Neurology India
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The neurointensivist needs to have a thorough understanding of hemodynamic issues and the interaction of the brain and the cardiovascular system. Before one decides to intervene and try to correct an apparent "abnormal hemodynamic parameter" one needs to think whether such an intervention is indeed warranted and what effect the intervention would have on the cerebral circulation. The neurointensivist thus needs to approach these issues differently from the approach an internist or general intensivist would take.
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Increased intracranial pressure (ICP) is a pathological state common to a variety of neurological diseases, all of which are characterized by the addition of volume to the skull contents. Elevated ICP may lead to brain damage or death by two principle mechanisms: 1) global hypoxic-ischemic injury, as a consequence of reduced cerebral perfusion pressure (CPP) and cerebral blood flow; and 2) mechanical distortion and compression of brain tissue as a result of intracranial mass effect and ICP compartmentalization. All ICP therapies have as a goal, reduction of intracranial volume. ⋯ Application of moderate hypothermia (32 to 33 degrees C) shows promise as a newer method for treating refractory ICP. Placement of an ICP monitor is the critical first step in management of ICP. Treatment is best done using a stepwise protocol, with careful attention to sedation and CPP control prior to using mannitol and hyperventilation.
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Nosocomial infections are common among hospitalized patients, more so in intensive care units (ICU). They contribute significantly to morbidity, mortality and cost of care. Few studies address the issue of nosocomial infections in Neurology and neurosurgery ICUs, (NNICU) and data from other ICUs probably cannot be extrapolated to acutely ill neurologic patients. ⋯ Nosocomial infections are common and to a large extent, preventable. However, an established infection by multidrug resistant bacteria is difficult to treat and results in a high mortality, morbidity and cost of care. This article addresses nosocomial infections in the context of the Neurology and Neurosurgery ICU (NNICU).
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Respiratory complications play an important part in the morbidity and mortality of critically ill neurological patients. Assurance of airway patency is of primary concern in such patients. A plethora of airway maintenance techniques and devices have been recommended for securing and maintaining the airway. ⋯ The role of early tracheotomy in patients who require prolonged ventilatory support can not be overemphasized. However, the development of inert and softer endotracheal tubes with low pressure cuff has reduced the complications associated with endotracheal intubation. Finally and most importantly the best place to acquire competence in securing the airway is the operation theater not the intensive care unit.
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Transcranial doppler ultrasonography (TCD) is a noninvasive monitoring tool which allows imaging of blood flow velocities in intracranial blood vessels. It is safe, portable, easy to perform and provides accurate information regarding underlying physiology which may help to guide therapy in critically ill neurologic patients. ⋯ Careful performance of the test and experienced interpretation can identify TCD waveforms indicative of cerebral circulatory arrest, an ancillary finding used for the diagnosis of brain death. TCD is likely to play a larger role in evaluation of the patient in the future because of its safety, portability and ability to define moment-to-moment changes in cerebral blood flow velocities and cerebral blood flow.