Neurocritical care
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Troponin and brain natriuretic peptide (BNP) levels are predictors of mortality following subarachnoid hemorrhage (SAH). Prior studies used strict cutoffs for BNP elevation; however, normal levels of BNP are increased in older persons and women. We explored the association of troponin elevation and BNP elevation adjusted for sex and age with 30-day mortality. ⋯ Elevated troponin was an independent predictor of 30-day mortality following SAH; however, when adjusted for age and sex, elevations in BNP did not have this association.
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T cells infiltrate into the infarcted brain within days after cerebral ischemia and play essential roles in exacerbating the delayed phase of the brain injury by producing pro-inflammatory factors. However, the involvement of these factors in brain damage is also demonstrated systemically. Such periphery-brain abnormalities are interesting because they may constitute a pathway to the central nervous system (CNS), which may be a target of therapeutic hypothermia. Although this therapy protects neurons after severe brain damage, the underlying mechanisms are partly understood. We examined the effects of hypothermic and hyperthermic cultures on peripheral T cell-derived release of interleukin (IL)-17 and granzyme B (GrB) and evaluated whether and how these factors induced neurotoxicity and activated brain endothelial cells. ⋯ Hypothermia reduced but hyperthermia augmented T cell-derived release of IL-17 and GrB that mediate neuronal cell death, suggesting that the attenuation of T cell-derived release of these factors by therapeutic hypothermia leads to the inhibition of neuronal cell death in the delayed phase of brain injury. Moreover, hypothermia may suppress but hyperthermia may promote the recruitment of inflammatory cells to CNS by regulating brain endothelial activation of IL-17.
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In the neuroscience intensive care unit (NICU), most patients lack the capacity to make their own preferences known. This fact leads to situations where surrogate decision makers must fill the role of the patient in terms of making preference-based treatment decisions, oftentimes in challenging situations where prognosis is uncertain. The neurointensivist has a large responsibility and role to play in this shared decision-making process. ⋯ We outline the process of reaching a shared decision between family and care team and describe a practice for conducting optimum family meetings based on studies of ICU families in crisis. We review challenges in the decision-making process between surrogate decision makers and medical teams in neurocritical care settings, as well as methods to ameliorate conflicts. Ultimately, the goal of shared decision making is to increase knowledge amongst surrogates and care providers, decrease decisional conflict, promote realistic expectations and preference-centered treatment strategies, and lift the emotional burden on families of neurocritical care patients.
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Devastating brain injuries (DBIs) profoundly damage cerebral function and frequently cause death. DBI survivors admitted to critical care will suffer both intracranial and extracranial effects from their brain injury. The indicators of quality care in DBI are not completely defined, and despite best efforts many patients will not survive, although others may have better outcomes than originally anticipated. ⋯ Following an extensive literature review, the panel used the GRADE methodology to evaluate the robustness of the data. They made actionable recommendations based on the quality of evidence, as well as on considerations of risk: benefit ratios, cost, and user preference. The panel generated recommendations regarding prognostication, psychosocial issues, and ethical considerations.
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One reason for refusal of donor hearts is the development of left ventricular systolic dysfunction, a condition reported to occur in up to 42 % of adults with brain death. Prior studies have suggested that appropriate donor management and evaluation of cardiac dysfunction with serial echocardiography (TTE) can improve organ procurement. The aims of our study are to examine the prevalence and describe longitudinal changes in cardiac dysfunction after brain death. ⋯ To our knowledge, the present study is the largest study describing the use of serial TTE and its utilization in adult donors. The prevalence of cardiac dysfunction after adult brain death is high, but given enough time and support, many of these donors have improvement in cardiac function, ultimately leading to transplantation.