Neurocritical care
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T cells infiltrate into the infarcted brain within days after cerebral ischemia and play essential roles in exacerbating the delayed phase of the brain injury by producing pro-inflammatory factors. However, the involvement of these factors in brain damage is also demonstrated systemically. Such periphery-brain abnormalities are interesting because they may constitute a pathway to the central nervous system (CNS), which may be a target of therapeutic hypothermia. Although this therapy protects neurons after severe brain damage, the underlying mechanisms are partly understood. We examined the effects of hypothermic and hyperthermic cultures on peripheral T cell-derived release of interleukin (IL)-17 and granzyme B (GrB) and evaluated whether and how these factors induced neurotoxicity and activated brain endothelial cells. ⋯ Hypothermia reduced but hyperthermia augmented T cell-derived release of IL-17 and GrB that mediate neuronal cell death, suggesting that the attenuation of T cell-derived release of these factors by therapeutic hypothermia leads to the inhibition of neuronal cell death in the delayed phase of brain injury. Moreover, hypothermia may suppress but hyperthermia may promote the recruitment of inflammatory cells to CNS by regulating brain endothelial activation of IL-17.
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Devastating brain injuries (DBIs) profoundly damage cerebral function and frequently cause death. DBI survivors admitted to critical care will suffer both intracranial and extracranial effects from their brain injury. The indicators of quality care in DBI are not completely defined, and despite best efforts many patients will not survive, although others may have better outcomes than originally anticipated. ⋯ Following an extensive literature review, the panel used the GRADE methodology to evaluate the robustness of the data. They made actionable recommendations based on the quality of evidence, as well as on considerations of risk: benefit ratios, cost, and user preference. The panel generated recommendations regarding prognostication, psychosocial issues, and ethical considerations.
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One reason for refusal of donor hearts is the development of left ventricular systolic dysfunction, a condition reported to occur in up to 42 % of adults with brain death. Prior studies have suggested that appropriate donor management and evaluation of cardiac dysfunction with serial echocardiography (TTE) can improve organ procurement. The aims of our study are to examine the prevalence and describe longitudinal changes in cardiac dysfunction after brain death. ⋯ To our knowledge, the present study is the largest study describing the use of serial TTE and its utilization in adult donors. The prevalence of cardiac dysfunction after adult brain death is high, but given enough time and support, many of these donors have improvement in cardiac function, ultimately leading to transplantation.
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Hyperglycemia has been found to be associated with higher risk of ICU-acquired weakness. However, the impact of hyperglycemia on the outcome of patients with respiratory failure from a primary neuromuscular condition is not known. ⋯ In our cohort, we did not find evidence that the duration of hyperglycemia or the amount of insulin given had any major impact on the outcomes of patients with primary acute neuromuscular respiratory failure.
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Limited data describe the frequency, timing, or indications for endotracheal intubation (ETI) in patients with status epilepticus. A better understanding of the characteristics of patients with status epilepticus requiring airway interventions could inform clinical care. We sought to characterize ETI use in patients with prehospital status epilepticus. ⋯ ETI is common in patients with status epilepticus, particularly among the elderly or those with refractory seizures. Any ETI and late ETI are both associated with higher mortality.