seizure prophylaxis in this setting.
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Many ICUs have implemented protocols for tight glucose control, but there are few data on hypoglycemia and neurologic outcomes in patients with subarachnoid hemorrhage (SAH). ⋯ In patients with SAH, nadir glucose < 80 mg/dl is associated with cerebral infarction, vasospasm, and worse functional outcomes in multivariate models. Protocols for target glucose 80-110 mg/dl effectively control hyperglycemia, but may place patients with SAH at risk for vasospasm, cerebral infarction, and poor outcome even when severe hypoglycemia does not occur.
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Serotonin syndrome is an iatrogenic disorder that results from serotonergic overactivity. Severe myoclonus and increased restlessness are hallmarks of the disorder. ⋯ Serotonin syndrome should be considered in the differential when elderly patients present with severe myoclonus. If unrecognized, this syndrome can lead to more severe manifestations including rhabdomyolysis, renal failure, and coma.