Treatments include calcium antagonists, triple H therapy and angioplasty chemical and physical if available, although significant morbidity and mortality remain. Experimentally EEG burst suppression induced by barbiturates protects against cerebral ischaemia. Unfortunately studies in utilising this technique in patients with ischaemia produced by vasospasm produced grim results and further investigation was halted.
To investigate the role of barbiturate coma in the management of vasospasm resistant to other treatments including angioplasty. Patients following urgent aneurysmal repair are managed according to a previously published protocol on the intensive care unit ICU. Essentially vasospasm detected electively by angiography at day following SAH maximum risk or earlier if clinically indicated is treated with papaverine injected into the appropriate artery.
Arterial systolic pressure is increased to mmHg and papaverine angioplasty is repeated each day until vasospasm resolves. Balloon angioplasty is attempted if vasospasm persists and then if this fails barbiturate induced burst suppression is implemented. Eleven patients who had attained 6 months of follow up were managed with barbiturate induced burst suppression. The Glasgow Outcome Scale was used to rate neurological outcome and mortality was compared to predicted APACHE II mortality, and previous studies utilising nimodipine to treat patients with ischaemic deficit secondary to vasospasm.
One hundred and sixty-four consecutive patients treated according to protocol were reviewed. Eleven patients with symptomatic vasospasm varying from mild cognitive to severe motor deficits and decreased conscious level received barbiturate coma therapy where chemical angioplasty had failed on a number of occasions. Intended duration of barbiturate therapy was 3 days but three patients required earlier discontinuation because of infectious complications and two patients received longer infusions because of persistent angiography proven vasospasm.
Theoretical benefits of barbiturate in IICP patients derive from vasoconstriction in normal brain areas shunting blood to ischemic brain tissue , and decreased metabolic oxygen demand with accompanying reduction of cerebral blood flow Other mechanisms by which barbiturate may exert protective effects include stabilization of lysosomal membrane, reduction of intracellular calcium concentration, modification of amino acid and neurotransmitter release, scavenging of free radicals, alteration of fatty acid metabolism, reduction in cerebrospinal fluid production, membrane stabilization, and suppression of seizure 1 , 2 , 5 , 17 , Sedatives and analgesics such as morphine sulfate, midazolam, fentanyl, sufentanyl, propofol were also common management strategies for ICP control although there is no evidence to support their efficacy in this regard and they have not been shown to positively affect outcome 9.
In , Kelly et al. According to their study, ICP was significantly lower on day 3 in patients receiving propofol without any improvement in mortality and GOS outcome. The association between the level of ICP and survival is well documented in most of the literatures on this subject 6 , 7 , 15 , Survival rate in the patients with adequately controlled ICP is clearly superior to that of the patients with persistently elevated ICP Michael et al.
Our results, a higher survival rate in BCT group, can be comparable with the results of previous studies 6 , 7 , 16 showing reciprocal relationship between survival and high ICP.
Eisenberg et al. They found that the patients in the pentobarbital group had improved in ICP control. Furthermore, our study showed higher 1-year survival rate, With the data showing lower mean age of the good outcome patients in BCT group, we could suggest that age might be a meaningful prognostic factor.
We had divided age group every 10 years, and we have found age related differences in the outcome between two age groups, aged up to 30 and older than 30 years. In BCT group, Etienne et al. However, well known risks and the ongoing controversies over the benefits of BCT have limited the use of BCT to the most extreme clinical situations 9. Complications of BCT were mostly transient and could be adequately resolved in the intensive care unit setting, and there was no significant difference in the complication rate between BCT and control group.
In Etienne's study group 6 , bronchopneumonia was the most common complication. In our study, hypernatremia was the most common complication in both groups. Systemic hypotension, which was more frequently observed in BCT group The lower incidence of hypotension in our study seems to be related with concomitant use of dopamine and dobutamine for maintaining adequate blood pressure. There are some limitations which could affect the reliability of the results of our study.
The patient groups include heterogenous conditions, head trauma and stroke. Under the basic idea that traumatic brain injury and stroke can roughly share the common pathophysiological pathway 4 , 8 , 14 , we tried to select patients having brain edema resulting from parenchymal injury at the corresponding brain region.
But, it still can have bias in the interpretation of our results. So, we are planning further study using patient groups that include more specified and homogeneous brain conditions if we can collect more number of IICP patients receiving BCT.
The different time periods of the BCT and control group might be another bias. Control and BCT group patients were admitted before and after , respectively, and there could be some differences in the IICP treatment between the two time periods. However, there have not been changes in our IICP management protocol since early 's except BCT which started in in our hospital, and it didn't seem to affect the results.
However, a larger, randomized and prospective study comparing more homogeneous disease groups must be required for further investigation. National Center for Biotechnology Information , U.
J Korean Neurosurg Soc. Published online Sep Young-Il Kim , M. Find articles by Young-Il Kim. Find articles by Seung-Won Park. Find articles by Taek-Kyun Nam. Crit Care Med 6 : 1 — 5 , false. Pediatrics 81 : — , Nussbaum E , Maggi JC : Pentobarbital therapy does not improve neurologic outcome in nearly drowned, flaccid-comatose children. Pediatrics 81 : — , false. Jpn false. Neurosurgery 15 : — , false. Pediatr Neurosci 15 : 13 — 17 , Pittman T , Bucholz R , Williams D : Efficacy of barbiturates in the treatment of resistant intracranial hypertension in severely head-injured children.
Pediatr Neurosci 15 : 13 — 17 , false. Resuscitation 17 : — , false. Eur J Clin Pharmacol 54 : — , Stover JF , Stocker R : Barbiturate coma may promote reversible bone marrow suppression in patients with severe isolated traumatic brain injury. Eur J Clin Pharmacol 54 : — , false. Abstract false. Crit Care Med 11 : — , false. Stroke 13 : — , false. Permissions Legal Notices Feedback. Sign in to annotate. Delete Cancel Save. Cancel Save. View Expanded. View Table.
View Full Size. Knees and ankles were banged against each other and against the bed rails, and bony points were subjected to much friction on the bed sheets. Involved skin quickly blistered, eroded, and crusted, but soon healed with simple dressings. We saw the women for the first time 5, 18, and 12 months later, and herein illustrate the lesions of the patients aged 27 and None gave personal or family histories of other keloids, and all were. Keloids and Barbiturate Coma. Arch Dermatol.
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