Seminars in neurology
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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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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.
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The management of severe brain injury requires a comprehensive approach in which imaging is an indispensable complement to the clinical and physiological information acquired at the bedside. Neuroimaging methods are routinely used in the diagnosis and prognosis of a broad spectrum of patients with acute neurological dysfunction. With incremental theoretical and technological refinements, imaging modalities are helping to unravel fundamental questions regarding the pathophysiology and neuroplasticity associated with critical neurological injury, and it is anticipated that this knowledge will lead to new and effective therapeutic interventions. We review some of the established and emerging structural and physiological imaging methods, and discuss their applications in patients with critical injuries including trauma and encephalopathy due to anoxia, liver failure, and sepsis.
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Acute ischemic stroke is a common disorder with a significant impact on morbidity and mortality in the United States. The number of interventions for acute stroke patients has increased over the past 15 years and patients increasingly require intensive care. There are several issues that are specific to ischemic stroke patients in intensive care unit (ICU) settings, including the care of the postthrombolytic stroke patient, respiratory issues in stroke care, evaluation of worsening or change in neurological status, and attention to factors that affect the ischemic penumbra. The management of the stroke patient in the critical care setting is discussed in this article.