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1.
J Intensive Care Med ; 28(6): 341-54, 2013.
Artigo em Inglês | MEDLINE | ID: mdl-22328599

RESUMO

INTRODUCTION: Aneurysmal subarachnoid hemorrhage (SAH) has very high morbidity and mortality rates. Optimal intensive care unit (ICU) management requires knowledge of the potential complications that occur in this patient population. METHODS: Review of the ICU management of SAH. Level of evidence for specific recommendations is provided. RESULTS: Grading scales utilizing clinical factors and brain imaging studies can help in determining prognosis and are reviewed. Misdiagnosis of SAH is fairly common so the clinical symptoms and signs of SAH are summarized. The ICU management of SAH is discussed beginning with a focus on avoiding aneurysm re-rupture and securing the aneurysm, followed by a review of the neurologic and medical complications that may occur after the aneurysm is secured. Detailed treatment strategies and areas of current and future research are reviewed. CONCLUSIONS: The ICU management of the patient with SAH can be particularly challenging and requires an awareness of all potential neurologic and medical complications and their urgent treatments.


Assuntos
Aneurisma Roto/diagnóstico , Aneurisma Roto/terapia , Cuidados Críticos/métodos , Unidades de Terapia Intensiva , Hemorragia Subaracnóidea/diagnóstico , Hemorragia Subaracnóidea/terapia , Adulto , Aneurisma Roto/complicações , Angiografia Cerebral , Drenagem , Feminino , Escala de Coma de Glasgow , Humanos , Procedimentos Neurocirúrgicos , Hemorragia Subaracnóidea/complicações , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares
2.
Neurocrit Care ; 18(3): 305-12, 2013 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-23479068

RESUMO

BACKGROUND: Introduction of neurocritical care services to dedicated neuro-ICUs is associated with improved quality of care. The impact of a neurocritical care service without a dedicated neuro-ICU has not been studied. METHODS: We retrospectively identified all patients admitted to our institution with intracerebral hemorrhage (ICH) in two 12-month periods: immediately before the arrival of the first neurointensivist ("before") and after the neurocritical care service was established ("after"). There was no nursing team, ICU housestaff/physician extender team, or physical unit dedicated to the care of patients with critical neurologic illness during either period. Using an uncontrolled before-after design, we compared clinical outcomes and performance on quality metrics between groups. RESULTS: We included 74 patients with primary supratentorial ICH. Mortality, length of stay (LOS), proportion of patients with modified Rankin Score 0-3, and destination on discharge did not differ between groups when adjusted for confounders. Time to first two consecutive systolic blood pressure (SBP) measurements <180 mmHg was shorter in the "after" cohort (mean 4.5 vs. 3.2 h, p = 0.001). Area under the curve measurement for change in SBP from baseline over the first 24 h after ED arrival demonstrated greater, sustained SBP reduction in the "after" cohort (mean -187.9 vs. -720.9, p = 0.04). A higher proportion of patients were fed without passing a dysphagia screen in the "before" group (45 vs. 0%, p < 0.001). CONCLUSIONS: Introduction of a neurocritical service without a neuro-ICU at our institution was associated with a trend toward longer ICU LOS and improvement in some key metrics of quality of care for patients with ICH.


Assuntos
Hemorragia Cerebral/terapia , Cuidados Críticos/métodos , Neurologia/métodos , Qualidade da Assistência à Saúde , Idoso , Idoso de 80 Anos ou mais , Hemorragia Cerebral/mortalidade , Estudos de Coortes , Feminino , Humanos , Unidades de Terapia Intensiva , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Estudos Retrospectivos
3.
Am J Hosp Palliat Care ; 40(2): 117-121, 2023 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-35513023

RESUMO

BACKGROUND: Palliative care is a service that focuses on quality of life and symptom management. It is particularly important for patients with chronic disease. Palliative care in general is an underutilized service for various reasons. Many nurses have only learned about palliative care from experience and express a need for more education. PURPOSE: This study focused on educating critical care nurses on palliative care through online training videos. This quasi-experimental study aims to determine if an online palliative care educational program improves critical care nurses' self-efficacy in providing palliative care. PROCEDURES: The study was conducted using a pre-survey and post-survey that was created with a validated tool called the Palliative Care Self-Efficacy Scale. In between the surveys, the respondents were directed to online education. MAIN FINDINGS: The overall Palliative Care Self-Efficacy Scale showed a median score of the Palliative Care Self-Efficacy Scale increased from pre education (Md=38) to post-education (Md = 43.5), z = -4.868, p <.001, with a large effect size (r = -.76). PRINCIPAL CONCLUSIONS: The majority of critical care nurses have received some form of palliative care education. Online resources similar to the VitalTalk videos and handouts provide added education and improve perceived self-efficacy in providing palliative care in both psychosocial and symptom management aspects of care. The data suggests that improvements to access to education can be done by employers. Further studies can be done to assess current access to palliative care education in undergraduate nursing programs.


Assuntos
Bacharelado em Enfermagem , Enfermagem de Cuidados Paliativos na Terminalidade da Vida , Enfermeiras e Enfermeiros , Estudantes de Enfermagem , Humanos , Cuidados Paliativos , Qualidade de Vida , Autoeficácia
4.
Neurocrit Care ; 15(3): 516-8, 2011 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-21519956

RESUMO

BACKGROUND: Intracranial hypertension is a crucial modifiable risk factor for poor outcome after traumatic brain injury (TBI). Limited evidence suggests that decompressive laparotomy may be an effective treatment for refractory ICH in patients who have elevated intra-abdominal pressure. METHODS: Case report. RESULTS: We present a multi-trauma patient who sustained severe TBI in a motor vehicle collision. Intracranial pressure (ICP) was initially medically managed but became refractory to standard therapies. Emergent decompressive laparotomy performed in the surgical intensive care unit for abdominal compartment syndrome concomitantly improved the patient's ICP. CONCLUSIONS: Elevated intra-abdominal pressure can exacerbate intracranial hypertension in patients with TBI. Recognition of this condition and treatment with decompressive laparotomy may be useful in patients with intracranial hypertension refractory to optimal medical therapy.


Assuntos
Lesões Encefálicas/cirurgia , Descompressão Cirúrgica/métodos , Hipertensão Intra-Abdominal/cirurgia , Hipertensão Intracraniana/cirurgia , Laparotomia/métodos , Traumatismo Múltiplo/cirurgia , APACHE , Acidentes de Trânsito , Atividades Cotidianas/classificação , Adolescente , Edema Encefálico/diagnóstico , Edema Encefálico/cirurgia , Lesões Encefálicas/diagnóstico , Terapia Combinada , Comportamento Cooperativo , Feminino , Escala de Coma de Glasgow , Escala de Resultado de Glasgow , Hematoma Subdural Intracraniano/diagnóstico , Hematoma Subdural Intracraniano/cirurgia , Humanos , Comunicação Interdisciplinar , Hipertensão Intra-Abdominal/diagnóstico , Pressão Intracraniana/fisiologia , Manitol/administração & dosagem , Traumatismo Múltiplo/diagnóstico , Tomografia Computadorizada por Raios X , Centros de Traumatologia
5.
Neurocrit Care ; 15(3): 542-6, 2011 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-21964775

RESUMO

BACKGROUND: Posterior reversible encephalopathy syndrome (PRES) is a rare complication of hemodynamic augmentation for subarachnoid hemorrhage (SAH)-associated vasospasm. The roles of hyperperfusion and hypoperfusion in the genesis of PRES remain uncertain. METHODS: Case report. RESULTS: We admitted a 35-year-old woman with Hunt & Hess grade II SAH secondary to rupture of a right middle cerebral artery (MCA) aneurysm. This was surgically clipped. Beginning on hospital day 3, she developed recurrent symptomatic vasospasm of the right MCA despite hemodynamic augmentation to a MAP as high as 130 mmHg and endovascular therapy. On hospital day 7, after 36 h of sustained MAP 120-130 mmHg, her level of arousal progressively declined, culminating in stupor and two generalized tonic-clonic seizures. MRI showed widespread, yet markedly asymmetric changes consistent with PRES largely sparing the right MCA territory. After the MAP was decreased to 85-100 mmHg, she had no further seizures. 2 days later she was fully alert with mild left hemiparesis. CONCLUSIONS: PRES is a rare complication of hemodynamic augmentation that should be considered in the differential diagnosis of delayed neurological decline in patients with aneurysmal SAH-associated cerebral vasospasm. The markedly asymmetric distribution of PRES lesions with sparing of the territory affected by vasospasm supports the hypothesis that hyperperfusion underlies the pathophysiology of this disorder.


Assuntos
Hemodinâmica/fisiologia , Aneurisma Intracraniano/complicações , Aneurisma Intracraniano/fisiopatologia , Síndrome da Leucoencefalopatia Posterior/complicações , Síndrome da Leucoencefalopatia Posterior/fisiopatologia , Hemorragia Subaracnóidea/complicações , Hemorragia Subaracnóidea/fisiopatologia , Vasoespasmo Intracraniano/complicações , Vasoespasmo Intracraniano/fisiopatologia , Adulto , Pressão Sanguínea/fisiologia , Angiografia Cerebral , Imagem de Difusão por Ressonância Magnética , Dominância Cerebral/fisiologia , Epilepsia Tônico-Clônica/complicações , Epilepsia Tônico-Clônica/fisiopatologia , Feminino , Humanos , Interpretação de Imagem Assistida por Computador , Imageamento Tridimensional , Imageamento por Ressonância Magnética , Artéria Cerebral Média/fisiopatologia , Exame Neurológico , Paresia/complicações , Paresia/fisiopatologia , Recidiva , Fluxo Sanguíneo Regional/fisiologia , Tomografia Computadorizada por Raios X
6.
Emerg Med Clin North Am ; 30(3): 713-44, 2012 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-22974646

RESUMO

Despite the success of acute reperfusion therapies for the treatment of acute ischemic stroke, only a minority of patients receive such treatment. Even patients who receive reperfusion therapy remain at risk for further neuronal death through progressive infarction and secondary injury mechanisms. The goal of neurocritical care for the patient with acute ischemic stroke is to optimize long-term outcomes by minimizing the amount of brain tissue that is lost to these processes. This is accomplished by optimizing brain perfusion, limiting secondary brain injury, and compensating for associated dysfunction in other organ systems. Because of the rapid and irreversible nature of ischemic brain injury, it is crucial for best neurocritical care practices to begin as early as possible. Therefore, this chapter will discuss optimal, pragmatic neurocritical care management of patients with acute ischemic stroke during the "golden" emergency department hours from the perspective of the neurointensivist. Major topics include cerebral perfusion optimization; management of cerebral edema; post-thrombolytic care; acute anticoagulation; treatment of commonly associated cardiac and pulmonary complications; fluid, electrolyte and glucose management; the role of induced normothermia and therapeutic hypothermia; and prophylaxis against common complications.


Assuntos
Cuidados Críticos , Acidente Vascular Cerebral/terapia , Encéfalo/irrigação sanguínea , Edema Encefálico/terapia , Infarto Encefálico/prevenção & controle , Infarto Encefálico/terapia , Cuidados Críticos/métodos , Serviço Hospitalar de Emergência , Humanos , Hipertensão/terapia , Monitorização Fisiológica , Insuficiência Respiratória/prevenção & controle , Convulsões/prevenção & controle , Acidente Vascular Cerebral/complicações , Terapia Trombolítica/métodos
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