Aug/Sept 2014

Dr I Tweedie For the purpose of this month’s papers the Aug/Sept issues of the following journals were perused: BJNS, JNSA, Neurosurgery, Neurocritical Care, Intensive Care Medicine, Critical Care Medicine, Neurology, Neurosurgery and Psychiatry, and Journal of Neurotrauma. The following articles were selected as they represent present issues or concerns such as old age anaesthesia, urgent care of SAH, debunking a myth and a consensus statement from international experts. Stovell MG, Jenkinson MD. Neurosurgery in Octogenarians. BJNS 2014; 28(5): 611-615 It is a retrospective single centre review of all patients over the age of 80 accepted for neurosurgical intervention. Thus it starts off with selection bias as presumably there were many patients of this age referred with neurosurgical pathology but not accepted as deemed inappropriate for treatment. The results are not surprising in that the emergency patients had poorer outcomes and greater mortality than the elective patients. However overall for this group 30 day mortality was 8.2% (2% elect: 12% emerg), with 69% assessed as being a good outcome at 6 months. Although this was a small study in terms of numbers, it does suggest that general nihilism in this age group is clearly inappropriate. Oudshoorn SC, Rinkel GJE, Molyneux AJ, Kerr RS, Dorhout Mees SM, Backes D, Algra A, Vergouwen MDI. Aneurysm Treatment <24 Versus 24–72 h After Subarachnoid Hemorrhage. Neurocrit Care 2014; 21(1):4–13. Ed. Bojanowski MW. Considerations About Ultra-early Treatment of Ruptured Aneurysms. Neurocrit Care 2014; 21(1):1-3. The above article and accompanying editorial look at the evidence of outcome benefit to support very early intervention in the treatment of aneurysmal SAH. The Utrecht paper is a retrospective review of their own data and also that of ISAT, separating out the patients who received definitive treatment in < 24 hours from Ictus and those who were treated at 24-72 hours. Part of the rationale of this study was to see if there was a significantly better outcome in the early treated group, such that the service providing emergency cover 24/7 is justified and needed. Their figures would suggest that outcome does not appear to be any better in either group, but they are cautious of recommending that this proves that a delay is not detrimental to the patients. The editorial provides a general and supportive comment to the paper and also provides a few historical insights to how far we have come. Zeiler FA, Teitelbaum J, West M, Gillman LM. The Ketamine Effect on ICP in Traumatic Brain Injury. Neurocrit Care 2014; 21(1): 163-173. This is a systematic review of the literature with regard to prospective studies which have documented the use of Ketamine in patients with TBI, whilst having evidence of ICP monitoring. Many text books have continued to state that caution needs to be used with Ketamine when there may be concerns with intracranial pressure, despite there being no clear evidence that it does cause an uncontrollable rise. The studies reviewed by this paper all suggest that ICP does not rise when Ketamine is administered either by bolus or continuous infusion to patients with TBI if they are already intubated and ventilated. They grade it as Oxford level 2b, grade C evidence. They suggest that specific prospective studies are required to answer this question fully. Le Roux P, Menon DK, Citerio G, et al. Consensus summary statement of the International Multidisciplinary Consensus Conference on Multimodality Monitoring in Neurocritical Care – A statement for healthcare professionals from the Neurocritical Care Society and the European Society of Intensive Care Medicine. Intensive Care Med 2014; 40:1189–1209 Expert consensus documents are often a useful source of evidence to support clinical practice. This one specifically looks at what evidence there is to justify the use of and the value in terms of outcomes of a variety of monitoring techniques relevant to Neurocritical care and based on that makes recommendations. It is a long read but covers a wide variety of areas including what is of use in clinical assessment of neuro-ICU patients, including conscious level and sedation level scoring.