Association between intracranial pulse pressure levels and brain energy metabolism in a patient with an aneurysmal subarachnoid haemorrhage.

This report addresses whether intracranial pulse pressure amplitudes are associated with brain energy metabolism, examined by intracerebral microdialysis. We present a 65-year-old female with an aneurysmal subarachnoid haemorrhage (SAH) from a left posterior communicating artery (PCOM) aneurysm. She underwent simultaneous intracranial pressure (ICP) monitoring and microdialysis (MD) as part of a diagnostic workout because of a lack of clinical improvement after long-term intensive care management. Over a 4-day period, a total of 128 samples of metabolites (glutamate, glycerol, lactate and pyruvate) were gathered, allowing retrospective comparisons with the levels of intracranial pulse pressure amplitudes (the mean ICP wave amplitude). During this 4-day period, mean ICP was normal (<15 mmHg), while mean ICP wave amplitude was high (>/=5 mmHg) in 47% of the recording time. There was a highly significant relationship between the levels of the mean ICP wave amplitude and the levels of glutamate, glycerol and lactate/pyruvate ratio. The levels of metabolites were increased when the mean ICP wave amplitude was >/=5 mmHg as compared with mean ICP wave amplitude levels <5 mmHg. We tentatively suggest that increased mean ICP wave amplitudes indicative of reduced intracranial compliance can be associated with brain ischaemia.

Monitoring urinary bladder volume and detecting post-operative urinary retention in children with an ultrasound scanner.

BACKGROUND: Post-operative urinary retention (PUR) is associated with a risk of over-distension and permanent detrusor damage. The prevention of PUR by routine catheterization may increase the risk of urinary tract infection. Post-operative monitoring of the bladder volume is a reliable method in adults, but has not been evaluated for reliability in children. METHODS: Forty-eight patients who, according to current clinical guidelines, required urinary bladder emptying were scanned before catheterization using the Bladderscan. Volumes estimated with ultrasound were compared with volumes measured after emptying the bladder with a catheter. Bladder emptying was controlled by concomitant fluoroscopy in 20 children. RESULTS: The mean difference between the ultrasound estimates and the catheter-emptied urine volumes was 4 ml [standard deviation (SD) = 25 ml] in 26 children above the age of 3 years and -18 ml (SD = 19 ml) in 22 younger children. In the subpopulation in whom complete bladder emptying could be confirmed by fluoroscopy (14 children; median age, 3 years; range, 1-11 years), the mean difference between the ultrasound estimates and the catheter-emptied volumes was -11 ml (SD = 24 ml). CONCLUSIONS: This study confirms agreement between the ultrasound scanner estimates of urinary bladder volume and the urine volume measured by emptying the bladder. Reliability was good in children above the age of 3 years. The volume was underestimated in younger children. Thus, routine monitoring of urinary bladder volume with an ultrasound scanner is a non-invasive, pain-free and reliable way of preventing over-distension of the urinary bladder in children after surgery and other procedures under general anaesthesia.

Predictable reduction of intracranial hypertension with hypertonic saline hydroxyethyl starch: a prospective clinical trial in critically ill patients with subarachnoid haemorrhage.

BACKGROUND: After head trauma, hypertonic saline lowers intracranial pressure (ICP) and preserves or increases cerebral perfusion pressure (CPP). Hypertonic saline has not been studied in patients with increased ICP due to subarachnoid haemorrhage (SAH). The aim of this study was to evaluate the effects on elevated ICP and on CPP in patients critically ill from SAH. METHODS: Critically ill SAH-patients needing urgent treatment for an elevated ICP, but otherwise stable, were included in this study. We infused 7.2% saline in 6% hydroxyethyl starch (HyperHAES((R)) Fresenius Kabi AG, Bad Homburg v.d.h., Germany) 2 ml kg(-1) during 20 min in 10 episodes of ICP > 20 mmHg in seven patients with SAH. Our primary outcome variables were changes in ICP and CPP during and for 3 h after this infusion. RESULTS: All interventions resulted in decreased ICP and elevation of CPP. The mean value for maximum ICP decrease in percent of baseline was 58% (range 43-83%, P = 0.002), which occurred at mean 40 min (range 25-90 min) after start of infusion. The mean percent peak increase in CPP was 26% (range 16-32%, P = 0.002). After 210 min, ICP was 35% lower than baseline (range 19-39%, P = 0.008). Serum sodium increase was mean 6.6 mmol l(-1) (range 5-9 mmol l(-1)) 30 min after start of infusion. CONCLUSIONS: 7.2% saline in 6% hydroxyethyl starch is an effective and safe therapy for intracranial hypertension after SAH. We demonstrate that an infusion of 2 ml kg(-1) during 20 min has a predictable and clinically significant beneficial effect on ICP and CPP. The effect was still present 3 h after end of infusion. Rebound ICP-increase was not observed within 3 h.

Cardiac arrest after intravenous metoclopramide - a case of five repeated injections of metoclopramide causing five episodes of cardiac arrest.

We describe a patient where intravenous injection of metoclopramide was immediately followed by asystole repeatedly. The patient received metoclopramide 10 mg i.v. five times during 48 h. After interviewing the attending nurses and reviewing the written documentation, it is clear that every administration of metoclopramide was immediately (within s) followed by asystole. The asystole lasted 15-30 s on four occasions, on one occasion it lasted 2 min. The patient received atropine 0.5-1 mg and chest compressions, before sinus rhythm again took over. We interpret this as episodes of cardiac arrest caused by metoclopramide. The rapid injection via the central venous route and the concomitant tapering of dopamine infusion might have contributed in precipitating the adverse drug reaction.

[Sclerotherapy of spermatoceles and hydroceles. Long-term results of polidocanol use]. / Sklerosering av spermatoceler og hydroceler. Langtidsresultater ved bruk av polidocanol.

Treatment of hydroceles and spermatoceles with evacuation, followed by injection of the sclerosing agent Polidocanol 3% (Aetoxysklerol), is a simple, low cost alternative to surgery. For the patient, it is also less painful compared to sclerotherapy using tetracycline. This article shows that the long term results are very promising. 28 patients, of whom two were treated for bilateral celes, gave us a total of 30 treatments. We interviewed the patients 62 months (52-67 months) after treatment, and found that in 24 of the 30 treatments there were no sign of relapse. In three cases the patient had noticed a small relapse, but had no pain. Three have later been treated with surgery.