Moisture chamber goggles for the treatment of postoperative dry eye in patients receiving SMILE and FS-LASIK surgery.

BACKGROUND: The incidence of refractive surgery-related dry eye disease (DED) is rising due to the increasing popularity of corneal refractive surgery. The moisture chamber goggles (MCGs) have been shown to tear evaporation by increasing local humidity and minimizing airflow. The current study aims to evaluate the efficacy of moisture chamber goggles for refractive surgery-related DED. METHODS: In this nonrandomized open-label controlled study, 78 participants (156 eyes) receiving refractive surgery were enrolled between July 2021 and April 2022, and sequentially allocated to MGC and control groups. 39 participants were allocated to the MGC groups, of which 53.8% received small-incision lenticule extraction (SMILE) and 46.2% received femtosecond laser-assisted in situ keratomileusis (FS-LASIK), and were instructed to wear MCGs for the duration of 1 month postoperatively, in addition to the standard postoperative treatment received by the control groups (56.4% SMILE, 43.6% FS-LASIK). Participants underwent full ophthalmic examinations, including visual acuity, manifest refraction, DED evaluations, and higher-order aberrations (HOAs), both preoperatively and at routine follow-ups 1 day, 1 week, and 1 month after surgery. DED parameters included non-invasive tear film break-up time (NIBUT), tear meniscus height (TMH), conjunctival congestion, lipid layer thickness (LLT), and ocular surface disease index (OSDI) questionnaires. Student's t-test was used for comparisons between control and MCG groups, and between preoperative and postoperative parameters within groups. RESULTS: Postoperative NIBUT decreased in both SMILE and FS-LASIK control groups 1 day after the surgery (SMILE, P = 0.001; FS-LASIK, P = 0.008), but not in the corresponding MCG groups (SMILE, P = 0.097; FS-LASIK, P = 0.331). TMH in the MCG group was significantly higher at 1 week (P = 0.039) and 1 month (P = 0.015) in SMILE, and 1 day (P = 0.003) in FS-LASIK groups. In FS-LASIK participants, significantly lower HOAs and coma levels in the MCG group were observed 1 day (total HOAs, P = 0.023; coma, P = 0.004) and 1 week (total HOAs, P = 0.010, coma, P = 0.004) after surgery. No consistent statistically significant intergroup difference was observed between MCG and control groups in conjunctival congestion, LLT, and OSDI. CONCLUSIONS: MCGs effectively slowed tear evaporation, increased tear film stability, and improved HOAs in patients receiving SMILE and FS-LASIK surgeries. MCG is an effective adjuvant therapy in the comprehensive management of refractive surgery-related DED.

Pentobarbital coma for management of intracranial hypertension following traumatic brain injury: Lack of early response to treatment portends poor outcomes.

INTRODUCTION: Traumatic brain injury (TBI) results in the death of over 50,000 and the permanent disability of 80,000 individuals annually in the United States. Much of the permanent disability is the result of secondary brain injury from intracranial hypertension (ICH). Pentobarbital coma is often instituted following the failure of osmotic interventions and sedation to control intracranial pressure (ICP). The goal of this study was to evaluate the efficacy of pentobarbital coma with respect to ICP management and long-term functional outcome. METHODS: Traumatic brain injury patients who underwent pentobarbital coma at a level 1 trauma center between 2014 and 2021 were identified. Patient demographics, injury characteristics, Glasgow Coma Scale (GCS) scores, intracranial pressures (ICPs), and outcomes were obtained from the trauma registry as well as inpatient and outpatient medical records. The proportion of ICPs below 20 for each hospitalized patient-day was calculated. The primary outcome measured was GCS score at the last follow-up visit. RESULTS: 25 patients were identified, and the majority were male (n â€‹= â€‹23, 92%) with an average age of 30.0 years â€‹± â€‹12.9 and median injury severity score of 30 (21.5-33.5). ICPs were monitored for all patients with a median of 464 (326-1034) measurements. The average hospital stay was 16.9 days â€‹± â€‹11.5 and intensive care stay was 16.9 â€‹± â€‹10.8 days. 9 (36.0%) patients survived to hospital discharge. Mean follow-up time in months was 36.9 â€‹± â€‹28.0 (min-max 3-80). 7 of the 9 surviving patients presented as GCS 15 on follow-up and the remaining were both GCS 9. Patients presenting at last follow-up with GCS 15 had a significantly higher proportion of controlled ICPs throughout their hospitalization compared to patients who expired or with follow-up GCS <15 (GCS 15: 88% â€‹± â€‹10% vs. GCS <15 or dead: 68% â€‹± â€‹22%, P â€‹= â€‹0.006). A comparison of the daily proportion of controlled ICPs by group revealed negligible differences prior to pentobarbital initiation. Groups diverged nearly immediately upon pentobarbital coma initiation with a higher proportion of controlled ICPs for patients with follow-up GCS of 15. CONCLUSION: Patients that do not have an immediate response to pentobarbital coma therapy for ICH universally had poor outcomes. Alternative therapy or earlier palliation should be considered for such patients. In contrast, patients whose ICPs responded quickly to pentobarbital had excellent long-term outcomes.

Duration of cardiopulmonary resuscitation and phenotype of post-cardiac arrest brain injury.

BACKGROUND: Patients resuscitated from cardiac arrest have variable severity of primary hypoxic ischemic brain injury (HIBI). Signatures of primary HIBI on brain imaging and electroencephalography (EEG) include diffuse cerebral edema and burst suppression with identical bursts (BSIB). We hypothesize distinct phenotypes of primary HIBI are associated with increasing cardiopulmonary resuscitation (CPR) duration. METHODS: We identified from our prospective registry of both in-and out-of-hospital CA patients treated between January 2010 to January 2020 for this cohort study. We abstracted CPR duration, neurological examination, initial brain computed tomography gray to white ratio (GWR), and initial EEG pattern. We considered four phenotypes on presentation: awake; comatose with neither BSIB nor cerebral edema (non-malignant coma); BSIB; and cerebral edema (GWR ≤ 1.20). BSIB and cerebral edema were considered as non-mutually exclusive outcomes. We generated predicted probabilities of brain injury phenotype using localized regression. RESULTS: We included 2,440 patients, of whom 545 (23%) were awake, 1,065 (44%) had non-malignant coma, 548 (23%) had BSIB and 438 (18%) had cerebral edema. Only 92 (4%) had both BSIB and edema. Median CPR duration was 16 [IQR 8-28] minutes. Median CPR duration increased in a stepwise manner across groups: awake 6 [3-13] minutes; non-malignant coma 15 [8-25] minutes; BSIB 21 [13-31] minutes; cerebral edema 32 [22-46] minutes. Predicted probability of phenotype changes over time. CONCLUSIONS: Brain injury phenotype is related to CPR duration, which is a surrogate for severity of HIBI. The sequence of most likely primary HIBI phenotype with progressively longer CPR duration is awake, coma without BSIB or edema, BSIB, and finally cerebral edema.

From Mild Gait Difficulties to a Sudden Coma: A Rare Case of Marchiafava-Bignami Disease.

ABSTRACT: In this case report we describe the case of a 66-year old man with subacute gait difficulties, with a progression to confusion coma with multiple generalised epileptic seizures during the following days. Biochemical analysis showed hyperglycaemia, cerebrospinal fluid (CSF) testing showed a mild lymphocytic pleocytosis and an elevated protein and lactate. Broad-spectrum antibiotics and antiviral therapy where initiated. However, all other CSF testing remained negative. Magnetic resonance imaging of the brain showed remarkably symmetric hyperintense T2 white matter lesions most noticable in the corpus callosum. The lesion pattern was suggestive of a metabolic or toxic encephalopathy, the preponderance for the corpus callosum was furthermore suggestive for Marchiafava-Bignami disease (MDB), as was the clinical course since admission of the patient. A high dose IV substitution of vitamin B1, B6 and B12 was started and antibiotic and antiviral therapy was discontinued. After one day the patient showed progressive regaining of consciousness and he returned to premorbid functioning in a matter of 1-2 weeks. MRI of the brain after 1 week showed notable improvement of the white matter lesions. At routine follow-up two weeks later he presented with icterus and a diagnosis of Epstein-Barr virus (EBV) hepatitis was made, lymph node biopsies showed an EBV positive diffuse large cell B-cell lymphoma (DLCBL). MDB is mostly associated with severe alcoholism, with malnourishment being the second leading cause, however there are case reports describing MDB in patients with chronically poorly controlled diabetes mellitus. We hypothesize that his condition may have been precipitated by his poorly controlled diabetes mellitus. However it is also possible that weight loss (probably related to the DLCBL diagnosis) might have contributed to a state of malnourishment and therefore played a role in the aetiology as well.

External ventricular drainage for intracranial hypertension after traumatic brain injury: is it really useful?

PURPOSES: External ventricular drainage (EVD) is frequently used to control raised intracranial pressure after traumatic brain injury. However, the available evidence about its effectiveness in this context is limited. The aim of this study is to evaluate the effectiveness of EVD to control intracranial pressure and to identify the clinical and radiological factors associated with its success. METHODS: For this retrospective cohort study conducted in a Level 1 traumacenter in Paris area between May 2011 and March 2019, all patients with intracranial hypertension and treated with EVD were included. EVD success was defined as an efficient and continuous control of intracranial hypertension avoiding the use of third tier therapies (therapeutic hypothermia, decompressive craniectomy, and barbiturate coma) or avoiding a decision to withdraw life sustaining treatment due to both refractory intracranial hypertension and severity of brain injury lesions. RESULTS: 83 patients with EVD were included. EVD was successful in 33 patients (40%). Thirty-two patients (39%) required a decompressive craniectomy, eight patients (9%) received barbiturate coma. In ten cases (12%) refractory intracranial hypertension prompted a protocolized withdrawal of care. Complications occurred in nine patients (11%) (three cases of ventriculitis, six cases of catheter occlusion). Multivariate analysis identified no independent factors associated with EVD success. CONCLUSION: In a protocol-based management for traumatic brain injury, EVD allowed intracranial pressure control and avoided third tier therapeutic measures in 40% of cases with a favorable risk-benefit ratio.

Is decompressive craniectomy necessary in malignant posterior reversible encephalopathy syndrome with brain edema caused uncal herniation? A case report of reversible coma without surgical decompression.

BACKGROUND: Posterior reversible encephalopathy syndrome (PRES) is considered a benign entity and is usually reversible with only medical management, but persistent neurologic deficits and disability or death can occur without adequate treatment. Favorable outcomes have been associated with surgical decompression in malignant-type PRES in which hemorrhagic transformation or brain stem compression has developed. CASE DESCRIPTION: Here we report a case of malignant PRES in a 61-year-old female of Asian descent in which the disease rapidly progressed to coma and a near-fatal condition with uncal herniation caused by severe brain edema; however, this patient achieved a dramatic recovery without surgical decompression. CONCLUSION: After reviewing previous reports regarding malignant PRES, we propose that hemorrhagic transformation is a crucial indicator for surgical decompression and an important prognostic factor in malignant PRES.

Cardiac arrest patients admitted to intensive care unit after cardiopulmonary resuscitation: a retrospective cohort study to find predictors for mortality

Abstract Background In-hospital cardiac arrest is a common situation in hospital settings. Therefore, healthcare providers should understand the reasons that could affect the results of cardiopulmonary resuscitation. We aimed to determine the independent predictors for poor outcomes after the return of spontaneous circulation in in-hospital cardiac arrest patients, and also look for a relationship between patient's background parameters and the status at intensive care unit. Methods We did a retrospective cohort study using cardiac arrest patients admitted to the intensive care unit after successful cardiopulmonary resuscitation between 2011-2015. Patients' data were gathered from hospital database. Estimated probabilities of survival were computed using the Kaplan-Meier method. Cox proportional hazard models were used to determine associated risk factors for mortality. Results In total, 197 cardiac arrest patients were admitted to anesthesia intensive care unit after successful cardiopulmonary resuscitation in a 4-years period. Of 197 patients, 170 (86.3%) died in intensive care unit. Median of survival days was 4 days. Comorbidity (p= 0.01), higher duration of cardiopulmonary resuscitation (p= 0.02), lower Glasgow Coma Score (p= 0.00), abnormal lactate level (p= 0.00), and abnormal mean blood pressure (p= 0.01) were the main predictors for increased mortality in cardiac arrest patients after intensive care unit admission. Conclusion The consequent clinical status of the patients is affected by the physiological state after return of spontaneous circulation. Comorbidity, higher duration of cardiopulmonary resuscitation, lower arrival Glasgow Coma Score, abnormal lactate level, and abnormal mean blood pressure were the main predictors for increased mortality in patients admitted to the intensive care unit after successful cardiopulmonary resuscitation.

[Permanent central diabetes insipidus after traumatic brain injury. Case report and literature review]. / Razvitie postoyannogo tsentral'nogo nesakharnogo diabeta posle travmaticheskogo povrezhdeniya golovnogo mozga. Klinicheskii sluchai i obzor literatury.

The authors report permanent central diabetes insipidus (CDI) in a patient after severe traumatic brain injury (TBI) in traffic accident. A 16-year-old boy entered to a medical facility in coma (GCS score 6) with the following diagnosis: acute TBI, severe cerebral contusion, subarachnoid hemorrhage, depressed comminuted cranial vault fracture, basilar skull fracture, visceral contusion. CDI was diagnosed in 3 days after injury considering polyuria and hypernatremia (155 mmol/l). Desmopressin therapy was initiated through a feeding tube. Thirst appeared when a patient came out of the coma after 21 days despite ongoing desmopressin therapy. Considering persistent thirst and polyuria, we continued desmopressin therapy in a spray form. Under this therapy, polyuria reduced to 3-3.5 liters per a day. Symptoms of CDI persisted in long-term period (2 years after TBI) while function of adenohypophysis was intact. This case demonstrates a rare development of permanent diabetes insipidus after TBI. CDI manifested only as polyuria and hypernatremia in coma. Thirst joined after recovery of consciousness. Probable causes of CDI were damage to neurohypophysis and partially injury of pituitary stalk because of extended basilar skull fracture and/or irreversible secondary lesion of hypothalamus following diffuse axonal damage after TBI.

Comparison of the Functional Optical Zone in Eyes With High Myopia With High Astigmatism After SMILE and FS-LASIK.

PURPOSE: To compare the functional optical zone (FOZ) in eyes with high myopia with high astigmatism after small incision lenticule extraction (SMILE) and femtosecond laser-assisted laser in situ keratomileusis (FS-LASIK). METHODS: In total, 45 eyes of 45 patients with high myopia with astigmatism greater than 2.00 diopters (D) who underwent SMILE or FS-LASIK were enrolled. The FOZ, optical zone decentration, and corneal aberrations were analyzed using Scheimpflug imaging. These values were then compared between the two groups 6 months postoperatively. RESULTS: No postoperative complications were observed during follow-up. The mean FOZ diameter was 5.03 ± 0.31 mm for the FS-LASIK group and 5.24 ± 0.27 mm for the SMILE group (P = .007), corresponding to reductions of 1.18 ± 0.23 and 1.01 ± 0.21 mm, respectively, compared with the programmed optical zone (POZ) (P = .013). A significant difference was noted in the FOZ on the short axis between the two groups (P = .002), whereas no significant difference was observed on the long axis (P = .088). The FOZ area in the FS-LASIK and SMILE groups was 65.39 ± 6.14% and 70.09 ± 5.46% of the POZ area, respectively (P = .010). There was no significant difference in decentration between the two groups (0.29 ± 0.13 mm for the FS-LASIK group vs 0.30 ± 0.13 mm for the SMILE group, P = .798). A significant increase in spherical aberration was observed in the FS-LASIK group (P < .001). However, the induction of vertical coma was higher in the SMILE group than in the FS-LASIK group (P = .002). CONCLUSIONS: Eyes with high myopia with high astigmatism following SMILE achieved a larger FOZ and less spherical aberration but a larger vertical coma introduction than following FS-LASIK. [J Refract Surg. 2022;38(9):595-601.].

Effect of Age on the Patterns of Traumatic Femoral Fractures: Seven Years of Experience at a Regional Tertiary Hospital.

OBJECTIVE: Femoral fractures are a common cause of mortality and functional loss, mainly among older people, and there are few studies about the age in relation to traumatic femoral fractures. The aim of this study was to investigate the effect of age on the patterns of traumatic femoral fractures in patients presenting to our regional tertiary hospital. METHODS: The records of 2020 patients who presented with traumatic femoral fractures between 2013 and 2019 were retrospectively reviewed. The patients' clinical and radiographic records were reviewed. Univariate and multivariable logistic regression were used to identify independent risk factors for associated injuries and complications. RESULTS: The patients were divided into a child group (CH group, n = 342) aged under 18 years, a young adult group (YA group, n = 484) aged 18-60 years, and an older people group (OP group, n = 1194) aged 60 years and over. There were significant differences among the three groups in several indexes, such as sex ratio (χ2  = 301.699, p < 0.001), osteoporosis (χ2  = 375.463, p < 0.001), injury time of day (χ2  = 114.913, p < 0.001), injury cause (χ2  = 748.187, p < 0.001), injury location (χ2  = 490.153, p < 0.001), fracture side (χ2  = 57.000, p < 0.001), fracture site (χ2  = 806.650, p < 0.001), associated injuries (χ2  = 322.921, p < 0.001), coma after injury (χ2  = 147.814, p < 0.001), non-surgery-related complications (χ2  = 7.895, p = 0.019), and surgery-related complications (χ2  = 82.186, p < 0.001). The YA group had a significantly higher percentage of patients with surgery-related complications than the OP group. The OP group had a higher frequency of non-surgery-related complications than the YA group and CH group. The most common non-surgery-related complications were pneumonia (7.1%) in the OP group and deep venous thrombosis (6.4%) in the YA group. Multivariable logistic regression showed that young adults, high-energy injury, outdoors, coma after injury, and fracture sites except for the proximal region were independent risk factors for associated injuries. Older age, male, and fracture site except for the proximal region were independent risk factors for complications. CONCLUSIONS: Traumatic femoral fractures are mostly the result of low-energy trauma and predominantly affect the proximal site of the femur among older people. A higher rate of shaft fractures, fractures occurring outdoors, and associated injuries were observed among young adults and children than among older people.

Case Report: A Patient With Neuroleptic Malignant Syndrome, Water Intoxication and Hyponatremia Associated With Severe Cerebral Edema and Coma.

Background: Water intoxication is typically caused by primary or psychogenic polydipsia that potentially may lead to fatal disturbance in brain functions. Neuroleptic malignant syndrome (NMS) is a serious complication induced by administration of antipsychotics and other psychotropic drugs. The combination of inappropriate secretion of antidiuretic hormone (SIDAH), NMS and rhabdomyolysis have been rarely reported. Our patient also developed severe water intoxication. Case presentation: Herein we report a comatose case of NMS complicated with water intoxication, syndrome of SIADH and rhabdomyolysis. This patient had severe cerebral edema and hyponatremia that were improved rapidly by the correction of hyponatremia within a couple of days. Conclusions: Malignant neuroleptic syndrome water intoxication, SIADH and rhabdomyolysis can occur simultaneously. Comatose conditions induced by cerebral edema and hyponatremia can be successfully treated by meticulous fluid management and the correction of hyponatremia.

Influence of Decompressive Craniectomy Post Evacuation of Epidural Hematoma in Comatose Patients.

BACKGROUND: Epidural hematoma causing brain herniation is a major cause of mortality and morbidity after severe traumatic brain injury, even if surgical treatment is performed quickly. Decompression may be effective in decreasing intracranial pressure, but its effect on outcomes remains unclear. METHODS: A retrospective analysis of deeply comatose patients (Glasgow Coma Scale score 3-5) who underwent surgical treatment during a 12-year period, either via osteoplastic craniotomy (OC) or decompressive craniectomy, was carried out. Patient groups were compared on the basis of demographics, admission clinical state, head computed tomography imaging characteristics, and discharge outcome. RESULTS: A total of 60 patients were examined. The first group of 31 patients (52%) needed decompression during primary surgery. The second group of 29 patients (48%) underwent OC with evacuation of epidural hematoma without decompression. Both patient groups were similar according to age (40.9 ± 13 vs. 40.6 ± 12.5 years), Glasgow Coma Scale score before surgery (4 [3-5] vs. 4 [3-5]), hematoma thickness (based on computed tomography) (3.44 ± 1 vs. 3.36 ± 1.62 cm), and midline shift (1.42 ± 0.83 vs. 1.36 ± 0.9 cm). Mortality was more evident in the decompression group (45.2% vs. 13.8%; P = 0.008), and the Glasgow Outcome Score was also lower, 2.26 ± 1.5 versus 3.45 ± 1.5 (P = 0.003). CONCLUSIONS: Decompressive craniectomy following the evacuation of an acute epidural hematoma in deeply comatose patients demonstrated inferior outcomes in comparison with OC. Brain injury in the decompressive craniectomy patient group was more severe (concomitant subdural hematoma, early brain ischemia, and early brain herniation), which may have influenced the outcome. Further prospective studies are needed.

Collision of Priorities in Posttraumatic Coma and Suspected Multiple Injuries: A Prospective Multicenter Trial.

OBJECTIVE: The presence of multiple injuries in addition to a traumatic brain injury (TBI) is initially uncertain in most patients with posttraumatic coma. The interdisciplinary team of physicians in charge of initial treatment after hospital admission may face a collision of vital priorities. The purpose of this study was to analyze which diagnostic and surgical measures were given priority over others in comatose patients after injury and to draw conclusions from these data. METHODS: In this prospective multicenter cohort study, the outcomes of 1,003 comatose patients with suspected multiple injuries were studied. The analysis was divided into an early and a late stage. Diagnostic and surgical measures were analyzed for a 6-month period. The prognostic value of the Glasgow Coma Scale (GCS) and the World Federation of Neurosurgical Societies grading scale were investigated. RESULTS: Removal of intracranial hematomas and decompressive craniotomies were the most frequent procedures within the first 48 hours after admission to the hospital. Prognosis depends on the location and the combination of injuries. Outcome is significantly correlated to initial signs of brainstem dysfunction. The GCS did not adequately predict clinical outcome. CONCLUSION: Comatose patients with suspected multiple injuries should only be admitted to hospitals with a continuous neurosurgical service because intracranial operations are more frequent in the first 48 hours than extracranial operations. Depending on the neurologic status of the patient, an urgent surgical decompression may be essential for a good outcome. The GCS alone is not a sufficient tool for the neurologic assessment and the prognosis of patients with multiple injuries. The onset of clinical signs of brainstem dysfunction indicates a critical deterioration of the functioning of the central nervous system. The priority of surgical measures should be tailored accordingly.

[Acute severe oral poisoning with 1,4-butandiol and ethanol with the development of coma]. / Ostroe tyazheloe peroral'noe otravlenie 1,4-butandiolom i etanolom s razvitiem komatoznogo sostoyaniya.

A case of acute oral poisoning by 1.4-butanediol, complicated by the development of severe hypoxia in a 34-year-old patient actively engaged in bodybuilding, is presented. The psychoactive substance was used by the patient to increase sexual activity and physical stamina. The duration of systematic daily intake was 4 months. The toxicogenic stage of acute poisoning was caused by a single dose of 50 ml of undiluted 13% 1.4-butanediol together with ethanol, manifested by convulsive syndrome, depression of consciousness to the level of coma II, acute respiratory failure with aspiration syndrome, respiratory acidosis (pH 7.22; partial pressure carbon dioxide 61.2 mm Hg), lactic acidosis up to 7 mmol / L, hyperammonemia up to 240 µmol / L, cerebral edema (decrease in white matter density to 21.6 ± 1.7 HU units), loss of vascular tone resistance (pareso arterioles) and a significant increase in cerebral blood flow rate to 115 ± 20.1 ml / 100 g per minute, increasing the volume of extracellular fluid (+ 130% of the proper volumes). Intensive therapy was complex, including infusion and detoxification therapy, correction of acid-base disorders, hypoxic disorders by using a substrate antihypoxant (Cytoflavin) in a daily dosage of 0.57 ml / kg body weight daily, for 9 days. The article discusses the toxicokinetics and toxicodynamics of 1.4-butanediol, radiation diagnostics and the clinical picture of acute poisoning, the features of its course, and pathogenetic approaches to therapy.

Low dose Iloprost effect on platelet aggregation in comatose out-of-hospital cardiac arrest patients: A predefined sub-study of the ENDO-RCA randomized -phase 2- trial.

PURPOSE: This is a predefined sub-study of the Endothelial Dysfunction in Resuscitated Cardiac Arrest (ENDO-RCA) trial. We aim to investigate Iloprost, a prostacyclin analogue, safety by evaluating change in whole blood platelet aggregometry (Multiplate) in out of hospital cardiac arrest (OHCA) patients from baseline to 96-h post randomization. METHODS: A randomized, placebo controlled double-blinded trial in 46 OHCA patients. Patients were allocated 1:2 to 48 h Iloprost infusion, (1 ng/kg/min) or placebo (saline infusion). Platelet aggregation was determined by platelet aggregation tests ASPI-test (arachidonic acid); TRAP-test (thrombin-receptor activating peptide (TRAP)-6; RISTO test (Ristocetin); ADP test (adenosin diphosphat). RESULTS: There was no significant difference between the iloprost and placebo groups according to ASPI, TRAP, RISTO and ADP platelet aggregation assays. Further, no significant differences regarding risk of bleeding were found between groups (Risk of bleeding: ASPI <40 U; TRAP <92 U; RISTO <35 U; ADP <50 U). CONCLUSIONS: In conclusion, the iloprost infusion did not influence platelet aggregation as evaluated by the ASPI, TRAP, RISTO and ADP assays. There was no increased risk of bleeding or transfusion therapy. A decline in platelet aggregation was observed for the ASPI and ADP assays during the initial 96 h after OHCA. TRIAL REGISTRATION: Trial registration at clinicaltrials.gov (identifier NCT02685618) on 18-02-2016.

Neurological outcome of postanoxic refractory status epilepticus after aggressive treatment.

Refractory status epilepticus (RSE) occurs in up to 30% of patients following resuscitation after cardiac arrest. The impact of aggressive treatment of postanoxic RSE on long-term neurological outcome remains uncertain. We investigated neurological outcome of cardiac arrest patients with RSE treated with a standardized aggressive protocol with antiepileptic drugs and anesthetics, compared with patients with other electroencephalographic (EEG) patterns. A prospective cohort of 166 consecutive patients with cardiac arrest in coma was stratified according to four independent EEG patterns (benign; RSE; generalized periodic discharges (GPDs); malignant nonepileptiform) and multimodal prognostic indicators. Primary outcomes were survival and cerebral performance category (CPC) at 6 months. Refractory status epilepticus occurred in 36 patients (21.7%) and was treated with an aggressive standardized protocol as long as multimodal prognostic indicators were not unfavorable. Refractory status epilepticus started after 3 ±â€¯2.3 days after cardiac arrest and lasted 4.7 ±â€¯4.3 days. A benign electroencephalographic patterns was recorded in 76 patients (45.8%), a periodic pattern (GPDs) in 13 patients (7.8%), and a malignant nonepileptiform EEG pattern in 41 patients (24.7%). The four EEG patterns were highly associated with different prognostic indicators (low flow time, clinical motor seizures, N20 responses, neuron-specific enolase (NSE), neuroimaging). Survival and good neurological outcome (CPC 1 or 2) at 6 months were 72.4% and 71.1% for benign EEG pattern, 54.3% and 44.4% for RSE, 15.4% and 0% for GPDs, and 2.4% and 0% for malignant nonepileptiform EEG pattern, respectively. Aggressive and prolonged treatment of RSE may be justified in cardiac arrest patients with favorable multimodal prognostic indicators. This article is part of the Special Issue "Proceedings of the 7th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures".

Real and illusory perceptions of patients in induced coma / Percepciones reales e ilusorias de pacientes en coma inducido / Percepções reais e ilusórias de pacientes em coma induzido

ABSTRACT Objective: To identify, in the scientific literature, real and illusory perceptions of adult patients in induced coma. Methods: This is an integrative review of 15 primary studies from the Medline, Web of Science, LILACS, CINAHL and SCOPUS databases. Results: The main memories reported after induced coma were thirst, cold, and pain. In some studies, patients reported they were unable to tell whether they were awake or dreaming, whether it was real or unreal. Satisfactory memories were reported by patients related to the care received and the use of bedside journals. Conclusion: Evidence showed a number of studies aiming to identify delirium, but without a focus on analyzing real or illusory perceptions of patients after induced coma. Thus, this integrative review identified scientific evidence of memories related to perceptions of sedated patients in the intensive care unit.

RESUMEN Objetivo: Identificar, a partir de la literatura científica, percepciones reales e ilusorias de pacientes adultos en coma inducido. Método: Revisión integrativa de 15 estudios primarios alojados en las bases de datos Medline, Web of Science, LILACS, CINAHL y SCOPUS. Resultados: Los recuerdos más reportados luego del coma inducido son sed, frío y dolor. Existen estudios en los que los pacientes afirmaron no distinguir si estaban despiertos o soñando, si era real o irreal. Se identificaron relatos de recuerdos satisfactorios relacionados al cuidado recibido y al uso diario de cabecera. Conclusión: Las evidencias mostraron un abanico de estudios cuyo objetivo era identificar el delirium, aunque con menor enfoque en la identificación real o ilusoria del paciente luego del coma inducido. Así, esta revisión integrativa consiguió identificar evidencias científicas acerca de los recuerdos relativos a la percepción del paciente sedado e internado en la Unidad de Terapia Intensiva.

RESUMO Objetivo: Identificar, a partir da literatura científica, percepções reais e ilusórias de pacientes adultos em coma induzido. Método: Revisão integrativa de 15 estudos primários localizados nas bases de dados Medline, Web of Science, LILACS, CINAHL e SCOPUS. Resultados: As principais memórias relatadas após o coma induzido são sede, frio e dor. Há estudos em que os pacientes afirmaram não distinguir se estavam acordados ou sonhando, se o que acontecia era real ou irreal. Identificaram-se relatos de memórias satisfatórias relacionadas ao cuidado recebido e ao uso de diários de cabeceira. Conclusão: As evidências mostraram um leque de estudos direcionados a identificar o delirium, porém com menor foco na identificação da percepção real ou ilusória do paciente após coma induzido. Desse modo, esta revisão integrativa proporcionou a identificação de evidências científicas sobre as memórias relativas à percepção do paciente sedado e em estadia na Unidade de Terapia Intensiva.

Recurrent moderate hypoglycemia exacerbates oxidative damage and neuronal death leading to cognitive dysfunction after the hypoglycemic coma.

Moderate recurrent hypoglycemia (RH) is frequent in Type 1 diabetes mellitus (TIDM) patients who are under intensive insulin therapy increasing the risk for severe hypoglycemia (SH). The consequences of RH are not well understood and its repercussions on neuronal damage and cognitive function after a subsequent episode of SH have been poorly investigated. In the current study, we have addressed this question and observed that previous RH during seven consecutive days exacerbated oxidative damage and neuronal death induced by a subsequent episode of SH accompanied by a short period of coma, in the parietal cortex, the striatum and mainly in the hippocampus. These changes correlated with a severe decrease in reduced glutathione content (GSH), and a significant spatial and contextual memory deficit. Administration of the antioxidant, N-acetyl-L-cysteine, (NAC) reduced neuronal death and prevented cognitive impairment. These results demonstrate that previous RH enhances brain vulnerability to acute hypoglycemia and suggests that this effect is mediated by the decline in the antioxidant defense and oxidative damage. The present results highlight the importance of an adequate control of moderate hypoglycemic episodes in TIDM.