Molecular mechanisms of traumatic brain injury: the missing link in management.

RIGHTS : This article is licensed under the BioMed Central licence at http://www.biomedcentral.com/about/license which is similar to the 'Creative Commons Attribution Licence'. In brief you may : copy, distribute, and display the work; make derivative works; or make commercial use of the work - under the following conditions: the original author must be given credit; for any reuse or distribution, it must be made clear to others what the license terms of this work are.Head injury is common, sometimes requires intensive care unit admission, and is associated with significant mortality and morbidity. A gap still remains in the understanding of the molecular mechanism of this condition. This review is aimed at providing a general overview of the molecular mechanisms involved in traumatic brain injury to a busy clinician. It will encompass the pathophysiology in traumatic brain injury including apoptosis, the role of molecules and genes, and a brief mention of possible pharmacological therapies

Perioperative care of a patient with stroke.

RIGHTS : This article is licensed under the BioMed Central licence at http://www.biomedcentral.com/about/license which is similar to the 'Creative Commons Attribution Licence'. In brief you may : copy, distribute, and display the work; make derivative works; or make commercial use of the work - under the following conditions: the original author must be given credit; for any reuse or distribution, it must be made clear to others what the license terms of this work are.Strokes and TIAs, with their high cumulative mortality and morbidity rates, are occurring with increasing frequency in western population 14. As such, it is vital for clinicians to provide optimal medical management in the perioperative period for those patients with this common neurological problem. This review aims to highlight the importance of the perioperative period and the stages of pre-optimization that can be taken by the multi-disciplinary team to aid this 171819. The evidence suggests that there are significant physiological advantages to early invasive monitoring and high dependency care in these complex patients. These cohort of patients are at increased risk of development of respiratory, gastrointestinal, nutritional and electrolyte disturbances so a constant vigil should be exercised in early recognition and treatment

Exploratory Analysis of Preoperative and Postoperative Risk Stratification Tools to Identify Acute Kidney and Myocardial Injury in Patients Undergoing Surgery for Chronic Subdural Haematoma.

Perioperative statistical risk stratification is widespread. Such tools inform intraoperative and postoperative care as part of the National Emergency Laparotomy Audit (NELA)1. Patients with chronic subdural haematomas (cSDH) are often elderly with significant comorbidity2. Despite this, there is a paucity of literature pertaining to risk stratification models in this cohort3. At our centre, as part of a multidisciplinary improvement initiative (the ‘Improving Care in Elderly Neurosurgery Initiative’ (ICENI)4) (Project ID:PRN7705) we demonstrated a significant association between postoperative complications and length of stay2. As a further analysis within this cohort of operated cSDH, we explore the potential of using retrospective electronic health record (EHR) data to generate prognostic statistical models for the identification of two end-organ complications (myocardial injury –troponin above the upper limit of normal and acute kidney injury (AKI) –a rise in serum creatinine of ≥ 1.5 times baseline). Outcomes were chosen based on data availability and veracity as well as clinical relevance. The integrated nature of our EHR permitted incorporation of variables reflecting intraoperative management. This enabled an exploratory analysis of models that, analogous to NELA, could be used preoperatively and updated postoperatively

Identification of factors associated with morbidity and postoperative length of stay in surgically managed chronic subdural haematoma using electronic health records: a retrospective cohort study.

INTRODUCTION: Chronic subdural haematoma (cSDH) tends to occur in older patients, often with significant comorbidity. The incidence and effect of medical complications as well as the impact of intraoperative management strategies are now attracting increasing interest. OBJECTIVES: We used electronic health record data to study the profile of in-hospital morbidity and examine associations between various intraoperative events and postoperative stay. DESIGN, SETTING AND PARTICIPANTS: Single-centre, retrospective cohort of 530 cases of cSDH (2014-2019) surgically evacuated under general anaesthesia at a neurosciences centre in Cambridge, UK. METHODS AND OUTCOME DEFINITION: Complications were defined using a modified Electronic Postoperative Morbidity Score. Association between complications and intraoperative care (time with mean arterial pressure <80 mm Hg, time outside of end-tidal carbon dioxide (ETCO2) range of 3-5 kPa, maintenance anaesthetic, operative time and opioid dose) on postoperative stay was assessed using Cox regression. RESULTS: 53 (10%) patients suffered myocardial injury, while 24 (4.5%) suffered acute renal injury. On postoperative day 3 (D3), 280 (58% of remaining) inpatients suffered at least 1 complication. D7 rate was comparable (57%). Operative time was the only intraoperative event associated with postoperative stay (HR for discharge: 0.97 (95% CI: 0.95 to 0.99)). On multivariable analysis, postoperative complications (0.61 (0.55 to 0.68)), anticoagulation (0.45 (0.37 to 0.54)) and cognitive impairment (0.71 (0.58 to 0.87)) were associated with time to discharge. CONCLUSIONS: There is a high postoperative morbidity burden in this cohort, which was associated with postoperative stay. We found no evidence of an association between intraoperative events and postoperative stay.Wellcome Trust Studentshi

Food for Thought: Dietary Intervention in a Rare Cause of Severe Ventilatory Failure

Plastic bronchitis is a rare condition characterised by endobronchial cast formation. We report the case of a 53-year-old women who deteriorated following an elective bronchoscopy procedure. She developed refractory ventilatory failure and required repeated bronchoscopy, which identified thick tenacious casts as the cause of her airway compromise. She did not respond to conventional therapies including endoscopic clearance, mucolytic therapy and nebulised tissue plasminogen activator (TPA). Total parenteral nutrition and a fat-free enteral diet were instituted while the patient was on extracorporeal membrane oxygenation (ECMO), which led to substantial improvement in her condition and demonstrated the importance of dietary strategies in this case

Effects of Prone Position and Positive End-Expiratory Pressure on Noninvasive Estimators of ICP: A Pilot Study.

BACKGROUND: Prone positioning and positive end-expiratory pressure can improve pulmonary gas exchange and respiratory mechanics. However, they may be associated with the development of intracranial hypertension. Intracranial pressure (ICP) can be noninvasively estimated from the sonographic measurement of the optic nerve sheath diameter (ONSD) and from the transcranial Doppler analysis of the pulsatility (ICPPI) and the diastolic component (ICPFVd) of the velocity waveform. METHODS: The effect of the prone positioning and positive end-expiratory pressure on ONSD, ICPFVd, and ICPPI was assessed in a prospective study of 30 patients undergoing spine surgery. One-way repeated measures analysis of variance, fixed-effect multivariate regression models, and receiver operating characteristic analyses were used to analyze numerical data. RESULTS: The mean values of ONSD, ICPFVd, and ICPPI significantly increased after change from supine to prone position. Receiver operating characteristic analyses demonstrated that, among the noninvasive methods, the mean ONSD measure had the greatest area under the curve signifying it is the most effective in distinguishing a hypothetical change in ICP between supine and prone positioning (0.86±0.034 [0.79 to 0.92]). A cutoff of 0.43 cm was found to be a best separator of ONSD value between supine and prone with a specificity of 75.0 and a sensitivity of 86.7. CONCLUSIONS: Noninvasive ICP estimation may be useful in patients at risk of developing intracranial hypertension who require prone positioning.DC and MC are partially supported by NIHR Brain Injury Healthcare Technology Co-operative, Cambridge, UK. JD is supported by a Woolf Fisher Scholarship (NZ)

Feasibility of fully automated closed-loop glucose control using continuous subcutaneous glucose measurements in critical illness: a randomized controlled trial.

INTRODUCTION: Closed-loop (CL) systems modulate insulin delivery according to glucose levels without nurse input. In a prospective randomized controlled trial, we evaluated the feasibility of an automated closed-loop approach based on subcutaneous glucose measurements in comparison with a local sliding-scale insulin-therapy protocol. METHODS: Twenty-four critically ill adults (predominantly trauma and neuroscience patients) with hyperglycemia (glucose, ≥10 mM) or already receiving insulin therapy, were randomized to receive either fully automated closed-loop therapy (model predictive control algorithm directing insulin and 20% dextrose infusion based on FreeStyle Navigator continuous subcutaneous glucose values, n = 12) or a local protocol (n = 12) with intravenous sliding-scale insulin, over a 48-hour period. The primary end point was percentage of time when arterial blood glucose was between 6.0 and 8.0 mM. RESULTS: The time when glucose was in the target range was significantly increased during closed-loop therapy (54.3% (44.1 to 72.8) versus 18.5% (0.1 to 39.9), P = 0.001; median (interquartile range)), and so was time in wider targets, 5.6 to 10.0 mM and 4.0 to 10.0 mM (P ≤ 0.002), reflecting a reduced glucose exposure >8 and >10 mM (P ≤ 0.002). Mean glucose was significantly lower during CL (7.8 (7.4 to 8.2) versus 9.1 (8.3 to 13.0] mM; P = 0.001) without hypoglycemia (<4 mM) during either therapy. CONCLUSIONS: Fully automated closed-loop control based on subcutaneous glucose measurements is feasible and may provide efficacious and hypoglycemia-free glucose control in critically ill adults. TRIAL REGISTRATION: ClinicalTrials.gov Identifier, NCT01440842

Molecular mechanisms of traumatic brain injury; the missing link in management

RIGHTS : This article is licensed under the BioMed Central licence at http://www.biomedcentral.com/about/license which is similar to the 'Creative Commons Attribution Licence'. In brief you may : copy, distribute, and display the work; make derivative works; or make commercial use of the work - under the following conditions: the original author must be given credit; for any reuse or distribution, it must be made clear to others what the license terms of this work are.Abstract Head injury is common, sometimes requires intensive care unit admission, and is associated with significant mortality and morbidity. A gap still remains in the understanding of the molecular mechanism of this condition. This review is aimed at providing a general overview of the molecular mechanisms involved in traumatic brain injury to a busy clinician. It will encompass the pathophysiology in traumatic brain injury including apoptosis, the role of molecules and genes, and a brief mention of possible pharmacological therapies