Neurocritical care
-
Meta Analysis
The Impact of Short-Term Hyperoxia on Cerebral Metabolism: A Systematic Review and Meta-Analysis.
Cerebral ischemia due to hypoxia is a major cause of secondary brain injury and is associated with higher morbidity and mortality in patients with acute brain injury. Hyperoxia could improve energetic dysfunction in the brain in this setting. Our objectives were to perform a systematic review and meta-analysis of the current literature and to assess the impact of normobaric hyperoxia on brain metabolism by using cerebral microdialysis. ⋯ Normobaric hyperoxia may improve cerebral metabolic disturbances in patients with acute brain injury. The clinical impact of such effects needs to be further elucidated.
-
Acute neurologic illnesses (ANI) contribute significantly to the global burden of disease and cause disproportionate death and disability in low-income and middle-income countries (LMICs) where neurocritical care resources and expertise are limited. Shifting epidemiologic trends in recent decades have increased the worldwide burden of noncommunicable diseases, including cerebrovascular disease and traumatic brain injury, which coexist in many LMICs with a persistently high burden of central nervous system infections such as tuberculosis, neurocysticercosis, and HIV-related opportunistic infections and complications. In the face of this heavy disease burden, many resource-limited countries lack the infrastructure to provide adequate care for patients with ANI. ⋯ Numerous opportunities exist to overcome these challenges through capacity-building efforts that improve outcomes for patients with ANI in resource-limited countries. These include research on needs and best practices for ANI management in LMICs, developing systems for effective triage, education and training to expand the neurology workforce, and supporting increased collaboration and data sharing among LMIC health care workers and systems. The success of these efforts in curbing the disproportionate and rising impact of ANI in LMICs will depend on the coordinated engagement of the global neurocritical care community.
-
Adequate oxygenation in patients with aneurysmal subarachnoid hemorrhage (SAH) is imperative. However, hyperoxia increases formation of reactive oxygen species and may be associated with a dose-dependent toxicity. We postulated a threshold for arterial partial pressure of oxygen (paO2) above which toxicity effects precipitate and sought to study the effects on 30-day mortality, favorable outcome at discharge and at 3 months, and delayed cerebral ischemia. ⋯ Integrals above the defined paO2 thresholds were dose-dependently associated with an increase in mortality in ventilated patients with SAH. When we considered time-weighted mean paO2, unfavorable outcomes and 30-day mortality were more frequent both below and above a certain range. Unfavorable outcomes increased in paO2 ranges usually defined as normoxia. This emphasizes the necessity to further characterize oxygenation thresholds in ventilated patients with SAH in prospective clinical studies.
-
Traumatic brain injury (TBI) is a major cause of morbidity and mortality in the United States. Older adults represent an understudied and growing TBI population. Current Brain Trauma Foundation guidelines support prophylactic antiseizure medication (ASM) administration to reduce the risk of early posttraumatic seizures (within 7 days of injury) in patients with severe TBI. Whether ASM decreases mortality or early seizure risk in this population remains unclear. This study addresses the knowledge gap regarding the impact of ASM administration on the risk of seizure or mortality after TBI in patients more than 65 years of age. ⋯ Early ASM administration was associated with reduced mortality at 7 days, 30 days, and 1 year but did not decrease the risk of early seizures among older adults who presented with TBI at an ICU. This benefit was observed in mild, moderate, and severe TBI assessed by Glasgow Coma Score on presentation among patients 65 years old and older and suggests broader recommendations for the use of ASM in older adults who present with TBI of any severity at an ICU.
-
Observational Study
Can Quantitative Pupillometry be used to Screen for Elevated Intracranial Pressure? A Retrospective Cohort Study.
Elevated intracranial pressure (ICP) is a serious complication in brain injury. Because of the risks involved, ICP is not monitored in all patients at risk. Noninvasive screening tools to identify patients with elevated ICP are needed. Anisocoria, abnormal pupillary size, and abnormal pupillary light reflex are signs of high ICP, but manual pupillometry is arbitrary and subject to interrater variability. We have evaluated quantitative pupillometry as a screening tool for elevated ICP. ⋯ Screening with NPi may inform high stakes clinical decisions by ruling out elevated ICP with a high degree of certainty. It may also aid in estimating probabilities of elevated ICP. This can help to weigh the risks of initiating invasive ICP monitoring against the risks of not doing so. Because of its ease of use and excellent interrater reliability, we suggest further studies of NPi as a screening tool for elevated ICP.