Outcome in neurocritical care: Advances in monitoring and treatment and effect of a specialized neurocritical care team

Neurocritical care for neonates

BACKGROUND

To describe the concept, implementation, patient characteristics, and preliminary outcomes of a Neonatal Neurocritical Care Service (NNCS) recently established at the University of California, San Francisco.

METHODS

The NNCS was developed to better address the special needs of neonates at risk for neurological injury. The service combines dedicated neurological care, specialized neonatal medical and nursing expertise, neuromonitoring, neuroimaging, neurodevelopmental care, and long-term follow up. Newborns evaluated by the NNCS between July 2008 and June 2009 were included in the analysis. Demographic data (gestational age at birth, sex, admission diagnosis, and reason for consult), outcome (mortality, length of stay), and neurophysiology and imaging resources were extracted from patient charts.

RESULTS

Over the 12-month period, 155 newborns were evaluated (approximately 25% of all admissions); of these, 51 were preterm (<36 weeks gestation) and 104 were term. Approximately half were admitted for primary medical diagnoses, such as preterm birth, congenital malformations or apnea/apparent life-threatening event (ALTE), with the remainder admitted for primary neurological problems, including perinatal asphyxia, seizures/possible seizures, or congenital cerebral malformation. The most common neurological diagnoses were hypoxic-ischemic encephalopathy (38%) and seizure (35%). Among preterm newborns, intraventricular hemorrhage grade III and periventricular hemorrhagic infarction were most common. Mortality was approximately 20% in both preterm and term populations.

CONCLUSIONS

While specialized neurocritical care has improved outcomes in adult populations, longitudinal studies are needed to determine whether specialized neurocritical care services will also result in improved neurodevelopmental outcomes for newborns.

Improvement in intensive care unit outcomes in patients with subarachnoid hemorrhage after initiation of neurointensivist co-management

OBJECT

Neurointensivists are specialists trained to manage all aspects of the intensive care unit (ICU) stay of neurologically ill patients. No study to date has examined the role of neurointensivists specifically in subarachnoid hemorrhage (SAH) management. This study examined the use of a team-based neurointensivist co-management approach.

METHODS

The authors reviewed all cases involving patients with SAH admitted to the neurosurgical service during a period of more than 4 years. A comparison was made between those patients admitted before and those admitted after the initiation of a mandatory neurointensivist co-management strategy. The primary outcome examined was length of ICU stay. Secondary outcomes included in-hospital mortality, ventriculoperitoneal shunt placement, and other complications such as fever, antibiotic use, pressor utilization, and ventilator-associated pneumonia.

RESULTS

A total of 512 patients were included, 216 prior to and 296 after the initiation of neurointensivist comanagement. Length of ICU stay was significantly decreased after the initiation of neurointensivist co-management (mean 12.4 vs 10.9 days, p = 0.02), even after adjusting for demographic characteristics and admission Hunt and Hess grade. The percentage of patients requiring a ventriculoperitoneal shunt significantly decreased after initiation of the co-management approach (23.0 vs 11.5%, p = 0.001), but in-house mortality was unaffected.

CONCLUSIONS

Initiation of a strategy of routine involvement of a neurointensivist, charged with managing all aspects of the patients' care, resulted in a significantly reduced length of ICU stay for neurosurgical SAH patients. This team-based approach, using neurointensivists to manage neurosurgical SAH patients, merits further study as a successful model of care.

Pediatric neurocritical care: is it time to come of age?

PURPOSE OF REVIEW

Neurocritical care in adults with life-threatening neurological disease is a distinct discipline that has developed out of critical care medicine and neurology. This review considers whether it is time for such a specialized service to be developed in pediatrics.

RECENT FINDINGS

Recent reports describe how some institutions and pediatric professional bodies have set about transferring the specialist neurocritical care experience in adults to pediatric practice. The issue, now, is whether such a development would improve pediatric healthcare, medical education and training in the newly defined field. Adult neurocritical care did not develop in a void. The historical influences were the polio epidemics and the investment in experimental neuroprotection. These traditions provided a foundation for success in recent clinical trials, patient outcomes and healthcare research. Pediatric neurocritical care does not have the equivalent parallels and track record in healthcare research. Size of practice and casemix is also significantly different, with one-third of potential beneficiaries of the new field having a primary medical, rather than neurological, disorder. Three types of development for pediatric neurocritical services are, therefore, suggested by the literature and the implications of these on cross-discipline staffing and education are discussed.

SUMMARY

Pediatric neurocritical care is the new frontier for pediatric critical care medicine and pediatric neurology. There is sufficient specialist interest and momentum for the development of a multidisciplinary collaboration that has the aim of improving patient care.

Therapeutic mild hypothermia improves outcome after out-of-hospital cardiac arrest

Purpose. Therapeutic mild hypothermia (TMH) is indicated for comatose survivors of an out-ofhospital cardiac arrest (OHCA) to improve general outcome. Although widely used, there are not many reports on its use on a critical care unit (CCU) or on the comparison of cooling methods.Methods. In a retrospective analysis covering January 2005 to December 2006, 75 consecutive comatose subjects post-OHCA due to ventricular fibrillation and nonventricular fibrillation rhythms (asystole/pulseless electrical activity) were studied in a single tertiary PCI centre. Subjects treated with conventional post-resuscitation care without TMH served as controls (n=26; Jan 2005-Sep 2005). Outcome from controls at hospital discharge was compared with subjects treated with TMH (n=49; Oct 2005-Dec 2006). During the study period, TMH was induced by either external (n=25; Oct 2005-Feb 2006) or endovascular (n=24; Mar 2006-Dec 2006) approach.Results. Besides more females in the control group, there were no major differences in baseline characteristics present between all groups. TMH improved survival (OR 0.36 [0.13-0.95], p<0.05) and neurological outcome (OR 0.23 [0.07-0.70], p<0.01). After subanalysis, TMH-improved outcome did not differ between the two cooling methods used. However, the times to reach TMH and normothermia were shorter with the endovascular approach.Conclusion. TMH induced on a CCU improves survival and neurological outcome after post-OHCA coma. TMH by endovascular approach was more feasible compared with external cooling, but the two cooling methods did not result in a different outcome. (Neth Heart J 2009;17:378-84.).

Effect of country or continent of treatment on outcome after aneurysmal subarachnoid hemorrhage

Object

Prognostic factors for outcome after aneurysmal subarachnoid hemorrhage (SAH) include the clinical and pathological characteristics of the patient and hemorrhage as well as some aspects of treatment. Because treatment can vary between countries and continents, the authors used a large database of patients with SAH to determine the effect of the geographic location of treatment on outcome.

Methods

Data obtained in 3567 patients who were entered into randomized trials of tirilazad between 1991 and 1997 were analyzed. Patients underwent treatment in 162 neurosurgical centers in 21 countries in North America, Europe, Africa, and Australia. The dependent variable was clinical outcome assessed 3 months after SAH with the Glasgow Outcome Scale, which was analyzed as a 5-point variable and dichotomized into favorable (good recovery or moderate disability) and unfavorable (severe disability, vegetative state, or death) outcomes. The effect of country or continent of treatment on outcome was assessed using univariate and multivariate logistic regression and proportional odds modeling before and after adjusting for numerous other factors significantly associated with outcome.

Results

The authors constructed several multivariate analysis models and demonstrated that for almost every model, country was not a significant predictor of outcome (p > 0.05). There was variation in outcome between countries, but this was mostly due to differences in other admission characteristics that influence outcome such as age, clinical grade, and subarachnoid clot thickness. Because the number of patients entered from some countries was small, countries were grouped, and the data were analyzed by continent. This grouping gave more stable estimates and created an appropriate model for both logistic and proportional odds models and again showed that continent had no significant effect on outcome.

Conclusions

Despite the variations in treatment that undoubtedly exist between countries and continents, the location of treatment had minimal effect on outcome. Outcome was influenced mostly by clinical characteristics on admission such as neurological grade, patient age, and amount of SAH.

Can we demonstrate the efficacy of monitoring?

This article will discuss the challenges related to the demonstration of the efficacy of monitoring in an intensive care environment. It will address interpretation, therapeutic intervention, sample size and compare efficacy to effectiveness in the context of the developing field of neurocritical care.

Controversies in neurosciences critical care

Perhaps the greatest recent controversy in the medical management of complex neurologic and neurosurgical patients has been the defining of the optimal care arena. Despite some early skepticism and measured recognition by the ICU community, neurosciences critical care has grown into a well-recognized subspecialty. Within this environment, the diverse expertise of surgeons, neurologists, and anesthesiologists come together to define best therapeutic strategies. Two neurologic disease states that, in particular, continue to elicit expansive interdisciplinary debate are spontaneous intracerebral hemorrhage and aneurysmal subarachnoid hemorrhage.

Neurocritical care: a distinct discipline?

PURPOSE OF REVIEW

We sought to review the evidence supporting neurocritical care as a distinct specialty of medicine.

RECENT FINDINGS

Over the past 20 years, neuro-intensive care units have evolved from neurosurgical units focused primarily on postoperative monitoring to units that provide comprehensive medical and specialized neurological support for patients with life-threatening neurological diseases. In addition to standard interventions, areas of expertise unique to neurocritical care include management of intracranial pressure, hemodynamic augmentation to improve cerebral blood flow, therapeutic hypothermia, and advanced neuromonitoring (i.e. continuous electroencephalography, brain-tissue oxygen, and microdialysis). Neurointensivists defragment care by focusing on the interplay between the brain and other systems, and by integrating all aspects of neurological and medical management into a single care plan. Outcomes research has established that victims of traumatic brain injury and hemorrhagic stroke experience reduced mortality, better functional outcomes, and reduced length of stay when cared for by neurointensivists in a dedicated neuro-intensive care unit. In the US a national system for accrediting training programs and certifying intensivists with special qualifications in neurocritical care is currently being established by the United Council of Neurologic Subspecialties.

SUMMARY

Neurocritical care is one of the newest subspecialties of medicine and is at the forefront of bringing effective new therapies to patients with life-threatening neurological diseases.