Neurocritical care
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The presence of pulmonary dysfunction after brain injury is well recognized. Acute lung injury (ALI) occurs in 20% of patients with isolated brain injury and is associated with a poor outcome. The "blast injury" theory, which proposes combined "hydrostatic" and "high permeability" mechanisms for the formation of neurogenic pulmonary edema, has been challenged recently by the observation that a systemic inflammatory response may play an integral role in the development of pulmonary dysfunction associated with brain injury. ⋯ Moreover, in patients with brain injury, hypoxemia represents a secondary insult associated with a poor outcome. Optimal oxygenation may be achieved by using an adequate FiO2 and by application of positive end-expiratory pressure (PEEP). PEEP may, however, affect the cerebral circulation by hemodynamic and CO2-mediated mechanisms and the effects of PEEP on cerebral hemodynamics should be monitored in these patients and used to titrate its application.
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Clinical Trial
Early EEG monitoring for detecting postanoxic status epilepticus during therapeutic hypothermia: a pilot study.
To determine whether routine electroencephalography (EEG) detected electrical status epilepticus (ESE), masked by neuromuscular blockade, in comatose cardiac-arrest survivors receiving therapeutic hypothermia. ⋯ These preliminary results indicate that postanoxic status epilepticus can be masked by neuromuscular blockade during our protocol of therapeutic hypothermia. Routine EEG monitoring might be helpful in cardiac-arrest survivors receiving therapeutic hypothermia. Further studies including continuous EEG monitoring are needed to determine whether early diagnosis and treatment of ESE during therapeutic hypothermia improves the outcome.
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The aim of our study is to confirm the reliability of optic nerve ultrasound as a method to detect intracranial hypertension in patients with spontaneous intracranial hemorrhage, to assess the reproducibility of the measurement of the optic nerve sheath diameter (ONSD), and to verify that ONSD changes concurrently with intracranial pressure (ICP) variations. ⋯ Our investigation confirms the reliability of optic nerve ultrasound as a non-invasive method to detect elevated ICP in intracranial hemorrhage patients. ONSD measurements proved to have a good reproducibility. ONSD changes almost concurrently with CSF pressure variations.
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Median nerve short-latency somatosensory evoked potentials (SSEPs) are useful in determining prognosis for awakening after coma following hypoxic ischemic encephalopathy, but reliability of interpretation is unclear. ⋯ Inter- and intra-observer reliability of SSEP interpretation in comatose patients varies from moderate to substantial, respectively. In order to reliably interpret the presence of small cortical responses, NMJ blockade should be used when baseline noise is excessive.
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Massive air embolism has been described in multiple clinical scenarios, especially in critical ill patients who undergo invasive procedures. Nevertheless, air embolism is often unrecognized and a high index of suspicion is required to diagnose this entity. Two previous cases of air embolism in lung transplant patients have been described in the literature; we describe a third case of fatal massive air embolism and cardiovascular collapse in a lung transplant patient. ⋯ This case underscores the potential severe consequences of air embolism and its systemic manifestations. A high index of suspicion for cerebral air embolism is warranted in lung transplant patients who present with neurological symptoms.