Neurocritical care
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Randomized Controlled Trial Multicenter Study
Effect of a liberal versus restrictive transfusion strategy on mortality in patients with moderate to severe head injury.
To compare a restrictive versus a liberal transfusion strategy in patients with moderate to severe closed head injury following multiple trauma in 13 Canadian intensive care units (ICUs). ⋯ We were unable to detect significant improvements in mortality with a liberal as compared to restrictive transfusion strategy in critically ill trauma victims with moderate to severe head injury.
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In this article, we review technologies available for direct monitoring of cerebral oxygenation and metabolic status, including jugular venous oxygen saturation, brain tissue oxygen tension, transcranial cerebral oximetry with near-infrared spectroscopy, Positron emission tomography oxidative metabolism, single-photon emission computed tomography/computed tomography perfusion and functional imaging, and cerebral metabolite measurement using microdialysis. We also introduce a novel method of monitoring cerebral perfusion that may substitute for direct monitoring of oxygenation in the future.
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The development of animal models of acute stroke has allowed the evaluation of mild and moderate hypothermia as a therapeutic modality in this clinical setting. Studies have demonstrated that animals subjected to hypothermia up to 3 hours after the primary central nervous system insult have reduced mortality and neuronal injury, and improved neurological outcome. These results warranted the evaluation of hypothermia in clinical trials. ⋯ Thus, therapeutic hypothermia for ischemic stroke remains a promising but fiercely debated therapeutic modality. This review summarizes the animal model studies that have led to clinical trials in acute ischemic stroke. The existing techniques for inducing brain cooling, the mechanisms of neuroprotection, the complications of therapeutic hypothermia, and the future perspective of the field are also discussed.
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Blood coagulation and hemostasis issues are important aspects of patient care in acute neurosurgical patients. Coagulopathy often complicates the already difficult management of cerebrovascular and intracranial hemorrhagic disease and injuries, adding to the already high associated morbidity and mortality. Common causes of coagulopathy, as well as its management in acute neurosurgical settings, are outlined in this review. Awareness of how to promptly evaluate and effectively treat coagulopathic processes is instrumental to the success of the neurosurgeon in managing acute intracranial pathologies.
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The treatment of anemia in critically ill patients has changed significantly in the past decade with a major shift toward restrictive blood-transfusion strategy. There is a paucity of studies regarding the approach toward anemia in the neurological critical care population. ⋯ Recent studies have shown a mixed response in the local oxygen saturations and patient outcomes after blood transfusion in neurological critically ill patients. Although there is little reason to suspect that restrictive transfusion protocols would be detrimental, further studies are needed to determine optimal transfusion threshold in this population.