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Chen J, Lu G, Wang Z, Zhang J, Ding J, Zeng Q, Chai L, Zhao L, Yu H, Li Y. Prediction Models for Dysphagia in Intensive Care Unit after Mechanical Ventilation: A Systematic Review and Meta-analysis. Laryngoscope 2024; 134:517-525. [PMID: 37543979 DOI: 10.1002/lary.30931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 06/16/2023] [Accepted: 07/13/2023] [Indexed: 08/08/2023]
Abstract
OBJECTIVE Dysphagia is a common condition that can independently lead to death in patients in the intensive care unit (ICU), particularly those who require mechanical ventilation. Despite extensive research on the predictors of dysphagia development, consistency across these studies is lacking. Therefore, this study aimed to identify predictors and summarize existing prediction models for dysphagia in ICU patients undergoing invasive mechanical ventilation. METHODS We searched five databases: PubMed, EMBASE, Web of Science, Cochrane Library, and the China National Knowledge Infrastructure. Studies that developed a post-extubation dysphagia risk prediction model in ICU were included. A meta-analysis of individual predictor variables was performed with mixed-effects models. The risk of bias was assessed using the prediction model risk of bias assessment tool (PROBAST). RESULTS After screening 1,923 references, we ultimately included nine studies in our analysis. The most commonly identified risk predictors included in the final risk prediction model were the length of indwelling endotracheal tube ≥72 h, Acute Physiology and Chronic Health Evaluation (APACHE) II score ≥15, age ≥65 years, and duration of gastric tube ≥72 h. However, PROBAST analysis revealed a high risk of bias in the performance of these prediction models, mainly because of the lack of external validation, inadequate pre-screening of variables, and improper treatment of continuous and categorical predictors. CONCLUSIONS These models are particularly susceptible to bias because of numerous limitations in their development and inadequate external validation. Future research should focus on externally validating the existing model in ICU patients with varying characteristics. Moreover, assessing the acceptance and effectiveness of the model in clinical practice is needed. LEVEL OF EVIDENCE NA Laryngoscope, 134:517-525, 2024.
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Affiliation(s)
- Juan Chen
- School of Nursing and Public Health, Yangzhou University, Yangzhou, China
| | - Guangyu Lu
- Institute of Public Health, Medical College of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Zhiyao Wang
- Department of Neurosurgery, Clinical Medical College of Yangzhou University, Yangzhou, China
- Neuro Intensive Care Unit, Department of Neurosurgery, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Jingyue Zhang
- School of Nursing and Public Health, Yangzhou University, Yangzhou, China
| | - Jiali Ding
- School of Nursing and Public Health, Yangzhou University, Yangzhou, China
| | - Qingping Zeng
- School of Nursing and Public Health, Yangzhou University, Yangzhou, China
| | - Liying Chai
- School of Nursing and Public Health, Yangzhou University, Yangzhou, China
- Institute of Public Health, Medical College of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Li Zhao
- School of Nursing and Public Health, Yangzhou University, Yangzhou, China
- Institute of Public Health, Medical College of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Hailong Yu
- Neuro Intensive Care Unit, Department of Neurosurgery, Clinical Medical College of Yangzhou University, Yangzhou, China
- Department of Neurology, Northern Jiangsu People's Hospital, Yangzhou, China
| | - Yuping Li
- Department of Neurosurgery, Clinical Medical College of Yangzhou University, Yangzhou, China
- Neuro Intensive Care Unit, Department of Neurosurgery, Clinical Medical College of Yangzhou University, Yangzhou, China
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Surge Capacity in the COVID-19 Era: a Natural Experiment of Neurocritical Care in General Critical Care. Neurocrit Care 2022; 38:320-325. [PMID: 35831731 PMCID: PMC9281288 DOI: 10.1007/s12028-022-01559-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 06/10/2022] [Indexed: 11/24/2022]
Abstract
Background COVID-19 surges led to significant challenges in ensuring critical care capacity. In response, some centers leveraged neurocritical care (NCC) capacity as part of the surge response, with neurointensivists providing general critical care for patients with COVID-19 without neurologic illness. The relative outcomes of NCC critical care management of patients with COVID-19 remain unclear and may help guide further surge planning and provide broader insights into general critical care provided in NCC units. Methods We performed an observational cohort study of all patients requiring critical care for COVID-19 across four hospitals within the Emory Healthcare system during the first three surges. Patients were categorized on the basis of admission to intensive care units (ICUs) staffed by general intensivists or neurointensivists. Patients with primary neurological diagnoses were excluded. Baseline demographics, clinical complications, and outcomes were compared between groups using univariable and propensity score matching statistics. Results A total of 1141 patients with a primary diagnosis of COVID-19 required ICU admission. ICUs were staffed by general intensivists (n = 1071) or neurointensivists (n = 70). Baseline demographics and presentation characteristics were similar between groups, except for patients admitted to neurointensivist-staffed ICUs being younger (59 vs. 65, p = 0.027) and having a higher PaO2/FiO2 ratio (153 vs. 120, p = 0.002). After propensity score matching, there was no correlation between ICU staffing and the use of mechanical ventilation, renal replacement therapy, and vasopressors. The rates of in-hospital mortality and hospice disposition were similar in neurointensivist-staffed COVID-19 units (odds ratio 0.9, 95% confidence interval 0.31–2.64, p = 0.842). Conclusions COVID-19 surges precipitated a natural experiment in which neurology-trained neurointensivists provided critical care in a comparable context to general intensivists treating the same disease. Neurology-trained neurointensivists delivered comparable outcomes to those of general ICUs during COVID-19 surges. These results further support the role of NCC in meeting general critical care needs of neurocritically ill patients and as a viable surge resource in general critical care. Supplementary Information The online version contains supplementary material available at 10.1007/s12028-022-01559-3.
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Lau KHV, Hamlyn E, Williams TJ, Qureshi MM, Mak K, Mian A, Cervantes-Arslanian A, Zhu S, Takahashi C. The Effects of Video Instruction on Neuroscience Intensive Care Unit Nursing Skills in Case Presentations and Neurological Examinations. J Neurosci Nurs 2021; 53:129-133. [PMID: 33840806 DOI: 10.1097/jnn.0000000000000591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT BACKGROUND: The emergence of neuroscience intensive care units (NSICUs) for the past decades has led to growing interest in targeted training for NSICU nurses. We sought to evaluate the use of video instruction on NSICU nurses' skills in case presentations and neurological examinations, which has timely advantages as an asynchronous and distanced learning modality. METHODS: We enrolled NSICU and surgical intensive care unit nurses who took shifts in the NSICU at our institution. Participants were observed by a neurocritical care attending physician presenting the clinical details of an admitted patient and conducting a neurological examination, with both parties completing a 10-item evaluation on NSICU nursing presentation and examination skills. Participants randomized to an intervention group were given access to an instructional video on NSICU nursing skills. A median of 21 days later, participants were observed by a physician blinded to study randomization, with both parties recompleting the evaluation. Differences between day 1 and day 21 scores were analyzed using paired sample t tests. RESULTS: Fifteen NSICU and 55 surgical intensive care unit nurses were enrolled. Surgical intensive care unit nurses in both the intervention and control groups had statistically significant improvement between day 1 and day 21 physician-rated scores, with a greater increase in the intervention group; self-rated scores did not change. For NSICU nurses, there were no differences in physician-rated or self-rated scores for either group. CONCLUSIONS: Surgical intensive care unit nurses who underwent direct observation and self-evaluation had improvement in physician-rated NSICU nursing skills, likely as these activities allowed for reflective observation in Kolb's experiential learning cycle. Greater improvement in participants who viewed an instructional video highlights its value as a teaching modality for nurses.
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Khandelwal A, Jangra K, Katikar MD, Durga P, Maheswara Rao GSU. Choosing Neuroanaesthesia as a career: Marching towards new horizons. Indian J Anaesth 2021; 65:35-42. [PMID: 33767501 PMCID: PMC7980245 DOI: 10.4103/ija.ija_1531_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 12/30/2020] [Accepted: 01/04/2021] [Indexed: 12/25/2022] Open
Abstract
Anaesthesiology is an ever-changing science and amongst its sub-specialities, the field of neuroanaesthesia is making rapid strides. The fragility of the brain and spinal cord and the multitude of complexities involved in neurosurgery and interventional neuroradiological procedures demand dedicated training in neuroanaesthesia. With rapid advancement in other neuroscience specialties, neuroanaesthesia too has made outstanding progress, owing to establishment of structured training, publication of high-quality scientific research, and invention of novel medications and monitoring modalities. The opportunities for training in India and abroad and resources to broaden knowledge in neuroanaesthesia have increased over the last two decades. A career in neuroanaesthesia offers a great future for budding anaesthesiologists.
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Affiliation(s)
- Ankur Khandelwal
- Department of Anaesthesia and Critical Care, School of Medical Sciences and Research & Sharda Hospital, Sharda University, Greater Noida, Uttar Pradesh, India
| | - Kiran Jangra
- Department of Anaesthesia and Intensive Care, PGIMER, Chandigarh, India
| | - Manisha D Katikar
- Balwant Institute of Neurosurgery & Intensive Trauma Care, Solapur, Maharashtra, India
| | - Padmaja Durga
- Department of Anaesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - G S Uma Maheswara Rao
- Department of Neuronaesthesia, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
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Jo KW, Kim H, Yoo DS, Hyun DK, Cheong JH, Park HK, Park BJ, Cho BM, Kim YW, Kim TH, Han I, Lee SW, Kwon TH. Current Status of Neurosurgical and Neurointensive Care Units in Korea : A Brief Report on Nationwide Survey Results. J Korean Neurosurg Soc 2020; 63:519-531. [PMID: 32664714 PMCID: PMC7365282 DOI: 10.3340/jkns.2020.0026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 03/23/2020] [Indexed: 11/27/2022] Open
Abstract
Objective The purpose of this study is identify the operation status of the neurosurgical care units (NCUs) in neurosurgical residency training hospitals nationwide and determine needed changes by comparing findings with those obtained from the Korean Neurosurgical Society (KNS) and Korean Society of Neurointensive Care Medicine (KNIC) survey of 2010.
Method This survey was conducted over 1 year in 86 neurosurgical residency training hospitals and two neurosurgery specialist hospitals and focused on the following areas : 1) the current status of the infrastructure and operating systems of NCUs in Korea, 2) barriers to installing neurointensivist team systems, 3) future roles of the KNS and KNIC, and 4) a handbook for physicians and practitioners in NCUs. We compared and analyzed the results of this survey with those from a KNIC survey of 2010.
Results Seventy seven hospitals (87.5%) participated in the survey. Nineteen hospitals (24.7%) employed a neurointensivist or faculty member; Thirty seven hospitals (48.1%) reported high demand for neurointensivists, and 62 hospitals (80.5%) stated that the mandatory deployment of a neurointensivist improved the quality of patient care. Forty four hospitals (57.1%) believed that hiring neurointensivist would increase hospital costs, and in response to a question on potential earnings declines. In terms of potential solutions to these problems, 70 respondents (90.9%) maintained that additional fees were necessary for neurointensivists’ work, and 64 (83.1%) answered that direct support was needed of the personnel expenses for neurointensivists.
Conclusion We hope the results of this survey will guide successful implementation of neurointensivist systems across Korea.
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Affiliation(s)
- Kwang Wook Jo
- Department of Neurosurgery, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hoon Kim
- Department of Neurosurgery, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Do Sung Yoo
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dong-Keun Hyun
- Department of Neurosurgery, Inha Hospital, Inha University School of Medicine, Incheon, Korea
| | - Jin Hwan Cheong
- Department of Neurosurgery, Hanyang University Guri Hospital, Guri, Korea
| | - Hae-Kwan Park
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Bong Jin Park
- Department of Neurosurgery, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Korea
| | - Byung Moon Cho
- Department of Neurosurgery, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Young Woo Kim
- Department of Neurosurgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Tae Hee Kim
- Department of Anesthology and Pain Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Insoo Han
- Department of Anesthology and Pain Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sang-Weon Lee
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Taek Hyun Kwon
- Department of Neurosurgery, Korea Universuty Guro Hospital, Seoul, Korea
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Venkatasubba Rao CP, Suarez JI, Martin RH, Bauza C, Georgiadis A, Calvillo E, Hemphill JC, Sung G, Oddo M, Taccone FS, LeRoux PD. Global Survey of Outcomes of Neurocritical Care Patients: Analysis of the PRINCE Study Part 2. Neurocrit Care 2020; 32:88-103. [PMID: 31486027 DOI: 10.1007/s12028-019-00835-z] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Neurocritical care is devoted to the care of critically ill patients with acute neurological or neurosurgical emergencies. There is limited information regarding epidemiological data, disease characteristics, variability of clinical care, and in-hospital mortality of neurocritically ill patients worldwide. We addressed these issues in the Point PRevalence In Neurocritical CarE (PRINCE) study, a prospective, cross-sectional, observational study. METHODS We recruited patients from various intensive care units (ICUs) admitted on a pre-specified date, and the investigators recorded specific clinical care activities they performed on the subjects during their first 7 days of admission or discharge (whichever came first) from their ICUs and at hospital discharge. In this manuscript, we analyzed the final data set of the study that included patient admission characteristics, disease type and severity, ICU resources, ICU and hospital length of stay, and in-hospital mortality. We present descriptive statistics to summarize data from the case report form. We tested differences between geographically grouped data using parametric and nonparametric testing as appropriate. We used a multivariable logistic regression model to evaluate factors associated with in-hospital mortality. RESULTS We analyzed data from 1545 patients admitted to 147 participating sites from 31 countries of which most were from North America (69%, N = 1063). Globally, there was variability in patient characteristics, admission diagnosis, ICU treatment team and resource allocation, and in-hospital mortality. Seventy-three percent of the participating centers were academic, and the most common admitting diagnosis was subarachnoid hemorrhage (13%). The majority of patients were male (59%), a half of whom had at least two comorbidities, and median Glasgow Coma Scale (GCS) of 13. Factors associated with in-hospital mortality included age (OR 1.03; 95% CI, 1.02 to 1.04); lower GCS (OR 1.20; 95% CI, 1.14 to 1.16 for every point reduction in GCS); pupillary reactivity (OR 1.8; 95% CI, 1.09 to 3.23 for bilateral unreactive pupils); admission source (emergency room versus direct admission [OR 2.2; 95% CI, 1.3 to 3.75]; admission from a general ward versus direct admission [OR 5.85; 95% CI, 2.75 to 12.45; and admission from another ICU versus direct admission [OR 3.34; 95% CI, 1.27 to 8.8]); and the absence of a dedicated neurocritical care unit (NCCU) (OR 1.7; 95% CI, 1.04 to 2.47). CONCLUSION PRINCE is the first study to evaluate care patterns of neurocritical patients worldwide. The data suggest that there is a wide variability in clinical care resources and patient characteristics. Neurological severity of illness and the absence of a dedicated NCCU are independent predictors of in-patient mortality.
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MESH Headings
- Academic Medical Centers/statistics & numerical data
- Adult
- Aged
- Asia/epidemiology
- Brain Injuries, Traumatic/epidemiology
- Brain Injuries, Traumatic/physiopathology
- Brain Injuries, Traumatic/therapy
- Brain Neoplasms/epidemiology
- Brain Neoplasms/physiopathology
- Brain Neoplasms/therapy
- Cerebral Hemorrhage/epidemiology
- Cerebral Hemorrhage/physiopathology
- Cerebral Hemorrhage/therapy
- Critical Care
- Disease Management
- Emergency Service, Hospital
- Europe/epidemiology
- Female
- Glasgow Coma Scale
- Health Resources
- Heart Arrest/epidemiology
- Heart Arrest/physiopathology
- Heart Arrest/therapy
- Hematoma, Subdural/epidemiology
- Hematoma, Subdural/physiopathology
- Hematoma, Subdural/therapy
- Hemodynamic Monitoring/statistics & numerical data
- Hospital Mortality
- Hospitals, Private/statistics & numerical data
- Hospitals, Public/statistics & numerical data
- Humans
- Intensive Care Units
- Internationality
- Ischemic Stroke/epidemiology
- Ischemic Stroke/physiopathology
- Ischemic Stroke/therapy
- Latin America/epidemiology
- Length of Stay/statistics & numerical data
- Logistic Models
- Male
- Middle Aged
- Middle East/epidemiology
- Multivariate Analysis
- Neurophysiological Monitoring/statistics & numerical data
- North America/epidemiology
- Oceania/epidemiology
- Odds Ratio
- Palliative Care/statistics & numerical data
- Patient Admission/statistics & numerical data
- Patient Comfort
- Patient Transfer/statistics & numerical data
- Referral and Consultation/statistics & numerical data
- Reflex, Pupillary
- Resuscitation Orders
- Risk Factors
- Severity of Illness Index
- Subarachnoid Hemorrhage/epidemiology
- Subarachnoid Hemorrhage/physiopathology
- Subarachnoid Hemorrhage/therapy
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Affiliation(s)
- Chethan P Venkatasubba Rao
- Division of Vascular Neurology and Neurocritical Care, Baylor College of Medicine and CHI Baylor St Luke's Medical Center, Houston, TX, USA
| | - Jose I Suarez
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, Johns Hopkins University School of Medicine, 1800 Orleans Street, Zayed 3014C, Baltimore, MD, 21287, USA.
| | - Renee H Martin
- Medical University of South Carolina, Charleston, SC, USA
| | - Colleen Bauza
- Department of Health Informatics, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Alexandros Georgiadis
- Division of Vascular Neurology and Neurocritical Care, Baylor College of Medicine and CHI Baylor St Luke's Medical Center, Houston, TX, USA
| | - Eusebia Calvillo
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, Johns Hopkins University School of Medicine, 1800 Orleans Street, Zayed 3014C, Baltimore, MD, 21287, USA
| | | | - Gene Sung
- University of Southern California, Los Angeles, CA, USA
| | - Mauro Oddo
- CHUV Lausanne University Hospital, Lausanne, Switzerland
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Cui Z, Gao L, Huang QB, Li LH, Qiu BH, Shi GZ, Yu XY, Wang Y, Zhang L, Wang Y, Zhang L, Zhou JX. Core competencies in neurocritical care training in China: consensus developed by a national Delphi consensus survey combined with nominal group technique. BMJ Open 2020; 10:e033441. [PMID: 31911520 PMCID: PMC6955523 DOI: 10.1136/bmjopen-2019-033441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES To define the core competencies essential for specialist training in neurocritical care in China. DESIGN Modified Delphi method and nominal group (NG) technique. SETTING National. PARTICIPANTS A total of 1094 respondents from 33 provinces in China participated in the online survey. A NG of 11 members was organised by the Neuro-Critical Care Committee affiliated with the Chinese Association of Critical Care Physicians and the National Center for Healthcare Quality Management in Neurological Diseases. RESULTS 1094 respondents from 33 provinces in China participated in the online survey. A formal list containing 329 statements was generated for the rating by a NG. After five rounds of NG meetings and one round of comments and iterative review, 198 core competencies (54 on neurological diseases, 64 on general medical diseases, 42 on monitoring of practical procedures, 20 on professionalism and system management, five on ethical and legal aspects, three on the principles of research and certification and 10 on scoring systems) formed the final list. CONCLUSION By using consensus techniques, we have developed a list of core competencies for neurocritical care training, which may serve as a reference for future specialist training programmes in China.
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Affiliation(s)
- Zhen Cui
- Department of Critical Care Medicine, Ji Shui Tan Hospital and Fourth Medical College of Peking University, Beijing, China
| | - Liang Gao
- Department of Neurosurgery, Shanghai Tenth People's Hospital, Shanghai, China
| | - Qi Bing Huang
- Department of Neurosurgery, Shandong University Qilu Hospital, Jinan, China
| | - Li Hong Li
- Department of Neurosurgery, Tangdu Hospital Fourth Military Medical University, Xi'an, China
| | - Bing Hui Qiu
- Department of Neurosurgery, Southern Medical University Nanfang Hospital, Guangzhou, China
| | - Guang Zhi Shi
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Beijing, China
| | - Xiang You Yu
- Department of Critical Care Medicine, Xinjiang Medical University Affiliated First Hospital, Urumqi, China
| | - Yan Wang
- Department of Critical Care Medicine, Xinjiang Medical University Affiliated First Hospital, Urumqi, China
| | - Li Zhang
- Department of Critical Care Medicine, Xinjiang Medical University Affiliated First Hospital, Urumqi, China
| | - Yumei Wang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Beijing, China
| | - Linlin Zhang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Beijing, China
| | - Jian-Xin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Beijing, China
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Cohen AS, Izzy S, Kumar MA, Joyce CJ, Figueroa SA, Maas MB, Hall CE, McDonagh DL, Lerner DP, Vespa PM, Shutter LA, Rosenthal ES. Education Research: Variation in priorities for neurocritical care education expressed across role groups. Neurology 2019; 90:1117-1122. [PMID: 29891575 DOI: 10.1212/wnl.0000000000005682] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To define expectations for neurocritical care (NCC) core competencies vs competencies considered within the domain of other subspecialists. METHODS An electronic survey was disseminated nationally to NCC nurses, physicians, fellows, and neurology residents through Accreditation Council for Graduate Medical Education neurology residency program directors, United Council for Neurologic Subspecialties neurocritical care fellowship program directors, and members of the Neurocritical Care Society. RESULTS A total of 268 neurocritical care providers and neurology residents from 30 institutions responded. Overall, >90% supported NCC graduates independently interpreting and managing systemic and cerebral hemodynamic data, or performing brain death determination, neurovascular ultrasound, vascular access, and airway management. Over 75% endorsed that NCC graduates should independently interpret EEG and perform bronchoscopies. Fewer but substantial respondents supported graduates being independent performing intracranial bolt (45.8%), ventriculostomy (39.0%), tracheostomy (39.8%), or gastrostomy (19.1%) procedures. Trainees differed from physicians and program directors, respectively, by advocating independence in EEG interpretation (92.8%, 61.8%, and 65.3%) and PEG placement (29.3%, 9.1%, and 8.5%). CONCLUSIONS Broad support exists across NCC role groups for wide-ranging NCC competencies including skills often performed by other neurology and non-neurology subspecialties. Variations highlight natural divergences in expectations among trainee, physician, and nurse role groups. These results establish expectations for core competencies within NCC and initiate dialogue across subspecialties about best practice standards for the spectrum of critically ill patients requiring neurologic care.
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Affiliation(s)
- Abigail S Cohen
- From Tulane University School of Medicine (A.S.C.), New Orleans, LA; Department of Neurology (S.I.), Brigham and Women's Hospital, Boston, MA; Department of Neurology (M.A.K.), University of Pennsylvania, Philadelphia; Department of Public Health Sciences (C.J.J.), Loyola University, Chicago, IL; Departments of Neurology and Neurotherapeutics (S.A.F., C.E.H.) and Anesthesiology, Neurology, and Neurosurgery (D.L.M.), UT Southwestern, Dallas, TX; Department of Neurology (M.B.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (D.P.L.), Lahey Clinic, Burlington, MA; Departments of Neurology and Neurosurgery (P.M.V.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Departments of Critical Care Medicine, Neurology & Neurosurgery (L.A.S.), University of Pittsburgh School of Medicine/UPMC, PA; and Department of Neurology (E.S.R.), Massachusetts General Hospital, Boston
| | - Saef Izzy
- From Tulane University School of Medicine (A.S.C.), New Orleans, LA; Department of Neurology (S.I.), Brigham and Women's Hospital, Boston, MA; Department of Neurology (M.A.K.), University of Pennsylvania, Philadelphia; Department of Public Health Sciences (C.J.J.), Loyola University, Chicago, IL; Departments of Neurology and Neurotherapeutics (S.A.F., C.E.H.) and Anesthesiology, Neurology, and Neurosurgery (D.L.M.), UT Southwestern, Dallas, TX; Department of Neurology (M.B.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (D.P.L.), Lahey Clinic, Burlington, MA; Departments of Neurology and Neurosurgery (P.M.V.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Departments of Critical Care Medicine, Neurology & Neurosurgery (L.A.S.), University of Pittsburgh School of Medicine/UPMC, PA; and Department of Neurology (E.S.R.), Massachusetts General Hospital, Boston
| | - Monisha A Kumar
- From Tulane University School of Medicine (A.S.C.), New Orleans, LA; Department of Neurology (S.I.), Brigham and Women's Hospital, Boston, MA; Department of Neurology (M.A.K.), University of Pennsylvania, Philadelphia; Department of Public Health Sciences (C.J.J.), Loyola University, Chicago, IL; Departments of Neurology and Neurotherapeutics (S.A.F., C.E.H.) and Anesthesiology, Neurology, and Neurosurgery (D.L.M.), UT Southwestern, Dallas, TX; Department of Neurology (M.B.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (D.P.L.), Lahey Clinic, Burlington, MA; Departments of Neurology and Neurosurgery (P.M.V.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Departments of Critical Care Medicine, Neurology & Neurosurgery (L.A.S.), University of Pittsburgh School of Medicine/UPMC, PA; and Department of Neurology (E.S.R.), Massachusetts General Hospital, Boston
| | - Cara J Joyce
- From Tulane University School of Medicine (A.S.C.), New Orleans, LA; Department of Neurology (S.I.), Brigham and Women's Hospital, Boston, MA; Department of Neurology (M.A.K.), University of Pennsylvania, Philadelphia; Department of Public Health Sciences (C.J.J.), Loyola University, Chicago, IL; Departments of Neurology and Neurotherapeutics (S.A.F., C.E.H.) and Anesthesiology, Neurology, and Neurosurgery (D.L.M.), UT Southwestern, Dallas, TX; Department of Neurology (M.B.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (D.P.L.), Lahey Clinic, Burlington, MA; Departments of Neurology and Neurosurgery (P.M.V.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Departments of Critical Care Medicine, Neurology & Neurosurgery (L.A.S.), University of Pittsburgh School of Medicine/UPMC, PA; and Department of Neurology (E.S.R.), Massachusetts General Hospital, Boston
| | - Stephen A Figueroa
- From Tulane University School of Medicine (A.S.C.), New Orleans, LA; Department of Neurology (S.I.), Brigham and Women's Hospital, Boston, MA; Department of Neurology (M.A.K.), University of Pennsylvania, Philadelphia; Department of Public Health Sciences (C.J.J.), Loyola University, Chicago, IL; Departments of Neurology and Neurotherapeutics (S.A.F., C.E.H.) and Anesthesiology, Neurology, and Neurosurgery (D.L.M.), UT Southwestern, Dallas, TX; Department of Neurology (M.B.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (D.P.L.), Lahey Clinic, Burlington, MA; Departments of Neurology and Neurosurgery (P.M.V.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Departments of Critical Care Medicine, Neurology & Neurosurgery (L.A.S.), University of Pittsburgh School of Medicine/UPMC, PA; and Department of Neurology (E.S.R.), Massachusetts General Hospital, Boston
| | - Matthew B Maas
- From Tulane University School of Medicine (A.S.C.), New Orleans, LA; Department of Neurology (S.I.), Brigham and Women's Hospital, Boston, MA; Department of Neurology (M.A.K.), University of Pennsylvania, Philadelphia; Department of Public Health Sciences (C.J.J.), Loyola University, Chicago, IL; Departments of Neurology and Neurotherapeutics (S.A.F., C.E.H.) and Anesthesiology, Neurology, and Neurosurgery (D.L.M.), UT Southwestern, Dallas, TX; Department of Neurology (M.B.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (D.P.L.), Lahey Clinic, Burlington, MA; Departments of Neurology and Neurosurgery (P.M.V.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Departments of Critical Care Medicine, Neurology & Neurosurgery (L.A.S.), University of Pittsburgh School of Medicine/UPMC, PA; and Department of Neurology (E.S.R.), Massachusetts General Hospital, Boston
| | - Christiana E Hall
- From Tulane University School of Medicine (A.S.C.), New Orleans, LA; Department of Neurology (S.I.), Brigham and Women's Hospital, Boston, MA; Department of Neurology (M.A.K.), University of Pennsylvania, Philadelphia; Department of Public Health Sciences (C.J.J.), Loyola University, Chicago, IL; Departments of Neurology and Neurotherapeutics (S.A.F., C.E.H.) and Anesthesiology, Neurology, and Neurosurgery (D.L.M.), UT Southwestern, Dallas, TX; Department of Neurology (M.B.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (D.P.L.), Lahey Clinic, Burlington, MA; Departments of Neurology and Neurosurgery (P.M.V.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Departments of Critical Care Medicine, Neurology & Neurosurgery (L.A.S.), University of Pittsburgh School of Medicine/UPMC, PA; and Department of Neurology (E.S.R.), Massachusetts General Hospital, Boston
| | - David L McDonagh
- From Tulane University School of Medicine (A.S.C.), New Orleans, LA; Department of Neurology (S.I.), Brigham and Women's Hospital, Boston, MA; Department of Neurology (M.A.K.), University of Pennsylvania, Philadelphia; Department of Public Health Sciences (C.J.J.), Loyola University, Chicago, IL; Departments of Neurology and Neurotherapeutics (S.A.F., C.E.H.) and Anesthesiology, Neurology, and Neurosurgery (D.L.M.), UT Southwestern, Dallas, TX; Department of Neurology (M.B.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (D.P.L.), Lahey Clinic, Burlington, MA; Departments of Neurology and Neurosurgery (P.M.V.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Departments of Critical Care Medicine, Neurology & Neurosurgery (L.A.S.), University of Pittsburgh School of Medicine/UPMC, PA; and Department of Neurology (E.S.R.), Massachusetts General Hospital, Boston
| | - David P Lerner
- From Tulane University School of Medicine (A.S.C.), New Orleans, LA; Department of Neurology (S.I.), Brigham and Women's Hospital, Boston, MA; Department of Neurology (M.A.K.), University of Pennsylvania, Philadelphia; Department of Public Health Sciences (C.J.J.), Loyola University, Chicago, IL; Departments of Neurology and Neurotherapeutics (S.A.F., C.E.H.) and Anesthesiology, Neurology, and Neurosurgery (D.L.M.), UT Southwestern, Dallas, TX; Department of Neurology (M.B.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (D.P.L.), Lahey Clinic, Burlington, MA; Departments of Neurology and Neurosurgery (P.M.V.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Departments of Critical Care Medicine, Neurology & Neurosurgery (L.A.S.), University of Pittsburgh School of Medicine/UPMC, PA; and Department of Neurology (E.S.R.), Massachusetts General Hospital, Boston
| | - Paul M Vespa
- From Tulane University School of Medicine (A.S.C.), New Orleans, LA; Department of Neurology (S.I.), Brigham and Women's Hospital, Boston, MA; Department of Neurology (M.A.K.), University of Pennsylvania, Philadelphia; Department of Public Health Sciences (C.J.J.), Loyola University, Chicago, IL; Departments of Neurology and Neurotherapeutics (S.A.F., C.E.H.) and Anesthesiology, Neurology, and Neurosurgery (D.L.M.), UT Southwestern, Dallas, TX; Department of Neurology (M.B.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (D.P.L.), Lahey Clinic, Burlington, MA; Departments of Neurology and Neurosurgery (P.M.V.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Departments of Critical Care Medicine, Neurology & Neurosurgery (L.A.S.), University of Pittsburgh School of Medicine/UPMC, PA; and Department of Neurology (E.S.R.), Massachusetts General Hospital, Boston
| | - Lori A Shutter
- From Tulane University School of Medicine (A.S.C.), New Orleans, LA; Department of Neurology (S.I.), Brigham and Women's Hospital, Boston, MA; Department of Neurology (M.A.K.), University of Pennsylvania, Philadelphia; Department of Public Health Sciences (C.J.J.), Loyola University, Chicago, IL; Departments of Neurology and Neurotherapeutics (S.A.F., C.E.H.) and Anesthesiology, Neurology, and Neurosurgery (D.L.M.), UT Southwestern, Dallas, TX; Department of Neurology (M.B.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (D.P.L.), Lahey Clinic, Burlington, MA; Departments of Neurology and Neurosurgery (P.M.V.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Departments of Critical Care Medicine, Neurology & Neurosurgery (L.A.S.), University of Pittsburgh School of Medicine/UPMC, PA; and Department of Neurology (E.S.R.), Massachusetts General Hospital, Boston
| | - Eric S Rosenthal
- From Tulane University School of Medicine (A.S.C.), New Orleans, LA; Department of Neurology (S.I.), Brigham and Women's Hospital, Boston, MA; Department of Neurology (M.A.K.), University of Pennsylvania, Philadelphia; Department of Public Health Sciences (C.J.J.), Loyola University, Chicago, IL; Departments of Neurology and Neurotherapeutics (S.A.F., C.E.H.) and Anesthesiology, Neurology, and Neurosurgery (D.L.M.), UT Southwestern, Dallas, TX; Department of Neurology (M.B.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (D.P.L.), Lahey Clinic, Burlington, MA; Departments of Neurology and Neurosurgery (P.M.V.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Departments of Critical Care Medicine, Neurology & Neurosurgery (L.A.S.), University of Pittsburgh School of Medicine/UPMC, PA; and Department of Neurology (E.S.R.), Massachusetts General Hospital, Boston.
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9
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Akavipat P, Thinkhamrop J, Thinkhamrop B, Sriraj W. ACUTE PHYSIOLOGY AND CHRONIC HEALTH EVALUATION (APACHE) II SCORE - THE CLINICAL PREDICTOR IN NEUROSURGICAL INTENSIVE CARE UNIT. Acta Clin Croat 2019; 58:50-56. [PMID: 31363325 PMCID: PMC6629196 DOI: 10.20471/acc.2019.58.01.07] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The APACHE II scoring system is approved for its benchmarking and mortality predictions, but there are only a few articles published to demonstrate it in neurosurgical patients. Therefore, this study was performed to acknowledge this score and its predictive performance to hospital mortality in a tertiary referral neurosurgical intensive care unit (ICU). All patients admitted to the Neurosurgical ICU from February 1 to July 31, 2011 were recruited. The parameters indicated in APACHE II score were collected. The adjusted predicted risk of death was calculated and compared with the death rate observed. Descriptive statistics including the receiver operating characteristic curve (ROC) was performed. The results showed that 276 patients were admitted during the mentioned period. The APACHE II score was 16.56 (95% CI, 15.84-17.29) and 19.08 (95% CI, 15.40-22.76) in survivors and non-survivors, while the adjusted predicted death rates were 13.39% (95% CI, 11.83-14.95) and 17.49% (95% CI, 9.81-25.17), respectively. The observed mortality was only 4.35%. The area under the ROC of APACHE II score to the hospital mortality was 0.62 (95% CI, 0.44-0.79). In conclusion, not only the APACHE II score in neurosurgical patients indicated low severity, but its performance to predict hospital mortality was also inferior. Additional studies of predicting mortality among these critical patients should be undertaken.
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Affiliation(s)
| | - Jadsada Thinkhamrop
- 1Anesthesiology Department, Prasat Neurological Institute, Bangkok, Thailand; 2Department of Obstetrics and Gynecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand; 3Department of Biostatistics and Demography, Faculty of Public Health, Khon Kaen University, Khon Kaen, Thailand; 4Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Bandit Thinkhamrop
- 1Anesthesiology Department, Prasat Neurological Institute, Bangkok, Thailand; 2Department of Obstetrics and Gynecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand; 3Department of Biostatistics and Demography, Faculty of Public Health, Khon Kaen University, Khon Kaen, Thailand; 4Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Wimonrat Sriraj
- 1Anesthesiology Department, Prasat Neurological Institute, Bangkok, Thailand; 2Department of Obstetrics and Gynecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand; 3Department of Biostatistics and Demography, Faculty of Public Health, Khon Kaen University, Khon Kaen, Thailand; 4Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
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10
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Pediatric Neurocritical Care: Evolution of a New Clinical Service in PICUs Across the United States. Pediatr Crit Care Med 2018; 19:1039-1045. [PMID: 30134362 DOI: 10.1097/pcc.0000000000001708] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Pediatric neurocritical care as a conceptual service is relatively new, and implementation of such specialized services may improve outcomes for children with disorders of the brain or spinal cord. How many pediatric neurocritical care services currently exist in the United States, and attitudes about such a service are unknown. DESIGN Web-based survey, distributed by e-mail. SETTING Survey was sent to PICU Medical Directors and Program Directors of Pediatric Neurosurgery fellowship and Child Neurology residency programs. PATIENTS None. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 378 surveys were distributed; 161 respondents representing 128 distinct hospitals completed the survey (43% response rate). Thirty-five percent (45/128) reported having a pediatric neurocritical care service. The most common type of service used a consultation model (82%; 32/39 responses). Other types of services were intensivist-led teams in the PICU (five hospitals) and dedicated PICU beds (two hospitals). Hospital characteristics associated with availability of pediatric neurocritical care services were level 1 trauma status (p = 0.017), greater numbers of PICU beds (χ [6, n = 128] = 136.84; p < 0.01), and greater volume of children with pediatric neurocritical care conditions (χ [3, n = 128] = 20.16; p < 0.01). The most common reasons for not having a pediatric neurocritical care service were low patient volume (34/119 responses), lack of subspecialists (30/119 responses), and lack of interest by PICU faculty (25/119 responses). The positive impacts of a pediatric neurocritical care service were improved interdisciplinary education/training (16/45 responses), dedicated expertise (13/45 responses), improved interservice communication (9/45 responses), and development/implementation of guidelines and protocols (9/45 responses). The negative impacts of a pediatric neurocritical care service were disagreement among consultants (2/45 responses) and splitting of the PICU population (2/45 responses). CONCLUSIONS At least 45 specialized pediatric neurocritical care services exist in the United States. Eighty percent of these services are a consultation service to the PICU. Hospitals with level 1 trauma status, greater numbers of PICU beds, and greater numbers of patients with pediatric neurocritical care conditions were associated with the existence of pediatric neurocritical care as a clinical service.
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11
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Sivakumar S, Taccone FS, Rehman M, Hinson H, Naval N, Lazaridis C. Hemodynamic and neuro-monitoring for neurocritically ill patients: An international survey of intensivists. J Crit Care 2017; 39:40-47. [DOI: 10.1016/j.jcrc.2017.01.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2016] [Accepted: 01/14/2017] [Indexed: 11/29/2022]
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Abstract
BACKGROUND Although attention to neurologic injuries and illnesses in pediatric critical care is not new, a sub-specialized field of pediatric neurocritical care has only recently been recognized. Pediatric neurocritical care is an emerging area of clinical and investigative focus. Little is known about the prevalence of specialized pediatric neurocritical care services nor about perceptions regarding how it is impacting medical practice. This survey sought to capture perceptions about an emerging area of specialized pediatric neurocritical care among practitioners in intersecting disciplines, including pediatric intensivists, pediatric neurologits and pediatric neurosurgeons. METHODS A web-based survey was distributed via email to members of relevant professional societies and groups. Survey responses were analyzed using descriptive statistics. Differences in responses between groups of respondents were analyzed using Chi-squared analysis where appropriate. MAIN RESULTS Specialized clinical PNCC programs were not uncommon among the survey respondents with 20% currently having a PNCC service at their institution. Despite familiarity with this area of sub-specialization among the survey respondents, the survey did not find consensus regarding its value. Overall, 46% of respondents believed that a specialized clinical PNCC service improves the quality of care of critically ill children. Support for PNCC sub-specialization was more common among pediatric neurologists and pediatric neurosurgeons than pediatric intensivists. This survey found support across specialties for creating PNCC training pathways for both pediatric intensivists and pediatric neurologists with an interest in this specialized field. CONCLUSIONS PNCC programs are not uncommon; however, there is not clear agreement on the optimal role or benefit of this area of practice sub-specialization. A broader dialog should be undertaken regarding the emerging practice of pediatric neurocritical care, the potential benefits and drawbacks of this partitioning of neurology and critical care medicine practice, economic and other practical factors, the organization of clinical support services, and the formalization of training and certification pathways for sub-specialization.
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Abstract
PURPOSE OF REVIEW In this review, we present an update on the relationship between anesthesia and intraoperative hemodynamic complications, early postanesthesia recovery, postoperative pain and postoperative nausea and vomiting after craniotomy. We also review latest advances in education and research in neuroanesthesia for brain surgery. RECENT FINDINGS Insights from clinical reports published from January 2012 to April 2013 on anesthesia for craniotomy will be summarized. Recent findings address the need for a tight intraoperative hemodynamic monitoring - that should include aggressive prevention of arterial hypotension and cardiac arrhythmias - and a careful management of fluids and electrolytes balance. Data on the relationship between anesthesia (selection of anesthetics used intraoperatively) and early recovery demonstrate a limited benefit when ultra-short acting drugs (as remifentanil vs fentanyl) are used. Evidence on postoperative pain and postoperative nausea and vomiting contribute to define how to better prevent and treat these complications. Latest guidelines on training and research in neuroanesthesia define unique end points in this subspecialty. SUMMARY Neuroanesthesia for craniotomy should be aimed to ensure intraoperative loss of consciousness (unless awake craniotomy is the selected anesthesiological approach), pain control and an uneventful postoperative recovery, but should also be addressed to manipulate physiological variables including cerebral blood flow and to obtain optimal surgical exposure.
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Abstract
The neurologically injured child, whether from trauma or other causes, is a common admission into any Pediatric critical care unit. Whatever the cause, the risk for death and life long disability remains very high. Unlike the adult population, neurological diseases in children are diverse and arise from a variety of factors that vary greatly in age and presentation. Nervous system dysfunction is often a complication of critical illness and interventions. While neurointensive care units may be ideal for the at-risk child, in mixed units, 40 % of admissions may be neurological or have neurological complications. Improved quality of care and the application of protocols and bundles, appear to have contributed significantly to improved outcomes. Since we are constantly facing an uphill task of dealing with deterioration while trying to preserve function, detection of early shifts of any nature would be deemed helpful. The intensivist must focus not only on saving life but also on preventing disability with full awareness that responsibility does not end with discharge from the pediatric intensive care unit (PICU). Outcome audits should include not only deaths and discharge from PICU but also one year mortality and even degree of disability at the end of one year from discharge.
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Affiliation(s)
- Soonu Udani
- Department of Pediatrics and Pediatric Intensive Care, P D Hinduja Hospital, Veer Savarkar Marg, Mahim, Mumbai, 400016, India,
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15
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Abstract
PURPOSE OF REVIEW The care of critically ill brain-injured patients is complex and requires careful balancing of cerebral and systemic treatment priorities. A growing number of studies have reported improved outcomes when patients are admitted to dedicated neurocritical care units (NCCUs). The reasons for this observation have not been definitively clarified. RECENT FINDINGS When recently published articles are combined with older literature, there have been more than 40 000 patients assessed in observational studies that compare neurological and general ICUs. Although results are heterogeneous, admission to NCCUs is associated with lower mortality and a greater chance of favorable recovery. These findings are remarkable considering that there are few interventions in neurocritical care that have been demonstrated to be efficacious in randomized trials. Whether the relationship is causal is still being elucidated but potential explanations include higher patient volume and, in turn, greater clinician experience; more emphasis on and adherence to protocols to avoid secondary brain injury; practice differences related to prognostication and withdrawal of life-sustaining interventions; and differences in the use and interpretation of neuroimaging and neuromonitoring data. SUMMARY Neurocritical care is an evolving field that is associated with improvements in outcomes over the past decade. Further research is required to determine how monitoring and treatment protocols can be optimized.
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Su Y, Wang M, Liu Y, Ye H, Gao D, Chen W, Zhang Y, Zhang Y. Module modified acute physiology and chronic health evaluation II: predicting the mortality of neuro-critical disease. Neurol Res 2014; 36:1099-105. [PMID: 24914905 DOI: 10.1179/1743132814y.0000000395] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVES This study aimed to conduct and assess a module modified acute physiology and chronic health evaluation (MM-APACHE) II model, based on disease categories modified-acute physiology and chronic health evaluation (DCM-APACHE) II model, in predicting mortality more accurately in neuro-intensive care units (N-ICUs). METHODS In total, 1686 patients entered into this prospective study. Acute physiology and chronic health evaluation (APACHE) II scores of all patients on admission and worst 24-, 48-, 72-hour scores were obtained. Neurological diagnosis on admission was classified into five categories: cerebral infarction, intracranial hemorrhage, neurological infection, spinal neuromuscular (SNM) disease, and other neurological diseases. The APACHE II scores of cerebral infarction, intracranial hemorrhage, and neurological infection patients were used for building the MM-APACHE II model. RESULTS There were 1386 cases for cerebral infarction disease, intracranial hemorrhage disease, and neurological infection disease. The logistic linear regression showed that 72-hour APACHE II score (Wals = 173.04, P < 0.001) and disease classification (Wals = 12.51, P = 0.02) were of importance in forecasting hospital mortality. Module modified acute physiology and chronic health evaluation II model, built on the variables of the 72-hour APACHE II score and disease category, had good discrimination (area under the receiver operating characteristic curve (AU-ROC = 0.830)) and calibration (χ2 = 12.518, P = 0.20), and was better than the Knaus APACHE II model (AU-ROC = 0.778). DISCUSSION The APACHE II severity of disease classification system cannot provide accurate prognosis for all kinds of the diseases. A MM-APACHE II model can accurately predict hospital mortality for cerebral infarction, intracranial hemorrhage, and neurologic infection patients in N-ICU.
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Hodgson TS, Brorson JR, Ardelt AA, Lukas RV. Accrediting neurology fellowships accelerates subspecialization. Front Neurol 2013; 4:94. [PMID: 23888152 PMCID: PMC3719470 DOI: 10.3389/fneur.2013.00094] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Accepted: 07/05/2013] [Indexed: 12/04/2022] Open
Affiliation(s)
- Trent S Hodgson
- Pritzker School of Medicine, University of Chicago , Chicago, IL, USA
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Abstract
Because pediatric intensive care units (PICUs) improve survival for a range of acute diseases, attention has turned toward ensuring the best possible functional outcomes after critical illness. The neurocritical care of children is of increasing interest. However, the pediatric population encompasses a heterogeneous set of neurologic conditions, with several possible models of how best to address them. This article reviews the special challenges faced by PICUs with regards to diseases, technologies, and skills and the progress that has been made in treatment, monitoring, and prognostication. Recent advances in translational research expected to modify the field in the near-term are described.
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Affiliation(s)
- Joshua Cappell
- Pediatric Critical Care Medicine, Department of Pediatrics, Morgan Stanley Children's Hospital, Columbia University Medical Center, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA
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Sheth KN, Drogan O, Manno E, Geocadin RG, Ziai W. Neurocritical care education during neurology residency: AAN survey of US program directors. Neurology 2012; 78:1793-6. [PMID: 22573636 DOI: 10.1212/wnl.0b013e3182583034] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Limited information is available regarding the current state of neurocritical care education for neurology residents. The goal of our survey was to assess the need and current state of neurocritical care training for neurology residents. METHODS A survey instrument was developed and, with the support of the American Academy of Neurology, distributed to residency program directors of 132 accredited neurology programs in the United States in 2011. RESULTS A response rate of 74% (98 of 132) was achieved. A dedicated neuroscience intensive care unit (neuro-ICU) existed in 64%. Fifty-six percent of residency programs offer a dedicated rotation in the neuro-ICU, lasting 4 weeks on average. Where available, the neuro-ICU rotation was required in the vast majority (91%) of programs. Neurology residents' exposure to the fundamental principles of neurocritical care was obtained through a variety of mechanisms. Of program directors, 37% indicated that residents would be interested in performing away rotations in a neuro-ICU. From 2005 to 2010, the number of programs sending at least one resident into a neuro-ICU fellowship increased from 14% to 35%. CONCLUSIONS Despite the expansion of neurocritical care, large proportions of US neurology residents have limited exposure to a neuro-ICU and neurointensivists. Formal training in the principles of neurocritical care may be highly variable. The results of this survey suggest a charge to address the variability of resident education and to develop standardized curricula in neurocritical care for neurology residents.
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Affiliation(s)
- K N Sheth
- Department of Neurology, Neurosurgery, and Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.
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Diaz-Guzman E, Colbert CY, Mannino DM, Davenport DL, Arroliga AC. 24/7 In-house Intensivist Coverage and Fellowship Education. Chest 2012; 141:959-966. [DOI: 10.1378/chest.11-2073] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Kuehlmeyer K, Racine E, Palmour N, Hoster E, Borasio GD, Jox RJ. Diagnostic and ethical challenges in disorders of consciousness and locked-in syndrome: a survey of German neurologists. J Neurol 2012; 259:2076-89. [PMID: 22407274 PMCID: PMC3464386 DOI: 10.1007/s00415-012-6459-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2011] [Revised: 02/14/2012] [Accepted: 02/15/2012] [Indexed: 11/03/2022]
Abstract
Diagnosis and decisions on life-sustaining treatment (LST) in disorders of consciousness, such as the vegetative state (VS) and the minimally conscious state (MCS), are challenging for neurologists. The locked-in syndrome (LiS) is sometimes confounded with these disorders by less experienced physicians. We aimed to investigate (1) the application of diagnostic knowledge, (2) attitudes concerning limitations of LST, and (3) further challenging aspects in the care of patients. A vignette-based online survey with a randomized presentation of a VS, MCS, or LiS case scenario was conducted among members of the German Society for Neurology. A sample of 503 neurologists participated (response rate 16.4%). An accurate diagnosis was given by 86% of the participants. The LiS case was diagnosed more accurately (94%) than the VS case (79%) and the MCS case (87%, p < 0.001). Limiting LST for the patient was considered by 92, 91, and 84% of the participants who accurately diagnosed the VS, LiS, and MCS case (p = 0.09). Overall, most participants agreed with limiting cardiopulmonary resuscitation; a minority considered limiting artificial nutrition and hydration. Neurologists regarded the estimation of the prognosis and determination of the patients’ wishes as most challenging. The majority of German neurologists accurately applied the diagnostic categories VS, MCS, and LiS to case vignettes. Their attitudes were mostly in favor of limiting life-sustaining treatment and slightly differed for MCS as compared to VS and LiS. Attitudes toward LST strongly differed according to circumstances (e.g., patient’s will opposed treatment) and treatment measures.
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Affiliation(s)
- Katja Kuehlmeyer
- Institute of Ethics, History and Theory of Medicine, University of Munich, Lessingstrasse 2, 80336, Munich, Germany.
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