Showing papers in "Neurocritical Care in 2011"

Critical Care Management of Patients Following Aneurysmal Subarachnoid Hemorrhage: Recommendations from the Neurocritical Care Society’s Multidisciplinary Consensus Conference

Abstract: Subarachnoid hemorrhage (SAH) is an acute cerebrovascular event which can have devastating effects on the central nervous system as well as a profound impact on several other organs SAH patients are routinely admitted to an intensive care unit and are cared for by a multidisciplinary team A lack of high quality data has led to numerous approaches to management and limited guidance on choosing among them Existing guidelines emphasize risk factors, prevention, natural history, and prevention of rebleeding, but provide limited discussion of the complex critical care issues involved in the care of SAH patients The Neurocritical Care Society organized an international, multidisciplinary consensus conference on the critical care management of SAH to address this need Experts from neurocritical care, neurosurgery, neurology, interventional neuroradiology, and neuroanesthesiology from Europe and North America were recruited based on their publications and expertise A jury of four experienced neurointensivists was selected for their experience in clinical investigations and development of practice guidelines Recommendations were developed based on literature review using the GRADE system, discussion integrating the literature with the collective experience of the participants and critical review by an impartial jury Recommendations were developed using the GRADE system Emphasis was placed on the principle that recommendations should be based not only on the quality of the data but also tradeoffs and translation into practice Strong consideration was given to providing guidance and recommendations for all issues faced in the daily management of SAH patients, even in the absence of high quality data

Optic nerve ultrasound for the detection of raised intracranial pressure.

Abstract: Background Optic nerve ultrasonography (ONUS) may help identify raised intracranial pressure (ICP). The optimal optic nerve sheath diameter (ONSD) cut-off for the identification of intracranial hypertension has not been established, with some clinical studies suggesting a higher cut-off than may be expected on the basis of prior laboratory investigation.

Sedation Confounds Outcome Prediction in Cardiac Arrest Survivors Treated with Hypothermia

Abstract: Background Therapeutic hypothermia is commonly used in comatose survivors’ post-cardiopulmonary resuscitation (CPR). It is unknown whether outcome predictors perform accurately after hypothermia treatment.

Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH) II: Design, Methods, and Rationale

Abstract: The December 2003 report from the National Institute of Neurological Disorders and Stroke (NINDS) Workshop on priorities for clinical research in intracerebral hemorrhage (ICH) recommended clinical trials for evaluation of blood pressure management in acute ICH as a leading priority. The Special Writing Group of the Stroke Council of the American Heart Association in 1999 and 2007 emphasized the need for clinical trials to ensure evidence-based treatment of acute hypertensive response in ICH. To address important gaps in knowledge, we conducted a pilot study funded by the NINDS, Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH) I Trial, during 2004–2008 to determine the appropriate level of systolic blood pressure (SBP) reduction. We now have initiated a multi-center, randomized Phase III trial, the ATACH II Trial, to definitively determine the efficacy of early, intensive, antihypertensive treatment using intravenous (IV) nicardipine initiated within 3 h of onset of ICH and continued for the next 24 h in subjects with spontaneous supratentorial ICH. The primary hypothesis of this large (N = 1,280), streamlined, and focused trial is that SBP reduction to ≤140 mm Hg reduces the likelihood of death or disability at 3 months after ICH, defined by modified Rankin scale score of 4–6, by at least 10% absolute compared to standard SBP reduction to ≤180 mm Hg. The ATACH II trial is a natural extension of numerous case series, the subsequent ATACH I pilot trial, and a preliminary, randomized, and controlled trial in this patient population funded by the Australian National Health and Medical Research Council. Both trials recently confirmed the safety and tolerability of both the regimen and goals of antihypertensive treatment in acutely hypertensive patients with ICH, as proposed in the present trial. The underlying mechanism for this expected beneficial effect of intensive treatment is presumably mediated through reduction of the rate and magnitude of hematoma expansion observed in approximately 73% of the patients with acute ICH. The Australian trial provided preliminary evidence of attenuation of hematoma expansion with intensive SBP reduction. The ATACH II trial will have important public health implications by providing evidence of, or lack thereof, regarding the efficacy and safety of acute antihypertensive treatment in subjects with ICH. This treatment represents a strategy that can be made widely available without the need for specialized equipment and personnel, and therefore, can make a major impact upon clinical practice for treating patients with ICH.

A randomized trial for the treatment of refractory status epilepticus.

Abstract: Refractory status epilepticus (RSE) has a mortality of 16–39%; coma induction is advocated for its management, but no comparative study has been performed. We aimed to assess the effectiveness (RSE control, adverse events) of the first course of propofol versus barbiturates in the treatment of RSE. In this randomized, single blind, multi-center trial studying adults with RSE not due to cerebral anoxia, medications were titrated toward EEG burst-suppression for 36–48 h and then progressively weaned. The primary endpoint was the proportion of patients with RSE controlled after a first course of study medication; secondary endpoints included tolerability measures. The trial was terminated after 3 years, with only 24 patients recruited of the 150 needed; 14 subjects received propofol, 9 barbiturates. The primary endpoint was reached in 43% in the propofol versus 22% in the barbiturates arm (P = 0.40). Mortality (43 vs. 34%; P = 1.00) and return to baseline clinical conditions at 3 months (36 vs. 44%; P = 1.00) were similar. While infections and arterial hypotension did not differ between groups, barbiturate use was associated with a significantly longer mechanical ventilation (P = 0.03). A non-fatal propofol infusion syndrome was detected in one patient, while one subject died of bowel ischemia after barbiturates. Although undersampled, this trial shows significantly longer mechanical ventilation with barbiturates and the occurrence of severe treatment-related complications in both arms. We describe practical issues necessary for the success of future studies needed to improve the current unsatisfactory state of evidence.

Prevention of Shivering During Therapeutic Temperature Modulation: The Columbia Anti-Shivering Protocol

Abstract: As the practice of aggressive temperature control has become more commonplace, new clinical problems are arising, of which shivering is the most common. Treatment for shivering while avoiding the negative consequences of many anti-shivering therapies is often difficult. We have developed a stepwise protocol that emphasizes use of the least sedating regimen to achieve adequate shiver control. All patients treated with temperature modulating devices in the neurological intensive care unit were prospectively entered into a database. Baseline demographic information, daily temperature goals, best daily GCS, and type and cumulative dose of anti-shivering agents were recorded. We collected 213 patients who underwent 1388 patient days of temperature modulation. Eighty-nine patients underwent hypothermia and 124 patients underwent induced normothermia. In 18% of patients and 33% of the total patient days only none-sedating baseline interventions were needed. The first agent used was most commonly dexmeditomidine at 50% of the time, followed by an opiate and increased doses of propofol. Younger patients, men, and decreased BSA were factors associated with increased number of anti-shivering interventions. A significant proportion of patients undergoing temperature modulation can be effectively treated for shivering without over-sedation and paralysis. Patients at higher risk for needing more interventions are younger men with decreased BSA.

Vasospasm versus delayed cerebral ischemia as an outcome event in clinical trials and observational studies.

Abstract: Delayed cerebral ischemia occurs in about 30% of patients during the first 2 weeks after subarachnoid hemorrhage, and can result in substantial disability and death. Research studies investigating the incidence of delayed cerebral ischemia and strategies for prevention and treatment are hampered by inconsistent use of terminology and definitions for this complication, and by reliance on indirect surrogate markers of ischemia. A literature review was conducted to search for studies that addressed the issue of inconsistent definitions of delayed cerebral ischemia through December 2010. A total of four studies were identified. Original research studies and consensus panel recommendations for definitions support limiting the use of combined measures that include both clinical and radiographic assessments, as well as indirect measures, and the current usage of the term vasospasm. Cerebral infarction was supported as the most appropriate definition for delayed cerebral ischemia in the context of clinical trials.

Detection and Monitoring of Vasospasm and Delayed Cerebral Ischemia: A Review and Assessment of the Literature

Abstract: Delayed cerebral ischemia (DCI) after subarachnoid hemorrhage can be evaluated using clinical assessment, non-invasive and invasive techniques. An electronic literature search was conducted on English-language articles investigating DCI in human subjects with subarachnoid hemorrhage. A total of 31 relevant papers were identified evaluating the role of clinical assessment, transcranial Doppler, computed tomographic angiography, and computed tomographic perfusion. Clinical assessment by bedside evaluations is limited, especially in patients initially in poorer clinical condition or who are receiving sedative medication for whom deterioration may be more difficult to identify. Transcranial Doppler is a useful screening tool for middle cerebral artery vasospasm, with less utility in evaluating other intracranial vessels. Computed tomographic angiography correlates well with digital subtraction angiography. Computed tomographic perfusion may help predict DCI when used early or identify DCI when used later.

Non-invasive methods of estimating intracranial pressure.

Abstract: Non-invasive measurement of intracranial pressure can be invaluable in the management of critically ill patients. We performed a comprehensive review of the literature to evaluate the different methods of measuring intracranial pressure. Several methods have been employed to estimate intracranial pressure, including computed tomography, magnetic resonance imaging, transcranial Doppler sonography, near-infrared spectroscopy, and visual-evoked potentials. In addition, multiple techniques of measuring the optic nerve and the optic nerve sheath diameter have been studied. Ultrasound measurements of the optic nerve sheath diameter and Doppler flow are especially promising and may be useful in selected settings.

Critical Thresholds for Transcranial Doppler Indices of Cerebral Autoregulation in Traumatic Brain Injury

Abstract: Transcranial Doppler-derived indices of cerebral autoregulation are related to outcome after TBI. We analyzed our retrospective material to identify thresholds discriminative of outcome for these indices. 248 sedated and ventilated patients after head injury were eligible for the study. The indices of autoregulation derived from transcranial Doppler were calculated as correlation coefficients of blood flow velocity with cerebral perfusion pressure (index Mx) or arterial blood pressure (index Mxa). 2 × 2 tables were created grouping patients according to survival–death or favorable–unfavorable outcomes and varying thresholds for Mx and Mxa. Pearson’s chi-square was calculated. Thresholds returning the highest chi-square value were assumed to have the best discriminative value between survival–death and favorable–unfavorable outcomes. Mx and Mxa demonstrated that worse autoregulation is associated with poorer outcome and greater mortality (P = 0.0033 for Mx and P = 0.047 for Mxa). Both indices were more effective for prediction of favorable outcome than mortality. Chi-square for Mx showed a double peak with thresholds at 0.05 and 0.3. Mxa had only one peak at 0.3. Peak chi-square for Mx (11.3) was greater than for Mxa (8.7), indicating that Mx was a better discriminant of outcome than Mxa. We propose that Mx greater than 0.3 indicates definitely disturbed autoregulation and lower than 0.05 good autoregulation. For values between 0.05 and 0.3 the state of autoregulation is uncertain.

Rebleeding after aneurysmal subarachnoid hemorrhage.

Abstract: Rebleeding after initial aneurysmal subarachnoid hemorrhage (SAH) can have substantial impact on overall patient outcome. While older studies have suggested rebleeding occurs in about 4% of patients during the first day after initial aneurysmal bleed, these studies may have failed to capture very early rebleeds and, consequently, underestimated the impact of rebleeding. An electronic literature search was performed to identify English-language articles published or available for review from February 1975 through October 2010. A total of 43 articles (40 original research and 3 review articles) focused on rebleeding after initial aneurysmal SAH in humans were selected for review. Although most studies supported an incidence of rebleeding ≤4%, studies investigating ultra-early rebleeding reported bleeding within the first 24 h following aneurysmal SAH in as many as 9–17% of patients, with most cases occurring within 6 h of initial hemorrhage. Overall, studies investigating antifibrinolytic therapy to reduce rebleeding have failed to clearly demonstrate overall therapeutic benefit. Short-course antifibrinolytic therapy may have a role prior to initial aneurysm repair, although insufficient data are currently available.

How does care differ for neurological patients admitted to a neurocritical care unit versus a general ICU

Abstract: Neurological patients have lower mortality and better outcomes when cared for in specialized neurointensive care units than in general ICUs. However, little is known about how the process of care differs between these types of units. The Greater New York Hospital Association conducted a city-wide 24-h ICU prevalence survey on March 15th, 2007. Data was collected on all patients admitted to 143 ICUs in 69 different hospitals. Of 1,906 ICU patients surveyed, 231 had a primary neurological diagnosis. Of these, 52 (22%) were admitted to one of 9 neuro-ICU’s in NY and 179 (78%) to a medical or surgical ICU. Neurological patients in neuro-ICUs were more likely to have been transferred from an outside hospital (37% vs. 11%, P < 0.0001). Hemorrhagic stroke was more frequent in neuro-ICUs (46% vs. 16%, P < 0.0001), whereas traumatic brain injury (2% vs. 24%, P < 0.0001) and ischemic stroke (0% vs. 19%, P = 0.001) were less common. Despite a lower rate of mechanical ventilation (39% vs. 50%, P = 0.15), ICU length of stay was longer in neuro-ICU patients (≥10 days, 40% vs. 17%, P < 0.0001). More neuro-ICU patients had undergone tracheostomy (35% vs. 15%, P = 0.04), invasive hemodynamic monitoring (40% vs. 20%, P = 0.002), and invasive intracranial pressure monitoring (29% vs. 9%, P < 0.001) than patients cared for in general ICUs. Intravenous sedation was less prevalent in neuro-ICUs (12% vs. 30%, P = 0.009) and more patients were receiving nutritional support compared to general ICUs (67% vs. 39%, P < 0.001). Neurological patients cared for in specialty neuro-ICUs underwent more invasive intracranial and hemodynamic monitoring, tracheostomy, and nutritional support, and received less IV sedation than patients in general ICUs. These differences in care may explain previously observed disparities in outcome between neurocritical care and general ICUs.

Vasopressor Use and Effect on Blood Pressure After Severe Adult Traumatic Brain Injury

Abstract: Background We describe institutional vasopressor usage, and examine the effect of vasopressors on hemodynamics: heart rate (HR), mean arterial blood pressure (MAP), intracranial pressure (ICP), cerebral perfusion pressure (CPP), brain tissue oxygenation (PbtO2), and jugular venous oximetry (SjVO2) in adults with severe traumatic brain injury (TBI).

Impact of a Dedicated Neurocritical Care Team in Treating Patients with Aneurysmal Subarachnoid Hemorrhage

Abstract: Intensivist staffing of intensive care units (ICUs) has been associated with a reduction in in-hospital mortality. These improvements in patient outcomes have been extended to neurointensivist staffing of neuroscience ICUs for patients with intracranial hemorrhage and traumatic brain injury. The primary objective of this study is to determine if hospital outcomes (measured by discharge status) for patients admitted with aneurysmal subarachnoid hemorrhage changed after the introduction of a neurointensivist-led multidisciplinary neurocritical care team. The authors retrospectively identified 703 patients admitted to the neuroscience ICU with a diagnosis of aneurysmal subarachnoid hemorrhage at a single academic tertiary care hospital between January 1, 1995 and December 31, 2002. It was compared with discharge outcomes for those patients treated prior to and following the development of a multidisciplinary neurocritical care team. Patients treated after the introduction of a neurocritical care team were significantly more likely to be discharged to home (25.2% vs. 36.5%) and less likely to be discharged to a rehab facility (25.2% vs. 36.5%). Patients treated after introduction of a neurocritical care team were also more likely to receive definitive aneurysm treatment (10.9% vs. 18%). The implementation of a neurointensivist-led neurocritical care team is associated with improved hospital discharge disposition for patients with aneurysmal subarachnoid hemorrhage.

Critical care guidelines on the endovascular management of cerebral vasospasm

Abstract: Cerebral vasospasm and delayed cerebral ischemia account for significant morbidity and mortality after aneurysmal subarachnoid hemorrhage. While most patients are managed with triple-H therapy, endovascular treatments have been used when triple-H treatment cannot be used or is ineffective. An electronic literature search was conducted to identify English language articles published through October 2010 that addressed endovascular management of vasospasm. A total of 49 articles were identified, addressing endovascular treatment timing, intra-arterial treatments, and balloon angioplasty. Most of the available studies investigated intra-arterial papaverine or balloon angioplasty. Both have generally been shown to successfully treat vasospasm and improve neurological condition, with no clear benefit from one treatment compared with another. There are reports of complications with both therapies including vessel rupture during angioplasty, intracranial hypertension, and possible neurotoxicity associated with papaverine. Limited data are available evaluating nicardipine or verapamil, with positive benefits reported with nicardipine and inconsistent benefits with verapamil.

Do neurocritical care units save lives? Measuring the impact of specialized ICUs.

Abstract: A variety of organizational models have been used to deliver care to critically ill patients with neurologic disorders. Primary care may be provided by general intensivists, who often rely heavily on consultative support from neurosurgeons and neurologists. This approach is especially common in Australia, New Zealand, Canada and some European countries. Intensive care units (ICUs) organized in this fashion are usually ‘‘closed’’, meaning that admissions and discharges are largely the responsibility of the attending intensivist. In this case, there are typically daily multidisciplinary rounds with a single team of clinicians. An alternative method is for primary care to be delivered by neurosurgeons or neurologists, in this case depending greatly on consultative input from various subspecialists. The corresponding ICUs are frequently ‘‘open’’; that is, at any given time, there may be multiple attending physicians with patients admitted under their care, each of which, in turn, has numerous consultants involved. This approach has, historically, been the most common to be used in the United States. The skill set of ICU bedside nurses and ancillary health professionals (e.g., respiratory therapists, pharmacists, social workers, and rehabilitation staff) may also vary. In ‘‘general ICUs’’, these individuals are usually well-trained in the provision of physiologic support, especially to patients with multi-organ failure; however, specific nuances that are important to neurocritical care patients may sometimes be under-recognized. In contrast, in specialized ICUs, nurses are specifically trained to detect and treat neurologic deterioration in a timely fashion; in this case, however, there may be less experience in the management of systemic complications. As a specialty, neurocritical care seeks to combine the advantages of each of these preceding models. Neurointensivists and neurocritical care nurses are content experts in both critical care and neurologic disorders. These individuals are trained especially to recognize when brainand spinalcord-injured individuals have unique physiologic considerations in relation to other critically ill patients. Thus, their presence influences the ‘‘ICU culture’’ to become highly focused on neuroprotection; treatment targets (e.g., blood pressure or temperature) are consistently chosen with the aim of preventing ‘‘secondary injury’’, increasingly with the aid of advanced multi-modal monitoring. Furthermore, these clinicians are well equipped to deal with the non-neurologic organ dysfunction that is commonly encountered in critically ill neurologic patients [1]. Allied health professionals in neurocritical care units become familiar with the specific implications of the therapeutic interventions that they provide. For example, respiratory therapists are keenly aware that even minor variations in the partial pressure of carbon dioxide can have major implications on cerebral blood flow and intracranial pressure; ‘‘neuro-pharmacists’’ become particularly knowledgeable about the neurologic complications of Electronic supplementary material The online version of this article (doi:10.1007/s12028-011-9530-y) contains supplementary material, which is available to authorized users.

Impact of continuous EEG monitoring on clinical management in critically ill children.

Abstract: Background Continuous EEG (cEEG) monitoring is being used with increasing frequency in critically ill patients, most often to detect non-convulsive seizures. While cEEG is non-invasive and feasible in the critical care setting, it is also expensive and labor intensive, and there has been little study of its impact on clinical care. We aimed to determine prospectively the impact of cEEG on clinical management in critically ill children.

Comparison of the Full Outline of UnResponsiveness and Glasgow Liege Scale/Glasgow Coma Scale in an Intensive Care Unit Population

Abstract: The Full Outline of UnResponsiveness (FOUR) has been proposed as an alternative for the Glasgow Coma Scale (GCS)/Glasgow Liege Scale (GLS) in the evaluation of consciousness in severely brain-damaged patients. We compared the FOUR and GLS/GCS in intensive care unit patients who were admitted in a comatose state. FOUR and GLS evaluations were performed in randomized order in 176 acutely (<1 month) brain-damaged patients. GLS scores were transformed in GCS scores by removing the GLS brainstem component. Inter-rater agreement was assessed in 20% of the studied population (N = 35). A logistic regression analysis adjusted for age, and etiology was performed to assess the link between the studied scores and the outcome 3 months after injury (N = 136). GLS/GCS verbal component was scored 1 in 146 patients, among these 131 were intubated. We found that the inter-rater reliability was good for the FOUR score, the GLS/GCS. FOUR, GLS/GCS total scores predicted functional outcome with and without adjustment for age and etiology. 71 patients were considered as being in a vegetative/unresponsive state based on the GLS/GCS. The FOUR score identified 8 of these 71 patients as being minimally conscious given that these patients showed visual pursuit. The FOUR score is a valid tool with good inter-rater reliability that is comparable to the GLS/GCS in predicting outcome. It offers the advantage to be performable in intubated patients and to identify non-verbal signs of consciousness by assessing visual pursuit, and hence minimal signs of consciousness (11% in this study), not assessed by GLS/GCS scales.

Fever management in SAH

Abstract: An electronic literature search through August 2010 was performed to obtain articles describing fever incidence, impact, and treatment in patients with subarachnoid hemorrhage. A total of 24 original research studies evaluating fever in SAH were identified, with studies evaluating fever and outcome, temperature control strategies, and shivering. Fever during acute hospitalization for subarachnoid hemorrhage was consistently linked with worsened outcome and increased mortality. Antipyretic medications, surface cooling, and intravascular cooling may all reduce temperatures in patients with subarachnoid hemorrhage; however, benefits from cooling may be offset by negative consequences from shivering.

Osmotherapy: Use Among Neurointensivists

Abstract: Cerebral edema and raised intracranial pressure are common problems in neurological intensive care. Osmotherapy, typically using mannitol or hypertonic saline (HTS), has become one of the first-line interventions. However, the literature on the use of these agents is heterogeneous and lacking in class I studies. The authors hypothesized that clinical practice would reflect this heterogeneity with respect to choice of agent, dosing strategy, and methods for monitoring therapy. An on-line survey was administered by e-mail to members of the Neurocritical Care Society. Multiple-choice questions regarding use of mannitol and HTS were employed to gain insight into clinician practices. A total of 295 responses were received, 79.7% of which were from physicians. The majority (89.9%) reported using osmotherapy as needed for intracranial hypertension, though a minority reported initiating treatment prophylactically. Practitioners were fairly evenly split between those who preferred HTS (54.9%) and those who preferred mannitol (45.1%), with some respondents reserving HTS for patients with refractory intracranial hypertension. Respondents who preferred HTS were more likely to endorse prophylactic administration. Preferred dosing regimens for both agents varied considerably, as did monitoring parameters. Treatment of cerebral edema using osmotically active substances varies considerably between practitioners. This variation could hamper efforts to design and implement multicenter trials in neurocritical care.

Current Practices of Triple-H Prophylaxis and Therapy in Patients with Subarachnoid Hemorrhage

Abstract: Medical management of cerebral vasospasm following aneurysmal subarachnoid hemorrhage (SAH) includes hypertensive, hypervolemic, and hemodilution (“triple-H”) therapy. However, there is little information regarding the indications and guidance used to initiate and adjust triple-H therapy. A 43-item questionnaire was e-mailed to 375 members of the Neurocritical Care Society. Questions were designed to investigate the diagnostic approach to cerebral vasospasm and prophylactic and therapeutic administration of triple-H therapy. Completed surveys were received from 167 respondents (45% response proportion). Eighty-six percent of respondents worked in hospitals with neurointensive care units (NICUs). SAH patients in hospitals with a NICU had longer ICU stay (P = 0.037) and had indwelling central venous catheters for longer (P < 0.01). Centers without dedicated NICUs were more likely to induce prophylactic hypervolemia (P < 0.01). Twenty seven percent of respondents (n = 45) reported using prophylactic hypervolemia in patients with SAH, while 100% reported inducing hypervolemia for severe or symptomatic vasospasm. Twelve percent (n = 20) of respondents reported inducing prophylactic hypertension, while all reported inducing hypertension with severe or symptomatic vasospasm. Half of respondents relied on the mean arterial pressure and half on systolic blood pressure as the clinical parameter for blood pressure titration. The most widely used agents to induce hypertension were phenylephrine (48%) and norepinephrine (39%). There was little variation in the use of hemodilution therapy comparing patients with or without evidence of vasospasm. There are substantial differences in the administration of prophylactic triple-H, but there was high agreement on indication for therapeutic use. There was wide variability in the extent of ICU monitoring, diagnostic approach, physiologic parameters and values used as target of therapy. NICU availability was associated with more intensive monitoring. Lack of evidence and guidelines for triple-H therapy might largely explain these findings.

Evaluation of Coma: A Critical Appraisal of Popular Scoring Systems

Abstract: Numerous scoring scales have been proposed and validated to evaluate coma for rapid pre-hospital assessment and triage, disease severity, and prognosis for morbidity and mortality. These scoring systems have been predicated on core features that serve as a basis for this review and include ease of use, inter-rater reliability, reproducibility, and predictive value. Here we review the benefits and limitations of the most popular coma scoring systems. The methods include search of Medline, databases, and manual review of article bibliographies. Few of the many available coma scales have gained widespread approval and popularity. The best known and widely accepted scale is the Glasgow Coma Scale (GCS). The Reaction Level Scale (RLS85) has utility and proven benefit, but little acceptance outside of Scandinavia. The newer Full Outline of UnResponsiveness (FOUR) score provides an attractive replacement for all patients with fluctuating levels of consciousness and is gradually gaining wide acceptance.

Cardiovascular and pulmonary complications of aneurysmal subarachnoid hemorrhage

Abstract: Cardiopulmonary complications after aneurysmal subarachnoid hemorrhage negatively affect overall morbidity and mortality. An electronic literature search was performed for English-language articles focused on cardiopulmonary complications with subarachnoid hemorrhage published through October 2010. A total of 278 citations were identified, including 72 clinical studies. In most cases, study quality was low or very low. Cardiac injury, evidenced by an elevation in troponin levels, is reported in about one-third of patients after aneurysmal subarachnoid hemorrhage. Arrhythmias also occur in about one-third of patients after subarachnoid hemorrhage. The incidence of pulmonary complications, especially neurogenic pulmonary edema, is more difficult to establish from available literature. Cardiopulmonary complications have been linked to worsened clinical outcome, suggesting a role for cardiac monitoring and interventions.

Hemodynamic management of subarachnoid hemorrhage.

Abstract: Hemodynamic augmentation therapy is considered standard treatment to help prevent and treat vasospasm and delayed cerebral ischemia. Standard triple-H therapy combines volume expansion (hypervolemia), blood pressure augmentation (hypertension), and hemodilution. An electronic literature search was conducted of English-language papers published between 2000 and October 2010 that focused on hemodynamic augmentation therapies in patients with subarachnoid hemorrhage. Among the eligible reports identified, 11 addressed volume expansion, 10 blood pressure management, 4 inotropic therapy, and 12 hemodynamic augmentation in patients with unsecured aneurysms. While hypovolemia should be avoided, hypervolemia did not appear to confer additional benefits over normovolemic therapy, with an excess of side effects occurring in patients treated with hypervolemic targets. Overall, hypertension was associated with higher cerebral blood flow, regardless of volume status (normo- or hypervolemia), with neurological symptom reversal seen in two-thirds of treated patients. Limited data were available for evaluating inotropic agents or hemodynamic augmentation in patients with additional unsecured aneurysms. In the context of sparse data, no incremental risk of aneurysmal rupture has been reported with the induction of hemodynamic augmentation.

Acute Kidney Injury in Patients with Severe Traumatic Brain Injury: Implementation of the Acute Kidney Injury Network Stage System

Abstract: Background There is limited information on the incidence and effect of acute kidney injury (AKI) in patients with severe traumatic brain injury (TBI), although AKI may affect outcome. Recently, acute kidney injury network (AKIN) classification has been widely accepted as a consensus definition for AKI. The aim of this study is to estimate the frequency and level of severity of AKI in patients with severe TBI by using AKIN criteria and to study whether AKI affects outcome.

Acute Intrathecal Baclofen Withdrawal: A Brief Review of Treatment Options

Abstract: Acute baclofen toxicity and withdrawal can present with a constellation of symptoms making differentiation between these two entities and other potential diagnoses challenging. Baclofen withdrawal is associated with numerous complications which may require neurocritical care expertise such as respiratory failure, refractory seizures, delirium, and blood pressure lability. Case report and literature review. This case report discusses a case of intrathecal baclofen (ITB) withdrawal, focusing on the differential diagnosis for acute baclofen withdrawal and reviews the various options that exist to treat the symptoms of acute baclofen withdrawal such as benzodiazepines, propofol, skeletal muscle relaxants, and tizanidine. Critical care practitioners should be prepared to treat this potentially devastating and often refractory complication of ITB therapy.

Short-term outcome prediction by electroencephalographic features in children treated with therapeutic hypothermia after cardiac arrest.

Abstract: Background Electroencephalographic (EEG) features may provide objective data regarding prognosis in children resuscitated from cardiac arrest (CA), but therapeutic hypothermia (TH) may impact its predictive value. We aimed to determine whether specific EEG features were predictive of short-term outcome in children treated with TH after CA, both during hypothermia and after return to normothermia.

Outcome in poor grade subarachnoid hemorrhage patients treated with acute endovascular coiling of aneurysms and aggressive intensive care.

Abstract: Patients with poor grade (World Federation of Neurosurgeons (WFNS) Grades 4 and 5) subarachnoid hemorrhage (SAH) were historically considered to have a poor neurological outcome and therefore not traditionally offered aggressive treatment. In recent years there has been increasing evidence that early aggressive treatment of this patient group can result in a good outcome. Aim of this study is to identify the outcome of patients with WFNS Grade-4 and -5 SAH treated acutely with endovascular detachable coil embolization (DCE) and aggressive neurocritical care within our institution. We retrospectively reviewed the records of patients with SAH WFNS Grades 4 and 5 treated with DCE within 7 days of admission between 1st January 2004 and 1st January 2008. Data collected included age, sex, grade SAH, position/number of Aneurysms, coiling complications, time spent on the neurosurgical critical care unit (NCCU), and 6-month outcome assessed by Glasgow outcome scale (GOS). GOS was dichotomized into good outcome (good recovery/moderate disability) and poor outcome (severe disability, vegetative, dead). A total of 193 acute SAH patients were admitted and treated within this time period, of these, 47 patients were classified as poor grade and included: 70% were female and 30% were male. The mean age was 56 years (33–88 years range). A total of 56 aneurysms were noted at angiography, 52 aneurysms were coiled. Complications of SAH Vasospasm was noted in 18 patients (38%), cerebral infarction in 13 patients (28%), seizures in 7 patients (15%), hydrocephalus in 25 patients (53%). Complications of DCE occurred in 2 patients (4% of total) these were an aneurysmal rupture and a peri-procedure thrombosis. Incomplete coiling occurred in another 5 patients (10.6% of total) due to technical difficulties. The median length of stay on the NCCU was 12 days (1–52 days range). Of the 47 poor grade patients coiled, 25 (53%) had a good outcome (good recovery/moderate disability) and 22 (47%) had a poor outcome (severe disability, vegetative, dead) by the time of the 6-month follow-up. Potentially, more than half the patients with WFNS Grade-4 and -5 SAH who are treated aggressively with coil embolization in association with supportive neurocritical care can achieve a good quality neurological outcome. However, it should be anticipated that these patients will spend a significant period of time in neurocritical care.

Anemia and Transfusion After Subarachnoid Hemorrhage

Abstract: Delayed cerebral ischemia after subarachnoid hemorrhage (SAH) may be affected by a number of factors, including cerebral blood flow and oxygen delivery. Anemia affects about half of patients with SAH and is associated with worse outcome. Anemia also may contribute to the development of or exacerbate delayed cerebral ischemia. This review was designed to examine the prevalence and impact of anemia in patients with SAH and to evaluate the effects of transfusion. A literature search was made to identify original research on anemia and transfusion in SAH patients. A total of 27 articles were identified that addressed the effects of red blood cell transfusion (RBCT) on brain physiology, anemia in SAH, and clinical management with RBCT or erythropoietin. Most studies provided retrospectively analyzed data of very low-quality according to the GRADE criteria. While RBCT can have beneficial effects on brain physiology, RBCT may be associated with medical complications, infection, vasospasm, and poor outcome after SAH. The effects may vary with disease severity or the presence of vasospasm, but it remains unclear whether RBCTs are a marker of disease severity or a cause of worse outcome. Erythropoietin data are limited. The literature review further suggests that the results of the Transfusion Requirements in Critical Care Trial and subsequent observational studies on RBCT in general critical care do not apply to SAH patients and that randomized trials to address the role of RBCT in SAH are required.

Medical Management of Compromised Brain Oxygen in Patients with Severe Traumatic Brain Injury

Abstract: Brain tissue oxygen (PbtO2) monitoring is used in severe traumatic brain injury (TBI) patients. How brain reduced PbtO2 should be treated and its response to treatment is not clearly defined. We examined which medical therapies restore normal PbtO2 in TBI patients. Forty-nine (mean age 40 ± 19 years) patients with severe TBI (Glasgow Coma Scale [GCS] ≤ 8) admitted to a University-affiliated, Level I trauma center who had at least one episode of compromised brain oxygen (PbtO2 10 min), were retrospectively identified from a prospective observational cohort study. Intracranial pressure (ICP), cerebral perfusion pressure (CPP), and PbtO2 were monitored continuously. Episodes of compromised PbtO2 and brain hypoxia (PbtO2 10 min) and the medical interventions that improved PbtO2 were identified. Five hundred and sixty-four episodes of compromised PbtO2 were identified from 260 days of PbtO2 monitoring. Medical management used in a “cause-directed” manner successfully reversed 72% of the episodes of compromised PbtO2, defined as restoration of a “normal” PbtO2 (i.e. ≥25 mmHg). Ventilator manipulation, CPP augmentation, and sedation were the most frequent interventions. Increasing FiO2 restored PbtO2 80% of the time. CPP augmentation and sedation were effective in 73 and 66% of episodes of compromised brain oxygen, respectively. ICP reduction using mannitol was effective in 73% of treated episodes, though was used only when PbtO2 was compromised in the setting of elevated ICP. Successful medical treatment of brain hypoxia was associated with decreased mortality. Survivors (n = 38) had a 71% rate of response to treatment and non-survivors (n = 11) had a 44% rate of response (P = 0.01). Reduced PbtO2 may occur in TBI patients despite efforts to maintain CPP. Medical interventions other than those to treat ICP and CPP can improve PbtO2. This may increase the number of therapies for severe TBI in the ICU.