Neurocritical care
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Review Meta Analysis
Locally-administered intrathecal thrombolytics following aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis.
The volume and clearance rate of blood in the basal cisterns and ventricles are important predictors of complications following aneurysmal subarachnoid hemorrhage (SAH). Thus, there is a strong rationale for interventions aimed at accelerating the clearance of blood. ⋯ Current data suggests that intrathecal thrombolytics improve outcomes following SAH. However, there are important limitations to existing RCTs, with considerable risk of bias. Further standardization of techniques and evaluation in larger, more rigorous RCTs is required.
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Brain tissue oxygen (PbtO(2)) monitoring is used in severe traumatic brain injury (TBI) patients. How brain reduced PbtO(2) should be treated and its response to treatment is not clearly defined. We examined which medical therapies restore normal PbtO(2) in TBI patients. ⋯ Reduced PbtO(2) may occur in TBI patients despite efforts to maintain CPP. Medical interventions other than those to treat ICP and CPP can improve PbtO(2). This may increase the number of therapies for severe TBI in the ICU.
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Delirium is defined by a fluctuating level of attentiveness and has been associated with increased ICU mortality and poor cognitive outcomes in both general ICU and neurocritical care populations. Sedation use in the ICU can contribute to delirium. Limiting ICU sedation allows for the diagnosis of underlying acute neurological insults associated with delirium and leads to shorter mechanical ventilation time, shorter length of stay, and improved 1 year mortality rates. Identifying the underlying etiology of delirium is critical to developing treatment paradigms.
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Strict glycemic control (SGC) is reported to have a beneficial effect on critical illness polyneuropathy/myopathy (CINM) and the duration of mechanical ventilation. The methodology used to diagnose CINM differs substantially in studies on this topic. This may influence the reported treatment effect. ⋯ SGC seems to have a beneficial effect on CINM, but the reported risk reduction is likely to be an overestimation of the treatment effect due to the diagnostic methods used. Duration of mechanical ventilation may not be a reliable surrogate marker for CINM and a beneficial effect of SGC on this parameter has not been proven. We propose to use the recently developed diagnostic criteria for ICU-acquired weakness and critical illness neuromyopathy in future studies.
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There is limited information on the incidence and effect of acute kidney injury (AKI) in patients with severe traumatic brain injury (TBI), although AKI may affect outcome. Recently, acute kidney injury network (AKIN) classification has been widely accepted as a consensus definition for AKI. The aim of this study is to estimate the frequency and level of severity of AKI in patients with severe TBI by using AKIN criteria and to study whether AKI affects outcome. ⋯ It is demonstrated using the newly defined AKIN criteria for renal dysfunction that AKI is a relatively common feature in patients with severe TBI, and even seemingly insignificant decrease in renal function may be associated with worse outcome. This study highlights the importance of close surveillance of renal function and stresses the value of renal hygiene in the severe TBI population.