Neurointensive Patients Research Articles

Amantadine for NeuroenhaNcement in acutE patients Study - a protocol for a prospective pilot proof of concept phase IIb study in intensive and intermediate care unit patients (ANNES)

BackgroundPersisting coma is a common complication in (neuro)intensive care in neurological disease such as acute ischemic stroke, intracerebral hemorrhage or subarachnoid hemorrhage. Amantadine acts as a nicotinic receptor antagonist, dopamine receptor agonist and non-competitive N-Methyl-D-aspartate receptor antagonist. Amantadine is a long-known drug, originally approved for treatment of influenza A and Parkinson`s Disease. It has been proven effective in improving vigilance after traumatic brain injury. The underlying mechanisms remain largely unknown, albeit anti-glutamatergic and dopaminergic effects might be most relevant. With limited evidence of amantadine efficacy in non-traumatic pathologies, the aim of our study is to assess the effects of amantadine for neuroenhancement in non-traumatic neurointensive patients with persisting coma.MethodsAn investigator-initiated, monocenter, phase IIb proof of concept open-label pilot study will be carried out. Based on the Simon design, 43 adult (neuro)intensive care patients who meet the clinical criteria of persisting coma not otherwise explained and < 8 points on the Glasgow Coma Scale (GCS) will be recruited. Amantadine will be administered intravenously for five days at a dosage of 100 mg bid. The primary endpoint is an improvement of at least 3 points on the GCS. If participants present as non-responders (increase < 3 points or decrease on the GCS) within the first 48 h, the dosage will be doubled from day three to five. Secondary objectives aim to demonstrate that amantadine improves vigilance via alternative scales. Furthermore, the incidence of adverse events will be investigated and electroencephalography (EEG) will be recorded at baseline and end of treatment.DiscussionThe results of our study will help to systematically assess the clinical utility of amantadine for treatment of persisting coma in non-traumatic brain injury. We expect that, in the face of only moderate treatment risk, a relevant number of patients will benefit from amantadine medication by improved vigilance (GCS increase of at least 3 points) finally leading to a better rehabilitation potential and improved functional neurological outcome. Further, the EEG data will allow evaluation of brain network states in relation to vigilance and potentially outcome prediction in this study cohort.Trial RegistrationNCT05479032.

Proposal and Efficacy of a Nurse-Led Pain Management Model for Neurointensive Care Based on the Precede-Proceed Model.

Objective This study's objective is to establish a nurse-led pain management model for neurointensive care based on the Precede-Proceed model to provide a theoretical basis for clinical pain management in neurointensive care. Methods. ICU nurses were randomly divided into a control group (giving conventional routine pain care) and an experimental group (managed pain based on the Precede-Proceed model). The nurses from the experimental group were trained in the Precede-Proceed-based management. The nurses then treated a total of 410 critically ill patients, and the patients were randomly divided into a control and an intervention group (205 cases/nursing group), and the data were prospectively recorded. Before and after the intervention, the pain assessment ability, discomfort level, satisfaction degree, usage of the analgesic drug, and the incidence of delirium of the patients from the two groups were evaluated. Nurses from both groups also assessed their knowledge of pain, attitude, and pain nursing behaviors using indicated self-designed questionnaires. Results Before the intervention, there was no statistical difference between the two groups of nurses in their baseline characteristics, pain knowledge, attitude, pain nursing behavior, and pain assessment ability for the patients. After the intervention, the nurses in the experimental group had better pain knowledge, attitude, pain nursing behavior, and pain assessment ability to patients than the nurses in the control group. Patients in the intervention group felt less discomfort, a higher satisfaction degree, reduced use of analgesics, and a lower incidence of delirium than patients in the control group. Conclusion. Pain management based on the Precede-Proceed model was beneficial in improving the care of neurointensive patients.

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Introduction: The delivery of enteral nutrition (EN) is often late and insufficient despite evidence that early and adequate enteral feeding reduces mortality, decreases the risks of gut atrophy, systemic infections, prolonged intubation and ICU stay, and may improve neurologic outcomes in head-injured patients. A review of case records of 83 intubated Neuro-ICU patients admitted to our institution TTSH, National Healthcare Group, Singapore, from July to December 2010, revealed that only 25% of patients received at least 80% of their estimated energy requirements in the pre-implementation phase. Hypothesis: This study hopes to determine the effectiveness of an evidence-based proactive nutrition protocol in improving patients’ nutrition in the neurointensive care unit (NICU). Methods: Using Clinical Practice Improvement Programme (CPIP) methodology, a multidisciplinary team of doctors, nurses and ICU dietician created a cause and effect (fish-bone) diagram to identify the root causes. The Pareto chart revealed the major causes as: 1. Excessive peri-procedural fasting for surgery and diagnostic scans; 2. High gastric residual volumes; 3. Delayed initiation or not stepping up to goal rate of enteral feeding; 4. Excessive fasting prior to and post-extubation. Interventions adhering to Plan-Do-Study-Act principles were implemented: electronic nutrition charting, adopting best practice guidelines for cut-off values for high gastric residual volumes, ICU dietician review for all new intubated admissions, protocol standardisation and dissemination including standardized peri-procedural fasting times and the use of electronic nutrition advisory alerts. This nutrition support protocol was subsequently implemented from January to June 2011, and the impact of this protocol was evaluated prospectively in 88 consecutive intubated neuro-intensive patients. Results: The time to initiation of EN was significantly improved. The percentage of adequately-fed patients significantly improved from 25% (pre-implementation) to 40% (post-implementation), p< 0.05. Conclusions: Application of an evidence-based nutrition protocol, standardization and strict enforcement of feeding/fasting protocols, continual education, frequent reminders and multidisciplinary collaboration can improve nutrition in intubated Neuro-ICU patients. We need to recognize of importance of nutritional care as critical to patient-centric ICU outcomes. Application of present & firm evidence to direct patient care (transfer to practice), standardisation/optimisation of processes, leveraging on IT to facilitate best practices, and multidisciplinary collaboration can help to improve patients’ nutritional therapy.

Effect of an analgo-sedation protocol for neurointensive patients: a two-phase interventional non-randomized pilot study

IntroductionSedation protocols are needed for neurointensive patients. The aim of this pilot study was to describe sedation practice at a neurointensive care unit and to assess the feasibility and efficacy of a new sedation protocol. The primary outcomes were a shift from sedation-based to analgesia-based sedation and improved pain management. The secondary outcomes were a reduction in unplanned extubations and duration of sedation.MethodsThis was a two-phase (before-after), prospective controlled study at a university-affiliated, 14-bed neurointensive care unit in Denmark. The sample included patients requiring mechanical ventilation for at least 48 hours treated with continuous sedative and analgesic infusions or both. During the observation phase the participants (n = 106) were sedated as usual (non-protocolized), and during the intervention phase the participants (n = 109) were managed according to a new sedation protocol.ResultsOur study showed a shift toward analgo-sedation, suggesting feasibility of the protocol. We found a significant reduction in the use of propofol (P < .001) and midazolam (P = .001) and an increase in fentanyl (P < .001) and remifentanil (P = .003). Patients selected for daily sedation interruption woke up faster, and estimates of pain free patients increased from 56.8% to 82.7% (P < .001), suggesting efficacy of the protocol. The duration of sedation and unplanned extubations were unchanged.ConclusionsOur pilot study showed feasibility and partial efficacy of our protocol. Some neurointensive patients might not benefit from protocolized practice. We recommend an interdisciplinary effort to target patients requiring less sedation, as issues of oversedation and inadequate pain management still need more attention.Trial registrationISRCTN80999859.

Review of central-line-related sepsis in neurointensive care patients

Central venous catheterisation is a core component of intensive care management. Despite advances in medicine, central venous catheters are associated with infection rates ranging between 2.5 and 70% [1,2]. There is, however, little isolated information regarding rates of central line sepsis in neurointensive patients. Microbiology results from the 3 months preceding this study identified six line-related infections. Following implementation of a new evidence-based medicine technique for central lines, this study set out to review central line sepsis in patients at Walton Neurological ITU.