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Peng L, Kang H, Chang H, Sun Y, Zhao Y, Zhao H. The ratio of parasternal intercostal muscle-thickening fraction-to-diaphragm thickening fraction for predicting weaning failure. J Crit Care 2024; 83:154847. [PMID: 38909540 DOI: 10.1016/j.jcrc.2024.154847] [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: 08/22/2023] [Revised: 05/22/2024] [Accepted: 06/14/2024] [Indexed: 06/25/2024]
Abstract
BACKGROUND Diaphragm dysfunction is associated with weaning outcomes in mechanical ventilation patients, in the case of diaphragm dysfunction, the accessory respiratory muscles would be recruited. The main purpose of this study is to explore the performance of parasternal intercostal muscle thickening fraction in relation to diaphragmatic thickening fraction ratio (TFic1/TFdi2) for predicting weaning outcomes, and compare its accuracy with D-RSBI in predicting weaning failure. MATERIALS AND METHODS We prospectively enrolled consecutive patients from 7/2022-5/2023. We measured TFic, TFdi, and diaphragmatic excursion (DE3) by ultrasound and calculated the TFic/TFdi ratio and diaphragmatic rapid shallow breathing index (D-RSBI4). Receiver-operator characteristic (ROC5) curves evaluated the accuracy of the TFic/TFdi ratio and D-RSBI in predicting weaning failure. RESULTS 161 were included in the final analysis, 114 patients (70.8%) were successfully weaned from mechanical ventilation. The TFic/TFdi ratio (AUROC = 0.887 (95% CI: 0.821-0.953)) was superior to the D-RSBI (AUROC = 0.875 (95% CI: 0.807-0.944)) for predicting weaning failure. CONCLUSIONS The TFic/TFdi ratio predicted weaning failure with high accuracy and outperformed the D-RSBI.
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Affiliation(s)
- Li Peng
- Department of Critical Care Medicine, Hebei Medical University, Shijiazhuang 050000, Hebei, China; Department of Intensive Care Unit, Hebei General Hospital, Shijiazhuang 050000, Hebei, China; Department of Intensive Care Unit, Harrison International Peace Hospital, Hengshui 053000, Hebei, China
| | - Hongshan Kang
- Department of Intensive Care Unit, Harrison International Peace Hospital, Hengshui 053000, Hebei, China
| | - Hairong Chang
- Department of Intensive Care Unit, Harrison International Peace Hospital, Hengshui 053000, Hebei, China
| | - Yue Sun
- Department of Intensive Care Unit, Harrison International Peace Hospital, Hengshui 053000, Hebei, China
| | - Yuanyuan Zhao
- Department of Intensive Care Unit, Harrison International Peace Hospital, Hengshui 053000, Hebei, China
| | - Heling Zhao
- Department of Critical Care Medicine, Hebei Medical University, Shijiazhuang 050000, Hebei, China; Department of Intensive Care Unit, Hebei General Hospital, Shijiazhuang 050000, Hebei, China.
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Ho UC, Hsieh CJ, Lu HY, Huang APH, Kuo LT. Predictors of extubation failure and prolonged mechanical ventilation among patients with intracerebral hemorrhage after surgery. Respir Res 2024; 25:19. [PMID: 38178114 PMCID: PMC10765847 DOI: 10.1186/s12931-023-02638-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 12/14/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND Spontaneous intracerebral hemorrhage (ICH) is a condition associated with high mortality and morbidity. Survivors may require prolonged intubation with mechanical ventilation (MV). The aim of this study was to analyze the predictors of extubation failure and prolonged MV in patients who undergo surgical evacuation. METHODS This retrospective study was conducted on adult patients with ICH who underwent MV for at least 48 h and survived > 14 days after surgery. The demographics, clinical characteristics, laboratory tests, and Glasgow Coma Scale score were analyzed. RESULTS A total of 134 patients with ICH were included in the study. The average age of the patients was 60.34 ± 15.59 years, and 79.9% (n = 107) were extubated after satisfying the weaning parameters. Extubation failure occurred in 11.2% (n = 12) and prolonged MV in 48.5% (n = 65) patients. Multivariable regression analysis revealed that a white blood cell count > 10,000/mm3 at the time of extubation was an independent predictor of reintubation. Meanwhile, age and initial Glasgow Coma Scale scores were predictors of prolonged MV. CONCLUSIONS This study provided the first comprehensive characterization and analysis of the predictors of extubation failure and prolonged MV in patients with ICH after surgery. Knowledge of potential predictors is essential to improve the strategies for early initiation of adequate treatment and prognosis assessment in the early stages of the disease.
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Affiliation(s)
- Ue-Cheung Ho
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, Yunlin Branch No. 579, Sec. 2, Yunlin Rd, Yunlin, 640, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, 100, Taiwan
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, Taipei, 100, Taiwan
| | - Chia-Jung Hsieh
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, Taipei, 100, Taiwan
| | - Hsueh-Yi Lu
- Department of Industrial Engineering and Management, National Yunlin University of Science and Technology, Yunlin, 640, Taiwan
| | - Abel Po-Hao Huang
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, Taipei, 100, Taiwan
- Institute of Polymer Science and Engineering, National Taiwan University, Taipei, 100, Taiwan
| | - Lu-Ting Kuo
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, Yunlin Branch No. 579, Sec. 2, Yunlin Rd, Yunlin, 640, Taiwan.
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, Taipei, 100, Taiwan.
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Matsumoto Y, Nakae R, Sekine T, Kodani E, Warnock G, Igarashi Y, Tagami T, Murai Y, Suzuki K, Yokobori S. Rapidly progressive cerebral atrophy following a posterior cranial fossa stroke: Assessment with semiautomatic CT volumetry. Acta Neurochir (Wien) 2023; 165:1575-1584. [PMID: 37119319 DOI: 10.1007/s00701-023-05609-3] [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: 01/31/2023] [Accepted: 04/25/2023] [Indexed: 05/01/2023]
Abstract
BACKGROUND The effect of posterior cranial fossa stroke on changes in cerebral volume is not known. We assessed cerebral volume changes in patients with acute posterior fossa stroke using CT scans, and looked for risk factors for cerebral atrophy. METHODS Patients with cerebellar or brainstem hemorrhage/infarction admitted to the ICU, and who underwent at least two subsequent inpatient head CT scans during hospitalization were included (n = 60). The cerebral volume was estimated using an automatic segmentation method. Patients with cerebral volume reduction > 0% from the first to the last scan were defined as the "cerebral atrophy group (n = 47)," and those with ≤ 0% were defined as the "no cerebral atrophy group (n = 13)." RESULTS The cerebral atrophy group showed a significant decrease in cerebral volume (first CT scan: 0.974 ± 0.109 L vs. last CT scan: 0.927 ± 0.104 L, P < 0.001). The mean percentage change in cerebral volume between CT scans in the cerebral atrophy group was -4.7%, equivalent to a cerebral volume of 46.8 cm3, over a median of 17 days. The proportions of cases with a history of hypertension, diabetes mellitus, and median time on mechanical ventilation were significantly higher in the cerebral atrophy group than in the no cerebral atrophy group. CONCLUSIONS Many ICU patients with posterior cranial fossa stroke showed signs of cerebral atrophy. Those with rapidly progressive cerebral atrophy were more likely to have a history of hypertension or diabetes mellitus and required prolonged ventilation.
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Affiliation(s)
- Yoshiyuki Matsumoto
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, 1-1-5, Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
| | - Ryuta Nakae
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, 1-1-5, Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan.
| | - Tetsuro Sekine
- Department of Radiology, Nippon Medical School Musashi Kosugi Hospital, Kanagawa, Japan
| | - Eigo Kodani
- Department of Radiology, Nippon Medical School Musashi Kosugi Hospital, Kanagawa, Japan
| | | | - Yutaka Igarashi
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, 1-1-5, Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
| | - Takashi Tagami
- Department of Emergency and Critical Care Medicine, Nippon Medical School Musashi Kosugi Hospital, Kanagawa, Japan
| | - Yasuo Murai
- Department of Neurological Surgery, Nippon Medical School Hospital, Tokyo, Japan
| | - Kensuke Suzuki
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Shoji Yokobori
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, 1-1-5, Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
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Beqiri E, Smielewski P, Guérin C, Czosnyka M, Robba C, Bjertnæs L, Frisvold SK. Neurological and respiratory effects of lung protective ventilation in acute brain injury patients without lung injury: brain vent, a single centre randomized interventional study. Crit Care 2023; 27:115. [PMID: 36941683 PMCID: PMC10026451 DOI: 10.1186/s13054-023-04383-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 02/25/2023] [Indexed: 03/23/2023] Open
Abstract
INTRODUCTION Lung protective ventilation (LPV) comprising low tidal volume (VT) and high positive end-expiratory pressure (PEEP) may compromise cerebral perfusion in acute brain injury (ABI). In patients with ABI, we investigated whether LPV is associated with increased intracranial pressure (ICP) and/or deranged cerebral autoregulation (CA), brain compensatory reserve and oxygenation. METHODS In a prospective, crossover study, 30 intubated ABI patients with normal ICP and no lung injury were randomly assigned to receive low VT [6 ml/kg/predicted (pbw)]/at either low (5 cmH2O) or high PEEP (12 cmH2O). Between each intervention, baseline ventilation (VT 9 ml/kg/pbw and PEEP 5 cmH2O) were resumed. The safety limit for interruption of the intervention was ICP above 22 mmHg for more than 5 min. Airway and transpulmonary pressures were continuously monitored to assess respiratory mechanics. We recorded ICP by using external ventricular drainage or a parenchymal probe. CA and brain compensatory reserve were derived from ICP waveform analysis. RESULTS We included 27 patients (intracerebral haemorrhage, traumatic brain injury, subarachnoid haemorrhage), of whom 6 reached the safety limit, which required interruption of at least one intervention. For those without intervention interruption, the ICP change from baseline to "low VT/low PEEP" and "low VT/high PEEP" were 2.2 mmHg and 2.3 mmHg, respectively, and considered clinically non-relevant. None of the interventions affected CA or oxygenation significantly. Interrupted events were associated with high baseline ICP (p < 0.001), low brain compensatory reserve (p < 0.01) and mechanical power (p < 0.05). The transpulmonary driving pressure was 5 ± 2 cmH2O in both interventions. Partial arterial pressure of carbon dioxide was kept in the range 34-36 mmHg by adjusting the respiratory rate, hence, changes in carbon dioxide were not associated with the increase in ICP. CONCLUSIONS The present study found that most patients did not experience any adverse effects of LPV, neither on ICP nor CA. However, in almost a quarter of patients, the ICP rose above the safety limit for interrupting the interventions. Baseline ICP, brain compensatory reserve, and mechanical power can predict a potentially deleterious effect of LPV and can be used to personalize ventilator settings. Trial registration NCT03278769 . Registered September 12, 2017.
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Affiliation(s)
- Erta Beqiri
- Department of Clinical Neurosciences, Neurosurgery Department, University of Cambridge, Cambridge, UK
| | - Peter Smielewski
- Department of Clinical Neurosciences, Neurosurgery Department, University of Cambridge, Cambridge, UK
| | - Claude Guérin
- University of Lyon, Lyon, France
- INSERM955, Créteil, France
| | - Marek Czosnyka
- Department of Clinical Neurosciences, Neurosurgery Department, University of Cambridge, Cambridge, UK
| | - Chiara Robba
- IRCCS for Oncology and Neuroscience, Policlinico San Martino, Genoa, Italy
- Department of Surgical Science Diagnostic and Integrated, University of Genova, Genoa, Italy
| | - Lars Bjertnæs
- Department of Anaesthesia and Intensive Care, University Hospital of North Norway, Tromsø, Norway
- Department of Clinical Medicine, UiT the Arctic University of Norway, Tromsø, Norway
| | - Shirin K Frisvold
- Department of Anaesthesia and Intensive Care, University Hospital of North Norway, Tromsø, Norway.
- Department of Clinical Medicine, UiT the Arctic University of Norway, Tromsø, Norway.
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Mechanical Ventilation in Patients with Traumatic Brain Injury: Is it so Different? Neurocrit Care 2023; 38:178-191. [PMID: 36071333 DOI: 10.1007/s12028-022-01593-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 08/16/2022] [Indexed: 10/14/2022]
Abstract
Patients with traumatic brain injury (TBI) frequently require invasive mechanical ventilation and admission to an intensive care unit. Ventilation of patients with TBI poses unique clinical challenges, and careful attention is required to ensure that the ventilatory strategy (including selection of appropriate tidal volume, plateau pressure, and positive end-expiratory pressure) does not cause significant additional injury to the brain and lungs. Selection of ventilatory targets may be guided by principles of lung protection but with careful attention to relevant intracranial effects. In patients with TBI and concomitant acute respiratory distress syndrome (ARDS), adjunctive strategies include sedation optimization, neuromuscular blockade, recruitment maneuvers, prone positioning, and extracorporeal life support. However, these approaches have been largely extrapolated from studies in patients with ARDS and without brain injury, with limited data in patients with TBI. This narrative review will summarize the existing evidence for mechanical ventilation in patients with TBI. Relevant literature in patients with ARDS will be summarized, and where available, direct data in the TBI population will be reviewed. Next, practical strategies to optimize the delivery of mechanical ventilation and determine readiness for extubation will be reviewed. Finally, future directions for research in this evolving clinical domain will be presented, with considerations for the design of studies to address relevant knowledge gaps.
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Zelmanovich R, Pierre K, Felisma P, Cole D, Goldman M, Lucke-Wold B. High Altitude Cerebral Edema: Improving Treatment Options. BIOLOGICS (BASEL, SWITZERLAND) 2022; 2:81-91. [PMID: 35425940 PMCID: PMC9006955 DOI: 10.3390/biologics2010007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
High altitude illness in its most severe form can lead to high altitude cerebral edema (HACE). Current strategies have focused on prevention with graduated ascents, pharmacologic prophylaxis, and descent at first signs of symptoms. Little is understood regarding treatment with steroids and oxygenation being commonly utilized. Pre-clinical studies with turmeric derivatives have offered promise due to its anti-inflammatory and antioxidant properties, but they warrant validation clinically. Ongoing work is focused on better understanding the disease pathophysiology with an emphasis on the glymphatic system and venous outflow obstruction. This review highlights what is known regarding diagnosis, treatment, and prevention, while also introducing novel pathophysiology mechanisms warranting further investigation.
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Affiliation(s)
| | - Kevin Pierre
- Department of Neurosurgery, University of Florida, Gainesville, FL 32611, USA
| | - Patrick Felisma
- Department of Neurosurgery, University of Florida, Gainesville, FL 32611, USA
| | - Dwayne Cole
- Department of Neurosurgery, University of Florida, Gainesville, FL 32611, USA
| | - Matthew Goldman
- Department of Neurosurgery, University of Florida, Gainesville, FL 32611, USA
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, FL 32611, USA
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7
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Huang CH, Ni SY, Lu HY, Huang APH, Kuo LT. Predictors of Prolonged Mechanical Ventilation Among Patients with Aneurysmal Subarachnoid Hemorrhage After Microsurgical Clipping. Neurol Ther 2022; 11:697-709. [PMID: 35184263 PMCID: PMC9095775 DOI: 10.1007/s40120-022-00336-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 02/07/2022] [Indexed: 11/28/2022] Open
Abstract
Introduction Aneurysmal subarachnoid hemorrhage (aSAH) is a fatal event with high mortality and morbidity rates. Survivors may require prolonged intubation with mechanical ventilation (MV). However, the risk factors for prolonged intubation in these patients remain unclear. The aim of this study was to determine the predictors of prolonged MV in aSAH patients who underwent surgical clipping. Methods In total, 108 adult patients with a primary diagnosis of aSAH who were on MV > 48 h and survived > 14 days after surgery were included. Clinicodemographic and radiological characteristics, laboratory tests on admission, and initial Glasgow Coma Scale (GCS) and its components were analyzed. Results The average age of the patients included in the analysis was 59.1 ± 12.5 years. Overall, 32 patients (29.6%) had prolonged MV. The group with prolonged MV showed a higher prevalence of diabetes mellitus and hypertension, lower initial GCS and its components, higher World Federation of Neurosurgeons (WFNS) and Hunt and Hess grades, and higher initial white cell counts. The independent factors associated with prolonged MV were a history of diabetes mellitus (odds ratio [OR] 5.799, 95% confidence interval [CI] 1.109–30.334; P = 0.037) and Hunt and Hess grade 3–5 (OR 7.217, 95% CI 1.090–47.770; P = 0.040). Conclusion A history of diabetes mellitus and Hunt and Hess grade 3–5 independently predict prolonged MV after microsurgical clipping in patients with aSAH. Thus, knowledge of potential predictors for prolonged MV is essential to improve the early initiation of adequate treatment in the early stages of treatment and provide useful information for communication between caregivers and families.
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Affiliation(s)
- Ching-Hua Huang
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei, 100 Taiwan
| | - Shih-Ying Ni
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsueh-Yi Lu
- Department of Industrial Engineering and Management, National Yunlin University of Science and Technology, Yunlin, Taiwan
| | - Abel Po-Hao Huang
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei, 100 Taiwan
| | - Lu-Ting Kuo
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei, 100 Taiwan
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Taran S, McCredie VA, Goligher EC. Noninvasive and invasive mechanical ventilation for neurologic disorders. HANDBOOK OF CLINICAL NEUROLOGY 2022; 189:361-386. [PMID: 36031314 DOI: 10.1016/b978-0-323-91532-8.00015-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Patients with acute neurologic injuries frequently require mechanical ventilation due to diminished airway protective reflexes, cardiopulmonary failure secondary to neurologic insults, or to facilitate gas exchange to precise targets. Mechanical ventilation enables tight control of oxygenation and carbon dioxide levels, enabling clinicians to modulate cerebral hemodynamics and intracranial pressure with the goal of minimizing secondary brain injury. In patients with acute spinal cord injuries, neuromuscular conditions, or diseases of the peripheral nerve, mechanical ventilation enables respiratory support under conditions of impending or established respiratory failure. Noninvasive ventilatory approaches may be carefully considered for certain disease conditions, including myasthenia gravis and amyotrophic lateral sclerosis, but may be inappropriate in patients with Guillain-Barré syndrome or when relevant contra-indications exist. With regard to discontinuing mechanical ventilation, considerable uncertainty persists about the best approach to wean patients, how to identify patients ready for extubation, and when to consider primary tracheostomy. Recent consensus guidelines highlight these and other knowledge gaps that are the focus of active research efforts. This chapter outlines important general principles to consider when initiating, titrating, and discontinuing mechanical ventilation in patients with acute neurologic injuries. Important disease-specific considerations are also reviewed where appropriate.
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Affiliation(s)
- Shaurya Taran
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada; Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Victoria A McCredie
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada; Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada; Department of Medicine, University Health Network, Toronto, ON, Canada.
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Nakae R, Sekine T, Tagami T, Murai Y, Kodani E, Warnock G, Sato H, Morita A, Yokota H, Yokobori S. Rapidly progressive brain atrophy in septic ICU patients: a retrospective descriptive study using semiautomatic CT volumetry. Crit Care 2021; 25:411. [PMID: 34844648 PMCID: PMC8628398 DOI: 10.1186/s13054-021-03828-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 11/17/2021] [Indexed: 12/02/2022] Open
Abstract
Background Sepsis is often associated with multiple organ failure; however, changes in brain volume with sepsis are not well understood. We assessed brain atrophy in the acute phase of sepsis using brain computed tomography (CT) scans, and their findings’ relationship to risk factors and outcomes. Methods Patients with sepsis admitted to an intensive care unit (ICU) and who underwent at least two head CT scans during hospitalization were included (n = 48). The first brain CT scan was routinely performed on admission, and the second and further brain CT scans were obtained whenever prolonged disturbance of consciousness or abnormal neurological findings were observed. Brain volume was estimated using an automatic segmentation method and any changes in brain volume between the two scans were recorded. Patients with a brain volume change < 0% from the first CT scan to the second CT scan were defined as the “brain atrophy group (n = 42)”, and those with ≥ 0% were defined as the “no brain atrophy group (n = 6).” Use and duration of mechanical ventilation, length of ICU stay, length of hospital stay, and mortality were compared between the groups. Results Analysis of all 42 cases in the brain atrophy group showed a significant decrease in brain volume (first CT scan: 1.041 ± 0.123 L vs. second CT scan: 1.002 ± 0.121 L, t (41) = 9.436, p < 0.001). The mean percentage change in brain volume between CT scans in the brain atrophy group was –3.7% over a median of 31 days, which is equivalent to a brain volume of 38.5 cm3. The proportion of cases on mechanical ventilation (95.2% vs. 66.7%; p = 0.02) and median time on mechanical ventilation (28 [IQR 15–57] days vs. 15 [IQR 0–25] days, p = 0.04) were significantly higher in the brain atrophy group than in the no brain atrophy group. Conclusions Many ICU patients with severe sepsis who developed prolonged mental status changes and neurological sequelae showed signs of brain atrophy. Patients with rapidly progressive brain atrophy were more likely to have required mechanical ventilation. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03828-7.
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Affiliation(s)
- Ryuta Nakae
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan.
| | - Tetsuro Sekine
- Department of Radiology, Nippon Medical School Musashi Kosugi Hospital, 1-396, Kosugi-cho, Nakahara-ku, Kawasaki, Kanagawa, 211-8533, Japan
| | - Takashi Tagami
- Department of Emergency and Critical Care Medicine, Nippon Medical School Musashi Kosugi Hospital, 1-396, Kosugi-cho, Nakahara-ku, Kawasaki, Kanagawa, 211-8533, Japan
| | - Yasuo Murai
- Department of Neurosurgery, Nippon Medical School Hospital, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Eigo Kodani
- Department of Radiology, Nippon Medical School Musashi Kosugi Hospital, 1-396, Kosugi-cho, Nakahara-ku, Kawasaki, Kanagawa, 211-8533, Japan
| | - Geoffrey Warnock
- PMOD Technologies Ltd., Sumatrastrasse 25, 8006, Zürich, Switzerland
| | - Hidetaka Sato
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Akio Morita
- Department of Neurosurgery, Nippon Medical School Hospital, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Hiroyuki Yokota
- Graduate School of Medical and Health Science, Nippon Sport Science University, 1221-1, Kamoshida-cho, Aoba-ku, Yokohama, Kanagawa, 227-0033, Japan
| | - Shoji Yokobori
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
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10
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Shi ZH, Jonkman AH, Tuinman PR, Chen GQ, Xu M, Yang YL, Heunks LMA, Zhou JX. Role of a successful spontaneous breathing trial in ventilator liberation in brain-injured patients. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:548. [PMID: 33987246 PMCID: PMC8105847 DOI: 10.21037/atm-20-6407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 12/18/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND Spontaneous breathing trials (SBTs) have been shown to improve outcomes in critically ill patients. However, in patients with brain injury, indications for intubation and mechanical ventilation are different from those of non-neurological patients, and the role of an SBT in patients with brain injury is less established. The aim of the present study was to compare key respiratory variables acquired during a successful SBT between patients with successful ventilator liberation versus failed ventilator liberation. METHODS In this prospective study, patients with brain injury (≥18 years of age), who completed a 30-min SBT, were enrolled. Airway pressure, flow, esophageal pressure, and diaphragm electrical activity (ΔEAdi) were recorded before (baseline) and during the SBT. Respiratory rate (RR), tidal volume, inspiratory muscle pressure (ΔPmus), ΔEAdi, and neuromechanical efficiency (ΔPmus/ΔEAdi) of the diaphragm were calculated breath by breath and compared between the liberation success and failure groups. Failed liberation was defined as the need for invasive ventilator assistance within 48 h after the SBT. RESULTS In total, 46 patients (51.9±13.2 years, 67.4% male) completed the SBT. Seventeen (37%) patients failed ventilator liberation within 48 h. Another 11 patients required invasive ventilation within 7 days after completing the SBT. There were no differences in baseline characteristics between the success and failed groups. In-depth analysis showed similar changes in patterns and values of respiratory physiological parameters between the groups. CONCLUSIONS In patients with brain injury, ventilator liberation failure was common after successful SBT. In-depth physiological analysis during the SBT did not provide data to predict successful liberation in these patients. TRIAL REGISTRATION The trial was registered at ClinicalTrials.gov (No. NCT02863237).
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Affiliation(s)
- Zhong-Hua Shi
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Intensive Care, Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
- Research VUmc Intensive Care (REVIVE), Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
| | - Annemijn H. Jonkman
- Department of Intensive Care, Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
- Research VUmc Intensive Care (REVIVE), Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
| | - Pieter Roel Tuinman
- Department of Intensive Care, Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
- Research VUmc Intensive Care (REVIVE), Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
| | - Guang-Qiang Chen
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ming Xu
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yan-Lin Yang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Leo M. A. Heunks
- Department of Intensive Care, Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
- Research VUmc Intensive Care (REVIVE), Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
| | - Jian-Xin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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11
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Garg R. Lung Protective Ventilation in Brain-Injured Patients: Low Tidal Volumes or Airway Pressure Release Ventilation? JOURNAL OF NEUROANAESTHESIOLOGY AND CRITICAL CARE 2020. [DOI: 10.1055/s-0040-1716800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
AbstractThe optimal mode of mechanical ventilation for lung protection is unknown in brain-injured patients as this population is excluded from large studies of lung protective mechanical ventilation. Survey results suggest that low tidal volume (LTV) ventilation is the favored mode likely due to the success of LTV in other patient populations. Airway pressure release ventilation (APRV) is an alternative mode of mechanical ventilation that may offer several benefits over LTV in this patient population. APRV is an inverse-ratio, pressure-controlled mode of mechanical ventilation that utilizes a higher mean airway pressure compared with LTV. This narrative review compares both modes of mechanical ventilation and their consequences in brain-injured patients. Fears that APRV may raise intracranial pressure by virtue of a higher mean airway pressure are not substantiated by the available evidence. Primarily by virtue of spontaneous breathing, APRV often results in improvement in systemic hemodynamics and thereby improvement in cerebral perfusion pressure. Compared with LTV, sedation requirements are lessened by APRV allowing for more accurate neuromonitoring. APRV also uses an open loop system supporting clearance of secretions throughout the respiratory cycle. Additionally, APRV avoids hypercapnic acidosis and oxygen toxicity that may be especially deleterious to the injured brain. Although high-level evidence is lacking that one mode of mechanical ventilation is superior to another in brain-injured patients, several aspects of APRV make it an appealing mode for select brain-injured patients.
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Affiliation(s)
- Ravi Garg
- Division of Neurocritical Care, Department of Neurology, Loyola University Medical Center, Maywood, Illinois, United States
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Naseh M, Dehghanian A, Keshtgar S, Ketabchi F. Lung injury in brain ischemia/reperfusion is exacerbated by mechanical ventilation with moderate tidal volume in rats. Am J Physiol Regul Integr Comp Physiol 2020; 319:R133-R141. [PMID: 32459970 DOI: 10.1152/ajpregu.00367.2019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Ischemic stroke is one of the most frequent causes of injury in the central nervous system which may lead to multiorgan dysfunction, including in the lung. The aim of this study was to investigate whether brain ischemia/reperfusion with or without mechanical ventilation leads to lung injury. Male Sprague-Dawley rats were assigned to four groups: Sham, 1-h brain ischemia (MCAO)/24-h reperfusion (I/R), mechanical ventilation with moderate tidal volume (MTV), and I/R+MTV. The pulmonary capillary permeability (Kfc) was measured in the isolated perfused lung. Mean arterial blood pressure (MAP), heart rate (HR), blood-gas variables, histopathological parameters, lung glutathione peroxidase, and TNF-α were measured. Kfc in the I/R, MTV, and I/R+MTV groups were higher than that in the Sham group. In the I/R, MTV, and I/R+MTV groups, arterial partial pressures of oxygen and the arterial partial pressure of oxygen/fraction of inspired oxygen ratios were lower, whereas arterial partial pressures of carbon dioxide were higher than those in the Sham group. The histopathological score in the I/R group was more than that in the Sham group, and in the MTV and I/R+MTV groups were higher than those in the Sham and I/R groups. Furthermore, there were stepwise rises in TNF-α in the I/R, MTV, and I/R+MTV groups, respectively. There was no significant difference in MAP between groups. However, HR in the MTV group was higher than that in the Sham group. Brain ischemia/reperfusion leads to pulmonary capillary endothelial damage and the impairment of gas exchange in the alveolar-capillary barrier, which is exacerbated by mechanical ventilation with moderate tidal volume partially linked to inflammatory reactions.
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Affiliation(s)
- Maryam Naseh
- Department of Physiology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Amirreza Dehghanian
- Department of Pathology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sara Keshtgar
- Department of Physiology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Farzaneh Ketabchi
- Department of Physiology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
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Cammarota G, Verdina F, Lauro G, Boniolo E, Tarquini R, Messina A, De Vita N, Sguazzoti I, Perucca R, Corte FD, Vignazia GL, Grossi F, Crudo S, Navalesi P, Santangelo E, Vaschetto R. Neurally adjusted ventilatory assist preserves cerebral blood flow velocity in patients recovering from acute brain injury. J Clin Monit Comput 2020; 35:627-636. [PMID: 32388653 PMCID: PMC7223974 DOI: 10.1007/s10877-020-00523-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 05/05/2020] [Indexed: 12/24/2022]
Abstract
Neurally adjusted ventilatory assist (NAVA) has never been applied in patients recovering from acute brain injury (ABI) because neural respiratory drive could be affected by intracranial disease with detrimental effects on cerebral blood flow (CBF) velocity. Our primary aim was to assess the impact of NAVA and pressure support ventilation (PSV) on CBF velocity. In fifteen adult patients recovering from ABI and undergoing invasive assisted ventilation, PSV and NAVA were applied over 30-min-lasting trials, in the following sequence: PSV1, NAVA, and PSV2. While PSV was set to deliver a tidal volume ranging between 6 and 8 ml kg−1 of predicted body weight, in NAVA the level of assistance was chosen to achieve the same inspiratory peak airway pressure as PSV. At the end of each trial, a sonographic evaluation of CBF mean velocity was bilaterally obtained on the middle cerebral artery and an arterial blood gas sample was taken for analysis. CBF mean velocity was 51.8 [41.9,75.2] cm s−1 at baseline, 51.9 [43.4,71.0] cm s−1 in PSV1, 53.6 [40.7,67.7] cm s−1 in NAVA, and 49.5 [42.1,70.8] cm s−1 in PSV2 (p = 0.0514) on the left and 50.2 [38.0,77.7] cm s−1 at baseline, 47.8 [41.7,68.2] cm s−1 in PSV1, 53.9 [40.1,78.5] cm s−1 in NAVA, and 55.6 [35.9,74.1] cm s−1 in PSV2 (p = 0.8240) on the right side. No differences were detected for pH (p = 0.0551), arterial carbon dioxide tension (p = 0.8142), and oxygenation (p = 0.0928) over the entire study duration. NAVA and PSV preserved CBF velocity in patients recovering from ABI. Trial registration: The present trial was prospectively registered at www.clinicatrials.gov (NCT03721354) on October 18th, 2018.
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Affiliation(s)
- Gianmaria Cammarota
- Department of Anesthesiology and Intensive Care, Azienda Ospedaliero-Universitaria "Maggiore Della Carità", Corso Mazzini18, 28100, Novara, Italy.
| | - Federico Verdina
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Gianluigi Lauro
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Ester Boniolo
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Riccardo Tarquini
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Antonio Messina
- Humanitas Clinical and Research Center - IRCCS, Rozzano, MI, Italy
| | - Nello De Vita
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Ilaria Sguazzoti
- Department of Anesthesiology and Intensive Care, Azienda Ospedaliero-Universitaria "Maggiore Della Carità", Corso Mazzini18, 28100, Novara, Italy
| | - Raffaella Perucca
- Department of Anesthesiology and Intensive Care, Azienda Ospedaliero-Universitaria "Maggiore Della Carità", Corso Mazzini18, 28100, Novara, Italy
| | - Francesco Della Corte
- Department of Anesthesiology and Intensive Care, Azienda Ospedaliero-Universitaria "Maggiore Della Carità", Corso Mazzini18, 28100, Novara, Italy.,Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Gian Luca Vignazia
- Department of Anesthesiology and Intensive Care, Azienda Ospedaliero-Universitaria "Maggiore Della Carità", Corso Mazzini18, 28100, Novara, Italy
| | - Francesca Grossi
- Department of Anesthesiology and Intensive Care, Azienda Ospedaliero-Universitaria "Maggiore Della Carità", Corso Mazzini18, 28100, Novara, Italy
| | - Samuele Crudo
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Paolo Navalesi
- Department of Medicine, University of Padua, Padua, Italy
| | - Erminio Santangelo
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Rosanna Vaschetto
- Department of Anesthesiology and Intensive Care, Azienda Ospedaliero-Universitaria "Maggiore Della Carità", Corso Mazzini18, 28100, Novara, Italy.,Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
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Racca F, Vianello A, Mongini T, Ruggeri P, Versaci A, Vita GL, Vita G. Practical approach to respiratory emergencies in neurological diseases. Neurol Sci 2019; 41:497-508. [PMID: 31792719 PMCID: PMC7224095 DOI: 10.1007/s10072-019-04163-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 11/15/2019] [Indexed: 02/06/2023]
Abstract
Many neurological diseases may cause acute respiratory failure (ARF) due to involvement of bulbar respiratory center, spinal cord, motoneurons, peripheral nerves, neuromuscular junction, or skeletal muscles. In this context, respiratory emergencies are often a challenge at home, in a neurology ward, or even in an intensive care unit, influencing morbidity and mortality. More commonly, patients develop primarily ventilatory impairment causing hypercapnia. Moreover, inadequate bulbar and expiratory muscle function may cause retained secretions, frequently complicated by pneumonia, atelectasis, and, ultimately, hypoxemic ARF. On the basis of the clinical onset, two main categories of ARF can be identified: (i) acute exacerbation of chronic respiratory failure, which is common in slowly progressive neurological diseases, such as movement disorders and most neuromuscular diseases, and (ii) sudden-onset respiratory failure which may develop in rapidly progressive neurological disorders including stroke, convulsive status epilepticus, traumatic brain injury, spinal cord injury, phrenic neuropathy, myasthenia gravis, and Guillain-Barré syndrome. A tailored assistance may include manual and mechanical cough assistance, noninvasive ventilation, endotracheal intubation, invasive mechanical ventilation, or tracheotomy. This review provides practical recommendations for prevention, recognition, management, and treatment of respiratory emergencies in neurological diseases, mostly in teenagers and adults, according to type and severity of baseline disease.
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Affiliation(s)
- Fabrizio Racca
- Department of Anaesthesia and Intensive Care, Sant'Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Andrea Vianello
- Respiratory Pathophysiology Division, University of Padua, Padua, Italy
| | - Tiziana Mongini
- Neuromuscular Center, Department of Neurosciences, University of Turin, Turin, Italy
| | - Paolo Ruggeri
- Unit of Pneumology, Department BIOMORF, University of Messina, Messina, Italy
| | - Antonio Versaci
- Intensive Care Unit, AOU Policlinico "G. Martino", Messina, Italy
| | - Gian Luca Vita
- Nemo Sud Clinical Centre for Neuromuscular Disorders, Messina, Italy
| | - Giuseppe Vita
- Nemo Sud Clinical Centre for Neuromuscular Disorders, Messina, Italy. .,Unit of Neurology and Neuromuscular Diseases, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy.
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Sakurai A. Sedation and Analgesia for Patients with Acute Brain Injury. Neurocrit Care 2019. [DOI: 10.1007/978-981-13-7272-8_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]
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Respiration: A New Mechanism for CSF Circulation? J Neurosci 2018; 37:7076-7078. [PMID: 28747391 DOI: 10.1523/jneurosci.1155-17.2017] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 06/09/2017] [Accepted: 06/16/2017] [Indexed: 11/21/2022] Open
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Chen H, Zhou J, Lin YQ, Zhou JX, Yu RG. Intracranial pressure responsiveness to positive end-expiratory pressure in different respiratory mechanics: a preliminary experimental study in pigs. BMC Neurol 2018; 18:183. [PMID: 30396336 PMCID: PMC6217765 DOI: 10.1186/s12883-018-1191-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Accepted: 10/28/2018] [Indexed: 12/13/2022] Open
Abstract
Background Respiratory mechanics affects the effect of positive end-expiratory pressure (PEEP) on intracranial pressure (ICP). Respiratory mechanics of the lung and the chest wall was not differentiated in previous studies. In the present study, we investigated the influence of the following possible determinants of ICP responsiveness to PEEP: chest wall elastance (ECW), lung elastance (EL), and baseline ICP. Methods Eight healthy Bama miniature pigs were studied. The increase of EL was induced by instillation of hydrochloride, and the increase of ECW was induced by strapping the animals’ chest wall and abdomen. A balloon-tipped catheter was placed intracranially for inducing intracranial hypertension. Six experimental conditions were investigated in sequence: 1) Normal; 2) Stiff Chest Wall; 3) Lung Injury; 4) Lung Injury + Stiff Chest Wall; 5) Lung Injury + Stiff Chest Wall + Intracranial Hypertension and 6) Lung Injury + Intracranial Hypertension. PEEP was gradually increased in a 5 cm H2O interval from 5 to 25 cm H2O in each condition. Blood pressure, central venous pressure, ICP, airway pressure and esophageal pressure were measured. Results Hydrochloride instillation significantly increased EL in conditions with lung injury. ECW significantly increased in the conditions with chest wall and abdomen strapping (all p < 0.05). ICP significantly increased with increments of PEEP in all non-intracranial hypertension conditions (p < 0.001). The greatest cumulative increase in ICP was observed in the Stiff Chest Wall condition (6 [5.3, 6.8] mm Hg), while the lowest cumulative increase in ICP was observed in the Lung Injury condition (2 [1.3, 3.8] mm Hg). ICP significantly decreased when PEEP was increased in the intracranial hypertension conditions (p < 0.001). There was no significant difference in cumulative ICP change between the two intracranial hypertension conditions (p = 0.924). Conclusions Different respiratory mechanics models can be established via hydrochloride induced lung injury and chest wall and abdominal strapping. The effect of PEEP on ICP is determined by respiratory mechanics in pigs with normal ICP. However, the responsiveness of ICP to PEEP is independent of respiratory mechanics when there is intracranial hypertension.
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Affiliation(s)
- Han Chen
- Surgical Intensive Care Unit, Fujian Provincial Clinical College, Fujian Medical University, No 134, Dongjie Street, Gulou District, Fuzhou, 350001, Fujian, China.
| | - Jing Zhou
- Surgical Intensive Care Unit, Fujian Provincial Clinical College, Fujian Medical University, No 134, Dongjie Street, Gulou District, Fuzhou, 350001, Fujian, China
| | - Yi-Qin Lin
- Surgical Intensive Care Unit, Fujian Provincial Clinical College, Fujian Medical University, No 134, Dongjie Street, Gulou District, Fuzhou, 350001, Fujian, China
| | - Jian-Xin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Rong-Guo Yu
- Surgical Intensive Care Unit, Fujian Provincial Clinical College, Fujian Medical University, No 134, Dongjie Street, Gulou District, Fuzhou, 350001, Fujian, China
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Airway Management Strategies for Brain-injured Patients Meeting Standard Criteria to Consider Extubation. A Prospective Cohort Study. Ann Am Thorac Soc 2017; 14:85-93. [PMID: 27870576 DOI: 10.1513/annalsats.201608-620oc] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Patients with acute brain injury are frequently capable of breathing spontaneously with minimal ventilatory support despite persistent neurological impairment. OBJECTIVES We sought to describe factors associated with extubation timing, success, and primary tracheostomy in these patients. METHODS We conducted a prospective multicenter observational cohort study in three academic hospitals in Toronto, Canada. Consecutive brain-injured adults receiving mechanical ventilation for at least 24 hours in three intensive care units were screened by study personnel daily for extubation consideration criteria. We monitored all patients until hospital discharge and used logistic regression models to examine associations with extubation failure and delayed extubation. MEASUREMENTS AND MAIN RESULTS Of 192 patients included, 152 (79%) were extubated and 40 (21%) received a tracheostomy without an extubation attempt. The rate of extubation failure within 72 hours was 32 of 152 (21%), which did not vary significantly between those extubated before (early; 6 of 37; 16.2%), within 24 hours (timely; 14 of 70; 20.0%), or more than 24 hours after meeting criteria to consider extubation (delayed; 12 of 45; 26.7%; P = 0.49). Delayed extubation was associated with lower a Glasgow Coma Scale (GCS) score at the time of consideration of extubation, absence of cough, and new positive sputum cultures. Factors independently associated with successful extubation were presence of cough (odds ratio [OR], 3.60; 95% confidence interval [CI], 1.42-9.09), fluid balance in prior 24 hours (OR, 0.75 per 1-L increase; 95% CI, 0.57-0.98), and age (OR, 0.97 per 10-yr increase; 95% CI, 0.95-0.99). A higher GCS score was not associated with successful extubation. CONCLUSIONS Extubation success was predicted by younger age, presence of cough, and negative fluid balance, rather than GCS score at extubation. These results do not support prolonging intubation solely for low GCS score in brain-injured patients.
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Della Torre V, Badenes R, Corradi F, Racca F, Lavinio A, Matta B, Bilotta F, Robba C. Acute respiratory distress syndrome in traumatic brain injury: how do we manage it? J Thorac Dis 2017; 9:5368-5381. [PMID: 29312748 PMCID: PMC5756968 DOI: 10.21037/jtd.2017.11.03] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 10/31/2017] [Indexed: 12/24/2022]
Abstract
Traumatic brain injury (TBI) is an important cause of morbidity and mortality worldwide. TBI patients frequently suffer from lung complications and acute respiratory distress syndrome (ARDS), which is associated with poor clinical outcomes. Moreover, the association between TBI and ARDS in trauma patients is well recognized. Mechanical ventilation of patients with a concomitance of acute brain injury and lung injury can present significant challenges. Frequently, guidelines recommending management strategies for patients with traumatic brain injuries come into conflict with what is now considered best ventilator practice. In this review, we will explore the strategies of the best practice in the ventilatory management of patients with ARDS and TBI, concentrating on those areas in which a conflict exists. We will discuss the use of ventilator strategies such as protective ventilation, high positive end expiratory pressure (PEEP), prone position, recruitment maneuvers (RMs), as well as techniques which at present are used for 'rescue' in ARDS (including extracorporeal membrane oxygenation) in patients with TBI. Furthermore, general principles of fluid, haemodynamic and hemoglobin management will be discussed. Currently, there are inadequate data addressing the safety or efficacy of ventilator strategies used in ARDS in adult patients with TBI. At present, choice of ventilator rescue strategies is best decided on a case-by-case basis in conjunction with local expertise.
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Affiliation(s)
- Valentina Della Torre
- Neurocritical Care Unit, Addenbrooke’s Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Rafael Badenes
- Department of Anesthesiology and Surgical Trauma Intensive Care, Hospital Clinic Universitari Valencia, University of Valencia, Valencia, Spain
| | | | - Fabrizio Racca
- Department of Anesthesiology and Intensive Care Unit, SS Antonio Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Andrea Lavinio
- Neurocritical Care Unit, Addenbrooke’s Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Basil Matta
- Neurocritical Care Unit, Addenbrooke’s Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Federico Bilotta
- Department of Anaesthesia and Intensive Care, La Sapienza University, Rome, Italy
| | - Chiara Robba
- Neurocritical Care Unit, Addenbrooke’s Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
- Department of Neuroscience, University of Genova, Italy
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Chen H, Xu M, Yang YL, Chen K, Xu JQ, Zhang YR, Yu RG, Zhou JX. Effects of increased positive end-expiratory pressure on intracranial pressure in acute respiratory distress syndrome: a protocol of a prospective physiological study. BMJ Open 2016; 6:e012477. [PMID: 27852713 PMCID: PMC5128838 DOI: 10.1136/bmjopen-2016-012477] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION There are concerns that the use of positive end-expiratory pressure (PEEP) in patients with brain injury may potentially elevate intracranial pressure (ICP). However, the transmission of PEEP into the thoracic cavity depends on the properties of the lungs and the chest wall. When chest wall elastance is high, PEEP can significantly increase pleural pressure. In the present study, we investigate the different effects of PEEP on the pleural pressure and ICP in different respiratory mechanics. METHODS AND ANALYSIS This study is a prospective, single-centre, physiological study in patients with severe brain injury. Patients with acute respiratory distress syndrome with ventricular drainage will be enrolled. An oesophageal balloon catheter will be inserted to measure oesophageal pressure. Patients will be sedated and paralysed; airway pressure and oesophageal pressure will be measured during end-inspiratory occlusion and end-expiratory occlusion. Elastance of the chest wall, the lungs and the respiratory system will be calculated at PEEP levels of 5, 10 and 15 cm H2O. We will classify each patient based on the maximal ΔICP/ΔPEEP being above or below the median for the study population. 2 groups will thus be compared. ETHICS AND DISSEMINATION The study protocol and consent forms were approved by the Institutional Review Board of Fujian Provincial Hospital. Study findings will be disseminated through peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER NCT02670733; pre-results.
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Affiliation(s)
- Han Chen
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Surgical Intensive Care Unit, Fujian Provincial Clinical College Hospital, Fujian Medical University, Fuzhou, China
| | - Ming Xu
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yan-Lin Yang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Intensive Care Unit, Beijing Electric Power Hospital, Capital Medical University, Beijing, China
| | - Kai Chen
- Surgical Intensive Care Unit, Fujian Provincial Clinical College Hospital, Fujian Medical University, Fuzhou, China
| | - Jing-Qing Xu
- Surgical Intensive Care Unit, Fujian Provincial Clinical College Hospital, Fujian Medical University, Fuzhou, China
| | - Ying-Rui Zhang
- Surgical Intensive Care Unit, Fujian Provincial Clinical College Hospital, Fujian Medical University, Fuzhou, China
| | - Rong-Guo Yu
- Surgical Intensive Care Unit, Fujian Provincial Clinical College Hospital, Fujian Medical University, Fuzhou, China
| | - Jian-Xin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Spadaro S, Grasso S, Mauri T, Dalla Corte F, Alvisi V, Ragazzi R, Cricca V, Biondi G, Di Mussi R, Marangoni E, Volta CA. Can diaphragmatic ultrasonography performed during the T-tube trial predict weaning failure? The role of diaphragmatic rapid shallow breathing index. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:305. [PMID: 27677861 PMCID: PMC5039882 DOI: 10.1186/s13054-016-1479-y] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 09/06/2016] [Indexed: 01/09/2023]
Abstract
Background The rapid shallow breathing index (RSBI), which is the ratio between respiratory rate (RR) and tidal volume (VT), is one of the most widely used indices to predict weaning outcome. Whereas the diaphragm plays a fundamental role in generating VT, in the case of diaphragmatic dysfunction the inspiratory accessory muscles may contribute. If this occurs during a weaning trial, delayed weaning failure is likely since the accessory muscles are more fatigable than the diaphragm. Hence, we hypothesised that the traditional RSBI could be implemented by substituting VT with the ultrasonographic evaluation of diaphragmatic displacement (DD). We named the new index the diaphragmatic-RSBI (D-RSBI). The aim of this study was to compare the ability of the traditional RSBI and D-RSBI to predict weaning failure in ready-to-wean patients. Methods We performed a prospective observational study. During a T-tube spontaneous breathing trial (SBT) we simultaneously evaluated right hemidiaphragm displacement (i.e., DD) by using M-mode ultrasonography as well as the RSBI. Outcome of the weaning attempt, length of mechanical ventilation, length of intensive care unit and hospital stay, and hospital mortality were recorded. Receiver operator characteristic (ROC) curves were used to evaluate the diagnostic accuracy of D-RSBI and RSBI. Results We enrolled 51 patients requiring mechanical ventilation for more than 48 h who were ready to perform a SBT. Most of the patients, 34 (66 %), were successfully weaned from mechanical ventilation. When considering the 17 patients that failed the weaning attempt, 11 (64 %) had to be reconnected to the ventilator during the SBT, three (18 %) had to be re-intubated within 48 h of extubation, and three (18 %) required non-invasive ventilation support within 48 h of extubation. The areas under the ROC curves for D-RSBI and RSBI were 0.89 and 0.72, respectively (P = 0.006). Conclusions D-RSBI (RR/DD) was more accurate than traditional RSBI (RR/VT) in predicting the weaning outcome. Trial registration Our clinical trial was retrospectively registered with ClinicalTrials.gov (identifier: NCT02696018). ClinicalTrials.gov processed our record on 25 February 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1479-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Savino Spadaro
- Department of Morphology, Surgery and Experimental Medicine, Intensive Care Unit University of Ferrara, Sant'Anna Hospital, Via Aldo Moro, 8, 44121, Ferrara, Italy.
| | - Salvatore Grasso
- Department of Emergency and Organ Transplant (DETO), "Aldo Moro" University of Bari, Bari, Italy
| | - Tommaso Mauri
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Grande Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesca Dalla Corte
- Department of Morphology, Surgery and Experimental Medicine, Intensive Care Unit University of Ferrara, Sant'Anna Hospital, Via Aldo Moro, 8, 44121, Ferrara, Italy
| | - Valentina Alvisi
- Department of Morphology, Surgery and Experimental Medicine, Intensive Care Unit University of Ferrara, Sant'Anna Hospital, Via Aldo Moro, 8, 44121, Ferrara, Italy
| | - Riccardo Ragazzi
- Department of Morphology, Surgery and Experimental Medicine, Intensive Care Unit University of Ferrara, Sant'Anna Hospital, Via Aldo Moro, 8, 44121, Ferrara, Italy
| | - Valentina Cricca
- Department of Morphology, Surgery and Experimental Medicine, Intensive Care Unit University of Ferrara, Sant'Anna Hospital, Via Aldo Moro, 8, 44121, Ferrara, Italy
| | - Giulia Biondi
- Department of Morphology, Surgery and Experimental Medicine, Intensive Care Unit University of Ferrara, Sant'Anna Hospital, Via Aldo Moro, 8, 44121, Ferrara, Italy
| | - Rossella Di Mussi
- Department of Emergency and Organ Transplant (DETO), "Aldo Moro" University of Bari, Bari, Italy
| | - Elisabetta Marangoni
- Department of Morphology, Surgery and Experimental Medicine, Intensive Care Unit University of Ferrara, Sant'Anna Hospital, Via Aldo Moro, 8, 44121, Ferrara, Italy
| | - Carlo Alberto Volta
- Department of Morphology, Surgery and Experimental Medicine, Intensive Care Unit University of Ferrara, Sant'Anna Hospital, Via Aldo Moro, 8, 44121, Ferrara, Italy
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Borsellino B, Schultz MJ, Gama de Abreu M, Robba C, Bilotta F. Mechanical ventilation in neurocritical care patients: a systematic literature review. Expert Rev Respir Med 2016; 10:1123-32. [DOI: 10.1080/17476348.2017.1235976] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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23
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Gradisek P, Dolenc S. Isoflurane rescue therapy for bronchospasm reduces intracranial pressure in a patient with traumatic brain injury. Brain Inj 2016; 30:1035-40. [PMID: 27120554 DOI: 10.3109/02699052.2016.1147598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PRIMARY OBJECTIVE To assess the unusual use of a volatile anaesthetic for treatment of life-threatening bronchospasm in a patient with traumatic brain injury (TBI). RESEARCH DESIGN Case report. METHODS AND PROCEDURES This study presents a previously healthy 30-year-old man with severe TBI and bronchospasm-induced acute hypercapnia. He was treated with inhaled isoflurane in combination with monitoring of intracranial pressure (ICP) and regional cerebral blood flow (rCBF). RESULTS Three-day-long isoflurane treatment resolved drug-refractory bronchospasm, decreased airway pressure and improved gas exchange, even at a low end-tidal concentration (0.3-0.5 vol%). Although rCBF was increased by 18 ml min(-1) 100 g(-1) during isoflurane treatment, there was a significant decrease in ICP (21 (SD = 3) mmHg, 9 (SD = 5) mmHg, 2 (SD = 3) mmHg; during pre-treatment, treatment and post-treatment, respectively; p < 0.001). Improved autoregulation due to lower partial pressure of carbon dioxide, restoration of carbon dioxide reactivity, isoflurane-induced regional differences in rCBF and improved microcirculation may have been responsible for the prompt and long-lasting normalization of ICP. The patient had no TBI-related disability at 6 months post-injury. CONCLUSIONS Isoflurane at a low dose can be an effective and safe treatment option for drug-refractory bronchospasm in a patient with traumatic intracranial hypertension, provided that multimodality neuromonitoring is used.
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Affiliation(s)
- Primoz Gradisek
- a Clinical Department of Anaesthesiology and Intensive Therapy , Centre for Intensive Therapy, University Medical Centre Ljubljana , Ljubljana , Slovenia
| | - Simon Dolenc
- a Clinical Department of Anaesthesiology and Intensive Therapy , Centre for Intensive Therapy, University Medical Centre Ljubljana , Ljubljana , Slovenia
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Abstract
Patients with refractory intracranial hypertension often require short-term mechanical ventilation because they cannot protect their airway. Airway pressure release ventilation (APRV) is less commonly used than other modes because it is thought to increase intracranial pressure. However, this case study describes how APRV improved alveolar recruitment and functional residual capacity in a patient with refractory intracranial hypertension secondary to severe traumatic brain injury.
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Esquenazi Y, Lo VP, Lee K. Critical Care Management of Cerebral Edema in Brain Tumors. J Intensive Care Med 2015; 32:15-24. [PMID: 26647408 DOI: 10.1177/0885066615619618] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 10/05/2015] [Accepted: 11/06/2015] [Indexed: 12/21/2022]
Abstract
Cerebral edema associated with brain tumors is extremely common and can occur in both primary and metastatic tumors. The edema surrounding brain tumors results from leakage of plasma across the vessel wall into the parenchyma secondary to disruption of the blood-brain barrier. The clinical signs of brain tumor edema depend on the location of the tumor as well as the extent of the edema, which often exceeds the mass effect induced by the tumor itself. Uncontrolled cerebral edema may result in increased intracranial pressure and acute herniation syndromes that can result in permanent neurological dysfunction and potentially fatal herniation. Treatment strategies for elevated intracranial pressure consist of general measures, medical interventions, and surgery. Alhough the definitive treatment for the edema may ultimately be surgical resection of the tumor, the impact of the critical care management cannot be underestimated and thus patients must be vigilantly monitored in the intensive care unit. In this review, we discuss the pathology, pathophysiology, and clinical features of patients presenting with cerebral edema. Imaging findings and treatment modalities used in the intensive care unit are also discussed.
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Affiliation(s)
- Yoshua Esquenazi
- Vivian L. Smith Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Victor P Lo
- Vivian L. Smith Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Kiwon Lee
- Vivian L. Smith Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, TX, USA
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Ngubane T. Mechanical ventilation and the injured brain. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2014. [DOI: 10.1080/22201173.2011.10872737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- T Ngubane
- Department of Anaesthesiology, Neurosurgical Intensive Care Unit, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand
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Marik PE, Young A, Sibole S, Levitov A. The effect of APRV ventilation on ICP and cerebral hemodynamics. Neurocrit Care 2013; 17:219-23. [PMID: 22829002 DOI: 10.1007/s12028-012-9739-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Airway pressure release ventilation (APRV) is an alternative approach to the low-tidal volume "open-lung" ventilation strategy. APRV is associated with a higher mean airway pressure than conventional ventilation and has therefore not been evaluated in patients with acute neurological injuries. METHODS Case report. RESULTS We report a patient with severe progressive hypoxemia following a subarachnoid hemorrhage who was converted from pressure-controlled mechanical ventilation to APRV. This change in ventilatory mode was associated with a significant improvement in oxygenation and alveolar ventilation with an associated increase in cerebral blood flow and a negligible increase in intracranial pressure. CONCLUSION APRV may safely be applied to neurocritically ill patients, and that this mode of ventilation may increase cerebral blood flow without increasing intracranial pressure.
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Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Department of Respiratory Services, Eastern Virginia Medical School, 825 Fairfax Ave, Suite 410, Norfolk, VA 23507, USA.
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Assouad J, Masmoudi H, Gonzalez-Bermejo J, Morelot-Panzini C, Diop M, Grunenwald D, Similowski T. Diaphragm pacing after bilateral implantation of intradiaphragmatic phrenic stimulation electrodes through a transmediastinal endoscopic minimally invasive approach: pilot animal data. Eur J Cardiothorac Surg 2012; 42:333-9. [DOI: 10.1093/ejcts/ezr324] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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29
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Abstract
OBJECTIVE Acute intracranial hemorrhage and intraventricular hemorrhage are devastating disorders. The goal of this review is to familiarize clinicians with recent information pertaining to the acute care of intracranial hemorrhage and intraventricular hemorrhage. DATA SOURCES PubMed search and review of the relevant medical literature. SUMMARY The management of intracranial hemorrhage and intraventricular hemorrhage is complex. Effective treatment should include strategies designed to reduce hematoma expansion and limit the medical consequences of intracranial hemorrhage and intraventricular hemorrhage. At present, there are a number of new approaches to treatment that may reduce mortality and improve clinical outcomes. Clinicians should recognize that patients with large hematomas may make a substantial recovery. CONCLUSIONS Patients with intracranial hemorrhage and intraventricular hemorrhage should be cared for in an intensive care unit. New therapies designed to stabilize hematoma growth and reduce hematoma burden may improve outcomes.
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Affiliation(s)
- Paul Nyquist
- Neurology/Anesthesiology Critical Care Medicine/ Neurosurgery, Johns Hopkins School of Medicine, Baltimore Maryland, USA.
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