Intracranial Monitoring Device Research Articles

Safety and Feasibility of Out-of-Bed Mobilization for Patients With External Ventricular Drains in a Neurosurgical Intensive Care Unit

Introduction: Prolonged bed rest is a frequent problem for patients with critical illness that may negatively impact survival, quality of life, and medical care cost. Patients with critical neurologic problems are often kept on bed rest or only cleared to perform bed-based activities because of the inherent risk of displacing or damaging intracranial monitoring devices such as the external ventricular drains (EVDs) during activity. Specific recommendations for out-of-bed (OOB) mobilization of such patients are lacking. Purpose: To review the occurrence of adverse events related to OOB mobilization in patients with EVDs. Methods: This was a retrospective study. Data from all adult patients with an EVD and medical clearance for OOB physical therapy (PT) from October 2014 to November 2016 were analyzed. Results: Eighteen patients with EVDs received 108 interventions of OOB PT sessions during this period. No catheter-related mechanical complications occurred during or immediately following the sessions. No serious adverse events were recorded. Minor adverse events included transient dizziness, headache, episodes of hypertension, and hypotension. Vital signs showed no clinically relevant variations before and after the sessions. Conclusions: OOB mobilization was feasible and safe in this group of patients. The effect on morbidity and survival should be further investigated in a larger prospective study.

Complications of invasive intracranial pressure monitoring devices in neurocritical care.

Intracranial pressure monitoring devices have become the standard of care for the management of patients with pathologies associated with intracranial hypertension. Given the importance of invasive intracranial monitoring devices in the modern neurointensive care setting, gaining a thorough understanding of the potential complications related to device placement-and misplacement-is crucial. The increased prevalence of intracranial pressure monitoring as a management tool for neurosurgical patients has led to the publication of a plethora of papers regarding their indications and complications. The authors aim to provide a concise review of key contemporary articles in the literature concerning important complications with the hope of elucidating practices that improve outcomes for neurocritically ill patients.

Safety of Chemical DVT Prophylaxis in Severe Traumatic Brain Injury with Invasive Monitoring Devices

Patients with traumatic brain injuries (TBIs) have an increased risk of developing a deep vein thrombosis (DVT), but the risk of hemorrhage expansion with intracranial monitoring devices remains unknown. We sought to determine the safety of chemical DVT prophylaxis in severe TBI patients with invasive intracranial pressure monitors. We retrospectively reviewed all patients with severe TBI admitted to the neurosurgical intensive care unit of a large tertiary care center over a three-year period. 155 patients were included with an incidence of DVT of 12%. The median length of time to a stable head CT was 2days, and the median time to initiation of chemical DVT prophylaxis was 3.6days. The odds of DVT increased with intraparenchymal hemorrhage [OR 7.21, 95% CI (1.43-36.47), p=0.0169], non-White ethnicity [OR 7.86, 95% CI (1.23-50.35), p=0.0295], female gender [OR 13.93, 95% CI (2.47-78.73), p=0.0029], smoking [OR 4.32, 95% CI (1.07-17.51), p=0.0405], no anticoagulation [OR 25.39, 95% CI (4.26-151.48), p<0.001], and an IVC filter [OR 15.82, 95% CI (3.14-79.76), p<0.001]. Twenty-eight (18%) of these subjects experienced in-hospital mortality. The risk of in-hospital death was significantly increased among those who did not receive anticoagulation. This study found no association between DVT formation, hemorrhage expansion, or increased risk from invasive monitoring devices between various doses of unfractionated heparin (UH) and low-molecular-weight heparin (LMWH). We conclude that DVT prophylaxis with either LMWH or UH is safe with intracranial pressure monitors in place.

Placement of a subdural evacuating port system for management of iatrogenic hyperacute subdural hemorrhage following intracranial monitor placement

A 22-year-old man was admitted with a severe traumatic brain injury developed a hyperacute subdural hematoma (SDH) following attempted brain tissue oxygen monitor placement. This patient was successfully treated by placement of a subdural evacuation portal system (SEPS). The patient presented to a Level I trauma center after a severe bike versus auto accident. On admission, he was found to have a Glasgow Coma Scale (GCS) score of 3. The patient had small areas of intraparechymal hemorrhage as well as suspicion for diffuse axonal injury in the midbrain. Based on the patient’s GCS score, neurological monitoring was indicated as a part of his intensive care unit treatment, however a SDH occurred during an attempted placement of a brain tissue oxygen monitor. This iatrogenic hyperacute SDH after burr hole monitoring device placement was treated with a SEPS drain. The SEPS drain has been shown to provide complete and/or temporary decompression of liquefied SDH. To our knowledge, this is the first report of using the SEPS to treat iatrogenic SDH associated with an intracranial monitoring device. This technique should be added to the armament of treatment options for a neurosurgeon to treat or temporize a hyperacute SDH with increased intracranial pressure in specific patients.

83 Time Correlation of Optic Nerve Sheath Diameter to Increasing Intracranial Pressure in a Cadaveric Model

Ultrasound (US) evaluation of the optic nerve sheath width (diameter) has been shown to correlate with intracranial pressure. Normal optic nerve sheath diameter as measured 3 mm distal to the posterior globe is less than 5 mm. As intracranial pressure increases, the optic nerve sheath dilates. However, the speed at which the optic nerve sheath dilation occurs is unknown. Our objective was to determine the speed and the extent of dilation of the optic nerve sheath using a cadaveric model with increasing intracranial pressure. This was a prospective observational cadaveric trial comparing 2D US measurements of the optic nerve sheath to invasive intracranial monitoring of the intracranial space. Using an intracranial monitoring device, 5 ml of saline was instilled in the intracranial space while simultaneous measurements of the optic nerve sheath diameter were made using a SonoSite Micromaxx US system and a L38 (10 - 5 MHz) linear transducer. Measurements of the intracranial pressure were noted as changes from the baseline intracranial pressure. US measurements of the optic nerve sheath were taken in a single plane 3 mm distal to the posterior globe. US measurements were made every 5 minutes after fluid instillation until no further changes in the optic nerve sheath were detected. Three measurements of the optic nerve sheath were averaged for each measurement trial. The intracranial pressure increased immediately after fluid instillation into the intracranial space. However, as the fluid redistributed within the intracranial space, the pressure would decrease and would reach a steady-state baseline within the first 5 minutes. The optic nerve sheath diameter changed immediately with instillation of fluid into the intracranial space. There was little change in the optic nerve sheath diameter as the fluid redistributed within the intracranial space. However, the amount of change in the optic nerve sheath diameter was not proportional to the amount of fluid instilled into the intracranial space or to the intracranial space measurements. Figure 1 demonstrates the change in optic nerve sheath diameter and intracranial pressure values for 1 hour duration of the experiment. Although the change in optic nerve sheath dilation is simultaneous with intracranial pressure increase, the behavior of optic nerve sheath dilation (varies from 4.2 mm to 5.3 mm) is less dynamic than change in intracranial pressure levels (4 cm/H¬2O to 34 cm/ H¬2O). The change in the optic nerve sheath diameter is simultaneous with the increase in the intracranial pressure. However, the optic nerve sheath dilation is less dynamic compared to change in the intracranial pressure level.

Bedside transpyloric tube placement in the pediatric intensive care unit.

The purpose of this study was to demonstrate the feasibility of placing transpyloric feeding tubes at the bedside without fluoroscopy in critically ill pediatric patients. The patient population consisted of 90 patients (ages 1 week to 15 years, median age 9 months) admitted to a 26-bed pediatric intensive care unit in a university-affiliated pediatric hospital. Patient weights ranged from 2.4 to 100 kg with a median weight of 7.5 kg. Seventy-six patients were endotracheally intubated and mechanically ventilated; one patient had a tracheotomy. A total of 24 patients were pharmacologically paralyzed; 38 patients were receiving catecholamine infusions, and 17 patients had intracranial monitoring devices in place. All had concurrent nasogastric suctioning. Nonweighted Silicone Rubber 6F or 8F nasoenteric tubes were inserted at the bedside using metoclopramide, air insufflation and positioning to achieve transpyloric passage. Blue-dyed water was instilled in 58 patients to test for reflux and confirm transpyloric position. Successful nonfluoroscopic bedside transpyloric (duodenal or jejunal) tube placement was verified radiographically in 84 (93%) patients; seven of these patients were less than 4 weeks of age. One patient had blue dye in the nasogastric fluids, consistent with duodenogastric reflux or failure of transpyloric passage. The abdominal radiographs confirmed the results of the blue dye test in all 58 patients. There were six (6.7%) unsuccessful attempts at transpyloric bedside tube placement: four were a result of hemodynamic instability, one was a result of oropharyngeal trauma, and one was due to intestinal malrotation. The average time for placement was 15 minutes with a range of 5 to 45 minutes. No complications from tube placement were observed. Bedside placement of transpyloric feeding tubes is a safe and effective method to institute enteral feedings in critically ill pediatric patients.