Our Experience with Management and Outcome of Isolated Traumatic Brain Injury Patients Admitted in Intensive Care Unit.

INTRODUCTION: Traumatic brain injury (TBI) is a major cause of death and disability throughout the world. Commonly used predictors of outcome both individually or in combination include age, Glasgow Coma Scale score, pupillary reactivity, early hypoxia, and hypotension. Most of the studies previously done to examine risk factors for mortality in severe TBI were done in the setting of polytrauma. AIMS AND OBJECTIVES: The aim and objective of this study was to do an in-depth analysis of various factors associated with the management and outcome of patients with isolated TBI admitted in an Intensive Care Unit (ICU). MATERIALS AND METHODS: A total of seventy adult patients who were admitted to Intensive Critical Care Unit (ICU) with isolated TBI were selected during a 12-month period from January 2016 to December 2016. This is a prospective analytical study and parameters studied included age, sex, cause of admission classified by type of trauma, premorbid functional status, acute and chronic comorbidities, brain noncontrast computed tomography scan data, Glasgow Coma Scale (GCS), hemodynamic status, respiratory status, and mechanical ventilation, blood gases, serum electrolytes, serum glucose, hemoglobin, leukocyte and platelet counts, renal function, and urinary output. RESULTS: The study population consisted of 46 (65.7%) males and 24 (34.2%) females. The mean age was 35.5 years (range, 18-65 years). The most common mode of trauma was road traffic accident (43.6%) followed by fall from height (35.7%). Statistically insignificant relationship (P < 0.05) was seen with sex and mode of injury among survivors and nonsurvivors; however, 61.9% of patients with age ≥40 years died (P < 0.005). Among clinical parameters at admission to ICU, low GCS, hypotension (mean arterial pressure ≤80 mmHg), hypoxia (pO2 ≤60 mmHg, spO2 ≤90 mmHg), and nonreacting pupils were significantly associated with increased mortality (P < 0.05). CONCLUSION: Isolated TBI still continues to have a good amount of morbidity and mortality which perhaps can be reduced by strict adherence to guidelines of management.

Evaluation of Effectiveness of Dexmedetomidine and Fentanyl-midazolam Combination on Sedation and Safety during Awake Fiberoptic Intubation: A Randomized Comparative Study.

BACKGROUND: Awake fiberoptic intubation (AFOI) is a recommended technique for anticipated difficult airway. An ideal regime should provide patient comfort, cooperation, amnesia, hemodynamic stability, and blunt airway reflexes and maintain a patent airway with spontaneous ventilation. The aim of our study was to compare intubation conditions between dexmedetomidine and fentanyl-midazolam combination during AFOI. METHODS: This prospective, randomized study was conducted on a total of sixty patients of the American Society of Anesthesiologists physical status I and II of either sex, in the age group of 18-60 years having predicted difficult intubation undergoing elective surgeries and the patients were allocated to two groups of thirty patients each. After premedication and topicalization of airways, dexmedetomidine group (Group I, n = 30) received dexmedetomidine 1 µg/kg over 10 min and midazolam-fentanyl group (Group II, n = 30) received fentanyl 2 µg/kg plus midazolam 0.02 mg/kg over 10 min. Adequacy of intubation condition was evaluated by cough score and postintubation score. Incidence of desaturation, hemodynamic changes, and sedation using Ramsay sedation scale were noted and compared between two groups. RESULTS: The demographic characteristics were comparable in the two groups (P > 0.05). The mean Ramsay sedation score in Group I was 3.13 ± 0.937 and Group II was 3.16 ± 0.949, and the comparison between two groups was statistically insignificant (P = 0.891). Cough scores and postintubation scores were favorable in dexmedetomidine group than midazolam-fentanyl group and were statistically significant with P < 0.001 and 0.0001, respectively. Group I also showed better hemodynamics and less episodes of desaturation than Group II. CONCLUSIONS: Dexmedetomidine is more effective than midazolam-fentanyl during AFOI, as it provides better intubation condition, hemodynamic stability, and preservation of airway and spontaneous ventilation.

Effects of Lignocaine Administered Intravenously or Intratracheally on Airway and Hemodynamic Responses during Emergence and Extubation in Patients Undergoing Elective Craniotomies in Supine Position.

INTRODUCTION: Sympathoadrenergic responses during emergence and extubation can lead to an increase in heart rate (HR) and blood pressure whereas increased airway responses may lead to coughing and laryngospasm. The aim of our study was to compare the effects of lignocaine administered intravenously (IV) or intratracheally on airway and hemodynamic responses during emergence and extubation in patients undergoing elective craniotomies. METHODOLOGY: Sixty patients with physical status American Society of Anaesthesiologists Classes I and II aged 18-70 years, scheduled to undergo elective craniotomies were included. The patients were randomly divided into three groups of twenty patients; Group 1 receiving IV lignocaine and intratracheal placebo (IV group), Group 2 receiving intratracheal lignocaine and IV placebo (I/T group), and Group 3 receiving IV and intratracheal placebo (placebo group). The tolerance to the endotracheal tube was monitored, and number of episodes of cough was recorded during emergence and at the time of extubation. Hemodynamic parameters such as HR and blood pressure (systolic, diastolic, mean arterial pressure) were also recorded. RESULTS: There was a decrease of HR in both IV and intratracheal groups in comparison with placebo group (P < 0.005). Rise in blood pressure (systolic blood pressure, diastolic blood pressure and mean arterial pressure) was comparable in both Groups 1 and 2 but was lower in comparison with placebo group (P < 0.005). Cough suppression was comparable in all the three groups. Grade III cough (15%) was documented only in placebo group. CONCLUSION: Both IV and intratracheal lignocaine are effective in attenuation of hemodynamic response if given within 20 min from skull pin removal to extubation. There was comparable cough suppression through intratracheal route and IV routes than the placebo group.

Improved diagnosis of central nervous system tuberculosis by MPB64-Target PCR / Diagnóstico da tuberculose do sistema nervoso central por MPB64-Target PCR

Central nervous system (CNS) tuberculosis is a serious clinical problem, the treatment of which is sometimes hampered by delayed diagnosis. Clearly, prompt laboratory diagnosis is of vital importance as the spectrum of disease is wideand abnormalities of the cerebrospinal fluid (CSF) are incredibly variable. Since delayed hypersensitivity is the underlying immune response, bacterial load is very low. The conventional bacteriological methods rarely detect Mycobacterium tuberculosis in CSF and are of limited use in diagnosis of tuberculous meningitis (TBM). This double blind study was, therefore, directed to the molecular analysis of CNS tuberculosis by an in-house-developed PCR targeted for amplification of a 240bp nucleotidesequence coding for MPB64 protein specific for Mycobacterium tuberculosis. Based on the clinical criteria, 47 patients with CNS tuberculosis and a control group of 10 patients having non-tubercular lesions of the CNS were included in the study. Analyses were done in three groups; one group consisting of 27 patients of TBM, a second group of 20 patients with intracranial tuberculomas and a third group of 10 patients having non-tubercular lesions of the CNS acted as control. There were no false positive results by PCR and the specificity worked out to be 100 percent. In the three study groups, routine CSF analysis (cells and chemistry), CSF for AFB smear and culture were negative in all cases. PCR was positive for 21/27 patients (77.7 percent sensitivity) of the first group of TBM patients, 6/20 patients (30 percent sensitivity) of the second group with intracranial tuberculomas were positive by PCR and none was PCR-positive (100 percent specificity) in the third group. Thus, PCR was found to be more sensitive than any other conventional method in the diagnosis of clinically suspected tubercular meningitis.

A tuberculose do sistema nervoso central (CNS) é um problema clínico sério, cujo tratamento é dificultado pelo diagnóstico tardio. O diagnóstico laboratorial rápido é de importância vital considerando que o espectro da doença é amplo e as anormalidades do liquor são muito variáveis. Considerando que a hipersensibilidade tardia é a resposta imune fundamental, a carga bacteriana é muito baixa. Os métodos bacteriológicos convencionais raramente detectam Mycobacterium tuberculosis no liquor e são de uso limitado para diagnóstico da meningite tuberculosa (TBM). O presente estudo duplo-cego objetivou a análise molecular da tuberculose do CNS através de um PCR desenvolvido in-house direcionado para a amplificação de uma seqüência de nucleotídios de 240pb que codificam a proteína MPB64 especifica de Mycobacterium tuberculosis. Baseando-se em critérios clínicos, selecionou-se 47 pacientes com tuberculose do CNS e um grupo controle de 10 pacientes com lesões não-tuberculosas no CNS. As análises foram divididas em três grupos: um grupo de 27 pacientes com TBM, um segundo grupo com 20 pacientes com tuberculomas intracraniais e um terceiro grupo de 10 pacientes com lesões não-tuberculosas no CNS (controles). O PCR não forneceu nenhum resultado falso-positivo, com 100 por cento de especificidade. Em todos os três grupos de estudo, os resultados das análises de rotina do liquor por histologia, química e baciloscopia e também cultura foram negativos em todos os casos. No primeiro grupo de pacientes com TBM, PCR foi positivo em 21/27 pacientes (sensibilidade de 77,7 por cento). No segundo grupo de pacientes com tuberculomas intracraniais, 6/20 foram positivos (sensibilidade de 30 por cento). Nenhum dos pacientes do grupo controle foi positivo (100 por cento de especificidade). Dessa forma, o PCR mostrou-se mais sensível que os métodos convencionais no diagnóstico de casos suspeitos de meningite tuberculosa.

Improved diagnosis of central nervous system tuberculosis by MPB64-Target PCR.

Central nervous system (CNS) tuberculosis is a serious clinical problem, the treatment of which is sometimes hampered by delayed diagnosis. Clearly, prompt laboratory diagnosis is of vital importance as the spectrum of disease is wide and abnormalities of the cerebrospinal fluid (CSF) are incredibly variable. Since delayed hypersensitivity is the underlying immune response, bacterial load is very low. The conventional bacteriological methods rarely detect Mycobacterium tuberculosis in CSF and are of limited use in diagnosis of tuberculous meningitis (TBM). This double blind study was, therefore, directed to the molecular analysis of CNS tuberculosis by an in-house-developed PCR targeted for amplification of a 240bp nucleotide sequence coding for MPB64 protein specific for Mycobacterium tuberculosis. Based on the clinical criteria, 47 patients with CNS tuberculosis and a control group of 10 patients having non-tubercular lesions of the CNS were included in the study. Analyses were done in three groups; one group consisting of 27 patients of TBM, a second group of 20 patients with intracranial tuberculomas and a third group of 10 patients having nontubercular lesions of the CNS acted as control. There were no false positive results by PCR and the specificity worked out to be 100%. In the three study groups, routine CSF analysis (cells and chemistry), CSF for AFB smear and culture were negative in all cases. PCR was positive for 21/27 patients (77.7% sensitivity) of the first group of TBM patients, 6/20 patients (30% sensitivity) of the second group with intracranial tuberculomas were positive by PCR and none was PCR-positive (100% specificity) in the third group. Thus, PCR was found to be more sensitive than any other conventional method in the diagnosis of clinically suspected tubercular meningitis.