Neurocritical Care最新文献

Introduction: Neuropalliative care is an emerging subspecialty of palliative care designed to address the unique supportive care needs of patients with serious neurological illness, including those receiving neurocritical care in intensive care units. Spiritual care is a vital component in the provision of holistic and humanized care to these patients. A chaplain who is specially trained and credentialed in care for those with serious illness is the health care professional responsible for making spiritual assessments and contributes to the plan of care, facilitating decision making, and guiding other clinicians in the provision of generalist spiritual care.

Methods: This article illustrates the role of chaplains in supporting neurocritical care patients and highlights two fundamental aspects of spiritual care: (1) spiritual screening/assessment and (2) assistance with goals-of-care conversations.

Results: These cases clarify the role of professionally trained and credentialed chaplains with experience in both neurocritical and palliative care and the value added to the interprofessional team.

Background: The Uniform Determination of Death Act requires brain death/death by neurologic criteria (BD/DNC) determination to be in accordance with "accepted medical standards." The medical organizations responsible for delineating these guidelines are only specified statutorily in two states. State health organizations (SHOs) are composed of policy experts and medical professionals who are responsible for addressing medical, ethical, and legislative problems related to health. We sought to evaluate information publicly available on SHO websites regarding BD/DNC.

Methods: From December 2023 to August 2024, we searched SHO (health department, medical board, medical society, and hospital association) websites for the 48 states without statutory guidance regarding what constitutes accepted medical standards for information regarding BD/DNC using the terms "brain death," "brain stem," and "determination of death." All posts related to BD/DNC were reviewed and categorized via thematic analysis.

Results: Of the 192 SHO websites searched, there were 35 from 28 states that provided information regarding BD/DNC: 14 medical societies, 12 health departments, 8 hospital associations, and 1 medical board. Of these 35 SHOs, 12 referenced the state's legal statute, 11 referenced hospital/state/model policies or guidance, 3 referenced both legal statutes and hospital/state/model policies or guidelines, 3 referenced explicit support for standardized BD/DNC guidelines, and 6 made other mention of BD/DNC. New York was the only state with an SHO that provided clear guidance regarding accepted medical standards for BD/DNC determination.

Conclusions: For most states, the accepted medical standards for BD/DNC determination are not identified on SHO websites or statutorily. This contributes to inconsistencies across hospital BD/DNC determination policies, leading to medical, ethical, and legal challenges. Delineation of the accepted medical standards for BD/DNC determination in each state could help facilitate consistency and accuracy in BD/DNC determination, prevent false positive determinations of death, and promote public trust in BD/DNC determination and the medical system overall.

Background: Acute ischemic lesions seen on brain magnetic resonance imaging (MRI) are associated with poor intracerebral hemorrhage (ICH) outcomes, but drivers for these lesions are unknown. Rapid hemoglobin decrements occur in the initial days after ICH and may impair brain oxygen delivery. We investigated whether acute hemoglobin decrements after ICH are associated with MRI ischemic lesions and poor long-term ICH outcomes.

Methods: Consecutive patients with acute spontaneous ICH enrolled into a single-center prospective cohort study were assessed. Change in hemoglobin levels from admission to brain MRI was defined as the exposure variable. The presence of MRI ischemic lesions on diffusion-weighted imaging was the primary radiographic outcome. Poor 6-month modified Rankin Scale score (4-6) was assessed as our clinical outcome. Separate regression models assessed relationships between exposure and outcomes adjusting for relevant confounders. These relationships were also assessed in a separate prospective single-center cohort of patients with ICH receiving minimally invasive hematoma evacuation.

Results: Of 190 patients analyzed in our primary cohort, the mean age was 66.7 years, the baseline hemoglobin level was 13.4 g/dL, and 32% had MRI ischemic lesions. Greater hemoglobin decrements were associated with MRI ischemic lesions (adjusted odds ratio [OR] 0.77 for every 1 g/dL change, 95% confidence interval [CI] 0.60-0.99) and with poor 6-month outcomes (adjusted OR 0.73, 95% CI 0.55-0.98) after adjusting for demographics, ICH and medical disease severity, and antithrombotic use. In our separate cohort of 172 surgical patients with ICH, greater hemoglobin concentration decrements similarly associated with MRI ischemic lesions (adjusted OR 0.74, 95% CI 0.56-0.97) and poor 6-month outcomes (adjusted OR 0.69, 95% CI 0.48-0.98).

Conclusions: Greater hemoglobin decrements after acute ICH are associated with ischemic lesions on brain MRI and poor long-term outcomes. Further work is required to clarify drivers for these relationships and whether anemia treatment and prevention can be used to improve ICH outcomes.

Background: This study aims to evaluate the safety of visual percutaneous tracheostomy (vPDT) in neurologic intensive care unit (NICU) patients who are under anticoagulant and antithrombotic therapy.

Methods: A retrospective cohort study was conducted on 54 NICU patients who underwent vPDT at Tai'an Central Hospital from September 2022 to September 2023. The cohort included 36 men and 18 women aged 36-90 years (mean age 62.24 ± 12.24 years). Patients were divided into two groups based on their treatment: an anticoagulant and antithrombotic group (22 patients) and a non-anticoagulant and non-antithrombotic group (32 patients). Clinical data, including demographic information, comorbidities, Glasgow Coma Scale (GCS) score before vPDT, time from NICU admission to vPDT, laboratory indicators, and vPDT complications, were analyzed.

Results: The incidence of vPDT complications in the anticoagulant and antithrombotic group was 18.2%, involving three cases of minor intraoperative bleeding and one case of posterior airway wall injury. The non-anticoagulant and non-antithrombotic group had an 18.8% complication rate, including four cases of minor intraoperative bleeding, one case of subcutaneous emphysema with local infection, and one unrelated death. No significant difference in vPDT complications was observed between the two groups (P > 0.05). However, the anticoagulant and antithrombotic group had a higher average age, higher GCS scores, and longer time intervals from NICU admission to vPDT and from intubation to vPDT (all P < 0.05).

Conclusion: vPDT appears to be a safe and feasible procedure for NICU patients receiving anticoagulant and antithrombotic therapy, with no significant increase in complications compared to those not on such therapies.

Background: Family caregivers of patients with severe acute brain injury (SABI) are at risk for clinically significant chronic emotional distress, including depression, anxiety, and posttraumatic stress. Existing psychosocial interventions for caregivers of intensive care unit (ICU) patients are not tailored to the unique needs of caregivers of patients with SABI, do not demonstrate long-term efficacy, and may increase caregiver burden. In this study, we explored the needs and preferences for psychosocial services among SABI caregivers to inform the development and adaptation of interventions to reduce their emotional distress during and after their relative's ICU admission.

Methods: In this multicenter longitudinal qualitative study, we conducted semistructed interviews with SABI caregivers at two time points: during their relative's ICU admission (n = 30) and 2 months later (n = 20). We analyzed qualitative data using a hybrid of inductive and deductive analytic techniques. We recruited family caregivers of patients with SABI from 14 US neuroscience ICUs. We conducted interviews over live video. Our convenience sample of SABI caregivers (n = 30) was recruited through referral by medical teams and nursing staffs across participating neuroscience ICUs. Caregivers included spouses, children, parents, and siblings to patients with SABI.

Results: We identified themes and subthemes related to participants' preferences for (1) the content of psychosocial support services and (2) the delivery and implementation of psychosocial support services. Findings revealed an unmet need for psychosocial support around the time of ICU discharge and 2 months later, including information to understand their loved one's condition and guide difficult decision-making, education regarding how best to communicate with the patient's care team and other family members, and emotional and behavioral coping skills.

Conclusions: Our findings provide specific recommendations to justify and inform the development and adaptation of psychosocial support services for SABI caregivers for delivery in the ICU and after discharge.

Background: Traumatic brain injury (TBI) is a significant cause of morbidity and mortality in the older adult population, and palliative care consultation can assist in goals-of-care discussions. However, patterns of hospital care delivered before consultation are understudied for older adult patients with TBI. The objective of this study was to identify demographic and clinical drivers of preconsultation care intensity in this population.

Methods: We retrospectively identified older adult (≥ 75 years) patients admitted at our institution who experienced a traumatic fall leading to TBI, neurosurgical consultation, and palliative care consultation. Therapy intensity level (TIL) scores were assigned from interventions administered before consultation. We constructed a multivariable linear regression model for associations with preconsultation TIL. Then, to evaluate associations between demographic and clinical drivers and preconsultation care intensity with consideration for the complex interplay between variables, we employed structural equation modeling in a separate model.

Results: A total of 122 patients were included (median age 85 years; 46% female). In the original multivariable model, patients who identified as Asian (β = 1.4; P = 0.04) or multiracial/other race (β = 2.9; P = 0.006) had higher preconsultation TIL scores. Increasing midline shift (MLS) was also associated with increased care intensity in this model (β = 0.20 per mm; P < 0.001). With structural equation modeling, demographic factors driving increased preconsultation care intensity included female sex (β = 0.110; P = 0.049) and Black (β = 0.118 per mm; P = 0.01) or multiracial/other (β = 0.201; P = 0.005) race, whereas clinical factors driving decreased care intensity were MLS (β = - 1.219 per mm; P < 0.001) and abnormal pupillary reactivity (β = - 0.425; P < 0.001).

Conclusions: Demographic factors such as sex and race were associated with differential prepalliative care consultation care intensity. Although MLS was associated with increased care intensity in the original multivariable model, when considering complex interactions between variables, greater injury severity drove decreased care intensity potentially due to perceptions of medical futility. These findings serve to inform discussions about disparities and clinical considerations surrounding palliative care for older adult patients with TBI.

Background:  Acute ischemic stroke with medium and large vessel occlusion is a leading cause of morbidity and mortality, in which timely intervention with mechanical thrombectomy (MT) is crucial for restoring cerebral blood flow and improving patient outcomes. Effective analgosedation and hemodynamic management during MT are critical to patient outcomes and typically managed by anesthesia. Because of inconsistent anesthesia support at our institution, we implemented a dedicated neurocritical care rapid response team (NCC-RRT) to manage these aspects of care. The primary outcome of our study was door-to-groin puncture time, before and after the implementation of the NCC-RRT. Secondary outcomes included door-to-recanalization time, patient disposition status, and the need for emergent anesthesia support.

Methods:  We conducted a prospective analysis of patients with acute ischemic stroke undergoing MT at a comprehensive stroke center between January 2021 and December 2023. The study compared two periods: era 1 (pre-NCC-RRT, January to October 2021) and era 2 (post-NCC-RRT, December 2021 to December 2023). We excluded inpatient stroke alerts and patients intubated at outside hospitals. The NCC-RRT was responsible for the expedited transfer, airway management, procedural analgosedation, and hemodynamic support.

Results:  A total of 373 patients were included in the study, with 86 patients in era 1 and 287 in era 2. The implementation of the NCC-RRT was associated with a statistically significant reduction in median DGP and door-to-recanalization times by 11.7% and 12.6%, respectively. NCC-RRT was also associated with a 21.4% increase in general anesthesia utilization, and no patients required emergent anesthesia support.

Conclusions:  The introduction of a dedicated NCC-RRT led to substantial improvements in MT process efficiency, highlighting the critical role of neurocritical care in optimizing stroke treatment and enhancing patient outcomes. This model offers an effective alternative for centers where dedicated neuroanesthesia teams are unavailable.

Background: Intracranial hemorrhage (ICH) is a devastating stroke subtype with a high rate of mortality and disability. Therapeutic options available are primarily limited to supportive care and blood pressure control, whereas the surgical approach remains controversial. In this study, we explored the effects of noninvasive vagus nerve stimulation (nVNS) on hematoma volume and outcome in a rat model of collagenase-induced ICH.

Methods: Adult male Wistar rats were randomized into two study groups: (1) ICH-treated (rats treated with five 2-min nVNS) and (2) ICH-control (ICH with sham nVNS). Each group received either a 0.1-U or a 0.2-U collagenase dose. After assessing neurological function, rats were euthanized at 24 h for spectrophotometric hemoglobin assay, hematoma volume measurements, and histological studies.

Results: The ICH-treated group that received the 0.1-U collagenase dose demonstrated significantly smaller hematoma volume and improved motor function compared with the ICH-control with the same dose. Furthermore, the pooled data for the ICH-treated groups (both 0.1 U and 0.2 U of collagenase) revealed a reduction in neuronal loss in the perihematomal region in the histopathological studies. This effect was not significant for the group that received a 0.2-Ucollagenase dose.

Conclusions: nVNS therapy in acute settings may provide a neuroprotective effect and limit hematoma expansion in smaller volumes, improving neurological function post-ICH.

Background: Ultrasonographic optic nerve sheath diameter (ONSD) is a satisfactory noninvasive intracranial pressure (ICP) monitoring test. Our aim was to evaluate ONSD as an objective screening tool to predict and diagnose ICP changes early in sepsis-associated encephalopathy (SAE).

Methods: Our prospective observational study was conducted on patients with sepsis, and after intensive care unit (ICU) admission, the time to diagnose SAE was recorded, and patients were divided into a non-SAE group including conscious patients with sepsis and a SAE group including patients with sepsis with acute onset of disturbed conscious level. ONSD was measured within 24 h of ICU admission for all patients and then every other day for up to 10 consecutive days until ICU discharge or death. The primary outcome was to compare ONSD measurements of both groups to find if there was a correlation between ONSD and SAE occurrence.

Results: Eighty-nine patients with sepsis were divided into a non-SAE group (n = 45) and an SAE group (n = 44). ONSD showed a statistically significant difference at day 0 and a highly significant difference at days 2, 4, 6, 8, and 10. Day 2 ONSD had the best accuracy for predicting SAE, with a cutoff > 5.2 mm (sensitivity of 93.2%, specificity of 100%), a statistically positive correlation with the Sequential Organ Failure Assessment score (r = 0.485, P < 0.001) and ICU length of stay (r = 0.238, P < 0.001), and a statistically significant wider in patients who died compared to those who survived (P < 0.001).

Conclusions: ONSD could be an objective screening method for early diagnosis of SAE, with a cutoff > 5.2 mm. Trial registration NCT05849831 ( https://clinicaltrials.gov/study/NCT05849831 ).