Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Apr 2011
ReviewThe complex interplay between delirium, sedation, and early mobility during critical illness: applications in the trauma unit.
Critically ill patients are prescribed sedatives and analgesics to decrease pain and anxiety, improve patient-ventilator dyssynchrony and ensure patient safety. These medications may themselves lead to delirium and ICU-acquired weakness, which are associated with worse clinical outcomes. This review will focus on the epidemiology of these two disease processes and discuss strategies aimed at reducing these devastating complications of critical illness. ⋯ Delirium and ICU-acquired weakness are complications of critical illness associated with worse clinical outcomes and functional decline in survivors. An evidence-based approach based on the following tenets - minimization of sedative medication, particularly benzodiazepines, delirium monitoring and management and early mobilization may mitigate these complications.
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This review focuses on the role of various intracranial monitoring technologies in the diagnosis and therapy of traumatic brain injury injury. ⋯ Increased adherence to guideline-based and protocol-driven neurointensive care utilizing multimodality in monitoring technology for patients with severe traumatic brain injury is likely to give clinicians increased insight into the elusive mechanisms underlying the complex pathophysiology of this disease process and may further improve outcomes in this patient population.
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Curr Opin Anaesthesiol · Apr 2011
ReviewCerebral blood flow and the injured brain: how should we monitor and manipulate it?
Cerebral ischemia plays a major role in the pathophysiology of the injured brain, including traumatic brain injury and subarachnoid hemorrhage, thus improvement in outcome may necessitate monitoring and optimization of cerebral blood flow (CBF). To interpret CBF results in a meaningful way, it may be necessary to quantify cerebral autoregulation as well as cerebral metabolism. This review addresses the recent evidence related to the changes in CBF and its monitoring/management in traumatic brain injury. ⋯ Current neurocritical care management strategies are focused on the prevention and limitation of secondary brain injury where neuronal insult continues to evolve during the hours and days after the primary injury. Appropriately chosen multimodal monitoring including CBF and management measures can result in reduction in mortality and morbidity.
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Curr Opin Anaesthesiol · Apr 2011
ReviewShould tracheostomy practice in the setting of trauma be standardized?
Trauma is a common predisposing condition in patients developing acute respiratory failure. Selection criteria for tracheostomy use in trauma remain poorly defined. The purpose of this review is to discuss contemporary knowledge regarding the benefits and risks of tracheostomy and to highlight potential strategies to standardize practice. ⋯ Variation in clinical practice is costly. To the extent that variation in tracheostomy practice reflects suboptimal use of this procedure, greater understanding of tracheostomy utility has the potential to enhance the quality of care and more effectively target resources.
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Decisions to withdraw or withhold potentially life-sustaining treatment are common in intensive care and precede the majority of deaths. When families resist or oppose doctors' suggestions that it is time to stop treatment, it is often unclear what should be done. This review will summarize recent literature around futility judgements in intensive care emphasising ethical and practical questions. ⋯ Specific criteria for unilateral withdrawal of treatment have proved hard to define or defend. However, it is ethical for doctors to decline to provide treatment that is medically inappropriate or futile. Understanding the justification for a futility judgement may be relevant to deciding the most appropriate way to resolve futility disputes.