Neurocritical care
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Observational Study
Impact of Head-of-Bed Posture on Brain Oxygenation in Patients with Acute Brain Injury: A Prospective Cohort Study.
Therapeutic head positioning plays a role in the management of patients with acute brain injury. Although intracranial pressure (ICP) is typically lower in an upright posture than in a flat position, limited data exist concerning the effect of upright positioning on brain oxygenation and circulation. We sought to determine the impact of supine (0°) and semirecumbent (15° and 30°) postures on ICP, brain oxygenation, and brain circulation. ⋯ Changing the positioning of stable patients with acute brain injury resulted in opposite changes of ICP versus brain oxygenation and circulation. This information supports the concept of an individualized approach to head positioning that is based on the multimodal monitoring of brain parameters.
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Evidence suggests that early physical activity can be accomplished safely in the neurocritical care unit (NCCU); however, many NCCU patients are often maintained in a state of inactivity due to impaired consciousness, sensorimotor deficits, and concerns for intracranial pressure elevation or cerebral hypoperfusion in the setting of autoregulatory failure. Structured in-bed mobility interventions have been proposed to prevent sequelae of complete immobility in such patients, yet the feasibility and safety of these interventions is unknown. We studied neurological and hemodynamic changes before and after cycle ergometry (CE) in a subset of NCCU patients with external ventricular drains (EVDs). ⋯ These data suggest that supine CE in a heterogeneous cohort of neurocritical care patients with EVDs is safe and tolerable. Larger prospective studies are needed to determine the efficacy and optimal dose and timing of supine CE in neurocritical care patients.
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Subarachnoid hemorrhage (SAH) is characterized by the worst headache of life and associated with long-term opioid use. Discrete pain trajectories predict chronic opioid use following other etiologies of acute pain, but it is unknown whether they exist following SAH. If discrete pain trajectories following SAH exist, it is uncertain whether they predict long-term opioid use. We sought to characterize pain trajectories after SAH and determine whether they are associated with persistent opioid use. ⋯ Discrete pain trajectories following SAH exist. Recognition of pain trajectories may help identify those at risk for long-term opioid use.
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Sodium chloride (NaCl) 23.4% solution has been shown to reduce intracranial pressure (ICP) and reverse transtentorial herniation. A limitation of 23.4% NaCl is its high osmolarity (8008 mOsm/l) and the concern for tissue injury or necrosis following extravasation when administered via peripheral venous access. The use of this agent is therefore often limited to central venous or intraosseous routes of administration. Our objective was to evaluate the safety and efficacy of administration of 23.4% NaCl via peripheral venous access compared with administration via central venous access. ⋯ Peripheral venous administration of 23.4% NaCl is safe and achieves a reduction in ICP equivalent to that achieved by administration via central venous access.
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Editorial Comment
Making Waves: Will It Help Children with Traumatic Brain Injury?