Abbreviated environmental enrichment confers neurobehavioral, cognitive, and histological benefits in brain-injured female rats.

Environmental enrichment (EE) promotes behavioral recovery after experimental traumatic brain injury (TBI). However, the chronic rehabilitation provided in the laboratory is not analogous to the clinic where physiotherapy is typically limited. Moreover, females make up approximately 40% of the clinical TBI population, yet they are seldom studied in brain trauma. Hence, the goal of this study was to test the hypothesis that abbreviated EE would confer neurobehavioral, cognitive, and histological benefits in brain injured female rats. Anesthetized rats received a cortical impact of moderate-to-severe injury (2.8mm tissue deformation at 4m/s) or sham surgery and then were randomly assigned to groups receiving standard (STD) housing or 4h, 6h, or 24h of EE daily. Motor function (beam-balance/walk and rotarod) was assessed on post-operative days 1-5 and every other day from 1 to 19, respectively. Spatial learning/memory (Morris water maze) was evaluated on days 14-19, and cortical lesion volume was quantified on day 21. No statistical differences were appreciated among the sham controls in any assessment and thus the data were pooled. All EE conditions improved motor function and memory retention, but only 6h and 24h enhanced spatial learning relative to STD (p<0.05). Moreover, EE, regardless of duration reduced cortical lesion volume (p<0.05). These data confirm that abbreviated EE confers robust neurobehavioral, cognitive, and histological benefits in TBI female rats, which supports the hypothesis and strengthens the utility of EE as a pre-clinical model of neurorehabilitation.

Just a routine operation: a critical discussion.

This article has summarised a critical discussion of the human factors that contributed to the death of a patient from a failure to respond appropriately to a 'can't intubate, can't ventilate' scenario. The contributory factors included the clinical team's inability to communicate, prioritise tasks and demonstrate effective leadership and assertive followership. The film Just a routine operation has now been in circulation for several years. When a system is designed and introduced with the intention of making a change to clinical practice, it can quickly become just another component of an organisation's architecture and complacency around its use can develop. This article has been written specifically for perioperative practitioners to renew the debate around the human factors that contribute to patient harm. By critically discussing Just a routine operation and attempting to review why the incident occurred, this article has attempted to emphasise that some of the conditions and behaviours that contributed to the death of Elaine Bromiley may be latent within our organisations and teams, and may continue to contribute to failures that affect patient safety.

Modifiable and nonmodifiable risk factors for falls after traumatic brain injury: an exploratory investigation with implications for medication use.

PURPOSE: Falls are a challenge for rehabilitation nurses, facilities, families, and individuals. Studies related to the causes of falls and potential strategies for risk management have been conducted across disability groups and with the elderly. Still, a focus on individuals with traumatic brain injuries (TBI), specifically, has been limited. This paper presents a brief review of relevant research and the results of a preliminary investigation. METHODS: This study was a retrospective study of 125 individuals with TBI in residential treatment. Specific risk factors for falls in this population were identified. FINDINGS: Results indicate that age, injury severity, medical complications, specific medications and polypharmacy are significantly linked to falls in individuals with brain injuries. Specifically, the use of anticholinergic medications was associated with falls in this study. CONCLUSIONS: The results of this study are limited both by the use of a convenience sample and the fact that it is an initial exploratory step to future multicenter research. Still, the resulting fall risk profile that emerged is an important consideration for rehabilitation practitioners working in brain injury. CLINICAL RELEVANCE: Identifying those individuals with TBI most at risk for falling and taking appropriate measures to prevent falling, including consideration of both number and type of medication used, are important measures for rehabilitation teams working with this population to take.

Patterns and clinical correlates of pain among brain injury patients in critical care assessed with the critical care pain observation tool.

This study was conducted to assess the patterns and clinical correlates of acute pain in brain injury patients during the critical care period using the Critical Care Pain Observation Tool (CPOT). Data were collected from 31 brain-injury patients admitted to an intensive care unit (ICU) at a university hospital located in Incheon, Republic of Korea. Glasgow Coma Scale and CPOT scores were assessed on days 1, 3, 6, 9, and 14 after ICU admission. Results showed that temporal changes in pain intensity displayed a consistent pattern in critical care patients with a brain injury during the first 14 days of ICU admission. Mean pain score was highest on day 1, decreased rapidly to reach a minimum on day 3 or 6, and then increased on day 9. In most patients, pain reduced slightly on day 14. Mean CPOT scores were significantly higher in the nonsurgery group than in the surgery group. There was also a nonsignificant trend of higher pain intensity scores among patients with moderate brain injury compared with those with severe injury. CPOT scores immediately after endotracheal suctioning were significantly higher than before endotracheal suctioning, but CPOT scores 20 minutes after suctioning were similar to those before suctioning. The present study may be meaningful in terms of presenting valid clinical information regarding the patterns and characteristics of acute pain in brain injury patients who are often unable to self-report on the presence and intensity of pain.

The impact of enriched environment and transplantation of murine cortical embryonic stem cells on recovery from controlled cortical contusion injury.

PURPOSE: The effectiveness of embryonic stem cell (eSC) therapy has been explored in many models of neurological disease and several research groups have shown that eSC treatment leads to improved outcomes in pre-clinical models of traumatic brain injury (TBI). Though functional recovery occurs, few surviving eSCs appear to develop neuronal characteristics; instead the majority of the surviving eSC express glial phenotypes. Additionally, researchers have shown that enriching the post-surgical environment of the subject promotes functional recovery following TBI. The purpose of the current project was to determine if post-surgical environmental enrichment (EE) impacts the survival, migration, and integration of eSCs in a rodent model of TBI and if the presence of these cells lead to improved outcomes. METHODS: In the current study, the medial frontal cortex (MFC) of rats was injured using a controlled cortical impact (CCI) device. Immediately following injury the rats were placed into either EE or standard environment (SE) housing and then seven days post-injury rats received either murine cortical eSC or media. Behavioral testing consisted of the Morris water maze (MWM), Barnes Maze (BM), and Rotarod tasks (RR). RESULTS: On the MWM task, TBI/eSC/EE animals performed as well as the Sham/SE and Sham/EE groups. The TBI/eSC/SE, TBI/Media/EE, and TBI/Media/SE groups were impaired compared to the controls. By the end of training on the BM there were no differences between the Sham, TBI/Media/EE, and TBI/eSC/EE groups. On the RR task all animals placed in the EE performed equally well and significantly better than their SE housed counterparts. By the end of training on the RR task, the TBI/eSC/EE group performed as well as the sham counterparts, and though not significant they also surpassed the performance of the injured animals that received enrichment or eSC treatment alone. CONCLUSIONS: Combing therapeutic strategies with enriching the post-injury environment is likely to be an important addition to determining the efficacy of pre-clinical therapies.

Central nervous system injury and neurobiobehavioral function in children with brain tumors: a review of the literature.

BACKGROUND: Children with brain tumors present a complex set of factors when considering treatment decisions, including type and location of tumor and age of the child. Two-thirds of children will survive, but historically have had poorer neurocognitive and quality-of-life outcomes when compared with survivors of other childhood cancers. Delaying or forgoing cranial radiation completely is thought to lead to improved neurobiobehavioral outcomes, but there is still relatively little research in this area. OBJECTIVES: The objectives of this study were to review and consolidate what is known about the effects of cranial radiation and chemotherapy on normal brain tissue and to synthesize that information relative to neurobiobehavioral findings in children with brain tumors. METHODS: A literature search using PubMed and PsycINFO from 2000 to 2011 was done using a variety of terms related to childhood brain tumor treatment and outcome. A total of 70 articles were reviewed, and 40 were chosen for inclusion in the review based on most relevance to this population. RESULTS: Both cranial radiation and certain chemotherapy agents cause damage to or loss of healthy neurons, as well as a decrease in the number of progenitor cells of the hippocampus. However, in general, children treated with chemotherapy alone appear to have less of a neurobiobehavioral impact than those treated with cranial radiation. CONCLUSIONS: The trend toward delaying or postponing cranial radiation when possible may improve overall neurocognitive and quality-of-life outcomes. IMPLICATIONS FOR PRACTICE: Nurses require knowledge of these issues when discussing treatment with families and with caring for long-term survivors.

Experiences of military CRNAs with service personnel who are emerging from general anesthesia.

We conducted this qualitative study to understand the experiences of military Certified Registered Nurse Anesthetists (CRNAs) working with service personnel who have traumatic brain injury (TBI) and/or posttraumatic stress disorder (PTSD) and are emerging from general anesthesia. This study is important because there are no studies in the literature that describe the experiences of anesthetists working with patients with these specific problems. The leading questions were: "Out of all the anesthesia cases both abroad and stateside (post 9/11/2001), have you noticed service members wake from general anesthesia (not utilizing total intravenous anesthesia (TIVA), in a state of delirium? If so, can you tell me your experiences and thought processes as to why it was occurring?" Five themes emerged: (1) Emergence delirium (ED) exists and to a much higher degree in the military than in the general population. (2) ED was much more prevalent in the younger military population. (3) TIVA was a superior anesthetic for patients thought to have TBI and/or PTSD. (4) Talking to all patients suspected of having TBI and/or PTSD before surgery and on emergence was vital for a smooth emergence. (5) There is something profound happening in regard to ketamine and PTSD and TBI.

Effect of body position on cerebral oxygenation and physiologic parameters in patients with acute neurological conditions.

How body position influences brain tissue oxygen (PbtO2) and intracranial pressure (ICP) in critically ill neurosurgical patients remains poorly defined. In a prospective observational repeated measures study, we examined the effects of 12 different body positions on neurodynamic and hemodynamic outcomes. Thirty-three consecutive patients (mean +/- SD, age = 48.3 +/- 16.6 years; 22 men), admitted after traumatic brain injury, subarachnoid hemorrhage, or craniotomy for tumor, were evaluated in a neurocritical care unit at a level 1 academic trauma center. Patients were eligible if the admission score in the Glasgow Coma Scale was < or =8 and they had a Licox CMP Monitoring System (Integra Neurosciences, Plainsboro, NJ). Patients were exposed to all 12 positions in random order. Changes from baseline to the 15-minute postposition assessment mean change scores showed a downward trend for PbtO2 for all positions with statistically significant decreases observed for supine head of bed (HOB) elevated 30 degrees and 45 degrees (p < .01) and right and left lateral positioning HOB 30 degrees (p < .05). ICP decreased with supine HOB 45 degrees (p < .01) and knee elevation, HOB 30 degrees and 45 degrees (p < .05), and increased (p < .05) with right and left lateral HOB 15 degrees. Hemodynamic parameters were similar in the various positions. Positioning practices can positively or negatively affect PbtO2 and ICP and fluctuate with considerable variability among patients. Nurses must consider potential effects of turning, evaluate changes with positioning on the basis of monitoring feedback from multimodality devices, and make independent clinical judgments about optimal positions to maintain or improve cerebral oxygenation.

Therapeutic positioning of the multiply-injured trauma patient in ICU.

Critically-ill patients who have sustained multiple traumatic injuries have complex, and often conflicting, physiological needs. These have profound implications on the way in which nursing staff approach the physical positioning of these patients to minimize the risks of further physiological injury and damage, maintain homeostasis and promote optimum recovery. This article reviews and discusses the evidence base underpinning therapeutic positioning of the multiply-injured trauma patient within the intensive-care unit (ICU), focusing on patients with a known or suspected unstable spinal injury, pelvic injury, traumatic brain injury, chest injury, or multiple limb fractures. Included are guidelines on the therapeutic positioning of the multiply-injured trauma patient within the ICU, based on the current available evidence and also drawn from practical experience within the author's own place of work. There is also a brief discussion of how such guidelines may be introduced into clinical practice.

Brain death and organ procurement.

Patients with severe brain injuries (as can result from trauma, subarachnoid hemorrhage, or brain tumor) are monitored closely by nursing staff. It's often the nurse who first recognizes clinical signs of decompensation and begins the process of determining whether the patient is a potential organ donor. When a person is declared brain dead, it's the nurse who maintains hemodynamic stability so that donor organs remain viable. It's therefore crucial for nurses to know how brain death is determined in adults and how potential organ donors are identified, and to know the major physiologic changes that occur upon brain death, as well as essential nursing interventions.

[Effects of backrest position on central venous pressure and intracranial pressure in brain surgery patients].

PURPOSE: This study was done to investigate the effects of backrest elevation of 0 degree and 30 degrees that minimize the risk of increasing ICP when CVP is measured. METHODS: Subjects were sixty-four patients who stayed in the neurosurgical intensive care unit after brain surgery at two university-based hospitals. CVP, blood pressure, heart rate and ICP were measured along with position changes in order of backrest position with primary 30 degrees backrest position, 0 degree backrest position and secondary 30 degrees backrest position. For data analysis, one-group, repeated-measures analysis of variance design was used in SAS program. RESULTS: Backrest elevations from 0 degree to 30 degrees did not alter the CVP without increasing the ICP. Therefore, 30 degrees backrest position is a preventive position without increasing ICP. CONCLUSION: 30 degrees backrest position might be appropriate for brain injury patients when CVP is measured.

Measuring grief in caregivers of persons with acquired brain injury.

PRIMARY OBJECTIVE: To investigate the psychometric and validity properties and applicability of a modified version of the Marwit-Meuser Caregiver Grief Inventory (MM-CGI) for use with caregivers of patients with acquired brain injury (ABI). RESEARCH DESIGN: Replicate Marwit and Meuser's original psychometric study assessing grief in caregivers of dementia patients. METHODS AND PROCEDURES: The MM-CGI was administered to 28 ABI caregivers along with standardized measures of caregiver strain, depression, well-being and family support. MAIN OUTCOMES AND RESULTS: Results for ABI caregivers were similar to those for dementia caregivers with the instrument demonstrating excellent internal consistency reliability for total and sub-scale grief scores and strong divergent validity. Results also parallel those of a recent study of cancer caregivers. CONCLUSIONS: The MM-CGI is as useful for diagnosing and treating grief in ABI caregivers as it is for those caring for persons with other serious illnesses.

Antenatal events causing neonatal brain injury in premature infants.

Understanding possible causes of neonatal brain injury is important for perinatal nurses because neonatal brain injury predicts subsequent infant mortality and morbidity in the premature infant. The pathogenesis of the brain injury, germinal matrix/intraventricular hemorrhage and white matter damage, is usually related to a hypoxic event. The hypoxic event may occur in utero, resulting from various conditions, such as maternal infection, maternal alcohol consumption, maternal smoking, placental bleeding disorders, maternal hypercoagulability conditions, metabolic disorders (diabetes and hyperthyroidism), and oligohydramnios. Strategies for prevention beginning before and in pregnancy are needed.

Postanesthesia care of the patient suffering from traumatic brain injury.

Each year 1.5 million people in the United States suffer a traumatic brain injury (TBI), and many of these patients require immediate surgery. TBI patients provide additional assessment and technological challenges for perianesthesia nursing care. A major goal of PACU nursing is the prevention of secondary head injury during the postanesthesia period.

Periventricular leukomalacia: pathophysiological concerns due to immature development of the brain.

Periventricular leukomalacia (PVL) is a result of injury and necrosis of myelinated fibers around the lateral ventricles. PVL is now considered the principal form of brain injury in preterm infants. This injury can have long-term effects on physical, motor, sensory, cognitive, and social development. Some proposed pharmacological treatments being considered to aid in prevention of this injury are raising concerns because they have failed to show evidence of efficacy or have potential for deleterious long-term effects. Current treatment is aimed at injury prevention; therefore, nurses play a critical role. Awareness of the pathophysiologic concerns about preterm neonates can help nurses focus their assessments to identify patients at risk.

Ritalin revisited: does it really help in neurological injury?

Methylphenidate (Ritalin) is a commonly used central nervous stimulant. It has been used in various neurological conditions, including attention deficit disorder, depression, and narcolepsy. Methylphenidate has been advocated in patients with traumatic brain injury and stroke for a variety of cognitive, attention, and behavioral problems. It also has been shown to speed recovery from poststroke depression so that patients can participate more fully in rehabilitation programs. Research suggests that it also may have a role in augmenting activity of injured neuronal tissue in the comatose patient, thus facilitating a return to consciousness. The neuroscience nurse plays an important role in monitoring response to Ritalin, including identifying its side effects. A review of the limited studies on the use of Ritalin, its mechanisms of action, dosing, and weaning provide a current understanding of this adjunctive agent's role in treatment for the neurological population.

Estresse e estressores dos familiares de pacientes com traumatismo crânio-encefálico em terapia intensiva / Stress and stressors in family members of patients with traumatic brain injury in intensive care

Trata-se de um estudo descritivo desenvolvido no CTI de um Hospital Municipal do Rio de Janeiro, de novembro/96 a março/98, com 103 familiares de pacientes com TCE, com os objetivos de avaliar o nível de estresse dos familiares e relaciona-los com as variáveis do paciente: idade, tipo de causa externa e grau de gravidade; dos familiares: sexo, idade, grau de parentesco, classe social, grau de instrução, experiência prévia com CTI e religião; identificar as necessidades dos familiares, relacionar o seu grau de satisfação com o nível de estresse, e descrever os estressores. Os instrumentos usados foram Inventário com Dados de Caracterização do paciente e familiares, Classificação de Classes Sócio-Econômicas no Brasil, Lista de Sintomas de Stress (LSS/VAS) e Inventário de Necessidades e Estressores de Familiares em Terapia Intensiva (INEFTI). Para análise estatística foi utilizado o SPSS....

Management of intracranial hemodynamics in the adult: a research analysis of head positioning and recommendations for clinical practice and future research.

Head elevation is a conventional nursing intervention used to control raised intracranial pressure and avoid complications in patients with neurotrauma or other conditions requiring management of intracranial hemodynamics. This therapy, however, provides a particular dilemma for health care providers. While elevating the head of the bed does decrease intracranial pressure, it may put some patients at risk for intracranial hypertension and cerebral ischemia due to decreases in cerebral perfusion pressure. This article analyzes research on head positioning that provides individual outcome measurements versus group means in adult patients with various conditions. The risk/benefit method of analysis used in this review revealed that in addition to only monitoring and controlling for ICP, we must also monitor and control CPP with a greater emphasis on this particular measurement. This analysis also revealed that optimal head positioning to manage intracranial hemodynamics should be decided upon on an individual basis using both ICP and CPP measurements.