High-osmolarity saline in neurocritical care: systematic review and meta-analysis.

BACKGROUND AND PURPOSE: Intracranial hypertension and cerebral edema are known contributors to secondary brain injury and to poor neurologic outcomes. Small volume solutions of exceedingly high osmolarity, such as 23.4% saline, have been used for the management of intracranial hypertension crises and as a measure to prevent or reverse acute brain tissue shifts. We conducted a systematic literature review on the use of 23.4% saline in neurocritically ill patients and a meta-analysis of the effect of 23.4% saline on intracranial pressure reduction. DESIGN: We searched computerized databases, reference lists, and personal files to identify all clinical studies in which 23.4% saline has been used for the treatment of neurocritical care patients. Studies that did not directly involve either effects on cerebral hemodynamics or the treatment of patients with clinical or radiographic evidence of intracranial hypertension and/or cerebral swelling were eliminated. MEASUREMENTS AND MAIN RESULTS: We identified 11 clinical studies meeting eligibility criteria. A meta-analysis was performed to evaluate the percent decrease in intracranial pressure and the 95% confidence intervals, from baseline to 60 minutes or nadir from the six studies from which this information could be extracted. A fixed effects meta-analysis estimated that the percent decrease in intracranial pressure from baseline to either 60 minutes or nadir after administration of 23.4% saline was 55.6% (se 5.90; 95% confidence interval, 43.99-67.12; p < 0.0001). CONCLUSIONS: Highly concentrated hypertonic saline such as 23.4% provides a small volume solution with low cost and an over 50% reduction effect on raised intracranial pressure. Side effects reported are minor overall in view of the potentially catastrophic event that is being treated. High quality data are still needed to define the most appropriate osmotherapeutic agent, the optimal dose, the safest and most effective mode of administration and to further elucidate the mechanism of action of 23.4% saline and of osmotherapy in general.

Causes and consequences of sports concussion.

Concussion in sports is a topic that is receiving increasing amounts of publicity and attention. Increasing recognition of concussion as well as improving understanding of the short- and long-term physiologic effects of concussion have resulted in widespread legislation governing the recognition and treatment of sports concussion. The increasing amount of medical research in the field and oftentimes subjective symptoms of concussion leave many ethical questions to be answered.

Familial nontraumatic, nonaneurysmal subarachnoid hemorrhage: a report on three first-degree siblings.

Family history is a recognized risk factor in aneurysmal subarachnoid hemorrhage (SAH). The genetic and environmental contributions are actively researched. The authors of this report present a case series of 3 first-degree siblings affected by nontraumatic, angiographically negative SAH. Data in this study suggest that familial predisposition may also apply to spontaneous, nonaneurysmal SAH and that family history should be actively investigated in all such patients. The identification of families with multiple affected members could lead to an improved understanding of the genetic and environmental factors associated with this condition.

Increased adolescent opioid use and complications reported to a poison control center following the 2000 JCAHO pain initiative.

CONTEXT: Adolescents are at risk to abuse opioid analgesics for many reasons, including inaccurate perception of risk and increased drug availability. In 2000, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) released pain management standards that emphasized pain control as a patient rights issue. This focus on analgesia may have increased both the prescribing and use of opioid analgesics, thereby increasing availability. OBJECTIVE: Using data from a US poison center, this study aims to compare the number of adolescent opioid cases and their outcome severity before and after the 2000 JCAHO pain initiative. METHODS: Retrospective case series of opioid exposures involving persons 12-18 years of age reported to a US poison center from 1994 to 2007. The main outcome measure was the number of adolescent opioid cases reported for 1994-2000 compared to 2001-2007. Secondary outcomes included outcome severity, number of cases involving specific opioids, and correlation between the number of cases and the amount of opioids distributed to the state. RESULTS: There were 1634 adolescent opioid-related cases with 187 cases developing medical complications. Compared with 1994-2000, the rate ratio of cases involving adolescents and opioid analgesics for the years 2001-2007 was 1.69 (95% CI: 1.53, 1.86), and these cases were 2.84 (95% CI: 2.06, 3.91) times more likely to have had medical complications. Medical complications involving methadone (p =0.001) increased after the JCAHO initiative, while complications related to codeine (p =0.001) and propoxyphene (p =0.030) decreased. There were 15 deaths in 2001-2007 and none in 1994-2000 (p =0.012). Lastly, there was a correlation between the rate of adolescent opioid cases and the amount of opioids distributed to the state (r(2) =0.90; p < 0.001). CONCLUSION: In the 7 years following the JCAHO pain standards, there was an increase in the number and severity of adolescent opioid-related poison center cases. The increase correlates with statewide availability of opioids. These data may prove useful in drug education and prevention programs targeting adolescents.