Minerva anestesiologica
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Postoperative care of major neurosurgical procedures is aimed at the prevention, detection and treatment of secondary brain injury. This consists of a series of pathological events (i.e. brain edema and intracranial hypertension, cerebral hypoxia/ischemia, brain energy dysfunction, non-convulsive seizures) that occur early after the initial insult and surgical intervention and may add further burden to primary brain injury and thus impact functional recovery. Management of secondary brain injury requires specialized neuroscience intensive care units (ICU) and continuous advanced monitoring of brain physiology. ⋯ Additional invasive (i.e. brain tissue PO2, cerebral microdialysis, regional cerebral blood flow) and non-invasive (i.e. transcranial doppler, near-infrared spectroscopy, EEG) brain monitoring devices might complement ICP monitoring and help clinicians to target therapeutic interventions (e.g. management of cerebral perfusion pressure, blood transfusion, glucose control) to patient-specific pathophysiology. Several independent studies demonstrate such multimodal approach may optimize patient care after major neurosurgical procedures. The aim of this review is to evaluate some of the available monitoring systems and summarize recent important data showing the clinical utility of multimodal neuromonitoring for the management of main acute neurosurgical conditions, including traumatic brain injury, subarachnoid hemorrhage and stroke.
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Minerva anestesiologica · Jul 2012
Sedation practices in a cohort of critically ill patients receiving prolonged mechanical ventilation.
The aim of this paper was to describe type and amount of sedatives, opioid analgesics and anti- psychotics administered to critically ill patients receiving prolonged mechanical ventilation and identify patient-specific factors associated with their administration. ⋯ In critically ill patients receiving prolonged ventilation, history of substance abuse predicted a 3-fold increase in 14-day cumulative dose of sedatives and opioids used. Conversely, older age was associated with decreased use of sedatives and opioids and history of alcohol abuse was only associated with decreased opioid use. Overall, patients receiving prolonged mechanical ventilation appeared to consume high cumulative doses of sedatives and opioids, with less frequent use of antipsychotics. Accounting for patient characteristics may help identify individuals with varying sedative needs.
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Minerva anestesiologica · Jul 2012
Randomized Controlled TrialS+ -ketamine for control of perioperative pain and prevention of post thoracotomy pain syndrome: a randomized, double-blind study.
Post-thoracotomy pain syndrome (PTPS) often complicates the long term outcome of patients; its appearance has been related to perioperative acute pain. The main goal of this study was to evaluate a possible role of S(+)-ketamine in the prevention of PTPS up to 6 months and secondarily its efficacy in the control of perioperative pain when added to thoracic epidural analgesia (TEA) and adjuvants. ⋯ S(+)-ketamine had no effects in respect to placebo in the prevention of PTPS at 3 and 6 months but had a significant role in maintaining a NRS≤3 in the early postoperative period. A tight control of perioperative pain seems to be associated with a low incidence of moderate and severe PTPS.
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Non-invasive ventilation (NIV) is increasingly used in patients with acute respiratory failure, but few data exist regarding current sedation practices during NIV. Mask intolerance or claustrophobia, and delirium and agitation, may lead to NIV failure, requiring endotracheal intubation. Judicious use of sedation during NIV could be one of the valuable options for some of these patients at risk of intubation. ⋯ Pilot studies suggest that continuous infusion of a single sedative agent may decrease patient discomfort, with no significant effects on respiratory drive, respiratory pattern, or hemodynamics. In addition, gas exchange improved under NIV with sedation. While the current limited data available suggests that sedation during NIV is safe and feasible, more widespread application should await the results of randomized clinical trials.