Neurocritical care
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The occurrence of hypovolemia in the setting of cerebral vasospasm reportedly increases the risk for delayed ischemic neurologic deficits. Few studies have objectively assessed blood volume (BV) in response to fluid administration targeting normovolemia (NV) or hypervolemia (HV) and none have done so with crystalloids alone. The primary purpose was to evaluate the BV of patients with SAH receiving crystalloid fluid administration targeting NV or HV. ⋯ Routinely targeting prophylactic HV using crystalloids does not result in a higher circulating BV compared to targeting NV, but the possibility of clinically unrecognized hypovolemia remains.
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Reintubation among neurosurgical patients is poorly characterized. The aim of this study was to delineate the rate of reintubation among neurosurgical patients. In addition, we seek to characterize the patient demographic features, comorbidities, and surgical characteristics that may be associated with reintubation among neurosurgical patients. ⋯ Reintubation after neurosurgery is associated with older patients with a greater number of comorbidities. In particular, renal, pulmonary, and severe neurologic comorbidities; longer operative duration; and cranial, rather than spinal, pathology were associated with increased risk for reintubation. These findings may be helpful in triage decisions regarding postoperative intensity of care and monitoring.
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Until recently, use of nimodipine in aneurysmal subarachnoid hemorrhage patients unable to swallow required extraction of gel from inside the commercially available capsule. Despite the Black-Box warning against inadvertent intravenous administration, bedside extraction of the gel from the capsule continues to be a common practice in some institutions. The accuracy of bedside extraction has not been formally evaluated. ⋯ Combined with reports of significant patient harm and death with inadvertent intravenous administration, this study suggests that there is no role for bedside extraction of nimodipine in clinical practice.
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The presence of coagulopathy is common after severe trauma. The aim of this study was to identify whether isolated severe traumatic brain injury (TBI) is an independent risk factor for coagulopathy. ⋯ Isolated severe TBI is not an independent risk factor for the development of coagulopathy. However, severe TBI patients who develop coagulopathy have extremely high mortality rates.
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Sedation and analgesia regimens during targeted temperature management (TTM), after cardiac arrest varies widely, are poorly described in the literature and may have a negative impact on outcome. Since implementing TTM in 2005, we have used moderate-dose sedation and describe our experience with this approach. ⋯ A moderate-dose sedation and analgesia regimen was well tolerated and effective during therapeutic hypothermia after cardiac arrest and is an effective alternative to very deep sedation. We recommend more complete description of sedation and analgesia protocols in future studies, including expanded outcome reporting to include variables affected by sedation therapy. Further study is required to define which sedation approach for TTM may be best.