Christian Sebat

Dexmedetomidine for Refractory Intracranial Hypertension.

Dexmedetomidine (DEX) is a selective α2 adrenergic agonist that is commonly used for sedation in the intensive care unit (ICU). The role of DEX for adjunctive treatment of refractory intracranial hypertension is poorly defined. The primary objective of this study was to determine the effect of DEX on the need for rescue therapy (ie, hyperosmolar boluses, extraventricular drain [EVD] drainages) for refractory intracranial hypertension. Secondary objectives included the number of intracranial pressure (ICP) excursions, bradycardic, hypotensive, and compromised cerebral perfusion pressure episodes. This retrospective cohort study evaluated patients admitted to the neurosurgical ICU from August 1, 2009, to July 29, 2015, and who received DEX for refractory intracranial hypertension. The objectives were compared between the 2 time periods—before (pre-DEX) and during therapy (DEX). Twenty-three patients with 26 episodes of refractory intracranial hypertension met the inclusion criteria. The number of hyperosmolar boluses was decreased after DEX therapy was initiated. Mannitol boluses required were statistically reduced (1 vs 0.5, P = .03); however, reduction in hypertonic boluses was not statistically significant (1.3 vs 0.9, P = .2). The mean number of EVD drainages per 24 hours was not significantly different between the time periods (15.7 vs 14.0, P = .35). The rate of ICP excursions did not differ between the 2 groups (24.3 vs 22.5, P = .62). When compared to pre-DEX data, there was no difference in the median number of hypotensive (0 vs 0), bradycardic (0 vs 0), or compromised cerebral perfusion pressure episodes (0.5 vs 1.0). Dexmedetomidine may avoid increases in the need for rescue therapy when used as an adjunctive treatment of refractory intracranial hypertension without compromising hemodynamics.

Comparison of Self-Reported and Behavioral Pain Assessment Tools in Critically Ill Patients:

Background: Self-reported and behavioral pain assessment scales are often used interchangeably in critically ill patients due to fluctuations in mental status. The correlation between scales is not well elucidated. The purpose of this study was to describe the correlation between self-reported and behavioral pain scores in critically ill patients. Methods: Pain was assessed using behavioral and self-reported pain assessment tools. Behavioral pain tools included Critical Care Pain Observation Tool (CPOT) and Behavioral Pain Scale (BPS). Self-reported pain tools included Numeric Rating Scale (NRS) and Wong-Baker Faces Pain Scales. Delirium was assessed using the confusion assessment method for the intensive care unit. Patient preference regarding pain assessment method was queried. Correlation between scores was evaluated. Results: A total of 115 patients were included: 67 patients were nondelirious and 48 patients were delirious. The overall correlation between self-reported (NRS) and behavioral (CPOT) pain scales was poor (0.30, P = .018). In patients without delirium, a strong correlation was found between the 2 behavioral pain scales (0.94, P < .0001) and 2 self-reported pain scales (0.77, P < .0001). Self-reported pain scale (NRS) and behavioral pain scale (CPOT) were poorly correlated with each other (0.28, P = .021). In patients with delirium, there was a strong correlation between behavioral pain scales (0.86, P < .0001) and a moderate correlation between self-reported pain scales (0.69, P < .0001). There was no apparent correlation between self-reported (NRS) and behavioral pain scales (CPOT) in patients with delirium (0.23, P = .12). Most participants preferred self-reported pain assessment. Conclusion: Self-reported pain scales and behavioral pain scales cannot be used interchangeably. Current validated behavioral pain scales may not accurately reflect self-reported pain in critically ill patients.

Simulação in situ: vantagens, desafios e obstáculo

A simulacao medica tem sido cada vez mais reconhecida como uma modalidade a ser utilizada para reduzir os erros medicos em uma variedade de configuracoes de cuidados e diferentes graus de realismo. A simulacao in situ, definida como treinamento baseado em simulacao que ocorre em ambiente clinico com profissionais no local de trabalho ou de atuacao, tem sido utilizada como ferramenta para melhorar e identificar lacunas na formacao do profissional de saude. O objetivo desse artigo e descrever as vantagens, desafios e obstaculos para a implementacao da simulacao in situ em um hospital de ensino de cuidados tercia- rios. O programa levou a uma melhoria na organizacao e avaliacao de sistemas de gerenciamento de codigo (Code Blue) utilizado pelo hospital. Como licoes aprendidas destacamos: metas claras devem ser estabelecidas, avaliadas e revistas ao longo do processo; a tecnica de debriefing melhora o desempenho da equipe, ajuda a identificar problemas, bem como solucoes, e permite aos participantes de contribuir e processar emocionalmente a sua formacao, e; a atividade desenvolvida in situ identifica deficiencias no atendimento ao paciente especialmente no que se relaciona as necessidades do gerenciamento de risco. A experiencia indica que a simulacao in situ e uma ferramenta valiosa e segura para identificar as necessidades, promover a comunicacao eficaz, melhorar as habilidades tecnicas e implementar melhorias de processos em um ambiente medico de alto risco.

569: EFFECT OF SODIUM AND FLUID ON SERUM SODIUM LEVELS IN PATIENTS WITH INTRACRANIAL HYPERTENSION

was available for analysis.10 patients had a combination of traumatic subdural hematoma, intraparenchymal and subarachnoid hemorrhage.1 patient had nonconvulsive status epilepticus and 3 had malignant MCA stroke.Left sided oximetry values had a spearman correlation co-efficient of 0.201(p< 0.001),0.146(p< 0.001) and -0.369(p< 0.001) with pulse pressure,MAP and ICP respectively. Right sided oximetry values had a spearman correlation co-efficient of 0.209(p< 0.001),0.346(p< 0.001) and -0.142(p=0.004) with MAP,pulse pressure and ICP respectively. Conclusions: Brain oximetry showed a weak but positive correlation with MAP and pulse pressure indicating some preservation of cerebral autoregulation.ICP had weak but negative correlation with Cerebral oxygenation suggesting minor changes in ICP may be important in optimizing cerebral oxygenation in acute brain injuries.Further studies using longer monitoring and more patients are needed to confirm these findings.

Cerebral gas embolism in a case of Influenza A-associated acute respiratory distress syndrome treated with high-frequency oscillatory ventilation

A 22-year-old obese asthmatic woman with Influenza A (H1N1)-associated acute respiratory distress syndrome died from cerebral artery gas emboli with massive cerebral infarction while being treated with High-Frequency Oscillatory Ventilation in the absence of a right to left intracardiac shunt. We review and briefly discuss other causes of systemic gas emboli (SGE). We review proposed mechanisms of SGE, their relation to our case, and how improved understanding of the risk factors may help prevent SGE in positive pressure ventilated patients.

Cutaneous Rhizopus infection at a central venous catheter site in a critically ill renal transplant patient

Invasive fungal infections are increasing in incidence, along with the use of immunosuppressive medications for the prevention of organ transplant rejection, graft versus host disease and treatment of auto-immune disorders. Additionally, the incidence of invasive fungal infections is increasing with the use of new antineoplastic therapies for malignancy, increasing incidence of diabetes mellitus, expanded use of broad-spectrum antimicrobial therapy and with an aging population with chronic medical problems such as chronic renal failure, chronic obstructive pulmonary disease and HIV. We present a case of primary cutaneous zygomycosis at the insertion site of a central venous catheter in a 45-year-old renal transplant patient admitted for acute pancreatitis. In the critical care setting, clinicians must retain a high index of suspicion for invasive fungal infections in immunocompromised individuals to ensure early diagnosis and provide aggressive medical and surgical intervention. Liposomal amphoterin B is the first line antimicrobial therapy, and reduction or discontinuation of immunosuppressive therapy should be considered. Currently there are no consensus opinions or recommendations for routine, scheduled replacement of central venous catheters to prevent infections, even in immunosuppressed patients.