Neurocritical care
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Delirium is the most common mental disturbance in critically-ill patients and results in significant morbidity and mortality. Haloperidol is a preferred agent for the treatment of delirium in this population because of its rapid onset of action and lack of hemodynamic effects. Despite its widespread use in the critical care setting, most of the relevant data are obtained from case series or extrapolated from non-critically-ill populations. ⋯ Only three studies were controlled studies, but all had small sample sizes and methodological flaws. Randomized, double-blind, active-comparator trials of haloperidol with allocation concealment are needed. Subsequent research should focus on using validated delirium screening and assessment scales for more objective identification and measurement of delirium outcomes.
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Advanced hemodynamic monitoring is necessary for many patients with acute brain and/or spinal cord injury. Optimizing cerebral and systemic physiology requires multi-organ system function monitoring. ⋯ These include transpulmonary thermodilution, arterial pressure pulse contour, and waveform analysis and bedside critical care ultrasound. A thorough understanding of hemodynamics and of the available monitoring modalities is an essential skill for the neurointensivist.
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Neurocritical care diseases carry a high morbidity and mortality. Therapeutic and technological advances in neurocritical care have greatly improved the outcome of a variety of life-threatening disorders including traumatic brain injury, acute ischemic stroke, intracerebral and subarachnoid hemorrhage, and anoxic injury following cardiac arrest. These advances have stemmed from a better understanding of the physiology of neurocritical care illnesses, improved neuromonitoring techniques, and the introduction of more efficacious treatments. ⋯ Such a system may help us overcome potential impediments to the future advancement of neurocritical care research. We propose the creation of the neurocritical care research network. The mission of the Network is to facilitate multicenter and multidisciplinary collaboration and patient enrollment in clinical trials of specific neurocritical care diseases.
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The daily practice of neurointensivists focuses on the recognition of subtle changes in the neurological examination, interactions between the brain and systemic derangements, and brain physiology. Common alterations such as fever, hyperglycemia, and hypotension have different consequences in patients with brain insults compared with patients of general medical illness. ⋯ We have summarized the topics discussed in this session. We have provided a brief overview of the current status of these technologies, and put forward recommendations for future research applications in the field of neurocritical care.
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The aim of this study is to review and summarize the relevant literature regarding pharmacologic and non-pharmacologic methods of prophylaxis against gastrointestinal (GI) stress ulceration, and upper gastrointestinal bleeding in critically ill patients. Stress ulcers are a known complication of a variety of critical illnesses. The literature regarding epidemiology and management of stress ulcers and complications thereof, is vast and mostly encompasses patients in medical and surgical intensive care units. ⋯ There is a paucity of high-level evidence studies that apply to the neurocritical care population. From this study, it is concluded that stress ulcer prophylaxis among critically ill neurologic and neurosurgical patients is important in preventing ulcer-related GI hemorrhage that contributes to both morbidity and mortality. Further, prospective trials are needed to elucidate which methods of prophylaxis are most appropriate and efficacious for specific illnesses in this population.