Articles: neurocritical-care.
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Journal of neurotrauma · Oct 2020
Predicting neurological recovery following traumatic brain injury in children: a systematic review of prognostic models.
Predictive modeling is foundational to treatment and long-term management of children with traumatic brain injury (TBI). Assessment of injury severity in the acute-care setting enables early stratification of patients based on their risk of death, lifelong disability, or unfavorable outcome. This review evaluates predictive models that have been developed or validated for pediatric TBI patients. ⋯ Most studies solely focused on clinical variables, with two studies incorporating biochemical and imaging variables. Predictive models for pediatric TBI are primarily based on methods and variables identified in adult studies. Although adult models have proven effective in select pediatric cohorts, they may be suboptimal when compared with models derived or adjusted for children.
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Journal of anesthesia · Oct 2020
ReviewAn overview of management of intracranial hypertension in the intensive care unit.
Intracranial hypertension (IH) is a clinical condition commonly encountered in the intensive care unit, which requires immediate treatment. The maintenance of normal intracranial pressure (ICP) and cerebral perfusion pressure in order to prevent secondary brain injury (SBI) is the central focus of management. SBI can be detected through clinical examination and invasive and non-invasive ICP monitoring. ⋯ To control elevated ICP refractory to maximum standard medical and surgical treatment, at first, high-dose barbiturate administration and then decompressive craniectomy as a last step are recommended with unclear and probable benefit on outcomes, respectively. The therapeutic strategy should be based on a staircase approach and be individualized for each patient. Since most therapeutic interventions have an uncertain effect on neurological outcome and mortality, future research should focus on both studying the long-term benefits of current strategies and developing new ones.
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Organ donation after brain death remains the deceased organ donation pathway of choice. In the UK, the current identification and referral rate for potential donation after brain death donors is 99%, the testing rate for determining death using neurological criteria is 86% and the approach to families for donation is 91%. Increasing donation after brain death donation will primarily require a large increase in the current consent rate of 72% to one matching the consent rate of 80-90% achieved in other European countries. ⋯ Alternatively, the UK will need to look at more challenging ways of increasing the pool of potential donors after brain death. The first would be to delay the withdrawal of life-sustaining treatment in patients with devastating brain injury to allow progression to brain death after the family have given consent to organ donation and with their consent to this delay. Even more challenging would be the consideration of re-introducing intensive care to facilitate organ donation programmes that have been so successful at increasing the number of organ donors elsewhere.
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The use of standardized management protocols (SMPs) may improve patient outcomes for some critical care diseases. Whether SMPs improve outcomes after subarachnoid hemorrhage (SAH) is currently unknown. We aimed to study the effect of SMPs on 6-month mortality and neurologic outcomes following SAH. ⋯ Given the substantial heterogeneity in reporting practices between studies, a meta-analysis for 6-month mortality and neurologic outcomes could not be performed, and the effect of SMPs on these measures thus remains inconclusive. Our systematic review highlights the need for large, rigorous RCTs to determine whether providing standardized, best-practice management through the use of a protocol impacts outcomes in critically ill patients with SAH. Trial registration Registration number: CRD42017069173.
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Abusive head trauma (AHT), used to be named shaken baby syndrome, is an injury to the skull and intracranial components of a baby or child younger than 5 years due to violent shaking and/or abrupt impact. It is a worldwide leading cause of fatal head injuries in children under 2 years. The mechanism of AHT includes shaking as well as impact, crushing or their various combinations through acceleration, deceleration and rotational force. ⋯ The prognosis of patients with AHT correlates with the extent of injury identified on CT and MRI imaging. The outcome is associated with the clinical staging, the extent of increased intracranial pressure and the existence of neurological complications such as acquired hydrocephalus or microcephalus, cortical blindness, convulsive disorder, and developmental delay. AHT is a potentially preventable disease, therefore, prevention should be stressed in all encounters within the family, the society and all the healthcare providers.