Neurocritical care
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Prophylactic anticonvulsants are routinely prescribed in the acute setting for intracerebral hemorrhage (ICH) patients, but some studies have reported an association with worse outcomes. We sought to characterize the prevalence and predictors of prophylactic anticonvulsant administration after ICH as well as guideline adherence. We also sought to determine whether prophylactic anticonvulsants were independently associated with poor outcome. ⋯ Levetiracetam was routinely prescribed following ICH and was not associated with worse outcomes. Future investigations should examine the effect of prophylactic levetiracetam on cost and neuropsychological outcomes as well as the role of continuous EEG in identifying subclinical seizures.
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The effect of mild hypothermia (MH) on microcirculation after resuscitation from cardiac arrest is controversial. The aim of this study was to determine whether MH improves or aggravates the disturbance of cerebral microcirculation. ⋯ MH decreases cerebral small microvessel blood flow and cerebral metabolism after ROSC compared with NH. However, the total effect is that cerebral oxygen supply-demand relationship is improved during hypothermia.
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The Glasgow Coma Scale (GCS) has some limitations when evaluating the unconscious patient. This study aims to validate the Persian version of the FOUR (Full Outline of Unresponsiveness) score as a proposed substitute. ⋯ The researchers conclude that the Persian version of the FOUR score is a reliable and valid scale to assess unconscious patients with traumatic brain injury and can be substituted for the GCS.
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Surrogate decision-makers ("surrogates") and physicians of incapacitated patients have different views of prognosis and how it should be communicated, but this has not been investigated in neurocritically ill patients. We examined surrogates' communication preferences and physicians' practices during the outcome prognostication for critically ill traumatic brain injury (ciTBI) patients in two level-1 trauma centers and seven academic medical centers in the USA. ⋯ We identified fundamental differences in the communication preferences of prognostic information between ciTBI patient surrogates and physicians. These findings inform the content of a future decision aid for goals-of-care discussions in ciTBI patients. If validated, these findings may have important implications for improving communication practices in the neurointensive care unit independent of whether a formal decision aid is used.
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Case Reports
Ethical and Legal Considerations in the Management of an Unbefriended Patient in a Vegetative State.
Patients without surrogates are referred to as "unbefriended." Because these patients do not have representatives to assist with medical decision-making, patient autonomy and self-determination, fundamental concepts of American healthcare, are jeopardized. ⋯ The unbefriended are one of the most high-risk patient groups. Because our patient had no surrogate with whom we could have a goals-of-care discussion, we were obligated to continue aggressive management despite knowing it would prolong, but not improve, his life. Proactive preventative measures to identify and document end-of-life wishes may make management of these patients less ethically and legally complicated.