Articles: critical-care.
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Neurosurg. Clin. N. Am. · Oct 1994
Review Case ReportsStatus epilepticus. A perspective from the neuroscience intensive care unit.
Patients with GCSE and NCSE are common and may present to the emergency department or the NICU. In the NICU, NCSE is a more common presentation than GCSE. In the emergency department, GCSE commonly evolves to NCSE, either as a late sequela of prolonged SE or due to partial treatment with antiepileptic medication or neuromuscular blocking agents. ⋯ The knowledgeable and prompt use of intravenous lorazepam, a diazepam-phenytoin combination, or phenobarbital is acceptable as first-line treatment and as part of a systematic treatment algorithm. Refractory SE has been treated conventionally with high-dose intravenous barbiturate coma. Recent evidence suggests that high-dose intravenous midazolam may provide a useful alternative.
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Critical care of a patient with SAH should focus on the prevention or immediate treatment of the common sequelae of this disorder that adversely affect outcome: vasospasm, rebleeding, hydrocephalus, seizures, and associated medical problems. The frequency of rebleeding can be lessened by early surgical or endovascular intervention. The extent of SAH on the CT scan can identify those patients at highest risk for vasospasm, and all patients must be closely monitored in the ICU with serial neurological examinations and transcranial Doppler studies. ⋯ Seizures, which can cause intracranial and systemic hypertension, high cerebral metabolic demand, and delayed neurological injury, should be prevented with prophylactic use of anticonvulsants. In addition, early recognition and treatment of associated medical complications are critical. Novel endovascular approaches, meticulous surgical technique, and aggressive ICU care will undoubtedly lead to improved outcome following aneurysmal SAH.
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Transcranial Doppler ultrasonography is an extremely useful adjunct in neurosurgical intensive care. Continuous improvements in TCD equipment as well as computer software have improved examination success and also vessel identification. ⋯ In the future, TCD may offer the ability to estimate the ICP using noninvasive means by evaluating velocity in the middle cerebral artery and arterial blood pressure tracings. The noninvasive determination of cerebral autoregulation may be useful in evaluating strategies to improve cerebral autoregulation as well as aid in the optimal management of ICP control and preservation of optimal cerebral circulation.
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Critical care clinics · Oct 1994
ReviewPharmacology of neuromuscular blocking agents in the intensive care unit.
In critically ill patients, organ function, blood flow, and caregiving personnel change constantly. The risks inherent in paralyzing a patient, such as those of positioning (nerve injuries, stasis injuries) and ventilator disconnection are compounded by the duration of paralysis in the ICU. When used with attention to the pharmacologic properties, patient organ function, and cost, however, muscle relaxants are a useful adjunct to ICU management.