Enteral nutrition in the hemodynamically unstable critically ill patient.

The benefit of enteral nutrition in critically ill patients has been demonstrated by several studies, especially when it is started early, in the first 24-48h of stay in the Intensive Care Unit, and this practice is currently advised by the main clinical guidelines. The start of enteral nutrition is controversial in patients with hemodynamic failure, since it may trigger intestinal ischemia. However, there are data from experimental studies in animals, as well as from observational studies in humans that allow for hypotheses regarding its beneficial effect and safety. Interventional clinical trials are needed to confirm these findings.

Contralateral extraaxial hematomas after urgent neurosurgery of a mass lesion in patients with traumatic brain injury.

PURPOSE: The development of a contralateral extraaxial hematoma has repeatedly been described in small series and descriptive studies. However, the evidence available to date is limited. OBJECTIVES: To evaluate the incidence and risk factors leading to the development of a contralateral extraaxial hematoma and to describe the characteristics of cases. METHODS: A retrospective cohort study with prospective data collection was undertaken. All patients admitted to an intensive care unit (ICU) from 2006 to 2010 were studied. The inclusion criteria were as follows: severe trauma [Injury Severity Score (ISS ≥ 16)], neurosurgery (NeuroSx) in the first 24 h. The following were excluded: subacute/chronic subdural hematomas, first bilateral NeuroSx. Cases were those who required immediate contralateral NeuroSx after the first NeuroSx due to the occurrence of a new extraaxial injury or significant growth of a previous one. Controls were those patients those who did not require second NeuroSx or who required reoperation due to ipsilateral lesions. The variables considered were: demographics, neurological assessment, traumatic injuries and severity, image and surgical findings, clinical course, and outcome. Statistics analysis comprised descriptive, inferential, and multivariate analysis by logistic regression. RESULTS: A total of 120 patients were included, among which there were 11 cases (incidence 9.2 %). The cases showed a significantly higher frequency of coma or severe traumatic brain injury (TBI) at admission, contralateral injury and contralateral skull fracture in the preoperative computed tomography (CT) scan, as well as decompressive craniectomy. There were no significant differences in the severity scores, clinical course, or outcomes. The presence of contralateral fracture was identified as an independent risk factor [relative risk (RR) 47.9, 95 % confidence interval (CI) 5.2-443]. CONCLUSIONS: Contralateral extraaxial hematoma is a rare entity, although it has a high mortality rate. Therefore, it requires a high index of suspicion, especially in patients with severe TBI, with minimal contralateral injury and mainly with contralateral skull fracture on the initial CT scan.