Search

OBJECTIVE Traumatic brain injuries (TBIs) play a significant role in pediatric mortality and morbidity. Decompressive hemicraniectomy (DHC) is a treatment option for severe pediatric TBI (pTBI) not amenable to medical management of intracranial pressure. Posttraumatic hydrocephalus (PTH) is a known sequela of DHC that may lead to further injury and decreased capacity for recovery if not identified and treated. The goal of this study was to characterize risk factors for PTH after DHC in patients with pTBI by using the Kids’ Inpatient Database (KID). METHODS The records collected in the KID from 2016 to 2019 were queried for patients with TBI using International Classification of Diseases, 10th Revision codes. Data defining demographics, complications, procedures, and outcomes were extracted. Multivariate regression was used to identify risk factors associated with PTH. The authors also investigated length of stay and hospital charges. RESULTS Of 68,793 patients with pTBI, 848 (1.2%) patients underwent DHC. Prolonged mechanical ventilation (PMV) was required in 475 (56.0%) patients with pTBI undergoing DHC. Three hundred (35.4%) patients received an external ventricular drain (EVD) prior to DHC. PTH was seen in 105 (12.4%), and 50 (5.9%) received a ventriculoperitoneal shunt. DHC before hospital day 2 was negatively associated with PTH (OR 0.464, 95% CI 0.267–0.804; p = 0.006), whereas PMV (OR 2.204, 95% CI 1.344–3.615; p = 0.002) and EVD placement prior to DHC (OR 6.362, 95% CI 3.667–11.037; p < 0.001) were positively associated with PTH. PMV (OR 7.919, 95% CI 2.793–22.454; p < 0.001), TBI with subdural hematoma (OR 2.606, 95% CI 1.119–6.072; p = 0.026), and EVD placement prior to DHC (OR 4.575, 95% CI 2.253–9.291; p < 0.001) were independent predictors of ventriculoperitoneal shunt insertion. The mean length of stay and total hospital charges were significantly increased in patients with PMV and in those with PTH. CONCLUSIONS PMV, presence of subdural hematoma, and EVD placement prior to DHC are risk factors for PTH in patients with pTBI who underwent DHC. Higher healthcare resource utilization was seen in patients with PTH. Identifying risk factors for PTH may improve early diagnosis and efficient resource utilization.

For several years, physicians have been required to evaluate a continuing medical education (CME) session before receiving a certificate of participation from an accredited provider. The mandatory nature of these evaluations has led to a high number of evaluations that offer information of questionable utility.We asked our CME evaluation vendor Eeds for all of the CME evaluation timestamps for our grand rounds from August 5 to September 16, 2020. We obtained time-stamped evaluation data from our CME services vendor and compared the times that sessions were evaluated to the start and completion times of those CME sessions.While almost all attendees completed electronic evaluations, 8% did so before the start of the session and half did so before its completion.Making evaluations mandatory has had the effect of lowering the quality of the data thus obtained. In an age that has been described as the "graying of grand rounds," there are more effective strategies to enhance educational value and learner satisfaction.

Background: For several years, learners have been required to evaluate a continuing medical education (CME) session prior to receiving a certificate of participation from an accredited provider. The mandatory nature of these evaluations has led to a high number of evaluations that offer information of questionable utility. Results: We obtained time stamped evaluation data from our CME services vendor, and compared the times that sessions were evaluated to the start and completion times of those CME sessions. While almost all attendees completed evaluations, 8% did so prior to the start of the session and half did so prior to its completion. Conclusions: Making evaluations mandatory has had the effect of lowering the quality of the data thus obtained. In an age that has been described as the “graying of grand rounds,” there are more effective strategies to enhance educational value and learner satisfaction.

Objective Recent randomized trials have demonstrated that endovascular therapy improves outcomes in patients with an acute ischemic stroke from a large vessel occlusion. Subgroup analysis of the Multicenter Randomized CLinical trial of Endovascular treatment for Acute ischemic stroke in the Netherlands (MR CLEAN) study found that patients undergoing general anesthesia (GA) for the procedure did worse than those with nongeneral anesthesia (non-GA). Current guidelines now suggest that we consider non-GA over GA, without large, randomized trials specifically designed to address this issue. We sought to review our experience and outcomes in a program where we routinely use GA in patients undergoing mechanical thrombectomy with similar techniques. Methods Patients with anterior circulation strokes who received intravenous tissue plasminogen activator (IV-tPA) and endovascular stroke therapy were included in the analysis. The National Institutes of Health Stroke Scale (NIHSS) on admission and discharge and modified Rankin scale scores at discharge were recorded and compared with the outcome measurements of MR CLEAN. Results Sixty patients were identified: 39 males and 21 females with a mean age of 62 (range of 29–88). Forty-seven patients were transferred from outside primary stroke centers, while 13 patients presented directly to our institution. Median NIHSS on admission was 15. The median time of symptom onset to endovascular therapy was 265 minutes, with an interquartile range of 81 minutes. Using the thrombolysis in cerebral infarction (TICI) scale, recanalization of TICI 2b–3 was achieved in 76.4% of recorded patients (42/55 recorded). At discharge, mortality was 16.7% (10/60), median NIHSS was 5, and 38.3% (23/60) of patients had a modified Rankin Scale score of 0–2. Conclusions General anesthesia does not worsen outcome in patients undergoing mechanical thrombectomy when compared to historical subgroups. Despite a longer time from symptom onset to treatment, our outcomes for patients receiving GA compare favorably to the GA and non-GA groups in MR CLEAN.

Traumatic brain injury encompasses two different types of pathology: that caused at the time of the initial physical insult, called primary injury, and then further, secondary injury caused by either host cellular responses such as oxidative injury and inflammation or by physiological insults such as ischemia, hypoxia, hypo- or hypercapnia, intracranial hypertension, and hypo- or hyperglycemia. While primary injury falls to the realm of public health (e.g., encouraging helmet use for sports, discouraging impaired driving, etc.), many secondary injuries are avoidable with proper medical management. As the stem case for this chapter, an older patient experiences a fall and is incoherent on presentation to the emergency room. This case concerns her initial management, stabilization, diagnosis, and airway management. With progression of her traumatic brain injury, the authors discuss intracranial pressure management, surgical management, and resuscitation as well as likely postoperative sequelae.

Pseudocholinesterase deficiency manifests as prolonged motor blockade after the administration of succinylcholine. A previously unknown homozygous form of the disease, became apparent during a lumbar laminectomy seriously limiting the ability to monitor motor evoked potentials and perform electromyelography (EMG). Moreover, concerns were raised as to how the enzyme deficiency would affect the metabolism of remifentanil and other esters during a total intravenous anesthetic. We present the perioperative management of the patient and a literature review of the syndrome. The patient provided written permission for the authors to publish this report. At our institution, IRB review and approval is not required for a single case report.

While undergoing emergency C6-C7 corpectomy and anterior and posterior fusion, our prone patient in whom airway management had been difficult experienced unplanned tracheal extubation. Herein, we describe emergency airway management including reintubation and provide suggestions for airway management in the prone-positioned patient.