Assessment of depth of sedation using Bispectral Index™ monitoring in patients with severe traumatic brain injury in UK intensive care units.

Introduction: Severe traumatic brain injury affects ∼4500 per year across the UK. Most patients undergo a period of sedation to prevent secondary brain injury, however the optimal sedation target is unclear. This study aimed to assess the relationship between the electroencephalogram (EEG)-based Bispectral Index™ (BIS™) value and the clinical sedation score, along with other clinical outcomes. Methods: Patients with severe traumatic brain injury in four UK ICUs were recruited to have blinded BIS data collected for a 24-h period while sedated on the ICU. Drug, physiological, and outcome data were recorded from the ICU record. Sedation management was at the discretion of the ICU clinical team. Results: Twenty-six participants were recruited to the study. The mean BIS was 38 (inter-quartile range 29-44) and there was poor correlation between BIS and sedation score as a group (correlation coefficient 0.17, 95% confidence interval 0.08-0.26), however the spread in BIS values increased with decreasing sedation score. There was no statistically significant relationship between BIS and intracranial pressure, vasopressor use, osmotherapy use, or need for an additional sedative. Conclusion: This study supports previous work showing that BIS decreases with decreasing sedation score. However, the variation in BIS values increased with deeper levels of clinical sedation. Patients may not be benefiting from the full potential of sedation in traumatic brain injury and further studies of sedation titrated to an EEG-based parameter are needed. Clinical trial registration: NCT03575169.

N-acetylcysteine infusion in preventing hepatotoxicity secondary to intravenous injection of household bleach.

We present a case of non-accidental injection of 40 ml of domestic bleach through a long-term central venous catheter (CVC) with subsequent AKI, and for the first time in the literature severe coagulopathy and acute liver injury. We detail the clinical course of events and our management plan which adds to the body of evidence for prognosis and treatment in these unusual cases.

Differential diagnosis of cystic neck lesions.

OBJECTIVES: In patients less than 40 years of age who present with an upper anterior triangle cystic mass, branchial cyst is the presumed clinical diagnosis. Squamous cell malignancy is the important differential diagnosis in a patient more than 40 years of age. We sought to identify the range of lesions that can be clinically mistaken for, and removed as, branchial cysts. METHODS: We performed retrospective reviews of 29 neck masses removed as branchial cysts and 47 solitary neck masses diagnosed as cancer between January 2003 and January 2008 across two teaching hospitals in Leeds, England. RESULTS: Of the 29 lesions removed, 23 (79.3%) were confirmed to be branchial cysts. The remainder comprised 2 thyroid papillary carcinomas (6.9%) and 4 benign lesions (13.6%; laryngocele, neurilemmoma, parotid gland cyst, and cystadenoma). Of the 47 cases of metastatic cancer, 3 lesions (6.4%) were clinically mistaken as branchial cysts but were subsequently diagnosed as squamous cell carcinomas. CONCLUSIONS: When presented with a solitary lateral cystic mass, clinicians should consider the possibility of squamous cell carcinoma in patients more than 40 years of age, and thyroid papillary cancer should be considered particularly in the younger age groups. In our series, 30.8% of the neck lesions believed to be branchial cysts in patients over 40 were malignant, in contrast to 5.3% of those lesions in patients under 40.

Cyanoacrylate ("superglue") injury to the nasal cavity: case report and a proposed management algorithm.

We report the case of a deliberate application of cyanoacrylate adhesive (commonly called "superglue") to the nose of a 9-year-old boy during a fight. The glue was successfully removed under general anesthesia without causing trauma to the nasal mucosa. To the best of our knowledge, only 1 other case of cyanoacrylate injury to the nasal cavity has been published in the literature. We also provide an algorithm to guide clinicians in the future management of this unusual circumstance.