European journal of anaesthesiology. Supplement最新文献

Decision-making at the end-of-life in the United States has evolved over the last 50 yr, beginning with the development of the concept of brain death as a criterion for permitting patients who are in a state of 'irreversible coma' to be considered as 'dead' for purposes of ventilator withdrawal and organ transplantation. Since then, a firm consensus has emerged in American law and ethics that 'Patients have a virtually unlimited right to refuse any unwanted medical treatment, even if necessary for life itself.' With regard to patients who are unable to make decisions for themselves, both Europe and the United States are converging toward a view that respects a role for surrogates in decision-making while recognizing the need to limit their authority. Beyond decisions to withdraw and withhold treatments, both the United States and Europe are experimenting with active hastening of the dying process through euthanasia and physician-assisted suicide. In the author's opinion, the next big question to be addressed in end-of-life decision-making is 'Just how bad does the neurological condition and prognosis need to be before it is acceptable to allow a decision to withdraw life support'? Although the practices described here have wide acceptance throughout the United States and Europe, the worldwide emergence of religious fundamentalism and the associated vitalistic view about the sanctity of life may result in significant changes over the next few decades.

Weakness of the limbs and respiratory muscles has increasingly been found to be a frequent event that complicates the medical history of patients in Intensive Care. The problem normally affects more serious cases and presents as muscular weakness leading to flaccid paralysis and difficulty in weaning patients off mechanical ventilation. This latter sign leads the intensivist to suspect possible involvement of the neuromuscular respiratory system. Unfortunately, in-depth clinical assessment of the neuromuscular respiratory system is difficult with critically ill patients, and electrophysiological studies have been used instead to overcome this problem. Of these latter, electric and electromagnetic stimulation of the phrenic nerve have been successful (along with needle electromyography of the diaphragm) in identifying the causes of neuromuscular respiratory insufficiency, especially in Intensive Care. In this brief chapter, we will be discussing the technique of electric stimulation of the phrenic nerve and neuromuscular respiratory insufficiency within the field of critical illness polyneuropathy.

Follow-up studies on individuals who suffer severe head injury give a picture of poor cognitive and psychosocial outcome. However, recent evidence suggests that with the passage of time, many individuals make adjustments that compensate for early disability, leading to a reduction in social handicap with a corresponding improvement in life quality and personal satisfaction. This article will attempt to briefly review the main sources of evidence contributing to long-term outcome following serious head trauma.

In 1892 Osler described 'rapid loss of flesh' in prolonged sepsis. Thereafter, for years, limb weakness was attributed to cachectic myopathy, and difficulty weaning from mechanical ventilation was attributed to diaphragmatic fatigue. In 1961 Mertens described 'coma-polyneuropathies', and in 1971 Henderson and colleagues described polyneuropathy in patients with burns. In 1984 Bolton and colleagues, in a series of reports, defined the clinical, electrophysiological and morphological features of septic encephalopathy and critical illness polyneuropathy. Evidence suggested that polyneuropathy was due to the 'toxic' effects of sepsis. Polyneuropathy was a common cause of difficulty in weaning when lung and cardiac cause had been excluded. Since 1984, cases of critical illness polyneuropathy have been reported from several countries. Moreover, a number of investigators reported instances of critical illness myopathy. Comprehensive studies by Latronico and colleagues indicated that polyneuropathy and myopathy often occurred together in the same patient. With successful treatment of sepsis, improvement often occurred in encephalopathy, polyneuropathy and myopathy, except in very severe cases.

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 responsibilities of nurses in the conduction of research trials are wide ranging from the collection and recording of data, recruitment and screening of patients, ensuring informed consent has been gained, randomization of drugs, the follow-up of patients to development and training for staff to the required international standards. In the past, clinical research nurses have been considered as data collectors by their peers, due to the lack of knowledge of the true extent of the role of the clinical research nurse. 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.