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Godoy DA, Seifi A, Garza D, Lubillo-Montenegro S, Murillo-Cabezas F. Hyperventilation Therapy for Control of Posttraumatic Intracranial Hypertension. Front Neurol 2017; 8:250. [PMID: 28769857 PMCID: PMC5511895 DOI: 10.3389/fneur.2017.00250] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 05/19/2017] [Indexed: 12/30/2022] Open
Abstract
During traumatic brain injury, intracranial hypertension (ICH) can become a life-threatening condition if it is not managed quickly and adequately. Physicians use therapeutic hyperventilation to reduce elevated intracranial pressure (ICP) by manipulating autoregulatory functions connected to cerebrovascular CO2 reactivity. Inducing hypocapnia via hyperventilation reduces the partial pressure of arterial carbon dioxide (PaCO2), which incites vasoconstriction in the cerebral resistance arterioles. This constriction decrease cerebral blood flow, which reduces cerebral blood volume and, ultimately, decreases the patient’s ICP. The effects of therapeutic hyperventilation (HV) are transient, but the risks accompanying these changes in cerebral and systemic physiology must be carefully considered before the treatment can be deemed advisable. The most prominent criticism of this approach is the cited possibility of developing cerebral ischemia and tissue hypoxia. While it is true that certain measures, such as cerebral oxygenation monitoring, are needed to mitigate these dangerous conditions, using available evidence of potential poor outcomes associated with HV as justification to dismiss the implementation of therapeutic HV is debatable and remains a controversial subject among physicians. This review highlights various issues surrounding the use of HV as a means of controlling posttraumatic ICH, including indications for treatment, potential risks, and benefits, and a discussion of what techniques can be implemented to avoid adverse complications.
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Affiliation(s)
- Daniel Agustín Godoy
- Neurointensive Care Unit, Sanatorio Pasteur, San Fernando del Valle de Catamarca, Argentina.,Intensive Care Unit, Hospital San Juan Bautista, Catamarca, Argentina
| | - Ali Seifi
- University of Texas Health Science Center San Antonio, San Antonio, TX, United States
| | - David Garza
- Department of Neurosurgery, University of Texas Health Science Center San Antonio, San Antonio, TX, United States
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Grände PO. Critical Evaluation of the Lund Concept for Treatment of Severe Traumatic Head Injury, 25 Years after Its Introduction. Front Neurol 2017; 8:315. [PMID: 28725211 PMCID: PMC5495987 DOI: 10.3389/fneur.2017.00315] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 06/16/2017] [Indexed: 12/24/2022] Open
Abstract
When introduced in 1992, the Lund concept (LC) was the first complete guideline for treatment of severe traumatic brain injury (s-TBI). It was a theoretical approach, based mainly on general physiological principles-i.e., of brain volume control and optimization of brain perfusion and oxygenation of the penumbra zone. The concept gave relatively strict outlines for cerebral perfusion pressure, fluid therapy, ventilation, sedation, nutrition, the use of vasopressors, and osmotherapy. The LC strives for treatment of the pathophysiological mechanisms behind symptoms rather than just treating the symptoms. The treatment is standardized, with less need for individualization. Alternative guidelines published a few years later (e.g., the Brain Trauma Foundation guidelines and European guidelines) were mainly based on meta-analytic approaches from clinical outcome studies and to some extent from systematic reviews. When introduced, they differed extensively from the LC. We still lack any large randomized outcome study comparing the whole concept of BTF guidelines with other guidelines including the LC. From that point of view, there is limited clinical evidence favoring any of the s-TBI guidelines used today. In principle, the LC has not been changed since its introduction. Some components of the alternative guidelines have approached those in the LC. In this review, I discuss some important principles of brain hemodynamics that have been lodestars during formulation of the LC. Aspects of ventilation, nutrition, and temperature control are also discussed. I critically evaluate the most important components of the LC 25 years after its introduction, based on hemodynamic principles and on the results of own an others experimental and human studies that have been published since then.
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Affiliation(s)
- Per-Olof Grände
- Anesthesia and Intensive Care, Department of Clinical Sciences Lund, Faculty of Medicine, Lund University, Lund, Sweden
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Abstract
Although urgent surgical hematoma evacuation is necessary for most patients with subdural hematoma (SDH), well-orchestrated, evidenced-based, multidisciplinary, postoperative critical care is essential to achieve the best possible outcome. Acute SDH complicates approximately 11% of mild to moderate traumatic brain injuries (TBIs) that require hospitalization, and approximately 20% of severe TBIs. Acute SDH usually is related to a clear traumatic event, but in some cases can occur spontaneously. Management of SDH in the setting of TBI typically conforms to the Advanced Trauma Life Support protocol with airway taking priority, and management breathing and circulation occurring in parallel rather than sequence.
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Affiliation(s)
- Fawaz Al-Mufti
- Endovascular Surgical Neuroradiology Program, Rutgers University-New Jersey Medical School, Newark, NJ, USA
| | - Stephan A Mayer
- Department of Neurology, Henry Ford Health System, 2799 W Grand Boulevard, Detroit, MI 48202, USA.
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54
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Iordanova B, Li L, Clark RSB, Manole MD. Alterations in Cerebral Blood Flow after Resuscitation from Cardiac Arrest. Front Pediatr 2017; 5:174. [PMID: 28861407 PMCID: PMC5561008 DOI: 10.3389/fped.2017.00174] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 07/28/2017] [Indexed: 01/07/2023] Open
Abstract
Greater than 50% of patients successfully resuscitated from cardiac arrest have evidence of neurological disability. Numerous studies in children and adults, as well as in animal models have demonstrated that cerebral blood flow (CBF) is impaired after cardiac arrest. Stages of cerebral perfusion post-resuscitation include early hyperemia, followed by hypoperfusion, and finally either resolution of normal blood flow or protracted hyperemia. At the level of the microcirculation the blood flow is heterogeneous, with areas of no flow, low flow, and increased flow. CBF directed therapies in animal models of cardiac arrest improved neurological outcome, and therefore, the alterations in CBF after cardiac arrest likely contribute to the development of hypoxic ischemic encephalopathy. Current intensive care after cardiac arrest is centered upon maintaining systemic oxygenation, normal blood pressure values for age, maintaining general homeostasis, and avoiding hyperthermia. Assessment of CBF and oxygenation is not routinely performed after cardiac arrest. Currently available and underutilized techniques to assess cerebral perfusion include transcranial doppler, near-infrared spectroscopy, and arterial spin labeling magnetic resonance imaging. Limited clinical studies established the role of CBF and oxygenation monitoring in prognostication after cardiac arrest and few studies suggest that guiding critical care post-resuscitation to mean arterial pressures above the minimal autoregulatory range might improve outcome. Important knowledge gaps thus remain in cerebral monitoring and CBF and oxygen goal-directed therapies post-resuscitation from cardiac arrest.
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Affiliation(s)
- Bistra Iordanova
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, United States
| | - Lingjue Li
- School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, United States
| | - Robert S B Clark
- Safar Center for Resuscitation Research, Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, United States.,Safar Center for Resuscitation Research, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Mioara D Manole
- Safar Center for Resuscitation Research, Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, United States
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55
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Discussion. Plast Reconstr Surg 2016; 138:1030e-1031e. [DOI: 10.1097/prs.0000000000002779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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56
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Abstract
Airway management and ventilation are central to the resuscitation of the neurologically ill. These patients often have evolving processes that threaten the airway and adequate ventilation. Furthermore, intubation, ventilation, and sedative choices directly affect brain perfusion. Therefore, airway, ventilation, and sedation was chosen as an emergency neurological life support protocol. Topics include airway management, when and how to intubate with special attention to hemodynamics and preservation of cerebral blood flow, mechanical ventilation settings, and the use of sedative agents based on the patient's neurological status.
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Abstract
Neurologic complications of cancer are common and are frequently life-threatening events. Certain neurologic emergencies occur more frequently in the cancer population, specifically elevated intracranial pressure, epidural cord compression, status epilepticus, ischemic and hemorrhagic stroke, central nervous system infection, and treatment-associated neurologic dysfunction. These emergencies require early diagnosis and prompt treatment to ensure the best possible outcome and are best managed in the intensive care unit. This article reviews the presentation, pathophysiology, and management of the most common causes of acute neurologic decompensation in the patient with cancer.
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Affiliation(s)
- Andrew L Lin
- 1 Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Edward K Avila
- 1 Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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58
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Le Guennec L, Schmidt M, Bréchot N, Lebreton G, Leprince P, Combes A, Luyt CE. Complications neurologiques de l’assistance circulatoire de courte durée. MEDECINE INTENSIVE REANIMATION 2016. [DOI: 10.1007/s13546-016-1217-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Cerebral oximetry with blood volume index and capnography in intubated and hyperventilated patients. Am J Emerg Med 2016; 34:1102-7. [DOI: 10.1016/j.ajem.2016.03.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Revised: 02/29/2016] [Accepted: 03/01/2016] [Indexed: 11/21/2022] Open
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Sun HT, Zheng M, Wang Y, Diao Y, Zhao W, Wei Z. Monitoring intracranial pressure utilizing a novel pattern of brain multiparameters in the treatment of severe traumatic brain injury. Neuropsychiatr Dis Treat 2016; 12:1517-23. [PMID: 27382294 PMCID: PMC4922802 DOI: 10.2147/ndt.s106915] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The aim of the study was to evaluate the clinical value of multiple brain parameters on monitoring intracranial pressure (ICP) procedures in the therapy of severe traumatic brain injury (sTBI) utilizing mild hypothermia treatment (MHT) alone or a combination strategy with other therapeutic techniques. A total of 62 patients with sTBI (Glasgow Coma Scale score <8) were treated using mild hypothermia alone or mild hypothermia combined with conventional ICP procedures such as dehydration using mannitol, hyperventilation, and decompressive craniectomy. The multiple brain parameters, which included ICP, cerebral perfusion pressure, transcranial Doppler, brain tissue partial pressure of oxygen, and jugular venous oxygen saturation, were detected and analyzed. All of these measures can control the ICP of sTBI patients to a certain extent, but multiparameters associated with brain environment and functions have to be critically monitored simultaneously because some procedures of reducing ICP can cause side effects for long-term recovery in sTBI patients. The result suggested that multimodality monitoring must be performed during the process of mild hypothermia combined with conventional ICP procedures in order to safely target different clinical methods to specific patients who may benefit from an individual therapy.
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Affiliation(s)
- Hong-Tao Sun
- Sixth Department of Neurosurgery, Affiliated Hospital of Logistics University of People's Armed Police Force, Tianjin
| | - Maohua Zheng
- Department of Neurosurgery, The First Hospital of Lanzhou University, Lanzhou, People's Republic of China
| | - Yanmin Wang
- Sixth Department of Neurosurgery, Affiliated Hospital of Logistics University of People's Armed Police Force, Tianjin
| | - Yunfeng Diao
- Sixth Department of Neurosurgery, Affiliated Hospital of Logistics University of People's Armed Police Force, Tianjin
| | - Wanyong Zhao
- Sixth Department of Neurosurgery, Affiliated Hospital of Logistics University of People's Armed Police Force, Tianjin
| | - Zhengjun Wei
- Sixth Department of Neurosurgery, Affiliated Hospital of Logistics University of People's Armed Police Force, Tianjin
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Abstract
Aneurysmal subarachnoid hemorrhage (SAH) is a worldwide health burden with high fatality and permanent disability rates. The overall prognosis depends on the volume of the initial bleed, rebleeding, and degree of delayed cerebral ischemia (DCI). Cardiac manifestations and neurogenic pulmonary edema indicate the severity of SAH. The International Subarachnoid Aneurysm Trial (ISAT) reported a favorable neurological outcome with the endovascular coiling procedure compared with surgical clipping at the end of 1 year. The ISAT trial recruits were primarily neurologically good grade patients with smaller anterior circulation aneurysms, and therefore the results cannot be reliably extrapolated to larger aneurysms, posterior circulation aneurysms, patients presenting with complex aneurysm morphology, and poor neurological grades. The role of hypothermia is not proven to be neuroprotective according to a large randomized controlled trial, Intraoperative Hypothermia for Aneurysms Surgery Trial (IHAST II), which recruited patients with good neurological grades. Patients in this trial were subjected to slow cooling and inadequate cooling time and were rewarmed rapidly. This methodology would have reduced the beneficial effects of hypothermia. Adenosine is found to be beneficial for transient induced hypotension in 2 retrospective analyses, without increasing the risk for cardiac and neurological morbidity. The neurological benefit of pharmacological neuroprotection and neuromonitoring is not proven in patients undergoing clipping of aneurysms. DCI is an important cause of morbidity and mortality following SAH, and the pathophysiology is likely multifactorial and not yet understood. At present, oral nimodipine has an established role in the management of DCI, along with maintenance of euvolemia and induced hypertension. Following SAH, hypernatremia, although less common than hyponatremia, is a predictor of poor neurological outcome.
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Affiliation(s)
- Stanlies D'Souza
- Department of Neuroanesthesiology, Baystate Medical Center, Tufts University School of Medicine, Springfield, MA
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Anson JA, Vaida S, Giampetro DM, McQuillan PM. Anesthetic management of labor and delivery in patients with elevated intracranial pressure. Int J Obstet Anesth 2015; 24:147-60. [PMID: 25794413 DOI: 10.1016/j.ijoa.2015.01.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Revised: 12/31/2014] [Accepted: 01/12/2015] [Indexed: 10/24/2022]
Abstract
The anesthetic management of labor and delivery in patients with elevated intracranial pressure is complex. This review discusses the etiologies of diffuse and focal pathologies which lead to elevated intracranial pressure in pregnancy. The role of neuraxial and general anesthesia in the management of labor and delivery is also examined. Finally, a comprehensive review of strategies to minimize increases in intracranial pressure during general anesthesia for cesarean delivery is presented.
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Affiliation(s)
- J A Anson
- Department of Anesthesiology, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA.
| | - S Vaida
- Department of Anesthesiology, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - D M Giampetro
- Department of Anesthesiology, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - P M McQuillan
- Department of Anesthesiology, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
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Popugaev KA, Savin IA, Oshorov AV, Kurdumova NV, Ershova ON, Lubnin AU, Kadashev BA, Kalinin PL, Kutin MA, Killeen T, Cesnulis E, Melieste R. Postsurgical meningitis complicated by severe refractory intracranial hypertension with limited treatment options: the role of mild therapeutic hypothermia. J Neurol Surg Rep 2014; 75:e224-9. [PMID: 25485219 PMCID: PMC4242895 DOI: 10.1055/s-0034-1387188] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Accepted: 06/03/2014] [Indexed: 12/19/2022] Open
Abstract
Intracranial hypertension is a commonly encountered neurocritical care problem. If first-tier therapy is ineffective, second-tier therapy must be initiated. In many cases, the full arsenal of established treatment options is available. However, situations occasionally arise in which only a narrow range of options is available to neurointensivists. We present a rare clinical scenario in which therapeutic hypothermia was the only available method for controlling intracranial pressure and that demonstrates the efficacy and safety of the Thermogard (Zoll, Chelmsford, Massachusetts, United States) cooling system in creating and maintaining a prolonged hypothermic state. The lifesaving effect of hypothermia was overshadowed by the unfavorable neurologic outcome observed (minimally conscious state on intensive care unit discharge). These results add further evidence to support the role of therapeutic hypothermia in managing intracranial pressure and provide motivation for finding new strategies in combination with hypothermia to improve neurologic outcomes.
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Affiliation(s)
- Konstantin A. Popugaev
- Neurocritical Care Department, Burdenko Neurosurgical Research Institute, Russian Academy of Medical Sciences, Moscow, Russian Federation
| | - Ivan A. Savin
- Neurocritical Care Department, Burdenko Neurosurgical Research Institute, Russian Academy of Medical Sciences, Moscow, Russian Federation
| | - Andrew V. Oshorov
- Neurocritical Care Department, Burdenko Neurosurgical Research Institute, Russian Academy of Medical Sciences, Moscow, Russian Federation
| | - Natalia V. Kurdumova
- Neurocritical Care Department, Burdenko Neurosurgical Research Institute, Russian Academy of Medical Sciences, Moscow, Russian Federation
| | - Olga N. Ershova
- Neurocritical Care Department, Burdenko Neurosurgical Research Institute, Russian Academy of Medical Sciences, Moscow, Russian Federation
| | - Andrew U. Lubnin
- Department of Neuroanesthesia, Burdenko Neurosurgical Research Institute, Russian Academy of Medical Sciences, Moscow, Russian Federation
| | - Boris A. Kadashev
- 8th Neurosurgical Department, Burdenko Neurosurgical Research Institute, Russian Academy of Medical Sciences, Moscow, Russian Federation
| | - Pavel L. Kalinin
- 8th Neurosurgical Department, Burdenko Neurosurgical Research Institute, Russian Academy of Medical Sciences, Moscow, Russian Federation
| | - Maxim A. Kutin
- 8th Neurosurgical Department, Burdenko Neurosurgical Research Institute, Russian Academy of Medical Sciences, Moscow, Russian Federation
| | - Tim Killeen
- Department of Neurosurgery, Klinik Hirslanden, Zürich, Switzerland
| | - Evaldas Cesnulis
- Department of Neurosurgery, Klinik Hirslanden, Zürich, Switzerland
| | - Ronald Melieste
- Temperature Management Division Europe, Zoll Medical Corporation, Chelmsford, Massachusetts, United States
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Glaser N, Bundros A, Anderson S, Tancredi D, Lo W, Orgain M, O'Donnell M. Brain cell swelling during hypocapnia increases with hyperglycemia or ketosis. Pediatr Diabetes 2014; 15:484-93. [PMID: 24443981 PMCID: PMC4104267 DOI: 10.1111/pedi.12114] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Revised: 11/07/2013] [Accepted: 12/18/2013] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Severe hypocapnia reduces cerebral blood flow (CBF) and is known to be a risk factor for diabetic ketoacidosis (DKA)-related cerebral edema and cerebral injury in children. Reductions in CBF resulting from hypocapnia alone, however, would not be expected to cause substantial cerebral injury. We hypothesized that either hyperglycemia or ketosis might alter the effects of hypocapnia on CBF and/or cerebral edema associated with CBF reduction. METHODS We induced hypocapnia (pCO₂ 20 ± 3 mmHg) via mechanical ventilation in three groups of juvenile rats: 25 controls, 22 hyperglycemic rats (serum glucose 451 ± 78 mg/dL), and 15 ketotic rats (β-hydroxy butyrate 3.0 ± 1.0 mmol/L). We used magnetic resonance imaging to measure CBF and apparent diffusion coefficient (ADC) values in these groups and in 17 ventilated rats with normal pCO₂ (40 ± 3 mmHg). In a subset (n = 35), after 2 h of hypocapnia, pCO₂ levels were normalized (40 ± 3 mmHg) and ADC and CBF measurements were repeated. RESULTS Declines in CBF with hypocapnia occurred in all groups. Normalization of pCO₂ after hypocapnia resulted in hyperemia in the striatum. These effects were not substantially altered by hyperglycemia or ketosis. Declines in ADC (suggesting brain cell swelling) during hypocapnia, however, were greater during both hyperglycemia and ketosis. CONCLUSIONS We conclude that brain cell swelling associated with hypocapnia is increased by both hyperglycemia and ketosis, suggesting that these metabolic conditions may make the brain more vulnerable to injury during hypocapnia.
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Affiliation(s)
- Nicole Glaser
- Department of Pediatrics, University of California Davis, School of Medicine
| | - Angeliki Bundros
- Department of Pediatrics, Physiology and Membrane Biology, University of California Davis, School of Medicine
| | - Steve Anderson
- Department of Pediatrics, Physiology and Membrane Biology, University of California Davis, School of Medicine
| | - Daniel Tancredi
- Department of Pediatrics, University of California Davis, School of Medicine
| | - Weei Lo
- Department of Pediatrics, University of California Davis, School of Medicine
| | - Myra Orgain
- Department of Pediatrics, University of California Davis, School of Medicine
| | - Martha O'Donnell
- Department of Pediatrics, Physiology and Membrane Biology, University of California Davis, School of Medicine
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Stretti F, Gotti M, Pifferi S, Brandi G, Annoni F, Stocchetti N. Body temperature affects cerebral hemodynamics in acutely brain injured patients: an observational transcranial color-coded duplex sonography study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:552. [PMID: 25311035 PMCID: PMC4213544 DOI: 10.1186/s13054-014-0552-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 09/23/2014] [Indexed: 11/18/2022]
Abstract
Introduction Temperature changes are common in patients in a neurosurgical intensive care unit (NICU): fever is frequent among severe cases and hypothermia is used after cardiac arrest and is currently being tested in clinical trials to lower intracranial pressure (ICP). This study investigated cerebral hemodynamics when body temperature varies in acute brain injured patients. Methods We enrolled 26 patients, 14 with acute brain injury who developed fever and were given antipyretic therapy (defervescence group) and 12 who underwent an intracranial neurosurgical procedure and developed hypothermia in the operating room; once admitted to the NICU, still under anesthesia, they were re-warmed before waking (re-warming group). We measured cerebral blood flow velocity (CBF-V) and pulsatility index (PI) at the middle cerebral artery using transcranial color-coded duplex sonography (TCCDS). Results In the defervescence group mean CBF-V decreased from 75 ± 26 (95% CI 65 to 85) to 70 ± 22 cm/s (95% CI 61 to 79) (P = 0.04); the PI also fell, from 1.36 ± 0.33 (95% CI 1.23 to 1.50) to 1.16 ± 0.26 (95% CI 1.05 to 1.26) (P = 0.0005). In the subset of patients with ICP monitoring, ICP dropped from 16 ± 8 to 12 ± 6 mmHg (P = 0.003). In the re-warming group mean CBF-V increased from 36 ± 10 (95% CI 31 to 41) to 39 ± 13 (95% CI 33 to 45) cm/s (P = 0.04); the PI rose from 0.98 ± 0.14 (95% CI 0.91 to 1.04) to 1.09 ± 0.22 (95% CI 0.98 to 1.19) (P = 0.02). Conclusions Body temperature affects cerebral hemodynamics as evaluated by TCCDS; when temperature rises, CBF-V increases in parallel, and viceversa when temperature decreases. When cerebral compliance is reduced and compensation mechanisms are exhausted, even modest temperature changes can greatly affect ICP.
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66
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Capillary transit time heterogeneity and flow-metabolism coupling after traumatic brain injury. J Cereb Blood Flow Metab 2014; 34:1585-98. [PMID: 25052556 PMCID: PMC4269727 DOI: 10.1038/jcbfm.2014.131] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2014] [Revised: 06/10/2014] [Accepted: 06/20/2014] [Indexed: 12/26/2022]
Abstract
Most patients who die after traumatic brain injury (TBI) show evidence of ischemic brain damage. Nevertheless, it has proven difficult to demonstrate cerebral ischemia in TBI patients. After TBI, both global and localized changes in cerebral blood flow (CBF) are observed, depending on the extent of diffuse brain swelling and the size and location of contusions and hematoma. These changes vary considerably over time, with most TBI patients showing reduced CBF during the first 12 hours after injury, then hyperperfusion, and in some patients vasospasms before CBF eventually normalizes. This apparent neurovascular uncoupling has been ascribed to mitochondrial dysfunction, hindered oxygen diffusion into tissue, or microthrombosis. Capillary compression by astrocytic endfeet swelling is observed in biopsies acquired from TBI patients. In animal models, elevated intracranial pressure compresses capillaries, causing redistribution of capillary flows into patterns argued to cause functional shunting of oxygenated blood through the capillary bed. We used a biophysical model of oxygen transport in tissue to examine how capillary flow disturbances may contribute to the profound changes in CBF after TBI. The analysis suggests that elevated capillary transit time heterogeneity can cause critical reductions in oxygen availability in the absence of 'classic' ischemia. We discuss diagnostic and therapeutic consequences of these predictions.
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67
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Aronovich D, Scumpia A, Edwards D. Cushing's reflex in a rare case of adult medulloblastoma. World J Emerg Med 2014; 5:148-50. [PMID: 25215166 DOI: 10.5847/wjem.j.issn.1920-8642.2014.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Accepted: 04/06/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Medulloblastoma is a primitive neuro-ectodermal tumor. It is common in childhood, but rarely seen at adult age, comprising only 1% of primary brain tumors. METHODS We treated a 31-year-old man presented to the emergency department (ED) with a chief complaint of nausea and vomiting for one week duration. Immediate frozen section revealed a grade IV medulloblastoma. During the hospital course, the patient was given craniospinal irradiation with chemotherapy. RESULTS The patient was eventually discharged from the hospital to an assisted living facility after an uneventful 15-day course with the aid of social work. CONCLUSIONS Despite intracranial tumors generally being slow growing masses, this patient demonstrates how quickly one can decompensate, and how important it is to recognize these clinical signs and symptoms of an intracranial lesion. Although these symptoms (i.e. Cushing response) are extremely rare, the ED physician should be aware and appreciate their clinical significance.
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Affiliation(s)
- Daniel Aronovich
- Mount Sinai Medical Center, Department of Emergency Medicine, Miami Beach, FL 33140, USA
| | - Alexander Scumpia
- Mount Sinai Medical Center, Department of Emergency Medicine, Miami Beach, FL 33140, USA
| | - David Edwards
- Mount Sinai Medical Center, Department of Emergency Medicine, Miami Beach, FL 33140, USA
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68
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Affiliation(s)
- Nino Stocchetti
- From the Department of Pathophysiology and Transplantation, Milan University, and Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Cà Granda-Ospedale Maggiore Policlinico - both in Milan (N.S.); and the Department of Neurosurgery, Antwerp University Hospital-University of Antwerp, Edegem, Belgium (A.I.R.M.)
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A survey of routine treatment of patients with intracranial hypertension (ICH) in specialized trauma centers in Sao Paulo, Brazil: a 11 million metropole! Clin Neurol Neurosurg 2014; 116:4-8. [PMID: 24388507 DOI: 10.1016/j.clineuro.2013.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Revised: 10/31/2013] [Accepted: 11/09/2013] [Indexed: 11/22/2022]
Abstract
OBJECTIVE A survey of intensive care units (ICU) in São Paulo that care for patients with TBI and ICH using the hyperventilation technique. METHODS A questionnaire was given to the physiotherapist coordinator at 57 hospitals in São Paulo, where 24-h neurosurgery service is provided. RESULTS Fifty-one (89.5%) hospitals replied. From this total, thirty-four (66.7% perform the hyperventilation technique, 30 (85%) had the objective to reach values below 35 mmHg, four (11%) levels between 35 mmHg and 40 mmHg and one (3%) values over 40 mmHg. CONCLUSIONS We concluded that most hospitals in São Paulo perform hyperventilation in patients with severe brain trauma although there are not any specific Brazilian guidelines on this topic. Widespread controversy on the use of the hyperventilation technique in patients with severe brain trauma highlights the need for a specific Global policy on this topic.
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Abstract
OPINION STATEMENT After brain injury, neurologic intensive care focuses on the detection and treatment of secondary brain insults that may compound the initial injury. Increased intracranial pressure (ICP) contributes to secondary brain injury by causing brain ischemia, hypoxia, and metabolic dysfunction. Because ICP is easily measured at the bedside, it is the target of numerous pharmacologic and surgical interventions in efforts to improve brain physiology and limit secondary injury. However, ICP may not adequately reflect the metabolic health of the underlying brain tissue, particularly in cases of focal brain injury. As a result, ICP control alone may be insufficient to impact patients' long-term recovery. Further studies are needed to better understand the combination of cerebral, hemodynamic, and metabolic markers that are best utilized to ensure optimal brain and systemic recovery and overall patient outcome after brain injury.
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71
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Byrne AL, Bennett MH, Pace NL, Thomas P. Peripheral venous blood gas analysis versus arterial blood gas analysis for the diagnosis of respiratory failure and metabolic disturbance in adults. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2013. [DOI: 10.1002/14651858.cd010841] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
- Anthony L Byrne
- St Vincents Hospital; Heart Lung Clinic; Xavier building Victoria Street Darlinghurst NSW Australia 2010
| | - Michael H Bennett
- Prince of Wales Clinical School, University of NSW; Department of Anaesthesia; Sydney NSW Australia
| | - Nathan L Pace
- University of Utah; Department of Anesthesiology; 3C444 SOM 30 North 1900 East Salt Lake City UT USA 84132-2304
| | - Paul Thomas
- Prince of Wales Hospital; Department of Respiratory Medicine; Level 2 Campus Centre Barker Street, Randwick Sydney Australia 2031
- University of New South Wales; Sydney Australia
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72
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Cerebral hyperemia measured with near infrared spectroscopy during treatment of diabetic ketoacidosis in children. J Pediatr 2013; 163:1111-6. [PMID: 23871731 PMCID: PMC3792791 DOI: 10.1016/j.jpeds.2013.06.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Revised: 04/26/2013] [Accepted: 06/06/2013] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To use near infrared spectroscopy (NIRS) to evaluate the timing of onset and duration of cerebral hyperemia during diabetic ketoacidosis (DKA) treatment in children, and to investigate the relationship of cerebral hyperemia to intravenous fluid treatment. STUDY DESIGN We randomized children aged 8-18 years with DKA to either more rapid or slower intravenous fluid treatment (19 total DKA episodes). NIRS was used to measure rSo2 during DKA treatment. NIRS monitoring began as soon as informed consent was obtained and continued until the patient was transferred out of the critical care unit. RESULTS rSo2 values above the normal range (>80%) were detected in 17 of 19 DKA episodes (mean rSo2 during initial 8 hours of DKA treatment: 86% ± 7%, range 65%-95%). Elevated rSo2 values were detected as early as the second hour of DKA treatment and persisted for as long as 27 hours. Hourly mean rSo2 levels during treatment did not differ significantly by fluid treatment group. CONCLUSIONS During DKA treatment, children have elevated rSo2 values consistent with cerebral hyperemia. Hyperemia occurs as early as the second hour of DKA treatment and may persist for ≥ 27 hours. Cerebral rSo2 levels during treatment did not differ significantly in patients treated with slower versus more rapid intravenous rehydration.
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73
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Mesquita RC, Schenkel SS, Minkoff DL, Lu X, Favilla CG, Vora PM, Busch DR, Chandra M, Greenberg JH, Detre JA, Yodh AG. Influence of probe pressure on the diffuse correlation spectroscopy blood flow signal: extra-cerebral contributions. BIOMEDICAL OPTICS EXPRESS 2013; 4:978-94. [PMID: 23847725 PMCID: PMC3704102 DOI: 10.1364/boe.4.000978] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Revised: 05/13/2013] [Accepted: 05/14/2013] [Indexed: 05/03/2023]
Abstract
A pilot study explores relative contributions of extra-cerebral (scalp/skull) versus brain (cerebral) tissues to the blood flow index determined by diffuse correlation spectroscopy (DCS). Microvascular DCS flow measurements were made on the head during baseline and breath-holding/hyperventilation tasks, both with and without pressure. Baseline (resting) data enabled estimation of extra-cerebral flow signals and their pressure dependencies. A simple two-component model was used to derive baseline and activated cerebral blood flow (CBF) signals, and the DCS flow indices were also cross-correlated with concurrent Transcranial Doppler Ultrasound (TCD) blood velocity measurements. The study suggests new pressure-dependent experimental paradigms for elucidation of blood flow contributions from extra-cerebral and cerebral tissues.
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Affiliation(s)
- Rickson C. Mesquita
- Department of Physics & Astronomy, University of Pennsylvania, 3231 Walnut St., Philadelphia, PA 19104, USA
- Institute of Physics, University of Campinas, 777 Sergio Buarque de Holanda St., Campinas, SP 13083-859, Brazil
| | - Steven S. Schenkel
- Department of Physics & Astronomy, University of Pennsylvania, 3231 Walnut St., Philadelphia, PA 19104, USA
| | - David L. Minkoff
- Department of Physics & Astronomy, University of Pennsylvania, 3231 Walnut St., Philadelphia, PA 19104, USA
| | - Xiangping Lu
- Department of Neurology, University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104, USA
| | - Christopher G. Favilla
- Department of Neurology, University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104, USA
| | - Patrick M. Vora
- Department of Physics & Astronomy, University of Pennsylvania, 3231 Walnut St., Philadelphia, PA 19104, USA
| | - David R. Busch
- Department of Physics & Astronomy, University of Pennsylvania, 3231 Walnut St., Philadelphia, PA 19104, USA
- Department of Pediatrics, Division of Neurology, Children’s Hospital of Philadelphia, 34th St. & Civic Center Blvd., Philadelphia, PA 19104, USA
| | - Malavika Chandra
- Department of Physics & Astronomy, University of Pennsylvania, 3231 Walnut St., Philadelphia, PA 19104, USA
| | - Joel H. Greenberg
- Department of Neurology, University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104, USA
| | - John A. Detre
- Department of Neurology, University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104, USA
- Department of Radiology, University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104, USA
| | - A. G. Yodh
- Department of Physics & Astronomy, University of Pennsylvania, 3231 Walnut St., Philadelphia, PA 19104, USA
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74
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Chang WTW, Nyquist PA. Strategies for the use of mechanical ventilation in the neurologic intensive care unit. Neurosurg Clin N Am 2013; 24:407-16. [PMID: 23809034 DOI: 10.1016/j.nec.2013.02.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Mechanical ventilation in neurologically injured patients presents unique challenges. Patients with acute neurologic injuries may require mechanical ventilation for reasons beyond respiratory failure. There is also a subset of pulmonary pathologic abnormality directly associated with neurologic injuries. Balancing the need to maintain brain oxygenation, cerebral perfusion, and control of intracranial pressure can be in conflict with concurrent ventilator strategies aimed at lung protection. Weaning and liberation from mechanical ventilation also require special considerations. These issues are examined in the ventilator management of the neurologically injured patient.
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Affiliation(s)
- Wan-Tsu W Chang
- Department of Neurology, The Johns Hopkins School of Medicine, Baltimore, MD, USA
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75
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Godoy DA, Rabinstein AA, Biestro A, Ainslie PN, Di Napoli M. Effects of indomethacin test on intracranial pressure and cerebral hemodynamics in patients with refractory intracranial hypertension: a feasibility study. Neurosurgery 2013; 71:245-57; discussion 257-8. [PMID: 22531711 DOI: 10.1227/neu.0b013e318256b9f5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Intracranial hypertension is the final pathway of many neurocritical entities, such as spontaneous intracerebral hemorrhage (sICH) and severe traumatic brain injury (sTBI). OBJECTIVE This study aimed to (1) determine alterations in intracranial pressure (ICP) and cerebral hemodynamics after an indomethacin (INDO) infusion test and the related association with survival in patients with refractory intracranial hypertension (RICH) secondary to sICH or sTBI and (2) assess the safety profile after INDO. METHODS INDO was administered in a loading dose (0.8 mg/kg/15 min), followed by a 2-hour continuous infusion (0.5 mg/kg/h) in RICH patients with ICP greater than 20 mm Hg who did not respond to first-line therapies. Changes in ICP, cerebral perfusion pressure (CPP), and cerebrovascular variables (assessed by transcranial Doppler and jugular bulb saturation) were observed. Clinical outcome was assessed at 1 and 6 months according to the Glasgow Outcome Scale and correlated with INDO infusion test response. Analysis of INDO safety profile was conducted. RESULTS Thirteen sICH and 10 sTBI patients were studied. The median GCS score at admission was 6. Within 30 minutes of INDO infusion, ICP decreased (42.0 ± 13.5 vs 27.70 ± 12.7 mm Hg; Δ%: -48.4%; P < .001), and both CPP (57.7 ± 4.8 vs 71.9 ± 7.0 mm Hg; Δ%: +26.0%; P < .001) and middle cerebral artery velocity (35.2 ± 5.6 vs 42.0 ± 5.1 cm·s(-1); Δ%: +26.1%; P < .001) increased. The CPP response to a 2-hour INDO infusion test was correlated (R2 = 0.72, P < .001) with survival. No adverse events were observed after INDO. CONCLUSION Our findings support the effectiveness and feasibility of an INDO test in decreasing ICP and improving cerebral hemodynamics in surviving RICH patients. Future studies to evaluate different doses, lengths of infusion, and longer term effects are needed.
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Affiliation(s)
- Daniel A Godoy
- Neurocritical Care Unit, Sanatorio Pasteur, Catamarca, Argentina.
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76
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Brochard L, Martin GS, Blanch L, Pelosi P, Belda FJ, Jubran A, Gattinoni L, Mancebo J, Ranieri VM, Richard JCM, Gommers D, Vieillard-Baron A, Pesenti A, Jaber S, Stenqvist O, Vincent JL. Clinical review: Respiratory monitoring in the ICU - a consensus of 16. Crit Care 2012; 16:219. [PMID: 22546221 PMCID: PMC3681336 DOI: 10.1186/cc11146] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Monitoring plays an important role in the current management of patients with acute respiratory failure but sometimes lacks definition regarding which 'signals' and 'derived variables' should be prioritized as well as specifics related to timing (continuous versus intermittent) and modality (static versus dynamic). Many new techniques of respiratory monitoring have been made available for clinical use recently, but their place is not always well defined. Appropriate use of available monitoring techniques and correct interpretation of the data provided can help improve our understanding of the disease processes involved and the effects of clinical interventions. In this consensus paper, we provide an overview of the important parameters that can and should be monitored in the critically ill patient with respiratory failure and discuss how the data provided can impact on clinical management.
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Affiliation(s)
- Laurent Brochard
- Department of Intensive Care, Hôpitaux Universitaires de Genève, Rue
Gabrielle-Perret-Gentil 4, 1211 Geneva, Switzerland; and Université de
Genève, Switzerland
| | - Greg S Martin
- Division of Pulmonary, Allergy and Critical Care, Emory University School of
Medicine, Grady Memorial Hospital, 615 Michael Street, Suite 205, Atlanta, GA
30322, USA
| | - Lluis Blanch
- Critical Care Center, Corporacio Sanitaria Universitària Parc Tauli,
Universitat Autònoma de Barcelona, 08208 Sabadell, Spain, CIBER Enfermedades
Respiratorias, ISCiii, Madrid, Spain
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa,
San Martino Hospital, Largo Rosanna Benzi 8 16132, Genoa, Italy
| | - F Javier Belda
- Department of Anesthesia and Surgical Critical Care, Hospital Clínico
Universitario, Avda Blasco Ibañez 17, 46010 Valencia, Spain
| | - Amal Jubran
- Division of Pulmonary and Critical Care Medicine, Edward Hines Jr. VA Hospital,
111N, 5th Avenue and Roosevelt Road, Hines, IL 60141, USA
| | - Luciano Gattinoni
- Dipartimento di Anestesiologia, Terapia Intensive e Scienze Dermatologiche, and
Dipartimento do Anestesia, Rianimazione (Intensive e Subintensiva) e Terapia del
Dolore, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico,
Università degli Studi di Milano, via F, Sforza 35, 20122, Milan, Italy
| | - Jordi Mancebo
- Servicio Medicina Intensiva, Hospital de la Santa Creu i Sant Pau, Carrer St.
Quintí 89, 08041 Barcelona, Spain
| | - V Marco Ranieri
- Department of Anesthesia and Intensive Care Medicine, University of Turin, S.
Giovanni Battista, Molinette Hospital, Corso Dogliotti 14, 10126 Turin, Italy
| | - Jean-Christophe M Richard
- Department of Intensive Care, Hôpitaux Universitaires de Genève, Rue
Gabrielle-Perret-Gentil 4, 1211 Geneva, Switzerland; and Université de
Genève, Switzerland
| | - Diederik Gommers
- Adult Intensive Care, Erasmus MC, Room H623, 's Gravendijkwal 230, 3015CE
Rotterdam, The Netherlands
| | - Antoine Vieillard-Baron
- Intensive Care Unit, Section Thorax - Vascular disease - Abdomen - Metabolism, CHU
Ambroise Paré, 9 avenue Charles-de-Gaulle, 92104 Boulogne, France
| | - Antonio Pesenti
- Anesthesia and Intensive Care, University of Milan-Bicocca, A.O. Ospedale S.
Gerardo, Via Pergolesi 33, 20900 Monza, Italy
| | - Samir Jaber
- Department of Critical Care Medicine and Anesthesiology, Saint Eloi University
Hospital and Montpellier School of Medicine, 80 Avenue Augustin Fliche, 34295
Montpellier - Cedex 5, France
| | - Ola Stenqvist
- Department of Anesthesiology and Intensive Care, Sahlgrenska University Hospital,
Bla Straket 5, Gothenburg, SE 413 45, Sweden
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles,
808 route de Lennik, 1070 Brussels, Belgium
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77
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Abstract
Injury is a major cause of critical illness worldwide. Severely injured patients often require mechanical ventilation not only to manage primary respiratory failure but also as adjunct to manage other conditions. Injury induces fundamental changes in multiple organ systems which directly impact ventilator management; these changes are not shared by patients without concomitant tissue injury. In this article, we review the physiologic changes after injury and discuss the impact of injury on ventilator strategies and management. We also explore the special considerations in patients with traumatic brain injury, thermal injury, blast injury or bronchopleural fistula.
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Affiliation(s)
- Adrian A Maung
- Department of Surgery, Section of Trauma, Surgical Critical Care and Surgical Emergencies, Yale University School of Medicine, New Haven, CT, USA
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78
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Sabir H, Jary S, Tooley J, Liu X, Thoresen M. Increased inspired oxygen in the first hours of life is associated with adverse outcome in newborns treated for perinatal asphyxia with therapeutic hypothermia. J Pediatr 2012; 161:409-16. [PMID: 22521111 DOI: 10.1016/j.jpeds.2012.03.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2011] [Revised: 01/23/2012] [Accepted: 03/05/2012] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To assess whether increased inspired oxygen and/or hypocarbia during the first 6 hours of life are associated with adverse outcome at 18 months in term neonates treated with therapeutic hypothermia. STUDY DESIGN Blood gas values and ventilatory settings were monitored hourly in 61 newborns for 6 hours after birth. We investigated if there was an association between increased inspired oxygen and/or hypocarbia and adverse outcome (death or disability by Bayley Scales of Newborn Development II examination at 18-20 months). RESULTS Hypothermia was started from 3 hours 45 minutes (10 minutes-10 hours) and median lowest Pco(2) level within the first 6 hours of life was 30 mm Hg (16.5-96 mm Hg). The median highest fraction of inspiratory oxygen within the first hour of life was 0.43 (0.21-1.00). The area under the curve fraction of inspiratory oxygen and Pao(2) for hours 1-6 of life was 0.23 (0.21-1.0) and 86 mm Hg (22-197 mm Hg), respectively. We did not find any association between any measures of hypocapnia and adverse outcome (P > .05), but increased inspired oxygen correlated with adverse outcome, even when excluding newborns with initial oxygenation failure (P < .05). CONCLUSION Increased fraction of inspired oxygen within the first 6 hours of life was significantly associated with adverse outcome in newborns treated with therapeutic hypothermia following hypoxic ischemic encephalopathy.
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Affiliation(s)
- Hemmen Sabir
- School of Clinical Sciences, University of Bristol, St Michael's Hospital, Bristol, United Kingdom
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79
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Bhalla T, Dewhirst E, Sawardekar A, Dairo O, Tobias JD. Perioperative management of the pediatric patient with traumatic brain injury. Paediatr Anaesth 2012; 22:627-40. [PMID: 22502728 DOI: 10.1111/j.1460-9592.2012.03842.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
TBI and its sequelae remain a major healthcare issue throughout the world. With an improved understanding of the pathophysiology of TBI, refinements of monitoring technology, and ongoing research to determine optimal care, the prognosis of TBI continues to improve. In 2003, the Society of Critical Care Medicine published guidelines for the acute management of severe TBI in infants, children, and adolescents. As pediatric anesthesiologists are frequently involved in the perioperative management of such patients including their stabilization in the emergency department, familiarity with these guidelines is necessary to limit preventable secondary damage related to physiologic disturbances. This manuscript reviews the current evidence-based medicine regarding the care of pediatric patients with TBI as it relates to the perioperative care of such patients. The issues reviewed include those related to initial stabilization, airway management, intra-operative mechanical ventilation, hemodynamic support, administration of blood and blood products, positioning, and choice of anesthetic technique. The literature is reviewed regarding fluid management, glucose control, hyperosmolar therapy, therapeutic hypothermia, and corticosteroids. Whenever possible, management recommendations are provided.
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Affiliation(s)
- Tarun Bhalla
- Departments of Anesthesiology, Nationwide Children's Hospital and the Ohio State University, Columbus, OH, USA
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80
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Solano C. ME, Castillo B. I, Niño de Mejía MC. Hypocapnia in Neuroanesthesia: Current Situation. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2012. [DOI: 10.1016/s2256-2087(12)70029-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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81
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Solano C. ME, Castillo B. I, Niño De Mejía MC. Hipocapnia en neuroanestesia: estado actual. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2012. [DOI: 10.1016/s0120-3347(12)70029-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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82
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Kim YS, An SJ, Lee HJ, Choi HJ. Change in the electroencephalogram delta wave in the frontal cranial region of rats with the hyperventilation. Respir Physiol Neurobiol 2012; 181:177-82. [PMID: 22406840 DOI: 10.1016/j.resp.2012.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2011] [Revised: 02/28/2012] [Accepted: 02/29/2012] [Indexed: 10/28/2022]
Abstract
Hyperventilation is one way to cause activation on the electroencephalogram (EEG) to diagnose brain disorders. The hyperventilation is also known to affect on the delta power in EEG. This study divided the total delta wave into low, middle, and high bands corresponding to the wave frequency. The power in these three delta wave bands was examined in the frontal cranial region of adult male Sprague-Dawley rats hyperventilated with ventilation (VE) of 360, 540, and 720 ml/min for 5 min. The control group was ventilated normally with a volume of 160 ml/min. The results show that the relative power of the low delta band in the rats hyperventilated at 360 ml/min VE was significantly increased compared with powers of pre-hyperventilation (p<0.05). The relative power of the middle delta band was not significantly affected by hyperventilation at any VE, and in the high delta band, all of the relative powers were decreased significantly in all hyperventilated rats compared with powers of pre-hyperventilation (p<0.05). We concluded that hyperventilation affects the frontal cranial region, by increasing the low delta band and decreasing the high delta band.
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Affiliation(s)
- Young Sik Kim
- Department of Smart Foods and Drugs, Inje University, Gimhae 621-749, Republic of Korea.
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83
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Stover JF. Contemporary view on neuromonitoring following severe traumatic brain injury. World J Crit Care Med 2012; 1:15-22. [PMID: 24701397 PMCID: PMC3956064 DOI: 10.5492/wjccm.v1.i1.15] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2011] [Revised: 10/27/2011] [Accepted: 12/21/2011] [Indexed: 02/06/2023] Open
Abstract
Evolving brain damage following traumatic brain injury (TBI) is strongly influenced by complex pathophysiologic cascades including local as well as systemic influences. To successfully prevent secondary progression of the primary damage we must actively search and identify secondary insults e.g. hypoxia, hypotension, uncontrolled hyperventilation, anemia, and hypoglycemia, which are known to aggravate existing brain damage. For this, we must rely on specific cerebral monitoring. Only then can we unmask changes which otherwise would remain hidden, and prevent adequate intensive care treatment. Apart from intracranial pressure (ICP) and calculated cerebral perfusion pressure (CPP), extended neuromonitoring (SjvO2, ptiO2, microdialysis, transcranial Doppler sonography, electrocorticography) also allows us to define individual pathologic ICP and CPP levels. This, in turn, will support our therapeutic decision-making and also allow a more individualized and flexible treatment concept for each patient. For this, however, we need to learn to integrate several dimensions with their own possible treatment options into a complete picture. The present review summarizes the current understanding of extended neuromonitoring to guide therapeutic interventions with the aim of improving intensive care treatment following severe TBI, which is the basis for ameliorated outcome.
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Affiliation(s)
- John F Stover
- John F Stover, Surgical Intensive Care Medicine, University Hospital Zürich, Rämistrasse 100, 8091 Zürich, Switzerland
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84
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Hypocapnia in Neuroanesthesia: Current Situation. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2012. [DOI: 10.1097/01819236-201240020-00012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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85
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Silva S, Geeraerts T. Pourquoi et comment contrôler les agressions cérébrales secondaires en urgence lors d’une d’une agression cérébrale. MEDECINE INTENSIVE REANIMATION 2011. [DOI: 10.1007/s13546-011-0326-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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86
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Seshia SS, Bingham WT, Kirkham FJ, Sadanand V. Nontraumatic Coma in Children and Adolescents: Diagnosis and Management. Neurol Clin 2011; 29:1007-43. [DOI: 10.1016/j.ncl.2011.07.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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87
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Mejaddam AY, Velmahos GC. Randomized controlled trials affecting polytrauma care. Eur J Trauma Emerg Surg 2011; 38:211-21. [PMID: 26815952 DOI: 10.1007/s00068-011-0141-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Accepted: 07/16/2011] [Indexed: 12/22/2022]
Abstract
Trauma remains the leading cause of death in the world in patients under 45 years of age. The evaluation, resuscitation, and appropriate management of polytraumatized patients are paramount to successful outcomes. The advance of evidence-based medicine has had a powerful and positive impact on trauma care, even though the nature of many traumatic injuries lends itself poorly to study in a randomized fashion. During the initial management of bleeding patients, hypotensive resuscitation prior to surgical control has found strong support in the literature, and its use has been adopted by many surgeons. Head injury is the most common cause of traumatic death, and while high-level evidence is limited, adherence to management guidelines is associated with improved outcomes. For abdominal trauma, the concept of damage control surgery, while popular, has never been put to the test in a randomized controlled trial. Numerous randomized trials in the field of critical care have affected the management of severely injured patients, including intensive insulin therapy and low tidal volume ventilation in patients with compromised respiratory function. Finally, a multidisciplinary approach to trauma care in designated trauma centers allows for improved outcomes in polytraumatized patients.
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Affiliation(s)
- A Y Mejaddam
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA
| | - G C Velmahos
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA.
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88
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Simard JM, Sahuquillo J, Sheth KN, Kahle KT, Walcott BP. Managing malignant cerebral infarction. Curr Treat Options Neurol 2011; 13:217-29. [PMID: 21190097 DOI: 10.1007/s11940-010-0110-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OPINION STATEMENT Managing patients with malignant cerebral infarction remains one of the foremost challenges in medicine. These patients are at high risk for progressive neurologic deterioration and death due to malignant cerebral edema, and they are best cared for in the intensive care unit of a comprehensive stroke center. Careful initial assessment of neurologic function and of findings on MRI, coupled with frequent reassessment of clinical and radiologic findings using CT or MRI are mandatory to promote the prompt initiation of treatments that will ensure the best outcome in these patients. Significant deterioration in either neurologic function or radiologic findings or both demand timely treatment using the best medical management, which may include osmotherapy (mannitol or hypertonic saline), endotracheal intubation, and mechanical ventilation. Under appropriate circumstances, decompressive craniectomy may be warranted to improve outcome or to prevent death.
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Affiliation(s)
- J Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, 22 S. Greene St., Suite S12D, Baltimore, MD, 21201-1595, USA
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89
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Dumont TM, Visioni AJ, Rughani AI, Tranmer BI, Crookes B. Inappropriate prehospital ventilation in severe traumatic brain injury increases in-hospital mortality. J Neurotrauma 2011; 27:1233-41. [PMID: 20373856 DOI: 10.1089/neu.2009.1216] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
In the setting of acute brainstem herniation in traumatic brain injury (TBI), the use of hyperventilation to reduce intracranial pressure may be life-saving. However, undue use of hyperventilation is thought to increase the incidence of secondary brain injury through direct reduction of cerebral blood flow. This is a retrospective review determining the effect of prehospital hyperventilation on in-hospital mortality following severe TBI. All trauma patients admitted directly to a single level 1 trauma center from January 2000 to January 2007 with an initial Glasgow Coma Scale (GCS) score <or=8 were included in the study (n = 77). Patients without documented or with late (>20 min) arterial blood gas at presentation (n = 12) were excluded from the study. The remaining population (n = 65) was sorted into three groups based on the initial partial pressure of carbon dioxide: hypocarbic (Pco(2) < 35 mm Hg), normocarbic (Pco(2) 35-45 mm Hg), and hypercarbic (Pco(2) > 45 mm Hg). Outcome was based on mortality during hospital admission. Survival was found to be related to admission Pco(2) in head trauma patients requiring intubation (p = 0.045). Patients with normocarbia on presenting arterial blood gas testing had in-hospital mortality of 15%, significantly improved over patients presenting with hypocarbia (in-hospital mortality 77%) or hypercarbia (in-hospital mortality 61%). Although there are many reports of the negative impact of prophylactic hyperventilation following severe TBI, this modality is frequently utilized in the prehospital setting. Our results suggest that abnormal Pco(2) on presentation after severe head trauma is correlated with increased in-hospital mortality. We advocate normoventilation in the prehospital setting.
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Affiliation(s)
- Travis M Dumont
- Division of Neurosurgery, University of Vermont College of Medicine, Burlington, Vermont 05401, USA.
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90
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Gupta RK, Jamjoom AAB, Nikkar-Esfahani A, Jamjoom DZA. Spontaneous intracerebral haemorrhage: a clinical review. Br J Hosp Med (Lond) 2011; 71:499-504. [PMID: 20852544 DOI: 10.12968/hmed.2010.71.9.78160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This article provides a clinical overview of spontaneous intracerebral haemorrhage, focusing on clinical aspects of the aetiology, diagnosis and management (both in the emergency department and in a critical care environment) of this important and devastating condition.
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Affiliation(s)
- R K Gupta
- Department of Acute Medicine, University College Hospital, London
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91
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Effects of Spontaneous Breathing During Airway Pressure Release Ventilation on Cerebral and Spinal Cord Perfusion in Experimental Acute Lung Injury. J Neurosurg Anesthesiol 2010; 22:323-9. [DOI: 10.1097/ana.0b013e3181e775f1] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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92
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Impact of hyperventilation on stimulus efficiency during the early phase of an electroconvulsive therapy course: a randomized double-blind study. J ECT 2010; 26:91-4. [PMID: 20514695 DOI: 10.1097/yct.0b013e3181c18901] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The question whether hyperventilation during electroconvulsive therapy (ECT) can improve stimulus efficiency is as yet unanswered. METHODS Twenty-five consecutive consenting patients (N = 25) with major depression who were administered ECT entered into the study. Right unilateral ECT at thrice the threshold dose was administered using Mecta spECTrum 5000Q (Mecta Corp, Lake Oswego, Ore), with standard titration procedures and stimulus configurations. At the second ECT session, they were randomly allocated to ECT either with hyperventilation or with no hyperventilation. Hyperventilation was actively administered by an anesthetist just after anesthetic paralysis and before the ECT stimulus during the second, third, and fourth ECT sessions. Assessments were double-blind and performed at baseline and 24 to 48 hours after the fourth ECT session. Time to reorient after ECT was assessed during the first up to the fourth ECT session. Ictal electroencephalogram (EEG) quality was visually assessed using standard scales. RESULTS There were no significant differences across the 2 groups about depression severity and global cognitive impact. However, the orientation time was 34% longer among those who did not receive hyperventilation. The ratio of orientation time without hyperventilation to that with hyperventilation equals 1.34 (95% confidence interval, 0.94-1.92; P = 0.103). There was a significant increase in threshold over time across both groups (mean difference, 16.4; SE, 5.5; P = 0.006) with no significant main effect for the groups (P = 0.399). There were no significant group differences in the EEG quality. CONCLUSIONS The addition of hyperventilation during the early phase of the ECT course shows a trend to lessen the impact on immediate orientation without impeding clinical response. This does not seem to be mediated by differential threshold changes or change to the ictal EEG quality.
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93
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Sande A, West C. Traumatic brain injury: a review of pathophysiology and management. J Vet Emerg Crit Care (San Antonio) 2010; 20:177-90. [DOI: 10.1111/j.1476-4431.2010.00527.x] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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94
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95
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Eberspächer E, Blobner M, Werner C, Ruf S, Eckel B, Engelhard K, Schmahl W, Gelb AW. The Long-Term Effect of Four Hours of Hyperventilation on Neurocognitive Performance and Lesion Size After Controlled Cortical Impact in Rats. Anesth Analg 2010; 110:181-7. [DOI: 10.1213/ane.0b013e3181c2203b] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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96
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Abstract
This article explains the pathophysiology and causes of raised intracranial pressure (ICP), and the significance of assessing and recording vital observations for all patients when admitted to hospital. It discusses the nursing care, treatment and management required in order to minimize the risk of further increases in ICP.
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Affiliation(s)
- Kathryn May
- West Berkshire Community Hospital, Thatcham, UK
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97
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Concordance of End-Tidal Carbon Dioxide and Arterial Carbon Dioxide in Severe Traumatic Brain injury. ACTA ACUST UNITED AC 2009; 67:526-30. [DOI: 10.1097/ta.0b013e3181866432] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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98
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Pallanti S, Bernardi S. Neurobiology of repeated transcranial magnetic stimulation in the treatment of anxiety: a critical review. Int Clin Psychopharmacol 2009; 24:163-73. [PMID: 19455047 DOI: 10.1097/yic.0b013e32832c2639] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Transcranial magnetic stimulation (TMS) has been applied to a growing number of psychiatric disorders as a neurophysiological probe, a primary brain-mapping tool, and a candidate treatment. Although most investigations have focused on the treatment of major depression, increasing attention has been paid to anxiety disorders. The aim of this study is to summarize published findings about the application of TMS as a putative treatment for anxiety disorders. TMS neurophysiological and mapping findings, both clinical and preclinical, have been included when relevant. We searched Medline, PsycInfo, and the Cochrane Library from 1980 to January 2009 for the terms 'generalized anxiety disorder', 'social anxiety disorder', 'social phobia', 'panic', 'anxiety', or 'posttraumatic stress disorder' in combination with 'TMS', 'cortex excitability', 'rTMS', 'motor threshold', 'motor evoked potential', 'cortical silent period', 'intracortical inhibition', 'neuroimaging', or 'intracortical facilitation'. Most of the therapeutic experiences with repetitive TMS available in the literature are in the form of case reports, not controlled or blinded studies. Stimulation of the right dorsolateral prefrontal cortex, especially at high frequencies, has been reported to reduce anxiety symptoms in posttraumatic stress disorder and panic disorder; nevertheless, results are mixed. A specific role for the right dorsolateral prefrontal cortex in the posttraumatic stress disorder symptom core can be hypothesized. TMS remains an investigational intervention that has not yet gained approval for the clinical treatment of any anxiety disorder. Clinical sham-controlled trials are scarce. Many of these trials have supported the idea that TMS has a significant effect, but in some studies, the effect is small and short lived. The neurobiological correlates suggest possible efficacy for the treatment of social anxiety that still has to be investigated.
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Affiliation(s)
- Stefano Pallanti
- Department of Psychiatry, The Mount Sinai School of Medicine, New York, NY 10029, USA.
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99
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Abstract
Raised intracranial pressure (ICP) is a life threatening condition that is common to many neurological and non-neurological illnesses. Unless recognized and treated early it may cause secondary brain injury due to reduced cerebral perfusion pressure (CPP), and progress to brain herniation and death. Management of raised ICP includes care of airway, ventilation and oxygenation, adequate sedation and analgesia, neutral neck position, head end elevation by 20 degrees-30 degrees, and short-term hyperventilation (to achieve PCO(2) 32-35 mm Hg) and hyperosmolar therapy (mannitol or hypertonic saline) in critically raised ICP. Barbiturate coma, moderate hypothermia and surgical decompression may be helpful in refractory cases. Therapies aimed directly at keeping ICP <20 mmHg have resulted in improved survival and neurological outcome. Emerging evidence suggests that cerebral perfusion pressure targeted therapy may offer better outcome than ICP targeted therapies.
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100
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Piechnik S, Evans J, Bary L, Wise R, Jezzard P. Functional changes in CSF volume estimated using measurement of waterT2relaxation. Magn Reson Med 2009; 61:579-86. [DOI: 10.1002/mrm.21897] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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