Curr Treat Option Ne
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Providing adequate sedation in the neurologic intensive care unit (ICU) depends on determination of proper goals for sedation, adequate assessment of the level of sedation, and appropriate choice of drug based on the patient's physiology. The management of sedation in the ICU will influence long-term outcome. Delirium, anxiety, and pain must be identified and treated separately. ⋯ Propofol and dexmedetomidine may be used for rapidly titratable sedation, benzodiazepines for anxiolysis, neuroleptics for treatment of delirium, and opiates for analgesia. Unique aspects of patients with acute brain disease, such as elevated intracranial pressure or status epilepticus, require adaptation of sedative regimens. Processed EEG monitoring and volatile anesthetic agents have not yet proven beneficial or practical for use in the ICU.
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Episodes of paroxysmal sympathetic hyperactivity, sometimes referred to as autonomic storms, are not uncommon in patients with severe traumatic brain injury. Their distinctive characteristics include fever, tachycardia, hypertension, tachypnea, hyperhidrosis, and dystonic posturing. The episodes may be induced by stimulation or may occur spontaneously. ⋯ Intrathecal baclofen may be effective in refractory cases. Bromocriptine and clonidine are helpful in some patients, but their efficacy is less consistent. Early recognition and adequate treatment of paroxysmal sympathetic hyperactivity is important to avoid prolongation of the patient's stay in the intensive care unit and to enable recovering patients to participate without restrictions in rehabilitation therapy.
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Curr Treat Option Ne · Mar 2007
Diagnosis and management of critical illness polyneuropathy and critical illness myopathy.
Newly acquired neuromuscular weakness commonly develops in the setting of critical illness. This weakness delays recovery and often causes prolonged ventilator dependence. An axonal sensory-motor polyneuropathy, critical illness polyneuropathy (CIP), is seen in up to a third of critically ill patients with the systemic inflammatory response syndrome (usually due to sepsis). ⋯ Prevention of CIP and CIM is feasible in part by avoiding risk factors and by aggressive medical management of critically ill patients. Intensive insulin therapy in intensive care unit patients appears to reduce the likelihood of developing CIP and/or CIM. Future treatments of sepsis may further reduce the incidence of these neuromuscular consequences of critical illness.
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This review focuses on recent advances in the treatment of traumatic brain injury (TBI) during 2004 and 2005. Injured brain is a very heterogeneous structure, significantly evolving over time. Implementation of multimodal neuromonitoring will certainly provide more insights into pathophysiology of TBI. ⋯ Hypertonic saline may become a preferred osmotherapeutic agent in severely head-injured patients, especially those with refractory intracranial hypertension. Benefit and indications for performing a decompressive craniectomy remain to be determined. Overall, individualized treatment respecting actual status of a patient's intra- and extracranial homeostasis should be the key principle of our current therapeutic approach toward severely head-injured patients.
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Headache is one of the most common somatic complaints of patients seeking medical care. Most headaches are not of serious cause and can be diagnosed easily with a good history and physical examination. ⋯ Headache can also manifest as an acute or chronic complication of radiation treatment and/or chemotherapy in patients with intracranial neoplasm, but there are few data in the literature specifically addressing this subject. This article provides an overview of headache in patients with primary and secondary brain tumor, including headache characteristics, the putative mechanism for these headaches, the role of diagnostic testing, and the general principles of management.