Neurocritical care
-
Neuromuscular disorders increasingly are recognized as a complication in patients in the intensive care unit (ICU) and represent a common cause of prolonged ventilator dependency. The distinct syndromes of critical illness myopathy, prolonged neuromuscular blockade, and critical illness polyneuropathy (CIP) may arise as a consequence of sepsis, multi-organ failure, and exposure to various medications--notably, intravenous corticosteroids and neuromuscular blocking agents--but the pathophysiology of these disorders remains poorly understood. More than one syndrome may occur simultaneously, and the distinctions may be difficult in a particular patient, but a specific diagnosis usually can be established after careful clinical, electrodiagnostic, and, when necessary, histological evaluation. ⋯ Repetitive nerve stimulation shows a decrement of the compound muscle action potential and, in most cases, establishes a disorder of neuromuscular transmission. With the recent epidemic of West Nile virus infection, a clinical syndrome of acute flaccid paralysis with several features indistinguishable from poliomyelitis has emerged. This article critically examines the clinical, electrophysiological, and pathological features of these and other acute neuromuscular syndromes that arise in the context of ICU care and summarizes the current understanding of the pathophysiology and treatment of these disorders.
-
The noise produced by oscillatory movements of secretions in the oropharynx, hypopharynx, and trachea during inspiration and expiration in unconscious terminal patients is often described as "the death rattle." The secretions are produced by the salivary glands and bronchial mucosa. These patients are usually too weak to expectorate or swallow the migrating secretions. Sputum usually only accumulates in these areas if there is a significant impairment of the cough reflex, as in deep coma or near death. ⋯ Death rattle was most commonly reported in patients dying from pulmonary malignancies, primary brain tumors, or brain metastases, and predicts death within 48 hours in 75% of the patients. After withdrawal of artificial ventilation from the intensive care unit, excessive respiratory secretion resulting in a rattling breathing during the last hours of life is not uncommon, especially not in pulmonary and neurological patients. The distressing experience and negative influence in the bereavement process indicates an ethical demand to treat this symptom from the perspective of others merely than that of the patient.
-
Tuberculous meningitis (TBM) remains a common serious neurological emergency especially in the developing world. Elevated intracranial pressure (ICP) is often a feature of severe TBM and is associated with high morbidity and mortality. The pathology associated with TBM, such as cerebral edema, hydrocephalus, tuberculoma(s), and infarcts related to arthritis, contribute to increase in intracranial volume and, therefore, elevated ICP. ⋯ Use of steroids reduces not only cerebral edema but also the production of cytokines and other chemicals involved in the immunopathogenesis of TBM. Fever associated with TBM should be aggressively treated, because fever can worsen the impact of elevated ICP. Hyponatremia may complicate TBM and requires appropriate correction because it can aggravate cerebral edema.
-
Review Case Reports
Medical futility: definition, determination, and disputes in critical care.
Physicians may employ the concept of medical futility to justify a decision not to pursue certain treatments that may be requested or demanded by patients or surrogates. Medical futility means that the proposed therapy should not be performed because available data show that it will not improve the patient's medical condition. Medical futility remains ethically controversial for several reasons. ⋯ Medical futility has been conceptualized as a power struggle for decisional authority between physicians and patients/surrogates. Medical futility disputes are best avoided by strategies that optimize communication between physicians and surrogates; encourage physicians to provide families with accurate, current, and frequent prognostic estimates; assure that physicians address the emotional needs of the family and try to understand the problem from the family's perspective; and facilitate excellent palliative care through the course of the illness. Critical care physicians should support the drafting of state laws embracing futility considerations and should assist hospital policymakers in drafting hospital futility policies that both provide a fair process to settle disputes and embrace an ethic of care.
-
Numerous systems are reported for grading the clinical condition of patients following subarachnoid hemorrhage (SAH). The literature was reviewed for articles pertaining to the grading of such patients, including publications on the Hunt and Hess Scale, Fisher Scale, Glasgow Coma Score (GCS), and World Federation of Neurological Surgeons Scale. This article reviews the advantages and limitations of these scales as well as more recent proposals for other grading systems based on these scales with or without addition of other factors known to be prognostic for outcome after SAH. ⋯ Most grading scales were derived retrospectively, and the intra- and interobserver variability has seldom been assessed. Inclusion of additional factors increases the complexity of the scale, possibly making it less likely to be adopted for routine usage and increasing (only marginally in some cases) the ability to predict prognosis. Until further data are available, it is recommended that publications on patients with SAH report at least the admission GCS as well as factors commonly known to influence prognosis, such as age, pre-existing hypertension, the amount of blood present on admission computed tomography, time of admission after SAH, aneurysm location and size, presence of intracerebral or intraventricular hemorrhage, and blood pressure at admission.