Minerva anestesiologica
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Minerva anestesiologica · Apr 2016
Intracranial pressure and outcome in critically ill patients with aneurysmal subarachnoid hemorrhage: a systematic review.
Evidences supporting the use of ICP monitoring after aneurysmal subarachnoid hemorrhage (aSAH) are limited. The aim of our paper is to examine whether elevated intracranial pressure (ICP) and ICP-derived variables predict mortality and functional outcomes after aSAH. ⋯ Elevated ICP was associated with higher mortality however absolute ICP values per se were not independent predictors of functional recovery. Variables derived from ICP monitoring are more accurate than ICP absolute values in predicting outcome. Given the absence of good quality data, additional large studies may help to better define the prognostic value of ICP after aSAH.
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Minerva anestesiologica · Apr 2016
ReviewAnother failed attempt of neuroprotection: Progesterone for moderate and severe traumatic brain injury.
Two large phase-III prospective, multicenter, controlled, double-blind, randomized clinical trials (the PROTECT III study; the SYNAPSE study) evaluated the effectiveness of an early administration of progesterone in patients with moderate to severe traumatic brain injury (TBI). In the PROTECT III Trial, patients were included if the admission Glasgow Coma Scale (GCS) was within 4-12, whereas the SYNAPSE Trial only included patients with GCS 4-8. The total dose of progesterone was nearly similar in both studies and drug administration was initiated early after injury (within 4 hours for a total of 96 hours in PROTECT; within 8 hours for 120 hours in SYNAPSE). ⋯ In PROTECT, the proportion of patients with favourable outcome was similar between groups (51% for progesterone vs. 56% for placebo; RR 3.03 [95% CI 1.96-4.66]); in SYNAPSE, no difference in GOS between the progesterone and placebo group was found (OR 0.96 [95% CI 0.77-1.18]). There was no difference in 6-month mortality or any of the other secondary outcomes between groups in the two trials. These studies demonstrated that early progesterone administration did not provide any benefit on the neurological recovery of TBI patients.
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Minerva anestesiologica · Apr 2016
ReviewNon-pharmacological interventions to reduce ICU-related psychological distress: a systematic review.
Patients frequently suffer stress in intensive care units (ICUs) and many develop serious psychological morbidity after discharge. Little is known about the nature and efficacy of interventions to reduce ICU-related distress. There is growing evidence that administering sedative drugs can be harmful. Therefore we carried out a systematic review of non-pharmacological interventions to reduce ICU-related distress. ⋯ Evidence indicates that non-pharmacological approaches to reducing ICU distress, in particular psychological interventions, may be beneficial. The evidence base would be strengthened by the implementation of fully-powered studies using robust designs, that measure longer-term outcomes.
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Minerva anestesiologica · Apr 2016
How to protect incompetent clinical research subjects involved in critical care or emergency settings.
Clinical research is an essential component of medical activity, and this is also true in intensive care. Adequate information and consent are universally considered necessary for the protection of research subjects. However, in emergency situations, the majority of critical patients are unable to consent and a valid legal representative is often unavailable. ⋯ Indeed, it specifically addresses the issue of "research in emergency situations" and introduces detailed rules aimed at protecting patients while allowing research. In this article, we argue that obtaining informed consent during emergency research on incompetent subjects in unrealistic, and that in most cases substituted judgment on the part of a proxy carries major flaws. Strict criteria in evaluating the risk-benefit ratio of proposed intervention and a careful evaluation of the trial by a local or national Research Ethics Committee are perhaps the most practicable solution.