Expert consensus on late stage of critical care management / 中华内科杂志

We wished to establish an expert consensus on late stage of critical care (CC) management. The panel comprised 13 experts in CC medicine. Each statement was assessed based on the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) principle. Then, the Delphi method was adopted by 17 experts to reassess the following 28 statements. (1) ESCAPE has evolved from a strategy of delirium management to a strategy of late stage of CC management. (2) The new version of ESCAPE is a strategy for optimizing treatment and comprehensive care of critically ill patients (CIPs) after the rescue period, including early mobilization, early rehabilitation, nutritional support, sleep management, mental assessment, cognitive-function training, emotional support, and optimizing sedation and analgesia. (3) Disease assessment to determine the starting point of early mobilization, early rehabilitation, and early enteral nutrition. (4) Early mobilization has synergistic effects upon the recovery of organ function. (5) Early functional exercise and rehabilitation are important means to promote CIP recovery, and gives them a sense of future prospects. (6) Timely start of enteral nutrition is conducive to early mobilization and early rehabilitation. (7) The spontaneous breathing test should be started as soon as possible, and a weaning plan should be selected step-by-step. (8) The waking process of CIPs should be realized in a planned and purposeful way. (9) Establishment of a sleep-wake rhythm is the key to sleep management in post-CC management. (10) The spontaneous awakening trial, spontaneous breathing trial, and sleep management should be carried out together. (11) The depth of sedation should be adjusted dynamically in the late stage of CC period. (12) Standardized sedation assessment is the premise of rational sedation. (13) Appropriate sedative drugs should be selected according to the objectives of sedation and drug characteristics. (14) A goal-directed minimization strategy for sedation should be implemented. (15) The principle of analgesia must be mastered first. (16) Subjective assessment is preferred for analgesia assessment. (17) Opioid-based analgesic strategies should be selected step-by-step according to the characteristics of different drugs. (18) There must be rational use of non-opioid analgesics and non-drug-based analgesic measures. (19) Pay attention to evaluation of the psychological status of CIPs. (20) Cognitive function in CIPs cannot be ignored. (21) Delirium management should be based on non-drug-based measures and rational use of drugs. (22) Reset treatment can be considered for severe delirium. (23) Psychological assessment should be conducted as early as possible to screen-out high-risk groups with post-traumatic stress disorder. (24) Emotional support, flexible visiting, and environment management are important components of humanistic management in the intensive care unit (ICU). (25) Emotional support from medical teams and families should be promoted through"ICU diaries"and other forms. (26) Environmental management should be carried out by enriching environmental content, limiting environmental interference, and optimizing the environmental atmosphere. (27) Reasonable promotion of flexible visitation should be done on the basis of prevention of nosocomial infection. (28) ESCAPE is an excellent project for late stage of CC management.

Should prophylactic antiepileptic drugs be applied in severe traumatic brain injury? / 中国实用内科杂志

The patients with severe traumatic brain injury(sTBI)have a higher incidence of epilepsy.It's controversial whether prophylactic antiepileptic drugs(AEDs)are needed to prevent epilepsy in sTBI.Patients with sTBI do not need prophylactic AEDs on the basis of analgesic and sedative treatment in the early stage(within 7 days),and prophylactic AEDs are also not needed in late stage.Patients diagnosed with epilepsy need to take AEDs.

Surgical treatment of 247 cases of Chiari-I malformation complicated with syringomyelia / 中华外科杂志

<p><b>OBJECTIVE</b>To discuss the surgical treatment of chiari-I malformation complicated with syringomyelia.</p><p><b>METHODS</b>The surgical treatments of 247 cases were analyzed retrospectively. The indication of operation styles was proposed by various surgical treatment to different MRI (magnetic resonance imaging) findings. MRI findings includes: tonsillar herniation with no or slight syringomyelia (126 cases), tonsillar herniation with syringomyelia above C(2) (second cervical vertebrae) vertebral level (38 cases), serious tonsillar herniation (to C(2) approximately C(3) level) with syringomyelia of isolated spinal segments (67 cases), serious tonsillar herniation (to C(2) approximately C(3) level) with syringomyelia above C(2) vertebral level (16 cases). They were performed by posterior fossa decompression, posterior fossa decompression and incision of the syringomyelia, posterior fossa decompression and resection of the cerebellar tonsils, posterior fossa decompression and incision of the syringomyelia combined with resection of the cerebellar tonsils respectively.</p><p><b>RESULTS</b>The clinical signs and symptoms had been markedly improved or improved in 197 cases (79.8%) until patients were discharged from hospital, unchanged in 39 cases (15.8%), deteriorated in 7 cases (2.8%). there were 4 death in all cases after surgery. 107 cases were followed up from 5 months to 9 years. The postoperative MRI findings in the 107 patients demonstrated that the cavities in spinal cords disappeared completely or nearly in 78 cases, reduced in 14 cases, unchanged in 15 cases.</p><p><b>CONCLUSIONS</b>Posterior fossa decompression, posterior fossa decompression and incision of the syringomyelia, posterior fossa decompression and resection of the cerebellar tonsils, posterior fossa decompression and incision of the syringomyelia combined with resection of the cerebellar tonsils should be an effective method for treatment of chiari-I malformation complicated with syringomyelia. Surgical treatment may fully ameliorate the clinical syndromes.</p>