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JOURNAL WATCH pressure (ICP) control as determined by injury severity scoring p=0.004) and percent time in MC (41.95 +/- 27.74 vs. 8.35 +/- systems, jugular bulb saturations, and clinical assessment. 9.78, p=0.002) were both lower after catheter placement. In a multivariate analysis of contributors to MC, temperature and ICP Standard fever management (STAN) was implemented for all were identifi ed as the most signifi cant contributors to biochemical patients demonstrating fever (T >38°C two or more times within improvement. a 24-hour period) and included acetaminophen, ibuprofen, and surface cooling blankets. Patients with refractory fever with Data are plentiful regarding the adverse impact of fever upon the treated with an aggressive intravascular cooling catheter (AGG) neurologically injured brain. Neurocritical care units routinely with continuous feedback loop monitoring set at a target of devote a signifi cant amount of effort and resources toward fever 36.5 °C. Cerebral microdialysis probes were placed in normal control based on the assumption of clinical effi cacy. Nonetheless, appearing frontal white matter (mean insertion time = 33 hours) questions have persisted whether fever was a marker of injury and metabolic crisis (MC) was defi ned as cerebral hypoglycemia severity or a modifi able component and potential therapeutic (glucose <0.8 mmol / L) with elevated lactate:pyruvate ratio target for improving outcomes. The impact of relatively modest (LPR) (LPR >25). Both cohorts (STAN, AGG) were managed TTM upon metabolic crisis after TBI shown in this study suggests with identical treatment goals including ICP <20 mmHg, cerebral that there may be potential clinical benefi t to this management perfusion pressure >60 mmHg, serologic blood glucose 80-140 strategy. Interestingly, the benefi t of TTM was apparent with mg/dL, and continuous EEG surveillance. relatively minor alterations in temperature and with well- controlled ICP. Fifty-two subjects in the STAN group were compared to 10 subjects in the AGG group. The STAN group was older (50.41 +/- 17.36 Considering the hemodynamic characterization of the patients, vs. 37.9 +/- 12.45 years, p=0.034) and had higher GCS (8.04 defi nition of MC, and response of pyruvate concentrations to +/- 4.12 vs. 4.60 +/- 3.44, p=0.016). Mean core temperature was cooling, the benefi t of TTM likely resulted from reduction of signifi cantly lower in the AGG group (37.40 +/- 0.79 vs. 36.76 infl ammation or effects on mitochondrial metabolism as opposed +/- 1.16, p<0.001) as was percent time with temperature <37.5 to reduction of ischemic events. It should be noted that the °C (39.28 +/- 19.53 vs. 30.25 +/- 30.25 +/- 24.98, p<0.001). The study does not represent an effort to compare treatment between AGG cohort spent a lower portion of time in MC (32.17 +/- 27.25 two similar patient groups. Rather, treatment in the AGG group vs. 22.60 +/- 20.45, p<0.001). ICP was similar between the two resulted only from failure of conservative measures in the STAN groups (STAN 13.5 +/- 3.37 vs. AGG 14.15 +/- 3.50, p=0.584). cohort. The study was not powered to demonstrate clinical When the AGG group was compared pre- and post-catheter benefi t, but adds to the growing literature that suggests that neuro- placement, temperature (37.62 +/- 0.34 vs. 36.69 +/- 0.90 °C, centric and patient-specifi c care may improve patient outcomes. TECH CORNER Critical Care Educational On-Line each followed by three quiz questions as well as links to the Modules at American Thoracic Society Unfortunately, upon submitting the answers to the quiz questions,New England Journal of Medicine Procedure Videos library. By Susanne Muehlschlegel, MD, MPH I encountered a dead link. Finally, “Critical Care Quick Hits” contains short cases with After several articles about medically relevant apps, I would like images of ventilator waveform abnormalities and ultrasound or to draw your attention to free clinical education available on- echo fi ndings with questions. Answers and a brief discussion line from the Critical Care Section of the American Thoracic are provided. I went through several of these and they are quick Society (ATS), an international society of pulmonary-critical care and fun to read. In summary, I fi nd these free educational providers. On their webpage, under the “Professionals” section, general critical care teaching modules helpful and fun, both for the content is available by clicking on “Critical Care” and then board preparation or refreshing “Clinical Education.” Here, one fi nds a plethora of clinical tools one’s general critical care fund of and teaching modules. knowledge. Please click on: http://www.thoracic.org/ “Clinical Cases” contains 13 general surgical and critical care cases professionals/clinical-resources/ (including one neurocritical care case), with clinical information, critical-care/clinical-education/ to radiological and pathological images, and one multiple-choice give it a try. question per case. Unfortunately, the answers to the questions are not provided on-line. The next tab, “Hemodynamic Monitoring,” contains a series of lectures by Michael Pinsky, an expert on hemodynamics, recorded as part of the University of Pittsburgh Multidisciplinary Critical Care Fellowship Curriculum. Clicking on one of the links results in a download of MP4 videos, which are quite large (15-40MB). “Interpretation of ABGs” includes a six-step process that teaches complete interpretation of ABGs and includes summary tables after each step. “Mechanical Ventilation” includes an overview, as well as waveform interpretation and analysis, all in the form of downloadable Powerpoint presentations. I can highly recommend the slides on the latter, as they contain very helpful graphics and images and discuss different waveforms on various ventilators. “Procedures” includes bulleted summaries with images on “fi beroptic intubation,” “endotracheal intubation via direct laryngoscopy,” and “bronchoalveolar lavage,” 27


224000_NCS_June Currents_2-eMag
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