Neurotrauma Intensive Care Unit Research Articles

Personalized music for cognitive and psychological symptom management during mechanical ventilation in critical care: A qualitative analysis.

Patients experience high symptom burden during critical care hospitalization and mechanical ventilation. Medications are of limited effectiveness and are associated with increased morbidity such as delirium and long-term cognitive and psychological impairments. Music-based interventions have been used for pain and anxiety management in critical care but remain understudied in terms of music selection and range of symptoms. This study aimed to describe the ways in which a diverse sample of critically ill adults used personalized music listening and their perceptions of the effects of music listening on symptom experience after critical injury. Semi-structured interviews (N = 14) of adult patients, families and friends who were provided with personalized music in an urban, academic, neurotrauma intensive care unit were collected and analyzed with grounded theory methodology. Open coding of transcripts, field notes and memos was performed using Atlas.ti.9.1. Recruitment and data collection were deemed complete once thematic saturation was achieved. We identified 6 uses of personalized music listening in critical care: 1) Restoring consciousness; 2) Maintaining cognition; 3) Humanizing the hospital experience; 4) Providing a source of connection; 5) Improving psychological wellbeing; and 6) Resolving the problems of silence. Patients used music to address psychological experiences of loneliness, fear, confusion, and loss of control. Personalized music helped patients maintain their identity and process their trauma. Additional benefits of music included experiencing pleasure, hope, resilience, and feelings of normalcy. Patients disliked being sedated and used music to wake up. Findings also highlighted the problem of the lack of meaningful stimulation in critical care. Critically injured adults used personalized music to achieve psychological and cognitive homeostasis during critical care hospitalization. These results can inform future studies designed to explore the use of music-based interventions to prevent and treat the cognitive and emotional morbidity of critical care.

Nutrition status in neuro trauma intensive care units- A cross sectional descriptive study

Nutrition status in neuro trauma intensive care units- A cross sectional descriptive study

Feasibility, acceptability, and usability of implementing a medical device-related pressure injury algorithm for critically ill patients using non-invasive ventilation

ObjectivesDescribe the feasibility, acceptability, and usability of implementing a nurse-led intervention to prevent medical device-related pressure injury in critical care patients using non-invasive ventilation during hospitalization. Study designA quality improvement project, using a descriptive single-arm study design with convenience sampling. Setting and participantsThis study was conducted at a Midwestern medical center with 640 beds (two hospital campuses). After an educational session, the nurse-led algorithm for non-invasive ventilation medical device-related pressure injury prevention was implemented in two critical care nursing units (cardiac medical progressive care and neurotrauma intensive care unit). Nursing staff were full or part-time critical care nurses. Main outcome measuresFeasibility, acceptability, and usability of the non-invasive ventilation medical device-related pressure injury algorithm were measured (bedside rounding and pre/post System Usability Scale). ResultsThirty-five nurses (52.2 %) completed a pre-educational survey; 8 (11.2 %) completed a post-survey. The total mean pre-survey score was 70.7 (SD ± 13.6) and the post-survey mean score was 71.3(SD ± 19.6). There was a statistically significant increase in the post-survey mean score {Χ2 (1, N = 43) = 43.5, p <.05}, however, the 0.06 increase was not clinically meaningful. Bedside rounding interviews (n = 22) indicated 82 % (n = 18) of the nurses used the algorithm. The SUS tool mean score was 83.3 (10.73) pre-implementation (n = 21); and 85.63 (8.26) post-implementation (n = 5), indicating clinical usability of the algorithm pre- and post-implementation. ConclusionThe feasibility, acceptability, and usability of implementing a medical device-related pressure injury algorithm for critically ill patients using non-invasive ventilation were demonstrated during this study. More nursing research is needed to develop scalable interdisciplinary clinical algorithms to reduce medical device-related pressure injuries in patients using non-invasive ventilation. Implications for clinical practiceThis study focused on the bedside usability of the algorithm in a clinical setting. Implementing this nursing-developed algorithm created an interdisciplinary framework in which nursing assessment may guide clinical care.

Ultrasound Assessment of Diaphragm Function in Traumatic Brain Injury: A Prospective Observational Study

Abstract Background Prolonged mechanical ventilation is associated with weaning failure in severe TBI patients. Ultrasound is a noninvasive modality for evaluating diaphragm function. On ultrasonography (USG), diaphragm thickness is observed to decrease over time in mechanically ventilated patients. However, little literature exists on the severity of diaphragmatic dysfunction in traumatic brain injury (TBI) patients. This study aimed to observe the changes occurring in diaphragmatic function in mechanically ventilated TBI patients. Methods TBI patients aged 18 to 65 years, requiring mechanical ventilation, were included. USG assessment of diaphragm function was done on days 0, 3, 5 and 7 of neurotrauma intensive care unit (NICU) admission in the supine position, during sedation holiday and spontaneous breathing trial. Measurements were done at end expiration (TE) and at maximal inspiration (TI) using 7- to 13-MHz linear array probe for three consecutive times and then averaged. Thickness fraction was calculated as (TI – TE/TE) × 100. Diaphragmatic excursion (DE) was measured in the M mode using 1- to 5-MHz phased array probe, as maximal height of inspiration. Results Forty patients were evaluated. The mean diaphragmatic thickness fraction (DTF) at days 0, 3, 5, and 7 was 33.58 ± 10.08, 33.4 ± 9.76, 32.32 ± 8.36, and 31.65 ± 8.23, respectively. Change in DTF was statistically significant on day 7 (p = 0.040). The mean DE at days 0, 3, 5, and 7 was 9.61 ± 3.99, 9.02 ± 3.46, 8.87 ± 2.63, 8.56 ± 2.74, respectively. Changes in DE over days 3, 5, and 7 were statistically significant (p &lt; 0.001). The mean DTF was lower on day 3 in patients who were admitted for less than 20 days than those who required hospital admission for more than 20 days (p = 0.044). Conclusion Decrease in DTF and DE over the period of 7 days was observed with a significant decrease occurring on the 7th day following TBI.

Predicting mortality in moderate-severe TBI patients without early withdrawal of life-sustaining treatments including ICU complications: The MYSTIC-score

PurposeTo develop and internally validate the MortalitY in Moderate-Severe TBI plus ICU Complications (MYSTIC)-Score to predict in-hospital mortality of msTBI patients without early (<24 h) withdrawal-of-life-sustaining treatments. MethodsWe analyzed data from a Neuro-Trauma Intensive Care Unit prospectively collected between 11/2009–5/2019. Consecutive adult msTBI patients were included if Glasgow Coma Scale≤12, and neither died nor had withdrawal-of-life-sustaining treatments within 24 h of admission (n = 485). Using univariate and multivariable logistic regression in a random-split cohort approach (2/3 derivation;1/3 validation), we identified independent predictors of in-hospital mortality while adjusting for validated predictors of mortality (IMPACT-variables). We constructed the MYSTIC-Score and examined discrimination and calibration. ResultsThe MYSTIC-Score included the ICU complications brain edema, herniation, systemic inflammatory response syndrome, sepsis, acute kidney injury, cardiac arrest, and urinary tract infection. In the derivation cohort(n = 324), discrimination and calibration were excellent (area-under-the-receiver-operating-curve [AUC-ROC] = 0.95;Hosmer-Lemeshow p-value = 0.09, with p > 0.05 indicating good calibration). Internal validation revealed an AUC-ROC = 0.93 and Hosmer-Lemeshow-p-value = 0.76 (n = 161). ConclusionsCertain ICU complications are independent predictors of in-hospital mortality and strengthen outcome prediction in msTBI when combined with validated admission predictors of mortality. However, external validation is needed to determine robustness and practical applicability of our model given the high potential for residual confounders.

Incidence of Anaemia and Blood Transfusion Practice in Neurosurgical and Neurotrauma Intensive Care Units at National Hospital of Sri Lanka

A prospective cross-sectional single centre clinical study was performed to determine the incidence of anaemia and blood transfusion practice in neurosurgical and neurotrauma intensive care units (ICU). All the adult patients who met the criteria and were admitted to the neurosurgical and neurotrauma ICUs of National Hospital of Sri Lanka from 15th April to 14th June 2013 were included in the study. Out of the 100 patients in the study, 82% were anaemic on admission and 95% had anaemia at some point during ICU stay. The mean haemoglobin (Hb) level was less than10g/dl in 30% of patients. 47% of patients received blood transfusion in the ICU. Only 23.6% of the transfusion events met the standards for the transfusion trigger.

Patient Characteristics and Clinical and Intraoperative Variables Affecting Outcome in Pediatric Traumatic Brain Injury

Abstract Background Pediatric traumatic brain injury (TBI) has distinctive pathophysiology and characteristics that differ from adults. These can be attributed to age-related anatomical and physiological differences and distinct patterns of injuries seen in children. Our aim was to identify the patient characteristics, clinical variables during intensive care and intraoperative management associated with poor functional outcome in a cohort of pediatric TBI patients. Methods Retrospective chart review of pediatric TBI patients admitted to neurotrauma intensive care unit (NICU) over a period of 1 year. Results A total of 105 children (&lt; 12 years) with head injury were admitted in the NICU during the study period. The most common mechanism of injury was fall in 78% cases. Fifty-four patients (51.4%) presented with a severe head injury (Glasgow coma scale [GCS] ≤ 8), while 31 (29.5%) and 20 (19.1%) had a mild and moderate head injury. The most common finding was skull fractures (59%), contusions (36.2%), and subdural hematoma (SDH) (30.4%). Forty nine patients (46.7%) required surgical management. The median duration of anesthesia was 205 (interquartile range [IQR] 65, 375) minutes, and median blood loss during the surgery was 16.7 mL/kg body weight with 41% requiring intraoperative blood transfusions. Median duration of ICU and hospital stay was 5 (IQR 1, 47) and 8 (IQR 1, 123) days, respectively. GOS at discharge ≤ 3 representing poor outcome was present in 35 patients (33.3%). Mortality was seen in 15 (14.3%) patients. Multivariate analysis identified postresuscitation GCS ≤ 8 on admission as independent predictor of mortality, and postresuscitation GCS ≤ 8 on admission and NICU stay of &gt; 7 days as independent predictor of poor outcome. Conclusion Despite advances in neurointensive care, mortality and morbidity remains high in pediatric head trauma and is mainly dependent on postresuscitation GCS and NICU stay of more than 7 days. Multidimensional approach is required for its prevention and management.

Impact of Hand Hygiene on Hospital-Acquired Infection Rate in Neuro Trauma ICU at a Level 1 Trauma Center in the National Capital Region of India.

Introduction Compliance to hand hygiene (HH) is an important measure in preventing infections to patients in health-care settings. Wellness and safety of patients and health-care workers (HCWs) can be achieved by promoting best practices in infection control through education and advocacy. Aims and Objectives To assess the compliance to HH among all cadres of HCWs and its association with hospital-acquired infection (HAI) in patients. Materials and Methods A prospective, observational study was conducted for a period of 5 years (January 2014 to December 2018) in Neuro Trauma intensive care unit. A standard checklist based on World Health Organization’s 5 Moments for Hand Hygiene was used as a tool to measure the HH compliance. Results HAI rate was found to be directly proportional to the compliance to HH. Reduction in HAI rates was reported when there was an increase in HH compliance. HAI of 4.25% was found to be lowest in the year 2015 with the compliance to HH of 63.65%. The HH compliance was also found to be highest (64.63%) in the year 2016 followed by 64.12% in the year 2017. During this period HAI rates were 4.35% and 4.8%, respectively. When the HH compliance declined in the year 2018 to 53.95%, there was an increase in the rate of HAI to 6.9%. Conclusion It could be concluded that HH compliance was associated with the decrease in HAIs. HH could be a simple and cost-effective method in the prevention of HAIs.

Respiratory morbidity and mortality of traumatic cervical spinal cord injury at a level I trauma center in India.

Study designDescriptive retrospective.ObjectivesTo evaluate the burden of respiratory morbidity in terms of ventilator dependence (VD) days and length of stay in neurotrauma ICU (NICU) and hospital, and to determine mortality in patients with traumatic cervical spinal cord injury (CSCI) in a low middle-income country (LMIC).SettingJai Prakash Narayan Apex Trauma Center (JPNATC), All India Institute of Medical Sciences (AIIMS), New Delhi, India.MethodsA total of 135 patients admitted with CSCI in the NICU between January 2017 to December 2018 were screened. Information regarding age, gender, American Spinal Injury Association (ASIA) impairment scale (AIS), level of injury, duration of VD, length of NICU, hospital stay, and outcome in terms of mortality or discharge from the hospital were obtained from the medical records.ResultsA total of 106 CSCI patients were analyzed. The mean (SD) age of patients was 40 (±16) years and male: female ratio was 5:1. The duration of VD, duration of NICU, and hospital stay was a median of 8 days (IQR 1127), 6 days (IQR 1118), and 15 days (IQR 3127) respectively. Mortality was 19% (20/106). The mortality was significantly associated with poorer AIS score, VD, and duration of ICU and hospital stay. All patients were discharged to home only after they became ventilator-free.ConclusionsThe ventilator burden, hospital stay, and mortality are high in patients with CSCI in LMICs. Poor AIS scores, prolonged VD, ICU and hospital stay are associated with mortality. There is a need for comprehensive CSCI rehabilitation programs in LMICs to improve outcome.

Admission Features Associated With Paroxysmal Sympathetic Hyperactivity After Traumatic Brain Injury: A Case-Control Study.

Paroxysmal sympathetic hyperactivity occurs in a subset of critically ill traumatic brain injury patients and has been associated with worse outcomes after traumatic brain injury. The goal of this study was to identify admission risk factors for the development of paroxysmal sympathetic hyperactivity in traumatic brain injury patients. Retrospective case-control study of age- and Glasgow Coma Scale-matched traumatic brain injury patients. Neurotrauma ICU at the R. Adams Cowley Shock Trauma Center of the University of Maryland Medical System, January 2016 to July 2018. Critically ill adult traumatic brain injury patients who underwent inpatient monitoring for at least 14 days were included. Cases were identified based on treatment for paroxysmal sympathetic hyperactivity with institutional first-line therapies and were confirmed by retrospective tabulation of established paroxysmal sympathetic hyperactivity diagnostic and severity criteria. Cases were matched 1:1 by age and Glasgow Coma Scale to nonparoxysmal sympathetic hyperactivity traumatic brain injury controls, yielding 77 patients in each group. None. Admission characteristics independently predictive of paroxysmal sympathetic hyperactivity included male sex, higher admission systolic blood pressure, and initial CT evidence of diffuse axonal injury, intraventricular hemorrhage/subarachnoid hemorrhage, complete cisternal effacement, and absence of contusion. Paroxysmal sympathetic hyperactivity cases demonstrated significantly worse neurologic outcomes upon hospital discharge despite being matched for injury severity at admission. Several anatomical, epidemiologic, and physiologic risk factors for clinically relevant paroxysmal sympathetic hyperactivity can be identified on ICU admission. These features help characterize paroxysmal sympathetic hyperactivity as a clinical-pathophysiologic phenotype associated with worse outcomes after traumatic brain injury.

Family satisfaction in a neuro trauma ICU.

The purpose of this quality improvement initiative was to evaluate satisfaction of family members of patients in a neuro trauma ICU (NTICU). Adult patients (age 18+) admitted to the NTICU for at least 24 hours between June 2017 and November 2018 were identified. Near or at the time of discharge from the NTICU, the health unit coordinator or registered nurse identified the family member who was either the next-of-kin, surrogate decision-maker, or person who had been most frequently present at the patient's bedside. This person was provided a packet containing a letter of consent and the Critical Care Family Satisfaction Survey (CCFSS). Surveys were completed by 78 family members, the majority of whom were the wife of the patient (n=35, 44%), 60 years and older (n=48, 60.8%). Fifty-seven percent of patients (n=45) were in the ICU less than 3 days and 59% (n=47) of medical events were injury-related. Total CCFSS scores ranged from 69 to 100 (median 95). The item with the largest number of dissatisfied responses was "Noise level in the critical care unit" (n=4, 5.3% not satisfied). Open-ended question comments were primarily positive (n=60, 66%), with 32% (n=29) representing areas for improvement. Results of this satisfaction survey have been disseminated to leadership and have been taken into consideration in the planning of a new hospital building currently being built, including ICU patient rooms that allow for more privacy and reduced noise, and more comfortable family rooms. Family members are a very useful source of feedback for ICU care. Several concerns identified by family members in this study are likely to be relevant to other sites. These included: communication between health care providers and family about patient status, noise in the ICU, peaceful waiting areas for family, and slow transfers.

Audit on enteral drug administration (EDA) and enteral nutrition (EN) practices in neurotrauma intensive care units (NICU):

Audit on enteral drug administration (EDA) and enteral nutrition (EN) practices in neurotrauma intensive care units (NICU):

Catching CAUTIs Midstream: Impact of a Nurse-driven Infection Prevention Initiative in a Neurotrauma Intensive Care Unit

<h3>Background</h3> A preventable hospital-associated condition, Catheter-Associated Urinary Tract Infection (CAUTI) increases morbidity, mortality, and hospital length of stay and cost. Neurologic and injured patients are at high-risk for adverse outcomes associated with bladder dysfunction. Thus, higher utilization, reinsertion and infection rates related to indwelling urinary catheter use is reported in these complex populations. What is the impact of an innovative nurse-driven initiative to reduce CAUTI incidence in a neurotrauma intensive care unit (NTICU) to a Standardized Infection Ratio (SIR) < 1.0? <h3>Methods</h3> A nurse-led interprofessional team utilized a Define-Measure-Analyze-Improve-Control model to implement an evidence-based CAUTI prevention initiative. A 12-bed unit providing care to neurologic and injured patients in a level one trauma, academic medical center was the study setting. Cornerstone interventions included conduct of a staff culture of safety survey; revision of ICU Fever and Bladder Management Guidelines; interprofessional education; and use of a trial without catheter (TWOC) checklist to assess for catheter removal readiness. To sustain improvements, a nursing clinical team leader (CTL) driven initiative included daily patient rounds and audits of catheter care bundle and guideline compliance over a two-year period. Infection rates, device utilization rates and SIR were compared pre and post intervention. <h3>Results</h3> CAUTI rates reduce post intervention by nearly 40% (CAUTI rate 2017, 5.48; 2018, 2.91) and sustained through 2019 (2.97). The SIR for CAUTI reduce nearly 50% from 2.0 in 2017 to 1.06 in 2018 and sustained at 0.92 in 2019. No significant change in the utilization rate was noted (2017, 0.49; 2018, 0.55; 2019, 0.50). <h3>Conclusions</h3> At the unit level, a CTL driven initiative sustains quality improvements in catheter care bundle and guideline compliance, significantly reducing CAUTI incidence in a NTICU. Innovative use of an additional assessment checklist for catheter removal readiness may further support CAUTI reduction in high-risk neurologic and injured ICU populations.

A pilot study evaluating a simple cardiac dysfunction score to predict complications and survival among critically-ill patients with traumatic brain injury

PurposeTo describe the frequency of cardiovascular complications and cardiac dysfunction in critically-ill patients with moderate-severe traumatic brain injury (msTBI) and cardiac factors associated with in-hospital survival. MethodsRetrospective analysis of a prospective cohort study at a single Level-1 trauma center with a dedicated neuro-trauma intensive care unit (ICU). Adult patients admitted to the ICU with msTBI were consecutively enrolled in the prospective OPTIMISM study between November 2009 and January 2017. Cardiac dysfunction was measured using a combination of EKG parameters, echocardiography abnormalities, and peak serum troponin-I levels during the index hospitalization. These items were combined into a cardiac dysfunction index (CDI), ranging from 0 to 3 points and modeled in a Cox regression analysis. ResultsA total of 326 patients with msTBI were included. For every one-point increase in the CDI, the multivariable adjusted risk of dying during the patient's acute hospitalization more than doubled (adjusted HR 2.41; 95% CI 1.29–4.53). ConclusionCardiac dysfunction was common in patients with msTBI and independently associated with more severe brain injury and a reduction in hospital survival in this population. Further research is needed to validate the CDI and create more precise scoring tools.

Assessing circadian rhythms and entrainment via intracranial temperature after severe head trauma

We seek a methodological approach to assess circadian processes in subjects who have recently experienced traumatic brain injury, using regularly gathered intracranial temperature data. The health effects of circadian regulation are profound, yet assessments of circadian processes are often infeasible in the neurotrauma intensive care unit (ICU). We assess circadian periodicity through the energy density spectrum, applying model-based and model-free methods: an extended Kalman filter (using the Kronauer model) in conjunction with a fast Fourier transform (FFT), and the Lomb–Scargle periodogram, respectively. We compute the change in relative energy in a narrow band of the spectrum, corresponding to a period of 23-25 h, over the first 48 and last 48 h of each subject's stay in the ICU. The change in relative energy in the spectrum increases in subjects with Good outcomes, and decreases in subjects with Poor outcomes, with statistical significance. For those subjects with Good outcome, we show evidence of regulation in circadian phase using an adaptive notch filter.

Cardiac Dysfunction in Adult Patients with Traumatic Brain Injury: A Prospective Cohort Study.

There are limited data regarding the development of myocardial dysfunction after a traumatic brain injury (TBI). We investigated incidence, risk factors, and prognostic importance of cardiac dysfunction in adult patients admitted to the intensive care unit (ICU) after a moderate to severe TBI. Prospective observational study of consecutive patients admitted to neuro-trauma ICU with moderate to severe TBI from August 2014 to June 2015. A total of 46 patients were included. Patients' mean (±SD) age was 44.7 (±20.7) years and mean Glasgow Coma Scale value was 5.6 (±3). Motor vehicle accident was the most common mechanism of TBI, with subdural and subarachnoid hemorrhages as the most common pathologies. Cardiac dysfunction developed in 6 of 46 (13%) patients. Patients with cardiac dysfunction had higher prevalence of diabetes mellitus (50% vs. 10%, P = 0.03) and higher proportion of electrocardiogram abnormalities (83% vs. 27%, P = 0.02) compared to the patients without cardiac dysfunction. Mean Glasgow Coma Scale scores were not significantly different between patients who developed cardiac dysfunction from those who did not (5.5 vs. 5.6, P = 0.95). Requirement for vasopressor support (33.3% vs. 40%, P = 1.0) and median ventilator days (5.2 vs. 4.7, P = 0.9) were similar between patients with and without cardiac dysfunction. There were no significant differences in hospital lengths of stay (12.3 vs. 13.8 days, P = 0.34) and hospital mortality (33% vs. 17.5%, P = 0.58) between the two groups. Cardiac dysfunction occurs in patients after moderate to severe TBI, with mild to moderate reduction in left ventricular ejection fraction. Patients who developed cardiac dysfunction after TBI had a higher prevalence of diabetes mellitus and higher proportion of abnormalities in electrocardiograms. Development of cardiac dysfunction was not associated with adverse clinical outcomes.

Epidemiological investigation and successful management of a Burkholderia cepacia outbreak in a neurotrauma intensive care unit

ObjectiveThe detailed epidemiological and molecular characterization of an outbreak of Burkholderia cepacia at a neurotrauma intensive care unit of a level 1 trauma centre is described. The stringent infection control interventions taken to successfully curb this outbreak are emphasized. MethodsThe clinical and microbiological data for those patients who had more than one blood culture that grew B. cepacia were reviewed. Bacterial identification and antimicrobial susceptibility testing was done using automated Vitek 2 systems. Prospective surveillance, environmental sampling, and multilocus sequence typing (MLST) were performed for extensive source tracking. Intensive infection control measures were taken to further control the hospital spread. ResultsOut of a total 48 patients with B. cepacia bacteraemia, 15 (31%) had central line-associated blood stream infections. Two hundred and thirty-one environmental samples were collected and screened, and only two water samples grew B. cepacia with similar phenotypic characteristics. The clinical strains characterized by MLST typing were clonal. However, isolates from the water represented a novel strain type (ST-1289). Intensive terminal cleaning, disinfection of the water supply, and the augmentation of infection control activities were done to curb the outbreak. A subsequent reduction in bacteraemia cases was observed. ConclusionEarly diagnosis and appropriate therapy, along with the rigorous implementation of essential hospital infection control practices is required for successful containment of this pathogen and to curb such an outbreak.

Physiotherapy in the neurotrauma intensive care unit: A scoping review

PurposeThis scoping review summarizes the literature on the safety and effectiveness of physiotherapy interventions in patients with neurological and/or traumatic injuries in the intensive care unit (ICU), identifies literature gaps and provides recommendations for future research. Materials and methodsWe searched five databases from inception to June 2, 2018. We included published retrospective studies, case studies, observation and randomized controlled trials describing physiotherapy interventions in ICU patients with neurotrauma injuries. Two reviewers reviewed the databases and independently screened English articles for eligibility. Data extracted included purpose, study design, population (s), outcome measures, interventions and results. Thematic analysis and descriptive numerical summaries are presented by intervention type. Results12,846 titles were screened and 72 met the inclusion criteria. Most of the studies were observational studies (44 (61.1%)) and RCTs (14 (19.4%)). Early mobilization, electrical stimulation, range of motion, and chest physiotherapy techniques were the most common interventions in the literature. Physiotherapy interventions were found to be safe with few adverse events. ConclusionsGaps in the literature suggest that future studies require assessment of long term functional outcomes and quality of life, examination of homogenous populations and more robust methodologies including clinical trials and larger samples.

Integrating Quantitative Pupillometry Into Regular Care in a Neurotrauma Intensive Care Unit.

In the setting of acute traumatic brain injury (TBI), an abnormal pupil assessment may suggest a worsening intracranial lesion. Early detection of pupillary changes may expedite emergent care to improve outcomes. Automated, handheld pupillometers have been commercially available for 20 years, and several studies suggest that their use may facilitate early recognition of worsening injury and intracranial hypertension. The use of pupillometry as a bedside tool in the routine care of patients with severe TBI (Glasgow Coma Scale score ≤ 8) has not been described. We performed a quality improvement project to implement routine use of quantitative pupillometry in our neurotrauma intensive care unit. Nursing staff were trained on device use and the project's aims in a 30-minute in-service session. Nurses caring for severe TBI patients completed standard pupil assessments using (a) a flashlight and (b) a pupillometer to quantify pupil size and reactivity (Neurological Pupil index) every hour. Abnormal results were reported to on-call providers. We administered surveys to evaluate knowledge, practical use of the pupillometer data, and satisfaction with the device every 3 months. Data were available for 22 nurses at 4 separate time points. Staff were positive about their ability to use and understand the device (µ = 8.7 and 9.1, respectively, on a 10-point scale) and reported that it added value to patient care and critical decision-making. Use of automated pupillometry is acceptable to nursing staff in a neurotrauma intensive care unit, and staff believed that pupillometry results enhanced clinical decision-making.

Integrating Quantitative Pupillometry Into Regular Care in a Neurotrauma Intensive Care Unit.

Integrating Quantitative Pupillometry Into Regular Care in a Neurotrauma Intensive Care Unit.