Effect of volume replacement during combined experimental hemorrhagic shock and traumatic brain injury in prostanoids, brain pathology and pupil status / Efeito da reposição volêmica durante o choque hemorrágico combinado com traumatismo craniencefálico sobre prostanóides, patologia cerebral e status pupilar

Traumatic brain injury (TBI) is the main cause of trauma-related deaths. Systemic hypotension and intracranial hypertension causes cerebral ischemia by altering metabolism of prostanoids. We describe prostanoid, pupilar and pathological response during resuscitation with hypertonic saline solution (HSS) in TBI. Method Fifteen dogs were randomized in three groups according to resuscitation after TBI (control group; lactated Ringer’s (LR) group and HSS group), with measurement of thromboxane, prostaglandin, macroscopic and microscopic pathological evaluation and pupil evaluation.Result Concentration of prostaglandin is greater in the cerebral venous blood than in plasma and the opposite happens with concentration of thromboxane. Pathology revealed edema in groups with the exception of group treated with HSS.Discussion and conclusion There is a balance between the concentrations of prostaglandin and thromboxane. HSS prevented the formation of cerebral edema macroscopically detectable. Pupillary reversal occurred earlier in HSS group than in LR group.

O traumatismo cranioencefálico (TCE) é a principal causa de morte relacionada ao trauma. O choque hemorrágico e hipertensão intracraniana causam isquemia cerebral alterando o metabolismo de prostanóides. Neste estudo, relatamos o comportamento dos prostanóides, resposta pupilar e patologia durante a reposição volêmica com solução salina hipertônica (SSH) no TCE. Método Quinze cachorros foram randomizados em três grupos (controle, grupo de Ringer lactato e grupo de SSH) e foram avaliados tromboxane, prostaglandina, avaliação patológica macroscópica e microscópica e status pupilar.Resultado A concentração de prostaglandina é maior no sangue cerebral em comparação ao plasma, e o inverso ocorre com o tromboxane. A patologia revelou edema em todos os grupos, com exceção do grupo tratado com SSH.Discussão e conclusão Existe um equilíbrio entre concentrações cerebrais e plasmáticas de prostaglandina e tromboxane. A SSH protegeu o cérebro da formação de edema pós traumático.

Hipotermia terapêutica como ponte até transplante em pacientes com falência hepática fulminante / Therapeutic hypothermia as a bridge to transplantation in patients with fulminant hepatic failure

Os tópicos mais importantes na falência hepática fulminante são o edema cerebral e a hipertensão intracraniana. Dentre todas as opções terapêuticas, tem sido relatado que a hipotermia sistêmica induzida em níveis entre 33 - 34ºC reduz a elevação da pressão e aumenta o tempo durante o qual os pacientes podem tolerar um enxerto. Esta revisão discutiu as indicações e os efeitos adversos da hipotermia.

The most important topics in fulminant hepatic failure are cerebral edema and intracranial hypertension. Among all therapeutic options, systemic induced hypothermia to 33 - 34ºC has been reported to reduce the high pressure and increase the time during which patients can tolerate a graft. This review discusses the indications and adverse effects of hypothermia.

Algoritmo de tratamiento de la cetoacidosis diabética en pediatría: [revisión] / Treatment algorithm of diabetic ketoacidosis in pediatric: [review]

La cetoacidosis diabética (CAD) es la complicación más importante de la diabetes mellitus. La piedra angular para el diagnóstico de la CAD son la historia clínica y la exploración física, en ellas generalmente encontramos los factores precipitantes y podemos clasificar el estado de hidratación del paciente. Los estudios de laboratorio son de gran utilidad para monitorizar la hiperglucemia, el estado ácido-base y el desequilibrio electrolítico inicial. La terapia inicial durante la primera hora es administración de líquidos intravenosos, generalmente cristaloides, con revaloraciones del estado de hidratación y de los niveles séricos de potasio antes de comenzar el tratamiento con insulina, que debe hacerse en la segunda hora. El monitoreo de la glucemia y de los electrolitos séricos es la base para un tratamiento exitoso en la CAD, sobre todo para evitar el edema cerebral, que es la complicación más seria. Afortunadamente, dicha complicación es rara y uno de los factores de riesgo asociados es el tratamiento inadecuado; si bien se han propuesto otros factores de riesgo, no están totalmente identificados.

Neurocysticercosis in children.

Neurocysticercosis (NCC) is a common cause of seizures and neurologic disease. Although there may be variable presentations depending on the stage and location of cysts in the nervous system, most children (> 80%) present with seizures particularly partial seizures. About a third of cases have headache and vomiting. Diagnosis is made by either CT or MRI. Single enhancing lesions are the commonest visualization of a scolex confirms the diagnosis. Some cases have multiple cysts with a characterstic starry-sky appearance. Management involves use of anticonvulsants for seizures and steroids for cerebral edema. The use of cysticidal therapy continues to be debated. Controlled studies have shown that cysticidal therapy helps in increased and faster resolution of CT lesions. Improvement in long - term seizure control has not yet been proven. Children with single lesions have a good outcome and seizure recurrence rate is low. Children with multiple lesions have recurrent seizures. Extraparenchymal NCC has a guarded prognosis but it is rare in children. In endemic areas NCC must be considered in the differential diagnosis of seizures and various other neurological disorders.

[Comparison of the effects of progesterone, allopregnanolone and gender on suppressing edema formation after traumatic brain injury in rats]

Brain edema is one of the most important causes of death within the first few days following head trauma. In this study we investigated the role of gender as well as the effects of progesterone and allopregnanolone one hour after diffuse traumatic brain injury on edema formation in rats. This interventional-experimental study was performed on 12 groups of female and male rats. They were divided into 12 groups as follows: 1 and 2: intact female and male rats, 3 and 4: trauma male and female rats, 5: vehicle of progesterone [benzyl alcohol with sesame oil], 6: sham [ovariectomized female rats: ovx], 7: sham [no ovx], 8: sham[male], 9 and 10: low dose [4mg/kg] and high dose [8mg/kg] of progesterone, 11: allopregnanolone and 12: vehicle of allopregnanolone [water]. Hormones were injected i. p one hour after diffuse traumatic brain injury through Marmarou model. The results showed a significant increase of 5.32 times in Evans blue and 2.42% in water content in trauma male group comparing to control groups, while in female rats the difference was significant just for Evans blue [4.68 times]. Evans blue and water content were also significantly greater in traumatic males than female rats [1.57 times and 2.04% respectively]. After injection of low and high doses of progesterone, there was a significant decrease in water content [2.21% and 2.30%] and Evans blue content [2.55 and 2.98 times]. Allopregnanolone significantly decreased these parameters [2.36% and 1.82 times respectively]. Moreover, the injection of progesterone in both low and high doses increased the serum progesterone of female ovarectomized rats as compared to vehicle group. Based on these results, it can be concluded that the rate of edema formation in traumatic male rats is higher compared to traumatic female rats. Moreover, both progesterone and allopregnanolone decrease edema formation in ovariectomized female rats

Perspectivas atuais do tratamento da cetoacidose diabética em pediatria: [revisão] / Current perspectives for treating children with diabetic ketoacidosis: [review]

OBJETIVO: Revisar os conceitos atuais da fisiopatologia, diagnóstico e tratamento da cetoacidose diabética (CAD) na infância, assim como as medidas preventivas para evitar o edema cerebral. FONTES DOS DADOS: Os autores selecionaram artigos na MEDLINE com as palavras-chave diabetes, cetoacidose, hiperglicemia e edema cerebral, priorizando estudos realizados em crianças, que tenham textos completos publicados em inglês, português ou espanhol. Revisaram, ainda, capítulos de livros publicados no Brasil descrevendo o tratamento de CAD em unidade de tratamento intensivo pediátrico. Baseados na literatura revisada e em sua experiência, apresentam as medidas mais eficazes e recomendadas no manejo da CAD. SÍNTESE DOS DADOS: Consolida-se cada vez mais a utilização de solução fisiológica (NaCl 0,9 por cento) tanto na fase de reposição rápida quanto na fase de hidratação, em substituição às soluções diluídas (hipotônicas), assim como a contra-indicação do uso de bicarbonato de sódio para corrigir acidose metabólica na CAD. A insulina regular deve ser utilizada sob a forma de infusão contínua (0,1 UI/kg/h) sem a necessidade de dose de ataque. Para rápidas correções das oscilações da glicemia, é apresentado um esquema prático com duas bolsas de soluções eletrolíticas. Revisam edema cerebral, seu mecanismo fisiopatológico e o tratamento atual. CONCLUSÕES: O uso de infusão contínua de insulina regular associada à reposição hídrica adequada com soluções isotônicas, além de tratamentos efetivos da CAD, preserva a osmolaridade plasmática e previne a ocorrência de edema cerebral.

OBJECTIVE:To review current concepts of physiopathology, diagnosis and treatment of diabetic ketoacidosis (DKA) in childhood, as well as preventive measures to avoid cerebral edema. SOURCES: The authors selected articles from MEDLINE with the keywords diabetes, ketoacidosis, hyperglycemia and cerebral edema, and priority was given to studies including children and that contained complete texts published in English, Portuguese or Spanish. Chapters of books published in Brazil describing the treatment of DKA in pediatric intensive care unit were also reviewed. Based on the reviewed literature and on the author's experience, the most efficient and recommended measures for DKA management are presented. SUMMARY OF THE FINDINGS: Normal saline solution (NaCl 0.9 percent) has been increasingly used for fast replacement and hydration, as a substitute to diluted (hypotonic) solutions, as well as contraindication of sodium bicarbonate to repair metabolic acidosis in DKA. Regular insulin should be used as continuous infusion (0.1 IU/kg/h) without the need of a loading dose. For fast corrections of glucose oscillations, a practical scheme using two bags of electrolytic solutions is presented. Cerebral edema, its physiopathological mechanism and current treatment are reviewed. CONCLUSIONS: Use of continuous infusion of regular insulin associated with adequate water and electrolyte replacement using isotonic solutions, besides being an effective treatment for DKA, preserves plasma osmolarity and prevents cerebral edema.

Prescribing pattern of antiedema therapy in stroke by neurologists and general physicians.

BACKGROUND: In acute stroke, a number of drugs are used to reduce the raised intracranial pressure (ICP) although their scientific basis has not been established or shown in randomized controlled trials. AIMS: In this communication, we report the pattern of use of antiedema therapy in acute stroke by general physicians (GPs) and neurophysicians (NPs) in India. MATERIAL AND METHODS: A questionnaire was developed regarding the use of various antiedema measures in stroke and responses were collected either through post or when the responders were attending a national conference. The use of antiedema therapy by NPs and GPs was analyzed employing the Chi-square test. RESULTS: We could collect responses from 102 physicians, of whom 48 were NPs and 54 GPs. More than two-thirds of the physicians managed more than three strokes per week and all used antiedema therapy at some time or the other. Thirteen used it in all the patients and the remaining used it in patients with large and moderate strokes or in patients with herniation. Twelve used only one drug, while the remaining physicians used various combinations in different doses and frequency. The prescribing pattern was significantly different between GPs and NPs with respect to the frequency of the antiedema drugs used, type of stroke where these were used, combination of drugs, timing and dose of mannitol. CONCLUSION: This study highlights that antiedema therapy in acute stroke is practiced without any uniformity.