Observational case series: six neurosurgical patients with septic shock demonstrating clinical improvement after a combination of standard care and blood purification.

BACKGROUND: For patients with primary brain injury, septic shock is especially dangerous due to the possibility of secondary cerebral damage. The key factor of sepsis-associated brain injury is inflammatory mediators, pathogen and damage-associated molecular patterns (PAMPs, DAMPs) release. Theoretically, blood purification may be beneficial for patients with primary brain injury due to its possibility for fast removal of inflammatory mediators. CASE PRESENTATION: We report on six post-neurosurgery septic shock patients treated with combined blood purification (CBP), which included CRRT with high adsorption capacity membrane in combination with CytoSorb adsorber. Clinical improvement in the course of CBP was registered in all patients. Three patients had a stable clinical improvement; the other three patients had only a transient improvement due to underlying neurological and cardiac deficits aggravation. We observed septic shock reversal in four patients. The key observations of the case series are a significant decrease in MOF severity (measured by SOFA score) and in catecholamine need (not statistically significant). By the end of CBP we observed a significant decrease in blood lactate, PCT and IL-6 levels. Two patients demonstrated level of consciousness increase in the setting of CBP therapy measured by GCS and FOUR score. CONCLUSION: This case series demonstrates that CBP therapy may have a role for septic shock patients with primary brain injury.

[Influence of cerebral hyperthermia on intracranial pressure and autoregulation of cerebral circulation in patients with acute brain injury]. / Vliyanie tserebral'noi gipertermii na vnutricherepnoe davlenie i autoregulyatsiyu mozgovogo krovotoka u patsientov s ostroi tserebral'noi patologiei.

Background. Hyperthermia is a common symptom in ICU patients with brain injury. OBJECTIVE: To study the effect of hyperthermia on intracranial pressure (ICP) and cerebral autoregulation (Prx). MATERIAL AND METHODS: There were 8 patients with acute brain injury, signs of brain edema and intracranial hypertension. Cerebral autoregulation was assessed by using of PRx. ICP, CPP, BP, PRx were measured before and during hyperthermia. We have analyzed 33 episodes of cerebral hyperthermia over 38.30 C. Statistica 10.0 (StatSoft) was used for statistical analysis. RESULTS: Only ICP was significantly increased by 6 [3; 11] mm Hg (p<0.01). In patients with initially normal ICP, hyperthermia resulted increase of ICP in 48% of cases (median 24 [22; 28] mm Hg). In patients with baseline intracranial hypertension, progression of hypertension was noted in 100% cases (median 31 [27; 32] mm Hg) (p<0.01). Hyperthermia resulted intracranial hypertension regardless brain autoregulation status. CONCLUSION: Cerebral hyperthermia in patients with initially normal ICP results intracranial hypertension in 48% of cases. In case of elevated ICP, further progression of intracranial hypertension occurs in 100% of cases. Cerebral hyperthermia is followed by ICP elevation in both intact and impaired cerebral autoregulation.

[Severe postoperative intracranial hemorrhagic complications in a neurosurgical patient with von Willebrand disease not diagnosed before surgery (a case report and literature review)]. / Tiazhelye posleoperatsionnye intrakranial'nye gemorragicheskie oslozhneniia u neirokhirurgicheskogo bol'nogo s ne diagnostirovannoi do operatsii bolezn'iu Villebranda (klinicheskoe nabliudenie i obzor literatury).

The article describes a rare clinical case of a patient with previously undiagnosed von Willebrand disease and basal meningioma; an intracranial neurosurgical intervention was complicated by delayed intracranial hematomas, both at the resected tumor site and distantly. The diagnosis of von Willebrand disease was established only after special hematology tests and only after surgery. Despite the use of specific therapy, the patient died due to intracranial hemorrhagic complications in the postoperative period. The paper discusses the problem of preoperative diagnosis of asymptomatic hemostasis disorders in neurosurgical patients and potential ways of its solution.

[Paradoxical air embolism resulted in acute myocardial infarction and massive ischemic brain injury in a patient operated on in a sitting position].

Paradoxical air embolism (PAE) is a rare life-threatening complication when air emboli enter arteries of the systemic circulation and cause their occlusion. Here, we describe a clinical case of PAE developed during neurosurgery in a patient in the sitting position. PAE led to injuries to the cerebral blood vessels, coronary arteries, and lungs, which caused death of the patient. An effective measure for preventing PAE is abandoning surgery in the sitting position in favor of surgery in the prone position.

[SEPTIC SHOCK IN PATIENT WITH SEVERE HEAD TRAUMA].

The clinical observation illustrates the role of screening of inflammatory markers and advanced hemodynamic monitoring in optimization of the treatment of the patient with severe traumatic brain injury (sTBI). The level of consciousness by the Glasgow Coma Scale at admission was 5 points. From the first day of stay the patient suffered hyperthermia to 39,0° C° The diagnosis of the aspiration pneumonia was determined by radiological signs, bronchoscopy and inflammatory blood markers, C-reactive protein, leukocytosis. From the second day the constant infusion of norepinephrine was necessary to maintain mean ABP above 80 mmHg. On the 10th day the patient's condition deteriorated sharply. Developed hyperthermia to 40, 2° and cardiovascular collapse (in spite of the high level of norepinephrine support a sharp decline in ABP up to 49/20 mmHg). Invasive advanced hemodynamic PiCCO monitoring (transpulmonary thermodilution) was started Septic shock was suspected. Standard laboratory tests did not meet the criteria for septic shock. Witnessed a slight increase in CRP and procalcitonin (PCT) was within normal limits. Diagnostic search was supplemented by a study of interleukins (IL-6 and IL-2R) in the blood plasma. The significant increase in their values, was regarded as the initial manifestations of the systemic inflammatory response. Sepsis was confirmed. The extended antibiotic therapy started Continuous Veno-Venous hemofiltration was used as part of treatment of the inflammatory-toxic condition. In two days of the therapy the patient's condition has stabilized, the patient recovered consciousness in the form of opening the eyes, simple instructions. At discharge, the patient's condition according to the Glasgow outcome scale was estimated at 4 points.

[Continuous mechanical ventilation in a neurosurgical intensive care unit (one-year analysis of results)].

This was a retrospective study. Its inclusion criterion was mechanical ventilation (MV) for more than 48 hours. One hundred and eighty-four case records of 184 neurosurgical intensive care unit patients were analyzed. Ventilation modes, upper airway cares and prosthetic replacement were chosen by the protocol accepted at the Institute. Great differences were found in the structure of indications for MV and in the duration of respiratory support in relation to the neurosurgical nosological entity and the site of a major process. The upper airway care protocols accepted at the Institute were shown to reduce the incidence of ventilator-associated pneumonia. Some risk factors for ventilator-associated pneumonia were identified.

[Intraoperative and early postoperative complications of puncture-dilation tracheostomy in neurosurgical patients].

The paper provides a detailed analysis of the most common and clinically significant complications due to percutaneous dilation tracheostomy performed in 479 patients with neurosurgical diseases in 2002-2007. It also considers such complication of the technique, which is specific to neurosurgical patients, as elevated intracranial pressure (ICP), and describes a procedure of tracheostomy in patients with elevated ICP. Percutaneous dilation tracheostomy made by a skilled surgeon is shown to be effective and safe.

[Diabetes insipidus in acute subarachnoidal hemorrhage after clipping of aneurysm of the anterior cerebral artery and the anterior communicating artery].

In the presented case, clipping of aneurysm of the anterior cerebral artery (A CeA) and the anterior communicating artery (ACoA) in acute subarachnoidal hemorrhage (SAH) was complicated by the development of vasospasm and transient diabetes insipidus (DI). The cause of DI was ischemia of the anterior portions of the hypothalamus due to ACeA and ACoA spasm. The use of the standard triple H-therapy protocol in the presence of DI failed to achieve the optimal parameters of hemodynamics and cerebral perfusion pressure due to the development of severe polyuria. Addition of the standard triple H-therapy protocol by hormonal replacement therapy with desmopressin could yield adequate systemic hemodynamic parameters. During this treatment, the state became stable and vasospasm regressed. The manifestations of DI ceased with the values of cerebral circulation being normal.

[Stepwise surgical treatment in a patient with concomitant cerebrovascular pathology].

The paper describes a relatively rare clinical case of stepwise surgical treatment in a patient with concomitant cerebrovascular pathology: thrombosis of the left internal carotid artery + critical stenosis of the right internal carotid artery + arteriovenous malformation of the right occipital lobe. The patient underwent open right carotid endarterectomy left extra-intracranial microvascular anastomotic application, and histoacryl endovascular embolization of the major afferents and arteriovenous malformation stroma in the stepwise fashion. Management policy, possible complications, and ways of their prevention in these patients are discussed.