Neurocritical Care Unit Research Articles

Point-of-Care Ultrasound and Critical Care Ultrasound use Among Providers in Neurocritical Units: A National Survey.

Point-of-care ultrasound (POCUS)/critical care ultrasound (CCU) use in medical and surgical intensive care units has surged over the last few decades. It is unclear if this has similarly translated in neurocritical care (NCC) units. We designed a survey to describe the current state of POCUS/CCU use and training among NCC providers. An online 13-question survey was distributed nationally through newsletters and social media after endorsement by the Neurocritical Care Society. Participation was voluntary, and responses were anonymous. The survey queried respondent demographics, training, clinical use, confidence in POCUS/CCU, and barriers to POCUS/CCU use. Overall, 119 NCC providers responded to the survey. Most respondents were attending neurointensivists (52.1%) and had completed neurology residency training (62.2%). Approximately 23% of respondents did not have training in POCUS/CCU, and 71% of respondents had not completed POCUS/CCU board-certified training. Fifty-five percent of respondents used POCUS/CCU in their practice frequently, and 37% used it rarely on a weekly basis. Thirty-six percent and 42% of respondents felt moderately skilled at acquiring and interpreting POCUS/CCU images, respectively. Ultrasound guidance for procedures was the most common technique used by respondents. Most respondents felt that using ultrasound for volume status, procedural guidance, and evaluation of shock influenced clinical decision-making. Lack of confidence in interpreting data/imaging and comfort in performing POCUS/CCU were the most common barriers to ultrasound use. Respondents agreed with incorporation of POCUS/CCU training in NCC fellowship milestones and creating resources for credentialing providers in POCUS/CCU to increase use of POCUS/CCU in NCC. This national survey indicated that POCUS/CCU is moderately used among NCC providers. However, more formalized and robust training in POCUS/CCU is needed for trainees and practitioners in NCC to enhance comfortability with using ultrasound for clinical assessments.

Reducing Blood Loss From Phlebotomy in Adult Neurocritical Care Patients: An Evidence-Based Practice Project.

BACKGROUND: Blood loss from phlebotomy is a significant cause of hospital-acquired anemia. Use of small-volume (Pedi) tubes in adult patients reduces blood loss by 40% and does not increase need for repeated labs. Although this practice is evidencebased, it has not been widely implemented. Using Pedi tubes for phlebotomy is a key component of blood management programs to decrease the incidence of hospital-acquired anemia and blood transfusions in the intensive care unit (ICU). Our aim was to implement the use of Pedi tubes for labs in the adult neurocritical care unit to demonstrate feasibility in this population. METHODS: This was a pre-/postintervention quality improvement project. All consecutive patients admitted to the neurocritical care unit from April 10, 2023, to October 10, 2023, aged 18-99 years, were included in the project. During the intervention period from July 10, 2023, to October 10, 2023, Pedi tubes were used for all laboratory draws except admission and crisis labs. A retrospective chart review from April 10 to July 9, 2024, established standard practice for comparison. We recorded hospital and ICU admission, nadir, and discharge hemoglobin, length of stay, number of rejected specimens, number of blood transfusions, discharge disposition, and 30-day readmission for all subjects. RESULTS: Pedi tube use was successfully implemented with significantly less need for repeat laboratory collections in the postintervention cohort (P = .001). Although no difference was noted in hemoglobin levels, there was a decrease in both ICU and hospital length of stay by 1 day in the intervention arm. Fewer transfusions were required in the intervention cohort. CONCLUSIONS: Small-volume tube use for phlebotomy in adult neurocritical care patients is feasible and can lead to decreased blood transfusion need in the ICU.

Personalizing Prediction of High Opioid Use in the Neurointensive Care Unit: Development and Validation of a Stratified Risk Model for Acute Brain Injury Due to Stroke or Traumatic Brain Injury.

Background/Objectives: This study aimed to develop and validate a stratified risk model for predicting high opioid use in patients with acute brain injury due to stroke or traumatic brain injury (TBI) admitted to a neurocritical care intensive care unit. Methods: We examined the factors associated with the use of high-opioids (≥75th quartile, ≥17.5 oral morphine equivalent/ICU day) in a retrospective cohort study including patients with acute ischemic stroke, spontaneous intracerebral hemorrhage, spontaneous subarachnoid hemorrhage, and TBI. We then developed, trained, and validated a risk model to predict high-dose opioids. Results: Among 2490 patients aged 45-64 years (β = -0.25), aged 65-80 years (β = -0.97), and aged ≥80 years (β = -1.17), a history of anxiety/depression (β = 0.57), a history of illicit drug use (β = 0.79), admission diagnosis (β = 1.21), lowest Glasgow Coma Scale Score (GCSL) [GCSL 3-8 (β = -0.90], {GCS L 9-12 ((β = -0.34)], mechanical ventilation (β = 1.21), intracranial pressure monitoring (β = 0.69), craniotomy/craniectomy (β = 0.6), and paroxysmal sympathetic hyperactivity (β = 1.12) were found to be significant predictors of high-dose opioid use. When validated, the model demonstrated an area under the curve ranging from 0.72 to 0.82, accuracy ranging from 0.68 to 0.91, precision ranging from 0.71 to 0.94, recall ranging from 0.75 to 1, and F1 ranging from 0.74 to 0.95. Conclusions: A personalized stratified risk model may allow clinicians to predict the risk of high opioid use in patients with acute brain injury due to stroke or TBI. Findings need validation in multi-center cohorts.

Unsupervised Clustering in Neurocritical Care: A Systematic Review.

Managing patients with acute brain injury in the neurocritical care (NCC) unit has become increasingly complex because of technological advances and increasing information derived from multiple data sources. Diverse data streams necessitate innovative approaches for clinicians to understand interactions between recorded variables. Unsupervised clustering integrates different data streams and could be supportive. Here, we provide a systematic review on the use of unsupervised clustering using NCC data. The primary objective was to provide an overview of clustering applications in NCC studies. As a secondary objective, we discuss considerations for future NCC studies. Databases (Medline, Scopus, Web of Science) were searched for unsupervised clustering in acute brain injury studies including traumatic brain injury (TBI), subarachnoid hemorrhage, intracerebral hemorrhage, acute ischemic stroke, and hypoxic-ischemic brain injury published until March 13th 2024. We performed the systematic review in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. We identified 18 studies that used unsupervised clustering in NCC. Predominantly, studies focused on patients with TBI (12 of 18 studies). Multiple research questions used a variety of resource data, including demographics, clinical- and monitoring data, of which intracranial pressure was most oftenincluded (8 of 18 studies). Studies also covered various clustering methods, both traditional methods (e.g., k-means) and advanced methods, which are able to retain the temporal aspect. Finally, unsupervised clustering identified novel phenotypes for clinical outcomes in 9 of 12 studies. Unsupervised clustering can be used to phenotype NCC patients, especially patients with TBI, in diverse disease stages and identify clusters that may be used for prognostication. Despite the need for validation studies, this methodology could help to improve outcome prediction models, diagnostics, and understanding of pathophysiology.Registration number: PROSPERO: CRD4202347097676.

Treatment of patients with aneurysmal subarachnoid hemorrhage and multiple aneurysms: concurrent versus delayed treatment

Objective8 to 30% of patients who present with aneurysmal subarachnoid hemorrhage (aSAH) have multiple intracranial aneurysms (MIA). Although prompt treatment to secure ruptured aneurysms (RA) is standard of care, there is no clear consensus regarding whether incidental unruptured aneurysms (UA) should be treated during the same procedural time as the RA. This study aims to examine the effect of treatment of UA during the same procedural time as treatment for the RA (concurrent treatment) versus delaying the treatment of an UA after discharging the patient (delayed treatment). MethodsThis is a retrospective review of the medical records of patients with the diagnosis of aSAH and MIA admitted to a single neurocritical care unit between 2013 to 2021, and who underwent treatment of at least 1 aneurysm during the index hospitalization. Data was divided in 2 groups: concurrent treatment (2 or more aneurysms treated), and delayed treatment (1 aneurysm treated). Clinical and radiological data including demographic characteristics, modified Fisher Scale (mFS), treatment modality (clipping or endovascular), ventriculoperitoneal shunt (VPS) rates, surgical/procedural complications, delayed cerebral ischemia (DCI), length of stay (LOS), modified Rankin Score (mRS) and type of insurance of the patients during the hospitalization were collected. ResultsWe identified 109 patients with aSAH and MIA, who fit criteria. The median age was 58 (48-67) years old. 91 were female (83.5%). A total of 287 aneurysms were found, 109 were ruptured. 64 patients underwent treatment of a single aneurysm (delayed treatment group), and 45 patients underwent treatment of 2 or more aneurysms (concurrent treatment group). mFS were similar in both groups (p=.56). Clipping (52.3%) was the treatment modality most frequently used. No significant differences in surgical/procedural complications (p=.54) or VPS (p=.91) rates were seen among the 2 groups. No significant differences in delayed cerebral ischemia rates were seen (p=.85) There were no significant differences between the mRS at discharge (mRS 0-3v 4-6 (p=.78)), LOS in the ICU (12 vs 13 (p=.58) days) and LOS in the hospital (16 vs 14.5 (p=.95) days) between the delayed and concurrent treatment groups respectively. ConclusionsNo difference in functional status at discharge was observed between delayed treatment versus concurrent treatment. Treatment of most or all surgically amenable aneurysms, at the time when the RA is being treated, does not increase the risk of DCI or poor outcomes at discharge.

Development and Validation of a New Nomogram for Predicting Early Neurological Deterioration in Young and Middle-Aged Individuals With Stroke in the Neurocritical Care Unit.

To analyse risk factors for early neurological damage in young and middle-aged stroke cases. Totally 405 young and middle-aged stroke patients in the neurocritical care unit (NCU) were selected and divided into the developmental (260 patients) and validation (145 patients) sets. The 405 cases were also grouped based on whether early neurological deterioration (END) occurred. The influencing factors of END were analysed by logistic regression, followed by the construction of a nomogram for predicting the risk of END. The Bootstrap method was applied to internally verify the predictive value of the model, using validation set data. Age, type of stroke, diabetes, mechanical ventilation, pulse, initial National Institute of Health stroke scale (NIHSS), Barthel index (BI), haemoglobin, hypersensitive C-reactive protein (hs-CRP), triglyceride glucose (TyG) index and CONUT showed statistically significant differences (p < 0.05). Logistic regression analysis revealed type of stroke, initial NIHSS, CONUT, TyG index and hs-CRP were risk factors for END in young and middle-aged stroke cases (OR > 1, p < 0.05). The area under the curve (AUC) for the developmental set was 0.842, and internal validation results showed a C-index of 0.843; the AUC for the validation set was 0.843. The nomogram constructed in this study has good predictive efficacy and can provide reference for early clinical prediction of END in young and middle-aged stroke cases. The importance of this research lies in shedding light on the significant impact of early neurological deterioration on the health outcomes of young and middle-aged stroke patients, particularly in the short term. To guide clinical workers to identify risk factors early and improve the prognosis of stroke patients.

Clinical Outcomes Associated with the Implementation of a Dedicated Clinical Pharmacy Service in a Resource-Limited Neurocritical Intensive Care Unit.

Background: Patients in neurocritical care units are particularly vulnerable to medication errors and adverse drug events, necessitating specialized care and comprehensive pharmacological management. Despite this need, the scarcity of clinical pharmacist specialists in South Korean hospitals results in limited direct patient care within multidisciplinary teams. Objective: This study aimed to evaluate the impact of a dedicated pharmacy service program in the neurocritical care intensive care unit (neuro-ICU) on patient outcomes and to propose a clinical pharmacy service model tailored for resource-limited settings. Methods: We conducted a retrospective cohort study comparing neuro-ICU mortality rates and length of stay between periods with and without the presence of a dedicated neurocritical care pharmacist (d-NCP) from May 1, 2016, to December 31, 2017. The study also assessed the frequency and nature of pharmacy interventions alongside factors associated with patient outcomes. Results: The analysis included 769 patients in the group with d-NCP and 676 patients in the group without d-NCP. The presence of a d-NCP was associated with significantly shorter neuro-ICU stays (3.4 ± 8 days vs 3.5 ± 6.4 days, P = .012). Multivariate analysis indicated that the involvement of a d-NCP correlated with reduced length of neuro-ICU stay (β coefficient -0.077, 95% CI: -0.148 to -0.006, P = .033), whereas the number of prescribed medications was linked to longer stays (β coefficient 0.004, 95% CI: 0.014 to 0.005, P < .001). Conclusion: The implementation of a dedicated pharmacy service program in the neuro-ICU leads to improved patient outcomes and mitigates drug-related complications. This model offers a feasible and effective approach for enhancing care in hospitals with limited resources.

Trajectory of mean platelet volume changes after aneurysmal subarachnoid hemorrhage in patients with or without delayed cerebral ischemia

The morbidity of aneurysmal subarachnoid hemorrhage (aSAH) remains high, particularly because of secondary cerebral lesions that significantly aggravate the primary lesions. The main type of secondary lesions is delayed cerebral ischemia (DCI), in which platelets (PLT) appear to play a key role. Mean platelet volume (MPV) is an indirect marker of platelet activation. We aimed to determine the individual trajectories of MPV over time in patients with and without DCI during the course of aSAH. This is a single-center, retrospective, longitudinal analysis of individual trajectories of MPV over time, in a cohort of aSAH patients included in the Prospective, Observational Registry of Patient with Subarachnoid Hemorrhage in Neurocritical Care Unit (ProReSHA). A mixed-effects linear regression model was used to compare the trajectories of MPV and MPV/PLT ratio between patients who developed a DCI and those who did not. A total of 3634 MPV values were collected in 587 patients. The analysis of MPV as a function of DCI occurrence showed a significant difference in the trajectory over time between patients with DCI and those without, with an estimate of 0.02 (95%CI 0.01, 0.04, p = 0.009). The analysis of the MPV/PLT ratio as a function of DCI occurrence and other covariates showed a significant difference in the trajectory over time only for patients with a modified Fisher score less than 3, with an estimate of -0.59 (95%CI: -0.94, -0.23, p = 0.001). The individual trajectories of MPV over time differ between patients with DCI and those without. However, MPV values vary greatly over time and between patients. Thus it does not appear as a reliable biomarker for stratifying patients based on their specific risk of developing DCI. ClinicalTrials.gov identifier: (NCT02890004), registered in August 2016.

Analysis of selective neurocritical care admission costs following elective endovascular treatment of unruptured intracranial aneurysms.

No consensus exists on the necessity of neurocritical care unit (NCU)-level care following unruptured intracranial aneurysm (UIA) treatment. We aim to identify patients requiring NCU-level care post-treatment and determine potential cost savings utilizing a selective NCU admission protocol. A retrospective analysis of all UIA patients who underwent endovascular treatment at a single center from 2017-2022 was conducted. Data on demographics, preprocedural variables, radiographic features, procedural techniques, intra/postoperative events, and length of stay (LOS) were collected. Multivariable analysis was performed to identify patients requiring NCU-level care post-treatment. Cost analysis using hospital cost data (not charges/reimbursement) was performed using simulated step-down and floor protocols for patients without NCU indications following a hypothetical six-hour post-anesthesia care unit observation period. Of 209 patients, 179 were discharged within 24 h and 30 had prolonged LOS. In our analysis, intra- and postoperative events independently predicted prolonged LOS. In our subanalysis, 47 patients demonstrated NCU needs: 24 with intraoperative indications, 18 with postoperative indications, and five with both. Of the 23 with postoperative indications, 20 were identified within six hours, while three were identified within six to 24 h. The median variable cost per patient for the current NCU protocol was $31,505 (IQR, $26,331-$37,053) vs. stepdown protocol $29,514 (IQR, $24,746-$35,011;p = 0.061) vs. floor protocol $26,768 (IQR, $22,214-$34,107;p < 0.001). Total variable costs were $6,211,497 for the current NCU protocol vs. $5,921,912 for the step-down protocol (4.89% savings) and $5,509,052 for the floor protocol (12.75% savings). Most patients requiring NCU-level care following UIA treatment were identified within a six-hour postoperative window. Thus, selective NCU admission for this cohort following a six-hour observation period may be a logical avenue for cost reduction. Our analysis demonstrated 5% and 13% savings for uncomplicated patients using step-down and floor admission protocols, respectively.

Multidisciplinary Approach to Cardioembolic Stroke Due to Infectious Endocarditis in the Neurocritical Care Unit

Multidisciplinary Approach to Cardioembolic Stroke Due to Infectious Endocarditis in the Neurocritical Care Unit

Validating the Fluctuating Mental Status Evaluation in Neurocritically Ill Patients With Acute Stroke.

Neurocritically ill patients are at high risk for developing delirium, which can worsen the long-term outcomes of this vulnerable population. However, existing delirium assessment tools do not account for neurologic deficits that often interfere with conventional testing and are therefore unreliable in neurocritically ill patients. We aimed to determine the accuracy and predictive validity of the Fluctuating Mental Status Evaluation (FMSE), a novel delirium screening tool developed specifically for neurocritically ill patients. Prospective validation study. Neurocritical care unit at an academic medical center. One hundred thirty-nine neurocritically ill stroke patients (mean age, 63.9 [sd, 15.9], median National Institutes of Health Stroke Scale score 11 [interquartile range, 2-17]). None. Expert raters performed daily Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition-based delirium assessments, while paired FMSE assessments were performed by trained clinicians. We analyzed 717 total noncomatose days of paired assessments, of which 52% (n = 373) were rated by experts as days with delirium; 53% of subjects were delirious during one or more days. Compared with expert ratings, the overall accuracy of the FMSE was high (area under the curve [AUC], 0.85; 95% CI, 0.82-0.87). FMSE scores greater than or equal to 1 had 86% sensitivity and 74% specificity on a per-assessment basis, while scores greater than or equal to 2 had 70% sensitivity and 88% specificity. Accuracy remained high in patients with aphasia (FMSE ≥ 1: 82% sensitivity, 64% specificity; FMSE ≥ 2: 64% sensitivity, 84% specificity) and those with decreased arousal (FMSE ≥ 1: 87% sensitivity, 77% specificity; FMSE ≥ 2: 71% sensitivity, 90% specificity). Positive FMSE assessments also had excellent accuracy when predicting functional outcomes at discharge (AUC, 0.86 [95% CI, 0.79-0.93]) and 3 months (AUC, 0.85 [95% CI, 0.78-0.92]). In this validation study, we found that the FMSE was an accurate delirium screening tool in neurocritically ill stroke patients. FMSE scores greater than or equal to 1 indicate "possible" delirium and should be used when prioritizing sensitivity, whereas scores greater than or equal to 2 indicate "probable" delirium and should be used when prioritizing specificity.

Feasibility and Safety of Integrating Extended TCD Assessments in a Full Multimodal Neuromonitoring Protocol After Traumatic Brain Injury

Targeting single monitoring modalities such as intracranial pressure (ICP) or cerebral perfusion pressure alone has shown to be insufficient in improving outcome after traumatic brain injury (TBI). Multimodality monitoring (MMM) allows for a more complete description of brain function and for individualized management. Transcranial Doppler (TCD) represents the gold standard for continuous cerebral blood flow velocity assessment, but requires high levels skill and time. In TBI, the practical aspects of conducting extended TCD monitoring sessions have yet to be evaluated. Patients with acute moderate-to-severe TBI admitted to the neurocritical care unit between March 2022 and December 2023 receiving invasive ICP measurements were evaluated for inclusion. Exclusion criteria included trauma incompatible with TCD monitoring and if MMM was unwarranted. Daily MMM sessions (in addition to regular monitoring) were performed using TCD (Delica EMS 9D System or the DWL Doppler Box) for ≤5 d. Quantitative and qualitative feasibility, safety, and quality metrics were assessed. Of 74 patients, 36 (75% male; mean age, 44 ± 17 y) were included. Common reasons for exclusion were skull fractures (n = 12) and decompressive craniectomy (n = 9). We acquired 88 recordings (mean, 275 ± 88 min). Overall monitoring times increased, and set-up times decreased. Physiologic variables (including ICP/brain temperature) did not change with TCD application. A single adverse event (dislodging of a microdialysis catheter) occurred. Implementing extended TCD monitoring in MMM protocols is feasible and safe. Considering these results, inclusion of long-term TCD as part of the MMM is strongly encouraged to allow for in-depth description and direct evaluation of hemodynamic changes after TBI.

Smartphone pupillometry for detection of cerebral vasospasm after aneurysmal subarachnoid hemorrhage

ObjectivesVasospasm is a complication of aneurysmal subarachnoid hemorrhage (aSAH) that can change the trajectory of recovery and is associated with morbidity and mortality. Earlier detection of vasospasm could improve patient outcomes. Our objective is to evaluate the accuracy of smartphone-based quantitative pupillometry in the detection of radiographic vasospasm and delayed cerebral ischemia (DCI) after aSAH. Materials and MethodsWe prospectively collected pupillary light reflex (PLR) parameters from patients with aSAH admitted to a neurocritical care unit at a single hospital twice daily using quantitative smartphone pupillometry recordings. PLR parameters included: Maximum pupil diameter, minimum pupil diameter, percent change in pupil diameter, latency in beginning of pupil constriction to light, mean constriction velocity, maximum constriction velocity, and mean dilation velocity. Two-tailed t-tests for independent samples were performed to determine changes in average concurrent PLR parameter values between the following comparisons: (1) patients with and without radiographic vasospasm (defined by angiography with the need for endovascular intervention) and (2) patients with and without DCI. Results49 subjects with aSAH underwent 323 total PLR recordings. For PLR recordings taken with (n=35) and without (n=241) radiographic vasospasm, significant differences were observed in MIN (35.0 ± 7.5 pixels with vasospasm versus 31.6 ± 6.2 pixels without; p=0.002). For PLR recordings taken with (n=43) and without (n=241) DCI, significant differences were observed in MAX (48.9 ± 14.3 pixels with DCI versus 42.5 ± 9.2 pixels without; p<0.001). ConclusionsQuantitative smartphone pupillometry has the potential to be used to detect radiographic vasospasm and DCI after aSAH.

Delirium in Neurocritical Care: Uncovering Undisclosed Psychotropic Substance and Medication Use and Stress Exposure by Hair Analysis.

In intensive care, delirium is frequent, prolongs the stay, increases health care costs, and worsens patient outcome. Several substances and medications as well as stress can impact the risk of delirium; however, assessment of previous exposure to psychotropic agents and stress by self-reports or third-party information is not always reliable. Hair analysis can be used to objectively assess medication and substance use (including chronic alcohol consumption), and allows for the determination of stress-related long-term changes in steroid hormones and endocannabinoids. Consecutive adult patients with acute brain injury admitted to the neurocritical care unit were included. Delirium was diagnosed using the Confusion Assessment Method for the Intensive Care Unit. Liquid chromatography coupled with tandem mass spectrometry was used to investigate psychoactive substances and medications, ethyl glucuronide, steroid hormones, and endocannabinoids in hair samples. Univariable and multivariable analyses were used to reveal any associations with the occurrence of delirium. Of 50 consecutive patients, 21 (42%) were diagnosed with delirium. Detection of antipsychotics or antidepressants in hair was more frequent in patients with delirium (antidepressants: 43% vs. 14%, p = 0.040; antipsychotics: 29% vs. 0%, p = 0.021). These patients also displayed higher ethyl glucuronide levels (p = 0.049). Anandamide (AEA) concentrations were higher in patients with delirium (p = 0.005), whereas oleoylethanolamide (p = 0.045) and palmitoylethanolamide (PEA) (p = 0.017) concentrations were lower in patients with delirium. Backward stepwise logistic regression analysis revealed antidepressants and AEA/PEA to be independent relevant predictors of delirium. Hair analysis provides crucial and otherwise unattainable information regarding chronic stress and the use of psychotropic substances and medications. Undisclosed antidepressant/antipsychotic use or intense chronic alcohol consumption is susceptible to treatment (continuation of medication or provision of low-dose benzodiazepines in case of alcohol). Chronic stress can be evaluated using stress markers and endocannabinoids in hair, potentially allowing for personalized delirium risk stratification and preventive measures.

Neurological outcomes and mortality of hyperoxaemia in patients with acute brain injury: protocol for a systematic review and meta-analysis

IntroductionOxygen is frequently prescribed in neurocritical care units. Avoiding hypoxaemia is a key objective in patients with acute brain injury (ABI). However, several studies suggest that hyperoxaemia may also be...

Behavioral Assessment With the Coma Recovery Scale-Revised Is Safe and Feasible in Critically Ill Patients With Disorders of Consciousness.

Accurate classification of disorders of consciousness (DoC) is key in developing rehabilitation plans after brain injury. The Coma Recovery Scale-Revised (CRS-R) is a sensitive measure of consciousness validated in the rehabilitation phase of care. We tested the feasibility, safety, and impact of CRS-R-guided rehabilitation in the ICU for patients with DoC after acute hemorrhagic stroke. Retrospective cohort study. This single-center study was conducted in the neurocritical care unit at the University of Maryland Medical Center. We analyzed records from consecutive patients with subarachnoid hemorrhage (SAH) or intracerebral hemorrhage (ICH), who underwent serial CRS-R assessments during ICU admission from April 1, 2018, to December 31, 2021, where CRS-R less than 8 is vegetative state/unresponsive wakefulness syndrome (VS/UWS); CRS-R greater than or equal to 8 is a minimally conscious state (MCS). None. Outcomes included adverse events during CRS-R evaluations and associations between CRS-R and discharge disposition, therapy-based function, and mobility. We examined the utility of CRS-R compared with other therapist clinical assessment tools in predicting discharge disposition. Seventy-six patients (22 SAH, 54 ICH, median age = 59, 50% female) underwent 276 CRS-R sessions without adverse events. Discharge to acute rehabilitation occurred in 4.4% versus 41.9% of patients with a final CRS-R less than 8 and CRS-R greater than or equal to 8, respectively (odds ratio [OR] 13.4; 95% CI, 2.7-66.1; p < 0.001). Patients with MCS on final CRS-R completed more therapy sessions during hospitalization and had improved mobility and functional performance. Compared with other therapy assessment tools, the CRS-R had the best performance in predicting discharge disposition (area under the curve: 0.83; 95% CI, 0.72-0.94; p < 0.0001). Early neurorehabilitation guided by CRS-R appears to be feasible and safe in the ICU following hemorrhagic stroke complicated by DoC and may enhance access to inpatient rehabilitation, with the potential for lasting benefit on recovery. Further research is needed to assess generalizability and understand the impact on long-term outcomes.

Sustainability of a Pediatric Neurointensive Care Unit Model Within a Mixed Pediatric Intensive Care Unit and Its Effect on Nursing Sentiment.

BACKGROUND: Pediatric neurocritical care (PNCC) and pediatric neurointensive care units (neuro-PICU) are growing fields. Although some institutions have established independent neuro-PICUs meeting most Neurocritical Care Society (NCS) standards for neurocritical care units, many centers lack the resources to do so. We describe an alternative neuro-PICU model as a designated unit within a mixed pediatric intensive care unit (PICU) and its effects on nursing sentiment. METHODS: We established a 6-bed neuro-PICU within a 36-bed noncardiac PICU. Charge nurses were tasked with admitting PNCC patients into these beds. For nursing expertise, we used a core group of 12 PNCC specialty nurses and instituted PNCC nursing education to PICU nurses. We observed the number of PNCC patients admitted to neuro-PICU beds and surveyed charge nurses to identify barriers to assigning patients. We surveyed PICU nursing staff to explore sentiment regarding PNCC before and after establishing the neuro-PICU. Nursing criteria were compared with NCS standards. RESULTS: In the 40-month period, our PICU saw 2060 PNCC admissions. Overall, occupied neuro-PICU beds housed PNCC patients 74.1% of the time. The biggest barriers to patient placement were too many competing placement requests, not enough neuro-PICU beds when specialty census was high, and difficulty assigning one nurse to two PNCC patients. In surveys after establishing the neuro-PICU, compared to before, experienced nurses reported being more interested in obtaining Emergency Neurological Life Support certification (94.2% vs 80.6%, P = .0495), and inexperienced nurses reported being more familiar with PNCC clinical pathways (53.5% vs 31.7%, P = .0263). Most NCS criteria related to nursing organization were met. CONCLUSIONS: Focused neuro-PICUs should be developed to complement advances in the field of PNCC. Alternative neuro-PICU models are possible and can increase nursing interest in further education and awareness of clinical pathways, but barriers exist that require institutional commitment to nursing development to sustain the delivery of specialized care to this population.

Augmented renal clearance in neurocritical care patients: A retrospective cohort study

Background: Augmented renal clearance (ARC) in critical patients is concerning because it is associated with subtherapeutic antimicrobial or antiepileptic drug concentrations, increased length of stay, and possibly higher mortality. This study aimed to describe the characteristics between ARTIC score and estimated glomerular filtration rate (eGFR) in the neurocritical care population. Methods: A retrospective cohort study was conducted in the neurocritical care unit. Patients admitted to the neurocritical care unit between 2016 and 2018 with a stay longer than 48 h were retrospectively analyzed regarding the incidence, risk factors, and outcomes of ARC. Results: An ARTIC score of 6 or higher was present in 54.2% of patients, and 5.0% met the criteria for ARC due to eGFRCKD-EPI. The incidence of AKI was 23.5%. Polyuria was observed in 50.0% of patients, and hyponatremia and hypernatremia were observed in 16.9% and 40.9% of patients, respectively. Conclusion: ARC is a common phenomenon in the neurocritical care unit, especially in younger patients without cardiovascular comorbidities, and was associated with less acute kidney injury and less mortality.

Evaluation of the Use of Phenobarbital and Benzodiazepines in the Management of Alcohol Withdrawal Syndrome in Patients Requiring Neurological/Neurosurgical Critical Care: A Propensity-Matched Analysis.

Objective There is growing interest in the use of phenobarbital for alcohol withdrawal syndrome in critically ill patients, though experience in neurologically injured patients is limited. The purpose of this study was to compare the safety and effectiveness of phenobarbital-containing alcohol withdrawal regimens versus benzodiazepine monotherapy in the neurocritical care unit. Methods We conducted a retrospective cohort study of adult patients admitted to the neurocritical care unit from January 2014 through November 2021 who received pharmacologic treatment for alcohol withdrawal. Treatment groups were defined as benzodiazepine monotherapy versus phenobarbital alone or in combination with benzodiazepines. The primary outcome was the percentage of patients requiring intubation after receiving alcohol withdrawal treatment. Secondary outcomes included all-cause, in-hospital mortality, intensive care unit length of stay, discharge disposition, change in Glasgow Coma Scale (GCS) score, and the use of adjunctive agents. Results We analyzed data from 156 patients, with 77 (49%) in the benzodiazepine group and 79 (51%) in the phenobarbital combination group. The groups were well-balanced for baseline characteristics, though more males (67, 85%) were in the phenobarbital group. Only three (1.9%) patients received phenobarbital monotherapy, and the rest (153, 98.1%) received combination therapy. The percentage of patients requiring mechanical ventilation was significantly higher in the phenobarbital combination group compared to benzodiazepine monotherapy (39% (n=31) versus 13% (n=10); OR: 4.33, 95% CI: 1.94-9.66; p<0.001). The use of adjunctive propofol and dexmedetomidine was higher in the phenobarbital group (propofol 35% (n= 28) versus 9% (n=7) and dexmedetomidine 30% (n=24) versus 5% (n=4), respectively). Patients in the phenobarbital group also had lower GCS scores and higher Clinical Institute Withdrawal Assessment of Alcohol (CIWA-Ar) scores during their intensive care unit admission, possibly suggesting more severe alcohol withdrawal. There was no difference in intensive care unit length of stay, all-cause, in-hospital mortality, discharge disposition, or therapeutic adjuncts. Conclusions Combination therapy of phenobarbital plus benzodiazepines was associated with higher odds of requiring mechanical ventilation. Few patients received phenobarbital monotherapy. Additional studies are needed to better compare the effects of phenobarbital monotherapy versus benzodiazepines in neurocritical patients.

Low frequency oscillations reflect neurovascular coupling and disappear after cerebral death

Spectrum power analysis in the low frequency oscillations (LFO) region of functional near infrared spectroscopy (fNIRS) is a promising method to deliver information about brain activation and therefore might be used for prognostication in patients with disorders of consciousness in the neurocritical care unit alongside with established methods. In this study, we measure the cortical hemodynamic response measured by fNIRS in the LFO region following auditory and somatosensory stimulation in healthy subjects. The significant hemodynamic reaction in the contralateral hemisphere correlation with the physiologic electric response suggests neurovascular coupling. In addition, we investigate power spectrum changes in steady state measurements of cerebral death patients and healthy subjects in the LFO region, the frequency of the heartbeat and respiration. The spectral power within the LFO region was lower in the patients with cerebral death compared to the healthy subjects, whereas there were no differences in spectral power for physiological activities such as heartbeat and respiration rate. This finding indicates the cerebral origin of our low frequency measurements. Therefore, LFO measurements are a potential method to detect brain activation in patients with disorders of consciousness and cerebral death. However, further studies in patients are needed to investigate its potential clinical use.