Neurocritical care management of poor-grade subarachnoid hemorrhage: Unjustified nihilism to reasonable optimism.

BACKGROUND AND PURPOSE: Historically, overall outcomes for patients with high-grade subarachnoid hemorrhage (SAH) have been poor. Generally, between physicians, either reluctance to treat, or selectivity in treating such patients has been the paradigm. Recent studies have shown that early and aggressive care leads to significant improvement in survival rates and favorable outcomes of grade V SAH patients. With advancements in both neurocritical care and end-of-life care, non-treatment or selective treatment of grade V SAH patients is rarely justified. Current paradigm shifts towards early and aggressive care in such cases may lead to improved outcomes for many more patients. MATERIALS AND METHODS: We performed a detailed review of the current literature regarding neurointensive management strategies in high-grade SAH, discussing multiple aspects. We discussed the neurointensive care management protocols for grade V SAH patients. RESULTS: Acutely, intracranial pressure control is of utmost importance with external ventricular drain placement, sedation, optimization of cerebral perfusion pressure, osmotherapy and hyperventilation, as well as cardiopulmonary support through management of hypotension and hypertension. CONCLUSIONS: Advancements of care in SAH patients make it unethical to deny treatment to poor Hunt and Hess grade patients. Early and aggressive treatment results in a significant improvement in survival rate and favorable outcome in such patients.

Rezum for retention-retrospective review of water vaporization therapy in the management of urinary retention in men with benign prostatic hyperplasia.

OBJECTIVE: Rezum vapor ablation is a minimally invasive treatment for benign prostatic hyperplasia (BPH) that uses injections of sterile water vapor directly into the prostate for tissue ablation. Although Rezum is currently indicated for use in men with prostate sizes ≥30 and ≤80 ml, it is unclear how effective Rezum is for men in urinary retention. We sought to determine whether Rezum is effective in the treatment of catheter-dependent urinary retention secondary to BPH. METHODS: A retrospective chart review was conducted on consecutive patients who presented for urinary retention and subsequently treated with Rezum. We evaluated procedural details and examined variables pre- and post-Rezum (at 6 months) including International Prostate Symptom Score (IPSS), IPSS quality of life (IPSS-QOL), maximum flow (Qmax ), post void residual volume (PVR), prostate specific antigen, rate of retention, and use of alpha blockers and 5-alpha reductase inhibitor (5ARI). RESULTS: Of the 49 patients included in this study, median age of was 73 years, median prostate volume was 73cc (Interquartile range [IQR]: 50, 103) and a median lobe was present in 80% of patients. All patients were in urinary retention before treatment with a median PVR of 900 ml (IQR: 566, 1146). Following Rezum, IPSS (17 pre-Rezum, 4 post-Rezum) and IPSS-QOL (4 pre-Rezum, 1 post-Rezum) both improved at 6 months (p < 0.01). Qmax increased from 3 to 6 ml/s (p = 0.03) and PVR decreased from 900 to 78 ml (p < 0.01). Only 17/38 patients taking alpha-blockers and 7/15 patients on 5ARIs continued therapy at 6 months following Rezum (p < 0.01). Of the 49 patients treated, 10 (20.4%) remained in catheter dependent urinary retention following the procedure, and 6 remained in retention at 6 months (12.2%) even after further surgical therapies for BPH (p < 0.01). CONCLUSION: Rezum is a safe and effective therapy for treating catheter dependent urinary retention in patients with BPH, including those with median lobes. As a minimally invasive therapy, it is a promising option in patient, particularly those who are not suitable for prolonged anesthesia.

Evolving case of emphysematous pyelonephritis in a second renal allograft.

Emphysematous pyelonephritis is an acute necrotizing infection with gas in the kidney that portends a poor prognosis. Patients present with sepsis, requiring fluid resuscitation, glucose control, and broad-spectrum antibiotics. Surgical intervention ranges from relief of urinary obstruction (nephrostomy tube or stent), percutaneous drainage or nephrectomy. We present a 51-year-old second kidney transplant recipient diabetic male, suffering from sepsis of unknown etiology which was subsequently revealed to be due to emphysematous pyelonephritis. Percutaneous drainage was performed initially followed by renal transplant nephrectomy after no improvement of his clinical status. Herein, we describe the clinical course and escalation in management.