Neurocritical care
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Case Reports
Strategic placement of bedside ventriculostomies using ultrasound image guidance: report of three cases.
The blind free-hand technique for external ventricular drain (EVD) placement sometimes requires multiple attempts, and catheter location is often less than ideal. Our institution has adapted an intraoperative ultrasound-guided ventriculostomy technique for the placement of EVDs at the bedside. Our experience with ultrasound at the bedside has proven to be invaluable in certain circumstances. We present three cases of strategic EVD catheter trajectories that were made possible at the bedside with the use of ultrasound. ⋯ Ultrasound-guided bedside EVD placement allows EVD trajectories to be customized based on real-time information to accommodate for distorted and dynamic anatomy of the brain and its ventricles.
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Propofol infusion syndrome (PRIS) is well known, often associated with, lethal complication of sedation with propofol. PRIS seems to be associated with young age, traumatic brain injury (TBI), higher cumulative doses of propofol, and the concomitant use of catecholamines. Known manifestations of PRIS are metabolic acidosis, rhabdomyolysis, and cardiac failure. While fatal PRIS can occur suddenly and rapidly, there is no sensitive test or early warning sign, and the only preventive measure is to limit propofol dosage and its duration. ⋯ From the findings of this study, we conclude that meticulous observation and analysis of the ECG during propofol sedation might result in earlier recognition of developing PRIS.
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Airway pressure release ventilation (APRV) is an alternative approach to the low-tidal volume "open-lung" ventilation strategy. APRV is associated with a higher mean airway pressure than conventional ventilation and has therefore not been evaluated in patients with acute neurological injuries. ⋯ APRV may safely be applied to neurocritically ill patients, and that this mode of ventilation may increase cerebral blood flow without increasing intracranial pressure.
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In clinical practice, magnetic resonance imaging (MRI) is commonly used to assess the severity of a cardiac arrest patient's cerebral injury, utilizing treating neurologists' imaging interpretation. We sought to determine whether clinical interpretation of diffusion-weighted imaging (DWI) helps to determine poor outcome in comatose cardiac arrest patients. ⋯ The qualitative evaluation of imaging abnormalities by stroke physicians in comatose cardiac arrest patients is a highly sensitive method of predicting poor outcome, but with limited specificity.
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Cerebral autoregulation assessed using transcranial Doppler (TCD) mean flow velocity (FV) in response to various physiological challenges is predictive of outcome after traumatic brain injury (TBI). Systolic and diastolic FV have been explored in other diseases. This study aims to evaluate the systolic, mean and diastolic FV for monitoring autoregulation and predicting outcome after TBI. ⋯ Systolic flow indices (Sx and Sxa) demonstrated a stronger association with outcome than the mean flow indices (Mx and Mxa), irrespective of whether CPP or ABP was used for calculation.