Patients In Neurocritical Care Unit Research Articles

A supervised, externally validated machine learning model for artifact and drainage detection in high-resolution intracranial pressure monitoring data.

In neurocritical care, data from multiple biosensors are continuously measured, but only sporadically acknowledged by the attending physicians. In contrast, machine learning (ML) tools can analyze large amounts of data continuously, taking advantage of underlying information. However, the performance of such ML-based solutions is limited by different factors, for example, by patient motion, manipulation, or, as in the case of external ventricular drains (EVDs), the drainage of CSF to control intracranial pressure (ICP). The authors aimed to develop an ML-based algorithm that automatically classifies normal signals, artifacts, and drainages in high-resolution ICP monitoring data from EVDs, making the data suitable for real-time artifact removal and for future ML applications. In their 2-center retrospective cohort study, the authors used labeled ICP data from 40 patients in the first neurocritical care unit (University Hospital Zurich) for model development. The authors created 94 descriptive features that were used to train the model. They compared histogram-based gradient boosting with extremely randomized trees after building pipelines with principal component analysis, hyperparameter optimization via grid search, and sequential feature selection. Performance was measured with nested 5-fold cross-validation and multiclass area under the receiver operating characteristic curve (AUROC). Data from 20 patients in a second, independent neurocritical care unit (Charité - Universitätsmedizin Berlin) were used for external validation with bootstrapping technique and AUROC. In cross-validation, the best-performing model achieved a mean AUROC of 0.945 (95% CI 0.92-0.969) on the development dataset. On the external validation dataset, the model performed with a mean AUROC of 0.928 (95% CI 0.908-0.946) in 100 bootstrapping validation cycles to classify normal signals, artifacts, and drainages. Here, the authors developed a well-performing supervised model with external validation that can detect normal signals, artifacts, and drainages in ICP signals from patients in neurocritical care units. For future analyses, this is a powerful tool to discard artifacts or to detect drainage events in ICP monitoring signals.

Limitation of life sustaining measures in neurocritical care: sex, timing, and advance directive

BackgroundThe limitation of life sustaining treatments (LLST) causes ethical dilemmas even in patients faced with poor prognosis, which applies to many patients admitted to a Neurocritical Care Unit (NCCU). The effects of social and cultural aspects on LLST in an NCCU population remain poorly studied.MethodsAll NCCU patients between 01.2018 and 08.2021 were included. Medical records were reviewed for: demographics, diagnosis, severity of disease, and outcome. Advance directives (AD) and LLST discussions were reviewed evaluating timing, degree, and reason for LLST. Social/cultural factors (nationality, language spoken, religion, marital status, relationship to/sex of legal representative) were noted. Associations between these factors and the patients’ sex, LLST timing, and presence of AD were evaluated.ResultsOut of 2975 patients, 12% of men and 10.5% of women underwent LLST (p = 0.30). Women, compared to men, more commonly received withdrawal instead of withholding of life sustaining treatments (57.5 vs. 45.1%, p = 0.028) despite comparable disease severity. Women receiving LLST were older (73 ± 11.7 vs. 69 ± 14.9 years, p = 0.005) and often without a partner (43.8 vs. 25.8%, p = 0.001) compared to men. AD were associated with female sex and early LLST, but not with an increased in-hospital mortality (57.1 vs. 75.2% of patients with and without AD respectively).ConclusionsIn patients receiving LLST, the presence of an AD was associated with an increase of early LLST, but not with an increased in-hospital mortality. This supports the notion that the presence of an AD is primarily an expression of the patients’ will but does not per se predestine the patient for an unfavorable outcome.

Effect of Swallowing Exercises on Improving Dysphagia among Stroke Patients in Neurocritical Care Unit

Effect of Swallowing Exercises on Improving Dysphagia among Stroke Patients in Neurocritical Care Unit

Plasma Inflammatory Markers and Ventriculostomy-Related Infection in Patients With Hemorrhagic Stroke: A Retrospective and Descriptive Study.

BackgroundDiagnosis of ventriculostomy-related infection (VRI) remains difficult due to the various existing definitions. In patients with hemorrhagic stroke, its diagnosis might be further complicated by the presence of intraventricular blood. Furthermore, hemorrhagic stroke per se may cause symptoms compatible with VRI. This study aimed to evaluate the benefit of plasma inflammatory markers for the diagnosis of VRI and its differentiation from patients with non-cerebral infection and patients without infection in a cohort of patients with hemorrhagic stroke.MethodsA total of 329 patients with hemorrhagic stroke and an external ventricular drain (EVD) in situ were admitted to the Neurocritical Care Unit, University Hospital Zurich over a period of 6 years. Of those patients, 187 with subarachnoid hemorrhage and 76 with spontaneous intracerebral hemorrhage were included. Patients with VRI were compared to patients without any infection and to patients with non-cerebral infection, with regards to their clinical characteristics, as well as their inflammatory plasma and cerebrospinal fluid (CSF) markers. For the analysis, peak values were considered.ResultsThe VRI was diagnosed in 36% of patients with subarachnoid and in 17% of patients with intracerebral hemorrhage. The VRI was diagnosed on an average day 9±6.2 after EVD insertion, one day after the white blood cell count (WBC) peaked in CSF (8 ± 6.3). Plasma inflammatory markers (WBC, C-reactive protein “CRP” and procalcitonin “PCT”) did not differ among patients with VRI compared to patients without infection. The CRP and PCT, however, were higher in patients with non-cerebral infection than in patients with VRI. The WBC in CSF was generally higher in patients with VRI compared to both patients without any infection and patients with non-cerebral infection.ConclusionsNo differences in plasma inflammatory markers could be found between patients with VRI and patients without any infection. Conversely, CRP/PCT were higher in patients with non-cerebral infection than in patients with VRI. Altogether, CRP, PCT, and WBC are not suitable parameters for VRI diagnosis in neurocritical care unit patients.

Noninvasive Optical Measurements of Dynamic Cerebral Autoregulation by Inducing Oscillatory Cerebral Hemodynamics.

Objective: Cerebral autoregulation limits the variability of cerebral blood flow (CBF) in the presence of systemic arterial blood pressure (ABP) changes. Monitoring cerebral autoregulation is important in the Neurocritical Care Unit (NCCU) to assess cerebral health. Here, our goal is to identify optimal frequency-domain near-infrared spectroscopy (FD-NIRS) parameters and apply a hemodynamic model of coherent hemodynamics spectroscopy (CHS) to assess cerebral autoregulation in healthy adult subjects and NCCU patients.Methods: In five healthy subjects and three NCCU patients, ABP oscillations at a frequency around 0.065 Hz were induced by cyclic inflation-deflation of pneumatic thigh cuffs. Transfer function analysis based on wavelet transform was performed to measure dynamic relationships between ABP and oscillations in oxy- (O), deoxy- (D), and total- (T) hemoglobin concentrations measured with different FD-NIRS methods. In healthy subjects, we also obtained the dynamic CBF-ABP relationship by using FD-NIRS measurements and the CHS model. In healthy subjects, an interval of hypercapnia was performed to induce cerebral autoregulation impairment. In NCCU patients, the optical measurements of autoregulation were linked to individual clinical diagnoses.Results: In healthy subjects, hypercapnia leads to a more negative phase difference of both O and D oscillations vs. ABP oscillations, which are consistent across different FD-NIRS methods and are highly correlated with a more negative phase difference CBF vs. ABP. In the NCCU, a less negative phase difference of D vs. ABP was observed in one patient as compared to two others, indicating a better autoregulation in that patient.Conclusions: Non-invasive optical measurements of induced phase difference between D and ABP show the strongest sensitivity to cerebral autoregulation. The results from healthy subjects also show that the CHS model, in combination with FD-NIRS, can be applied to measure the CBF-ABP dynamics for a better direct measurement of cerebral autoregulation.

Physiological Responses to In-Bed Cycle Ergometry Treatment in Intensive Care Unit Patients with External Ventricular Drainage.

PurposeEvidence suggests that early physical activity can be accomplished safely in the neurocritical care unit (NCCU); however, many NCCU patients are often maintained in a state of inactivity due to impaired consciousness, sensorimotor deficits, and concerns for intracranial pressure elevation or cerebral hypoperfusion in the setting of autoregulatory failure. Structured in-bed mobility interventions have been proposed to prevent sequelae of complete immobility in such patients, yet the feasibility and safety of these interventions is unknown. We studied neurological and hemodynamic changes before and after cycle ergometry (CE) in a subset of NCCU patients with external ventricular drains (EVDs).MethodsPatients admitted to the NCCU who had an EVD placed for cerebrospinal fluid drainage and intracranial pressure (ICP) monitoring underwent supine CE therapy with passive and active cycling settings. Neurologic status, ICP and hemodynamic parameters were monitored before and after each CE session.ResultsTwenty-seven patients successfully underwent in-bed CE in the NCCU. No clinically significant changes were recorded in neurologic or in physiological parameters before or after CE. There were no device dislodgements or other adverse effects requiring cessation of a CE session.ConclusionThese data suggest that supine CE in a heterogeneous cohort of neurocritical care patients with EVDs is safe and tolerable. Larger prospective studies are needed to determine the efficacy and optimal dose and timing of supine CE in neurocritical care patients.

Implementation of Diagnostic Stewardship Algorithms by Bedside Nurses to Improve Culturing Practices: Factors Associated With Success

Background: Bedside nurses have been recognized as potential antibiotic stewards; however, data on effective ways that nurses can contribute to stewardship activities in acute-care hospitals are scarce. Methods: A nurse-driven urine culture intervention to improve urine culture ordering practices was implemented in a medicine and a neurocritical care unit (NCCU) at The Johns Hopkins Hospital. Bedside nurses implemented an algorithm (Fig. 1) developed by the antibiotic stewardship program (ASP) to review the appropriateness of urine culture and to guide discussions with ordering providers regarding unnecessary urine cultures. Nurses received in-person training by an ASP physician champion on how to use the algorithm and education on the definition and indications for evaluation for asymptomatic bacteriuria and urinary tract infections. The ASP physician periodically visited the units to address concerns and questions. In both units, a nurse champion was identified to serve as liaison between the ASP and bedside nurses, and physician support was obtained before the intervention. The pre- and postintervention periods for the medicine unit were September 2017–August 2018 and September 2018–August 2019, respectively. For the NCCU, these periods were September 2018–February 2019 and March 2019–September 2019, respectively. Trends in urine cultures per 100 patient days (PD) were examined with statistical process charts and compared before and after the intervention using a standard incident ratio (IRR) and Poisson regression. Results: In total, 327 urine cultures were collected in the medicine unit and 293 in the NCCU over the study period. Although the intervention led to a significant 34% reduction in the rate of urine cultures on the medicine unit (from 2.3 to 1.5 cultures/100 PD; IRR, 0.66; 95% CI, 0.50–0.87; P < .01), the number of urine cultures remained without a significant change in the NCCU (from 4.5 to 3.7 cultures/100 PD; IRR, 0.89; 95% CI, 0.65–1.22; P = .48) (Fig. 2). Conclusions: Algorithm-based, nurse-driven review of urine culture indications reduced urine cultures on a medicine unit but not in a neurosciences ICU. Success on the medicine unit may have been driven by highly engaged nurse and physician champions and by patients being able to respond questions about symptoms. The following factors might have impacted results on NCCU: presence of conflicting protocols (eg, panculturing patients every 48 hours per a hypothermia protocol), unit tradition (eg, obtaining cultures to assess treatment response), perception of greater risk benefit in NCCU patients, and unit dynamics (open unit with other primary services placing orders for patients). Unit and team dynamics can affect effective implementation of antimicrobial stewardship interventions by nurses.Funding: NoneDisclosures: None

14-Day Continuous Glucose Level and Mortality in Aneurysm SAH: A Retrospective Study in Neurocritical Care Unit

Background: Aneurysm subarachnoid hemorrhage (aSAH) is a life-threatened disease. Stress responded hyperglycemia following aSAH was one of most important predictors that was associated with poor outcomes and higher mortality of patients critically suffered from aSAH. Thus, optimal glucose management strategy could improve outcomes of aSAH patients in Neurocritical Care Unit (NCU). However, it’s still lacks of evidence on glucose level which is beneficial for severe aSAH patients. Recently, glucose variability (GV) was not only used to predict clinical outcomes and mortality, but also used as a more appropriated clinical target than blood glucose range only to manage glucose level. Our study aimed to find a relatively suitable glucose control for aSAH patients in NCU. Method: 332 patients were recruited from a retrospectively collected database of all patients with aneurysm SAH (aSAH) who were admitted to Tiantan Hospital in Beijing, China between January 2015 and December 2017. We collected continuous 14-day blood glucose and calculated glucose variability. Continuous 14-day blood glucose level were divided into four groups: stable, unstable, well-controlled, bad-controlled. Other predictor variables also included admission Hunt and Hess grade, age, gender, cardiovascular risk factors, and surgical treatment. In-patient mortality was the main outcome measure. Results: Univariate survival analysis showed that the stable and well-controlled groups have higher percentage of cumulative survival than the rest two groups. Then, Multivariate COX regression analysis showed that Hunt Hess scale (HR 2.666, 95% CI, 1.438-4.944), receiving Surgery (HR 0.073, 95% CI, 0.025-0.219), having hydrocephalus (HR 3.844, 95% CI, 1.038-14.228), bleeding in cisterna ambiens (HR 8.288, 95% CI, 2.270-30.259),bad-controlled glucose (HR 5.788, 95% CI, 1.441-23.237) and unstable glucose (HR 15.403, 95% CI, 2.666-88.987). Conclusions: GV is helpful to predict aSAH mortality, either long-term or short-term. Glucose fluctuated between 7 and 10 mmol/L is associated with better 14-day clinical outcomes for critically ill aSAH patients in NCU. Funding Statement: None. Declaration of Interests: The authors declare that they have no conflict of interest. Ethics Approval Statement: This retrospective study was approved by the Ethics Committee at the Tiantan Hospital in Beijing, in accordance with the Declaration of Helsinki; patient informed consent was not required because of the anonymous nature of the data.

Fever in the Neurointensive Care Unit

AbstractFever occurs commonly in patients admitted to the neurocritical care unit. An increase in the body temperature is known to have deleterious effects on patients with acute nervous system injury and in most cases is associated with an increase in mortality and morbidity of these patients. There are multiple causes of fever in these patients. Due to the potentially devastating effects of fever in patients with cerebral diseases, it warrants treatment in every case. In all patients with acute cerebral damage, treatment of fever and maintenance of euthermia is important to obtain a better functional recovery and to limit any further secondary insult to the brain. This review highlights the etiology and pathophysiology of fever in neurocritical care unit patients, the effects on various organ systems and associated systemic complications, and the evaluation and different therapeutic options available for the management of fever in this patient subset.

Better ICU Management by Analysis of Clinical Profile and Outcomes of Neuro-Critical Patients in Neurocritical Care Unit

Background: Nowadays, it has been suggested that the care of neurocritically ill patients in the Neurocritical Care Unit can outcome, hospitalization time and ICU stay. Therefore, the aim of this study was to evaluate the clinical condition and outcomes of these patients in our setting. Methods: We conducted a cross-sectional study in patients in the neurocritical care unit (NCCU) of Loghman Hakim hospital. The medical findings and outcome (discharge/death) were gathered in the data collection form. We used SPSS version 18 for statistical analysis with significant level < 0.05. Results: A total of 432 patients, including 237 (56.2%) male and 185 (43.8%) female (P = 0.01) were enrolled. There was statistically no significant difference in the mean age between them (41.87 ± 18.52, 45.15 ± 16.26 respectively, P = 0.05). The most common admission diagnosis of patients was neuro-oncology (65.5%). The prolong length of stay (LOS) in NCCU (≥ 10) was found in 56 (13.5%). The highest rate of it was due to the neuro-oncology disease. There are statistically significant differences among the diagnosis groups in terms of age, LOS, and Charlson Comorbidity index (P = 0.002, P < 0.001, respectively). The mortality rate of patients was 11.6%, which neuro-oncology had the most frequency. Conclusions: The outcome of neuro-critical ill patients and length of stay in ICU can improve using special care and facilities in the neurocritical care unit. According to our results, most of our patients had neuro-oncology disease, which makes it necessary to expand the treatment interventions and various specialties in care of NCCU.

Empirical Combination Antibiotic Therapy Improves the Outcome of Nosocomial Meningitis or Ventriculitis in Neuro-Critical Care Unit Patients

Nosocomial meningitis and ventriculitis (MEN) are serious complications in neuro-critical care unit (NCCU) patients. Few data are available on the risk factors and mortality rates among NCCU patients with these disorders caused by multi-drug-resistant (MDR) pathogens. Our aim was to identify the risk factors for MEN caused by such pathogens and in-hospital deaths in critically ill neurologic patients and to evaluate the impact of empirical combination antibiotic therapy (ECAT) on the outcomes of these patients. We conducted a retrospective study of critically ill neurologic patients having nosocomial MEN who were admitted to the NCCU in a university teaching hospital from January 2003 to December 2013, with MEN being defined using the modified U.S. Centers for Disease Control and Prevention criteria for nosocomial infections. In total, 6,149 consecutive NCCU patients were screened; 132 had MEN. Logistic regression analysis demonstrated that MDR MEN was related to infection with gram-negative (GN) bacteria (odds ratio 3.16; 95% confidence interval [CI] 1.08-9.25; p = 0.036), and inadequate initial antibiotic therapy (odds ratio 9.80; 95% CI 3.79-25.32; p < 0.001). The ECAT was associated with a lower mortality rate (hazard ratio 0.35; 95% CI 0.14-0.86; p = 0.022) in Cox proportional hazard regression analysis. The other variable independently associated with a greater mortality rate was a greater Simplified Acute Physiology Score II (hazard ratio 1.07; 95% CI 1.01-1.13; p = 0.018). Initial combination therapy improves the in-hospital mortality rate among NCCU patients with nosocomial MEN. Inadequate initial antibiotic therapy and GN infection were associated with MDR MEN.

Clostridium difficile-Associated Disease Acquired in the Neurocritical Care Unit

Clostridium difficile is an important cause of nosocomial infection on the intensive care unit. Little is known about infection rates on the neurocritical care unit (NICU). The purpose of this study was to determine the prevalence, severity, and outcome associated with Clostridium difficile-associated disease (CDAD) acquired on the NICU. Patients on NICU with a positive stool Clostridium difficile toxin assay, from August 2004 to February 2008, were identified by the Department of Microbiology. Each patient's medical notes and charts were reviewed in turn. Patients with a positive assay within 48 h of NICU admission were excluded. Twenty-one (0.6%) NICU patients developed CDAD. All were emergency admissions, 18 (86.0%) were neurosurgical. Subarachnoid hemorrhage was the most common diagnosis, 5 (23.8%) patients. Median age and APACHE II score on admission were 55 (IQR 40-66) and 21 (IQR 16-24), respectively. Thirteen (61.9%) patients were female. Median interval between NICU admission and diarrhea onset and CDAD diagnosis were 5 (3-8) days and 7 (4-12) days, respectively. At the time of diagnosis most, 11 (52.4%) patients, had moderate CDAD. Previously identified risk factors for ICU-acquired CDAD comprised: age > 65 (6), antibiotics (21), and medical device requirements (21). Five (23.8%) patients deteriorated clinically as a result of CDAD. The overall in-hospital mortality for those with NICU acquired CDAD was 19%. Although CDAD is rarely acquired on the NICU, up to one quarter of affected patients may experience complications. Prospective validation of severity definitions and treatment guidelines may help to reduce the complication rates.