RESUMEN
The main goal at the acute phase of head injury is to prevent a decrease in blood pressure, which promotes cerebral ischemia. Volume loading is therefore frequently indicated. A normal or increased plasma osmolarity should be maintained. Thus hypotonic fluids should be avoided. Hyperglycaemia is also a risk factor for brain injury and glucose use has to be restricted in the first hours after trauma. Isotonic saline 0.9% is the first solution to be infused. Lactated Ringer solutions are mildly hypotonic as approximately 114 mL of free water is contained in each litre of the solution. Isotonic colloids are indicated to replace blood losses, but have no advantage over cristalloids, concerning the development of cerebral oedema. Fluid restriction minimally affects cerebral edema. Because of the severe consequences of hypovolaemia and hypotension, fluids should not be restricted until haemodynamic stability is achieved. Hypertonic fluids rapidly restore intravascular volume and decrease intracranial pressure. Although they probably have a place in prehospital intensive therapy, the demonstration of their benefit is still lacking. Monitoring of intravascular volume is essential. Continuous arterial pressure and central venous pressure monitoring are mandatory. New monitoring techniques as the measurement of systolic pressure variations or transoesophageal Doppler echocardiography will probably find a place in the management of trauma patients in the near future.
Asunto(s)
Lesiones Encefálicas/terapia , Traumatismos Craneocerebrales/terapia , Fluidoterapia , Lesiones Encefálicas/complicaciones , Lesiones Encefálicas/fisiopatología , Isquemia Encefálica/prevención & control , Traumatismos Craneocerebrales/complicaciones , Traumatismos Craneocerebrales/fisiopatología , HumanosRESUMEN
Simulation has become essential in all situations where reality was too risky, too expensive, difficult to manage or inaccessible. In anaesthesia, the low rate of accidents and incidents, as well as the necessity to assure patient's safety, limit education and training in crisis management. The progress in data processing allowed the development of realistic anaesthesia simulators, associating the usual environment of an operating room, and made possible the simulation of a wide range of events. Most clinical incidents, mishaps, or manipulation errors can be simulated. A video recording allows the focus of attention on human factors. We assessed simulators in three European University hospitals. In Brussels as in Leiden, simulation was mainly used for training in crisis management. In Basel, the complete operating room staff participated in sessions, including also surgical simulation and improvement of communication within the team was one of the main goals. Simulation is valuable for residents' training, as well as continuing medical education, in crisis management and a better understanding of human factors. It remains without risk for the patient, with video possibilities improving the repetition of selected cases. However, its use for evaluation seems to be premature, due to the absence of studies demonstrating the validity and reproducibility of the results gained with simulation. Beyond technical limits which are amended continuously, the development of simulation is hindered by the very high cost of equipment and instructors.