Category Archives: Neurology

Controversies in the Management of Neuro-ICU Patients

‘Permissive’ hypernatraemia in refractory intracranial hypertension

Continuous infusions rather than bolus osmolar therapy may make physiological sense but concerns have been raised about the hypernatraemia. Continuous hypertonic saline has been used effectively in a number of settings but what about generation of osmotic gradients at the risk of ALI/AKI.

Concerns raised in discussion about inappropriately high targets and picking appropriate patients

Continuous controlled-infusion of hypertonic saline solution in traumatic brain-injured patients: a 9-year retrospective study

New Trends in Hyperosmolar therapy?

 

Is there a better fluid?

Different dogma’s exist about the suitability of Hartmanns or balanced solution in neuroICU. We know chloride worsens renal function but concerns about using hypotonic or isotonic solutions have meant a preponderance of saline.

Increasing evidence suggests that the chloride can be harmful to the brain as well – we give lots of chloride in hypertonic saline as well. Meta-analyses have suggested hypertonic saline better at reducing ICP but doses were not equimolar, it might not be best for survival and mannitol has additional effects beyond ICP.

What about feeding the brain? Some evidence for lactate containing solutions in treatment of intracranial hypertension. Lactate is a vasodilator and may improve CBF.

Combination therapy might be best – saline + ringers lactate +/- sugar depending on cerebral micro dialysis with control of sugar.

The cellular mechanisms of neuronal swelling underlying cytotoxic edema.

Hypernatremia in patients with severe traumatic brain injury: a systematic review

Hypertonic saline versus mannitol for the treatment of elevated intracranial pressure: a meta-analysis of randomized clinical trials

Half-molar sodium lactate infusion to prevent intracranial hypertensive episodes in severe traumatic brain injured patients: a randomized controlled trial.

Equimolar doses of mannitol and hypertonic saline in the treatment of increased intracranial pressure

 

Fixed versus auto regulatory driven CPP targets

Where does ICP threshold 20mmHg comes from old data and BTF guidelines are based on poor quality evidence. Ditto CPP.

BEST-TRIP suggested ICP of 20 but it may be the burden of ICP is the main problem – some people won’t tolerate ICP of 15mmHg. Children almost never do

CPP and ICP targets need to be individualised and hence reactivity with respect to auto regulation is important and might change during treatment. THat’s why you measure it! However, we lack prospective trials and need more data. Delta CPP may correlate with outcome.

Visualizing the pressure and time burden of intracranial hypertension in adult and paediatric traumatic brain injury

Continuous determination of optimal cerebral perfusion pressure in traumatic brain injury.

 

Refractory Status Epilepticus

Status epilepticus definition has changed! Now anything other than a single self-limiting status (i.e. > 5 minutes) is now in status.

Refractory status is fits after benzodiazepines and second line AED (about two hours)

Super-refractory status fitting despite anaesthesia (about 24 hours)

Quicker you treat, more likely you are to terminate seizure

Once convulsive status exists, if becomes refractory will always progress to non-convulsive status equivalent to EMD. 48% of patients who don’t wake continue to fit in non-convulsive way.

Give Loraz > Phenytoin

Then equipoise – valproate? keppra? propofol?

Midazolam infusion may be better in refractory status – loading dose of 0.2mg/kg. Propofol infusion rates may be limited by PRIS issues. What about ketamine + midazlolam rather than barbiturate?!

Oral ketamine in paediatric non-convulsive status epilepticus.

Let’s talk about Post Intensive Care Unit Syndrome – Hannah Wunsch (presented 4th October)

In this presentation, Dr Wuncsh highlights some important key points:-

There are some significant negative consequences for our patients after discharge from the ICU.  Not only is QOL decreased for at least two years after hospital discharge, but patients can also suffer psychological and physical consequences such as anxiety and mood disorders, extreme fatigue, sleep disturbance, weakness, foot drip and more.

Some general tips for improving the patient experience and decreasing the impact of PICS include:-

  • Minimising sedation
  • Tailoring the environment to reduce noise and night disturbance
  • Early physical and cognitive therapy
  • Screening for psychiatric disease
  • ICU diaries

By

Dr Melissa Bloomer

What to do when there is no EBM?

Septic patients (Perel)

EBM de-emphasises intuition, unsystematic clinical experience & pathophysiological rationale as sufficient grounds for clinical decision making & stresses the examination of evidence from clinical research

No benefit to ARISE, PROCESS, PROMISE

Have multimodal approach to monitoring the CV system of septic patients

Solve therapeutic conflicts by choosing the least harmful option

Aim to de-escalate treatment as soon as possible and do not aim to normalise values

 

References:

Positive fluid balance in septic patients

A protocol-less approach to septic patient

 

The High Risk Surgical Patient (Zsolt)

References

EuSOS study

Pro-AQT study

OPTIMISE Study

Choice of monitoring device amongst anaesthetists

No benefits of SV optimisation in elective abdo surgery

 

Liver Failure (Wendon)

EASL Practical guidelines for the management of alcoholic liver disease

EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis

Hepatorenal syndrome: the 8th international consensus conference of the Acute Dialysis Quality Initiative (ADQI) Group

 

Subarachnoid Haemorrhage (Polderman)

Unsecured aneurysms rebleed 9-17% on day 0

Fever associated with poor outcomes

High incidence of CV dysfunction. Therefore would advocate CO monitoring

References

Critical care management of patients following aneurysmal subarachnoid hemorrhage: recommendations from the Neurocritical Care Society’s Multidisciplinary Consensus Conference.

 

NEXT Lounge: Experts discussion of Neuro Cases

Coma recovery score (revised) is used more prominently in the recovery literature which is validated in disorders of consciousness.

Carinal stimulation via suctioning rather than pain may be a more useful way of generating arousal.

Don’t say ‘squeeze my hands’ to assess commands – rather ‘give me (two) thumbs up’

Data from the IMPACT trials have been used to create a risk prediction model which is available online.

Prediction models for 6 month outcome after TBI

Alpha coma on EEG may have a poor prognosis but the cause is important to the outcome.

IMG_1550

Etiology, neurologic correlations, and prognosis in alpha coma

Medial temporal lobe seizures may not be well detected on surface EEG

American Clinical Neurophysiology Society’s Standardized Critical Care EEG Terminology

Anti-N-methyl-D-aspartate receptor antibodies: A potentially treatable cause of encephalitis in the intensive care unit