Current opinion in critical care
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Neuroprognostication after acute brain injury (ABI) is complex. In this review, we examine the threats to accurate neuroprognostication, discuss strategies to mitigate the self-fulfilling prophecy, and how to approach the indeterminate prognosis. ⋯ The approach to neuroprognostication after ABI should be systematic, use highly reliable multimodal data, and involve experts to minimize the risk of erroneous prediction and perpetuating the self-fulfilling prophecy. Even when such standards are rigorously upheld, the prognosis may be indeterminate. In such cases, clinicians should engage in shared decision-making with surrogates and consider the use of a time-limited trial.
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Curr Opin Crit Care · Jan 2025
Timely delivery of care in neurological emergencies: can standardized management protocols help?
To review the evidence that supports the implementation of goal-directed care bundle protocols to improve outcomes from neurocritical conditions, and of the possible advantage of specific over generalized protocols. ⋯ A goal-directed care protocol to guide standard management implemented by a multidisciplinary team can improve outcomes from neurological emergencies. However, implementation challenges need to be addressed before wide adoption of protocolized care for maximum benefit to populations.
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Curr Opin Crit Care · Jan 2025
Natural history of recovery and long-term outcome in critically ill patients with brain injury.
To increase knowledge of the natural history of recovery and long-term outcome following severe traumatic brain injury (sTBI). ⋯ Evidence from large multicenter studies with well characterized samples focusing on recovery trajectories beyond 1 year postinjury challenge conventional beliefs about outcome after sTBI. Signs of consciousness frequently emerge following discharge from the ICU setting and prediction of death and dependency within the first few weeks after injury is unreliable. Clinician knowledge of the frequency and time course to recovery of key behavioral milestones is central to evidence-based prognostic counseling.
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The increasing use of prone position, in intubated patients with acute respiratory distress syndrome as well as in patients with acute hypoxemic respiratory failure receiving noninvasive respiratory support, mandates a better definition and monitoring of the response to the manoeuvre. This review will first discuss the definition of the response to prone positioning, which is still largely based on its effect on oxygenation. We will then address monitoring respiratory and hemodynamic responses to prone positioning in intubated patients. Finally, we will also discuss monitoring inspiratory effort in nonintubated patients with acute hypoxemic respiratory failure who breathe spontaneously and receive noninvasive respiratory support. ⋯ The implications of present findings are to: better select those patients who will benefit from proning in physiological terms, better indicate the timing of onset and end of the sessions, and strengthen the relationship between physiological response and patient outcome.
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This review aims to examine recent advances in the understanding of injury-induced endotheliopathy and therapeutics to mitigate its development in critically injured patients. ⋯ Injury-induced endotheliopathy represents an important pathologic response to trauma. Key biomarkers, such as syndecan-1, can aid in the diagnosis, but testing is not yet available clinically. As the mechanisms of endotheliopathy are better understood, therapeutics are being identified and show promise. To date, plasma has been the most widely studied; however, like all therapeutics for injury-induced endotheliopathy, it has primarily been studied in the preclinical setting.