Sodium and brain injury: do we know what we are doing?

There is mounting evidence, including the recent report by Maggiore and colleagues, of an association between hypernatremia and mortality in patients with traumatic brain injury. This mandates a re-evaluation of routine administration of agents such as hypertonic saline for the management of intracranial hypertension in those with traumatic brain injury

Anemia and red blood cell transfusion in neurocritical care

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SOFA is superior to MOD score for the determination of non-neurologic organ dysfunction in patients with severe traumatic brain injury: a cohort study

INTRODUCTION: The objective of the present study was to compare the discriminative ability of the Sequential Organ Failure Assessment (SOFA) and Multiple Organ Dysfunction (MOD) scoring systems with respect to hospital mortality and unfavorable neurologic outcome in patients with severe traumatic brain injury admitted to the intensive care unit. METHOD: We performed a prospective cohort study at Foothills Medical Centre, the sole adult tertiary care trauma center servicing southern Alberta (population about 1.3 million). All patients aged 16 years or older with severe traumatic brain injury and intensive care unit length of stay greater than 48 hours between 1 May 2000 and 31 April 2003 were included. Non-neurologic organ dysfunction was measured using the SOFA and MODS scoring systems. Determination of organ dysfunction for each non-neurologic organ system was compared between the two systems by calculating the proportion of patients with SOFA and MOD component score defined organ failure. Consistent with previous literature, organ system failure was defined as a component score of three or greater. RESULTS: The odds of death and unfavorable neurologic outcome in patients with SOFA defined cardiovascular failure were 14.7 times (95% confidence interval [CI] 5.9–36.3) and 7.6 times (95% CI 3.5–16.3) that of those without cardiovascular failure, respectively. The development of SOFA-defined cardiovascular failure was a reasonable discriminator of hospital mortality and unfavorable neurologic outcome (area under the receiver operating characteristic [ROC] curve 0.75 and 0.73, respectively). The odds of death and unfavorable neurologic outcome in patients with MOD-defined cardiovascular failure were 2.6 times (95% CI 1.24–5.26) and 4.1 times (95% CI 1.3–12.4) that of those without cardiovascular failure, respectively. The development of MOD-defined cardiovascular failure was a poor discriminator of hospital mortality and unfavorable neurologic outcome (area under the ROC curve 0.57 and 0.59, respectively). Neither SOFA-defined nor MOD-defined respiratory failure was significantly associated with hospital mortality. CONCLUSION: In patients with brain injury, the SOFA scoring system has superior discriminative ability and stronger association with outcome compared with the MOD scoring system with respect to hospital mortality and unfavorable neurologic outcome

Pro/con debate: In patients who are potential candidates for organ donation after cardiac death, starting medications and/or interventions for the sole purpose of making the organs more viable is an acceptable practice

Several hospitals have been developing programmes for organ donation after cardiac death. Such programmes offer options for organ donation to patients who do not meet brain-death criteria but wish to donate their organs after withdrawal of life-support. These programmes also increase the available organ pool at a time when demand exceeds supply. Given that potential donors are managed in intensive care units, intensivists will be key components of these programmes. Donation after cardiac death clearly carries a number of important ethical issues with it. In the present issue of Critical Care two established groups debate the ethical acceptability of using medications/interventions in potential organ donors for the sole purpose of making the organs more viable. Such debates will be an increasingly common component of intensivists' future practice

Intensivists' base specialty of training is associated with variations in mortality and practice patterns

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History of the Innovation of Damage Control for Management of Trauma Patients: 1902-2016

Objective: To review the history of the innovation of damage control (DC) for management of trauma patients. Background: DC is an important development in trauma care that provides a valuable case study in surgical innovation. Methods: We searched bibliographic databases (1950-2015), conference abstracts (2009-2013), Web sites, textbooks, and bibliographies for articles relating to trauma DC. The innovation of DC was then classified according to the Innovation, Development, Exploration, Assessment, and Long-term study model of surgical innovation. Results: The innovation\u27\u27 of DC originated from the use of therapeutic liver packing, a practice that had previously been abandoned after World War II because of adverse events. It then developed\u27\u27 into abbreviated laparotomy using rapid conservative operative techniques.\u27\u27 Subsequent exploration\u27\u27 resulted in the application of DC to increasingly complex abdominal injuries and thoracic, peripheral vascular, and orthopedic injuries. Increasing use of DC laparotomy was followed by growing reports of postinjury abdominal compartment syndrome and prophylactic use of the open abdomen to prevent intra-abdominal hypertension after DC laparotomy. By the year 2000, DC surgery had been widely adopted and was recommended for use in surgical journals, textbooks, and teaching courses ( assessment\u27\u27 stage of innovation). Long-term study\u27\u27 of DC is raising questions about whether the procedure should be used more selectively in the context of improving resuscitation practices. Conclusions: The history of the innovation of DC illustrates how a previously abandoned surgical technique was adapted and readopted in response to an increased understanding of trauma patient physiology and changing injury patterns and trauma resuscitation practices

The epidemiology of intensive care unit-acquired hyponatraemia and hypernatraemia in medical-surgical intensive care units

Introduction: Although sodium disturbances are common in hospitalised patients, few studies have specifically investigated the epidemiology of sodium disturbances in the intensive care unit (ICU). The objectives of this study were to describe the incidence of ICU-acquired hyponatraemia and hypernatraemia and assess their effects on outcome in the ICU. Methods: We identified 8142 consecutive adults (18 years of age or older) admitted to three medical-surgical ICUs between 1 January 2000 and 31 December 2006 who were documented to have normal serum sodium levels (133 to 145 mmol/L) during the first day of ICU admission. ICU acquired hyponatraemia and hypernatraemia were respectively defined as a change in serum sodium concentration to below 133 mmol/L or above 145 mmol/L following day one in the ICU. Results: A first episode of ICU-acquired hyponatraemia developed in 917 (11%) patients and hypernatraemia in 2157 (26%) patients with an incidence density of 3.1 and 7.4 per 100 days of ICU admission, respectively, during 29,142 ICU admission days. The incidence of both ICU-acquired hyponatraemia (age, admission diagnosis, Acute Physiology and Chronic Health Evaluation (APACHE) II score, length of ICU stay, level of consciousness, serum glucose level, body temperature, serum potassium level) and ICU-acquired hypernatraemia (baseline creatinine, APACHE II score, mechanical ventilation, length of ICU stay, body temperature, serum potassium level, level of care) varied according to patients' characteristics. Compared with patients with normal serum sodium levels, hospital mortality was increased in patients with ICU-acquired hyponatraemia (16% versus 28%, p < 0.001) and ICU-acquired hypernatraemia (16% versus 34%, p < 0.001). Conclusions: ICU-acquired hyponatraemia and hypernatraemia are common in critically ill patients and are associated with increased risk of hospital mortality.</p

Prolonged refractory status epilepticus following acute traumatic brain injury: a case report of excellent neurological recovery

INTRODUCTION: Refractory status epilepticus (RSE) secondary to traumatic brain injury (TBI) may be under-recognized and is associated with significant morbidity and mortality. METHODS: This case report describes a 20 year old previously healthy woman who suffered a severe TBI as a result of a motor vehicle collision and subsequently developed RSE. Pharmacological coma, physiological support and continuous electroencephalography (cEEG) were undertaken. RESULTS: Following 25 days of pharmacological coma, electrographic and clinical seizures subsided and the patient has made an excellent cognitive recovery. CONCLUSION: With early identification, aggressive physiological support, appropriate monitoring, including cEEG, and an adequate length of treatment, young trauma patients with no previous seizure history and limited structural damage to the brain can have excellent neurological recovery from prolonged RSE