ВведениеБазовые принципы ведения неврологических и нейрохирургических пациентов при развитии у них критического состояния не отличаются от таковых у других реанимационных пациентов. Однако патогенез церебральных катастроф обладает рядом особенностей [1][2][3][4], которые иногда столь важны, что именно они определяют исход заболевания.Целесообразность создания специализированных отделений реанимации для пациентов неврологическо го и нейрохирургического профиля была доказана при проведении мета анализа, основанного на результатах лечения почти 25000 пациентов. Госпитализация этих пациентов в нейрореанимационное, а не в общереани мационное отделение, снижает риск развития леталь ного исхода и повышает шансы на благоприятный ис ход [5]. Ведение нейрореанимационного пациента нейрореаниматологом улучшает исходы заболевания. IntroductionThe basic principles for management of neurological and neurosurgical patients in a critical condition do not differ from those for other critical care patients. However, the pathogenesis of cerebral accidents has a number of fea tures that are sometimes so important that they determine the disease outcome. In this regard, the critical care in neu rology and neurosurgery is considered as a neurocritical care [1][2][3][4].The reasonability of establishing specialized critical care units for neurological and neurosurgical patients was proved by the meta analysis based on the results of treat ment of almost 25,000 patients. Admission of these patients to a neurocritical care unit, rather than to usual critical care unit, reduces the risk of death and increases the chances of a favorable outcome [5]. Management of the neurocritical care patient by the neurointensivist improves disease outcomes. This effect is most evident in the popu Течение критических состояний в неврологии и нейрохирургии обладает особенностями, связанными со сложностью патогенеза церебрального повреждения, что, в свою очередь, обуславливает специфику реанимационной помощи. Для краткости изложения методы общей реаниматологии в неврологии и нейрохирургии целесообразно характеризо вать термином нейрореаниматология. В статье освещены последние тенденции в проведении мультимодального мони торинга и специфической терапии в нейрореаниматологии. Кроме этого, приведены данные, показывающие исключи тельную важность осуществления инфекционного контроля при лечении пациентов неврологического и нейрохирургического профиля, находящихся в критическом состоянии. Ключевые слова: нейрореаниматология, мультимодальный мониторинг, нейромониторинг, нейропротекция, инфекционный контроль.The course of critical conditions in neurology and neurosurgery has specific features associated with the complex pathogen esis of brain injury, which in turn determines the specificity of resuscitation care. For a brief description, general resuscita tion methods in neurology and neurosurgery should be characterized by the term of neuroresuscitation. The paper presents the latest trends in multimodality monitoring and specific therapy in neuroresuscitation. F...
SummarySpinal fentanyl can improve analgesia during Caesarean section. However, there is evidence that, following its relatively short-lived analgesic effect, there is a more prolonged spinal opioid tolerance effect. The effectiveness of postoperative epidural fentanyl analgesia may therefore be reduced following the use of spinal fentanyl at operation. This randomised, double-blind study was designed to assess whether patient-controlled epidural fentanyl could produce effective analgesia following 25 lg of spinal fentanyl at operation. Patients undergoing elective Caesarean section received spinal bupivacaine combined with either fentanyl 25 lg (fentanyl group; n 18) or normal saline (saline group; n 18). Patient-controlled epidural fentanyl was used for postoperative analgesia. The fentanyl group used a mean of 23.4 (SD 14.5) lg.h A1 of fentanyl, compared with 27.0 (10.8) lg.h A1 for the saline group (p 0.41). Using a 0±100 mm visual analogue score for pain, the maximum pain score recorded at rest for the fentanyl group was
SummaryWe developed a screening questionnaire to be used by nurses to decide which patients should see an anaesthetist for further evaluation before the day of surgery. Our objective was to measure the accuracy of responses to the questionnaire. Agreement between questionnaire responses and the anaesthetist's assessment was assessed. For questions with a prevalence of 5 to 95%, the Kappa coefficient was used; percentage agreement was used for all other questions. Criterion validity was excellent ⁄ good for all questions with a prevalence between 5 and 95%, except for the question 'Do you have kidney disease?' For questions with prevalence < 5%, all demonstrated adequate criterion validity except the questions 'Has anyone in your family had a problem following an anaesthetic?' and 'If you have been put to sleep for an operation were there any anaesthetic problems?' Therefore, it is reasonable for nurses to use this questionnaire to determine which patients an anaesthetist should see before the day of surgery.Keywords Anaesthesia; pre-operative, assessment, questionnaire. Recent advances in anaesthetic and surgical practice have facilitated the growth of 'fast track' surgery [1, 2]. Careful outpatient assessment is fundamental to the success of this type of surgery and the Association of Anaesthetists of Great Britain and Ireland now recommends assessment at a pre-operative assessment (POA) clinic [3].The provision of a pre-operative screening and assessment service at POA clinics supplies background information about patient's general medical status and fitness for anaesthesia. POA clinics improve patient care by allowing careful pre-operative evaluation and optimisation of coexisting disease [4], reduce costs [5, 6], improve efficiency [7], and lower surgical cancellation rates [8, 9].In POA clinics, nurses increasingly carry out preoperative screening [10]. Although they are not qualified to decide if a patient is fit for anaesthesia, they play a valuable role in identifying patients who are at risk and require further evaluation and optimisation before the day of surgery [11]. Nurses screen patients for risk factors for fitness for anaesthesia and surgery using questionnaires [12]. These can be self-administered by the patient [9], or used during structured interviews [13], or computer programs [14]. Although many locally developed questionnaires exist, few have been formally assessed.We have developed a multi-tiered screening questionnaire to be used by nurses to decide which patients should be seen at a POA clinic by an anaesthetist for further evaluation and optimisation. Using Delphi consensus methods, we have already evaluated content validity for each question [15] to ensure that the questions are relevant to concept being measured.Our objective was to perform item analysis of the screening questionnaire and measure criterion validity [16], that is, is it a true measure of what it is designed to measure?By testing individual questions beyond basic content validity, we were able to put them together in a...
We have assessed the role of the cell-cell adhesion molecule, E-cadherin, in the pathogenesis of multiorgan failure in 24 intensive care patients with sepsis and varying degrees of organ dysfunction, compared with 21 healthy subjects. Plasma soluble E-cadherin (sE-cadherin) was measured by enzyme immunoassay. The median concentration of sE-cadherin in normal subjects was 3.21 micrograms ml-1 compared with 6.00 micrograms ml-1 in patients with sepsis and organ dysfunction (P = 0.0019). There was no statistically significant difference in concentrations of sE-cadherin in survivors compared with non-survivors. Concentrations of sE-cadherin tended to increase with the severity of organ failure. We conclude that sE-cadherin is increased in inflammation and injury, and may be related to the degree of multiorgan failure after sepsis.
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