[A protocol for the cessation of sedation in brain-injured patients]. / Évaluation d'un protocole d'arrêt de la sédation chez le patient cérébrolésé

OBJECTIVES: The cessation of sedation in brain-injured patients may result in severe agitation and/or acute withdrawal syndrome related to the prolonged administration of large doses of benzodiazepines and/or opioids. The aim of the present study was to assess the clinical efficacy of a written protocol to withdraw sedation for these patients. STUDY DESIGN: Observational prospective study. PATIENTS AND METHODS: After approval by the Institutional Review Board, 40 severely brain-injured patients were included. They had received continuous administration of midazolam and sufentanil or fentanyl for median 15 days. On cessation of midazolam infusion, patients were given clorazepate for 3 days. On cessation of opioid infusion and clorazepate, clinical data were collected for 48 hours: heart rate, systolic blood pressure, respiratory rate, agitation, and pupil diameter. If an opioid withdrawal syndrome occurred, patients received a 48-hour continuous infusion of buprenorphine. RESULTS: Of 40 patients, there were 10 who did not require buprenorphine. An agitation occurred 5 hours (1-21) after cessation of opioid, associated with tachycardia, arterial hypertension, and tachypnea. After 6 hours buprenorphine treatment, these parameters were normalized. No patient needed the reintroduction of the initial sedation. CONCLUSION: The cessation of sedation in severely brain-injured patients can be successfully managed with the use of clorazepate, associated with buprenorphine in the presence of agitation.

[Sedation in neurointensive care unit]. / Neurosédation en réanimation.

The objectives for using sedation in neurointensive care unit (neuroICU) are somewhat different from those used for patients without severe brain injuries. One goal is to clinically reassess the neurological function following the initial brain insult in order to define subsequent strategies for diagnosis and treatment. Another goal is to prevent severely injured brain from additional aggravation of cerebral blood perfusion and intracranial pressure. Depending on these situations is the choice of sedatives and analgesics: short-term agents, e.g., remifentanil, if a timely neurological reassessment is required, long-term agents, e.g., midazolam and sufentanil, as part of the treatment for elevated intracranial pressure. In that situation, a multimodal monitoring is needed to overcome the lack of clinical monitoring, including repeated measurements of intracranial pressure, blood flow velocities (transcranial Doppler), cerebral oxygenation (brain tissue oxygen tension), and brain imaging. The ultimate stop of neurosedation can distinguish between no consciousness and an alteration of arousing in brain-injured patients. During this period, an elevation of intracranial pressure is usual, and should not always result in reintroducing the neurosedation.

[Long-term outcome of patients after aneurysmal SAH]. / Devenir à long terme des patients après une HSA anévrismale.

Adequate instruments for measuring patient outcome after subarachnoid aneurysmal haemorrhage (SAH) are required to interpret results of clinical trials before making clinical recommendations. Graded measures are generally used, e.g. Glasgow Outcome Scale (GOS) and the modified Rankin Scale (mRS). However, these scales are inappropriate to measure cognitive dysfunction, particularly in patients with good outcome. We investigated the most frequent complains, the working status and the self-assessment of handicap (quality of life) in GOS-5 patients after their surgical treatment of a ruptured aneurysm. A questionnaire was sent to 126 patients one year following their discharge from hospital. The questionnaire assessed their motor activity, vitality and psychological troubles and handicap. Over 84 patients with GOS-5, 55 (65%) had persistent cognitive and psychological troubles including memory deficit, vitality and depressive troubles. Providing the use of combined scales to assess handicap and quality of life, these results suggest that SAH can result in a persistent alteration of cognitive function in patients, even in those classified as having a good outcome using the routine graded scales.

[Short-term change in sural venous thrombosis in patients in surgical intensive care when anticoagulants are contraindicated]. / Devenir a court terme des thromboses veineuses surales chez les patients de réanimation chirurgicale contre-indiqués aux anticoagulants.

Venous thrombo-embolic disease in neurosurgical and surgical intensive care units is a frequent disorder (between 4.3 and 43 per cent of patients according to studies). The treatment is often difficult. We carried out a retrospective study from January 1994 to September 1995 of 57 patients in neurosurgical and surgical intensive care who developed thrombosis of a sural vein and in whom anticoagulant at therapeutic doses was contraindicated. After a median follow up 14 days echography showed proximal extension of the thrombosis in 4 patients and distal extension in 3 others. Five cases of pulmonary embolism occurred during the follow up period, one of which led to death. No complications (pulmonary embolism or proximal extension of venous thrombosis) occurred in those patients receiving heparin at prophylactic doses (0/11 versus 8/46 in the non-heparin group; p = 0.13). No case of pulmonary embolus occurred in those patients with partial or complete regression of the thrombosis (0/21 versus 5/36 in the group with stable or extending thrombi, p = 0,05). Echographic monitoring enabled therapeutic modification in 5 cases. These results indicate that sural venous thrombosis in the context of neurosurgical and surgical intensive care is a potentially grave situation and that the prescription of anticoagulant therapy even at preventive dose should always be considered. Further, we propose regular echographic monitoring until the patient is mobile.

[Description of an unusual clinical picture of visual hallucinations (polyopsia, erythropsia) as expression of right temporo-occipital ischemia (visual association cortex, Brodman area 37]. / Descrizione di un insolito quadro clinico di allucinosi visiva (poliopsia, eritropsia) quale espressione di ischemia temporo-occipitale destra (corteccia dell'associazione visiva, area 37 di Brodman).

An unusual clinical picture (polypsia and erythropsia) as a consequence of an ischaemic lesion of the temporo-occipital junction, known as Brodman area 37 is reported. CT images showed that the lesion area was linked with the two particular function of visual association and memory peculiar to area 37 and, as is well known in the literature, predominant in right hemisphere damage.

Amniotic fluid testosterone and fetal sex determination (discussion of the endocrine function of the fetal testis).

Amniotic fluid testosterone levels were determined by the radioimmunoassay technique in 101 samples obtained by amniocentesis between 16 and 18 weeks of gestation from women with increased risk of chromosomal abnormalities. Fetal sex was determined by cell culture and chromosomal analysis of fetal amniotic cells and was confirmed at birth. In pregnancies with male fetuses (50 samples), the mean amniotic fluid testosterone level of 216 pg/ml (+/- 75) was significantly higher (p less than 0.001) than the mean value of 93 pg/ml (+/- 28) found in pregnancies with female fetuses (51 samples). The range for pregnancies with male fetuses was 130 to 500 pg/ml and for those with female fetuses 10 to 140 pg/ml, showing an area of overlap from 130 to 140 pg/ml.