Ron Neyens

High-osmolarity saline in neurocritical care: systematic review and meta-analysis.

Background and Purpose:Intracranial hypertension and cerebral edema are known contributors to secondary brain injury and to poor neurologic outcomes. Small volume solutions of exceedingly high osmolarity, such as 23.4% saline, have been used for the management of intracranial hypertension crises and as a measure to prevent or reverse acute brain tissue shifts. We conducted a systematic literature review on the use of 23.4% saline in neurocritically ill patients and a meta-analysis of the effect of 23.4% saline on intracranial pressure reduction. Design:We searched computerized databases, reference lists, and personal files to identify all clinical studies in which 23.4% saline has been used for the treatment of neurocritical care patients. Studies that did not directly involve either effects on cerebral hemodynamics or the treatment of patients with clinical or radiographic evidence of intracranial hypertension and/or cerebral swelling were eliminated. Measurements and Main Results:We identified 11 clinical studies meeting eligibility criteria. A meta-analysis was performed to evaluate the percent decrease in intracranial pressure and the 95% confidence intervals, from baseline to 60 minutes or nadir from the six studies from which this information could be extracted. A fixed effects meta-analysis estimated that the percent decrease in intracranial pressure from baseline to either 60 minutes or nadir after administration of 23.4% saline was 55.6% (se 5.90; 95% confidence interval, 43.99–67.12; p < 0.0001). Conclusions:Highly concentrated hypertonic saline such as 23.4% provides a small volume solution with low cost and an over 50% reduction effect on raised intracranial pressure. Side effects reported are minor overall in view of the potentially catastrophic event that is being treated. High quality data are still needed to define the most appropriate osmotherapeutic agent, the optimal dose, the safest and most effective mode of administration and to further elucidate the mechanism of action of 23.4% saline and of osmotherapy in general.

Manganese Encephalopathy: An Under-Recognized Condition in the Intensive Care Unit

BackgroundManganese encephalopathy is a potential complication of parenteral nutrition. Lack of early recognition leads to unnecessary testing and to continued exposure to manganese.MethodsCase report and review of the literature.ResultsWe describe the clinical and imaging findings of a patient with manganese encephalopathy in whom the diagnosis was delayed due to lack of recognition of the characteristic imaging findings.ConclusionManganese encephalopathy has protean clinical and imaging findings that can easily be overlooked.

Dabigatran-associated subdural hemorrhage: using thromboelastography (TEG(®)) to guide decision-making.

Novel oral anticoagulants present challenges and uncertainties in the management of hemorrhagic emergencies. An 84-year-old man taking dabigatran presented with a subdural hematoma requiring neurosurgical intervention. Routine coagulation assays were prolonged at admission and following administration of Factor VIII Inhibitor Bypassing Activity (FEIBA). Thromboelastography (TEG®) was utilized to assess clot dynamics prior to placement of a subdural drain, which was safely inserted despite a prolonged thrombin time (TT). Exclusive reliance on the TT may delay necessary interventions. TEG® may be a valuable tool to investigate hemostasis in patients on dabigatran requiring emergent procedures.

Aminoglycoside pharmacokinetic parameters in neurocritical care patients undergoing induced hypothermia.

Study Objective. To determine the effects of mild‐to‐moderate induced hypothermia—a neuroprotectant and/or therapeutic strategy for the management of intracranial hypertension in neurologically injured patients—on the pharmacokinetics of aminoglycoside therapy.

Liberation from mechanical ventilation in the neurocritically ill.

tion formula can reduce the inaccuracy caused by changes in hematocrit to 5% from the reference glucose value (4). This mathematical correction is developed using glucose and hematocrit values of a cohort of critically ill patients. Because no validation studies using this correction factor have been published so far, it should be used with great caution. The authors have not disclosed any potential conflicts of interest.