recommended. 1 , 3 Neurocritical care is the newest subspecialty of critical care. The development of neurocritical care units stemmed from the notion that neurological and neurosurgical critically ill patients were better served in ICUs staffed by health-care personnel trained to recognize and treat intracranial processes as well as the systemic factors affecting them. Evidence from two recent studies supports the idea that the admission of patients to a neurocritical care unit staffed by a neurocritical care team is associated with reduced mortality rates and resource
Jose I. Suarez
Samon Tavakoli, Geoffrey Peitz, William Ares, Shaheryar Hafeez and Ramesh Grandhi
patients treated for suspected VAI. 49 Furthermore, Harrop et al. described a prospective cohort study in which the introduction of AI-EVDs decreased the VAI rate from 8.2% to 1%. 28 Interestingly, the VAI rate increased to 7.6% when the institution reverted to standard catheters due to technical problems with the AI-EVDs; however, when the AI-EVDs were reintroduced, the VAI rate decreased to 0.9%. 28 Based on the available evidence and selected studies above, there seems to be a trend toward decreased rates of VAI with AI-EVDs. To this end, the 2016 Neurocritical Care
Jian Guan, Michael Karsy, Andrea A. Brock, Ilyas M. Eli, Holly K. Ledyard, Gregory W. J. Hawryluk and Min S. Park
vitamin D supplementation. 1 Vitamin D deficiency has also been shown to have an effect on immune, inflammatory, cardiac, and vascular functions, 17 including various neurological diseases such as stroke 8 , 34 and dementia. 23 Despite the important role of vitamin D, there have been no studies examining the impact of hypovitaminosis D in patients in specialized neurocritical care units (NCCUs). Given the significant differences in management of patients between NCCUs and more generalized ICUs, 20 there is a need for further inquiries into the impact of low vitamin
Thomas P. Bleck
types of critical care units, but also must master many components of the neurological examination to a much greater degree of sophistication and precision. Despite all of our imaging and electrophysiological technologies, the neurocritical care nurse at the bedside is the most important monitor. Furthermore, he or she is the chemical engineer who manages most of the therapy as well as the psychologist and spiritual advisor for patients and families who often find themselves in the most dire straits of their lives. The nurse can also make sure that everyone in the
Jian Guan, Michael Karsy, Andrea A. Brock, Ilyas M. Eli, Gabrielle M. Manton, Holly K. Ledyard, Gregory W. J. Hawryluk and Min S. Park
-hospital mortality rate in a specialized neurocritical care unit (NCCU) suggest an association between vitamin D deficiency on admission and worse outcomes within this unique population. 8 Although the results of several studies also suggest that the effects of hypovitaminosis D on patient outcome extend beyond the hospitalization itself, 3 , 12 a paucity of data on the relationship between vitamin D status on admission and postdischarge outcomes in neurocritical care patients exists. We prospectively studied the association between hypovitaminosis D on admission and 3-month
Michael F. Stiefel, Joshua D. Udoetuk, Alejandro M. Spiotta, Vicente H. Gracias, Aaron Goldberg, Eileen Maloney-Wilensky, Stephanie Bloom and Peter D. Le Roux
Control of intracranial pressure (ICP) and cerebral perfusion pressure (CPP) is the foundation of traumatic brain injury (TBI) management. In this study, the authors examined whether conventional ICP- and CPP-guided neurocritical care ensures adequate brain tissue O2 in the first 6 hours after resuscitation.
Resuscitated patients with severe TBI (Glasgow Coma Scale score ≤ 8 and Injury Severity Scale score ≥ 16) who were admitted to a Level I trauma center and who underwent brain tissue O2 monitoring within 6 hours of injury were evaluated as part of a prospective observational database. Therapy was directed to maintain an ICP of 25 mm Hg or less and a CPP of 60 mm Hg or higher.
Data from a group of 25 patients that included 19 men and six women (mean age 39 ± 20 years) were examined. After resuscitation, ICP was 25 mm Hg or less in 84% and CPP was 60 mm Hg or greater in 88% of the patients. Brain O2 probes were allowed to stabilize; the initial brain tissue O2 level was 25 mm Hg or less in 68% of the patients, 20 mm Hg or less in 56%, and 10 mm Hg or less in 36%. Nearly one third (29%) of patients with ICP readings of 25 mm Hg or less and 27% with CPP levels of 60 mm Hg or greater had severe cerebral hypoxia (brain tissue O2 ≤10 mm Hg). Nineteen patients had both optimal ICP (≤25 mm Hg) and CPP (> 60 mm Hg); brain tissue O2 was 20 mm Hg or less in 47% and 10 mm Hg or less in 21% of these patients. The mortality rate was higher in patients with reduced brain tissue O2.
Brain resuscitation based on current neurocritical care standards (that is, control of ICP and CPP) does not prevent cerebral hypoxia in some patients. This finding may help explain why secondary neuronal injury occurs in some patients with adequate CPP and suggests that the definition of adequate brain resuscitation after TBI may need to be reconsidered.
Aditya Vedantam, Claudia S. Robertson and Shankar P. Gopinath
H ypernatremia has been shown to increase mortality in critically ill patients, independent of comorbidities. 5 , 13 , 14 , 17 Although the negative impact of hypernatremia is well described for patients treated in medical or surgical ICUs, 5 , 14 , 17 there is increased interest in the effects of hypernatremia in patients treated in neurocritical care units. 2 , 18 In particular, few studies have evaluated the independent effect of hypernatremia on mortality after severe traumatic brain injury (TBI). 6 , 15 The relationship between hypernatremia and TBI is
Avital Perry, Christopher S. Graffeo, Waleed Brinjikji, William R. Copeland III, Alejandro A. Rabinstein and Michael J. Link
education regarding SIH must be improved, as the condition is widely underdiagnosed, placing patients at risk for avoidable complications including CVT, dural arteriovenous fistula, intracranial hemorrhage, and a range of other potentially devastating injuries. Although CVT may result in significant morbidity and mortality, excellent recovery is possible even among critically ill patients through aggressive management by the neurosurgical and neurocritical care teams. Disclosures The authors report no conflict of interest concerning the materials or methods used in this
Ramin Eskandari, Michael R. Filtz, Gary E. Davis and Robert E. Hoesch
injuries. The use of hypertonic fluids and mannitol has allowed control of elevated ICP, but only recently has the use of highly concentrated (14.6% or 23.4%) HTS become a mainstay in many neurocritical care units and gained acceptance among neurosurgeons involved in the care of patients with TBI. 2 , 14 , 15 , 19 , 27 , 28 , 30 , 36 , 41 Since the first reported successes with HTS therapy, its benefits have been touted in the literature. 8 , 42 Hypertonic saline infusions at concentrations from 1.6% to 23.4% have shown powerful ICP-lowering effects, 3 and recent
Nasser Mohammed, Amey R. Savardekar, Devi Prasad Patra, Vinayak Narayan and Anil Nanda
Neurosurgical infections due to multidrug-resistant organisms have become a nightmare that neurosurgeons are facing in the 21st century. This is the dawn of the so-called postantibiotic era. There is an urgent need to review and evaluate ways to reduce the high mortality rates due to these infections. The present study evaluates the efficacy of combined intravenous plus intrathecal or intraventricular (IV + IT) therapy versus only intravenous (IV) therapy in treating postneurosurgical Acinetobacter baumannii infections.
The authors performed a meta-analysis of all peer-reviewed studies from the PubMed, Cochrane Library database, ScienceDirect, and EMBASE in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Five studies were finally included in the present analysis: 126 patients were studied who had postneurosurgical A. baumannii infection. The Cochrane collaboration tool was used to evaluate risk of bias, and a test of heterogeneity was performed. The I2 statistic was calculated. The patients were divided into 2 groups: the IV group received only intravenous therapy and the IV + IT group received both intravenous and intrathecal or intraventricular antimicrobial therapy. The outcome was mortality attributed specifically to A. baumannii infection in postneurosurgical cases. The pooled data were analyzed using the Cochran-Mantel-Haenszel method in a fixed-effects model.
The total number of patients in the IV-only group was 73, and the number of patients in the IV + IT group was 53. The mean duration of intravenous therapy was 27 days. The mean duration of intrathecal colistin was 21 days. The intravenous dose of colistin ranged from 3.75 to 8.8 MIU per day. The dose of intrathecal colistin ranged between 125,000 and 250,000 IU per day. The overall calculated odds ratio for mortality for the IV + IT group after pooling the data was 0.16 (95% CI 0.06–0.40, p < 0.0001). The patients who received IV + IT therapy had an 84% lower risk of dying due to the infection compared with those who received only IV therapy.
There is an 84% lower risk of mortality in patients who have been treated with combined intrathecal or intraventricular plus intravenous antimicrobial therapy versus those who have been treated with intravenous therapy alone. The intrathecal or intraventricular route should be strongly considered when dealing with postneurosurgical multidrug-resistant A. baumannii infections.