European journal of anaesthesiology. Supplement
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The most informative neurophysiological techniques available in the neurosurgical intensive care unit are electroencephalograph and somatosensory evoked potentials. Such tools, which give an evaluation of cerebral function in comatose patients, support clinical evaluation and are complementary to neuroimaging. They serve both diagnostic/prognostic and monitoring purposes. ⋯ While somatosensory evoked potentials correlated with short-term outcome, intracranial pressure showed a poor correlation. We believe neurophysiological monitoring is an ideal complement to the other parameters monitored in the neurosurgical intensive care unit. Whereas intracranial pressure is simply a pressure index, electroencephalograph-somatosensory evoked potential monitoring reflects to what extent cerebral parenchyma still remains metabolically active during acute brain injury.
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Animal and human studies suggest that hypertonic saline is a potential therapeutic agent to assist with the medical treatment of patients with traumatic brain injury. It may have a place as osmotherapy to decrease brain size, predominantly of uninjured brain and has several potential advantages over mannitol. ⋯ Animal studies support its use, but definitive human trials using mortality end-points in brain trauma are lacking. Hypertonic saline may be considered a therapeutic adjunct to the medical management of traumatic brain injury, awaiting definitive evidence to support routine use.
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Eur J Anaesthesiol Suppl · Jan 2008
ReviewDoes ICP monitoring make a difference in neurocritical care?
Raised intracranial pressure and low cerebral perfusion pressure are associated with ischaemia and poor outcome after brain injury. Therefore, many management protocols target these variables. However, there are no randomized controlled trials that have demonstrated the effectiveness of intracranial pressure-guided care in severely head-injured patients. ⋯ Furthermore, intracranial pressure monitoring and aggressive management of intracranial pressure and cerebral perfusion pressure have been associated with increased lengths of stay in the neurocritical care unit, conceivable costs and possibly an increased rate of complications. Against this background, there is sufficient clinical equipoise to warrant an adequately powered randomized controlled trial to compare intracranial pressure-guided care with supportive critical care without intracranial pressure monitoring in patients with severe traumatic brain injury. However, the realization of such a trial is likely to be problematic for a number of reasons, not least of which the firmly held biases of many clinicians.
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Transcranial Doppler is an innovative, flexible, accessible tool for the bedside monitoring of static and dynamic cerebral flow and treatment response. Introduced by Rune Aaslid in 1982, it has become indispensable in clinical practice. The main obstacle to ultrasound penetration of the skull is bone. ⋯ Brain death is defined as the irreversible cessation of all functions of the whole brain. The clinical criteria are usually considered sufficient to establish a diagnosis of brain death; however, they might not be sufficient in patients who have been on sedatives or when there are ethical or legal controversies. Many authors have demonstrated the existence of a transcranial Doppler pattern, which is typical of brain death.
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Eur J Anaesthesiol Suppl · Jan 2008
Role of the specialized neuro intensive care nurse in neuroscience research.
It is widely acknowledged that the quality of research is greatly improved when nurses are involved at the investigators' site. Many papers highlight the knowledge, skills and expertise required by nurses for the conduct of trials. The known skills include reliability, organization, communication, motivation, self-discipline and critical thought. ⋯ The rise in popularity of the role and the publication of an employment brief for clinical research nurses by the Royal College of Nursing (RCN) and the UK Clinical Research Collaboration (UKCRC) publication on 'Developing the best research professionals' has readdressed this prior imbalance; recognizing in detail their role, knowledge, skills, expertise with appropriate grading and remuneration. The role of the clinical research nurse in the neuroscience setting is equally as diverse with the added requirement of a higher level of knowledge and understanding of the pathophysiology of neurological diseases and specific skills required to work in the intensive care environment. This paper will attempt to explore the role of the specialized neurosciences intensive care nurse and the relationship with high-quality neuroscience research.