Singh et al

6. Mariappan R, Manninen P, McAndrews MP, et al. Intracarotid etomidate is a safe alternative to sodium amobarbital for the wada test. J Neurosurg Anesthesiol. 2013; 25:408–413.

Utilization of a Mobile Videoconferencing Tool (FaceTime) for Real-time Evaluation of Critically Ill Neurosurgical Patients To JNA Readers: Telemedicine is applied in the management of neurologically critically ill patients at an increasing frequency; however, the cost of various telemedicine systems (ie, medical robots) is prohibitive in its application ($5000 to $6000/month for a mobile robot system).1 Recently, in our neurointensive care unit (NICU), there have been several patients who would benefit from a visual assessment of their presentation or monitoring information. Universally, there is a practical limitation to the amount of personal examination possible by the attending physician at odd hours in a 24 h/d call structure. As such, to optimize the care of the tertiary patients in our unit, we recently attempted utilizing FaceTime (FT), a videoconferencing tool readily available on the Apple iPhone. Although FT has been medically applied to a limited degree, to the author’s knowledge there are no reported instances of utilizing FT for clinical assessment by a NICU team.2 We utilized FT for 2 cases, the first case being a 30-year-old man who, following admission to the NICU for a motor vehicle versus pedestrian accident with resulting mild cerebral edema, was severely agitated following extubation requiring a propofol infusion (20 mcg/kg/min) and boluses (100 mg), dexmetatomidine (1.2 mcg/ kg/h), lorazepam IV, haloperidol IV, and hydromorphone IV. Urine toxicology and eventual history from the

The authors have no funding or conflicts of interest to disclose.

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patient revealed intoxication with alcohol, benzodiazepines, marijuana, cocaine, and heroin. The patient was saturating well on room air throughout this entire time and was in 4-point nylon restraints. To assess the degree of agitation throughout the evening, FT evaluation was undertaken and aided in accurate titration of therapy in this extubated patient requiring extraordinary doses of sedatives. The second case was a 60-yearold patient who presented to our NICU following emergent transfer to the NICU with a triple acid-base disorder characterized by nonanion gap metabolic acidosis, anion gap metabolic acidosis with diabetic ketoacidosis, and partial respiratory compensation (respiratory alkalosis). The patient was intubated following admission and found on workup to have an infected diabetic foot ulcer, non-ST segment elevation myocardial infarction, and hyperkalemia out of proportion to that expected from the diabetic ketoacidosis. FT was utilized to conduct late evening rounds and perform an analysis of the arterial and ECG waveforms (resolving a question about whether the waveform was indicative of arterial line dysfunction). This assessment allowed for realtime evaluation of the patients hemodynamic information and for robust discussion with the call team. In our NICU, we have a medical robot that is available to be utilized for off-hour assessment of neurocritically ill patients. The primary disadvantages of this system are that: (1) a joystick and laptop with specific software is required and (2) the robot is large and must be unplugged from its dock to be utilized. We believe that although the robot is useful, FT can be applied more readily and without a wireless internet connection. Furthermore, as in our cases, FT allowed for rapid assessment of neurocritically ill patients in a way not possible by telephone while remaining HIPPA compliant.



Volume 27, Number 1, January 2015

REFERENCES 1. Freeman WD, Barrett KM, Vatz KA, et al. Future neurohospitalist: teleneurohospitalist. Neurohospitalist. 2012;2:132–143. 2. Armstrong DG, Giovinco N, Mills JL, et al. FaceTime for physicians: using real time mobile phone-based videoconferencing to augment diagnosis and care in telemedicine. Eplasty. 2011;11:e23.

Subarachnoid Block in an Undiagnosed Isolated Traumatic Subarachnoid Hemorrhage

George W. Williams, MD* Francisco I. Buendia, MD* Olakunle O. Idowu, MDw

To JNA Readers: A 28-year-old male victim of a road-side accident presented to the emergency department with polytrauma and transient loss of consciousness. The patient had fractured his femur and fifth rib of the right side. Multiple bruises were present throughout the body along with a lacerated wound on right parietal region. There was neither bleeding from ear, nose, or throat nor any nausea, vomiting, or seizure episode. Patient was hemodynamically stable and neurologic examination revealed no abnormal findings. Noncontrast computed tomography scan of the head detected no abnormal findings and further neurosurgical opinion ruled out any active intervention. He complained of persistent headache of mild intensity, which was attributed to the lacerated wound of scalp. Alternate injections of diclofenac and tramadol injections kept it under control. The patient was posted for interlocking nailing for fracture shaft of femur 4 days after trauma. On preoperative visit, patient was conscious and oriented (GCS = 15/15) but complained of mild headache. Pulse rate, blood pressure, and respiratory rate were 70 min 1, 136/76 mm Hg, 20 min 1, respectively. All laboratory investigations were normal. Inside the operating room monitoring included 5 lead ECG, noninvasive blood pressure, and SpO2. After preloading with 1 L of

Departments of *Anesthesiology wAnesthesiology and Critical Care Medicine, The University of Texas Medical School at Houston, Houston, TX

The authors have no funding or conflicts of interest to disclose. r

2014 Lippincott Williams & Wilkins

J Neurosurg Anesthesiol



Volume 27, Number 1, January 2015

lactated ringer solution, lumber puncture (LP) was performed under sterile conditions with 25 G Quincke’s spinal needle inserted one time without trauma at the L3-4 interspace. Free flow of yellow-colored cerebrospinal fluid (CSF) appeared. The yellowish tinge of CSF made us suspicious of an undiagnosed traumatic subarachnoid hemorrhage (SAH). To confirm the same we collected 1 mL of CSF sample and sent it to the biochemistry department for spectrophotometric analysis. However, we proceeded with subarachnoid block in this patient using 2.7 mL of 0.5% hyperbaric bupivacaine (13.5 mg). Perioperative course remained uneventful. Result of spectrophotometric analysis of CSF confirmed xanthochromia, which occurs from hemoglobin catabolism and is diagnostic of SAH. A review by neurosurgeon established the diagnoses of isolated traumatic SAH. According to the literature, computed tomography (CT) scan has 95% sensitivity for diagnosing SAH and in CT-negative cases LP is carried out to visualize xanthochromia along with spectrophotometric analyses of the CSF to confirm the same.1–5 Nowadays, isolated traumatic SAH with subtle presentation is being increasingly recognized. A recent study by Quigley et al6 identified that isolated traumatic SAH in the settings of mild traumatic brain injury (GCSZ13) without other intracranial pathology are a form of benign head injury that does not warrant extensive observation and followup. Ours was one such case of benign SAH diagnosed accidently while performing neuraxial blockade. Despite suspecting the underlying pathology we proceeded with regional anesthesia as our patient was relatively asymptomatic, had no sign and symptoms of raised intracranial pressure, and had been neurologically cleared. His headache was mild in nature in contrast to characteristic severe thunderclap headache associated with SAH. To conclude, xanthochromic CSF on lumbar puncture should alert anesthesiologist about an underlying undiagnosed SAH, especially in settings of preceding trauma. Weather to proceed with neuraxial blockade in such cases must be viewed within the apr

2014 Lippincott Williams & Wilkins

propriate clinical context like signs of raised ICP, any neurologic deficits, and hemodynamic status of the patient. Tarandeep Singh, MBBS, MD, DNB Sarla Hooda, MBBS, MD Asha Anand, MBBS, DA, DNB Pooja Bihani, MBBS Department of Anesthesiology & Critical Care, Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India

REFERENCES 1. Vermuelen M, Hasan D, Blijenberg BG, et al. Xanthochromia after subarachnoid haemorrhage needs no revisitation. J Neurol. 1989;52:826–828. 2. Beetham R. Spectrophotometric examination of CSF for xanthochromia (Letter Comment). Lancet. 1992;339:1492. 3. Roost KT, Pimstone NR, Diamond I, et al. The formation of cerebrospinal fluid xanthochromia after subarachnoid haemorrhage: enzymic conversion of haemoglobin to bilirubin by the arachnoid and choroid plexus. Neurology. 1972;22:973–977. 4. MacDonald A, Mendelow AD. Xanthochromia revisited: a re-evaluation of lumbar puncture and CT scanning in the diagnosis of subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry. 1998;51:341–344. 5. Foot C, Staib A. How valuable is a lumber puncture in the management of patients with suspected subarachnoid hemorrhage? Emerg Med. 2001;13:326–332. 6. Quigley MR, Chew BG, Swartz CE, et al. The clinical significance of isolated traumatic subarachnoid hemorrhage. J Trauma Acute Care Surg. 2013;74:581–584.

Abnormal Bispectral Index Values Associated With the Presence of Periodic Lateralized Epileptiform Discharges To JNA Readers: We report a case in which the presence of periodic lateralized epileptiform discharges (PLEDs) in the unprocessed electroencephalogram (EEG) of a patient with acute herpes simplex encephalitis was associated with the display of an abnormally high processed bispectral index (BIS) value. Written consent was obtained from the next-ofkin of the deceased (for the publication of this report). The authors have no funding or conflicts of interest to disclose.

Correspondence

A 67-year-old man with a history of previous stroke presented to the emergency department with seizures and expressive dysphasia. A computed tomography brain scan demonstrated no focal lesions. He was admitted to the neurology ward where initial routine blood tests and lumbar puncture (LP) were unremarkable. The patient developed status epilepticus that failed to respond to maximum medical therapy, necessitating tracheal intubation and admission to the neurointensive care unit. BIS monitoring was instituted to guide sedation. Magnetic resonance imaging revealed appearances consistent with viral encephalitis. A repeat LP proved positive for herpes simplex virus. The patient had already been commenced on antimicrobials on admission including acyclovir. Sedation was stopped 3 days later to assess neurologic status, but the patient continued to be deeply comatose. Periodic high-amplitude spikes against electrophysiological silence were noted on the BIS monitor. Concurrent increase in the calculated BIS indices from near 0 to higher values (Fig. 1) seemed inconsistent with the underlying clinical picture. A formal EEG showed the presence of PLEDs in all montages with no underlying normal EEG pattern, suggestive of severe cerebral dysfunction. Despite treatment with acyclovir for 2 weeks, the patient remained comatose. The patient died soon after ventilatory support was withdrawn. PLEDs are patterns of abnormal EEG activity indicative of severe cerebral pathology and are associated with poor outcome. Etiological factors for PLEDs include viral encephalitis,1 as seen in our case. It has been suggested that the poor outcome that PLEDs confers is independent of etiology.2 The persistence of PLEDs on continuous full EEG monitoring during the process of death has been previously described.3 The phenomenon of PLEDs has not been previously reported when using BIS. In this case, the BIS monitor detected an actual clinical EEG anomaly and incorporated this anomaly into the processed value to produce an abnormally high BIS value. Although clinicians would rarely act on a BIS value in www.jnsa.com |

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Subarachnoid block in an undiagnosed isolated traumatic subarachnoid hemorrhage.

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