Neurocritical care
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Cerebral arterial vasospasm and delayed ischemic neurological deficits are significant contributors to morbidity and mortality following aneurysmal subarachnoid hemorrhage. Additional treatment modalities are needed. Intraventricular nicardipine has been suggested as a potential therapy for the treatment of cerebral vasospasm. It is an appealing option for multiple reasons: many of these patients already have ventricular drains in place, it can be safely administered at the bedside, and can be used in patients for whom conventional therapies are either not effective or not tolerated. ⋯ Intraventricular nicardipine was associated with a significant and sustained reduction in mean cerebral blood flow velocity as measured by transcranial Doppler when used in the treatment of suspected cerebral vasospasm following aneurysmal subarachnoid hemorrhage. We do not find significant safety concerns related to elevations of intracranial pressure or ventricular catheter related infections. Further prospective studies are warranted to better determine the efficacy and safety of this therapy.
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Intracerebral hemorrhage (ICH) is associated with the highest mortality of all strokes. Admission to a Neurosciences Critical Care Unit (NCCU) compared to a general ICU has been associated with reduced mortality following ICH. Such association has led to several hospitals transferring ICH patients to Neuro-ICUs in tertiary care centers. However, delays in optimizing ICH management prior to and during transfer can lead to deleterious consequences. To compare functional outcomes in ICH patients admitted to our NCCU directly from the ED versus inter-hospital transfer admissions. ⋯ Patients with ICH brought directly to our ED had significantly better outcomes than IHT; we hypothesize this may be caused by delays in optimizing management prior to arrival at the facility with a dedicated Neuro-ICU. Nevertheless, other equally plausible hypotheses need to be prospectively tested.
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Critical care management of patients with severe acute brain injury has undergone tremendous advances. Neurosurgeons and neurointensivists have a large armamentarium of invasive monitoring devices available to help detect secondary brain injury and guide therapy. No consensus exists regarding patient specific selection of monitoring devices, the placement of devices in relation to injured brain tissue, or the preferred insertion technique. Here we review our experience in a consecutive series of acutely brain injured patients who underwent multimodality monitoring. ⋯ Collaboration among institutions is necessary to establish practice guidelines for the choice and placement of multimodal monitors. Further advancement in device technology is needed to improve insertion techniques, inter-device compatibility, and device durability. Multimodality data needs to be analyzed to determine the preferable device location.
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Ventilator-associated pneumonia (VAP) is the most common nosocomial infection among medical intensive care unit (ICU) patients and is associated with increased mortality and length of stay (LOS). Neurologic disease is a risk factor for VAP development, but the relationship between VAP and outcomes in patients admitted to the ICU for neurologic reasons remains largely unknown. ⋯ VAP in neurocritical care patients is associated with increased LOS and ventilator hours, but is not associated with increased mortality, contrary to prior studies in medical ICU patients.