Neurocritical care
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The risk of death from venous thromboembolism (VTE) is high in intensive care unit patients with neurological diagnoses. This is due to an increased risk of venous stasis secondary to paralysis as well as an increased prevalence of underlying pathologies that cause endothelial activation and create an increased risk of embolus formation. ⋯ The lack of a solid evidentiary base has posed challenges for the establishment of consistent and evidence-based clinical practice standards. In response to this need for guidance, the Neurocritical Care Society set out to develop and evidence-based guideline using GRADE to safely reduce VTE and its associated complications.
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The use of antithrombotic agents, including anticoagulants, antiplatelet agents, and thrombolytics has increased over the last decade and is expected to continue to rise. Although antithrombotic-associated intracranial hemorrhage can be devastating, rapid reversal of coagulopathy may help limit hematoma expansion and improve outcomes. ⋯ This guideline provides timely, evidence-based reversal strategies to assist practitioners in the care of patients with antithrombotic-associated intracranial hemorrhage.
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External ventricular drains (EVDs) are commonly placed to monitor intracranial pressure and manage acute hydrocephalus in patients with a variety of intracranial pathologies. The indications for EVD insertion and their efficacy in the management of these various conditions have been previously addressed in guidelines published by the Brain Trauma Foundation, American Heart Association and combined committees of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons. While it is well recognized that placement of an EVD may be a lifesaving intervention, the benefits can be offset by procedural and catheter-related complications, such as hemorrhage along the catheter tract, catheter malposition, and CSF infection. ⋯ To address the need for a comprehensive set of evidence-based guidelines for EVD management, the Neurocritical Care Society organized a committee of experts in the fields of neurosurgery, neurology, neuroinfectious disease, critical care, pharmacotherapy, and nursing. The Committee generated clinical questions relevant to EVD placement and management. They developed recommendations based on a thorough literature review using the Grading of Recommendations Assessment, Development, and Evaluation system, with emphasis placed not only on the quality of the evidence, but also on the balance of benefits versus risks, patient values and preferences, and resource considerations.
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Review Case Reports
Bowel Ischemia in Refractory Status Epilepticus: Report of Two Cases and Review of the Literature.
Bowel ischemia is a rare life threatening complication seen in patients with refractory status epilepticus (RSE). The few reported cases of bowel ischemia in this setting have been associated with the use continuous barbiturate infusions. We report two patients with RSE in the absence of barbiturate infusion and without clear structural, infectious, anatomic, vascular, or autoimmune etiology. We review the clinical details of the cases and potential factors involved in the development of non-occlusive bowel ischemia in patients with RSE. ⋯ The mechanism of bowel infarction in these cases is likely multifactorial and was not associated with barbiturate use. Likely contributors to ischemia include RSE itself, systemic hypotension, vasopressor use, general anesthesia, and abnormal cardiac function. During the management of RSE, every effort must be made to avoid the secondary complications such as bowel ischemia.