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Results for “Persistent Vegetative State”

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PubMed2003

Effects of decompressive craniectomy on brain tissue oxygen in patients with intracranial hypertension.

This report examined the intraoperative course of partial pressure of brain tissue oxygen (P(ti)O(2)) and intracranial pressure (ICP) during surgical decompressive craniectomy for medically intractable intracranial hypertension due to diffuse brain swelling in three patients after severe subarachnoid haemorrhage and aneurysm coiling. The mean ICP decreased from 59 mm Hg to 10 mm Hg in a two step fashion, relating to bone flap removal and dural opening. Simultaneously, P(ti)O(2) increased rapidly from 0.8 kPa (6 mm Hg) to 3.07 kPa (23 mm Hg). P(ti)O(2) and ICP remained at non-critical ranges postoperatively. Despite these beneficial effects on ICP and P(ti)O(2), the patients' clinical status remained poor with two in a persistent vegetative state and one dead.

Adult↗

PubMed2002

Indications for percutaneous endoscopic gastrostomy insertion: ethical aspects.

Percutaneous endoscopic gastrostomy (PEG) is a popular technique for long-term enteral nutrition. However it is not beneficial in all cases, and may even prolong the process of dying. The present article discusses the main indications for PEG insertion, and the ethical considerations involved. Three main questions need to be answered: (1) for what purposes should PEG be used; (2) for what type of patients, and (3) when should PEG be inserted in the natural history of the patient's illness? PEG is used in patients unable to maintain sufficient oral intake. It has been found to improve quality of life and/or to increase survival in patients with head and neck cancer, acute stroke, neurogenic and muscle dystrophy syndrome, growth failure (children) and gastric decompression. It led to no improvement in nutritional or functional status in patients with cachexia, anorexia, aspiration (and aspiration pneumonia), and cancer with a short life expectancy. Several court decisions have stipulated that PEG need be offered in patients in a persistent vegetative state or patients with senile dementia who have lost the ability for self-determination. Since the 30-day mortality after PEG insertion is very high for patients hospitalized in a general medical center, a 'cooling off' period of 30-60 days should be scheduled from the time of the PEG request to actual insertion.

Enteral Nutrition↗

PubMed2004

New-onset seizures after liver transplantation: clinical implications and prognosis in survivors.

PURPOSE: To identify the probable etiologies and characteristics of new-onset seizures after orthotopic liver transplantation (OLT) and to assess their clinical implications and prognosis. METHODS: We retrospectively analyzed the clinical, electrophysiologic and laboratory data of 17 patients with new-onset seizures after OLT among 367 adult and pediatric patients who underwent OLT between 1999 and 2001. RESULTS: A suspected etiology of seizures was identified in most patients, including 6 (35.2%) with neurotoxicity due to immunosuppressive therapy, 4 (23.5%) with cerebrovascular disease, 3 (17.6%) with severe metabolic derangement by sepsis or rejection, and 1 each (5.8%) with hyperglycemia and brain edema due to fulminant hepatic failure. Causative factors could not be identified in 2 patients (11.8%). Seizures recurred in 15 patients (88.2%), with 9 occurring on the same day as the original seizure. Attacks caused by neurotoxicity tended to have an earlier onset, within 1 week in 4 of 6 patients, than those caused by cerebrovascular disease and sepsis/rejection, but this was not statistically significant. A total of 21 EEGs were performed in 13 patients. Eleven patients had abnormal EEG findings, of whom 4 (30.7%) showed epileptiform discharges, but the outcome of patients with epileptiform activity did not differ statistically from that of patients without such discharges (p > 0.6). The incidence of poor outcome (death or persistent vegetative state) in the group with seizures was almost 10 times higher than in the group without seizures (52.9 vs. 5.7%, p < 0.001). The prognosis of patients with seizures due to cerebrovascular disease and severe metabolic derangement by sepsis/rejection was poorer than that of patients with seizures caused by the neurotoxicity of immunosuppressive drugs (p < 0.02), suggesting that the underlying cause of seizures is important in determining prognosis. Of 8 patients who survived, 1 was lost to follow-up. The long-term outcome of seizures in surviving patients was excellent, with all survivors available for follow-up being seizure-free for a mean follow-up of 42.5 months (range, 16-58 months). CONCLUSION: New-onset seizures after OLT may herald fatal outcome, especially in patients with cerebrovascular disease or sepsis. The prognosis of seizures in survivors is excellent, and long-term antiepileptic drugs are not required in most cases.

Adolescent↗

PubMed1996

The prognostic value of the Glasgow Coma Scale, hypoxia and computerised tomography in outcome prediction of pediatric head injury.

The outcome of 151 children less than 15 years of age and admitted within 24 h of head injury was studied in relation to clinical and computed tomography (CT) scan features. Thirty one (20.5%) had a poor outcome (24 died, 6 were severely disabled at 6 months after injury and 1 was in a persistent vegetative state) while 120 (79.5%) had a good outcome (89 recovered well and 31 were moderately disabled). Factors associated with a poor outcome were Glasgow Coma Scale (GCS) score 24 h following injury, presence of hypoxia on admission and CT scan features of subarachnoid haemorrhage, diffuse axonal injury and brain swelling. GCS scores alone, in the absence of other factors, had limited predictive value. The prognostic value of GCS scores < 8 was enhanced two-to fourfold by the presence of hypoxia. The additional presence of the CT scan features mentioned above markedly increased the probability of a poor outcome to > 0.8, modified only by the presence of GCS scores > 12. Correct predictions were made in 90.1% of patients, indicating that it is possible to estimate the severity of a patient's injury based on a small subset of clinical and radiological criteria that are readily available.

Adolescent↗

PubMedDate not supplied

Brain injury from marked hypoxia in cats: role of hypotension and hyperglycemia.

The present study identifies several factors that govern brain pathologic response to marked hypoxia. None of 13 cats exposed to 25 minutes of marked hypoxia (FiO2 = 3.4%; PaO2 = 17 +/- 3 mm Hg, S.D.) that maintained mean arterial blood pressure (MABP) greater than 65 mm Hg were brain injured after reoxygenation and long term survival. In contrast, 12 of 13 exposed to the same hypoxia but that experienced reductions in MABP less than 45 mm Hg for 4 +/- 1 minutes developed a pattern of brain injury closely resembling that of humans surviving in a persistent vegetative state after cardiorespiratory arrest. Higher serum glucose and lactate concentrations and lower blood pH values significantly correlated with development of hypotension during hypoxia. Four of 8 cats exposed to 21 minutes of marked hypoxia followed by 4 minutes of 100% N2 breathing that also led to hypotension similarly developed brain injury. Among the hypoxic/hypotensive cats the magnitude of the hyperglycemic response to hypoxia as modulated by 0, 1, or 2 days of preexposure fasting, strongly correlated with occurrence and extent of brain damage. Peak cisterna magna CSF lactate concentrations 10 to 30 minutes into recovery distinguished those animals that remained brain-intact (less than 13 mM) from those that developed brain damage (greater than 15 mM) with 100% accuracy. Seven cats developed delayed cardiogenic shock 3 to 12 hours into the recovery period. This outcome was predicted by blood pH values less than 6.70 shortly after resuscitation while all 27 surviving cats exhibited values greater than 6.80.

Animals↗

PubMedDate not supplied

Neurological outcome of prolonged coma survivors of out-of-hospital cardiac arrest.

Nine adult survivors of out-of-hospital presumed cardiogenic cardiac arrest, who remained unresponsive for longer than their third hospital day and who eventually were discharged from the acute care hospital, are reported. Their neurological outcome fell into three distinct categories: (a) a persistent vegetative state, (b) able to follow some simple commands but requiring total nursing care, and (c) able to perform most activities of daily living but unemployable because of marked organic deficits.

Activities of Daily Living↗

PubMed2006

Tube feeding patients with dementia.

As the population ages, the incidence of dementia increases. All types of dementia, whether they are reversible or irreversible, lead to loss of intellectual function and judgment, memory impairment, and personality changes. The skills to feed oneself, use eating utensils, and consume items recognized as food, thereby maintaining nutrition status, may be lost as dementia progresses. Reports indicate that nutrition status may be maintained when patients are hand fed, but this is labor intensive and therefore expensive. Feeding via a percutaneous endoscopic gastrostomy tube is often chosen as an acceptable alternative. Research indicates that there is little benefit in this population when aggressive nutrition support is instituted. Providing tube feeding to patients with dementia does not necessarily extend life, increase weight, or reduce the incidence of pressure ulcers or aspiration. There are many legal and ethical issues involved in the decision to place a feeding tube in demented patients. The primary issue in patients with dementia may be autonomy and the right of an individual to decide whether or not a tube should be placed at all. Legally, there is clear precedent that the courts see the insertion of a feeding tube as extraordinary care that the patient has the right to refuse. However, much of case law is derived from cases of patients who were in a persistent vegetative state. Advance directives help to determine what the patient would want for himself. Considering all the options before the patient can no longer make decisions is the most desirable course.

Cost-Benefit Analysis↗

PubMed1999

Cerebral glucose metabolism in type I alpha-N-acetylgalactosaminidase deficiency: an infantile neuroaxonal dystrophy.

Cerebral glucose metabolism was investigated in a 4.8-year-old boy with alpha-N-acetylgalactosaminidase deficiency using 2-[18F]fluoro-2-deoxy-D-glucose and positron emission tomography (PET). In comparison to normal values for age, the overall cerebral glucose metabolism was reduced and the regional cerebral glucose metabolism was decreased in proportion to the degree of atrophy. In the supratentorial cortical regions, the hypometabolism was asymmetric. However, the level of regional cerebral glucose metabolism in all cortical regions excluded a persistent vegetative state. In the lentiform nucleus and the head of the caudate, comparatively increased regional cerebral glucose metabolism was documented, similar to findings in neurodegenerative disorders with active epilepsy. In contrast, the infratentorial structures (cerebellar hemispheres, brain stem, mesencephalon, and hypothalamus), which are predominantly affected by the atrophic process, showed distinct and symmetric hypometabolism. Thus, the 2-[18F]-fluoro-2-deoxy-D-glucose PET scans provided additional insight into and correlation of the functional and structural disturbances in type I alpha-N-acetylgalactosaminidase deficiency, in addition to documenting the hypometabolism due to brain atrophy.

Blood Glucose↗

PubMed2002

Developing prosthetics to treat cognitive disabilities resulting from acquired brain injuries.

Persistent cognitive disabilities represent the most troublesome consequences of acquired brain injury. Although these problems are widely recognized, few neuroprosthetic efforts have focused on developing therapeutic strategies aimed at improving general cognitive functions such as sustained attention, intention, working memory or awareness. If possible, effective modulation of these neuropsychologic components might improve recovery of interactive behaviors. The emerging field of neuromodulation holds promise that technologies developed to treat other neurological disorders may be adapted to address the cognitive problems of patients suffering from acquired brain injuries. We here discuss initial efforts at neuromodulation in patients in the persistent vegetative state and aspects of recent studies of the underlying neurobiology of PVS and other severe brain injuries. Innovative strategies for open-loop and closed-loop neuromodulation of impaired cognitive function are outlined. We discuss the possibilities of linking neuromodulation techniques to underlying neuronal mechanisms underpinning cognitive rehabilitation maneuvers. Ethical considerations surrounding the development of these strategies are reviewed.

Arousal↗

PubMed2006

Early combined cranioplasty and programmable shunt in patients with skull bone defects and CSF-circulation disorders.

OBJECTIVE: This study assesses the clinical outcome after early combined cranioplasty (own frozen bone) and shunt implantation (Codman-Medos programmable VP shunt) in patients with skull bone defects and cerebrospinal fluid (CSF) circulation disorders. METHOD: Medical records were reviewed retrospectively for the last 100 patients with CSF disorders after trauma or subarachnoid hemorrhage (SAH), who previously underwent decompressive craniotomy owing to therapy-resistant brain swelling. Patients treated with early (5 to 7 weeks after injury) combined cranioplasty and shunt implantation were analysed and a follow-up for the survivors was obtained. RESULTS: In 60 patients with a daily CSF external drainage over 150 ml and dilated ventricles in CT scan, a programmable VP shunt was implanted simultaneously with the cranioplasty within 5.1 weeks after decompression. The neurological condition 6 months later was good (independent patients) in 39 cases (65%); 12 patients (20%) survived with a severe disability; three patients (5%) remained in a persistent vegetative state and only six patients (10%) died. There were few complications: bone or shunt infection (three cases), post-operative intracranial bleeding (one case), transitory neurological impairment after bone reimplantation (two cases), bone resorption (two cases) and shunt dysfunction (three cases). CONCLUSION: The early reimplantation of the patient's own skull bone combined to the employment of a programmable shunt system allowed us a dynamic adjustment of the intracranial pressure (ICP) changes. The combined treatment reduced the number of required surgical procedures, complications and unsatisfactory patient outcomes.

Adult↗

PubMed2002

Percutaneous endoscopic gastrostomy feeding in a district rehabilitation service.

OBJECTIVES: To examine gender, diagnosis, age, reasons for feeding, nutritional status, complications, outcome and duration of feeding in patients who have required a percutaneous endoscopic gastrostomy (PEG) for nutritional support at a district rehabilitation unit in the six years since the service was established. To identify potential for improvements in the management of future patients. DESIGN: Retrospective case note review of cases from 1992 to 1998. SETTING: District rehabilitation service for ages 16-64 serving the population of Fife, Scotland (population circa 350 000). SUBJECTS: All patients (n = 42) who had been fed via a PEG feeding tube in the previous six years. RESULTS: Forty-four PEG tube insertions had been conducted for 43 episodes of feeding in 42 patients. Five episodes of feeding were because of persistent vegetative state or low awareness state and 38 because of neurological swallowing impairment. Twenty-six (60%) patients were nutritionally depleted when PEG feeding was commenced. Twenty-seven (64%) patients experienced minor complications and 15 (34%) had no complications. At three months post procedure four (9.5%) patients had died and 21 (50%) had been discharged home. The mean duration of feeding on 31 October 1998 of the 20 patients (48%) who continued feeding at that date was 3.19+/-1.89 (mean +/- SD) years. CONCLUSIONS: Patients requiring PEG feeding in a district rehabilitation service have a range of diagnoses and the main indication for intervention is neurological swallowing impairment. The majority of patients were nutritionally depleted when feeding commenced and the reasons for this require further investigation.

Enteral Nutrition↗

PubMed2003

Korean nurses' attitudes to good and bad death, life-sustaining treatment and advance directives.

This study was an investigation of which distinctive elements would best describe good and bad death, preferences for life-sustaining treatment, and advance directives. The following elements of a good death were identified by surveying 185 acute-care hospital nurses: comfort, not being a burden to the family, a good relationship with family members, a readiness to die, and a belief in perpetuity. Comfort was regarded as the most important. Distinctive elements of a bad death were: persistent vegetative state, sudden death, pain and agony, dying alone, and being a burden to the family. Of the 185 respondents, 90.8% answered that they did not intend to receive life-sustaining treatment if they suffered from a terminal illness without any chance of recovery; 77.8% revealed positive attitudes toward advance directives. Sixty-seven per cent of the respondents stated that they were willing to discuss their own death and dying; the perception of such discussions differed according to the medical condition (p = 0.001). The elements of a bad death differed significantly depending on the disease state (p = 0.003) and on economic status (p = 0.023).

Adult↗

PubMed2001

Toward a better death: applying Burkean principles of symbolic action to interpret family adaptation to Karen Ann Quinlan's coma.

This article considers the manner that families come to accept the collapse of identity in a family member who has entered a medical crisis with no hope of returning from it. The transformation is regarded as a "right of passage" and is characterized in terms of both the conditions that bring about resistance to the passage as well as the sorts of symbolic activities that ultimately allow the transformation to occur. The theoretical source that is used to discuss both these issues is Kenneth Burke's (1969) theory of Dramatism, regarded herein as a template that guides both interpersonal action and experience. The primary text used to illustrate these points is the story of Karen Ann Quinlan, a young woman who fell into persistent vegetative state in 1975, as told by her parents. A general goal of this article is to illustrate some of the characteristics of Dramatism as a theory of interpersonal action, especially after the collapse of routine. More particularly, it is hoped that the analysis will aid health professionals in sense making and interacting with families in crisis.

Adaptation, Psychological↗

PubMed2006

SSEPs and prognosis in postanoxic coma: only short or also long latency responses?

BACKGROUND: Short latency somatosensory evoked potential (SSEP) (N20) is a good predictor of poor outcome in postanoxic coma. It has been suggested that the long latency response (N70) may increase the sensitivity of SSEPs for predicting poor outcome. METHODS: As part of a prospective cohort study in 407 adult patients unconscious 24 hours after cardiopulmonary resuscitation (CPR), N20 was recorded 24, 48, and 72 hours after CPR, and N70 was recorded at least once in 319 patients. Poor outcome was defined as death or persistent vegetative state 1 month after CPR. RESULTS: Absent N20 had a 0% false positive test rate at all time intervals, with prevalence of poor test result varying from 37 to 48%. Addition of abnormal N70 (absent or delayed > 130 msec) with present N20 as poor test result added 21 to 28% to this prevalence, but at the cost of a false positive test rate of 4 to 15%. Good outcome could not be predicted reliably with either of the tests, as only 28% of patients with normal N20 and N70 had a good outcome. CONCLUSION: Determination of presence or absence of the N70 in patients with postanoxic coma gives additional information about the likelihood of poor outcome, but it is not precise enough to base treatment decisions solely on its absence.

Cohort Studies↗

PubMed1990

Prognostic implications of hyperglycemia and reduced cerebral blood flow in childhood near-drowning.

We retrospectively examined the clinical courses of 20 children with severe near-drowning and divided their outcomes into 3 groups: normal (4), persistent vegetative state (9), and dead (7). We reviewed serial blood glucose levels and cerebral blood flow measured by stable xenon computed tomography within the 1st 48 hours of admission to determine whether they were predictive of outcome. Total, frontal gray, frontal white, and temporal and parietal gray matter cerebral blood flows were significantly decreased in children who died compared with those who completely recovered. Only 1/2 the children surviving in a vegetative state had decreased flows compared with those who recovered. An elevated initial blood glucose was highly predictive of those patients who died (mean, 511 +/- 110 mg%) or those with vegetative survival (465 +/- 104 mg%) compared with those who recovered completely (238 +/- 170 mg%). The predictive value of initial blood glucose alone (68%) or CBF alone (50%) was similar to that of clinical rating scales or immersion/resuscitation times. The combination of blood glucose with CBF improved predictability to 79%. Our results suggest that CBF measurements are predictive of eventual death but cannot differentiate normal from vegetative survival. Combining multiple laboratory studies may be of value in predetermining the eventual outcome in near-drowning.

Blood Glucose↗

PubMed1994

Electroencephalographic sleep patterns in post-anoxic stupor and coma.

We analyzed EEGs performed over a 6-month period on patients with impaired consciousness following acute hypoxia or anoxia. There were 17 EEGs performed on 14 patients. Nine of the 17 records contained spindle activity. Spindles were present in 6/8 EEGs in stuporous patients, in 3/9 EEGs in comatose patients, in 6/10 patients who eventually died, and in 3/3 patients who regained consciousness. When spindle activity or background reactivity were absent, outcome was poor, ie, death or a persistent vegetative state. The presence of EEG spindle activity after hypoxic or anoxic injury did not indicate a favorable prognosis, but the absence of spindles or EEG background reactivity was associated with a poor outcome.

Coma↗

PubMed1998

Early anticoagulation in patients with prosthetic heart valves and intracerebral hematoma.

Anticoagulants are generally contraindicated in patients with intracerebral hematoma. However, in patients with prosthetic heart valves it may be dangerous to withhold such therapy because of possible thromboembolic complications. We treated four such patients with i.v. heparin starting early after the hemorrhage. The hematomas receded in all patients according to the follow-up CTs, and none had thromboembolic disorders. Three patients had good outcomes, and one remained in a persistent vegetative state after an event of acute pulmonary edema.

Adult↗

PubMed1981

Intracranial pressure monitoring in severe pediatric near-drowning.

Between April 1979 and April 1981, 20 near-drowned children admitted to Childrens Hospital of Los Angeles with a Glasgow coma score of 3 underwent intracranial pressure (ICP) monitoring and brain resuscitative therapy. By the 3rd hospital day, 14 patients had developed ICP elevation above 20 torr, and 11 of these had sustained intracranial hypertension above 30 torr. Ten of these children died, and 4 remain in a persistent vegetative state. Of 6 patients whose ICP never exceeded 20 torr, 3 recovered completely, 1 died, and 2 remain without any cognitive function. The salvage rate for patients with normal ICP after near-drowning accidents is significantly better than that for patients in whom the ICP is elevated (P = 0.017). Intracranial hypertension is associated with a uniformly bad outcome and is frequent in patients who die or suffer permanent, severe central nervous system damage after near-drowning.

Child↗