Neurocritical care
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Comparative Study
The effect of increased inspired fraction of oxygen on brain tissue oxygen tension in children with severe traumatic brain injury.
This study examines the effect of an increase in the inspired fraction of oxygen (FiO2) on brain tissue oxygen (PbO2) in children with severe traumatic brain injury (TBI). ⋯ Normobaric hyperoxia increases PbO2 in children with severe TBI, but the response is variable. The magnitude of this response is related to the change in PaO2 and the baseline PbO2. A greater response appears to be associated with worse outcome.
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Case Reports
Coma from worsening spontaneous intracranial hypotension after subdural hematoma evacuation.
Low cerebrospinal fluid volume is typically diagnosed in patients presenting with positional headaches. However, severe intracranial hypotension and brain sagging may cause orthostatic coma. We present a case that illustrates this uncommon presentation. ⋯ Evacuation of subdural fluid collections may be detrimental in patients with low CSF volume by exacerbating the intracranial hypotension. Extreme brain sagging may lead to anatomical distortion of the diencephalon and brainstem resulting in coma.
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To examine if the metabolic distress after traumatic brain injury (TBI) is associated with a unique proteome. ⋯ Metabolic distress after TBI is associated with a differential proteome that indicates cellular destruction during the acute phase of illness. This suggests that metabolic distress has immediate cellular consequences after TBI.
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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.