Neurocritical care
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Intrathecal nicardipine (ITN) is an investigational therapy for cerebral vasospasm (CVS) and delayed cerebral ischemia (DCI) in patients with aneurysmal subarachnoid hemorrhage (aSAH). The objective of this scoping review was to characterize the current state of the literature and map the current available evidence, examine research methodology, clarify key concepts and definitions in the literature, report procedural characteristics, identify and analyze knowledge gaps, and serve as a precursor for future systematic reviews, meta-analyses, and randomized controlled trials. An electronic search for studies on ITN for the treatment of CVS and DCI in patients with aSAH was conducted in accordance with published standards. ⋯ Study designs, drug administration, dosing regimens, drug concentrations, pharmacokinetics, patient selection, duration of therapy, outcome measures, adverse event monitoring, and definitions of CVS and DCI used are synthesized and discussed. Despite advances in the care of patients with aSAH, CVS and DCI remain leading causes of morbidity and mortality, and ITN represents a potential therapy to help prevent and treat this disease process. With one published randomized controlled trial on one method of administration, one trial underway on a second method of administration, and numerous heterogeneous and primarily retrospective studies published to date, future study with an emphasis on homogenizing study design and outcomes measured is needed to better understand this potential therapy.
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Head elevation is recommended as a tier zero measure to decrease high intracranial pressure (ICP) in neurocritical patients. However, its quantitative effects on cerebral perfusion pressure (CPP), jugular bulb oxygen saturation (SjvO2), brain tissue partial pressure of oxygen (PbtO2), and arteriovenous difference of oxygen (AVDO2) are uncertain. Our objective was to evaluate the effects of head elevation on ICP, CPP, SjvO2, PbtO2, and AVDO2 among patients with acute brain injury. ⋯ Increasing degrees of head elevation were associated, in general, with a lower ICP, whereas CPP and brain oxygenation parameters remained unchanged. The severe traumatic brain injury subanalysis found similar results.
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Review Meta Analysis
Safety and Outcome of Admission to Step-Down Level of Care in Patients with Low-Risk Spontaneous Intracerebral Hemorrhage: A Systematic Review and Meta-analysis.
Spontaneous intracerebral hemorrhage (ICH) is the most devastating type of stroke, and it is associated with high morbidity and mortality. Patients with a spontaneous ICH are routinely admitted to an intensive care unit (ICU). However, an ICU is a valuable and limited resource, and not all patients may require this level of care. ⋯ Risk of bias was low to moderate for each outcome. The available literature suggests that a select subgroup of patients with ICH may be safely admitted to the SU without affecting short-term outcome, potentially saving in-hospital resources and reducing length of stay. Further studies are needed to identify specific and reliable characteristics of this subgroup of patients.
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Review Meta Analysis
Safety and Outcome of Admission to Step-Down Level of Care in Patients with Low-Risk Spontaneous Intracerebral Hemorrhage: A Systematic Review and Meta-analysis.
Spontaneous intracerebral hemorrhage (ICH) is the most devastating type of stroke, and it is associated with high morbidity and mortality. Patients with a spontaneous ICH are routinely admitted to an intensive care unit (ICU). However, an ICU is a valuable and limited resource, and not all patients may require this level of care. ⋯ Risk of bias was low to moderate for each outcome. The available literature suggests that a select subgroup of patients with ICH may be safely admitted to the SU without affecting short-term outcome, potentially saving in-hospital resources and reducing length of stay. Further studies are needed to identify specific and reliable characteristics of this subgroup of patients.
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Comment Review
The Urban-Rural Divide in Neurocritical Care in Low-Income and Middle-Income Countries.
The term "urban-rural divide" encompasses several dimensions and has remained an important concern for any country. The economic disparity; lack of infrastructure; dearth of medical specialists; limited opportunities to education, training, and health care; lower level of sanitation; and isolating effect of geographical location deepens this gap, especially in low-income and middle-income countries (LMICs). This article gives an overview of the rural-urban differences in terms of facilities related to neurocritical care (NCC) in LMICs. ⋯ To facilitate delivery of NCC in resource-limited settings, proposed strategies include strengthening preventive measures, focusing on basics, having a multidisciplinary approach, promoting training and education, and conducting cost-effective research and collaborative efforts. The rural areas of LMICs bear the maximum impact because of their limited access to preventive health services, high incidence of acquired brain injury, inability to have timely management of neurological emergencies, and scarcity of specialist services in a resource-deprived health center. An increase in the health budget allocation for rural areas, NCC education and training of the workforce, and provision of telemedicine services for rapid diagnosis, management, and neurorehabilitation are some of the steps that can be quite helpful.