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Lapierre A, Proulx A, Gélinas C, Dollé S, Alexander S, Williamson D, Bernard F, Arbour C. Association Between Pupil Light Reflex and Delirium in Adults With Traumatic Brain Injury: Preliminary Findings. J Neurosci Nurs 2024; 56:107-112. [PMID: 38833515 DOI: 10.1097/jnn.0000000000000763] [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: 06/06/2024]
Abstract
ABSTRACT BACKGROUND: Delirium is a common neurological complication in patients admitted to the intensive care unit (ICU) after moderate to severe traumatic brain injury (TBI). Although current clinical guidelines prioritize delirium prevention, no specific tool is tailored to detect early signs of delirium in TBI patients. This preliminary 2-phase observational study investigated the correlation between the pupillary light reflex (PLR), measured with a pupillometer during mechanical ventilation, and the development of postextubation delirium in TBI patients. METHODS: A convenience sample of 26 adults with moderate to severe TBI under mechanical ventilation was recruited during their ICU stay. In phase I, PLR measurements were performed in the first 3 days of ICU admission using automated infrared pupillometry. In phase II, 2 raters independently extracted delirium data in the 72 hours post extubation period from medical records. Delirium was confirmed with a documented medical diagnosis. Point-biserial correlations ( rpb ) were used to examine the association between PLR scores and the presence of postextubation delirium. Student t tests were also performed to compare mean PLR scores between patients with and without delirium. RESULTS: Ten TBI patients (38%) were diagnosed with postextubation delirium, whereas 16 (62%) were not. Significant correlations between delirium and 2 PLR variables were found: pupil constriction percentage ( rpb (24) = -0.526, P = .006) and constriction velocity ( rpb (24) = -0.485, P = .012). The t test also revealed a significant difference in constriction percentage and velocity scores between TBI patients with and without delirium ( P ≤ .01). CONCLUSION: Our findings suggest that the use of pupillometry in the first 3 days of mechanical ventilation during an ICU stay may help identify TBI patients at risk for delirium after extubation. Although further research is necessary to support its validity, this technological tool may enable ICU nurses to better screen TBI patients for delirium and prevent its development.
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Cajanus K, Kytö V, Ruuskanen JO, Luoto TM, Rautava P, Tornio A, Posti JP. Association of Central Nervous System-Affecting Medications With Occurrence and Short-Term Mortality of Traumatic Brain Injury. Neurosurgery 2024; 94:721-728. [PMID: 37850916 DOI: 10.1227/neu.0000000000002732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 09/01/2023] [Indexed: 10/19/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The use of medications commonly prescribed after traumatic brain injury (TBI) has been little studied before TBI. This study examined the association between the use of medications that affect the central nervous system (CNS) and the occurrence and short-term mortality of TBI. METHODS Mandatory Finnish registries were used to identify TBI admissions, fatal TBIs, and drug purchases during 2005-2018. Patients with TBI were 1:1 matched to nontrauma control patients to investigate the association between medications and the occurrence of TBI and 30-day mortality after TBI. Number needed to harm (NNH) was calculated for all medications. RESULTS The cohort included 59 606 patients with TBI and a similar number of control patients. CNS-affecting drugs were more common in patients with TBI than in controls [odds ratio = 2.07 (2.02-2.13), P < .001)]. Benzodiazepines were the most common type of medications in patients with TBI (17%) and in controls (11%). The lowest NNH for the occurrence of TBI was associated with benzodiazepines (15.4), selective serotonin uptake inhibitors (18.5), and second-generation antipsychotics (25.8). Eight percent of the patients with TBI died within 30 days. The highest hazard ratios (HR) and lowest NNHs associated with short-term mortality were observed with strong opioids [HR = 1.41 (1.26-1.59), NNH = 33.1], second-generation antipsychotics [HR = 1.36 (1.23-1.50), NNH = 37.1], and atypical antidepressants [HR = 1.17 (1.04-1.31), NNH = 77.7]. CONCLUSION Thirty-seven percent of patients with TBI used at least 1 CNS-affecting drug. This proportion was significantly higher than in the control population (24%). The highest risk and lowest NNH for short-term mortality were observed with strong opioids, second-generation antipsychotics, and atypical antidepressants. The current risks underscore the importance of weighing the benefits and risks before prescribing CNS-affecting drugs in patients at risk of head injury.
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Affiliation(s)
- Kristiina Cajanus
- Department of Clinical Pharmacology, Turku University Hospital and University of Turku, Turku , Finland
| | - Ville Kytö
- Heart Centre and Center for Population Health Research, Turku University Hospital and University of Turku, Turku , Finland
- Research Services, Turku University Hospital, Turku , Finland
| | - Jori O Ruuskanen
- Neurocenter, Department of Neurology, Turku University Hospital and University of Turku, Turku , Finland
| | - Teemu M Luoto
- Department of Neurosurgery, Tampere University Hospital and Tampere University, Tampere , Finland
| | - Päivi Rautava
- Clinical Research Center, Turku University Hospital and University of Turku, Turku , Finland
| | - Aleksi Tornio
- Department of Clinical Pharmacology, Turku University Hospital and University of Turku, Turku , Finland
| | - Jussi P Posti
- Neurocenter, Department of Neurosurgery and Turku Brain Injury Center, Turku University Hospital and University of Turku, Turku , Finland
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Richey LN, Daneshvari NO, Young L, Bray MJ, Gottesman RF, Mosley T, Walker KA, Peters ME, Schneider AL. Associations of Prior Head Injury With Mild Behavioral Impairment Domains. J Head Trauma Rehabil 2024; 39:E48-E58. [PMID: 37335212 PMCID: PMC10728342 DOI: 10.1097/htr.0000000000000880] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
OBJECTIVE This study investigated associations of prior head injury and number of prior head injuries with mild behavioral impairment (MBI) domains. SETTING The Atherosclerosis Risk in Communities (ARIC) Study. PARTICIPANTS A total of 2534 community-dwelling older adults who took part in the ARIC Neurocognitive Study stage 2 examination were included. DESIGN This was a prospective cohort study. Head injury was defined using self-reported and International Classification of Diseases, Ninth Revision ( ICD -9) code data. MBI domains were defined using the Neuropsychiatric Inventory Questionnaire (NPI-Q) via an established algorithm mapping noncognitive neuropsychiatric symptoms to the 6 domains of decreased motivation, affective dysregulation, impulse dyscontrol, social inappropriateness, and abnormal perception/thought content. MAIN MEASURES The primary outcome was the presence of impairment in MBI domains. RESULTS Participants were a mean age of 76 years, with a median time from first head injury to NPI-Q administration of 32 years. The age-adjusted prevalence of symptoms in any 1+ MBI domains was significantly higher among individuals with versus without prior head injury (31.3% vs 26.0%, P = .027). In adjusted models, a history of 2+ head injuries, but not 1 prior head injury, was associated with increased odds of impairment in affective dysregulation and impulse dyscontrol domains, compared with no history of head injury (odds ratio [OR] = 1.83, 95% CI = 1.13-2.98, and OR = 1.74, 95% CI = 1.08-2.78, respectively). Prior head injury was not associated with symptoms in MBI domains of decreased motivation, social inappropriateness, and abnormal perception/thought content (all P > .05). CONCLUSION Prior head injury in older adults was associated with greater MBI domain symptoms, specifically affective dysregulation and impulse dyscontrol. Our results suggest that the construct of MBI can be used to systematically examine the noncognitive neuropsychiatric sequelae of head injury; further studies are needed to examine whether the systematic identification and rapid treatment of neuropsychiatric symptoms after head injury is associated with improved outcomes.
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Affiliation(s)
- Lisa N. Richey
- Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences
| | - Nicholas O. Daneshvari
- Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences
| | - Lisa Young
- Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences
| | - Michael J.C. Bray
- Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences
| | - Rebecca F. Gottesman
- National Institutes of Health, National Institute of Neurological Disorders and Stroke Intramural Research Program
| | | | | | - Matthew E. Peters
- Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences
| | - Andrea L.C. Schneider
- University of Pennsylvania Perelman School of Medicine, Department of Neurology, Division of Neurocritical Care
- University of Pennsylvania Perelman School of Medicine, Department of Biostatistics, Epidemiology, and Informatics
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Domensino AF, Tas J, Donners B, Kooyman J, van der Horst ICC, Haeren R, Ariës MJH, van Heugten C. Long-Term Follow-Up of Critically Ill Patients With Traumatic Brain Injury: From Intensive Care Parameters to Patient and Caregiver-Reported Outcome. J Neurotrauma 2024; 41:123-134. [PMID: 37265152 DOI: 10.1089/neu.2022.0474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023] Open
Abstract
Abstract Traumatic brain injury (TBI) is associated with a high social and financial burden due to persisting (severe) disabilities. The consequences of TBI after intensive care unit (ICU) admission are generally measured with global disability screeners such as the Glasgow Outcome Scale-Extended (GOSE), which may lack precision. To improve outcome measurement after brain injury, a comprehensive clinical outcome assessment tool called the Minimal Dataset for Acquired Brain Injury (MDS-ABI) was recently developed. The MDS-ABI covers 12 life domains (demographics, injury characteristics, comorbidity, cognitive functioning, emotional functioning, energy, mobility, self-care, communication, participation, social support, and quality of life), as well as informal caregiver capacity and strain. In this cross-sectional study, we used the MDS-ABI among formerly ICU admitted patients with TBI to explore the relationship between dichotomized severity of TBI and long-term outcome. Our objectives were to: 1) summarize demographics, clinical characteristics, and long-term outcomes of patients and their informal caregivers, and 2) compare differences between long-term outcomes in patients with mild-moderate TBI and severe TBI based on Glasgow Coma Scale (GCS) scores at admission. Participants were former patients of a Dutch university hospital (total n = 52; mild-moderate TBI n = 23; severe TBI n = 29) and their informal caregivers (n = 45). Hospital records were evaluated, and the MDS-ABI was administered during a home visit. On average 3.2 years after their TBI, 62% of the patients were cognitively impaired, 62% reported elevated fatigue, and 69% experienced restrictions in ≥2 participation domains (most frequently work or education and going out). Informal caregivers generally felt competent to provide necessary care (81%), but 31% experienced a disproportionate caregiver burden. All but four patients lived at home independently, often together with their informal caregiver (81%). Although the mild-moderate TBI group and the severe TBI group had significantly different clinical trajectories, there were no persisting differences between the groups for patient or caregiver outcomes at follow-up. As a large proportion of the patients experienced long-lasting consequences beyond global disability or independent living, clinicians should implement a multi-domain outcome set such as the MDS-AB to follow up on their patients.
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Affiliation(s)
- Anne-Fleur Domensino
- School for Mental Health and Neuroscience (MHeNS), Faculty of Psychology and Neuroscience (FPN), Maastricht University, Maastricht, The Netherlands
- Limburg Brain Injury Centre, Maastricht, The Netherlands
| | - Jeanette Tas
- School for Mental Health and Neuroscience (MHeNS), Faculty of Psychology and Neuroscience (FPN), Maastricht University, Maastricht, The Netherlands
- Department of Intensive Care Medicine, Maastricht University, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Babette Donners
- Department of Intensive Care Medicine, Maastricht University, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Joyce Kooyman
- School for Mental Health and Neuroscience (MHeNS), Faculty of Psychology and Neuroscience (FPN), Maastricht University, Maastricht, The Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care Medicine, Maastricht University, Maastricht University Medical Center+, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Roel Haeren
- School for Mental Health and Neuroscience (MHeNS), Faculty of Psychology and Neuroscience (FPN), Maastricht University, Maastricht, The Netherlands
- Department of Neurosurgery, Maastricht University, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Marcel J H Ariës
- School for Mental Health and Neuroscience (MHeNS), Faculty of Psychology and Neuroscience (FPN), Maastricht University, Maastricht, The Netherlands
- Department of Intensive Care Medicine, Maastricht University, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Caroline van Heugten
- School for Mental Health and Neuroscience (MHeNS), Faculty of Psychology and Neuroscience (FPN), Maastricht University, Maastricht, The Netherlands
- Limburg Brain Injury Centre, Maastricht, The Netherlands
- Department of Neuropsychology and Psychopharmacology, Faculty of Psychology and Neuroscience (FPN), Maastricht University, Maastricht, The Netherlands
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Pupillary light reflex measured with quantitative pupillometry has low sensitivity and high specificity for predicting neuroworsening after traumatic brain injury. J Am Assoc Nurse Pract 2023; 35:130-134. [PMID: 36763466 DOI: 10.1097/jxx.0000000000000822] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 11/15/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Triage and neurological assessment of the 1.7 million traumatic brain injuries occurring annually is often done by nurse practitioners and physician assistants in the emergency department. Subjective assessments, such as the neurological examination that includes evaluation of the pupillary light reflex (PLR), can contain bias. Quantitative pupillometry (QP) standardizes and objectifies the PLR examination. Additional data are needed to determine whether QP can predict neurological changes in a traumatic brain injury (TBI) patient. PURPOSE This study examines the effectiveness of QP in predicting neurological decline within 24 hours of admission following acute TBI. METHODOLOGY This prospective, observational, clinical trial used pragmatic sampling to assess PLR in TBI patients using QP within 24 hours of ED admission. Chi-square analysis was used to determine change in patient status, through Glasgow Coma Scale (GCS), at baseline and within 24 hours of admission, to the QP. RESULTS There were 95 participants included in the analysis; of whom 35 experienced neuroworsening, defined by change in GCS of >2 within the first 24 hours of admission. There was a significant association between an abnormal Neurological Pupil index (NPi), defined as NPi of <3, and neuroworsening (p < .0001). The sensitivity (51.43%) and specificity (91.67%) of abnormal NPi in predicting neuroworsening were varied. CONCLUSION There is a strong association between abnormal NPi and neuroworsening in the sample of TBI patients with high specificity and moderate sensitivity. IMPLICATIONS NPi may be an early indicator of neurological changes within 24 hours of ED admission in patients with TBI.
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Emotional Disturbances After Traumatic Brain Injury: Prevalence, Assessment, and Treatment. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2021. [DOI: 10.1007/s40141-021-00311-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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