Current opinion in critical care
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Curr Opin Crit Care · Apr 2008
ReviewOptimal hemoglobin concentration in patients with subarachnoid hemorrhage, acute ischemic stroke and traumatic brain injury.
The review outlines recent clinical and experimental studies regarding the effects of red blood-cell transfusion on clinical outcome in neurocritical patients, including patients with subarachnoid hemorrhage, acute ischemic stroke and traumatic brain injury. Optimal hemoglobin transfusion trigger and the role of other transfusion indicators for neurocritical patients are discussed. ⋯ Both severe anemia and red blood-cell transfusion may negatively influence clinical outcome in neurocritical patients. Acceptance of low hemoglobin concentrations may be justified by avoiding negative transfusion effects. No evidence-based transfusion trigger in neurocritical patients can be recommended.
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The incidence of cirrhosis is increasing exponentially and is associated with significant morbidity and mortality. This cirrhotic population is prone to infection, which is a frequent precipitant for the development of organ dysfunction; a syndrome often referred to as 'acute-on-chronic' liver failure. Historically, the perception of cirrhosis with organ dysfunction as having a poor prognosis has led to invariably iniquitous access to intensive care. Data to support this view, however, are lacking. ⋯ Admission to intensive care for many patients with cirrhosis is not futile, particularly for those with single organ dysfunction and acute variceal bleeding. It can be extremely challenging to manage patients with organ dysfunction and encephalopathy in a ward environment, and these patients frequently require, and indeed benefit from, augmented levels of care in high-dependency and intensive care environments.
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Curr Opin Crit Care · Apr 2008
ReviewBiomarkers of primary and evolving damage in traumatic and ischemic brain injury: diagnosis, prognosis, probing mechanisms, and therapeutic decision making.
Emerging data suggest that biomarkers of brain injury have potential utility as diagnostic, prognostic, and therapeutic adjuncts in the setting of traumatic and ischemic brain injury. Two approaches are being used, namely, assessing markers of structural damage and quantifying mediators of the cellular, biochemical, or molecular cascades in secondary injury or repair. Novel proteomic, multiplex, and lipidomic methods are also being applied. ⋯ Multifaceted cellular, biochemical, and molecular monitoring of proteins and lipids is logical as an adjunct to guiding therapies and improving outcomes in traumatic and ischemic brain injury and we appear to be on the verge of a breakthrough with the use of these markers as diagnostic, prognostic, and monitoring adjuncts, in neurointensive care.
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For decades it was assumed that cerebral ischemia was a major cause of secondary brain injury in traumatic brain injury, and management focused on improving cerebral perfusion and blood flow. Following the observation of mitochondrial dysfunction in traumatic brain injury and the widespread use of brain tissue oxygen tension (P(br)O(2) monitoring, however, recent work has focused on the use of hyperoxia to reduce the impact of traumatic brain injury. ⋯ Despite suggestive data from microdialysis studies, direct measurement of the ability of the brain to utilize oxygen indicates that hyperoxia does not increase oxygen utilization. This, combined with the real risk of oxygen toxicity, suggests that routine clinical use is not appropriate at this time and should await appropriate prospective outcome studies.
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The review provides key points and recent advances regarding the treatments of intracranial hypertension as a consequence of traumatic brain injury. The review is based on the pathophysiology of brain edema and draws on the current literature as well as clinical bedside experience. ⋯ One of the key issues is to consider that traumatic brain injury is more likely a syndrome than a disease. In particular, the presence or absence of a high contusional volume could influence the treatments to be implemented. The use of osmotherapy and/or high cerebral perfusion pressure should be restricted to patients without major contusions. Some physiopathological, experimental and clinical data, however, show that corticosteroids and albumin--therapies that have been proven deleterious if administered systematically--are worth reconsidering for this subgroup of patients. The current Pitié-Salpêtrière algorithm, where treatments are stratified according to their potential side effects, will be added at the end of the review as an example of an integrated strategy.