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219126_NCS_Currents_March_2_eMag

INTERNATIONAL NEUROCRITICAL CARE To Intubate or Not to Intubate?: A Short Study Report from the Burdenko Research Neurosurgical Institute By Konstanin Popugaev, MD To intubate or not to intubate? That is a frequent question in daily neurocritical care practice. It is not diffi cult to make a decision if the patient fulfi lls a defi nite criterion for intubation or if there is evidence of respiratory failure. However, in the real neurocritical care world, the two conditions may not occur and intubation may still be required. Mostly, the decision regarding intubation is almost exclusively based on the current attending physician’s opinion. The Neuro ICU at the Burdenko Research We created the Burdenko Respiratory Insuffi ciency Scale (BRIS), Neurosurgical Institute in Moscow which can objectify the process of decision making in the neurocritical care population (fi g. 1). If the patient has a score of seven (2-3-2). Mechanical ventilation was continued for 42 hours four in any part of the BRIS or a sum of all scores equal to fi ve or and the patient was extubated again. The BRIS score amounted to more, he or she should be intubated immediately. A BRIS score of three (0-3-0), and it decreased to two (0-2-0) on the next day due three or less is consistent with the patient breathing spontaneously to improvement of bulbar function. The patient was transferred and safely. A BRIS sum score of four in all three parts of BRIS is to the ward and discharged from the institute in ten days for the still a grey zone. further rehabilitation. Here I would like to present two cases. A 40-year-old woman The second patient is a 29-year-old woman with with a petroclival meningioma arrived at the neurocritical care neurofi bromatosis type II. She previously underwent fi ve different department after tumor resection. She met all critical care criteria tumor resections. Dysphagia was demonstrated preoperatively. for weaning extubation and was extubated after seven hours. The However, the patient could swallow porridge-like food and did postoperative CT scan did not show any postoperative hemorrhage not require a gastric tube. This time, a left acoustic neuroma or edema. Neurologic examination revealed deterioration of was removed. The patient was mechanically ventilated for fi ve bulbar function in comparison with the preoperative status. The days and extubated thereafter. The BRIS score was three (0-3-0). BRIS score was fi ve (1-3-1). The patient remained stable. She was discharged from the ICU According to the BRIS, the patient had to be reintubated on the next day and from the institute in seven days for further immediately, but the attending physician decided to leave the rehabilitation. patient breathing spontaneously. However, after fi ve hours, the Whether to use or not to use the BRIS is a very personal question, patient was reintubated for increasing drowsiness and impaired but further investigations are planned. oxygenation. Her BRIS score immediately before reintubation was Figure 1. Burdenko Respiratory Insuffi ciency Scale (BRIS) Score 0 Score 1 Score 2 Score 3 Score 4 First test RASS 0 RASS -1/+1 or RASS -2/+2 or RASS -3-4/+3+4 or stupor RASS -5 or coma Mental status or consciousness hypersomnia obtundation Second test Independent swallowing. Independent swallowing. Slight aspiration of liquids. Aspiration for two or Aspiration for two or Swallowing, cough, Eff ective cough. Normal Ineff ective cough. Normal Eff ective cough. Normal more food consistencies. more food consistencies. airway patency airway patency. airway patency. airway patency. Ineff ective cough. Normal Ineff ective cough. airway patency. Impaired airway patency. Third test >300 250-300 220-250 200-220 Index pO2/FiO2 Scoring is increased by one in obesity (body mass index >30). RASS – Richmond Agitation Sedation Scale. In this edition, Dr. Konstantin Popugaev provides his rich experience with a self-developed scale to assist the decision for or against intubation in neurocritical care patients that do not fulfi ll the formal intensive care intubation criteria. The Burdenko Research Neurosurgical Institute in Moscow is the fi rst address for neurosurgical procedures in Russia and was named after Nikolay Burdenko, the founder of Neurosurgery in Russia. Dr. Popugaev is an active member of the NCS International Committee. His aim is to promote and improve neurocritical care in Russia. - Katja Wartenberg, MD, FNCS, section editor 17


219126_NCS_Currents_March_2_eMag
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