Pro/con debate: should PaCO2 be tightly controlled in all patients with acute brain injuries?
| Autor: | Stephanie L. Go, Jeff Singh |
|---|---|
| Rok vydání: | 2013 |
| Předmět: |
medicine.medical_specialty
Intracranial Pressure Sedation Ventilator-Induced Lung Injury Conscious Sedation Intensivist Review Critical Care and Intensive Care Medicine Hypoxemia Brain Ischemia Permissive hypercapnia Hypocapnia medicine Humans Intensive care medicine Tidal volume Intracranial pressure Monitoring Physiologic business.industry Carbon Dioxide medicine.disease Clinical trial Brain Injuries Cerebrovascular Circulation Neuromuscular Blockade medicine.symptom business |
| Zdroj: | Critical Care |
| ISSN: | 1466-609X |
| Popis: | You are the attending intensivist in a neurointensive care unit caring for a woman five days post-rupture of a cerebral aneurysm (World Federation of Neurological Surgeons Grade 4 and Fisher Grade 3). She is intubated for airway protection and mild hypoxemia related to an aspiration event at the time of aneurysm rupture, but is breathing spontaneously on the ventilator. Your patient is spontaneously hyperventilating with high tidal volumes despite minimal support and has developed significant hypocapnia. She has not yet developed the acute respiratory distress syndrome. You debate whether to tightly control her partial pressure of arterial carbon dioxide, weighing the known risks of acute hypocapnia in other forms of brain injury against the potential loss of clinical neuromonitoring associated with deep sedation and neuromuscular blockade in this patient who is at high risk of delayed ischemia from vasospasm. You are also aware of the potential implications of tidal volume control if this patient were to develop the acute respiratory distress syndrome and the effect of permissive hypercapnia on her intracranial pressure. In this paper we provide a detailed and balanced examination of the issues pertaining to this clinical scenario, including suggestions for clinical management of ventilation, sedation and neuromonitoring. Until more definitive clinical trial evidence is available to guide practice, clinicians are forced to carefully weigh the potential benefits of tight carbon dioxide control against the potential risks in each individual patient based on the clinical issues at hand. |
| Databáze: | OpenAIRE |
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