Articles: outcome.
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Hypothermia for patients with severe traumatic brain injury (TBI) remains controversial despite a strong biological rationale and reasonable evidence from the literature. The "negative" Clifton study seems to have reduced enthusiasm for hypothermia, however the aim of this review is to analyse the evidence from all randomised controlled trials (RCT) and meta-analyses on this topic to determine whether there is adequate support for the view that hypothermia does improve outcome from TBI. The biological rationale for hypothermia is supported by animal and human mechanistic studies of TBI and human clinical studies of brain injury caused by out-of-hospital cardiac arrest. ⋯ Subsequent to these meta-analyses, a RCT was published which has confirmed that hypothermia is beneficial in a large group of TBI patients. When the published evidence is considered in total, even if hypothermia can't be justified in all TBI patients, if it is applied optimally in the most appropriate patients, hypothermia certainly improves outcome from TBI. If hypothermia is correctly applied (early, long and cool enough) in the optimal group of TBI patients (young with elevated ICP), there seems to be no doubt that hypothermia is effective in improving both survival and favourable neurological outcome from TBI.
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The impetus for cerebral hemodynamic monitoring in neurotrauma first arose from the original "talk and die" studies which described the group of head injured patients "who talk and then subsequently died". At necropsy, hypoxic or ischaemic brain damage was observed in a variable proportion of patients raising the possibility that systemic or cerebral hypoxia post trauma may have contributed to the poor neurological outcome. Improved understanding of the pathophysiology of neurotrauma influenced clinical practice in two ways: a) there was a plethora of monitoring modalities developed for evaluating cerebral hemodynamics and oxygenation and b) squeezing oxygenated blood through a swollen brain became the cornerstone of therapy in patients with head injury. ⋯ Although initial monitoring was largely confined to global indices of brain oxygenation, refinement in technology has made the measurement of oxygen tensions further down in the oxygen cascade at the level of the tissue possible and applicable by the bedside. Metabolic monitoring of the brain is now possible with the use of a variety of biochemical indices and with the availability of microdialysis. The purpose of this review is to examine the various modes of monitoring cerebral oxygenation, critically review the literature concerning their use in day to day intensive care practice, outline their limitations and define possible indications for their use.
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Analysis of cerebrospinal fluid (CSF) obtained by lumbar puncture (LP) is fundamental to the management of inflammatory disease of the central nervous system (CNS), particularly that due to infection. This review summarises the role of lumbar puncture, anatomy and pathophysiology of CSF, techniques of obtaining CSF, indications, contraindications and complications of LP, methods of analysis and some of the implications of specific changes in CSF. The CNS is protected by unique immunological barriers, and has some unique responses to processes that breach these barriers. ⋯ Some CSF testing is sensitive, specific and timely, but other CNS disease processes will generate obscure and ambiguous results, and interpretation may benefit from liaison with experienced specialists in several fields. Polymerase chain reaction (PCR) testing has changed the practice of LP and is likely to generate further evolution. Some findings on CSF analysis may have implications beyond the individual patient - the consequences of the diagnosis of meningococcal meningitis, emerging pathogens such as West Nile virus or Nipah virus, and the identification of anthrax meningitis in the USA may be quite profound on both a local and global scale.
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Curr Opin Anaesthesiol · Aug 2005
Arginine vasopressin as a rescue vasopressor agent in the operating room.
This review gives an overview of the current knowledge and research on the use of arginine vasopressin in cardiac arrest and severe shock states. ⋯ Whereas arginine vasopressin in combination with epinephrine can significantly increase hospital discharge in cardiac arrest, arginine vasopressin combined with catecholamines improved haemodynamics in vasodilatory and haemorrhagic shock, but effects on outcome remain unknown. Nonetheless, in the perioperative setting, arginine vasopressin may already be considered as a potent adjunct vasopressor agent in advanced shock states unresponsive to conventional therapy.
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Low doses of ketamine or isomers are promising possibilities for anesthesia and postoperative analgesia. This study aimed at reviewing major properties of low ketamine doses, which may justify their use in anesthesia and postoperative analgesia. ⋯ Most studies with low S(+) ketamine doses have shown preventive effects, decreasing central nervous system sensitization, opioid-induced tolerance and hyperalgesia, anesthetic and analgesic consumption, and the incidence of postoperative adverse effects.