Tamer Abdelhak

Clevidipine for acute hypertension in patients with subarachnoid hemorrhage: a pilot study

Purpose: Clevidipine is a novel, ultra-short acting dihydropyridine. We hypothesized that clevidipine would rapidly control elevated blood pressure (BP) in patients with aneurysmal subarachnoid hemorrhage (SAH). Materials and Methods: This prospective open-label pilot study evaluated the efficacy and safety of clevidipine in reducing blood pressure (BP) to a pre-specified range and within 30 min before or after clipping or coiling of the aneurysm. Results: We enrolled five patients who received eight clevidipine infusions, including 1587 systolic or diastolic BP data points. The mean SBP upper and lower goals were set at 154 and 122 mmHg. The primary end point of achieving SBP control within <30 min was reached in all patients within 14.2 ± 6.4 min at an infusion rate of 10.8 ± 9.1 mg/h. The mean pre-infusion, during infusion and post-infusion SBP measurements were 165.5 ± 2.55, 146.4 ± 2.48 and 159.3 ± 11.5 mmHg ( p < 0.05 for pre- vs infusion comparison), respectively. After reaching the primary end point and during the clevidipine infusion, 17.5% and 11.8% of SBP readings were above the upper and below the lower goals, respectively. No patients re-bled. In one patient, the infusion had to be stopped temporarily three times due to SBP decrease below the lower goal. Conclusion: Clevidipine controlled SBP in all patients with aneurysmal SAH in <22 min and kept it within the elective range 70% of the time without major complications.

Withdrawal of Life-Sustaining Therapies and Brain Death in the Intensive Care Unit

The majority of patients who die in intensive care units (ICUs), do so as a result of the withdrawal of life-sustaining treatments or as a result of brain death. With the increasing shortage of transplantable organs, there is growing interest in both these patient populations and their potential for organ donation after cardiac death (DCD) or death by neurological criteria. Therefore, it is imperative for neurologists and neurosurgeons to be familiar with both processes when consulted to evaluate these very sick patients in the ICU. The medicolegal and ethical considerations, the factors that lead to the decision for withdrawal (with special attention to prognostication of the major neurological diseases encountered in an ICU), the process of withdrawal of life-sustaining treatment itself, and the DCD process will be examined. The medicolegal aspects of brain death will also be examined, with particular focus on the process and the various pitfalls and misconceptions.

Variable change in renal function by hypertonic saline

AIM To investigate the effects of hypertonic saline in the neurocritical care population. METHODS We retrospectively reviewed our hospitals use of hypertonic saline (HS) since March of 2005, and prospectively since October 2010. Comparisons were made between admission diagnoses, creatinine change (Cr), and HS formulation (3% NaCl, 3% NaCl/sodium acetate mix, and 23.4% NaCl) to patients receiving normal saline or lactated ringers. The patients (n = 1329) of the retrospective portion were identified. The data presented represents the first 230 patients with data. RESULTS Significant differences in Acute Physiology and Chronic Health Evaluation II scores and Glasgow Coma Scale scores occurred between different saline formulations. No significant correlation of Cl(-) or Na(+) with Cr, nor with saline types, occurred. When dichotomized by diagnosis, significant correlations appear. Traumatic brain injury (TBI) patients demonstrated moderate correlation between Na(+) and Cr of 0.45. Stroke patients demonstrated weak correlations between Na(+) and Cr, and Cl(-) and Cr (0.19 for both). Patients receiving HS and not diagnosed with intracerebral hemorrhage, stroke, subarachnoid hemorrhage, or TBI demonstrated a weak but significant correlation between Cl(-) and Cr at 0.29. CONCLUSION Cr directly correlates with Na(+) or Cl(-) in stroke, Na(+) in TBI, and Cl(-) in other populations. Prospective comparison of HS and renal function is needed.

Neuroleptic Malignant Syndrome, Malignant Hyperthermia, and Serotonin Syndrome

Epidemiology Neuroleptic malignant syndrome (NMS) is rare, diagnosed annually in 2,000 hospitalized patients in the US Recent studies suggest an incidence of 0.01–0.02% in patients treated with antipsychotic medications Risk factors