Anesthesiology clinics of North America
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The current concepts in neurocritical care including advancement in therapeutic interventions and monitoring modalities are covered for four entities: stroke, subarachnoid hemorrhage, traumatic brain injury and spinal cord injury. Although therapies were mainly supportive in the past, acute ischemic stroke may now be treated with tissue plasminogen activator if inclusion and exclusion criteria are met. ⋯ Traumatic brain injury and spinal cord injury with prevention of secondary injury to limit further sequelae are also covered. Medical complications which increase morbidity and mortality are also presented.
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None of the monitors of cerebral oxygenation discussed above has proven to be effective enough to have become a standard of care in any given area of medical treatment. As described above, each has specific and well-defined shortcomings that prevent its widespread use. These shortcomings may not be so much a failure of technology as an acknowledgement of the complexity of our goal: a monitor that can divide the entire brain into small, focal, and discrete areas and accurately measure the oxygen tension in each one. ⋯ The fact that cerebral oximeters can be used on any patient, at any time, on almost any case, makes it, potentially, truly an ideal monitor for anesthesiologists and intensivists alike. There is no certainty that any of these limitations will be surmounted, at least to the degree necessary to achieve desired accuracy. But there is much to anticipate.
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Neurosurgerical techniques utilizing minimally invasive approaches will continue to emerge. For some of these future possibilities, anesthesia may not be required. ⋯ Anesthesia will keep pace with these innovations by accurately controlling the delivery of anesthetic to achieve optimal conditions. This control will allow for a safer, more comfortable surgical procedure while decreasing blood loss and morbidity associated with neurosurgery.
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Few human data exist concerning the impact of fluid administration on brain pathophysiology. Those factors that influence water movement into the brain are examined, in order to provide reasonable recommendations for peri-operative fluid management in the patients with brain pathology.
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The initial concept of brain protection during neurosurgery is based on research done in the 1970s-1980 which established the concept that by decreasing cerebral metabolic rate the brain could survive longer periods of ischemia. The first section of this chapter reviews some of this initial research that promoted the use of barbiturates for cerebral protection. The second section reviews current anesthetic drugs and their potential for cerebral protection in addition to the benefits of blood pressure, temperature and glucose control. The final section discusses the "new mechanisms of cerebral protection" and the role old and new drugs may play in the future for brain protection during neurosurgery.