Neurocritical care
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Propofol infusion syndrome is described in the pediatric literature as metabolic acidosis, rhabdomyolysis, and bradycardia that results in death. The pathogenesis of this syndrome is thought to be activation of the systemic inflammatory response, which culminates in acidosis and muscle necrosis. ⋯ These data show an association between extended propofol use and metabolic acidosis, rhabdomyolysis, and death in adults, as well as children. Risk factors for propofol infusion syndrome in adults include lean body mass index, high dose, and administration of more than 24-hour duration. Creatine phosphokinase, lactic acid levels, electrolytes, and arterial blood gases should be monitored frequently. Both bacterial and fungal cultures should be obtained. If this syndrome is suspected, hemodialysis should be considered. In fatal cases, autopsy should include electron microscopy of cardiac and skeletal muscle to look for mitochondrial dysfunction. Further study is warranted.
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Cerebral air embolism is a neurological emergency. It has been reported following cardiac catheterization, central venous catheter insertion, and cardiothoracic surgery. ⋯ The prompt recognition of cerebral air embolism secondary to IABP rupture requires a high level of suspicion and is confirmed by head CT.
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Brain tissue oxygen (PbrO2) monitoring is an emerging technique for detection of secondary brain injury in neurocritical care. Although it has been extensively reported in traumatic brain injury and aneurysmal subarachnoid hemorrhage, its use in nontraumatic intracerebral hemorrhage (ICH) has not been well described. We report complementary preliminary studies in a large animal model and in patients that demonstrate the feasibility of PbrO2 monitoring after ICH. ⋯ Brain tissue oxygen monitoring is feasible in ICH patients, as well as in a swine model of ICH. Translational research that emphasizes complementary information derived from human and animal studies may yield additional insights not available from either alone.
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Weaning patients with myasthenic crisis (MC) from mechanical ventilation is often difficult, and the ideal time for extubation is often uncertain. However, little is known about the risk of extubation failure and the factors that may affect its occurrence. The goals of this study were to assess the risk of extubation failure in patients with MC and to determine which clinical variables may predict unsuccessful extubation. ⋯ Extubation failure may often complicate MC. Older age and development of pulmonary complications during mechanical ventilation increase the risk of extubation failure.
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Comparative Study
Percutaneous dilational tracheostomy in neurosurgical patients.
Tracheostomy is often performed in patients requiring long-term mechanical ventilation after severe neurological injury. Percutaneous dilational tracheostomy (PDT) is an alternative to traditional surgical tracheostomy (TST) for creating a tracheostomy. We compared these techniques in neurosurgical patients and assessed the impact on cost and clinical course. ⋯ PDT appears to have a low incidence of complications in neurosurgical patients and may shorten the length of hospitalization and the overall cost compared with TST.