Category Archives: Neurology

Optimising Ventilation and Oxygenation to Protect Vital Organs in COPD and Hypercapnic Patients

This webinar brings together leading experts to discuss the delivery and monitoring of oxygen for chronic hypercapnic COPD patients and how to ensure that the brain and vital organs are well oxygenated.

 

#ESICMtv webinar: Protecting the brain in #COVID19 patients

By using Brain Function Monitoring, healthcare professionals can optimise sedation therapy and thereby reduce the risk of over-sedation, drug-usage, myocardial depression, the need for inotropes and the number of ventilator days – all of which can help improve patient outcome during this crisis.

The experts:

Co-Presenter: Pr. Ari Ercole is a consultant in Neuro Intensive Care at Cambridge University Hospitals NHS Foundation Trust (CUHFT) and Honorary Senior Research Associate in the Division of Anaesthesia. His principle research focus involves the physiological measurement, support and resuscitation of critically ill patients, in particular patients that have sustained life-threatening severe trauma. His other interests include data-driven research and he chairs the ESICM Data Science Section.
Co-Presenter: Pr. Rafael Badenes is a specialist in Anaesthesiology and Intensive Care, working in the Department of Anaesthesiology and Surgical-Trauma Intensive Care at the Hospital Clinic Universitari de Valencia, Spain. He is Full Professor of the Department of Surgery at the University of Valencia and a scientist of the INCLIVA Research Health Institute. His primary research interests are neuroscience and organ donation and transplantation.

Co-Presenter: Pr. Frank Rasulo is Associate Professor of Anaesthesia and Intensive Care and Head of Neuro Critical Care in the Department of Anaesthesia, Critical Care and Emergency at Spedali Civili University Hospital, Brescia, Italy. He is Chair of the Neuroanaesthesia and Neuro Intensive Care Study Group for the Italian National Society of Anaesthesiology, Intensive Care and Pain (SIAARTI).

Moderator: Dr. Basil Matta is immediate past Divisional Director for Musculoskeletal, Digestive Diseases, Major Trauma and Perioperative Care Medicine at Cambridge University Hospitals NHS Foundation Trust, where he is the Clinical Lead for the International Business Unit and a Consultant in Anaesthesia and Critical Care. He is an Associate Lecturer at the University of Cambridge.

The tweets (with references…):

The presentations:



#ESICMtv webinar – Management of sedation in #COVID19 patients

The experts:

Co-Presenter: Prof. Margaret Herridge is Professor of Medicine, Critical Care & Pulmonary Medicine at the University Health Network, Toronto, Canada; Senior Scientist at the Toronto General Research Institute; Director of Research in the Interdepartmental Division of Critical Care Medicine, University of Toronto, and Director of RECOVER, a clinical & research programme for patient and family-centred follow-up care after critical illness. Margaret was awarded Honorary Membership of ESICM in 2016 for her contribution to the international field of intensive care medicine.

Co-Presenter: Prof. Arjen Slooter is a consultant neurologist-intensivist at the Department of Intensive Care Medicine, UMC Utrecht (Netherlands) and Professor of Intensive Care Neuropsychiatry at Utrecht University. His research focus is on delirium and neuropsychiatric outcome after anaesthesia/surgery or critical illness. He is President of the European Delirium Association and he previously chaired the Delirium Section of the SCCM 2018 Guideline on Pain, Agitation, Delirium, Early Mobilisation and Sleep.

Moderator: Dr Björn Weiss is attending physician at Charité Universitätsmedizin Berlin in the Department of Anaesthesiology and Intensive Care Medicine. He is a clinician and researcher with a general interest in delirium, sedation and the effects of sedatives in critically ill patients. Björn has conducted several clinical studies in the ICU and was part of the development of two evidence and consensus-based guidelines.

Here some notes by M. Velia Antonini @FOAMecmo

The presentation

Lessons from Clinical Challenges in Neuro-Critical Care

Traumatic Brain Injury

Traumatic brain injury: integrated approaches to improve prevention, clinical care, and research

Trajectories of early secondary insults correlate to outcomes of traumatic brain injury: results from a large, single centre, observational study

Clinical applications of intracranial pressure monitoring in traumatic brain injury : report of the Milan consensus conference.

 

Intracranial Haemorrhage

Definition: non-traumatic bleeding into the brain parenchyma

2nd most common type of stroke (10-30%)

5.3 million cases worldwide, 3 million deaths (2010 Global Report on Diseases)

Less than 40% of patients regain functional independence

Most important risk factors:

  • hypertension
  • anticoagulation

The critical care management of spontaneous intracranial hemorrhage: a contemporary review

Blood pressure management: BPsys < 140 -160 mmHg

  • Higher systolic pressures may lead to hematoma expansion and increased edema.
  • Prospective trials: INTERACT II, ATACH II

Correction of coagulopathy, if possible… or not?

  • Vitamin-K-antagonists (Phenprocoumon, Marcumar): Yes. Use PCC (prothrombin complex concentrate)
    •  INR-goal: < 1.3
  • DOACs: if specific antidote available and within 2-3 half lifes of substance, probably yes.
  • Heparin: use protamine.
  • Aspirin / Clopidogrel: may depend on hemorrhage size

Summary: intracranial hemorrhage

  • Data: meanwhile useful prospective works available
  • Difficult to estimate who will decompensate
  • Prognosis difficult to estimate, likely to be worse after large ICH.
    No application of score systems for single patients
  • Superficial, cortical hemorrhage: open surgery
  • Large Basal ganglia hemorrhage (> 30 ml): minimally invasive surgery
  • Intraventriular hemorrhage: EVD + Lysis (+ lumbale Drainage)
  • Decompressive surgery: trial ongoing.
  • Massive hemorrhage (> 100 ml): conservative approach
  • ICP monitoring standard in ventilated patients, optionally pbtO2, EEG, eCox, …

Subarachnoid hemorrhage

Transcranial Doppler ultrasound goal-directed therapy for the early management of severe traumatic brain injury.

Calcium antagonists for aneurysmal subarachnoid haemorrhage – Cochrane Review

Transcranial Doppler versus angiography in patients with vasospasm due to a ruptured cerebral aneurysm: A systematic review.

Hyponatraemia: Practical Management

  • Monitor volemia and Natremia after SAH
  • Fluid restriction is not recommended
  • Isotonic saline (0.9%) for drug dilution and fluids (1-3L)
  • We rarely use 3% saline (1 ml/Kg of 3% NaCl increases the PNa by 1mmol/L)
  • Consider hydrocortisone in case of vasopressor use
  • Vaptans are not useful
  • Consider urea (0.5 -1g/Kg/Day) for HypoNa + euvolemia

Summary

  • Late risk: vasospasm
  • Monitoring: depends on severity and risk of vasospasm
  • At least: TCD and ICP, PbtO2 and CMD in tissue at risk
  • HypoNa is frequent: no fluid restriction! NaCl, Steroids, Urea

Acute Management of Status Epilepticus

International League Against Epilepsy (ILAE) task force on classification

SE = Status Epilepticus

◦ condition resulting

  • from the failure of the mechanisms responsible for seizure termination
  • from the initiation of mechanisms which lead to abnormally prolonged seizures

◦Long-term consequences

  • neuronal death, neuronal injury, alteration of neuronal networks, depending on the type and duration of seizures

RSE = Refractory Status Epilepticus

  • SE that persists despite adequate administration of benzodiazepines and at least one antiepileptic drug

SRSE = Super Refractory Status Epilepticus

  • SE that continues or recurs ≥24h after onset of anaesthetic therapy, including recurrence on the reduction or withdrawal of anaesthesia.

Convulsive status epilepticus (CSE)

  • SE with convulsions / seizures / myoclonus

Non-Convulsive Status Epilepticus (NCSE)

  • SE without clinical signs à EEG diagnosis