Pathophysiology and Management of Neurogenic Pulmonary Edema in Patients with Acute Severe Brain Injury.

Acute brain injury (ABI) consists of any acquired insult to the brain and is a significant cause of morbidity and mortality worldwide. Approximately 20% to 30% of patients with ABI develop a lung injury called neurogenic pulmonary edema (NPE), and its development often results in poor outcomes. This article provides a narrative review of the evidence regarding proposed mechanisms of injury, diagnosis, and treatment of NPE in the critical care setting. PubMed and Ovid databases were searched for observational or prospective studies relevant to the diagnosis and treatment of NPE. Overall, studies showed that although the specific mechanisms responsible for NPE remain uncertain, putative mechanisms include vaso- and venoconstriction, catecholamine release with resultant pulmonary vasoconstriction called the "blast injury theory," increased vagal tone, and increased capillary permeability. Diagnosis involves identifying signs of pulmonary edema in patients who experienced a neurologic insult. Management strategies aim to address both brain and lung injury, and treatment modalities appear to work best when balanced toward maintaining a normal physiologic state. In summary, NPE is an often underdiagnosed but important sequela of ABI, which may result in additional long-term morbidity. It is therefore an important entity for providers to recognize and tailor their clinical approach toward.

Predictors of Ventricular Dysrhythmias in Neurology Intensive Care Unit Patients with Prolonged QTc.

INTRODUCTION: Acute neurological injury and several medications commonly administered in the Neuro ICU pose a risk of fatal cardiac dysrhythmias. The objective of this study is to identify the predictors of ventricular dysrhythmias in the Neuro ICU patients with prolonged QTc, thereby helping the clinicians make important treatment decisions. METHODS: We performed a retrospective review of all consecutive adults admitted to the Neuro ICU from January 2015 to September 2015 with a QTc interval ≥ 450 ms on electrocardiogram. RESULTS: A total of 170 patients with a mean age of 66 years (SD ± 16) were included in the final analysis. Eighty-seven patients (51%) were women. Median duration of hospitalization was 9 days (IQR 4-16). Most common primary diagnosis was ischemic stroke (38%) followed by cerebral hemorrhage (19%) and subarachnoid hemorrhage (8%). Mean QTc was 487 ms (SD ± 35, range 450-659 ms). There were 27 episodes (16%) of monomorphic non-sustained ventricular tachycardia and one episode of Torsades (1%). Three cardiac arrests (2%) were recorded, none resulting from ventricular dysrhythmias. In multivariate analysis, prolonged QTc ≥ 492 ms (p = 0.0008), supratentorial acute ischemic stroke (p = 0.005), prolonged hospitalization (p = 0.03), and premature ventricular complexes on ECG (p = 0.047) were all independently associated with increased risk of ventricular dysrhythmias. CONCLUSIONS: In this group of patients with prolonged QTc in the Neuro ICU, we observed several episodes of non-sustained ventricular tachycardia and identified important risk factors associated with their occurrence. This knowledge is essential to inform clinical decisions.