Neurocritical care
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Alcoholic hand rubs (AHRs) have been proven effective in preventing nosocomial infections, and healthcare authorities include AHRs use among quality-of-care criteria. Since the onset of the influenza A (H1N1) pandemic, AHRs have gained considerable popularity among the general public. ⋯ Whereas overdrinking in social settings (wine and liquor) leads to a gradual increase in blood alcohol levels, AHRs poisoning is usually characterized by a sudden massive alcohol load. The unusual nature of the alcohol source may lead to diagnostic wanderings. AHRs are currently available in bottles that facilitate the ingestion of large amounts. Unit-dose packaging or dispensing might decrease the risk of AHRs poisoning.
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In a recent publication (Wijdicks et al. in Neurology 71(16):1240, 2008), apnea test safety during brain death determination was evaluated at a single tertiary care center. One major conclusion was that apnea testing was safe in hemodynamically compromised patients in most circumstances and rarely aborted. Determinants of apnea test completion failure are unknown. ⋯ Acute lung injury is common in patients undergoing brain death evaluation. Patients that failed completion of apnea testing tended to be younger, had significantly greater A-a gradients, and were more acidotic.
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Dexmedetomidine is a highly selective alpha(2)-adrenoreceptor agonist that produces dose-dependent sedation, anxiolysis, and analgesia without respiratory depression. Dexmedetomidine has been used in critically ill medical, surgical, and pediatric patients, as an adjunct to sedation and/or for treating drug or alcohol withdrawal. Information regarding the dosing and utilization of dexmedetomidine has been derived primarily from studies in critically ill patients in the medical intensive care unit. There has been no study designed specifically to evaluate dexmedetomidine for these therapeutic uses in the neurocritical care population. The primary and secondary objectives were to evaluate the starting dose of dexmedetomidine for neurocritical care patients and to assess the effect on hemodynamic parameters, respectively. ⋯ Neurocritically ill patients may require high doses of dexmedetomidine to achieve desired levels of sedation. The high rates and long duration of dexmedetomidine infusion had a statistically, but not clinically, significant impact on hemodynamic parameters.
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Brain energy metabolic crisis (MC) and lactate-pyruvate ratio (LPR) elevations have been linked to poor outcome in comatose patients. We sought to determine if MC and LPR elevations after subarachnoid hemorrhage (SAH) are associated with acute reductions in serum glucose. ⋯ Acute reductions in serum glucose, even to levels within the normal range, may be associated with brain energy metabolic crisis and LPR elevation in poor-grade SAH patients.
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Continuous EEG monitoring (cEEG) of critically ill patients is frequently utilized to detect non-convulsive seizures (NCS) and status epilepticus (NCSE). The indications for cEEG, as well as when and how to treat NCS, remain unclear. We aimed to describe the current practice of cEEG in critically ill patients to define areas of uncertainty that could aid in designing future research. ⋯ Continuous EEG monitoring (cEEG) is commonly employed in critically ill patients to detect NCS and NCSE. However, there is substantial variability in current practice related to cEEG indications and duration and to management of NCS and NCSE. The fact that such variability exists in the management of this common clinical problem suggests that further prospective study is needed. Multiple points of uncertainty are identified that require investigation.