Neurocritical care
-
To determine the impact of physiologic doses of hydrocortisone on neurologic outcome after traumatic brain injury (TBI). ⋯ Adrenal insufficiency is frequent after TBI, and hydrocortisone replacement therapy seems to be associated with a favorable neurologic outcome.
-
Warfarin-associated intracranial hemorrhage (ICH) requires rapid normalization of clotting function. Current therapies are associated with significant complications and/or prolonged time to correction of coagulopathy. Recombinant factor VIIa (FVIIa) might allow faster and safer correction of coagulopathy. ⋯ FVIIa may be an effective adjunct to FFP in warfarin-related ICH, facilitating faster correction of INR and decreasing FFP requirements. A prospective, randomized trial is needed to confirm these preliminary findings and to determine whether there is a clinical benefit.
-
Cerebral perfusion pressure (CPP) is one aspect of an all-encompassing approach in the management of traumatic brain injury (TBI). The clinical use of CPP is based on theoretical considerations that optimal cerebral blood flow is necessary to meet the metabolic needs of the injured brain. The goal is to preserve the ischemic penumbra and avoid secondary insults. ⋯ Recently, the Brain Trauma Foundation updated their Web-based recommendation of a lower CPP goal of 60 mmHg. However, the lack of definitive data, such as from a randomized prospective intention-to-treat clinical trials, leaves this goal open to controversy. Therefore, for a variety of reasons, the physician may be most prudent to use the published CPP guideline of 70 mmHg until a consensus statement is published advocating a different value.
-
Brain death is a concept used in situations in which life-support equipment obscures the conventional cardiopulmonary criteria of death, and it is legally recognized in most countries worldwide. Brain death during pregnancy is an occasional and tragic occurrence. The mother and fetus are two distinct organisms, and the death of the mother mandates consideration of the well-being of the fetus. ⋯ The current limits of fetal viability are then discussed. The complex ethical issues and the important variations in the legal context worldwide are considered. Finally, the likelihood of successfully sustaining maternal somatic function for prolonged periods and the medical and obstetric issues that are likely to arise are examined.
-
Review Case Reports
Medical futility: definition, determination, and disputes in critical care.
Physicians may employ the concept of medical futility to justify a decision not to pursue certain treatments that may be requested or demanded by patients or surrogates. Medical futility means that the proposed therapy should not be performed because available data show that it will not improve the patient's medical condition. Medical futility remains ethically controversial for several reasons. ⋯ Medical futility has been conceptualized as a power struggle for decisional authority between physicians and patients/surrogates. Medical futility disputes are best avoided by strategies that optimize communication between physicians and surrogates; encourage physicians to provide families with accurate, current, and frequent prognostic estimates; assure that physicians address the emotional needs of the family and try to understand the problem from the family's perspective; and facilitate excellent palliative care through the course of the illness. Critical care physicians should support the drafting of state laws embracing futility considerations and should assist hospital policymakers in drafting hospital futility policies that both provide a fair process to settle disputes and embrace an ethic of care.