Zero-Calibrating External Ventricular Drains: Exploring Practice.

ABSTRACT: BACKGROUND: Guidelines call for the removal of the nonvented cap (NVC) on the flushless transducer applied to the external ventricular drain (EVD) to zero the device to atmospheric pressure. Some hospitals have abandoned this practice to prevent opening the system to air. No data exist to determine the safest, most effective method of EVD zero-calibration. METHODS: A multidisciplinary team was assembled to use reflective practice to evaluate current zero-calibration of EVD practice. RESULTS: Clinical Nursing Focus showed recommendations largely out of date without detailed rationale or a high level of evidence. Manufacturer recommendations were fragmented and did not address rationale for technique. Bedside trial showed equivalence when comparing intracranial pressure (ICP) tidal, ICP after EVD zero with NVC removal, and ICP after EVD zero without NVC removal. CONCLUSION: Institutional guidelines were changed to reflect zero-calibration of EVD without NVC removal in systems that are amendable to this procedure. Further study is needed to determine best practice.

Herpes simplex reactivation following neurosurgery: case report and review of the literature.

Herpes simplex encephalitis is a common viral encephalitis associated with significant morbidity and mortality if not diagnosed and treated early. Neurosurgery may be an impetus for viral reactivation, either from direct nerve manipulation or high-dose steroids often administered during cases. The authors present the 40th known case of herpes simplex virus (HSV) encephalitis following neurosurgical intervention and review the previously reported cases. In their review, the authors observed positive HSV polymerase chain reaction (PCR), which had initially been negative in several cases. In cases in which there is high suspicion of HSV, it may be prudent to continue antiviral therapy and retest CSF for HSV PCR. Antiviral therapy significantly reduces mortality associated with HSV encephalitis.

Coffee Talk: A Jolt for Night Shift Education.

BACKGROUND: Education opportunities for night shift nurses are limited compared with those for their day-shift counterparts. However, patients remain critically ill regardless of shift and require intensive nursing care at all hours. Overnight, this care is often provided with fewer resources. These challenges can lead to disengagement and high turnover on the night shift. OBJECTIVES: To see whether initiation of an informal education series called "Coffee Talk" could improve accessibility to learning for night shift nurses and elevate perception of support from administrators and overall job satisfaction. METHODS: The lecture series was created to facilitate education for night shift nurses. The program features various speakers within the interdisciplinary team discussing topics chosen by the nursing staff. The talks are presented in an informal setting during overnight hours. An electronic survey tool was used to determine nurses' opinions regarding Coffee Talk, using a retrospective pretest and posttest format. Questions centered on the type of educational offerings, relevance to practice, perceived leadership support, convenience of attendance, and overall job satisfaction. RESULTS: More than half of the nurses (59%) responded. All scores improved from before to after the intervention. The largest increases occurred in convenience of educational offerings and nurses' perception of leaders removing barriers to learning. Overall job satisfaction increased from 83% to 93%. CONCLUSIONS: The introduction of an informal educational series improved nurses' access to education and nurses' feelings of support from administrators and overall job satisfaction.

Postoperative Pulmonary Edema Conundrum: A Case of Negative Pressure Pulmonary Edema.

Postobstructive pulmonary edema (POPE) also known as negative pressure pulmonary edema (NPPE) is an underdiagnosed entity in clinical practice and can lead to life-threatening hypoxemia. A 64-year-old male patient's perioperative course was complicated by acute hypoxemic respiratory failure, after extubation following general anesthesia, following the excision of the right vocal cord papilloma. His chest X-ray showed features of pulmonary edema, EKG showed dynamic ST-T changes in the lateral leads, and echocardiography showed evidence of regional motion abnormalities. His coronaries were normal on the immediate angiogram. He was managed with lung protective mechanical ventilation strategy, diuretics, and fluid restriction. His respiratory status improved, and trachea was extubated after 10 hours of intensive care unit (ICU) stay. The case illustrates the various differentials of immediate postoperative flash pulmonary edema and ensuing appropriate management strategy.

Hyperammonemia Presenting as Refractory Status Epilepticus after Lung Transplant in a Patient Positive for Ureaplasma parvum.

Hyperammonemia is a rare complication of lung transplant with a high mortality rate. It presents as encephalopathy and progresses to seizures, status epilepticus, coma, cerebral edema, and brain death. Multiple treatments have been documented including administration of medications, gut decontamination, and dialysis. However, no definitive treatments exist and mortality remains between 67% and 75%. We present the case of a 65-year-old male with idiopathic pulmonary fibrosis who developed refractory status epilepticus secondary to hyperammonemia following lung transplant. The patient presented on postoperative day 7 with super-refractory status epilepticus and normal computed tomography scan of the head. Hyperammonemia was suspected due to refractory seizures and confirmed with peak ammonia level >1000 µmol/L. Despite aggressive treatment, the patient developed global cerebral edema and died. Postmortem investigations revealed that the patient was positive for Ureaplasma parvum. Additional studies are needed to elucidate the exact mechanism of disease and investigate successful treatment options.

Sleep Deprivation in Neurointensive Care Unit Patients From Serial Neurological Checks: How Much Is Too Much?

OBJECTIVE: Hourly neurological examinations are frequently performed in the neurointensive care unit (NICU) to quickly detect neurological deterioration. These examinations require the patient to be awakened hourly for days disrupting the sleep cycle and potentially causing neurological deterioration through sleep deprivation and the development of delirium. This pilot study's aim was to describe the prevalence of neurologic deterioration and delirium in patients receiving hourly neuro checks. DESIGN: A 6-month prospective observational cohort study was conducted within the NICU at Mayo Clinic Florida. Twenty subjects were enrolled between July 24, 2016, and January 30, 2017. RESULTS: Neurological deterioration as defined as a decrease in Glasgow Coma Scale score of 2 or more, an increase in National Institute of Health Stroke Scale score by 4 or more, or a change in Confusion Assessment Method score for use in intensive care unit patients from negative to positive occurred in 19 of 20 patients (95%) for a total of 67 events, with most patients having multiple events. Seventy-five percent of the subjects experienced a decrease in Glasgow Coma Scale score of 2 or more at least once during the study period. The largest number of events occurred within the first 24 hours (39%). Surprisingly, 75% of the subjects also developed delirium. Forty percent of the subjects demonstrating neurological deterioration received computed tomography imaging to evaluate the change. Sixty-seven percent lacked deterioration evident on computed tomography imaging, and the deterioration was not attributed to medication effect or seizure by an experienced provider. CONCLUSIONS: Neurological deterioration is prevalent in the NICU population. Although hourly neurological examinations may be beneficial in the acute phase of neurological injury, prolonged use may be paradoxically harmful due to sleep deprivation.

Brief report of a novel advanced practice provider-led course for ultrasound novices.

BACKGROUND AND PURPOSE: Formal training for ultrasound use is essential for critical care providers. Despite a national increase in the utilization of advanced practice providers in critical care, ultrasound education is not routinely provided in their training programs. This study describes and evaluates a 1-day advanced care provider (APP)-led course designed to provide fellow APPs with the skills to obtain and evaluate basic ultrasound images. METHODS: A 15-question pretest was administered via anonymous use of a clicker response system. Participants had didactic lectures followed by hands-on experience with live models and instructor. Posttest was administered after achievement of basic ultrasound views. Postcourse evaluations were also administered. CONCLUSIONS: Pretest and posttest questions included identifying anatomy, pathology, quantifying cardiac function, and clinical decision making. Scores improved from 58% on the pretest to 78% on the posttest. All participants acknowledged the need for the course and their ability to transfer the course into practice. IMPLICATIONS FOR PRACTICE: This course established that APPs can both teach and learn from their peers in a formal setting. In addition, this course demonstrated that an APP-led course with a combined hands-on and didactic approach is an effective method for critical care ultrasound skills acquisition in ultrasound-novice APPs.

Aneurysmal Subarachnoid Hemorrhage Mortality After Implementation of Nocturnist Advanced Practice Provider Coverage.

INTRODUCTION: We hypothesized that a nocturnist advanced practice provider (APP) model compared with overnight neurocritical care coverage with general critical care physicians and neurology residents would provide similar patient outcomes, as measured by patient mortality. METHODS: This study is a retrospective review of healthcare outcomes of aneurysmal subarachnoid hemorrhage (aSAH) patients from 2013 and 2016, after implementation of specialty-trained neurocritical care nocturnist APPs. In 2013, overnight hours were covered by the general intensive care unit team and a junior neurology resident. In 2016, these patients were cared for by APPs overnight. The primary outcome measured was comparison of mortality before and after this change of overnight coverage because the daytime coverage remained similar between years. RESULTS: In 2013, 58 patients were admitted to the neurocritical care unit with aSAH. In 2016, 19 aSAH patients were admitted to the neurocritical care unit. The mean modified Fisher grade was 3.36 in 2013, with 14 of 58 deaths (mortality rate, 24%). In 2016, the mean modified Fisher grade was 3.4. Three patients died (mortality rate, 15.7%). CONCLUSION: The active nocturnist APP model was associated with an approximately 10% reduction in SAH mortality (P = .54). This supports the hypothesis that APPs can provide noninferior care as the previous model. Further studies are needed to demonstrate the effects of both nocturnist and APP-driven models.