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Kunovac F, Cicvaric A, Robba C, Turk T, Muzevic D, Kralik K, Kvolik S. Gastrointestinal Motility Disorders Correlate with Intracranial Bleeding, Opioid Use, and Brainstem Edema in Neurosurgical Patients. Neurocrit Care 2023; 39:368-377. [PMID: 36788178 DOI: 10.1007/s12028-023-01678-5] [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] [Received: 07/07/2022] [Accepted: 01/12/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND Gastrointestinal (GI) motility disorders may be directly associated with the intensity of acute brain injury, edema of the brainstem, and opioid use in neurosurgical patients. METHODS In this retrospective study, patient demographic characteristics, computed tomography (CT) scans, the occurrence of gastroparesis, constipation, and opioid use were registered during the intensive care unit (ICU) stay and correlated with days of mechanical ventilation, length of ICU stay, and survival. Gastroparesis was defined as residual gastric volume > 250 mL per day, and constipation was defined as the absence of stool for 3 days or more during the ICU stay. RESULTS Of 207 neurosurgical patients screened, 69 adult patients who spent more than 4 days in the ICU were included in the study. Gastroparesis was observed in 48 (69.6%) patients, constipation was observed in 67 (97.1%) patients, and stress ulcers were observed in 4 (5.8%) patients. Patients with brainstem edema (n = 57, 82.6%) had the first stool evacuation later compared with patients with no edema (8 [interquartile range (IQR) 5.25-9.75] vs. 3.5 [IQR 2.25-4] days; P < 0.001). In the logistic regression analysis, factors that were associated with GI dysmotility were central nervous system (CNS) bleeding (odds ratio [OR] 5.1, 95% confidence interval [CI] 1.26-20.8, P = 0.02), opioid use > 19.3 morphine equivalents (ME) per day (OR 5.37, 95% CI 1.1-27.1, P = 0.04), and brainstem edema (OR 4.9, 95% CI 1.1-21.6, P = 0.04). A receiver operating characteristic curve analysis confirmed that the cutoff value of > 6.78 ME per day was a good predictor determining GI dysmotility, with 89.5% sensitivity and 72.7% specificity (95% CI 0.67-0.88, area under the curve 0.784, Youden index 0.62, P = 0.001). Poor survival correlated with lower Glasgow Coma Score values (ρ = - 520, P < 0.001), CNS bleeding (ρ = 0.393, P < 0.001), associated cardiac diseases (ρ = 0.279, P < 0.001), and cardiorespiratory arrest on admission (ρ = 0.315, P < 0.001), but not with GI dysmotility (ρ = 0.175, P = 0.402). CONCLUSIONS Significant correlation was registered between brainstem edema, gastrointestinal dysmotility, and opioids. CNS bleeding was the most important single factor influencing GI dysmotility. Further studies with opioid and nonopioid sedation may distinguish the influence of acute brain lesions versus drugs on GI dysmotility.
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Affiliation(s)
- Franka Kunovac
- Faculty of Medicine, University of Osijek, Osijek, Croatia
| | - Ana Cicvaric
- Faculty of Medicine, University of Osijek, Osijek, Croatia
- Department of Anesthesiology, Resuscitation and Intensive Care Unit, University Hospital Osijek, Osijek, Croatia
| | - Chiara Robba
- Anesthesia and Intensive Care, Policlinico San Martino, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Tajana Turk
- Faculty of Medicine, University of Osijek, Osijek, Croatia
- Department of Radiology, University Hospital Osijek, J. Huttlera 4, Osijek, 31000, Croatia
| | - Dario Muzevic
- Faculty of Medicine, University of Osijek, Osijek, Croatia
- Department of Neurosurgery, University Hospital Osijek, J. Huttlera 4, Osijek, Croatia
| | | | - Slavica Kvolik
- Faculty of Medicine, University of Osijek, Osijek, Croatia.
- Department of Anesthesiology, Resuscitation and Intensive Care Unit, University Hospital Osijek, Osijek, Croatia.
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Barra ME, Iracheta C, Tolland J, Jehle J, Minova L, Li K, Amatangelo M, Krause P, Batra A, Vaitkevicius H. Multidisciplinary Approach to Sedation and Early Mobility of Intubated Critically Ill Neurologic Patients Improves Mobility at Discharge. Neurohospitalist 2023; 13:351-360. [PMID: 37701262 PMCID: PMC10494812 DOI: 10.1177/19418744231182897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023] Open
Abstract
Background and Purpose Over-sedation may confound neurologic assessment in critically ill neurologic patients and prolong duration of mechanical ventilation (MV). Decreased sedative use may facilitate early functional independence when combined with early mobility. The objective of this study was to evaluate the impact of a stepwise, multidisciplinary analgesia-first sedation pathway and early mobility protocol on medication use and mobility in the neuroscience intensive care unit (ICU). Methods We performed a single-center prospective cohort study with adult patients admitted to a neuroscience ICU between March and June 2016-2018 who required MV for greater than 48 hours. Patients were included from three separate phases of the study: Phase I - historical controls (2016); Phase II - analgesia-first pathway (2017); Phase III - early mobility protocol (2018). Primary outcomes included propofol requirements during MV, total rehabilitation therapy provided, and functional mobility during ICU admission. Results 156 patients were included in the analysis. Decreasing propofol exposure was observed during Phase I, II, and III (median 2243.7 mg/day vs 2065.6 mg/day vs 1360.8 mg/day, respectively; P = .04 between Phase I and III). Early mobility was provided in 59.7%, 40%, and 81.6% of patients while admitted to the ICU in Phase I, II, and III, respectively (P < .01). An increased proportion of patients in Phase III were walking or ambulating at ICU discharge (26.7%; 8/30) compared to Phase I (7.9%, 3/38, P = .05). Conclusions An interdisciplinary approach with an analgesia-first sedation pathway with early mobility protocol was associated with less sedative use, increased rehabilitation therapy, and improved functional mobility status at ICU discharge.
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Affiliation(s)
- Megan E. Barra
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA USA
| | - Christine Iracheta
- Department of Rehabilitation Services, Brigham and Women’s Hospital, Boston, MA USA
| | - Joseph Tolland
- Department of Rehabilitation Services, Brigham and Women’s Hospital, Boston, MA USA
| | - Johnathan Jehle
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA USA
- Department of Adult Palliative Care, Brigham and Women’s Hospital, Boston, MA USA
| | - Ljubica Minova
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA USA
| | - Karen Li
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA USA
| | - Mary Amatangelo
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA USA
| | - Patricia Krause
- Department of Pharmacy, Brigham and Women’s Hospital, Boston, MA USA
| | - Ayush Batra
- Department of Neurology & Pathology, Northwestern University Feinberg School of Medicine, Chicago IL USA
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Jain AK, Tansey G, Hartig R, Mitchell AS, Basso MA. Trends and Treatment Approaches for Complications in Neuroscience Experiments with Monkey Species. Comp Med 2023; 73:216-228. [PMID: 37208151 PMCID: PMC10290483 DOI: 10.30802/aalas-cm-22-000079] [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: 07/09/2022] [Revised: 09/12/2022] [Accepted: 01/12/2023] [Indexed: 05/21/2023]
Abstract
Our goal in this manuscript is to advance the assessment and treatment of monkey species in neuroscience research. We hope to begin a discussion and establish baseline data on how complications are identified and treated. We surveyed the neuroscience research community working with monkeys and compiled responses to questions about investigator demographics, assessment of animal wellbeing, treatment choices, and approaches to mitigate risks associated with CNS procedures and promote monkey health and wellbeing. The majority of the respondents had worked with nonhuman primates (NHP) for over 15 y. Identification of procedure-related complications and efficacy of treatment generally rely on common behavioral indices. Treatments for localized inflammatory responses are generally successful, whereas the treatment success for meningitis or meningoencephalitis, abscesses, and hemorrhagic stroke are less successful. Behavioral signs of pain are treated successfully with NSAIDs and opioids. Our future plans are to collate treatment protocols and develop best practices that can be shared across the neuroscience community to improve treatment success rates and animal welfare and therefore science. Human protocols can be used to develop best practices, assess outcomes, and promote further refinements in treatment practices for monkeys to enhance research outcomes.
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Affiliation(s)
- Aarti Kishore Jain
- Fuster Laboratory of Cognitive Neuroscience, Department of Psychiatry and Biobehavioral Sciences Jane and Terry Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, California
| | - Ginger Tansey
- National Eye Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland
| | - Renée Hartig
- Translational Neuroscience Division, Center for Biomedical Imaging and Neuromodulation, Nathan Kline Institute for Psychiatric Research, Orangeburg, New York; Department of Psychiatry and Psychotherapy, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Anna S Mitchell
- Department of Experimental Psychology, Oxford University, Tinsley Building, Oxford, United Kingdom; School of Psychology, Speech, and Hearing, University of Canterbury, Christchurch, New Zealand
| | - Michele A Basso
- Fuster Laboratory of Cognitive Neuroscience, Department of Psychiatry and Biobehavioral Sciences Jane and Terry Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, California; Washington National Primate Research Center, Departments of Biological Structure and Physiology and Biophysics, University of Washington, Seattle, Washington;,
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Sriganesh K, Bharadwaj S, Shanthanna H, Umamaheswara Rao GS, Kramer BW, Sathyaprabha TN. Opioid versus Nonopioid Analgesia for Craniotomy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. World Neurosurg 2023; 173:e66-e75. [PMID: 36739893 DOI: 10.1016/j.wneu.2023.01.111] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 01/27/2023] [Accepted: 01/28/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND Despite the use of intraoperative opioid analgesia, postoperative pain is often reported by patients undergoing craniotomies. Opioids also cause undesirable side effects in neurosurgical patients. Hence, the role of nonopioid analgesia has been explored for craniotomies in recent years. METHODS This systematic review evaluated evidence from randomized controlled trials (RCTs) comparing opioid and nonopioid analgesia during craniotomies regarding postoperative pain, recovery, and adverse events. RESULTS Of the 10,459 records obtained by searching MEDLINE, Embase, and Web of Science databases, 6 RCTs were included. No difference was observed in pain scores between opioid and nonopioid analgesia at 1 and 24 hours after surgery: mean difference (MD), 1.11 units; 95% confidence interval [CI], -0.16 to 2.38, P = 0.09 and MD, -0.06 units; 95% CI, -1.14 to 1.01, P = 0.91, respectively. The time for first postoperative analgesic requirement was shorter with opioids but was not statistically significant (MD, -84.77 minutes; 95% CI, -254.65 to 85.11; P = 0.33). Postoperative nausea and vomiting (relative risk = 1.60; 95% CI, 0.96-2.66; P = 0.07) was similar but shivering (relative risk = 2.01; 95% CI, 1.09-3.71; P = 0.03) was greater in the opioid group than nonopioid group. CONCLUSIONS There were no important differences in clinical outcomes between the groups in our review. The GRADE certainty of evidence was rated low for most outcomes. Available evidence does not suggest superiority of intraoperative nonopioid over opioid analgesia for postoperative pain in patients undergoing craniotomy. More studies are needed to firmly establish the role of nonopioid intraoperative analgesics as an alternative to opioids in this population.
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Affiliation(s)
- Kamath Sriganesh
- National Institute of Mental Health and Neurosciences, Bengaluru, India.
| | - Suparna Bharadwaj
- National Institute of Mental Health and Neurosciences, Bengaluru, India
| | - Harsha Shanthanna
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | | | - Boris W Kramer
- Maastricht University Medical Center, Maastricht, the Netherlands; School of Women's and Infants' Health, University of Western Australia, Crawley, WA, Australia
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Russo E, Latta M, Santonastaso DP, Bellantonio D, Cittadini A, Pietrantozzi D, Circelli A, Gamberini E, Martino C, Spiga M, Agnoletti V. Regional anesthesia in the intensive care unit: a single center's experience and a narrative literature review. DISCOVER HEALTH SYSTEMS 2023; 2:4. [PMID: 37520512 PMCID: PMC9870192 DOI: 10.1007/s44250-023-00018-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 01/04/2023] [Indexed: 08/01/2023]
Affiliation(s)
- Emanuele Russo
- Department of Surgery and Trauma, Anesthesia and Intensive Care Unit, Maurizio Bufalini Hospital, Cesena, Italy
| | - Marina Latta
- Anesthesia and Intensive Care Department, Alma Mater Studiorum – Università Di Bologna, Bologna, Italy
| | | | - Daniele Bellantonio
- Department of Surgery and Trauma, Anesthesia and Intensive Care Unit, Maurizio Bufalini Hospital, Cesena, Italy
| | - Alessio Cittadini
- Department of Surgery and Trauma, Anesthesia and Intensive Care Unit, Maurizio Bufalini Hospital, Cesena, Italy
| | - Dario Pietrantozzi
- Department of Surgery and Trauma, Anesthesia and Intensive Care Unit, Maurizio Bufalini Hospital, Cesena, Italy
| | - Alessandro Circelli
- Department of Surgery and Trauma, Anesthesia and Intensive Care Unit, Maurizio Bufalini Hospital, Cesena, Italy
| | - Emiliano Gamberini
- Department of Surgery, Anesthesia and Intensive Care Unit, Infermi Hospital, Rimini, Italy
| | - Costanza Martino
- Department of Anesthesiology and Acute Care, Umberto I Hospital of Lugo, Ausl Della Romagna, Lugo, Italy
| | - Martina Spiga
- Department of Surgery and Trauma, Anesthesia and Intensive Care Unit, Maurizio Bufalini Hospital, Cesena, Italy
| | - Vanni Agnoletti
- Department of Surgery and Trauma, Anesthesia and Intensive Care Unit, Maurizio Bufalini Hospital, Cesena, Italy
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Sorrentino ZA, Laurent D, Hernandez J, Davidson C, Small C, Dodd W, Lucke‐Wold B. Headache persisting after aneurysmal subarachnoid hemorrhage: A narrative review of pathophysiology and therapeutic strategies. Headache 2022; 62:1120-1132. [PMID: 36112096 DOI: 10.1111/head.14394] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 06/30/2022] [Accepted: 07/04/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Zachary A. Sorrentino
- Department of Neurosurgery University of Florida College of Medicine Gainesville Florida USA
| | - Dimitri Laurent
- Department of Neurosurgery University of Florida College of Medicine Gainesville Florida USA
| | - Jairo Hernandez
- Department of Neurosurgery University of Florida College of Medicine Gainesville Florida USA
| | - Caroline Davidson
- Department of Neurosurgery University of Florida College of Medicine Gainesville Florida USA
| | - Coulter Small
- Department of Neurosurgery University of Florida College of Medicine Gainesville Florida USA
| | - William Dodd
- Department of Neurosurgery University of Florida College of Medicine Gainesville Florida USA
| | - Brandon Lucke‐Wold
- Department of Neurosurgery University of Florida College of Medicine Gainesville Florida USA
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Maciel CB, Barlow B, Lucke-Wold B, Gobinathan A, Abu-Mowis Z, Peethala MM, Merck LH, Aspide R, Dickinson K, Miao G, Shan G, Bilotta F, Morris NA, Citerio G, Busl KM. Acute Headache Management for Patients with Subarachnoid Hemorrhage: An International Survey of Health Care Providers. Neurocrit Care 2022; 38:395-406. [PMID: 35915347 DOI: 10.1007/s12028-022-01571-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 07/05/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Severe headaches are common after subarachnoid hemorrhage. Guidelines recommend treatment with acetaminophen and opioids, but patient data show that headaches often persist despite multimodal treatment approaches. Considering an overall slim body of data for a common complaint affecting patients with SAH during their intensive care stay, we set out to assess practice patterns in headache management among clinicians who treat patients with SAH. METHODS We conducted an international cross-sectional study through a 37-question Web-based survey distributed to members of five professional societies relevant to intensive and neurocritical care from November 2021 to January 2022. Responses were characterized through descriptive analyses. Fisher's exact test was used to test associations. RESULTS Of 516 respondents, 329 of 497 (66%) were from North America and 121 of 497 (24%) from Europe. Of 435 respondents, 379 (87%) reported headache as a major management concern for patients with SAH. Intensive care teams were primarily responsible for analgesia during hospitalization (249 of 435, 57%), whereas responsibility shifted to neurosurgery at discharge (233 of 501, 47%). Most used medications were acetaminophen (90%), opioids (66%), corticosteroids (28%), and antiseizure medications (28%). Opioids or medication combinations including opioids were most frequently perceived as most effective by 169 of 433 respondents (39%, predominantly intensivists), followed by corticosteroids or combinations with corticosteroids (96 of 433, 22%, predominantly neurologists). Of medications prescribed at discharge, acetaminophen was most common (303 of 381, 80%), followed by opioids (175 of 381, 46%) and antiseizure medications (173 of 381, 45%). Opioids during hospitalization were significantly more prescribed by intensivists, by providers managing higher numbers of patients with SAH, and in Europe. At discharge, opioids were more frequently prescribed in North America. Of 435 respondents, 299 (69%) indicated no change in prescription practice of opioids with the opioid crisis. Additional differences in prescription patterns between continents and providers and while inpatient versus at discharge were found. CONCLUSIONS Post-SAH headache in the intensive care setting is a major clinical concern. Analgesia heavily relies on opioids both in use and in perception of efficacy, with no reported change in prescription patterns for opioids for most providers despite the significant drawbacks of opioids. Responsibility for analgesia shifts between hospitalization and discharge. International and provider-related differences are evident. Novel treatment strategies and alignment of prescription between providers are urgently needed.
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Affiliation(s)
- Carolina B Maciel
- Department of Neurology, College of Medicine, University of Florida, McKnight Brain Institute, L3-100, 1149 Newell Drive, Gainesville, FL, 32608, USA.,Department of Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Brooke Barlow
- Department of Pharmacy, University of Florida Health Shands Hospital, Gainesville, FL, USA
| | - Brandon Lucke-Wold
- Department of Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Arravintha Gobinathan
- Departments of Microbiology and Anthropology, University of Florida, Gainesville, FL, USA
| | - Zaid Abu-Mowis
- Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL, USA
| | - Mounika Mukherjee Peethala
- Department of Neurology, College of Medicine, University of Florida, McKnight Brain Institute, L3-100, 1149 Newell Drive, Gainesville, FL, 32608, USA
| | - Lisa H Merck
- Department of Emergency Medicine College of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Raffaele Aspide
- Anesthesia and Neurointensive Care Unit, Istituto delle Scienze Neurologiche di Bologna, Istituto di Ricovero e Cura a Carattere Scientifico, Bologna, Italy
| | - Katie Dickinson
- Department of Neurology, College of Medicine, University of Florida, McKnight Brain Institute, L3-100, 1149 Newell Drive, Gainesville, FL, 32608, USA
| | - Guanhong Miao
- Department of Biostatistics, University of Florida, Gainesville, FL, USA
| | - Guogen Shan
- Department of Biostatistics, University of Florida, Gainesville, FL, USA.,Research Design and Data Coordinating Center, Clinical and Translational Science Institute, University of Florida, Gainesville, FL, USA
| | - Federico Bilotta
- Department of Anesthesiology, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Nicholas A Morris
- Department of Neurology, School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Neurointensive Care Unit, San Gerardo Hospital, ASST-Monza, Monza, Italy
| | - Katharina M Busl
- Department of Neurology, College of Medicine, University of Florida, McKnight Brain Institute, L3-100, 1149 Newell Drive, Gainesville, FL, 32608, USA. .,Department of Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA.
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