European journal of anaesthesiology. Supplement
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In industrial countries it is estimated that the incidence of out-of-hospital sudden cardiac arrest lies between 36 and 128 per 100,000 inhabitants per year. Almost 80% of patients who initially survive a cardiac arrest present with coma lasting more than 1 h. Current therapy during cardiac arrest concentrates on the external support of circulation and respiration with additional drug and electrical therapy. ⋯ Most of these methods are quite invasive and are still in an experimental stage. The optimal timing and technique for the induction of hypothermia after cardiac arrest have not yet been defined, and it is currently a major topic of ongoing research. The induction of hypothermia after cardiac arrest needs to be an integral component of the initial evaluation and stabilization of the patient.
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Eur J Anaesthesiol Suppl · Jan 2008
ReviewEffects of catecholamines on cerebral blood vessels in patients with traumatic brain injury.
Data on the cerebrovascular effects of catecholamines after head injury are difficult both to interpret and to compare. Diverse parameters with regard to brain trauma animal models, methods of determining the effects on the cerebral blood flow and metabolism and choice of end-points have been used. Many studies investigate the cerebrovascular effects of catecholamines over a range of cerebral perfusion pressures above the range recommended by current guidelines. ⋯ For all other catecholamines and related substances there are insufficient data on the cerebrovascular effects after head injury. This suggests that norepinephrine may be the catecholamine that is the most suitable substance to maintain or restore adequate cerebral perfusion. The data, however, are insufficient to formulate a guideline.
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The most informative neurophysiological techniques available in the neurosurgical intensive care unit are electroencephalograph and somatosensory evoked potentials. Such tools, which give an evaluation of cerebral function in comatose patients, support clinical evaluation and are complementary to neuroimaging. They serve both diagnostic/prognostic and monitoring purposes. ⋯ While somatosensory evoked potentials correlated with short-term outcome, intracranial pressure showed a poor correlation. We believe neurophysiological monitoring is an ideal complement to the other parameters monitored in the neurosurgical intensive care unit. Whereas intracranial pressure is simply a pressure index, electroencephalograph-somatosensory evoked potential monitoring reflects to what extent cerebral parenchyma still remains metabolically active during acute brain injury.
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Eur J Anaesthesiol Suppl · Jan 2008
ReviewDoes multimodality monitoring make a difference in neurocritical care?
In spite of the many tools available for monitoring the central nervous system, there are no clinical trials which prove that continuous monitoring of any single variable in the intensive care unit has had any significant impact on the outcome of patients. Even in the absence of robust evidence proving the efficacy of neuromonitoring tools, we believe it is time to re-examine the basic objectives of neuromonitoring. The main reasons for monitoring neurocritical patients could be summarized as follows: (1) to detect early neurological worsening before irreversible brain damage occurs; (2) to individualize patient care decisions; (3) to guide patient management; (4) to monitor therapeutic response of some interventions and to avoid any consequent adverse effects; (5) to allow clinicians to be able to understand the pathophysiology of complex disorders; (6) to design and implement management protocols; and (7) to improve neurological outcome and quality of life in survivors of severe brain injuries. ⋯ In this review, the obstacles confronted in running randomized clinical trials in this field are discussed. The lack of equipoise and the ethical concerns in conducting such trials are discussed. In addition, the reasons for failure to improve outcome through the use of some monitoring devices are discussed and potential solutions proposed.
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Eur J Anaesthesiol Suppl · Jan 2008
ReviewHypothermia and neurological outcome after cardiac arrest: state of the art.
Multi-centred studies in patients who remain comatose after cardiac arrest and also in newborn babies with perinatal asphyxia have clearly demonstrated that mild hypothermia (32-34 degrees C) can improve neurological outcome after post-anoxic injury. This represents a highly promising development in the field of neurocritical care. This review discusses the place of mild therapeutic hypothermia in the overall therapeutic strategy for cardiac arrest patients. ⋯ Regarding the use of hypothermia, early induction and proper management of side-effects are the key elements of successful implementation. Treatment should include the rapid infusion of 1500-3000 mL of cold fluids to induce hypothermia and prevent hypovolaemia and hypotension. Educational activities to increase awareness and acceptance of new therapeutic options and European Resuscitation Council guidelines are urgently required.