Neurocritical care
-
To describe the development of a Pediatric Neurocritical Care (PNCCM) service; define the patient population that requires the service and describe important outcome parameters. ⋯ A PNCCM team was asked to assist in managing almost one-quarter of the total patient census in an urban, tertiary-care, teaching hospital. The number of consults is comparable to those observed in early studies in adult NCCM team development but the admission diagnoses are distinct. The PNCCM consulted on children with high mortality rates. Future studies will be needed to determine if the presence of a PNCCM can result in improved patient outcomes.
-
Analgesic therapy following intracranial procedures remains a source of concern and controversy. Although opioids are the mainstay of the "balanced" general anesthetic techniques frequently used during intracranial procedures, neurosurgeons and others have been reluctant to administer opioid analgesics to patients following such procedures. This practice is supported by the concern that the sedation and miosis associated with opioid administration could mask the early signs of intracranial catastrophe, or even exacerbate it through decreased ventilatory drive, elevated arterial carbon dioxide levels, and increased cerebral blood flow. ⋯ Here, this data is reviewed along with the relevant pain pathways, analgesic drugs and techniques, and the available data on their use following intracranial surgery. Although pain following intracranial surgery appears to be more intense than initially believed, it is readily treated safely and effectively with techniques that have proven useful following other types of surgery, including patient-controlled administration of opioids. The use of multimodal analgesic therapy is emphasized not only for its effectiveness, but to reduce dosages and, therefore, side effects, primarily of the opioids, that could be of legitimate concern to physicians and affect the comfort of their patients.
-
In intensive care unit (ICU) patients, seizure or status epilepticus treatment with intravenous benzodiazepines or conventional antiepileptic drugs (AEDs), such as phenytoin, may be accompanied by cardiovascular depression or hypotension. Levetiracetam (LVM) is a novel AED that does not undergo extensive liver metabolism, does not require drug level monitoring, and is not associated with hemodynamic instability. We retrospectively analyzed the use, safety, and efficacy of LVM in ICU patients. ⋯ LVM appears to be safe for ICU patients when dosing is adjusted for renal function.
-
Calcium plays a central role in neuronal function and injury. Dantrolene, an inhibitor of the ryanodine receptor, inhibits intracellular calcium release from the sarco-endoplasmic reticulum. We review the available data of dantrolene as a potential neuroprotective agent and briefly summarize its other pharmacologic effects that may have potential applications for patients in the neurointensive care unit (NICU). Areas with the need for continued research are identified.
-
Clinical Trial
Inpatient hyperglycemia following aneurysmal subarachnoid hemorrhage: relation to cerebral metabolism and outcome.
Despite its clear association with impaired prognosis, it remains controversial whether hyperglycemia after aneurysmal subarachnoid hemorrhage (SAH) actively contributes to neuronal damage. This study aimed to identify a threshold for blood glucose predicting unfavorable outcome, and to evaluate differences in cerebral metabolism in normo and hyperglycemic SAH patients. ⋯ Blood glucose levels >7.8 mmol/l (140 mg/dl), but not levels >6.1 mmol/l (110 mg/dl), independently predicted unfavorable outcome. While blood glucose levels >6.1 mmol/l (110 mg/dl) were already associated with slight metabolic derangements, cerebral glucose increased only at blood levels >7.8 mmol/l (140 mg/dl). Considering the risks associated with tight glycemic control, a moderate regimen accepting blood glucose levels up to 7.8 mmol/l (140 mg/dl) might be more reasonable after SAH.