European journal of anaesthesiology. Supplement最新文献

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. Observational studies of such therapy have yielded inconsistent results, ranging from decreased mortality to no effect or increased morbidity or mortality. A recent cohort study supports the notion that the possible benefits of intracranial pressure monitoring after traumatic brain injury are small - if present - and would exceed a number needed for the treatment of 16. 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.

This article will discuss the challenges related to the demonstration of the efficacy of monitoring in an intensive care environment. It will address interpretation, therapeutic intervention, sample size and compare efficacy to effectiveness in the context of the developing field of neurocritical care.

Current understanding of oral anticoagulant treatment and related intracerebral haemorrhage remains rather limited as compared to that of spontaneous intracerebral haemorrhage. Although intracerebral haemorrhage is the most serious complication of oral anticoagulant treatment, standardized treatment guidelines are still lacking. The currently employed treatments are aimed at normalization of the iatrogenic coagulation impairment, and are not based on randomized controlled trials evidence. Since most patients with oral anticoagulant treatment-intracerebral haemorrhage are at high risk of cardio-embolism and often myocardial infarction, it is uncertain whether the use of procoagulant treatments for oral anticoagulant treatment-intracerebral haemorrhage may increase their risk of thrombotic complications. Patients who receive chronic oral anticoagulant treatment urgently require effective treatments for acute oral anticoagulant treatment-intracerebral haemorrhage, and therefore controlled clinical trials are needed.

Nurses have become independent over the last few decades in Italy, thanks to a series of legislative changes. When dealing with organ donation, the nurses usually face unexpected and complex situations from both a technical and interpersonal point of view. When the death of a loved one has to be communicated to the family, the coordinator nurse, along with the doctor, talks with the relatives to help them decide whether or not to donate organs. It is fundamental that the death of the patient is communicated by the doctor in charge of the case and this has to be done before the question of donation is raised. The idea of donation is suggested when we believe the family has understood that their beloved is dead. We try to adapt our communication style to the background of the family. Experience has shown us that these situations are emotionally complex and tiring for both the family members and health workers. Sometimes the stress level amongst health workers is so high that psychological support is needed after the interview. If the family decides to donate, the restitution phase is very important. A meeting is organized for a month after the event to inform the relatives of the success of donation.

Activation of inflammation is the hallmark of pathological processes that follow acute injury. This process is mediated by inflammatory cytokines and adhesion molecules that reside on the surface of endothelium, leucocyte and inflammatory cells. Attenuation of the adhesion cascade has been the subject of several basic science and clinical trials in the management of neurological injury. This review will highlight the role of adhesion molecules in the evolution of secondary injury after cerebral ischaemia and trauma. Potential therapeutic avenues will then be discussed.

The interruption of life support poses different problems for he who interrogates himself regarding the possible juridical role of omissible behaviour or activities by part of the physician when dealing with end-of-life interventions within the boundary of life and death. The present contribution proposes to trace the coordinates necessary to answer the main query regarding the obligations which may be incumbent on the physician. For this reason, the necessity to interpret the legal sanctions in a technical key is highlighted. This is performed in sight of a progressive and inevitable adaptation to problems which are the result of a social evolution, and to the conception of values which constitute an object responsibility, as renewed by the constitution. The laws that discipline crimes against life and individual integrity must be interpreted while keeping in mind that the objective of maintaining the patient in life must be integrated with the control of suffering and the guarantee of a dignified death. When identifying the principles which have to inspire the decisions during 'borderline or boundary situations', it is highlighted the way the physician has to resort to a just equilibrium between benefit, which can be reasonably expected, and sacrifice, which should be imposed, taking into consideration the criteria of good clinical practice, among which attention to the patient's will must be taken into consideration.

The pathophysiology of hydrocephalus can be modelled and described in terms of altered biomechanical parameters. Shunting is aimed to correct the patient's cerebrospinal fluid dynamics, compensating for inadequate cerebrospinal fluid re-absorption or insufficient volume buffering reserve. Computerized infusion studies implement intracranial pressure and arterial pressure signal processing and model analysis to allow the estimation of cerebrospinal dynamics variables such as cerebrospinal fluid outflow resistance, brain compliance and pressure-volume index, estimated sagittal sinus pressure, cerebrospinal fluid formation rate, compensatory reserve and cerebral vasoreactivity. Infusion studies can assist in the prognostication of normal pressure hydrocephalus and in the diagnosis of idiopathic intracranial hypertension. The technique is also helpful in the assessment of shunt malfunction, including posture-related over-drainage and shunt obstruction.

Intracerebral haemorrhage accounts for 10-15% of strokes and is associated with high mortality and severe disability in survivors. Despite its seriousness, the treatment options for intracerebral haemorrhage are limited. Measures aimed at decreasing elevated intracranial pressure are of limited effectiveness. This has stimulated an interest in attempting to improve the prognosis of intracerebral haemorrhage by addressing the haematoma directly, either removing it by surgical means or limiting its early spontaneous growth. The international Surgical Trial in Intracerebral Haemorrhage (STICH), which randomized subjects with intracerebral haemorrhage within 72 h of symptom onset to medical management vs. surgery, failed to document the superiority of one treatment over the other, when compared with regard to mortality and functional outcome at 90 days. The subgroup of patients with lobar haematomas located at a depth of 1 cm or less from the cortical surface fared better with surgery than with medical management. A similar comparison trial is planned for this subgroup of patients. The neutral results of The international Surgical Trial in Intracerebral Haemorrhage (STICH) prompted the assessment of haemostatic therapies, based on the observation that haematomas often enlarge substantially in the hours that follow the onset of symptoms. Recombinant activated factor VII has been shown in a phase IIb, dose-finding trial to result in a significant reduction of haematoma growth, and both mortality and functional scales trended in favour of recombinant activated factor VIIa. The main complication of this therapy was arterial thromboembolic events (myocardial infarction and ischaemic stroke). A phase III randomized trial has recently been completed.

Neuromuscular complications encountered in intensive care can be due to peripheral nerves (polyneuropathies), muscles (myopathies), neuromuscular end-plate (transmission deficit) or a combination of these. Neurophysiopathological tests that enable us to diagnose and maybe differentiate between these causes are essentially electroneurographs and electromyographs. These assess, either directly or indirectly, the integrity of the peripheral system, both sensory (centripetal afferent pathways) and motor (lower motor neurones, neuromuscular junction, muscle membrane and contractile substrate). Electrical activity in the muscle is measured using a special device (an electromyograph) comprising preamplifiers, a computer with special programmes and algorithms for analysing, digitalizing, amplifying and filtering the recorded signal and a monitor on which to visualize the on-line trace. The machine also has speakers. These serve to recognize and identify the physiological events being recorded as they make such unusual, individual sounds. An electric stimulator with constant current can be used to stimulate branches of superficial nerves (motor, sensory or mixed) so that electric conduction speed can be studied and the sensory or motor response analysed. The results can be saved on a hard disc or on any magnetic or digital support, viewed off-line or even printed.

An uncontrolled rise in intracranial pressure is probably the most common cause of death in traumatic brain-injured patients. The intracranial pressure rise is often due to cerebral oedema. Diffusion-weighted imaging has been extensively used to study cerebral oedema formation after trauma in experimental studies. Nevertheless, this technology is difficult to perform at the acute phase, especially in unstable head trauma patients. For these reasons, a safe examination allowing us to better understand the pathophysiology of cerebral oedema formation in such patients would be of great interest. Radiological attenuation is linearly correlated with estimated specific gravity in human tissue. This property gives the opportunity to measure in vivo the volume, weight and specific gravity of any tissue by computed tomography. We recently developed a software package (BrainView) for Windows workstations, providing semi-automatic tools for brain analysis from DICOM images obtained from cerebral computed tomography. In this review, we will discuss the results of the in vivo analysis of brain weight, volume and specific gravity and consider the use of this software as a new technology to improve our knowledge of cerebral oedema formation after trauma and to evaluate the severity of traumatic brain-injured patients.