Neurocritical care
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Extubation failure in the neurocritical care unit (NCCU) is difficult to predict, and is an important source of prolonged intensive care, exposure to morbidity, and increased cost. ⋯ The ability to follow four commands and other examination criteria were strongly associated with extubation success in this observational study. Modeling suggests that specific neurologic examination parameters provide additional predictive information over GCS alone. A prospective, protocol-driven trial is needed to test and expand these findings.
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The influence of tracheostomy timing on outcome after severe head injury remains controversial. ⋯ These results indicate a complex relationship between tracheostomy timing and outcome, but suggest that a strategy of early tracheostomy, particularly when performed on patients with a reasonable chance of survival, results in a better overall clinical outcome than when the tracheostomy is performed in a delayed manner.
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Comparative Study
How does care differ for neurological patients admitted to a neurocritical care unit versus a general ICU?
Neurological patients have lower mortality and better outcomes when cared for in specialized neurointensive care units than in general ICUs. However, little is known about how the process of care differs between these types of units. ⋯ Neurological patients cared for in specialty neuro-ICUs underwent more invasive intracranial and hemodynamic monitoring, tracheostomy, and nutritional support, and received less IV sedation than patients in general ICUs. These differences in care may explain previously observed disparities in outcome between neurocritical care and general ICUs.
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Optic nerve ultrasonography (ONUS) may help identify raised intracranial pressure (ICP). The optimal optic nerve sheath diameter (ONSD) cut-off for the identification of intracranial hypertension has not been established, with some clinical studies suggesting a higher cut-off than may be expected on the basis of prior laboratory investigation. ⋯ Bedside ONSD measurement, performed by neurointensivists, is an accurate, non-invasive method to identify ICP > 20 mmHg in a heterogeneous group of patients with acute brain injury. ONSD ≥0.48 cm has the greatest accuracy, however, internal validation of ONSD criteria may be required.
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The pathogenesis of vasospasm (VS) post aneurysmal subarachnoid hemorrhage (SAH) is multifactorial and not completely understood. The authors hypothesize that circulating antiangiogenic factors play an important role in brain injury post SAH and that elevated levels predict the occurrence of symptomatic vasospasm. ⋯ Based on these results the authors conclude that elevated CSF levels of sFlt1 and sEng herald the occurrence of symptomatic VS post SAH.