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The effects of sedative medications in intensive complex treatment of the patients with acute cerebral injury


Author: Plămădeală Svetlana
Degree:doctor of medicine
Speciality: 14.00.37 - Anaesthesiology and Reanimathology
Year:2009
Scientific adviser: Boris Pîrgari (decedat)
doctor habilitat, professor, Nicolae Testemitanu State University of Medicine and Pharmacy of the Republic of Moldova
Scientific consultant: Gheorghe Ciobanu
doctor habilitat, professor, Nicolae Testemitanu State University of Medicine and Pharmacy of the Republic of Moldova
Institution:

Status

The thesis was presented on the 7 October, 2009
Approved by NCAA on the 17 December, 2009

Abstract

Adobe PDF document – 0.47 Mb / in romanian

Keywords

acute cerebral injuries, continuous sedation, sedative drug, secondary cerebral damage, neurological outcome

Summary

The structure of thesis is presented on 151 pages and includes general references, 5 chapters, conclusions, practical recommendations, and bibliography from 221 scientific articles, 7 annexes, 25 tables, 49 figures and 2 cases report. The principal thesis of the study as well as support ideas had been revealed in 12 scientific works.

Field of study. Patients with acute cerebral injuries (head trauma, cerebrovasculare strock, post-strangulation cerebral hypoxemia), who received continuous sedation medication.

Goals of study. To study systemic and cerebral effects of continuous sedation relevant to the drugs used (Sodium Thiopental, Propofol, Midazolam), to evaluate the homeostasy through plasma osmolarity and to reveal the factors which determine the evolution and outcome of patients with acute cerebral injuries.

The novelty and scientific originality. Maximal hemodynamic stability and minimal changes of systemic metabolism were registered in patients continuously sedated with Thiopental as compared with the concurrent groups of patients sedated with Propofol and Midazolam.

During our analysis of respiratory effects the PaO2/PAO2 ratio showed a higher sensitivity against PaO2/FiO2 ratio in predicting ALI (85% versus 64%), while the PaO2/FiO2 test was superior to the concurrent test in specificity (92% versus 38%) and we noted and proved the advantage of earlier intubation and the early start of mechanical ventilation. The rheoncephalographic examination showed a decrease of the vascular intracranial component determined by elevation of arterial and venouse tone in cerebral vascular system, which were higher in the primary non-injured hemisphere.

Hyper- and hyponatriemia associated with hiper- and hypo-osmolarity were noted as evolutive phases of osmostat reset and the study revealed the factors, which alone or in association with other factors, can be used as unfavourable outcome presumptive criteria: neurological state evaluated as 9-12 points, or less than 6 points; hypoxia and late intubation; association of nosocomial pneumonia; hyperventilation the first 24 hours; patient age over 50; high levels of blood sugar and Na+ , and seric hyperosmolarity.

Theoretical signification. Understanding the evolutionary peculiarities of patients with acute cerebral injury offers the possibility to prevent or precociously stop the secondary cerebral injury, which in many instances determines the outcome in these patients.

Practical application. “Aggressive” treatment of hypotension and hypoxia in patients with acute cerebral injury is the first goal of the Intensive Care specialist. Sedation as part of the complex treatment program offers the possibility to prevent the complications induced by high blood level of catecholamines, to exclude the “fight of patient with the ventilator“ and to ensure efficient patient’s ventilation, to reduce systemic and cerebral metabolic rate, adjusting systemic oxygen requirements to oxygen supply. The goal of complex and detailed monitoring of vital parameters is to preserve adequate cerebral perfusion through modulation of intracranial content.