Effect of mechanical chest percussion on intracranial pressure: a pilot study.

BACKGROUND: Treatment of brain injury is often focused on minimizing intracranial pressure, which, when elevated, can lead to secondary brain injury. Chest percussion is a common practice used to treat and prevent pneumonia. Conflicting and limited anecdotal evidence indicates that physical stimulation increases intracranial pressure and should be avoided in patients at risk of intracranial hypertension. OBJECTIVES: To explore the safety of performing chest percussion for patients at high risk for intracranial hypertension. METHODS: A total of 28 patients with at least 1 documented episode of intracranial hypertension who were having intracranial pressure monitored were studied in a prospective randomized control trial. Patients were randomly assigned to either the control group (no chest percussion) or the intervention group (10 minutes of chest percussion at noon). Intracranial pressure was recorded once a minute before, during, and after the intervention. RESULTS: Mean intracranial pressures for the control group before, during, and after the study period (14.4, 15.0, and 15.9 mm Hg, respectively) did not differ significantly from pressures in the intervention group (13.6, 13.7, and 14.2 mm Hg, respectively). CONCLUSIONS: Mechanical chest percussion may be a safe intervention for nurses to use on neurologically injured patients who are at risk for intracranial hypertension.

Apnea testing during brain death assessment: a review of clinical practice and published literature.

The diagnosis of brain death is a complex process. Strong knowledge of neurophysiology and an understanding of brain death etiology must be used to confidently determine brain death. The key findings in brain death are unresponsiveness, and absence of brainstem reflexes in the setting of a devastating neurological injury. These findings are coupled with a series of confirmatory tests, and the diagnosis of brain death is established based on consensus recommendations. The drive to breathe in the setting of an intense ventilatory stimulus (ie, respiratory acidosis) is a critical marker of brainstem function. As a consequence, apnea testing is an important component of brain death assessment. This procedure requires close monitoring of a patient as all ventilator support is temporarily removed and Paco2 levels are allowed to rise. A "positive" test is defined by a total absence of respiratory efforts under these conditions. While apnea testing is not new, it still lacks consensus standardization regarding the actual procedure, monitored parameters, and evidence-based safety measures that may be used to prevent complications. The purpose of this report is to provide an overview of apnea testing and discuss issues related to the administration and safety of the procedure.

Interrater reliability of the bedside shivering assessment scale.

BACKGROUND: Since its early development, the Bedside Shivering Assessment Scale (BSAS) has had only initial psychometric testing. Before this instrument is incorporated into routine practice, its interrater reliability should be explored in a diverse group of practitioners. METHODS: This prospective nonrandomized study used a panel of 5 observers who completed 100 paired assessments. Observers independently scored patients for shivering by using the BSAS. Kappa statistics were determined by using SAS version 9.4 with BSAS scores treated as ordinal data. RESULTS: A weighted kappa value of 0.48 from 100 paired observations of 22 patients indicates moderate agreement of the BSAS scores. Most of the BSAS scores were 0 or 1; dichotomizing shivering as little or no shivering versus significant shivering resulted in a kappa of 0.66 (substantial agreement). No relationship was found between timing of assessment or the role of the practitioner and the likelihood of both observers assigning the same BSAS score. CONCLUSION: The BSAS has adequate interrater reliability to be considered for use among a diverse group of practitioners.