Neurocritical Care: A Growing International Collaborative

Pediatric Perspectives on Palliative Care in the Neurocritical Care Unit

Pediatric neurocritical care teams care for patients and families facing the potential for significant neurologic impairment and high mortality. Such admissions are often marked by significant prognostic uncertainty, high levels of parental emotional overload, and multiple potentially life-altering decision points. In addition to clinical acumen, families desire clear and consistent communication, supported decision-making, a multidisciplinary approach to psychosocial supports throughout an admission, and comprehensive bereavement support after a death. Distinct from their adult counterparts, pediatric providers care for a broader set of rare diagnoses with limited prognostic information. Decision-making requires its own ethical framework, with substitutive judgment giving way to the best interest standard as well as "good parent" narratives. When a child dies, bereavement support is often needed for the broader community. There will always be a role for specialist palliative care consultation in the pediatric neurocritical care unit, but the care of every patient and family will be well served by improving these primary palliative care skills.

Utility and rationale for continuous EEG monitoring: a primer for the general intensivist

This review offers a comprehensive guide for general intensivists on the utility of continuous EEG (cEEG) monitoring for critically ill patients. Beyond the primary role of EEG in detecting seizures, this review explores its utility in neuroprognostication, monitoring neurological deterioration, assessing treatment responses, and aiding rehabilitation in patients with encephalopathy, coma, or other consciousness disorders. Most seizures and status epilepticus (SE) events in the intensive care unit (ICU) setting are nonconvulsive or subtle, making cEEG essential for identifying these otherwise silent events. Imaging and invasive approaches can add to the diagnosis of seizures for specific populations, given that scalp electrodes may fail to identify seizures that may be detected by depth electrodes or electroradiologic findings. When cEEG identifies SE, the risk of secondary neuronal injury related to the time-intensity "burden" often prompts treatment with anti-seizure medications. Similarly, treatment may be administered for seizure-spectrum activity, such as periodic discharges or lateralized rhythmic delta slowing on the ictal-interictal continuum (IIC), even when frank seizures are not evident on the scalp. In this setting, cEEG is utilized empirically to monitor treatment response. Separately, cEEG has other versatile uses for neurotelemetry, including identifying the level of sedation or consciousness. Specific conditions such as sepsis, traumatic brain injury, subarachnoid hemorrhage, and cardiac arrest may each be associated with a unique application of cEEG; for example, predicting impending events of delayed cerebral ischemia, a feared complication in the first two weeks after subarachnoid hemorrhage. After brief training, non-neurophysiologists can learn to interpret quantitative EEG trends that summarize elements of EEG activity, enhancing clinical responsiveness in collaboration with clinical neurophysiologists. Intensivists and other healthcare professionals also play crucial roles in facilitating timely cEEG setup, preventing electrode-related skin injuries, and maintaining patient mobility during monitoring.

Fit for Service: Preparing Residents for Neurointensive Care with Entrustable Professional Activities: A Delphi Study

BACKGROUND

Although the relevance of neurointensive medicine and high-quality training of corresponding physicians is increasingly recognized, there is high heterogeneity in the nature, duration, and quality of neurointensive care curricula around the world. Thus, we aimed to identify, define, and establish validity evidence for entrustable professional activities (EPAs) for postgraduate training in neurointensive care to determine trainees' readiness for being on-call.

METHODS

After defining EPAs through an iterative process by an expert group, we used a modified Delphi approach with a single-center development process followed by a national consensus and a single-center validation step. EPAs were evaluated by using the EQual rubric (Queen's EPA Quality Rubric). Interrater reliability was measured with Krippendorff's α.

RESULTS

The expert group defined seven preliminary EPAs for neurointensive care. In two consecutive Delphi rounds, EPAs were adapted, and consensus was reached for level of entrustment and time of expiration. Ultimately, EPAs reached a high EQual score of 4.5 of 5 and above. Interrater reliability for the EQual scoring was 0.8.

CONCLUSIONS

Using a multistep Delphi process, we defined and established validity evidence for seven EPAs for neurointensive medicine with a high degree of consensus to objectively describe readiness for on-call duty in neurointensive care. This operationalization of pivotal clinical tasks may help to better train clinical residents in neurointensive care across sites and health care systems and has the potential to serve as a blueprint for training in general intensive care medicine. It also represents a starting point for further research and development of medical curricula.

Effect of a physician-nurse integrated lung protection care model in neurocritical patients

Background

Lung injury resulting from diffuse pulmonary interstitial and other lung-related complications is a significant contributor to poor prognosis and mortality in patients with critical neurological diseases. To enhance patient outcomes, it is essential to investigate a lung protection model that involves the collaboration of doctors, nurses, and other medical professionals.

Methods

Patients receiving different care styles were divided into two groups: routine care (RC) and lung function protection care (LFPC). The LFPC group included airway and posture management, sedation and analgesia management, positive end-expiratory pressure titration in ventilation management, and fluid volume management, among others. Statistical analysis methods, such as chi-square, were used to compare the incidence of acute lung injury (ALI), neurogenic pulmonary edema (NPE), ventilator-associated pneumonia (VAP), acute respiratory distress syndrome (ARDS), and length of stay between the RC and LFPC groups.

Results

The RC group included 68 patients (33 males; 34-74 years of age). The LFPC group included 60 patients (29 males; 37-73 years of age). Compared with the RC group, the LFPC group had lower occurrence rates of ALI (20.0 % vs. 38.2 %, P = 0.024), NPE (8.3 % vs. 23.5 %, P = 0.021), VAP (8.3 % vs. 25.0 %, P = 0.013), and ARDS (1.7 % vs. 16.2 %, P = 0.015). The length of hospital stay was shorter in the LFPC group than in the RC group (11.3 ± 3.5 vs. 14.3 ± 4.4 days, P = 0.0001).

Conclusion

The physician-nurse integrated lung protection care model proved to be effective in improving outcomes, reducing complications, and shortening the hospital stay length for neurocritical patients.

Pediatric Neurocritical Care: Maximizing Neurodevelopmental Outcomes Through Specialty Care

The field of pediatric neurocritical care (PNCC) has expanded and evolved over the last three decades. As mortality from pediatric critical care illness has declined, morbidity from neurodevelopmental disorders has expanded. PNCC clinicians have adopted a multidisciplinary approach to rapidly identify neurological injury, implement neuroprotective therapies, minimize secondary neurological insults, and establish transitions of care, all with the goal of improving neurocognitive outcomes for their patients. Although there are many aspects of PNCC and adult neurocritical care (NCC) medicine that are similar, elemental difference between adult and pediatric medicine has contributed to a divergent evolution of the respective fields. The low incidence of pediatric critical care illness, the heterogeneity of neurological insults, and the limited availability of resources all shape the need for a PNCC clinical care model that is distinct from the established paradigm adopted by the adult neurocritical care community at large. Considerations of neurodevelopment are fundamental in pediatrics. When neurological injury occurs in a child, the neurodevelopmental stage at the time of insult alters the impact of the neurological disease. Developmental variables contribute to a range of outcomes for seemingly similar injuries. Despite the relative infancy of the field of PNCC, early reports have shown that implementation of a specialized PNCC service elevates the quality and safety of care, promotes education and communication, and improves outcomes for children with acute neurological injuries. The multidisciplinary approach of PNCC clinicians and researchers also promotes a culture that emphasizes the importance of quality improvement and education initiatives, as well as development of and adherence to evidence-based guidelines and family-focused care models.

Association of Neurocritical Care Services With Mortality and Functional Outcomes for Adults With Brain Injury: A Systematic Review and Meta-analysis

Importance

Neurocritical care (NCC) aims to improve the outcomes of critically ill patients with brain injury, although the benefits of such subspecialized care are yet to be determined.

Objective

To evaluate the association of NCC with patient-centered outcomes in adults with acute brain injury who were admitted to intensive care units (ICUs). The protocol was preregistered on PROSPERO (CRD42020177190).

Data Sources

Three electronic databases were searched (Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials) from inception through December 15, 2021, and by citation chaining.

Study Selection

Studies were included for interventions of neurocritical care units (NCCUs), neurointensivists, or NCC consulting services compared with general care in populations of neurologically ill adults or adults with acute brain injury in ICUs.

Data Extraction and Synthesis

Data extraction was performed in keeping with PRISMA guidelines and risk of bias assessed through the ROBINS-I Cochrane tool by 2 independent reviewers. Data were pooled using a random-effects model.

Main Outcomes and Measures

The primary outcome was all-cause mortality at longest follow-up until 6 months. Secondary outcomes were ICU length of stay (LOS), hospital LOS, and functional outcomes. Data were measured as risk ratio (RR) if dichotomous or standardized mean difference if continuous. Subgroup analyses were performed for disease and models of NCC delivery.

Results

After 5659 nonduplicated published records were screened, 26 nonrandomized observational studies fulfilled eligibility criteria. A meta-analysis of mortality outcomes for 55 792 patients demonstrated a 17% relative risk reduction (RR, 0.83; 95% CI, 0.75-0.92; P = .001) in those receiving subspecialized care (n = 27 061) compared with general care (n = 27 694). Subgroup analyses did not identify subgroup differences. Eight studies including 4667 patients demonstrated a 17% relative risk reduction (RR, 0.83; 95% CI, 0.70-0.97; P = .03) for an unfavorable functional outcome with subspecialized care compared with general care. There were no differences in LOS outcomes. Heterogeneity was substantial in all analyses.

Conclusions and Relevance

Subspecialized NCC is associated with improved survival and functional outcomes for critically ill adults with brain injury. However, confidence in the evidence is limited by substantial heterogeneity. Further investigations are necessary to determine the specific aspects of NCC that contribute to these improved outcomes and its cost-effectiveness.

The pattern of neurocritical disorders in multicenter in Khartoum State November 2020 to January 2021

BACKGROUND

Neurocritical care is a growing subspecialty. It concerns with the management of life-threatening neurological disorders. There is limited information regarding epidemiological data, disease characteristics, variability of clinical care, and in-hospital mortality of neurocritical patients worldwide.

OBJECTIVES

To study the pattern of neurocritical disorders in intensive care units.

METHODOLOGY

This prospective observational study was conducted on neurocritical patients who were admitted to four intensive care units of major hospitals in Khartoum state during the period from November 2020 to January 2021.

RESULTS

Seventy-two neurocritical patients were included in this study, 40 (55.6%) were males and 32(44.4%) were females. Twenty-three (31.9%) patients were with stroke, 12 (16.7%) with encephalitis, 9 (12.5%) with status epilepticus, 6 (8.3%) with Guillain Barre syndrome, and 4(5.6%) with Myasthenia Gravis (MG). Twenty-three patients (39.9%) needed mechanical ventilation (MV), which was the major indication for intensive care unit admission.

CONCLUSION

Stroke was the dominant diagnostic pattern requiring intensive care unit admission. Mechanical ventilation was the major indication for admission. Establishing specialized neurocritical intensive care units is highly recommended.

Basic considerations on magnesium in the management of neurocritical patients

Magnesium is an essential chemical element in human life. In the brain, it is physiologically responsible for a large number of processes involved in intracellular homeostasis, blood-brain barrier integrity, protein synthesis, neuronal proliferation, aging, and apoptosis. Considering that neurocritical care is a relatively new discipline in certain regions of the world and is an independent protective factor of neurological diseases in critical care, it is essential to disseminate basic concepts and utilities of tools that can positively impact the neurological disease burden. Magnesium and its use in neurocritical care are poorly understood. Therefore, this study aimed to review basic concepts regarding the physiology of magnesium in neurological dynamics, its role in the pathophysiology of neurological disorders, and the outcome of its use in the management of neurocritical illnesses.