Jan Kasal

Placement of intracranial pressure monitors by neurointensivists: Case series and a systematic review

Primary objective: Placement of an intracranial pressure (ICP) monitor to guide the management of patients with severe traumatic brain injury (TBI) has been historically performed by neurosurgeons. It is hypothesized that ICP monitors can be placed by non-surgeon neurointensivists, with placement success and complication rates comparable to neurosurgeons. Research design: Retrospective review and systematic review of the literature. Methods and procedures: This study reviewed the medical records of patients with TBI who required insertion of parenchymal ICP monitors performed by four neurointensivists in a large level I trauma centre. Patient data recorded were age, gender, CT findings, ICP monitor placement, location and length of placement, complications related to the ICP monitor and patient outcomes. Main outcomes and results: Thirty-eight (38) monitors (Camino) were placed. Patients’ average age was 43.0 years (SD = 21.6); 76% were males. The location of monitor was right frontal in 89% and left frontal in 11%. Mean ICP was 24 (SD = 15), duration of ICP monitor was 4.9 days (SD = 3.6). All monitors were placed successfully. There were no major technical complications, no episodes of major catheter-induced intracranial haemorrhage and no infectious complications. These findings were comparable to published outcomes from neurosurgeon placements. Conclusions: It is believed that insertion of ICP monitors by neurointensivists is safe and may aid in providing prompt monitoring of patients with severe TBI.

Bedside Ultrasound in the Intensive Care Unit: Where Is the Evidence?

Interest in bedside ultrasound in the intensive care unit and emergency department has exploded in recent years. This interest is driven in part by the utility of ultrasound for procedural guidance. In most cases, enthusiasm outstrips current evidence. While ultrasound is often felt to be risk-free, the important risk of ultrasound is the chance of false diagnosis. The vividness of visual images may make practitioners especially prone to cognitive errors in interpretation. Possible applications of ultrasound include management of shock and respiratory failure, two complex syndromes with multiple aspects. Reasonable evidence supports use of ultrasound to guide volume expansion, although its value remains to be demonstrated in an explicit protocol. Other possibilities include ventilator titration and guidance of diuresis. While the literature is more complicated, there is some early evidence that lung ultrasound may improve the diagnosis of dyspnea, although these results have not been well validated. Centers should avoid premature loss of equipoise and participate in studies of explicit protocols that incorporate ultrasound.

Venovenous ECMO cannulation in a patient with a pre-existing IVC filter

A 46-year-old female was admitted to our institution for respiratory failure due to pneumonia and heart failure. The patient had a history of recurrent pulmonary embolisms for which she was anticoagulated but also had a previously placed inferior vena cava (IVC) filter for unclear reasons. Her hospital course was complicated by the development of severe acute respiratory distress syndrome. After exhausting maximal efforts, the decision was made to initiate venovenous extracorporeal membrane oxygenation (ECMO). Under the guidance of transesophageal echocardiography and fluoroscopy, jugular and femoral cannulas were inserted without complications. She remained anticoagulated with heparin throughout her ECMO run. She improved clinically and radiographically and was gradually weaned from ECMO. Cannulas were safely removed without dislodgement of the IVC filter on ECMO day 23 (Fig. 1). Contrastenhanced CT imaging after decannulation did not reveal thrombosis of the IVC filter. The patient was eventually weaned from mechanical ventilation and discharged home after rehabilitation.

894: Proton Pump Inhibitors Versus Histamine 2 Receptor Antagonists for Stress Ulcer Prophylaxis

was a significance difference in the incidence of RAW between these hospitals (p<0.001), and hospital 1 had significantly more RAW admissions than all the rest (p<0.001). Of the 2,229 non-resistant (nRAW) admissions, which represented 1762 unique patients, 76% were male with a mean (SD) age of 52 (12). Conclusions: The presence of RAW is a marker for worsening clinical outcomes compared to withdrawal patients with nRAW. We identified a RAW incidence of 15% in patients with severe alcohol withdrawal. Future efforts to identify risk factors and standardize the care of this unique population are warranted.

886: STRESS ULCER PROPHYLAXIS IN CRITICALLY ILL PATIENTS

Introduction: Critically ill patients may develop bleeding caused by stress ulceration (SU). Stress ulcer prophylaxis (SUP) is commonly used in the intensive care unit (ICU) to prevent SU but may be associated with complications including Clostridium difficile (CD) infection and nosocomial pneumonia