Well-Being After Severe Brain Injury: What Counts as Good Recovery?

Disorders of consciousness (DOC) continue to profoundly challenge both families and medical professionals. Once a brain-injured patient has been stabilized, questions turn to the prospect of recovery. However, what “recovery” means in the context of patients with prolonged DOC is not always clear. Failure to recognize potential differences of interpretation—and the assumptions about the relationship between health and well-being that underlie these differences—can inhibit communication between surrogate decisionmakers and a patient’s clinical team, and make it difficult to establish the goals of care. The authors examine the relationship between health and well-being as it pertains to patients with prolonged DOC. They argue that changes in awareness or other function should not be equated to changes in well-being, in the absence of a clear understanding of the constituents of well-being for that particular patient. The authors further maintain that a comprehensive conception of recovery for patients with prolonged DOC should incorporate aspects of both experienced well-being and evaluative well-being.

Life-threatening Hypotension in a Multi-trauma-brain Injured Patient With Unilateral Adrenal Gland Damage; a Single Hydrocortisone Dose Unraveled Relative Corticosteroid Insufficiency.

BackgroundThe incidence of adrenal injury after trauma is very rare. Bilateral adrenal injury, which may lead to acute adrenal insufficiency and death, whereas unilateral adrenal trauma is often asymptomatic and masked by injuries to other organs. However, when unilateral adrenal trauma is associated with multiple injuries including brain trauma, critical illness‑related corticosteroid insufficiency (CIRCI) may be present; despite the importance, criteria for the diagnosis are not well established.Case presentationWe report a 16-year-old multi-trauma, brain-injured patient with unilateral adrenal gland injury. An intraparenchymal catheter for intracranial pressure (ICP) monitoring was inserted and craniectomy was performed. Postoperatively, the patient was admitted in the Intensive Care Unit (ICU) under sedation. He presented severe circulatory shock (noradrenaline dose of 1.86 μg/kg/min). which was not reversed despite red blood cell transfusions (noradrenaline increased to 2 μg/kg/min, lactate 1.8-2.1 mmol/L, although Hct was stabilized to 34 g/dl). Empiric hydrocortisone (150 mg intravenously) was administered for suspected adrenal insufficiency, after a blood sample for cortisol levels was drawn. An abrupt improvement in hemodynamics was noted [noradrenaline dose was reduced by half (1 μg/ kg/min) in less than 1 hour, and almost became insignificant during the next 8 hours, while lactate normalized (0.9 mmol/L)]. Hydrocortizone administration was continued for nine days. Fluid balance was restored after the first day. Baseline cortisol levels were 11.45 μg/dl. ICP was steadily less than 20 mmHg. Adrenal hematoma dimensions had increased (4 x 2.7 cm), as seen in the abdominal CT scan performed 9 hours after admission. Twenty days later, a follow up CT scan revealed regression of the hematoma. His remaining ICU course was complicated by fever and sepsis and remained in the ICU for 41 days.ConclusionAlthough, data do not support the use of empiric steroids in trauma patients (with or without brain injury), this case demonstrates that adrenal insufficiency must be considered in the differential diagnosis when shock exists; adrenal gland injury, even unilateral, may play an additional factor. An urgent decision is needed, that can influence outcome.

Neuropsychological rehabilitation focused on a daily activity in an extremely severe brain-injured patient

Despite the disabling consequences of severe traumatic brain injury (TBI) in daily life, very few studies focused on the re-education of specific “instrumental activities” in these patients. In this qualitative study, we present an ecological rehabilitation of a patient victim of an extremely severe TBI and presenting severe and diffuse cognitive impairment. The rehabilitation program, focused on the preparation of a vegetable soup, was structured in three steps conjugating various strategies: a phase of acquisition of basic knowledge and procedures, a phase of application to the actual preparation of the soup, and an adaptation phase devoted to making the activity a purposeful part of the patient’s life. Results showed that it is possible to increase the abilities of severely impaired patients in a daily task, as well as their self-awareness, by means of an individualized, contextualized and intensive rehabilitation. However, several limitations must be considered.