Journal of the neurological sciences
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This article highlights the experimental and clinical data, controversies and postulated mechanisms surrounding osmotherapy with hypertonic saline (HS) solutions in the neurocritical care arena and builds on previous reviews on the subject. Special attention is focused on HS therapy on commonly encountered clinical paradigms of acute brain injury including traumatic brain injury (TBI), post-operative "retraction edema", intracranial hemorrhage (ICH), tumor-associated cerebral edema, and ischemia associated with ischemic stroke.
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In the neurointensive care unit, neurologic monitoring is depended upon to signal the onset of neurologic decline. Many monitoring techniques such as intracranial pressure monitoring, cerebral perfusion pressure measurement, jugular venous oxygen saturation, transcranial Doppler ultrasound and continuous electroencephalogram are commonly practiced. ⋯ When used in combination, as in multimodal monitoring, the goal is to overcome some of the disadvantages of each technique and to achieve a higher degree of accuracy in detecting secondary brain insults. However, such a large amount of data can be generated that such combinations have to be chosen carefully, or the monitoring data will not be able to be acted upon quickly enough to be of benefit to the patient.
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Review
Hypothermia for neuroprotection after cardiac arrest: mechanisms, clinical trials and patient care.
Therapeutic hypothermia is a proven part of cardio-cerebral resuscitation after cardiac arrest as it improves neurologic outcomes after hypoxic brain injury. This article reviews the mechanisms of hypothermic neuroprotection, the clinical trials that support its use after cardiac arrest, as well as the impact of hypothermia on patient management and prognosis. In caring for patients suffering hypoxic brain injury after cardiac arrest, the role of the neurologist is no longer limited to prognosis but is now to become actively involved in clinical management which includes the use of therapeutic hypothermia.
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Because a large number of patients will suffer cardiac arrest each year, physicians must place attention on improving care for patients in the post-resuscitative setting. Part of this effort requires setting realistic goals based on patients' potential for recovery. Recovery from cardiac arrest often depends on the extent of anoxic brain injury, and for this reason primary teams consult neurologists to offer insight into potential for awakening from post-arrest coma. ⋯ These factors most reliably predict poor outcome, but do so with high specificity. However, the role of the neurology consultant must change to include guidance on strategies of neuroprotection. Aggressive efforts directed towards neuroprotection may change predictions for outcomes after cardiac arrest in the future.
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In order to meet the needs of the high acuity population in today's critical care environment, the role of the Acute Care Nurse practitioner (ACNP) has been adopted by many intensive care units (ICU's) across the country, including specialized neurocritical care units. In this chapter we will provide a brief historical review of the ACNP as well as their function in various ICU settings. Lastly, we will describe the current role of the ACNP in the Neurosciences Critical Care Unit at the Johns Hopkins Hospital as well as future plans and challenges of the role.