RESUMO
BACKGROUND: Cerebral perfusion pressure (CPP) is a key parameter in management of brain injury with suspected impaired cerebral autoregulation. CPP is calculated by subtracting intracranial pressure (ICP) from mean arterial pressure (MAP). Despite consensus on importance of CPP monitoring, substantial variations exist on anatomical reference points used to measure arterial MAP when calculating CPP. This study aimed to identify differences in CPP values based on measurement location when using phlebostatic axis (PA) or tragus (Tg) as anatomical reference points. The secondary study aim was to determine impact of differences on patient outcomes at discharge. METHODS: This was a prospective, repeated measures, multi-site national trial. Adult ICU patients with neurological injury necessitating ICP and CPP monitoring were consecutively enrolled from seven sites. Daily MAP/ICP/CPP values were gathered with the arterial transducer at the PA, followed by the Tg as anatomical reference points. RESULTS: A total of 136 subjects were enrolled, resulting in 324 paired observations. There were significant differences for CPP when comparing values obtained at PA and Tg reference points (p < 0.000). Differences remained significant in repeated measures model when controlling for clinical factors (mean CPP-PA = 80.77, mean CPP-Tg = 70.61, p < 0.000). When categorizing CPP as binary endpoint, 18.8% of values were identified as adequate with PA values, yet inadequate with CPP values measured at the Tg. CONCLUSION: Findings identify numerical differences for CPP based on anatomical reference location and highlight importance of a standard reference point for both clinical practice and future trials to limit practice variations and heterogeneity of findings.
Assuntos
Pressão Arterial/fisiologia , Lesões Encefálicas/fisiopatologia , Circulação Cerebrovascular/fisiologia , Cuidados Críticos/métodos , Pressão Intracraniana/fisiologia , Monitorização Neurofisiológica/métodos , Adulto , Idoso , Lesões Encefálicas/diagnóstico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Neurofisiológica/normas , Estudos Prospectivos , Adulto JovemRESUMO
Devastating brain injuries (DBIs) profoundly damage cerebral function and frequently cause death. DBI survivors admitted to critical care will suffer both intracranial and extracranial effects from their brain injury. The indicators of quality care in DBI are not completely defined, and despite best efforts many patients will not survive, although others may have better outcomes than originally anticipated. Inaccuracies in prognostication can result in premature termination of life support, thereby biasing outcomes research and creating a self-fulfilling cycle where the predicted course is almost invariably dismal. Because of the potential complexities and controversies involved in the management of devastating brain injury, the Neurocritical Care Society organized a panel of expert clinicians from neurocritical care, neuroanesthesia, neurology, neurosurgery, emergency medicine, nursing, and pharmacy to develop an evidence-based guideline with practice recommendations. The panel intends for this guideline to be used by critical care physicians, neurologists, emergency physicians, and other health professionals, with specific emphasis on management during the first 72-h post-injury. Following an extensive literature review, the panel used the GRADE methodology to evaluate the robustness of the data. They made actionable recommendations based on the quality of evidence, as well as on considerations of risk: benefit ratios, cost, and user preference. The panel generated recommendations regarding prognostication, psychosocial issues, and ethical considerations.
Assuntos
Lesões Encefálicas/terapia , Cuidados Críticos/normas , Gerenciamento Clínico , Guias de Prática Clínica como Assunto/normas , HumanosRESUMO
BACKGROUND: Traditional methods for intravascular volume status assessment are invasive and are associated significant complications. While focused bedside sonography of the inferior vena cava (IVC) has been shown to be useful in estimating intravascular volume status, it may be technically difficult and limited by patient factors such as obesity, bowel gas, or postoperative surgical dressings. The goal of this investigation is to determine the feasibility of subclavian vein (SCV) collapsibility as an adjunct to IVC collapsibility in intravascular volume status assessment. METHODS: A prospective study was conducted on a convenience sample of surgical intensive care unit patients to evaluate interchangeability of IVC collapsibility index (IVC-CI) and SCV-CI. After demographic and acuity of illness information was collected, all patients underwent serial, paired assessments of IVC-CI and SCV-CI using portable ultrasound device (M-Turbo; Sonosite, Bothell, WA). Vein collapsibility was calculated using the formula [collapsibility (%) = (max diameter - min diameter)/max diameter × 100%]. Paired measurements from each method were compared using correlation coefficient and Bland-Altman measurement bias analysis. RESULTS: Thirty-four patients (mean age 56 y, 38% female) underwent a total of 94 paired SCV-CI and IVC-CI sonographic measurements. Mean acute physiology and chronic health evaluation II score was 12. Paired SCV- and IVC-CI showed acceptable correlation (R(2) = 0.61, P < 0.01) with acceptable overall measurement bias [Bland-Altman mean collapsibility difference (IVC-CI minus SCV-CI) of -3.2%]. In addition, time needed to acquire and measure venous diameters was shorter for the SCV-CI (70 s) when compared to IVC-CI (99 s, P < 0.02). CONCLUSIONS: SCV collapsibility assessment appears to be a reasonable adjunct to IVC-CI in the surgical intensive care unit patient population. The correlation between the two techniques is acceptable and the overall measurement bias is low. In addition, SCV-CI measurements took less time to acquire than IVC-CI measurements, although the clinical relevance of the measured time difference is unclear.
Assuntos
Determinação do Volume Sanguíneo/métodos , Cuidados Críticos/métodos , Complicações Pós-Operatórias/diagnóstico por imagem , Veia Subclávia/diagnóstico por imagem , Ultrassonografia/métodos , Veia Cava Inferior/diagnóstico por imagem , Adulto , Idoso , Idoso de 80 Anos ou mais , Determinação do Volume Sanguíneo/normas , Cuidados Críticos/normas , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Modelos Cardiovasculares , Sistemas Automatizados de Assistência Junto ao Leito , Complicações Pós-Operatórias/fisiopatologia , Estudos Prospectivos , Reprodutibilidade dos Testes , Ressuscitação , Veia Subclávia/fisiologia , Ultrassonografia/normas , Veia Cava Inferior/fisiologia , Adulto JovemRESUMO
Health care reform and legislation of restricted resident work hours lead to the evaluation and the changes in health care delivery. In the early 1990s, the Acute Care Nurse Practitioner role evolved to fill the care gaps created by these changes. As the numbers and opportunities for nurse practitioners (NPs) in tertiary settings continue to increase, how to successfully integrate these providers into the health care setting becomes more of a challenge with limited published assimilation models to provide guidance. With few role models, the responsibility of integration is left in the hands of novice NPs, hospital administrators, or physician colleagues. The purpose of this article was to outline orientation, implementation, and evaluation strategies to optimize the transition of trauma NP into the inpatient setting.
Assuntos
Educação Continuada em Enfermagem/organização & administração , Capacitação em Serviço/organização & administração , Profissionais de Enfermagem , Papel do Profissional de Enfermagem , Traumatologia , Atitude do Pessoal de Saúde , Lista de Checagem , Currículo , Humanos , Relações Interprofissionais , Modelos Educacionais , Modelos de Enfermagem , Avaliação das Necessidades , Profissionais de Enfermagem/educação , Profissionais de Enfermagem/organização & administração , Profissionais de Enfermagem/psicologia , Papel do Profissional de Enfermagem/psicologia , Preceptoria/organização & administração , Autonomia Profissional , Competência Profissional , Autoeficácia , Visitas de Preceptoria/organização & administração , Pensamento , Traumatologia/educação , Traumatologia/organização & administraçãoRESUMO
Intradural spinal cord tumors present many challenges to patients and the healthcare professionals providing treatment. Given the tumor's attachment to dural tissue, cerebrospinal fluid (CSF) leaks are an anticipated challenge. If present, CSF leaks can lead to infection and increased length of stay. A 59-year-old female admitted for surgical excision of a cervical schwannoma developed a persistent postoperative CSF leak. Following multiple surgical attempts to repair the dura with concomitant lumbar drainage for decompression, a ventriculostomy with conversion to a shunt was performed. Following the procedure, the patient's wound healed completely 6 weeks after her initial surgery. Ventriculostomy is a viable option for treatment of persistent CSF wound drainage after excision of cervical schwannoma surgery.
Assuntos
Neurilemoma/cirurgia , Neoplasias da Medula Espinal/cirurgia , Derrame Subdural/cirurgia , Deiscência da Ferida Operatória/cirurgia , Ventriculostomia , Vértebras Cervicais , Eletromiografia , Feminino , Humanos , Laminectomia/efeitos adversos , Imageamento por Ressonância Magnética , Pessoa de Meia-Idade , Neurilemoma/complicações , Neoplasias da Medula Espinal/complicações , Fusão Vertebral/efeitos adversos , Derrame Subdural/diagnóstico , Derrame Subdural/etiologia , Deiscência da Ferida Operatória/diagnóstico , Deiscência da Ferida Operatória/etiologia , Resultado do Tratamento , Derivação Ventriculoperitoneal/métodos , Ventriculostomia/métodosRESUMO
INTRODUCTION: Head-of-bed (HOB) elevation is the standard of care for patients with intracranial pressure monitoring at risk for intracranial hypertension. Measurement of cerebral perfusion pressure (CPP) based on HOB elevation and arterial transducer position has not been adequately studied. METHODS: This is a planned secondary analysis of prospectively collected data in which paired, serial arterial blood pressure (ABP), intracranial pressure, and CPP measures were obtained once per day for 3 days, with measures leveled at the tragus (Tg) and the phlebostatic axis (PA). The HOB position was recorded for all paired readings. RESULTS: From 136 subjects, ABP and CPP values were lower when the transducer was leveled at the Tg, compared with the PA (P < .001); these differences persisted regardless of HOB position. CONCLUSION: The difference in CPP when ABP is referenced at the Tg versus PA is not consistently attributed to HOB elevation.
Assuntos
Circulação Cerebrovascular/fisiologia , Pressão Intracraniana/fisiologia , Posicionamento do Paciente , Postura , Pressão Arterial/fisiologia , Cuidados Críticos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Postura/fisiologiaRESUMO
A variety of imaging modalities are currently used to evaluate the brain. Prior to the 1970s, neurologic imaging involved radiographs, invasive procedures for spinal and carotid artery air and contrast injection, and painful patient manipulation. The brain was considered inaccessible to imaging and referred to as "the dark continent." Since then, advances in neuroradiology have moved the brain from being a dark continent to evaluation techniques that illuminate brain contents and pathology. These advances enable quick acquisition of images for prompt diagnosis and treatment. This article reviews anatomy, diagnostic principles, and clinical application of brain imaging beyond plain radiographs.
Assuntos
Encéfalo/diagnóstico por imagem , Neuroimagem/métodos , Radiologia , Encéfalo/anatomia & histologia , Humanos , Imageamento por Ressonância MagnéticaRESUMO
Status epilepticus is a medical emergency that requires rapid diagnosis and treatment. Nonconvulsive status epilepticus is frequently underdiagnosed and therefore undertreated, which can lead to permanent neuronal damage resulting in disability or death. Despite the frequent occurrence and morbidity associated with status epilepticus, this topic has received little attention within the literature. A systematic approach to treatment should start with management of airway, breathing, and circulation, followed by administration of benzodiazepines and intravenous antiepileptic drugs, and rapid escalation of therapy to prevent morbidity and mortality. Armed with the information in this article, nurses will have a higher-level understanding of what to do when encountering a patient in status epilepticus.
Assuntos
Anticonvulsivantes/uso terapêutico , Enfermagem de Cuidados Críticos/métodos , Respiração Artificial/métodos , Estado Epiléptico/diagnóstico , Estado Epiléptico/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estado Epiléptico/tratamento farmacológicoRESUMO
Demand for intensive care unit (ICU) resources often exceeds supply, and shortages of ICU beds and staff are likely to persist. Triage requires careful weighing of the benefits and risks involved in ICU admission while striving to guarantee fair distribution of available resources. We must ensure that the patients who occupy ICU beds are those most likely to benefit from the ICU's specialized technology and professionals. Although prognosticating is not an exact science, preference should be given to patients who are more likely to survive if admitted to the ICU but unlikely to survive or likely to have more significant morbidity if not admitted. To provide general guidance for intensivists in ICU triage decisions, a task force of the World Federation of Societies of Intensive and Critical Care Medicine addressed 4 basic questions regarding this process. The team made recommendations and concluded that triage should be led by intensivists considering input from nurses, emergency medicine professionals, hospitalists, surgeons, and allied professionals. Triage algorithms and protocols can be useful but can never supplant the role of skilled intensivists basing their decisions on input from multidisciplinary teams. Infrastructures need to be organized efficiently both within individual hospitals and at the regional level. When resources are critically limited, patients may be refused ICU admission if others may benefit more on the basis of the principle of distributive justice.
Assuntos
Tomada de Decisão Clínica , Cuidados Críticos , Hospitalização , Unidades de Terapia Intensiva , Médicos , Triagem , Comitês Consultivos , Recursos em Saúde , Médicos Hospitalares , Humanos , Sociedades MédicasRESUMO
End-of-life care in the intensive care unit (ICU) was identified as an objective in a series of Task Forces developed by the World Federation of Societies of Intensive and Critical Care Medicine Council in 2014. The objective was to develop a generic statement about current knowledge and to identify challenges relevant to the global community that may inform regional and local initiatives. An updated summary of published statements on end-of-life care in the ICU from national Societies is presented, highlighting commonalities and differences within and between international regions. The complexity of end-of-life care in the ICU, particularly relating to withholding and withdrawing life-sustaining treatment while ensuring the alleviation of suffering, within different ethical and cultural environments is recognized. Although no single statement can therefore be regarded as a criterion standard applicable to all countries and societies, the World Federation of Societies of Intensive and Critical Care Medicine endorses and encourages the role of Member Societies to lead the debate regarding end-of-life care in the ICU within each country and to take a leading role in developing national guidelines and recommendations within each country.
Assuntos
Cuidados Críticos , Unidades de Terapia Intensiva , Assistência Terminal , Comitês Consultivos , Cultura , Ética Médica , Humanos , Guias de Prática Clínica como Assunto , Sociedades MédicasRESUMO
In a health care system in which patient complexity, outcome indicators, and informed families are representative of current reality, an interdisciplinary approach to care is crucial to successful navigation of a patient's experience in the ICU. To guide practitioners toward favorable patient progression, a thorough understanding of interdisciplinary collaboration is necessary. This article focuses on definitions of, benefits of, and barriers to interdisciplinary collaboration and provides practical solutions for implementation.
Assuntos
Atitude do Pessoal de Saúde , Comportamento Cooperativo , Cuidados Críticos/organização & administração , Relações Interprofissionais , Equipe de Assistência ao Paciente/organização & administração , Comunicação , Conflito Psicológico , Cuidados Críticos/psicologia , Família/psicologia , Objetivos , Conhecimentos, Atitudes e Prática em Saúde , Necessidades e Demandas de Serviços de Saúde , Humanos , Satisfação no Emprego , Liderança , Moral , Negociação , Objetivos Organizacionais , Avaliação de Resultados em Cuidados de Saúde , Satisfação do Paciente , Resolução de Problemas , Competência Profissional/normas , Papel Profissional , Indicadores de Qualidade em Assistência à Saúde , Valores SociaisRESUMO
Depending on the causative agent, the differential diagnosis for acute nontraumatic weakness presentation can range from life threatening to trivial. Practitioners' comfort and experience with the rapid identification and evaluation of presenting neurological deficits vary widely. Given this fact and the reality that neurological presentation of weakness is common, the potential for missed diagnosis increases. To enhance knowledge of potentially life-threatening or morbidity-inducing complications, this article provides a systematic framework for physical and diagnostic evaluation of the most common differentials for acute causes of nontraumatic weakness.
Assuntos
Doenças do Sistema Nervoso Central/diagnóstico , Debilidade Muscular/diagnóstico , Doença Aguda , Diagnóstico Diferencial , HumanosAssuntos
Modelos de Enfermagem , Neurocirurgia/enfermagem , Procedimentos Neurocirúrgicos/enfermagem , Profissionais de Enfermagem/organização & administração , Papel do Profissional de Enfermagem , Centros Médicos Acadêmicos , Doença Aguda , Atitude do Pessoal de Saúde , Comunicação , Comportamento Cooperativo , Hospitais de Ensino , Humanos , Relações Interprofissionais , Corpo Clínico Hospitalar/psicologia , Neurocirurgia/educação , Procedimentos Neurocirúrgicos/educação , Profissionais de Enfermagem/educação , Profissionais de Enfermagem/psicologia , Pesquisa em Avaliação de Enfermagem , Recursos Humanos de Enfermagem Hospitalar/psicologia , Ohio , Avaliação de Resultados em Cuidados de Saúde , Alta do Paciente , Autonomia Profissional , Virginia , Carga de TrabalhoRESUMO
As the number and opportunities for acute care nurse practitioners (ACNPs) continue to increase, the successful integration of these providers into the health care setting becomes more of a challenge. This article outlines strategies for role development, implementation, and evaluation to optimize the performance of the neuroscience ACNP role. The concepts presented are applicable across all acute-care specialties that use ACNPs.
Assuntos
Cuidados Críticos/organização & administração , Neurociências/organização & administração , Profissionais de Enfermagem/organização & administração , Papel do Profissional de Enfermagem , Mobilidade Ocupacional , Credenciamento , Humanos , Candidatura a Emprego , Descrição de Cargo , Privilégios do Corpo Clínico , Modelos de Enfermagem , Negociação , Neurociências/educação , Profissionais de Enfermagem/educação , Profissionais de Enfermagem/psicologia , Pesquisa em Avaliação de Enfermagem , Avaliação de Resultados em Cuidados de Saúde , Autonomia Profissional , Gestão da Qualidade TotalAssuntos
Cuidados Críticos/métodos , Família/psicologia , Planejamento de Assistência ao Paciente/organização & administração , Apoio Social , Assistência Terminal/métodos , Adaptação Psicológica , Adulto , Algoritmos , Atitude Frente a Morte , Atitude Frente a Saúde , Recursos Audiovisuais , Comunicação , Traumatismos Craniocerebrais/enfermagem , Traumatismos Craniocerebrais/psicologia , Cuidados Críticos/psicologia , Tomada de Decisões , Feminino , Pesar , Humanos , Moral , Avaliação em Enfermagem , Ohio , Espiritualidade , Assistência Terminal/psicologiaRESUMO
Personal digital assistants (PDAs) are attaining increased functionality by acute care nurse practitioners (ACNPs). Supplemented by recently developed medical software, these devices assist nurse practitioners in having information available at the point of care. This article reviews the introductory use of PDAs throughout ACNP graduate training with an emphasis on clinical and classroom application.