Articles: neurocritical-care.
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Intracranial pressure (ICP) monitoring is fundamental for neurocritical care patient management. For many years, ventricular and parenchymal devices have been available for this aim. The purpose of this paper is to review the published literature comparing ICP recordings via an intraventricular catheter or an intraparenchymal (brain tissue) catheter. ⋯ We propose two new terms that more accurately identify the anatomical site of recording for the referenced ICP: intracranial pressure ventricular (ICP-v) and intracranial pressure brain tissue (ICP-bt). Further delineation of the conventional term "ICP" into these two new terms will clarify the difference between ICP-v and ICP-bt and their respective measurement locations.
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Optimal blood pressure (BP) management is controversial in neurocritically ill patients due to conflicting concerns of worsening ischemia with decreased BP versus cerebral edema and increased intracranial pressure with elevated BP. In addition, high-quality evidence is lacking regarding optimal BP goals in patients with most of these conditions. This review summarizes guideline recommendations and examines the literature for BP management in patients with ischemic stroke, intracerebral hemorrhage, aneurysmal subarachnoid hemorrhage, traumatic brain injury, and spinal cord injury.
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Stress ulcer prophylaxis (SUP) with acid-suppressive drug therapy is widely utilized in critically ill patients following neurologic injury for the prevention of clinically important stress-related gastrointestinal bleeding (CIB). Data supporting SUP, however, largely originates from studies conducted during an era where practices were vastly different than what is considered routine by today's standard. ⋯ This narrative review will discuss current controversies with SUP as they apply to neurocritical care patients. Specifically, the pathophysiology, prevalence, and risk factors for CIB along with the comparative efficacy, safety, and cost-effectiveness of acid-suppressive therapy will be described.
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A major goal in neurocritical care is to monitor for and prevent secondary brain injuries. However, injuries occurring at the cellular and molecular levels evade detection by conventional hemodynamic monitoring and the neurological exam. Cerebral microdialysis (CMD) is an invasive means of providing nearly continuous measurements of cerebral metabolism and is a promising tool that can detect signs of cellular distress before systemic manifestations of intracranial catastrophe. ⋯ In this review, we describe the technique of CMD and the common biomarkers used to monitor cerebral energy metabolism. We examine the published evidence on how CMD data reflect secondary injuries and improve understanding of the pathophysiology of traumatic brain injury (TBI) and aneurysmal subarachnoid hemorrhage. We also discuss some of the caveats of the technique, including how CMD probe position affect the sensitivity of capturing energy failures, and how abnormal levels of cerebral glucose and lactate can reflect different states of cerebral energy metabolism. In order to best incorporate cerebral metabolic monitoring into the management of neurocritical care patients, neurointensivists must be familiar with the nuances in the limitations as well as the interpretations of data obtained from cerebral microdialysis.
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Review Meta Analysis
A narrative review of the clinical application of pressure reactiviy indices in the neurocritical care unit.
Pressure reactivity indices are used in clinical research as a surrogate marker of the ability of the cerebrovasculature to maintain cerebral autoregulation. The use of pressure reactivity indices in patients with neurological injury represents a potential to move away from population-based physiological targets used in guidelines to individualized physiological targets. The aim of this review is to describe the underlying principles and development of pressure reactivity indices, alongside a critique of how they have been used in clinical research, including their limitations. ⋯ There is an association between pressure reactivity indices and neurological outcomes, however the use of pressure reactivity indices as a prognostication tool is to be challenged. Average values of cerebral perfusion pressure that are not close to averaged values of optimal cerebral perfusion pressure are also associated with poor outcome. Further research is required to ascertain whether targeting an optimal cerebral perfusion pressure may alter outcome.