Seminars in neurology
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The optimum provision of pharmacological sedation of the critically ill neurological patient requires defining the underlying etiology of agitation or need for sedation to determine the optimal agent: pain management, anxiolysis, or treatment of delirium. An appropriate regimen can then be decided upon based on the profiles of action of the several common classes of sedative agents. ⋯ Recognition of an individualized approach is also necessary as patients will vary considerably with respect to the kinetics and pharmacodynamics of sedative therapy. The drug classes often selected for sedation in an intensive care unit will be reviewed as well as the metrics by which physicians can achieve their objectives in a safe manner.
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Seminars in neurology · Nov 2008
ReviewWithdrawal of life-sustaining therapies and brain death in the intensive care unit.
The majority of patients who die in intensive care units (ICUs), do so as a result of the withdrawal of life-sustaining treatments or as a result of brain death. With the increasing shortage of transplantable organs, there is growing interest in both these patient populations and their potential for organ donation after cardiac death (DCD) or death by neurological criteria. ⋯ The medicolegal and ethical considerations, the factors that lead to the decision for withdrawal (with special attention to prognostication of the major neurological diseases encountered in an ICU), the process of withdrawal of life-sustaining treatment itself, and the DCD process will be examined. The medicolegal aspects of brain death will also be examined, with particular focus on the process and the various pitfalls and misconceptions.
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Intracranial hypertension implies profoundly disturbed intracranial physiology. Although a shared manifestation of myriad neurological disorders of patients admitted in the intensive care unit (ICU), the pathways leading to intracranial hypertension vary by etiology. ⋯ Several integrated management paradigms have been used to treat intracranial hypertension. Regrettably, there is a dearth of randomized clinical trials to confirm the efficacy of even our most routine therapeutic strategies.
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Seminars in neurology · Nov 2008
ReviewPreoperative evaluation of patients with neurological disease.
A thorough evaluation of patients with neurological diseases undergoing surgery can reduce perioperative morbidity and mortality, especially stroke. Various neurological disorders and neurosurgical procedures may influence the nature and extent of preoperative evaluation, selection and conduct of anesthesia, and perioperative management and care. Although anesthesiologists primarily perform a preoperative evaluation of neurological patients, neurologists can contribute further valuable information about the neurological condition and perioperative management of various neurological diseases to obtain the best possible outcome. This article outlines the basic elements of preoperative evaluation and highlights specific considerations for neurological patients undergoing surgery.
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Persistent seizures and failure to regain consciousness following witnessed seizure activity require emergency neurological consultation. Although outcome is largely dependent on underlying cause, early maximal anticonvulsant therapy is critical to reducing morbidity. This review covers important concepts in the clinical and EEG diagnosis of status epilepticus, and discusses treatment algorithms for single and recurrent seizures, emphasizing the need to rationalize therapy depending on the presumed duration of seizure activity. The review takes the perspective of the neurological consultant in the intensive care unit, and considers all pharmacological approaches available to the intensivist as described in the current literature and from clinical experience.