Caprini Risk Score
- a tool to assess risk of VTE among surgical patients
- includes 20 variables
- derived from a prospective study of 538 general surgery patients
Caprini Risk Score
New definition of STATUS EPILEPTICUS (Status Epilepticus: Current Treatment Strategies, by Ed Manno, published in Neurohospitalist 2015)
Status epilepticus (SE) can be defined as a seizure of sufficient duration to overcome the inherent cellular mechanisms designed to terminate the seizure. SE becomes a self-sustaining process.
Initial League against Epilepsy originally defined SE as 30 mins of sustained seizure activity or 2 or more seizures during this time period without full recovery of the patient.
Pathologically, hippocampal neurons begin to die after 30 mins of sustained seizure activity.
Newer operational definitions have suggested that seizures lasting longer than 5 mins are unlikely to discontinue spontaneously and should be treated.
There is an initiation and maintenance phase. SE is initiated through excessive excitatory stimulation but is maintained through lack of GABA-mediated neuronal suppression.
Failure to suppress initial excitatory focus may be due to development of changing GABA isoforms. With sustained seizure, hippocampal GABA A isoforms with different pharmacological properties may develop. This explains the resistance to benzodiazepines that develops during SE over time.
SE may also be sustained through excitatory NMDA’mediated neuronal stimulations. NMDA antagonists have been suggested as a possible pharmacologic strategy.
Prepare the following:
1. Three 3-way stopcocks
2. One sterile saline flush (preservative-free)
3. 2-4 10cc syringes
4. sterile gloves, sterile towels
5. gauze with betadine
6. cap, gown, mask
7. antibiotic in 2cc syringe
Put drape underneath shunt access port. Clean shunt access port with betadine thoroughly, paint line and port with betadine. Prepare sterile field (won’t be completely sterile), put on gown, mask and sterile gloves. Prepare stopcock, flush, empty syringe and antibiotic – connect in series as shown in photograph. Maintain one hand as sterile and another hand as “dirty.” Lock CSF drain to patient. Connect free end of stopcock to shunt access port. and open empty syringe (distal port) to patient. Withdraw CSF into empty syringes – draw fluid slowly, to max of 20 cc. (volume equal to or slightly more than amount of antibiotic and sterile flush to be infused). Close empty syringe (now filled with CSF) to patient. Open antibiotic port (proximal port) to patient and push antibiotic slowly. Close antibiotic port and open sterile flush port (middle port) to patient. Flush enough saline to push antibiotic in tubing into patient, and then push an extra 1-2 ml more. Close sterile flush port and disconnect intraventricular infusion set up from shunt access port. Maintain EVD clamped x 1 hour.
TREATMENT OF VENTRICULITIS:
Vancomycin 15mgkg q8-12h (max 2g) plus one of the following
Duration of treatment:
CHOICES: vanc 5-20mg/d; gent 4-8mg/d; ampho 0.1-1mg/d
INTRAVENOUS ABx PROPHYLAXIS PERIOP FOR CNS DEVICE PLACEMENT
Intraventricular application of antibiotics to reach effective concentrations within the CNS
Very comprehensive review of intra-CSF antibiotics was published May, 2018 – author went over 200 articles on this topic – by Mrowczynski, et al published in Clinical Neurology and Neurosurgery. See reference #3 below. A short summary is provided here.
Case report: successful use of intrathecal tigecycline after failed intravenous carbapenem antibiotic therapy of drug resistant Klebsiella ventriculitis.
Dose: 5mg/day, tigecycline diluted in saline up to a volume of 4ml; similar amount of CSF removed, and drug injected through EVD in 2 minutes; drain closed x 2 hours after dose; administered x total of 11d.
Pharma: 2 hours after dosing, levels peaked between 178.9 and 310.1 ug/mL, staying at 35.4-41.3 ug/mL at 6hours (which was 15-20 above MIC); after 24h, dose not detectable in CSF.
*reported doses in the literature = 1-10mg q12-24h; when los doses used, (+) CSF cultures persisted; IDSA recommends adjusting levels to 15-20x above MIC.
Nau, R., F. Sorgel, and H. Eiffert. “Penetration Of Drugs Through The Blood-Cerebrospinal Fluid/Blood-Brain Barrier For Treatment Of Central Nervous System Infections”. Clinical Microbiology Reviews 23.4 (2010): 858-883.
Mrowczynski, O., Langan, S. and Rizk, E. (2018). Intra-cerebrospinal fluid antibiotics to treat central nervous system infections: A review and update. Clinical Neurology and Neurosurgery, 170, pp.140-158.
Soto-Hernández, J., Soto-Ramírez, A., Pérez-Neri, I., Angeles-Morales, V., Cárdenas, G., & Barradas, V. (2019). Multidrug-resistant Klebsiella oxytoca ventriculitis, successfully treated with intraventricular tigecycline: A case report. Clinical Neurology And Neurosurgery, 188, 105592. doi: 10.1016/j.clineuro.2019.105592
10 basal cisterns and fissures
Utility of Hijdra Score:
In one study, Hijdra sum score and history of smoking was noted to be the strongest predictors of cerrebral vasospasm on angiography. This score was noted to be superior to the modified Fisher score as a tool to predict vasospasm after SAH.
Combined history of smoking and HSS >23 had positive and negative predictive values of 37 and 88%, respectively, for prediction of cerebral vasospasm after aneurysmal hemorrhage.
Dupont, Stefan A. et al. “Prediction Of Angiographic Vasospasm After Aneurysmal Subarachnoid Hemorrhage: Value Of The Hijdra Sum Scoring System”. Neurocritical Care 11.2 (2009): 172-176. Web.
Hijdra, A. et al. “Grading The Amount Of Blood On Computed Tomograms After Subarachnoid Hemorrhage”. Stroke 21.8 (1990): 1156-1161. Web.