Minimally Invasive Drainage of Intracerebral Hemorrhage. A South American Experience with the MISTIE Procedure.

BACKGROUND: Intracerebral hemorrhage (ICH) is the second most common subtype of stroke but is associated with greater rates of disability or mortality. One of the factors of a poor prognosis is large hematoma volume. The MISTIE III trial with the aim of decreasing clot size showed that the greater the ICH reduction, the higher likelihood of lower mortality without a net increase in the proportion of patients with severe disability. Our aim is to describe our experience with treating selective patients with ICH per the MISTIE trial protocol in a university hospital in Argentina during 4 years. METHODS: A retrospective analysis was performed of consecutive patients with ICH treated at a single university tertiary-care center from 2017 to 2021 with the MISTIE protocol. RESULTS: We deployed this procedure in 7 patients with a median age of 61 years, median National Institutes of Health Stroke Scale score of 14, an ICH volume of 35 mL and median ICH score of 2. Five of 7 patients achieved the target goal of hematoma reduction; 4 of the patients had a total independence level and 1 needed minimal help at 12 months after discharge. Five patients had a good functional outcome (modified Rankin Scale score 0-3 and extended Glasgow Outcome Scale score 4-8) and 2 patients had died but neither because of consequences of thrombolysis of the intracerebral hemorrhage. We did not find bleeding complications during catheter placement, alteplase infusion, or after catheter removal. CONCLUSIONS: The procedure can be carried out safely in Latin American centers that have experience in managing neurocritical patients.

Reversible focal intracranial hypertension swine model with continuous multimodal neuromonitoring.

BACKGROUND: Intracranial hypertension (HI) is associated with worse neurological outcomes and higher mortality. Although there are several experimental models of HI, in this article we present a reproducible, reversible, and reliable model of intracranial hypertension, with continuous multimodal monitoring. NEW METHOD: A reversible intracranial hypertension model in swine with multimodal monitoring including intracranial pressure, arterial blood pressure, heart rate variation, brain tissue oxygenation, and electroencephalogram is developed to understand the relationship of ICP and EEG. By inflating and deflating a balloon, located 20 mm anterior to the coronal suture and a 15 mm sagittal suture, we generate intracranial hypertension events and simultaneously measure intracranial pressure and oxygenation in the contralateral hemisphere and the EEG, simulating the usual configuration in humans. RESULTS: We completed 5 experiments and in all of them, we were able to complete at least 6 events of intracranial hypertension in a stable and safe way. For events of 20-40 mmHg of ICP we need an median (IQR) of 4.2 (3.64) ml of saline solution into the Foley balloon, a median (IQR) infusion time of 226 (185) second in each event and for events of 40-50 mmHg of ICP we need a median (IQR) of 5.1 (4.66) ml of saline solution, a median (IQR) infusion time of 280 (48) seconds and a median (IQR). The median (IQR) maintenance time was 352 (77) seconds and 392 (166) seconds for 20-40 mmHg and 40-50 mmHg of ICP, respectively. COMPARISON WITH EXISTING METHOD(S): Existing methods do not include EEG measures and do not present the reversibility of intracranial hypertension. CONCLUSIONS: Our model is fully reproducible, it is capable of generating reversible focal intracranial hypertension through strict control of the injected volume, it is possible to generate different infusion rates of the volume in the balloon, in order to generate different scenarios, the data obtained are sufficient to determine the brain complacency in real time. and useful for understanding the pathophysiology of ICP and the relationship between ICP (CPP) and EEG.

Implementation and results of a new ECMO program for lung transplantation and acute respiratory distress.

OBJECTIVE: The development of the extracorporeal membrane oxygenation in Latin America represents a challenge in this specialty field. The objective of this article was to describe the results of a new extracorporeal membrane oxygenation program in an intensive care unit. METHODS: This retrospective cohort study included 22 patients who required extracorporeal membrane oxygenation and were treated from January 2011 to June 2014. The baseline characteristics, indications, duration of the condition, days on mechanical ventilation, days in the intensive care unit, complications, and hospital mortality were evaluated. RESULTS: Fifteen patients required extracorporeal membrane oxygenation after lung transplantation, and seven patients required oxygenation due to acute respiratory distress. All transplanted patients were weaned from extracorporeal membrane oxygenation with a median duration of 3 days (Interquartile range - IQR: 2 - 5), were on mechanical ventilation for a median of 15.5 days (IQR: 3 - 25), and had an intensive care unit stay of 31.5 days (IQR: 19 - 53) and a median hospital stay of 60 days (IQR: 36 - 89) with 20% mortality. Patients with acute respiratory distress had a median oxygenation membrane duration of 9 days (IQR: 3 - 14), median mechanical ventilation time of 25 days (IQR: 13 - 37), a 31 day stay in therapy (IQR: 11 - 38), a 32 day stay in the hospital (IQR: 11 - 41), and 57% mortality. The main complications were infections (80%), acute kidney failure (43%), bleeding at the surgical site and at the site of cannula placement (22%), plateletopenia (60%), and coagulopathy (30%). CONCLUSION: In spite of the steep learning curve, we considered this experience to be satisfactory, with results and complications comparable to those reported in the literature.

Implementación y resultados de un nuevo programa de ECMO para trasplante de pulmón y distrés respiratorio agudo / Implementation and results of a new ECMO program for lung transplantation and acute respiratory distress

RESUMEN Objetivo: El desarrollo de la membrana de oxigenación extracorpórea en América Latina representa un desafío para la especialidad. El objetivo de este artículo fue describir los resultados de un nuevo programa de membrana de oxigenación extracorpórea en una unidad de cuidados intensivos. Métodos: Estudio de cohorte retrospectivo. Incluye 22 pacientes que requirieron membrana de oxigenación extracorpórea desde Enero de 2011 hasta Junio de 2014. Se evaluaron características basales, indicaciones, duración de la corrida, días de ventilación mecánica, días de unidad de cuidados intensivos, complicaciones y mortalidad hospitalaria. Resultados: Quince pacientes requirieron membrana de oxigenación extracorpórea post-trasplante pulmonar y 7 pacientes por distrés respiratorio agudo. Todos los pacientes trasplantados fueron destetados de membrana de oxigenación extracorpórea, con una duración mediana de 3 días (Rango intercuantil - IQR: 2 - 5), de ventilación mecánica 15,5 días (IQR: 3 - 35), de estadía unidad de cuidados intensivos 31,5 días (IQR: 19 - 53) y de estadía hospitalaria 60 días (IQR: 36 - 89), con una mortalidad de 20%. Los pacientes con distrés respiratorio agudo tuvieron una mediana de duración de membrana de oxigenación extracorpórea de 9 días (IQR: 3 - 14), mediana de ventilación mecánica 25 días (IQR: 13 - 37), de estadía en terapia 31 días (IQR: 11 - 38), y hospitalaria 32 días (IQR: 11 - 41), y 57% de mortalidad. Las principales complicaciones fueron infecciones (80%), insuficiencia renal aguda (43%), sangrados en sitio quirúrgico y de inserción de cánulas (22%), plaquetopenia (60%) y coagulopatía (30%). Conclusión: A pesar de encontrarnos transitando una curva de aprendizaje, consideramos la experiencia satisfactoria, con resultados y complicaciones comparables a las reportadas en la literatura. .

ABSTRACT Objective: The development of the extracorporeal membrane oxygenation in Latin America represents a challenge in this specialty field. The objective of this article was to describe the results of a new extracorporeal membrane oxygenation program in an intensive care unit. Methods: This retrospective cohort study included 22 patients who required extracorporeal membrane oxygenation and were treated from January 2011 to June 2014. The baseline characteristics, indications, duration of the condition, days on mechanical ventilation, days in the intensive care unit, complications, and hospital mortality were evaluated. Results: Fifteen patients required extracorporeal membrane oxygenation after lung transplantation, and seven patients required oxygenation due to acute respiratory distress. All transplanted patients were weaned from extracorporeal membrane oxygenation with a median duration of 3 days (Interquartile range - IQR: 2 - 5), were on mechanical ventilation for a median of 15.5 days (IQR: 3 - 25), and had an intensive care unit stay of 31.5 days (IQR: 19 - 53) and a median hospital stay of 60 days (IQR: 36 - 89) with 20% mortality. Patients with acute respiratory distress had a median oxygenation membrane duration of 9 days (IQR: 3 - 14), median mechanical ventilation time of 25 days (IQR: 13 - 37), a 31 day stay in therapy (IQR: 11 - 38), a 32 day stay in the hospital (IQR: 11 - 41), and 57% mortality. The main complications were infections (80%), acute kidney failure (43%), bleeding at the surgical site and at the site of cannula placement (22%), plateletopenia (60%), and coagulopathy (30%). Conclusion: In spite of the steep learning curve, we considered this experience to be satisfactory, with results and complications comparable to those reported in the literature. .