Neurocritical care
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Targeted temperature management (TTM) represents the standard of care in comatose survivors after cardiac arrest (CA) and may be applied targeting 33° or 36 °C. While multimodal prognostication has been extensively tested for 33 °C, scarce information exists for 36 °C. ⋯ Prediction of outcome after CA and TTM targeting 36 °C seems valid in adults using the same features tested at 33 °C. A reactive EEG under TTM appears highly sensitive for good outcome.
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Delaying extubation in neurologically impaired patients otherwise ready for extubation is a source for significant morbidity, mortality, and costs. There is no consensus to suggest one spontaneous breathing trial (SBT) over another in predicting extubation success. We studied an algorithm using zero pressure support and zero positive end-expiratory pressure (ZEEP) SBT followed by 5-cm H2O pressure support and 5-cm H2O positive end-expiratory pressure (i.e., 5/5) SBT in those who failed ZEEP SBT. ⋯ This study showed that the majority of patients could be successfully liberated from mechanical ventilation after a ZEEP SBT. In those who failed, a 5/5 SBT increased the successful liberation from mechanical ventilation.
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Death after withdrawal of mechanical ventilation frequently follows the sequence of progressive hypoxemia and hypotension leading to cardiac arrest. Accurate timing of the determination of death is fundamental to trust in controlled donation after circulatory death (cDCD) programs and is generally based on cessation of circulation (pulselessness), brain function (apnea), and the passage of time. If death is understood to be the unresuscitatable loss of brain function, the clinical determination that death following apnea and pulselessness has occurred is largely inferential. We sought to elucidate the relationship between the available clinical variables and the loss of brain function and its inability to be resuscitated. ⋯ These are important data that act as a conceptual reference point when clinicians undertake the inferential activity of identifying the time prior to which a patient has died following progressive hypoxemia and while observing apnea and pulselessness.
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Multicenter Study Comparative Study
Three-Factor Versus Four-Factor Prothrombin Complex Concentrate for the Emergent Management of Warfarin-Associated Intracranial Hemorrhage.
Four-factor prothrombin complex concentrates (PCC) produce a more rapid and complete INR correction compared with 3-factor PCC in patients receiving warfarin. It is unknown if this improves clinical outcomes in the setting of intracranial hemorrhage (ICH). ⋯ In-hospital mortality was not improved with the use of 4- versus 3-factor PCC in the emergent reversal of warfarin-associated ICH. Secondary clinical outcomes were similarly nonsignificant.
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Observational Study
Quantitative EEG Metrics Differ Between Outcome Groups and Change Over the First 72 h in Comatose Cardiac Arrest Patients.
Forty to sixty-six percent of patients resuscitated from cardiac arrest remain comatose, and historic outcome predictors are unreliable. Quantitative spectral analysis of continuous electroencephalography (cEEG) may differ between patients with good and poor outcomes. ⋯ These preliminary results suggest qEEG metrics correlate with outcome. In some patients, qEEG patterns change over the first three days post-arrest.