Neurocritical care
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A fundamental purpose of neurocritical care is the management of secondary brain injury. This is often accomplished by monitoring and managing individual patient parameters including physiological vital signs. Yet, the ability to record physiological data exceeds our ability to fully integrate it into patient care. We propose that advances in monitoring must be accompanied by advances in methods of high-frequency, multivariate data analysis that integrate the multiple processes occurring in critically ill patients. ⋯ Recording of many physiological variables across multiple patients is feasible and can lead to new clinical insights. Computational and analytical methods previously used primarily for basic science may have clinical relevance and can potentially be adapted to provide physicians with improved ability to integrate complex information for decision making in neurocritical care.
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Hypertensive, hypervolemic, and hemodilutional (HHH) therapy for vasospasm in subarachnoid hemorrhage (SAH) refractory to phenylephrine requires high doses of catecholamines, leading to adverse adrenergic effects. Arginine vasopressin (AVP) has been shown to stabilize advanced shock states while facilitating reduction of catecholamine doses, but its use has never been reported in SAH. In this retrospective study, we investigated the hemodynamic effects and feasibility of supplementary AVP in refractory HHH therapy in SAH. ⋯ AVP may be considered as an alternative supplementary vasopressor in refractory HHH therapy with phenylephrine in SAH. Although we did not observe any deleterious effect of AVP on cerebral circulation, close observation for development of cerebral vasospasm should be undertaken, until it is clearly demonstrated that AVP has no adverse effects on regional cerebral blood flow and symptomatic cerebral vasospasm. Our limited data suggest that low-dose AVP does not cause brain edema, but further study is merited.
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The importance of preoperative response to external ventricular drainage (EVD) for treatment of acute hydrocephalus (HCP) following poor grade (Hunt & Hess grade IV or V) aneurysmal subarachnoid hemorrhage (aSAH) has not been clearly defined. The effect of EVD response on preoperative grade and prognosis is described. ⋯ Long-term outcomes in poor grade patients who improve after EVD placement are similar to patients with lower grade hemorrhages. When an EVD is placed preoperatively in a poor grade aSAH patient, the neurological status after EVD determines the clinical grade.
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Recombinant activated factor VII (rFVIIa, NovoSeven, NovoNordisc, Danemark) has been approved for the treatment of patients with hemophilia with inhibitors, further indications, at least in some countries, include the treatment of factor VII deficiency and Glanzmann thrombasthenia refractory to conventional therapy. Apart from these indications, the agent is increasingly used for the treatment of severe and potentially life-threatening bleeding manifestations, irrespective of the underlying hemostatic abnormality. The agent has successfully been used for the treatment of both inherited and acquired coagulopathies as well as thrombocytopathia or thrombocytopenia, however, most information on off-label use derives from case reports and retrospective studies and therefore publication bias can-not be excluded. ⋯ We review the current knowledge regarding the physiology of hemostasis, the pharmacology of rFVIIa, and its clinical use in neurosciences. Further studies are urgently needed to define the efficacy and safety of recombinant activated factor VII in patients without hemophilia, factor VII deficiency, or Glanzmann thrombasthenia. At time, its use can be justified in life-threatening bleeding situations refractory to conventional treatment.
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The crucial importance of monitoring both the infarcted and non-infarcted hemispheres in management of space occupying middle cerebral artery (MCA) infarction is increasingly recognized, but optimal technique is debated. We investigated the potential for bilateral Near Infrared Spectroscopy (NIRS) to non-invasively provide relevant information on intracranial oxygenation. ⋯ Bilateral NIRS may provide more useful information on cerebral oxygenation than unilateral measurements and its clinical validity to help predict worsening of brain swelling should be investigated further.