Management of raised intracranial pressure in children

Hemorrhagic stroke: Uncommon complication of diabetic ketoacidosis in pediatric patients

Diabetic ketoacidosis (DKA) is a well-known complication of type 1 diabetes mellitus. Diabetic ketoacidosis predisposes patients into devastating neurological complications. The most common neurologic complication is cerebral edema. Stroke either ischemic or hemorrhagic are uncommon complications of DKA with worse patient's outcome. Hemorrhagic stroke can manifest as subarachnoid or intraparenchymal hemorrhage. We present a 14-year-girl presented with DKA and complicated with both subarachnoid and intraparenchymal hemorrhages. Owing to early diagnosis and prompt treatment the patient had good outcome.

Effects of hemodilution after traumatic brain injury in juvenile rats

BACKGROUND

Normovolemic hemodilution (HD) in adult animal studies has shown exacerbation of traumatic brain injury (TBI) lesion volumes. Similar studies in juvenile rats have not been reported and outcomes are likely to be different. This study investigated the effects of normovolemic hemodilution (21% hematocrit) in a juvenile TBI (jTBI) model.

METHODS

Twenty 17-day-old rats underwent moderate cortical contusion impact injury (CCI) and were divided into four groups: CCI/hemodilution (HD) (group HD), CCI/no HD (group C), Sham/HD (group SHD), and Sham/no HD (group S). Regional laser Doppler flowmetry (LDF), edema formation (MRI-T2WI), water mobility assessed using diffusion weighted imaging (MRI-DWI), open field activity tests, and histological analyses were evaluated for lesion characteristics.

RESULTS

Hemodilution significantly increased blood flow in the HD compared to the C group after TBI. T2WI revealed a significantly increased extravascular blood volume in HD at 1, 7, and 14 days post-CCI. Edematous tissue and total contusional lesion volume were higher in HD-treated animals at 1 and 14 days. DWI revealed that HD, SHD, and C groups had elevated water mobility compared to S groups in the ipsilateral cortex and striatum. Histology showed a larger cortical lesion in the C than HD group. Open field activity was increased in HD, C, and SHD groups compared to the S group.

CONCLUSIONS

Hemodilution results in significant brain hyperemia with increased edema formation, extravascular blood volume, and water mobility after jTBI. Hemodilution results in less cortical damage but did not alter behavior. Hemodilution is likely not to be clinically beneficial following jTBI.

Neonatal liver failure: aetiologies and management--state of the art

Acute liver failure in neonates is rare, but carries a high mortality. Neonatal liver failure can be defined as "failure of the synthetic function of liver within 4 weeks of birth". Encephalopathy is not essential for the diagnosis. Acute liver failure in neonates differs from children with regard to aetiology and outcome. Common causes of neonatal liver failure are neonatal hemochromatosis, haematological malignancies, viral infections and liver-based metabolic defects. Early diagnosis and referral to a paediatric liver centre is recommended as liver transplantation is the only definitive treatment when supportive or a disease-specific treatment fails.

Brain temperature: heat production, elimination and clinical relevance

Neurological insults are a leading cause of morbidity and mortality, both in adults and especially in children. Among possible therapeutic strategies to limit clinical cerebral damage and improve outcomes, hypothermia remains a promising and beneficial approach. However, its advantages are still debated after decades of use. Studies in adults have generated conflicting results, whereas in children recent data even suggest that hypothermia may be detrimental. Is it because brain temperature physiology is not well understood and/or not applied properly, that hypothermia fails to convince clinicians of its potential benefits? Or is it because hypothermia is not, as believed, the optimal strategy to improve outcome in patients affected with an acute neurological insult? This review article should help to explain the fundamental physiological principles of brain heat production, distribution and elimination under normal conditions and discuss why hypothermia cannot yet be recommended routinely in the management of children affected with various neurological insults.

Subjective assessment of backrest elevation: magnitude of error

BACKGROUND

Backrest elevation, defined as the angle of the backrest height above the horizontal position, is a common nursing intervention that is often used by subjective visual estimation in critically ill patients.

OBJECTIVES

The aim of the study was to describe the magnitude of error during the subjective assessment of backrest elevation.

METHODS

This prospective study was conducted in a sample of 160 subjects: 97 registered nurses, 48 undergraduate nursing students, and 15 nursing assistants. Data were collected by recording the degrees of backrest elevation identified by the subjects through an individual random presentation of the selected study angles of 20 degrees, 30 degrees, 35 degrees, 40 degrees, and 45 degrees. A measurement instrument was developed for determination of the angles.

RESULTS

Of the 800 investigated angles, 14.9% were estimated accurately, 61.6% were overestimated, and 23.5% were underestimated, with an error average of 8 degrees (+/-13.5 degrees). It was determined that the larger the angle estimated, the greater the average error. A statically significant difference (P <or= .001) was found between the actual degree of backrest elevation and the estimated backrest elevation for 20 degrees, 40 degrees, and 45 degrees with the exception of 30 degrees and 35 degrees, which had similar averages of error. Years of critical care experience did not significantly influence the magnitude of error.

CONCLUSION

The results indicate that the subjective assessment of backrest angle may result in errors that may potentially compromise the patient's condition and supports the need for a more objective method for determining backrest angle.

Nursing care of the acute head injury: a review of the evidence

This article aims to review the current evidence in relation to acute head injury care. Head injuries are a frequent cause of death and disability in western society with the first 72 h being an important period for prevention of further brain damage. The underlying physiology behind head injury and intracranial pressure will be discussed. The monitoring of intracranial pressure and implications for practice will be addressed. The specialized nursing care and drug therapy management that is necessary for acute head injury patients will be highlighted. Recommendations for practice will be given.

Does oxygen deficit to the cerebral blood flow caused by subdural hematoma and/or increased intracranial pressure affect the variations in auditory evoked potentials in white New Zealand rabbits?

The experiment entails surgically placing two subarachnoid bolts and a subdural balloon through the skull of white New Zealand rabbits. One bolt is used to raise the intracranial pressure (ICP) by continuously infusing lactated Ringer's solution (LRS) into the subarachnoid space to maintain the desired level of ICPs, and the second bolt is to monitor the ICP. A subdural balloon is inflated with a known volume of LRS to simulate a subdural hematoma condition. Using various levels of ICP and/or different sizes of balloons, auditory evoked potentials (AEPs) were recorded from a rabbit. The results indicate that a major correlation of changes in AEP peak latencies is due to mechanical forces of a mass (inflated balloon simulating a hematoma) on the brain matter rather than increased ICP. The AEP peak latencies are relatively insensitive to an increase in ICP without the simulated intracranial hematoma. This study provides evidence that oxygen deficit to the cerebral blood flow caused by deformation of certain parts of the brain could be identified using AEPs.