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Tominey S, Baweja K, Woodfield J, Chambers TJG, Poon MTC, Wiggins AN, Brennan PM, Loan JJM. Investigation and management of serum sodium after subarachnoid haemorrhage (SaSH): a survey of practice in the United Kingdom and Republic of Ireland. Br J Neurosurg 2022; 36:192-195. [PMID: 33470851 DOI: 10.1080/02688697.2020.1859460] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 11/21/2020] [Accepted: 11/30/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Hyponatraemia is a common complication of aneurysmal subarachnoid haemorrhage (SAH). We aimed to determine current neurosurgical practice for the identification, investigation and management of hyponatraemia after SAH. METHODS An online questionnaire was completed by UK and Irish neurosurgical trainees and consultant collaborators in the Sodium after Subarachnoid Haemorrhage (SaSH) audit. RESULTS Between August 2019 and June 2020, 43 responses were received from 31 of 32 UK and Ireland adult neurosurgical units (NSUs). All units reported routine measurement of serum sodium either daily or every other day. Most NSUs reported routine investigation of hyponatraemia after SAH with paired serum and urinary osmolalities (94%), urinary sodium (84%), daily fluid balance (84%), but few measured glucose (19%), morning cortisol (13%), or performed a short Synacthen test (3%). Management of hyponatraemia was variable, with units reporting use of oral sodium supplementation (77%), fluid restriction (58%), hypertonic saline (55%), and fludrocortisone (19%). CONCLUSIONS Reported assessment of serum sodium after SAH was consistent between units, whereas management of hyponatraemia varied. This may reflect the lack of a specific evidence-base to inform practice.
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Affiliation(s)
- Steven Tominey
- Department of General Medicine, Queen Elizabeth University Hospital, Glasgow, UK
| | - Kirun Baweja
- Department of Surgery, Glasgow Royal Infirmary, Glasgow, UK
| | - Julie Woodfield
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Department of Clinical Neurosciences, NHS Lothian, Edinburgh, UK
| | - Thomas J G Chambers
- Centre for Discovery Brain Sciences, University of Edinburgh, Edinburgh, UK
- Edinburgh Centre for Diabetes and Endocrinology, NHS Lothian, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Michael T C Poon
- Department of Clinical Neurosciences, NHS Lothian, Edinburgh, UK
- Usher Institute, University of Edinburgh, Edinburgh, Edinburgh, UK
| | | | - Paul M Brennan
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Department of Clinical Neurosciences, NHS Lothian, Edinburgh, UK
| | - James J M Loan
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Department of Clinical Neurosciences, NHS Lothian, Edinburgh, UK
- Centre for Discovery Brain Sciences, University of Edinburgh, Edinburgh, UK
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Al-Mufti F, Mayer SA, Kaur G, Bassily D, Li B, Holstein ML, Ani J, Matluck NE, Kamal H, Nuoman R, Bowers CA, S Ali F, Al-Shammari H, El-Ghanem M, Gandhi C, Amuluru K. Neurocritical care management of poor-grade subarachnoid hemorrhage: Unjustified nihilism to reasonable optimism. Neuroradiol J 2021; 34:542-551. [PMID: 34476991 PMCID: PMC8649190 DOI: 10.1177/19714009211024633] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND AND PURPOSE Historically, overall outcomes for patients with high-grade subarachnoid hemorrhage (SAH) have been poor. Generally, between physicians, either reluctance to treat, or selectivity in treating such patients has been the paradigm. Recent studies have shown that early and aggressive care leads to significant improvement in survival rates and favorable outcomes of grade V SAH patients. With advancements in both neurocritical care and end-of-life care, non-treatment or selective treatment of grade V SAH patients is rarely justified. Current paradigm shifts towards early and aggressive care in such cases may lead to improved outcomes for many more patients. MATERIALS AND METHODS We performed a detailed review of the current literature regarding neurointensive management strategies in high-grade SAH, discussing multiple aspects. We discussed the neurointensive care management protocols for grade V SAH patients. RESULTS Acutely, intracranial pressure control is of utmost importance with external ventricular drain placement, sedation, optimization of cerebral perfusion pressure, osmotherapy and hyperventilation, as well as cardiopulmonary support through management of hypotension and hypertension. CONCLUSIONS Advancements of care in SAH patients make it unethical to deny treatment to poor Hunt and Hess grade patients. Early and aggressive treatment results in a significant improvement in survival rate and favorable outcome in such patients.
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Affiliation(s)
- Fawaz Al-Mufti
- Department of Neurology, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
- Department of Neurosurgery, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Stephan A Mayer
- Department of Neurosurgery, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Gurmeen Kaur
- Department of Neurology, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
- Department of Neurosurgery, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Daniel Bassily
- School of Medicine, New York Medical College, New York Medical College, Valhalla, USA
| | - Boyi Li
- School of Medicine, New York Medical College, New York Medical College, Valhalla, USA
| | - Matthew L Holstein
- School of Medicine, New York Medical College, New York Medical College, Valhalla, USA
| | - Jood Ani
- School of Medicine, New York Medical College, New York Medical College, Valhalla, USA
| | - Nicole E Matluck
- School of Medicine, New York Medical College, New York Medical College, Valhalla, USA
| | - Haris Kamal
- Department of Neurosurgery, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Rolla Nuoman
- Department of Neurology, Westchester Medical Center, Maria Fareri Children’s Hospital, Westchester Medical Center, Valhalla, USA
| | | | - Faizan S Ali
- Department of Neurology, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Hussein Al-Shammari
- Department of Neurology, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Mohammad El-Ghanem
- Department of Neurology, Neurosurgery and Medical Imaging, University of Arizona, Tucson, USA
| | - Chirag Gandhi
- Department of Neurosurgery, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Krishna Amuluru
- Goodman Campbell Brain and Spine, Ascension St. Vincent Medical Center, Indianapolis, USA
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Garijo C, Chabert F, Armonia C, Boucheix P. [Specificities of nursing care in neurological intensive care]. Rev Infirm 2018; 67:40-43. [PMID: 29331194 DOI: 10.1016/j.revinf.2017.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In the acute phase of the treatment of patients with brain injuries, the management of secondary brain injuries of systemic origin is a priority. A neurosurgical intensive care paramedical team shares their experience of the care delivered and the constant monitoring carried out to optimise, with the medical team, the patient's outcome and to innovate practices.
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Affiliation(s)
- Christelle Garijo
- Unité de réanimation neurochirurgicale, Centre hospitalier universitaire Grenoble Alpes, CS 10217, 38043 Grenoble cedex 9, France
| | - Flavien Chabert
- Unité de réanimation neurochirurgicale, Centre hospitalier universitaire Grenoble Alpes, CS 10217, 38043 Grenoble cedex 9, France
| | - Cécile Armonia
- Unité de réanimation neurochirurgicale, Centre hospitalier universitaire Grenoble Alpes, CS 10217, 38043 Grenoble cedex 9, France.
| | - Perrine Boucheix
- Unité de réanimation neurochirurgicale, Centre hospitalier universitaire Grenoble Alpes, CS 10217, 38043 Grenoble cedex 9, France
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Johnsen B, Nøhr KB, Duez CHV, Ebbesen MQ. The Nature of EEG Reactivity to Light, Sound, and Pain Stimulation in Neurosurgical Comatose Patients Evaluated by a Quantitative Method. Clin EEG Neurosci 2017; 48:428-437. [PMID: 28844160 DOI: 10.1177/1550059417726475] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
EEG reactivity (EEG-R) is regarded as an important parameter in coma prognosis but knowledge is sparse on the nature of EEG changes due to different kinds of stimulation and their prognostic significance. EEG-R was quantified in a study of 39 comatose neurosurgical patients. Six 30-second standardized visual, auditory, and painful stimulations were applied. EEG-R in the delta, theta, alpha, and beta band was normalized in z-scores as the power of a stimulation epoch relative to average power of 6 resting epochs. Outcome measure was 3 months Glasgow Outcome Scale. Increase in EEG activity was related to poor outcome, was more common (13.4% of tests), and grew continuously during the 30-second stimulation epoch. Decrease in EEG activity was related to good outcome, was rarer (2.5%), and peaked around 15 seconds. Pain was the most provocative stimulation (20.4%) followed by sound (8.7%) and eye-opening (6.7%). Discrimination between good (n = 6) and poor (n = 33) outcome was best in the theta and alpha bands for pain stimulation in the first 10-20 seconds and for sound stimulation in the first 5 to 10 seconds, eye-opening did not discriminate. Increase in activity predicted poor outcome with a high specificity 100% (CI = 52%-100%) and a modest sensitivity of 39% (CI = 23%-58%). Decrease in activity predicted good outcome with a high specificity of 100% (CI = 87%-100%) and a modest sensitivity of 33% (CI = 6%-76%). This quantitative study reveals new knowledge about the nature of EEG-R, which contribute to the development of more reliable and objective clinical procedures for outcome prediction.
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Affiliation(s)
- Birger Johnsen
- 1 Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark
| | - Kristoffer B Nøhr
- 1 Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark
| | - Christophe H V Duez
- 1 Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark.,2 Research Centre for Emergency Medicine, Aarhus University, Aarhus, Denmark
| | - Mads Q Ebbesen
- 1 Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark
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Abstract
The optimal timing of tracheostomy in patients with traumatic brain injury (TBI) remains unclear. The purpose of this study was to examine the effects of tracheostomy performed within 72 h after admission. In this retrospective cohort study, the authors reviewed the data for a series of 120 consecutive patients who underwent tracheostomy after suffering TBI with an Abbreviated Injury Scale (AIS) score of ≥4. The exclusion criteria were as follows: age <18 years, severe chest injury with an AIS score of ≥4, and a requirement for intubation because of upper airway obstruction. Patients who underwent tracheostomy ≤72 h and >72 h after admission were classified into early group and control groups, respectively. The duration of mechanical ventilation, length of stay (LOS) in intensive care unit (ICU), incidence of pneumonia, adverse event rate, unnecessary tracheostomy and outcomes were compared between the two groups. Of the 120 patients, 29 were excluded from the study, 40 were classified into the early group, and 51 were classified into the control group. The duration of mechanical ventilation and LOS in ICU were significantly less in the early group than in the control group. The 30-day mortality rates were 3% and 8% for the early and control groups, respectively. There was no significant difference in the adverse event rate, incidence of pneumonia, unnecessary tracheostomy rate and the rate of favorable outcome between groups. The results of this study suggest that the performance of tracheostomy within 72 h of admission may decrease the duration of mechanical ventilation and LOS in ICU, with acceptable mortality and morbidity rates.
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Affiliation(s)
- Keita Shibahashi
- a Department of Emergency and Intensive Care Center , Tokyo Metropolitan Bokutoh Hospital , Sumida-ku , Tokyo , Japan
| | - Kazuhiro Sugiyama
- a Department of Emergency and Intensive Care Center , Tokyo Metropolitan Bokutoh Hospital , Sumida-ku , Tokyo , Japan
| | - Hidenori Houda
- a Department of Emergency and Intensive Care Center , Tokyo Metropolitan Bokutoh Hospital , Sumida-ku , Tokyo , Japan
| | - Yuichi Takasu
- a Department of Emergency and Intensive Care Center , Tokyo Metropolitan Bokutoh Hospital , Sumida-ku , Tokyo , Japan
| | - Yuichi Hamabe
- a Department of Emergency and Intensive Care Center , Tokyo Metropolitan Bokutoh Hospital , Sumida-ku , Tokyo , Japan
| | - Akio Morita
- b Department of Neurological Surgery , Nippon Medical School , Bunkyou-ku , Tokyo , Japan
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Carter EL, Hutchinson PJA, Kolias AG, Menon DK. Predicting the outcome for individual patients with traumatic brain injury: a case-based review. Br J Neurosurg 2016; 30:227-32. [PMID: 26853860 DOI: 10.3109/02688697.2016.1139048] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Traumatic brain injuries result in significant morbidity and mortality. Accurate prediction of prognosis is desirable to inform treatment decisions and counsel family members. Objective To review the currently available prognostic tools for use in traumatic brain injury (TBI), to analyse their value in individual patient management and to appraise ongoing research on prognostic modelling. METHODS AND RESULTS We present two patients who sustained a TBI in 2011-2012 and evaluate whether prognostic models could accurately predict their outcome. The methodology and validity of current prognostic models are analysed and current research that might contribute to improved individual patient prognostication is evaluated. CONCLUSION Predicting prognosis in the acute phase after TBI is complex and existing prognostic models are not suitable for use at the individual patient level. Data derived from these models should only be used as an adjunct to clinical judgement and should not be used to set limits for acute care interventions. Information from neuroimaging, physiological monitoring and analysis of biomarkers or genetic polymorphisms may be used in the future to improve accuracy of individual patient prognostication. Clinicians should consider offering full supportive treatment to patients in the early phase after injury whilst the outcome is unclear.
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Affiliation(s)
- Eleanor L Carter
- a Division of Anaesthesia and Intensive Care Medicine, Department of Medicine , Addenbrooke's Hospital & University of Cambridge , Cambridge , UK ;,b Department of Anaesthesia , National Hospital for Neurology and Neurosurgery , London , UK
| | - Peter J A Hutchinson
- c Division of Neurosurgery, Department of Clinical Neurosciences , Addenbrooke's Hospital & University of Cambridge , Cambridge , UK
| | - Angelos G Kolias
- c Division of Neurosurgery, Department of Clinical Neurosciences , Addenbrooke's Hospital & University of Cambridge , Cambridge , UK
| | - David K Menon
- a Division of Anaesthesia and Intensive Care Medicine, Department of Medicine , Addenbrooke's Hospital & University of Cambridge , Cambridge , UK
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Tasker RC, Fleming TJ, Young AE, Morris KP, Parslow RC. Severe head injury in children: intensive care unit activity and mortality in England and Wales. Br J Neurosurg 2011; 25:68-77. [PMID: 21083365 PMCID: PMC3038595 DOI: 10.3109/02688697.2010.538770] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2010] [Accepted: 11/04/2010] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To explore the relationship between volume of paediatric intensive care unit (PICU) head injury (HI) admissions, specialist paediatric neurosurgical PICU practice, and mortality in England and Wales. METHODS Analysis of HI cases (age <16 years) from the Paediatric Intensive Care Audit Network national cohort of sequential PICU admissions in 27 units in England and Wales, in the 5 years 2004-2008. Risk-adjusted mortality using the Paediatric Index of Mortality (PIM) model was compared between PICUs aggregated into quartile groups, first to fourth based on descending number of HI admissions/year: highest volume, medium-higher volume, medium-lower volume, and lowest volume. The effect of category of PICU interventions - observation only, mechanical ventilation (MV) only, and intracranial pressure (ICP) monitoring - on outcome was also examined. Observations were reported in relation to specialist paediatric neurosurgical PICU practice. RESULTS There were 2575 admissions following acute HI (4.4% of non-cardiac surgery PICU admissions in England and Wales). PICU mortality was 9.3%. Units in the fourth-quartile (lowest volume) group did not have significant specialist paediatric neurosurgical activity on the PICU; the other groups did. Overall, there was no effect of HI admissions by individual PICU on risk-adjusted mortality. However, there were significant effects for both intensive care intervention category (p<0.001) and HI admissions by grouping (p<0.005). Funnel plots and control charts using the PIM model showed a hierarchy in increasing performance from lowest volume (group IV), to medium-higher volume (group II), to highest volume (group I), to medium-lower volume (group III) sectors of the health care system. CONCLUSIONS The health care system in England and Wales for critically ill HI children requiring PICU admission performs as expected in relation to the PIM model. However, the lowest-volume sector, comprising 14 PICUs with little or no paediatric neurosurgical activity on the unit, exhibits worse than expected outcome, particularly in those undergoing ICP monitoring. The best outcomes are seen in units in the mid-volume sector. These data do not support the hypothesis that there is a simple relationship between PICU volume and performance.
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Affiliation(s)
- Robert C Tasker
- Department of Paediatrics, Cambridge University Clinical School, Addenbrooke's Hospital, Cambridge, UK.
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Abstract
OBJECTIVE To analyse the process of end of life decisions in a neurosurgical environment. METHODS All 113 neurosurgical patients, who were subject to so called end of life decisions within a one year period were prospectively enrolled in a computerised data bank. Decision pathways according to patient and physician related parameters were assessed. RESULTS Leading primary diagnoses of the patients were traumatic brain injury and intracranial haemorrhage. Forty-five patients had undergone an emergency neurosurgical operation prior to end of life decision, N = 69 were conservatively treated, which included intracranial pressure recording, or they were not offered neurosurgical care because of futile prognosis. N = 111 died after a median of two (zero to nine) days. Two, in whom the end of life decisions were revised, survived. Clear decisions to terminate further treatment were made by a senior staff member on call being informed by the senior resident on call (27.4%), difficult decisions on the basis of extensive round discussions (71.7%), and very difficult decision by an interdisciplinary ethical consult (0.9%). Decisions were further substantiated by electrophysiological examinations in N = 59. CONCLUSION End of life decisions are to be considered standard situations for neurosurgeons. These decisions may reach a high rate of "positive" prediction, if substantiated by electrophysiological examinations as well as on the grounds of clinical experience and respect for the assumed will of the patient. The fact that patients may survive following revision of an end of life decision underlines the necessity for repeated reassessment of these decisions. Ethical training for neurosurgeons is to be encouraged.
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Affiliation(s)
- C Schaller
- Department of Neurosurgery, University of Bonn Medical Center, Sigmund-Freud-Str 25, 53127 Bonn, Germany.
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