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Wang J, Fang Y, Ramesh S, Zakaria A, Putman MT, Dinescu D, Paik J, Geocadin RG, Tahsili-Fahadan P, Altaweel LR. Intraosseous Administration of 23.4% NaCl for Treatment of Intracranial Hypertension. Neurocrit Care 2020; 30:364-371. [PMID: 30397844 DOI: 10.1007/s12028-018-0637-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND/OBJECTIVE Prompt treatment of acute intracranial hypertension is vital to preserving neurological function and frequently includes administration of 23.4% NaCl. However, 23.4% NaCl administration requires central venous catheterization that can delay treatment. Intraosseous catheterization is an alternative route of venous access that may result in more rapid administration of 23.4% NaCl. METHODS Single-center retrospective analysis of 76 consecutive patients, between January 2015 and January 2018, with clinical signs of intracranial hypertension received 23.4% NaCl through either central venous catheter or intraosseous access. RESULTS Intraosseous cannulation was successful on the first attempt in 97% of patients. No immediate untoward effects were seen with intraosseous cannulation. Time to treatment with 23.4% NaCl was significantly shorter in patients with intraosseous access compared to central venous catheter (p < 0.0001). CONCLUSIONS Intraosseous cannulation resulted in more rapid administration of 23.4% NaCl with no immediate serious complications. Further investigations to identify the clinical benefits and safety of hypertonic medication administration via intraosseous cannulation are warranted.
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Affiliation(s)
- Jing Wang
- Neuroscience Intensive Care Unit, Medical Critical Care Service, Department of Medicine, INOVA Fairfax Hospital, 3300 Gallows Rd, Falls Church, VA, 22042, USA
| | - Yun Fang
- Neuroscience Intensive Care Unit, Medical Critical Care Service, Department of Medicine, INOVA Fairfax Hospital, 3300 Gallows Rd, Falls Church, VA, 22042, USA
| | - Subhashini Ramesh
- Neuroscience Intensive Care Unit, Medical Critical Care Service, Department of Medicine, INOVA Fairfax Hospital, 3300 Gallows Rd, Falls Church, VA, 22042, USA
| | - Asma Zakaria
- Neuroscience Intensive Care Unit, Medical Critical Care Service, Department of Medicine, INOVA Fairfax Hospital, 3300 Gallows Rd, Falls Church, VA, 22042, USA
| | - Maryann T Putman
- Neuroscience Intensive Care Unit, Medical Critical Care Service, Department of Medicine, INOVA Fairfax Hospital, 3300 Gallows Rd, Falls Church, VA, 22042, USA
| | - Dan Dinescu
- Neuroscience Intensive Care Unit, Medical Critical Care Service, Department of Medicine, INOVA Fairfax Hospital, 3300 Gallows Rd, Falls Church, VA, 22042, USA
| | - James Paik
- Neuroscience Intensive Care Unit, Medical Critical Care Service, Department of Medicine, INOVA Fairfax Hospital, 3300 Gallows Rd, Falls Church, VA, 22042, USA
| | - Romergryko G Geocadin
- Neurocritical Care Unit Division, Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | - Pouya Tahsili-Fahadan
- Neuroscience Intensive Care Unit, Medical Critical Care Service, Department of Medicine, INOVA Fairfax Hospital, 3300 Gallows Rd, Falls Church, VA, 22042, USA.,Neurocritical Care Unit Division, Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | - Laith R Altaweel
- Neuroscience Intensive Care Unit, Medical Critical Care Service, Department of Medicine, INOVA Fairfax Hospital, 3300 Gallows Rd, Falls Church, VA, 22042, USA. .,Neuroscience Research, Neuroscience and Spine Institute, INOVA Fairfax Hospital, Falls Church, VA, USA.
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Abstract
Respiratory impairment in myasthenia gravis is usually attributed to weakness of the diaphragm and thoracic chest wall muscles, and is rarely attributed to upper airway obstruction. Myasthenia gravis is characterized by weakness of the striated muscles and usually affects those innervated by the bulbar cranial nerves. Weakness of these bulbar and upper airway muscles can lead to upper airway obstruction. To our knowledge, there are only five case reports in the literature associating upper airway obstruction with myasthenia gravis. Therefore, we attempted to further define its occurrence in myasthenia gravis patients by reviewing their flow volume loops. We present a case of upper airway obstruction causing respiratory symptoms in a myasthenia gravis patient. We then surveyed a total of 61 patients with myasthenia gravis who were tested in our pulmonary function laboratory between February 1990 and August 1993. Of these 61 patients, 12 had flow volume loops and 7 of these 12 disclosed a pattern of extrathoracic upper airway obstruction. The FVC was 80% or more in five of seven patients. Our data suggest that upper airway obstruction is much more common in patients with myasthenia gravis than previously recognized. In conclusion, we recommend the performance of flow volume loops in patients with myasthenia gravis to evaluate their respiratory impairment.
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Affiliation(s)
- M T Putman
- Department of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, USA
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