Current opinion in anaesthesiology
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Fluid resuscitation in trauma patients with hemorrhagic shock is controversially discussed in the literature. The coincidence of brain injury complicates management of these patients. This article summarizes the current knowledge on nonblood component fluid resuscitation and choice of fluids in patients with multiple trauma. ⋯ To date no large-scale clinical studies exist to either support or refute the use of nonblood component fluid resuscitation of hemorrhagic shock in trauma patients. The optimal choice of fluid remains to be determined, but existing evidence suggests avoiding crystalloids in favor of hypertonic solutions. The role of modern, iso-oncotic colloids in the treatment of hemorrhagic shock has not yet been sufficiently defined. In patients with concomitant brain injury, arterial hypotension must be avoided and infusion of hypotonic solutions is obsolete, whereas administration of hypertonic solutions may exert beneficial effects beyond hemodynamic stabilization.
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In the current era of limited resources, organizations are evaluating the cost-effectiveness of their care. To analyze the cost-effectiveness of a physiologic monitor, one must first determine what negative outcome will be reduced or what positive outcome will be promoted. For example, if one was studying the cost-effectiveness of the pulse oximeter, it would be important to state whether the endpoint is prevention of hypoxic events or prevention of myocardial infarction. One would then need outcome data demonstrating the incidence of the chosen endpoint with and without the monitor. With these data, one can begin to construct a model for cost-effectiveness. Like many medical technologies, the bispectral index (BIS) monitor has recently been the subject of several articles which study its cost-effectiveness. This review examines the rationale of cost-effectiveness analyses and their application specifically to the BIS monitor. ⋯ Given the trivial cost of the BIS and the proven benefits demonstrated in prospective randomized studies, we consider its use justified in every general anesthetic.
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Curr Opin Anaesthesiol · Apr 2011
ReviewIntracranial pressure: why we monitor it, how to monitor it, what to do with the number and what's the future?
The review touches upon the current physiopathological concepts relating to the field of intracranial pressure (ICP) monitoring and offers an up-to-date overview of the ICP monitoring technologies and of the signal-analysis techniques relevant to clinical practice. ⋯ Current recommendations for the management of traumatic brain injury indicate ICP monitoring in patients who remain comatose after resuscitation if the admission computed tomography scan reveals intracranial abnormalities such as haematomas, contusions and cerebral oedema. The most reliable methods of ICP monitoring are ventricular catheters and intraparenchymal systems. A growing number of these devices are being safely placed by neurointensivists. The consensus is to treat ICP exceeding the 20 mmHg threshold, and to target cerebral perfusion pressure between 50 and 70 mmHg. Recent evidence suggests that such thresholds should be optimized based on multimodality monitoring and individual brain physiology. Noninvasive ICP estimation using transcranial Doppler can have a role as a screening tool in patients with low to intermediate risk of developing intracranial hypertension. However, the technology remains insufficiently accurate and too cumbersome for continuous ICP monitoring.
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To review the emerging literature on traumatic brain injury (TBI) caused by explosive blast. ⋯ Explosive blast TBI is being addressed at all levels - basic research through clinical care. New clinical practice guidelines are being used in a standardized system-wide approach.
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Decisions to withdraw or withhold potentially life-sustaining treatment are common in intensive care and precede the majority of deaths. When families resist or oppose doctors' suggestions that it is time to stop treatment, it is often unclear what should be done. This review will summarize recent literature around futility judgements in intensive care emphasising ethical and practical questions. ⋯ Specific criteria for unilateral withdrawal of treatment have proved hard to define or defend. However, it is ethical for doctors to decline to provide treatment that is medically inappropriate or futile. Understanding the justification for a futility judgement may be relevant to deciding the most appropriate way to resolve futility disputes.