Intracranial pressure monitoring with and without brain tissue oxygen pressure monitoring for severe traumatic brain injury in France (OXY-TC): an open-label, randomised controlled superiority trial

BACKGROUND

Optimisation of brain oxygenation might improve neurological outcome after traumatic brain injury. The OXY-TC trial explored the superiority of a strategy combining intracranial pressure and brain tissue oxygen pressure (PbtO2) monitoring over a strategy of intracranial pressure monitoring only to reduce the proportion of patients with poor neurological outcome at 6 months.

METHODS

We did an open-label, randomised controlled superiority trial at 25 French tertiary referral centres. Within 16 h of brain injury, patients with severe traumatic brain injury (aged 18-75 years) were randomly assigned via a website to be managed during the first 5 days of admission to the intensive care unit either by intracranial pressure monitoring only or by both intracranial pressure and PbtO2 monitoring. Randomisation was stratified by age and centre. The study was open label due to the visibility of the intervention, but the statisticians and outcome assessors were masked to group allocation. The therapeutic objectives were to maintain intracranial pressure of 20 mm Hg or lower, and to keep PbtO2 (for those in the dual-monitoring group) above 20 mm Hg, at all times. The primary outcome was the proportion of patients with an extended Glasgow Outcome Scale (GOSE) score of 1-4 (death to upper severe disability) at 6 months after injury. The primary analysis was reported in the modified intention-to-treat population, which comprised all randomly assigned patients except those who withdrew consent or had protocol violations. This trial is registered with ClinicalTrials.gov, NCT02754063, and is completed.

FINDINGS

Between June 15, 2016, and April 17, 2021, 318 patients were randomly assigned to receive either intracranial pressure monitoring only (n=160) or both intracranial pressure and PbtO2 monitoring (n=158). 27 individuals with protocol violations were not included in the modified intention-to-treat analysis. Thus, the primary outcome was analysed for 144 patients in the intracranial pressure only group and 147 patients in the intracranial pressure and PbtO2 group. Compared with intracranial pressure monitoring only, intracranial pressure and PbtO2 monitoring did not reduce the proportion of patients with GOSE score 1-4 (51% [95% CI 43-60] in the intracranial pressure monitoring only group vs 52% [43-60] in the intracranial pressure and PbtO2 monitoring group; odds ratio 1·0 [95% CI 0·6-1·7]; p=0·95). Two (1%) of 144 participants in the intracranial pressure only group and 12 (8%) of 147 participants in the intracranial pressure and PbtO2 group had catheter dysfunction (p=0.011). Six patients (4%) in the intracranial pressure and PbtO2 group had an intracrebral haematoma related to the catheter, compared with none in the intracranial pressure only group (p=0.030). No significant difference in deaths was found between the two groups at 12 months after injury. At 12 months, 33 deaths had occurred in the intracranial pressure group: 25 (76%) were attributable to the brain trauma, six (18%) were end-of-life decisions, and two (6%) due to sepsis. 34 deaths had occured in the intracranial pressure and PbtO2 group at 12 months: 25 (74%) were attributable to the brain trauma, six (18%) were end-of-life decisions, one (3%) due to pulmonary embolism, one (3%) due to haemorrhagic shock, and one (3%) due to cardiac arrest.

INTERPRETATION

After severe non-penetrating traumatic brain injury, intracranial pressure and PbtO2 monitoring did not reduce the proportion of patients with poor neurological outcome at 6 months. Technical failures related to intracerebral catheter and intracerebral haematoma were more frequent in the intracranial pressure and PbtO2 group. Further research is needed to assess whether a targeted approach to multimodal brain monitoring could be useful in subgroups of patients with severe traumatic brain injury-eg, those with high intracranial pressure on admission.

FUNDING

The French National Program for Clinical Research, La Fondation des Gueules Cassées, and Integra Lifesciences.

Transradial access with Simmons guiding catheter for carotid artery stenting: Feasibility and procedural complications in a single-center experience

BACKGROUND

There is an increasing number of transradial approach (TRA) for carotid artery stenting (CAS), however, similar techniques and materials as for femoral access are used. We report the results of TRA lower profile technique for CAS using a 7 F Simmons guiding catheter, especially in terms of feasibility and procedural safety in a single center.

MATERIALS AND METHODS

We retrospectively analyzed 68 consecutive patients with symptomatic extracranial carotid stenoses who underwent 75 CAS between January 2018 and December 2021. The success and crossover rate, procedural time, fluoroscopy, clinical outcomes, technical considerations, and procedural complications were analyzed.

RESULTS

TRA CAS with Simmons guiding catheter was successful in 67/75 (89.3%) cases, with a 7 (9.3%) crossover rate. Fluoroscopy mean time was 15.8 minutes. Two forearm hematomas were described. No ischemic or surgical site complications were reported.

CONCLUSIONS

In our experience frontline TRA with a 7 F Simmons guiding catheter is feasible with high procedural success and a low rate of access site complications.

General anesthesia or conscious sedation for endovascular therapy of basilar artery occlusions: ETIS registry results

BACKGROUND AND PURPOSE

Acute basilar artery occlusions (BAO) are associated with poor outcome despite modern endovascular treatment (EVT). The best anesthetic management during EVT is not known and may affect the procedure and clinical outcome. We compared the efficacy and safety of general anesthesia (GA) and conscious sedation/local anesthesia (CS/LA) in a large cohort of stroke patients with BAO treated with EVT in current clinical practice.

METHODS

Data from the ongoing prospective multicenter Endovascular Treatment In Ischemic Stroke Registry of consecutive acute BAO patients who had EVT indication from January 1st, 2015, to December 31st, 2021, were retrospectively analyzed. Two groups were compared: patients treated with CS/LA versus GA (both types of anesthesia being performed in the angiosuite). Good outcome was defined as modified Rankin Scale (mRS) score 0-3 at 90 days.

RESULTS

Among the 524 included patients, 266 had GA and 246 had CS/LA (67 LA). Fifty-three patients finally did not undergo EVT: 15 patients (5.9%) in the GA group and 38 patients (16.1%) in the CS/LA group (P < 0.001). After matching, two groups of 129 patients each were retained for primary analysis. The two groups were well balanced in terms of baseline characteristics. After adjustment, CS/LA compared to GA was not associated with good outcome (OR=0.90 [95%CI 0.46-1.77] P=0.769) or mortality (OR=0.75 [0.37-1.49] P=0.420) or modified thrombolysis in cerebral infarction score 2b-3 (OR=0.43 [0.16-1.16] P=0.098). On mixed ordinal logistic regression, the modality of anesthesia was not associated with any significant change in the overall distribution of the 90-day mRS (adjusted OR=1.08 [0.62-1.88] P=0.767).

CONCLUSIONS

Safety, outcome and quality of EVT under either CS/LA or GA for stroke due to acute BAO appear similar. Further randomized trials are warranted.

Impact of platelet transfusion on outcomes in trauma patients

Background

Trauma-induced coagulopathy includes thrombocytopenia and platelet dysfunction that impact patient outcome. Nevertheless, the role of platelet transfusion remains poorly defined. The aim of the study was 1/ to evaluate the impact of early platelet transfusion on 24-h all-cause mortality and 2/ to describe platelet count at admission (PCA) and its relationship with trauma severity and outcome.

Methods

Observational study carried out on a multicentre prospective trauma registry. All adult trauma patients directly admitted in participating trauma centres between May 2011 and June 2019 were included. Severe haemorrhage was defined as ≥ 4 red blood cell units within 6 h and/or death from exsanguination. The impact of PCA and early platelet transfusion (i.e. within the first 6 h) on 24-h all-cause mortality was assessed using uni- and multivariate logistic regression.

Results

Among the 19,596 included patients, PCA (229 G/L [189,271]) was associated with coagulopathy, traumatic burden, shock and bleeding severity. In a logistic regression model, 24-h all-cause mortality increased by 37% for every 50 G/L decrease in platelet count (OR 0.63 95% CI 0.57–0.70; p < 0.001). Regarding patients with severe hemorrhage, platelets were transfused early for 36% of patients. Early platelet transfusion was associated with a decrease in 24-h all-cause mortality (versus no or late platelets): OR 0.52 (95% CI 0.34–0.79; p < 0.05).

Conclusions

PCA, although mainly in normal range, was associated with trauma severity and coagulopathy and was predictive of bleeding intensity and outcome. Early platelet transfusion within 6 h was associated with a decrease in mortality in patients with severe hemorrhage. Future studies are needed to determine which doses of platelet transfusion will improve outcomes after major trauma.

Age and Outcome after Endovascular Treatment in Anterior Circulation Large-Vessel Occlusion Stroke: ETIS Registry Results

BACKGROUND

Increasing patient age has been identified in clinical trials as a poor prognostic factor for functional independence after endovascular treatment (EVT) for acute ischemic stroke. These findings may not be fully generalizable to clinical practice due to strict inclusion and exclusion criteria in these trials. We aim to assess and quantify the association of patient age, especially in patients >80 and >90 years old, with functional outcome after EVT in current, everyday clinical practice.

METHODS

The ETIS (Endovascular Treatment in Ischemic Stroke) Registry is an ongoing, prospective, observational study of 6 comprehensive stroke centers in France. We analyzed 1,708 patients treated between January 2017 and December 2018 and assessed the association of patient age with functional outcome adjusting for demographic and procedural predictors of functional outcome.

RESULTS

The positive effect of mechanical thrombectomy diminished significantly with increasing age: compared to the 18-80 years age group, the odds for achieving a good functional outcome at 90 days after the procedure decreased in the 80-90 and >90 years groups (multilevel OR: 0.38, 95% CI: 0.28-0.51 and OR: 0.2, 95% CI: 0.09-0.45, respectively, p < 0.001). Increasing age was associated with increased mortality (multilevel OR: 2.46, 95% CI: 1.72-3.54 for the 80-90 years group and multilevel OR: 5.49, 95% CI: 2.97-10.16 for the >90 years group).

CONCLUSION

Patient age is strongly associated with functional outcome after EVT for acute ischemic stroke. The positive effect of thrombectomy persists in older age groups, even after adjustment for prognostic factors related to poor functional outcome. Stroke physicians should provide EVT irrespective of the patient's age.

[Decision-making regarding treatment limitation after severe traumatic brain injury: A survey of French neurosurgeons]

BACKGROUND/INTRODUCTION

In France, the law defines and prohibits "unreasonable obstinacy" and provides a framework for the subsequent decision to limit or to cease treatment. It also gives the person the right to appoint a trusted person and to draft advance directives regarding this issue. There have been few studies of neurosurgeons' involvement in decision-making in regard to treatment limitation after severe traumatic brain injury.

AIM OF THE STUDY

The first aim of the study was to assess French neurosurgeons' adherence to the law on patients' rights and end of life which governs such decision-making. The second aim was to assess the prognostic and decision-making criteria applied by neurosurgeons.

METHODS

A declarative practice and opinion survey, using a self-administered questionnaire emailed to all practising neurosurgeons members of the French Society of Neurosurgery, was conducted from April to June 2016.

RESULTS

Of the 197 neurosurgeons contacted, 62 filled in the questionnaire. Discussions regarding treatment limitation were in all cases collegial, as required under the law, and the patient's neurosurgeon was always involved. The trusted person and/or family were always informed and consulted, but their opinions were not consistently taken into account. Advance directives were most often lacking (68%) [56; 80] or inappropriate (27%) [16; 38]. The most frequently used prognostic criteria were clinical parameters, intracranial pressure, cerebral perfusion pressure, and imaging, with significant interindividual variation in their use. The main decision-making criteria were foreseeable disability, expected future quality of life, and age.

CONCLUSIONS

Neurosurgeons showed good compliance with legal requirements, except in the matter of calling for the opinion of an external consultant. Furthermore, this survey confirmed variability in the use of prognosis predictors, and the need for further clinical research so as to achieve more-standardized practices to minimise the subjectivity in decision-making.

Cerebral vasospasm after traumatic brain injury: an update

BACKGROUND

Post-traumatic vasospasm (PTV) remains a poorly understood entity. Using a systematic review approach, we examined the incidence, mechanisms, risk factors, impact on outcome and potential therapies of PTV.

METHODS

A search on Medline database up to 2015 performed with "traumatic brain injury" and "vasospasm" key-words retrieved 429 references. This systematic review was reported and analysed following the PRISMA criteria and according to the relevance in human clinical practice.

RESULTS

The research retrieved 429 references of which 226 were excluded from analysis because of their irrelevance and 87 finally included in the review.

CONCLUSION

Mechanical stretching, inflammation, calcium dysregulation, endotelin, contractile proteins, products of cerebral metabolism and cortical spreading depolarization have been involved in PTV pathophysiology. PTV occurs in up to 30-40% of the patients after severe traumatic brain injury. Usually, PTV starts within the first 3 days following head trauma and may last 5 to 10 days. Young age, low Glasgow Coma Score at admission and subarachnoid hemorrhage have been identified as risk factors of PTV. Suspected on transcranial Doppler, PTV diagnosis is best confirmed by angiography, CT angiography or MR angiography, and perfusion and ischaemic consequences by perfusion CT or MRI. Early PTV is associated with poor outcome. No PTV prevention strategy has proved efficient up to now. Regarding PTV treatment, only nimodipine and intra-arterial papaverine have been studied up to now. Treatment with milrinone has been described in a few cases reports and may represent a new therapeutic option.

[Risks acceptability related to obstetrical epidural analgesia]

OBJECTIVES

Evaluation of the acceptability of complications related to obstetrical epidural analgesia in two populations, parturients and anesthesiologists.

STUDY DESIGN

Prospective, transversal, single center study.

MATERIALS AND METHODS

Evaluation of the acceptability of complications associated with obstetric epidural analgesia performed using a questionnaire of six clinical scenarii in two populations: parturients cared at the University maternity of Nancy and anesthesiologists of Lorraine. Patients were interviewed by an anesthesiologist, physicians via Internet. Acceptability was assessed using two tools, the absolute acceptability with a visual analog scale and the relative acceptability obtained by classifying clinical scenario against each other, in ascending order of acceptability.

RESULTS

One hundred and forty-six parturients and 87 anesthetists assessed the acceptability of the different scenarios. The three less serious scenarios (hypotension, failure, dural tap) were acceptable for both populations. One case (spinal hematoma) was unacceptable for parturients. Three cases of varying severity (failure, dural tap, plexus injury with sequelae) were judged significantly less acceptable by patients than physicians (5.9 vs. 7.9 [P<0.001], 5.75 vs. 8.1 [P<0.01], 4.1 vs. 5.1 [P=0.035]). Multivariate analysis did not show any predictive factor of acceptability in both populations.

CONCLUSION

In this study, the overall acceptability of the inherent complications of epidural analgesia was good in the two populations. It was essentially based on the notion of severity and preventability. A large interindividual variability was observed and a better acceptance by the anesthesiologists.

Neuraxial anesthesia in patients with intracranial hypertension or cerebrospinal fluid shunting systems: what should the anesthetist know?

The management of patients with central nervous system disorders such as brain tumours, hydrocephalus, intracranial hypertension, or subarachnoid hemorrhage has improved in recent years resulting in increased life expectancy. Consequently, the prevalence of patients with increased intracranial pressure or cerebrospinal fluid shunting devices presenting for non-neurological procedures has increased. These patients commonly receive a general anesthetic, as the safety profile of neuraxial anesthesia in this clinical setting remains uncertain. This article reviews literature on neuraxial anesthesia in patients with intracranial hypertension or cerebrospinal fluid shunting systems. It describes current knowledge, exposes and weighs the real benefits and risks of this technique in this setting. It provides several scenarios and anesthetic options to help the practitioner with choosing a tailored approach in this specific population.

[Hemorrhagic stroke and new oral anticoagulants]

The recent release of new oral anticoagulants (NOAC) raises the question of the management of intracranial hemorrhage occurring during treatment with these molecules. Dabigatran, rivaroxaban and apixaban have different pharmacological characteristics that physicians need to know to adjust their prescription to each patient. Studies of efficacy and safety prior to the marketing of these molecules showed a decreased risk of intracranial hemorrhage compared with vitamin K antagonists. However, no reliable data are available regarding the prognosis of these hemorrhages occurring during NOAC treatment. In addition, there is no specific antidote and reversal protocol validated in humans. So, physicians are in a difficult situation when critical bleeding occurs. The timing of recovering normal hemostatic capacity is then a determinant factor of prognosis. Studies in animals or healthy volunteers showed a correction of the biological parameters using prothrombin complex concentrates activated or not, without reducing the volume of hematoma. On this basis, proposals have been issued by the french group of interest for perioperative hemostasis (GIHP) for the management of bleeding under NOAC treatment, which include management of intracranial hemorrhage.

[Cardiac complications of acute brain injury]

The clinical importance of cardiovascular consequences resulting from cerebral injury has long been recognized. However, interactions between the brain and the cardiovascular system remain poorly defined and their importance for the management of patients suffering from acute brain injury is largely underestimated. This should have profound consequences on treatment strategies during anaesthesia and intensive cares of these patients, taking into account not only brain perfusion, but also cardiovascular optimisation. This report summarizes the main data available regarding the cardiovascular consequences of brain death, traumatic brain injury, stroke and epilepsy.

[Management of hypotension during spinal anaesthesia for elective caesarean section: a survey of practice in Lorraine region]

OBJECTIVE

The aim of the survey was to describe current practice in management of hypotension during spinal anaesthesia for elective caesarean section in Lorraine.

STUDY DESIGN

Cross-sectional study by a mail survey.

METHODS

A 20-item postal questionnaire was sent to all anaesthetists working in public or private hospital with a maternity unit in Lorraine.

RESULTS

The response rate was 65%. Fifty-one percent of the respondents did not have a written procedure for the management of spinal-induced hypotension. Fluid preloading with or without vasopressor was the most common practice. Colloids were used by 20% of the respondents. For prevention of hypotension, 37% used ephedrine, 28% used phenylephrine mostly in association with ephedrine and 9% based their choice on heart rate. Twenty-six percent did not administer any vasopressor to prevent hypotension. First choice vasopressor for treatment of hypotension was ephedrine. Anaesthetists in academic practice were more likely to use coloading and phenylephrine administration, but none of them used colloids for pre- or coloading.

CONCLUSION

Management of hypotension during spinal anaesthesia for elective caesarean section was significantly influenced by the type of practice.

[Perioperative anaesthetic management of an epileptic patient treated with a vagus nerve stimulation]

The vagal nerve stimulation is approved for medically refractory epilepsy and major depression. We report the perioperative management of an epileptic patient with this indwelling device. This observation summarizes the physiologic implications and the specific anaesthetic considerations for procedures with this pre-existing device.

[Interest of evaluation of professional practice for the improvement of the management of postoperative pain with patient controlled analgesia (PCA)]

OBJECTIVES

To evaluate the daily practice of postoperative PCA in Nancy University Hospital, in continuity with a quality program of postoperative pain (POP) care conducted in 2003.

TYPE OF STUDY

A retrospective audit of patient medical records.

MATERIAL AND METHODS

A review of all the medical records of consecutive surgical patients managed by PCA over a 5-week period in six surgical services. Criteria studied: Evaluation of hospital means (eight criteria) and of medical and nursing staff practice (16 criteria). A second audit was conducted 6 months after the implementation of quality improvement measures.

RESULTS

Assessment of the hospital means: temperature chart including pain scores and PCA drug consumption, patient information leaflet, PCA protocol, postoperative pre-filled prescription form (PFPF) for post-anaesthesia care including PCA, and optional training of nurses in postoperative pain management. EVALUATION OF PRACTICES: One hundred and fifty-nine files of a total of 176 patients were analyzed (88%). Improvements noted after 6 months: trace of POP evaluation progressed from 73 to 87%, advance prescription of PCA adjustment increased from 56 to 68% and of the treatment of adverse effects from 54 to 68%, trace of PCA adaptation by attending nurse from 15 to 43%, trace of the administration of the treatment of adverse effects by attending nurse from 24% to 64%, as did the use of PFPF from 59 to 70%.

CONCLUSIONS

The usefulness of a pre-filled prescription form for post-anaesthesia care including PCA prescription is demonstrated. Quality improvement measures include: poster information and pocket guides on PCA for nurses, training of 3 nurses per service to act as "PCA advisers" who will in turn train their ward colleagues in PCA management and the use of equipment until an acute pain team is established.

Cerebrospinal fluid outflow and intracranial pressure in hydrocephalic patients with external ventricular drainage

BACKGROUND AND PURPOSE

The aim of this study was to monitor the 24 h cerebrospinal fluid (CSF) outflow and intracranial pressure (ICP) in hydrocephalic adult patients with external ventricular drainage (EVD).

PATIENTS AND METHODS

Twelve patients (5M/7F) aged 30-69 years suffering from acute hydrocephalus requiring EVD were admitted in the neuro-intensive care unit. The CSF collecting bag was continuously weighted using a high-precision scale, the filtered output of which was fed at 1 Hz to a computer and converted to flow (Q'ext(csf)). ICP was also recorded.

RESULTS

One patient was excluded because more than 80% of the Q'ext(csf) data were rejected by the system. The mean +/- SD Q'ext(csf) and ICP were respectively 7.5 +/- 3.4 ml/h (range 1.6-12.1 ml/h) and 12.4 +/- 2.7 mmHg. Two patterns of Q'ext(csf) were identified: a continuous profile and a discontinuous one with numerous bursts frequently associated with manoeuvres such as cough or chest physiotherapy. The short-term variations of Q'ext(csf) and ICP were usually unrelated.

CONCLUSION

The study stresses the important inter and intra-subject variability of Q'ext(csf) in patients with EVD. The mean Q'ext(csf) is lower than the reference production rate (21 ml/h), raising the question of persistent CSF absorption and/or depressed secretion. The independent changes of Q'ext(csf) and ICP on the short term is likely to be explained by the pressure-volume characteristics of the intracranial space.

Hypersensitivity reactions to neuromuscular blocking agents

Neuromuscular blocking agents are the leading drugs responsible for immediate hypersensitivity reactions during anaesthesia. Most hypersensitivity reactions represent IgE-mediated allergic reactions. Their incidence is estimated to be between 1 in 3,000 to 1 in 110,000 general anaesthetics. However striking variations have been reported among countries. The mechanism of sensitisation seems to implicate the presence of a substituted ammonium ion in the molecule. Due to lack of exposure prior to the reaction in a large number of reactors, it has been hypothesised that sensitisation may involve other, as yet undefined, substituted (quaternary and tertiary) ammonium ion containing compounds such as pholcodine, present in the environment of the patient. This hypothesis is still under investigation. The mechanism of non-IgE mediated hypersensitivity reactions is less well known. Identified mechanisms correspond to direct histamine release or interactions with muscarinic and nicotinic receptors. Allergic reactions cannot be clinically distinguished from non-IgE-mediated reactions. Therefore, any suspected hypersensitivity reaction must be investigated using combined pre and postoperative testing. Because of the frequent but not systematic cross-reactivity observed with muscle relaxants, every available neuromuscular blocking agent should be tested, using intradermal tests to confirm the responsibility of the suspected drug which should be definitely excluded. Cross-sensitivity investigation will also try to identify the safety of drugs that can be potentially used in future anaesthesia. The determination of basophil activation investigations using direct leukocyte histamine release test or flow cytometry would be of particular interest to investigate cross sensitisation in complement to skin tests. There is no demonstrated evidence supporting systematic pre-operative screening in the general population at this time. However, since no specific treatment has been shown to reliably prevent anaphylaxis, allergy assessment must be performed in all high-risk patients. In view of the relative complexity of allergy investigation, and of the differences between countries, an active policy to identify patients at risk and to provide any necessary support from expert advice to anaesthetists and allergologists through the constitution of allergo-anaesthesia centres in every country should be promoted.

[Deleterious role of hyperthermia in neurocritical care]

Fever is a secondary brain injury and may worsen neurological prognosis of neurological intensive care unit (NICU) patients. In response to an immunological threat, fever associates various physiological reactions, including hyperthermia. Its definition may vary but the most commonly used threshold is 37.5 degrees C. In animal studies, hyperthermia applied before, during or after cerebral ischemia may increase the volume of ischemic lesions. The mechanism of this effect may include increase in blood brain barrier permeability, increase in excitatory amino acid release and increase in free radical production. In NICU patients, fever is frequent, occurring in up to 20-30% of patients. Moreover, after haemorrhagic stroke, fever has been reported in 40-50% of patients. In half of the patients, fever may be related to an infectious cause but in more than 25% of patients, hyperthermia may be of central origin. After ischemic stroke, hyperthermia during the first 72 hours is associated with an increase in infarct size and increase in morbidity and mortality. This holds true also after subarachnoid haemorrhage. After traumatic brain injury, fever is not related to mortality but may increase morbidity. Whereas no causal link has been established between fever and unfavourable outcome, it seems reasonable to treat hyperthermia in patients suffering from brain injuries. In such patients, antipyretics have a moderate efficacy. In case of failure, they should be replaced by physical cooling techniques.

Continuous intravenous lidocaine in the treatment of paralytic ileus due to severe spinal cord injury

Paralytic ileus is a major concern in the acute phase of spinal cord injury. Classical treatment with neostigmine is often ineffective. Continuous intravenous (i.v.) lidocaine infusion has been previously proposed intra and post-operatively in order to decrease the duration of post-operative ileus after abdominal surgery. We report the cases of seven patients suffering from complete paralytic spinal cord injury-related ileus with colectasy resistant to neostigmine, who were treated by i.v. lidocaine infusion.

[Transfusion in neurosurgery]

In neurosurgery, the question of the optimal transfusion "trigger" remains a controversial matter. Regarding the brain, the current data are still incomplete, justifying the continuation of experimental and clinical studies. The existing expert advices are based on these rather poor data and would probably evolve after the completion of clinical studies in progress. In spine surgery, the situation is simpler and the transfusional stakes are quite similar to those of orthopedics and traumatology. With regard to hemostasis, standardized recommendations exist depending on the laboratory test results or the anticoagulant treatments of the patient.

Relationship between procalcitonin values and infection in brain-dead organ donors

BACKGROUND AND AIMS

An association between the inflammatory reactions estimated by several biomarkers and organ dysfunction has been reported in brain-dead organ donors (BDOD). Procalcitonin (PCT), a biomarker of inflammation due to bacterial infection, is increased among BDOD. However, is not known whether infection changes PCT values in BDOD.

MATERIALS AND METHODS

We retrospectively analyzed 82 BDOD including several demographic and clinical parameters, bacterial culture results, antibiotics prescription, and plasma values of PCT measured before organ harvesting. Infection was diagnosed to be either a positive bacterial culture (restricted definition) and/or prescription of antibiotics (extended definition).

RESULTS

The median PCT value was 1.5 (interquartile range [IQR], 0.4 to 6.9; range, 0 to 526 ng/mL; n=82). Thirty-eight (46%) and 24 (29%) patients had PCT values>2 ng/mL and >5 ng/mL, respectively. Median PCT values among infected (1.18; IQR, 0.27 to 6.55 ng/mL) versus noninfected (1.57; IQR, 0.53 to 7.15 ng/mL) BDOD (restricted definition) were not different (P=.36). The area under the receiver operating characteristic curve using PCT to predict infection (restricted definition) was 0.52. Specificity of PCT to predict infection was above 80% at PCT values>9 ng/mL.

CONCLUSION

Our results confirmed PCT values are increased in BDOD, suggesting that this was not related to an infectious cause (whatever definition was used) unless PCT values are high.

Neurogenic pulmonary edema

Neurogenic pulmonary edema (NPE) is usually defined as an acute pulmonary edema occurring shortly after a central neurologic insult. It has been reported regularly for a long time in numerous and various injuries of the central nervous system in both adults and children, but remains poorly understood because of the complexity of its pathophysiologic mechanisms involving hemodynamic and inflammatory aspects. NPE seems to be under-diagnosed in acute neurologic injuries, partly because the prevention and detection of non-neurologic complications of acute cerebral insults are not at the forefront of the strategy of physicians. The presence of NPE should be high on the list of diagnoses when patients with central neurologic injury suddenly become dyspneic or present with a decreased P(a)o(2)/F(i)o(2) ratio. The associated mortality rate is high, but recovery is usually rapid with early and appropriate management. The treatment of NPE should aim to meet the oxygenation needs without impairing cerebral hemodynamics, to avoid pulmonary worsening and to treat possible associated myocardial dysfunction. During brain death, NPE may worsen myocardial dysfunction, preventing heart harvesting.

[Cerebral microdialysis as a clinical tool]

Microdialysis is the only technique available for cerebral metabolic monitoring in the clinical setting. By the mean of a probe inserted in the brain, it provides an extracellular space sampling. Values of various substrates including cerebral glucose, lactate, pyruvate, glycerol or glutamate can be obtained at the bedside at intervals between minutes and hours. Values are critically dependent on the flow of the perfusion liquid and reflect a highly localized cerebral metabolism. Cerebral microdialysis improves our understanding of acute neurological events such as intracranial hypertension or decrease in brain tissue oxygen pressure. Cerebral microdialysis can be used for detection of ischaemia, especially after malignant stroke or vasospasm complicating subarachnoid haemorrhage. In these cases, it may influence the therapeutic management. Moreover, it permits the assessment of metabolic changes after therapeutic interventions. Finally, some markers (like lactate/pyruvate ratio) are related to outcome, especially after traumatic brain injury.

[Prevention of venous perioperative thromboembolism in ENT and maxillofacial surgery]

There are few studies of poor methodological quality on the risk of thromboembolism in head and neck surgery. The incidence of symptomatic deep vein thrombosis is estimated between, 0.1% and 0.6%. The patient's risk factors (cancer, alcoholism, smoking, malnutrition) determine for the assessment of the potential benefit of thromboembolism prophylaxis. No method can be recommended based on the literature. In patients receiving anticoagulant therapy undergoing superficial head and neck surgery or dental extraction, the literature suggest to continue anticoagulation throughout the perioperative period.

Thromboprophylaxie en chirurgie rachidienne traumatologique et non traumatologique

The risk of deep vein thrombosis (DVT) after spinal cord injury is very high. Without prophylaxis the incidence of DVT using venography is 81% and the risk of symptomatic DVT is between 12 and 23%. The risk is much lower in elective spine surgery. After discectomy or laminectomy on less than two spine levels, the risk of DVT is less than 1%. After spinal fusion or extended laminectomy, the risk can be estimated between 0.3 and 2.2%. A prophylaxis is recommended for all patients after spinal cord injury (grade A). The association of a mechanical method and heparin is recommended (grade B). The duration of prophylaxis is 3 months in patients with a motor deficit (grade C). No prophylaxis is recommended after discectomy or limited laminectomy in patients without additional risk factors. Mechanical methods are recommended after spinal fusion or extended laminectomy. For patients with additional risk factors a low molecular weight heparin is recommended.

Thromboprophylaxie en neurochirurgie et en neurotraumatologie intracrânienne

The incidence of deep vein thrombosis (DVT) is between 20 and 35% using contrast venography, with a rate of symptomatic DVT between 2.3 and 6% in neurosurgery without any prophylaxis. The risk of DVT is poorly evaluated in head injured patients but is around 5%. Specific risk factors in neurosurgery are: a motor deficit, a meningioma or malignant tumour, a large tumour, age over 60 years, surgery lasting more than 4 hours, a chemotherapy. The benefit of mechanical methods or low molecular weight heparin (LMWH) for the prevention of DVP in neurosurgery is demonstrated (grade A). Each method decreases the risk by about 50%. A postoperative prophylaxis with a LMWH does not seem to increase the risk of intracranial bleeding (grade C). There is no demonstrated benefit to begin a prophylaxis with LMWH before the intervention. The duration of the prophylaxis is 7 to 10 days but this has not been scientifically determined.