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Copy of neurosurgery

Copy of neurosurgery

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Published by Danielle

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Published by: Danielle on Feb 20, 2011
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hyperglycaemia has long been known to worsen the outcome following cerebral ischaemia
laboratory evidence indicates that even a mildly elevated plasma glucose may be deleterious
the assumption is that an increased supply of glucose leads to increased anaerobic metabolism
and lactate production
however, recent in vitro work suggests that an elevation of lactate per se does not lead to
neuronal damage and may actually ameliorate some of the effects of ischaemia
insulin has been shown to have a protective effect partially independent of a reduction in plasma
glucose, however, hypoglycaemia is equally as detrimental

NB: until the controversy regarding this is settled, glucose containing fluids are best
avoided and normoglycaemia should be maintained

all 3 of the commonly used volatiles increase CBF and ICP
although isoflurane is considered safe for neuroanaesthesia, early enthusiasm for its protective
effects have not been substantiated

the association between CMRO2 reduction and protection has been challenged upon these
grounds, see argument by Todd & Hanson to follow
others argue that all methods of CMR reduction also have deleterious effects, and the net result
is a combination of these superimposed upon the protective effect of CMR reduction (Cottrell)
ie., the benefit of CMR reduction remains constant, but the cost of achieving this varies with the
method used, ranging from mild hypothermia to irreversible neurotoxins

sevoflurane is similar in most respects to isoflurane, but may produce substantially smaller rises
in ICP and has shown some protective effect in vitro cf. fentanyl/N2O
desflurane substantially increases ICP in neurosurgical patients cf. isoflurane, despite
hyperventilation to a PaCO2 ~ 24-28 mmHg
from one isolated paper and requires validation, however in the interim desflurane is best avoided
nitrous oxide has been shown to,

elevate ICP in humans
ii.aggravate the potential for gas embolism
iii.negate the protective effects of the barbiturates in laboratory studies
iv.attenuate the beneficial effects of isoflurane relative to N2O alone
v.reduce recovery subsequent to anoxia in the hippocampal slice model

recent work has shown that the effects of N2O on ICP and metabolic stimulation are markedly
attenuated by the prior administration of thiopentone, or in the isoelectric brain

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