Ultrasound-assisted Thoracic Intervertebral Foramen Block. A Cadaveric Study.

BACKGROUND: A thoracic paravertebral block can be a useful opioid-sparing technique for controlling postoperative pain after thoracic and visceral abdominal surgery. OBJECTIVES: Our aim was to assess dye spread into the ventral branch, connecting branch, sympathetic trunk, thoracic paravertebral space, and epidural space after performing a modified ultrasound-assisted thoracic paravertebral block via the intervertebral foramen. STUDY DESIGN: This was a nonrandomized cadaveric study. SETTING: The cadavers were kept at the Department of Anatomopathology of the San Salvatore Academic Hospital of L'Aquila (L'Aquila, Italy). METHODS: We performed a bilateral thoracic paravertebral block via the intervertebral foramen at the second, fifth, ninth, and twelfth thoracic vertebrae. A linear array ultrasound transducer was used. Then, cadaveric dissection was performed. A Tuohy needle was gently inserted in-plane with the ultrasound beam in a lateromedial direction to contact the spinous process. Subsequently, the needle tip was advanced 2 mm along the transverse process of the vertebra, and 5 mL of methylene blue 1% dye was injected at each level. Then, 2 continuous catheter sets were inserted. RESULTS: Forty intervertebral foramen blocks were performed in 5 cadavers. For 38 injection sites, we found dye on both sides of the thoracic paravertebral space and epidural space at each level of puncture. The retropleural organs were also stained. In 2 cases, methylene blue accumulated intramuscularly at the level of the twelfth thoracic vertebra. RESULTS: The spread of dye into the ventral rami, communicating rami, and sympathetic trunk in the thoracic paravertebral space and the epidural space was assessed. We also evaluated the position and the distance (mm) between the catheter tip and the thoracic intervertebral foramen content. Finally, puncturing of intervertebral blood vessels, nerve rootlet and root damage, lung and pleural injuries, and the extent of intramuscular dye accumulation were evaluated and recorded as iatrogenic complications related to the anesthetic procedure. Forty thoracic paravertebral blocks in 5 cadavers were performed. For 38 injection sites, we found dye on both sides of the thoracic paravertebral space and the epidural space at each level of puncture. The ventral rami, the communicating rami, and the sympathetic trunk were also stained. In 2 cases, methylene blue accumulated intramuscularly at the level of the twelfth thoracic vertebra. LIMITATIONS: The first limitation of this study is its small sample size. In addition, the study design did not consider or measure the width of the transverse processes. Another limitation is that the ultrasound beam could not identify the thoracic intervertebral foramen content or the needle tip behind the acoustic shadow of the transverse and vertebral articular processes. CONCLUSION: Paravertebral block via the thoracic intervertebral foramen achieved consistent dye spread into the thoracic paravertebral space and epidural space, capturing retropleural organs.

Emergency Cricothyrotomy in a Harsh Environment: A Case Report of Complete Airway Obstruction Following a Lightning Strike.

A lightning strike is an extreme event with the highest mortality rate among electrical injuries. Death from a lightning strike is caused by either cardiac arrest or respiratory arrest. It is rare for upper airway damage to occur, but in these cases, airway control is recommended. If transoral intubation is unsuccessful, an emergency cricothyrotomy should be considered. Our case report describes an emergency cricothyroidotomy performed in a harsh environment on a mountain 2300 m above sea level on a patient with extensive burns of his supraglottic structures, after being directly hit by a lightning strike.

Health Status Perception and Psychological Sequelae in Buried Victims: An Observational Study on Survivors of the Earthquake in Amatrice (Italy), Three Years Later.

INTRODUCTION: The extrication from rubble is particularly critical for the survival of the victims of an earthquake. Early repeated infusion of sedative agents (SAs) in the acute trauma phase may interfere with neural processes leading to posttraumatic stress disorder (PTSD). STUDY OBJECTIVE: This study aimed to analyze the psychological status reported by the buried victims of the earthquake in Amatrice (August 24, 2016; Italy) by considering type of the SAs administered during the extrication maneuvers. METHODS: This was an observational study on data from 51 patients directly rescued under the rubble during the earthquake in Amatrice. During extrication maneuvers, a moderate sedation was administered by titrating ketamine (0.3-0.5mg/kg) or morphine (0.1-0.15mg/kg) with respect to the Richmond Agitation and Sedation Scale (RASS; between -2 and -3) in buried victims.Three years following the rescue, the survivors were interviewed on their perceived health status and stress using a questionnaire which consisted of 17 items: the standard four-item set of healthy days core questions (CDC HRQOL-4); the 12-item General Health Questionnaire (GHQ-12); and in addition, survivors were asked if they had a diagnosis for anxiety, depression, or for PTSD. RESULTS: The study analyzed data from the complete clinical documentation of 51 survivors; 30 were males and 21 females, with an average age of 52 years. Twenty-six (26) subjects were treated with ketamine, while 25 were treated with morphine, during the extrication procedures. Concerning the quality-of-life analysis, only 10 survivors out of 51 perceived their health status as good; the others reported psychological disorders. The GHQ-12 scores showed that all survivors had psychological distress with a mean total score of 22.2 (SD = 3.5). Eighteen (18) victims declared to have had a diagnosis of generalized anxiety (35%), while 29 were treated for depression (57%) and PTSD (57%) by a specialist. With regards to the perceived distress level and the anxiety disorder, this analysis showed significant associations with SAs used during extrication, with a better performance for ketamine than for morphine. CONCLUSION: These findings suggest investigating whether early sedation with ketamine directly in the disaster setting may promote the prophylaxis and reduce the risk of developing trauma-related disorders (TRDs) on the buried victims of major natural disasters in future studies.

Hypopharynx, oropharynx morphology and histology in severe Coronavirus 2 patients treated by noninvasive ventilation: comparison between full-face mask and helmet strategies.

BACKGROUND: Non-invasive ventilation may alter the morphology and histology of the upper airway mucosa. This study aimed to investigate the alterations of hypopharynx and oropharynx mucosa, identified during oro-tracheal intubation procedure via video-assisted laryngoscopy, in severe acute respiratory syndrome Coronavirus 2 related, treated by non-invasive ventilation via full-face mask or helmet. METHODS: Data of patients affected by Coronavirus 2 admitted to COVID Hospital of L'Aquila (Italy), presenting hypopharynx and oropharynx morphology alterations, requiring oro-tracheal intubation for invasive ventilation and initially treated with non-invasive ventilation were included in the study. The study aimed to investigate the upper airway mucosa alterations using oropharyngeal and hypopharyngeal images and biopsies taken during video-assisted-laryngoscopy. Data from the hypopharynx and oropharynx morphology and histology alterations between non-invasive ventilation via a full-face mask or helmet used during hospitalization were compared. RESULTS: From 220 data recorded, 60 patients were included in the study and classified into non-invasive ventilation full-face mask group (30/60) and via helmet group. Comparing data between groups, significant differences were found with respect to hyperemia (77% vs. 20%), laryngeal bleeding ulcerations (87% vs. 13%), and vocal cord edema with >50% narrowing of the tracheal lumen (73% vs. 7%), respectively. The histology examination revealed fibrin-necrotic exudate with extensive necrotic degenerative changes in the sample tissue of the groups. There were not any differences in the duration time of non-invasive ventilation, time from hospitalization and the start of ventilation between groups. CONCLUSIONS: The data from this research suggested that there were differences in airway mucosa damages among patients treated with a full-face mask or helmet. Further studies should be planned to understand which non-invasive ventilation support may mitigate upper airway mucosa damages when oro-tracheal intubation is requested for invasive respiratory support.

Pain in critically ill COVID-19 patients: An Italian retrospective study.

We retrospectively analyzed the data from patients admitted to the intensive care unit (ICU) of the Hospital of L'Aquila during the first and second waves of pandemic to identify pain related to COVID-19. Pain was evaluated by using the Numerical Rating Scale, and the assessment for neuropathic disturbances of pain was performed with von Frey's hair and Lindblom tests. Pain increased significantly during hospitalization (from 48% at hospital admission to 94.3% at ICU discharge). Female patients were affected by somatic pain in 32.8% of the cases and by somatic pain and pain with neuropathic features (NFs) in 23.5% of the cases, during the ICU stay. Somatic pain and pain with NFs affected more frequently patients with cardiological and respiratory comorbidities. Patients treated with continuous positive airway pressure via helmet had a higher frequency of somatic pain and pain with neuropathic disturbances (84 and 74%, respectively). The frequency of somatic pain and pain with neuropathic disturbances was lower in patients sedated with propofol combined with ketamine. Females have been associated with a higher risk of somatic pain and pain with NFs. Patients with cardiological and respiratory comorbidities undergoing noninvasive ventilation had higher levels of pain. As conclusion, ketamine may reduce the promotion or the worsening of pain in COVID-19 patients.

The Perioperative Anesthetic Management of the Pediatric Patient with Special Needs: An Overview of Literature.

The perioperative management of pediatric patients with psycho-physical disorders with related relational and cognitive problems must be carefully planned, in order to make the entire hospitalization process as comfortable and as less traumatic as possible. This article reports an overview of the anesthetic management of non-cooperative patients between 6 and 14 years old. The pathologies most frequently responsible for psycho-physical disorders can be summarized into three groups: (1) collaboration difficulties (autism spectrum disorders, intellectual impairment, phobia); (2) motor dysfunction (cerebral palsy, epilepsy, other brain pathologies, neuromuscular disorders), and (3) craniofacial anomalies (Down syndrome, other genetic syndromes). Anesthesia can be performed safely and successfully due to careful management of all specific problems of these patients, such as a difficult preoperative evaluation (medical history, physical examination, blood sampling, evaluation of vital parameters and predictive indices of difficult airway) and the inapplicability of a "standard" perioperative path (timing and length of the hospitalization, anesthetic premedication, postoperative management). It is necessary to ensure a dedicated perioperative process that is safe, comfortable, tailored to specific needs, and as less traumatic as possible. At the same time, all necessary precautions must be taken to minimize possible complications.

A Modified Approach for Ultrasound-Guided Thoracic Paravertebral Block via Thoracic Intervertebral Foramen in an Adolescent Patient: A Case Report.

This case report describes a modified approach for a thoracic paravertebral block by performing a bilateral ultrasound-assisted injection of 12 mL of 0.5% levobupivacaine near the thoracic intervertebral foramen, combined with general anesthesia, in a patient who underwent emergent laparotomy for small intestinal volvulus. Two continuous catheter sets were used for a bilateral continuous block with levobupivacaine 0.25% at a rate of 5-8 mL/h. No complications during the execution of the block were recorded. No supplemental opioids were administered and the patient was hemodynamically stable, requiring no pharmacological cardiovascular support during surgery. At the end of the surgical procedure, the patient received a continuous flow of 0.2% levobupivacaine as postoperative analgesia, at a basal flow of 4 mL/h per each side, a bolus of 4 mL, and a lockout time of 60 min was used. The postoperative pain on the Numeric Rating Scale was 2 at rest and it was 4 in motion, without neurological or respiratory sequelae due to block in the first 72 h after surgery.

Arterial Blood Gas and Rotational Thromboelastometry Parameters in Healthy Rescuers Incidentally Exposed to Nitroglycerin, Nitrogen Compounds, and Combustion Products.

INTRODUCTION: Acute exposure to nitrogen compounds combined with a massive inhalation of air pollutants can influence respiratory and cardiovascular symptoms and coagulation abnormalities in accidentally exposed healthy adults during cave detonation operations. METHODS: Italian alpine and cave rescuers widened a cave in the Abisso Luca Kralj in Trieste, Italy. Volunteers inside the cave were accidentally exposed to the fumes from an uncontrolled detonation of blasting gelatin microcharges. We performed a retrospective cohort study on the clinical data, arterial blood gas analysis, and rotational thromboelastometry parameters from the rescuers involved in the accident. RESULTS: Ninety-three healthy rescuers were involved in the uncontrolled detonation: 47 volunteers handled a mixture of nitrogen compounds (blaster group), and 46 volunteers did not (nonblaster group). After the accident, statistically significant differences (P<0.05) in arterial blood gas values were observed between the groups, with a pattern of mild respiratory acidosis with hypercapnia in the nonblaster group and severe mixed acid-base disorder with hypoxia and hypercapnia in the blaster group. Mild hyperfibrinolysis was observed in 44 volunteers in the blaster group, as were associated bleeding symptoms in 34 volunteers; no significant coagulation modifications were recorded in the nonblaster group. CONCLUSIONS: Respiratory acidosis with hypoxia, hypercapnia, a compensatory metabolic response, and mild hyperfibrinolysis were probably related to the combined effect of nitrogen compounds and the inhaled toxic products of detonation. Therefore, each element exerts a determinant effect on promoting the biological toxicity of the others.

Litigation in Anesthesia and Intensive Care Units: An Italian Retrospective Study.

Anesthesiologists consider professional insurance and its medico-legal problems as a remarkable aspect of their job. "Associazione Anestesisti Rianimatori Ospedalieri Italiani-Emergenza ed Area Critica" (AAROI-EMAC) is the Italian professional association of anesthesiologists and intensivists that works to train its subscribers on safety measures. This is a retrospective observational study on an insurance complaints database for anesthetic accidents that result in injuries to patients. The analyzed period runs from 1 January 2014 to 31 December 2016. A total of 1309 complaints related to 873 insurance claims were analyzed. Criminal complaints comprised 805 (64.4%) of the total, and civil complaints were 445 (35.6%). The iatrogenic damage claimed included: death (58% of the cases); peripheral nerve damage (8%); spinal cord injuries (5%); unspecified injuries (7%); dental damage (4%); infections (3%); needing second surgical procedure (2%); and other injuries (13%). There is a statistical significance between the size of the hospital and the number of the claims: small hospital complaints comprised 40.1% of the cases, while complaints against medium-sized and large hospitals constituted 20.6% of the cases (χ2GL = 8 = 39.87, p = 0.00). In Italy, anesthesiologists and intensivists are often involved in litigation even when they are not directly responsible for iatrogenic injuries, and the most frequent claims in ICU are related post-operative complications.

Dietary Plant Extracts Improve the Antioxidant Reserves in Weaned Piglets.

Reducing the use of antibiotics in livestock in order to contain antibiotic resistance and studying natural substance additives are key to sustainability. Among the various biological activities of plant extracts, antioxidant activity plays an important role. The present study assesses the total antioxidant activity and antioxidant reserves using the Kit Radicaux Libres test (KRL™ Kirial International, Couternon, France). One hundred and sixty piglets (Topics × Tempo) weaned at 28 days of age were divided into four dietary treatment groups that were fed a commercial diet (the control group, C); 500 mg/kg Boswellia extract (BOS); 200 and 50 mg/kg Uncaria and Tanacetum extracts (UT) respectively; and 225 mg/kg of an antioxidant plant extract mixture (AOX). The blood antioxidant activity of the piglets was measured using the KRL test and the reserves were analyzed on whole blood samples after hydrolysis with glucosidase, sulfatase and glucuronidase. No significant differences were observed in growth performance. The delta KRL values of the whole blood showed a significantly higher total antioxidant status of the piglets from the BOS and AOX groups than the UT and C groups (+30.7 BOS; +27.7 AOX vs. +17.81 UT +13.30 C; p = 0.002) between 18 and 28 days post-weaning. The delta KRL values of red blood cells (RBCs) showed a significantly higher total antioxidant status of the piglets from the AOX groups than the UT and BOS groups (+22.2 AOX; vs. +9.90 UT +9.4 BOS; p = 0.016) between the two sampling times. Reserves of UT and AOX were higher than C and BOS for all enzymes, glucosides, sulphates, and glucuronides. The biological KRL test proved to be an extremely sensitive tool to evaluate the piglets' antioxidant status. Determining the antioxidant reserve also provides a better understanding of the real antioxidant status of pigs.

Intermediate Cervical Plexus Block in the Management of Persistent Postoperative Pain Post Carotid Endarterectomy: A Prospective, Randomized, Controlled, Clinical Trial.

BACKGROUND: The mechanisms of persistent postoperative pain (PPP) with neuropathic features after carotid endarterectomy (CEA) are multifaceted and are incompletely understood. OBJECTIVES: The aim of this research was to assess whether the ultrasound-guided (USG) intermediate cervical plexus block (ICPB) could provide better control of PPP and neuropathic disturbances (NPDs) after CEA than the USG superficial cervical plexus block (SCPB). STUDY DESIGN: Prospective, randomized, controlled, clinical trial. SETTING: This clinical trial was conducted at the SS Filippo and Nicola Academic Hospital of Avezzano (L'Aquila, Italy). METHODS: Patients who were scheduled for primary CEA were chosen. In the experimental group, the USG-ICPB was performed unilaterally, at the level of the third cervical vertebra. The needle was inserted into the deep lamina of the deep fascia of the neck, between the posterior border of the middle scalene muscle and the anterior border of the posterior scalene muscle. Three milliliters saline solution was injected into the opening of the deep lamina, and 20 mL 0.375% levobupivacaine was injected. In the control group, the anesthetic target was located at the inferior border of the sternocleidomastoid muscle at the level of the third cervical vertebra. The needle was superficially inserted below the skin, and 2 to 3 mL saline solution was injected into the opening of the superficial lamina of the deep fascia of the neck. A total of 20 mL 0.375% isobaric levobupivacaine was subsequently injected.The primary outcome measure was the proportion of patients with PPP on movement and at rest 3 months after surgery. The secondary outcome measures were NPD assessment scores using the von Frey hair test and the Lindblom test, opioid and pregabalin consumption. Adverse effects were also recorded. RESULTS: A total of 98 consecutive patients were enrolled and randomized to receive either a USG-SCPB (control group, n = 49) or a USG-ICPB (experimental group, n = 49). The sensory blockade was longer in the experimental group. Three months after surgery, the proportions of patients with PPP on movement were significantly different between the experimental and control groups (33%, 95% confidence intervals [CI], 20%-47% vs. 71%, 95% CI, 57%-83%; P < 0.001), whereas there were no differences in the proportions of patients with pain at rest between groups (31%, 95% CI, 18%-45% vs. 49%, 95% CI, 34%-64%; P = 0.063). The proportions of patients with NPDs were not different between the groups, whereas the sizes of the areas of interest (cm2) were significantly different. LIMITATIONS: A limitation of this study is that we assessed NPDs for only 3 months using the von Frey hair test and the Lindblom test without additional instrumental techniques. Additionally, there are many risk factors for NPDs after CEA. For this reason, another limitation of this research is that we neglected to consider the relationship between the choice of anesthetic block and the presence of these risk factors. CONCLUSIONS: The USG-ICPB provided long-lasting analgesia during the postoperative period and might mitigate the development of NPDs, thereby decreasing the analgesic drug requirement. KEY WORDS: Carotid endarterectomy, intermediate cervical plexus block, myofascial planes of neck, neuropathic disturbances, persistent postoperative pain, superficial cervical plexus blocks, ultrasound guidance, vascular disease.

Wireless and Low-Weight Technologies: Advanced Medical Assistance During a Cave Rescue: A Case Report.

Trauma care in cave rescue is a unique situation that requires an advanced and organized approach with medical and technical assistance because of the extreme environmental conditions and logistical factors. In caving accidents, the most common injuries involve lower limbs. We describe an advanced medical rescue performed by the Italian Corpo Nazionale del Soccorso Alpino e Speleologico, in which extended focused assessment with sonography for trauma and an ultrasound-guided adductor canal block were performed on a patient with a knee distortion directly in the cave. The rescue team inside the cave shared data on patient monitoring and the ultrasound scanning in real time with rescuers at the entrance, using a video conference powered by the new Ermes system. The use of handheld, battery-powered, low-weight, multiparametric monitors, ultrasound machines, and digital data transmission systems could ensure complete medical assistance in harsh environmental conditions such as those found in a cave.

First Rescue Under the Rubble: The Medical Aid in the First Hours After the Earthquake in Amatrice (Italy) on August 24, 2016.

Specific Event Identifiers a. Event Type: Earthquake measuring 6.2 (SD=0.016) on the moment magnitude; b. Event Onset: August 24, 2016 - 03:36:32 CEST (01:36 UTC); c. Location of Event: Central Italy, in the town of Amatrice; d. Geographic Coordinates: latitude (DMS): 42°37'45.77″N; longitude (DMS): 13°17'18.14″E; elevation: 955 meters above sea-level; e. Dates: August 24, 2016 at 4:48 AM; f. Response Type: Medical Relief. ABSTRACT: On August 24, 2016, an earthquake hit the town of Amatrice (Italy). This study aims to document the first medical aid provided to earthquake victims in Amatrice immediately following the earthquake. Patient data were collected and recorded during the first clinical evaluation and before definitive hospitalization. Blood gas tests were performed on survivors extricated from the rubble using the iSTAT (Abbott Point of Care Inc.; Princeton, New Jersey USA) handheld blood analyzer. Performing "victim-side" blood gas tests could provide concrete information to facilitate clinical evaluation and decision making when treating buried victims. After a natural disaster, it is essential to provide effective analgo-sedation to victims. Blasetti AG , Petrucci E , Cofini V , Pizzi B , Scimia P , Pozone T , Necozione S , Fusco P , Marinangeli F . First rescue under the rubble: the medical aid in the first hours after the earthquake in Amatrice (Italy) on August 24, 2016. Prehosp Disaster Med. 2018;33(1):109-113.

Inferior vena cava distensibility as a predictor of fluid responsiveness in patients with subarachnoid hemorrhage.

BACKGROUND: The objective of our study is to assess the reliability of the distensibility of the inferior vena cava (dIVC), as measured by ultrasound, as an indicator of fluid responsiveness in patients with subarachnoid hemorrhage. METHODS: We enrolled 29 adult patients requiring advanced hemodynamic monitoring, sedation, and mechanical ventilation. Inferior vena cava diameter was measured during a single mechanical breath. The dIVC was calculated as (the diameter of the inferior vena cava on inspiration-the diameter on expiration)/the diameter on expiration. All the hemodynamic parameters were collected at baseline and after a fluid challenge (7 ml/kg) with 6% hydroxyethyl starch. A 15% increase of cardiac index was the standard criterion used to differentiate patients with and without a response to fluid therapy. RESULTS: Apart from stroke volume variation (SVV) and dIVC, which were significantly higher in fluid responders (17 patients), the other baseline characteristics did not differ significantly between groups (responders versus non-responders). Significant changes in hemodynamic parameters after volume load were observed only in fluid responders. The area under the ROC curve was 0.779 (95% confidence interval 0.587-0.911) for SVV and 0.902 (95% confidence interval 0.733-0.979, P = NS) for dIVC. Central venous pressure was a less reliable indicator of fluid responsiveness than dIVC. A dIVC value of >16% yielded the most favorable balance of test characteristics, with 70.59% sensitivity and 100% specificity. There was a trend toward a lower incidence of delayed ischemic lesions in fluid responders (11.7 vs. 25%, P = NS). CONCLUSION: dIVC proved to be a reliable predictor of fluid responsiveness in ICU patients with subarachnoid hemorrhage.

Reliability of optic nerve ultrasound for the evaluation of patients with spontaneous intracranial hemorrhage.

INTRODUCTION: The aim of our study is to confirm the reliability of optic nerve ultrasound as a method to detect intracranial hypertension in patients with spontaneous intracranial hemorrhage, to assess the reproducibility of the measurement of the optic nerve sheath diameter (ONSD), and to verify that ONSD changes concurrently with intracranial pressure (ICP) variations. METHODS: Sixty-three adult patients with subarachnoid hemorrhage (n = 34) or primary intracerebral hemorrhage (n = 29) requiring sedation and invasive ICP monitoring were enrolled in a 10-bed multivalent ICU. ONSD was measured 3 mm behind the globe through a 7.5-MHz ultrasound probe. Mean binocular ONSD was used for statistical analysis. ICP values were registered simultaneously to ultrasonography. Twenty-eight ONSDs were measured consecutively by two different observers, and interobserver differences were calculated. Twelve coupled measurements were taken before and within 1 min after cerebrospinal fluid (CSF) drainage to control elevated ICP. RESULTS: Ninety-four ONSD measurements were analyzed. 5.2 mm proved to be the optimal ONSD cut-off point to predict raised ICP (>20 mmHg) with 93.1% sensitivity (95% CI: 77.2-99%) and 73.85% specificity (95% CI: 61.5-84%). ONSD-ICP correlation coefficient was 0.7042 (95% CI for r = 0.5850-0.7936). The median interobserver ONSD difference was 0.25 mm. CSF drainage to control elevated ICP caused a rapid and significant reduction of ONSD (from 5.89 ± 0.61 to 5 ± 0.33 mm, P < 0.01). CONCLUSION: Our investigation confirms the reliability of optic nerve ultrasound as a non-invasive method to detect elevated ICP in intracranial hemorrhage patients. ONSD measurements proved to have a good reproducibility. ONSD changes almost concurrently with CSF pressure variations.

Optic nerve ultrasound for detection of intracranial hypertension in intracranial hemorrhage patients: confirmation of previous findings in a different patient population.

Bedside ultrasonographic measurement of optic nerve sheath diameter (ONSD) has been proposed as a method to detect raised intracranial pressure (ICP) in various clinical settings. The aim of our study is to evaluate the use of ultrasonography in the case of intracranial hemorrhage and to assess the validity of the conventional cut-off point of 5 mm. A prospective blind observational study in a 10-bed multivalent intensive care unit was carried out by enrolling 53 adult patients with primary intracerebral hemorrhage (23) or subarachnoid hemorrhage (30), requiring ICP monitoring, sedation, and mechanical ventilation and 53 control patients with no intracranial pathology, requiring sedation and mechanical ventilation. ONSD was measured 3 mm behind the globe by using a 7.5 MHz linear ultrasound probe. Mean binocular ONSD was used for data analysis. Nineteen patients proved to have raised ICP (>20 mm Hg). In this group, ONSD at admission was 6.2+/-0.6 mm, a significantly higher value than in low ICP patients (P<0.01). In the 34 patients with ICP <20 mm Hg, ONSD was 5.0+/-0.5 mm, and it resulted not significantly different from ONSD in the control group (4.9+/-0.4 mm). A receiver operator characteristic curve was constructed and an ONSD threshold of 5.2 mm as a predictor of ICP >20 mm Hg proved to be an attractive combination of sensitivity and specificity (94% and 76%, respectively). In conclusion, our study confirms the utility of optic nerve ultrasound in the early diagnostic evaluation of patients with known or suspected intracranial hemorrhage.