Survivorship After Neurocritical Care: A Scoping Review of Outcomes Beyond Physical Status.

Following intensive care unit hospitalization, survivors of acute neurological injury often experience debilitating short-term and long-term impairments. Although the physical/motor impairments experienced by survivors of acute neurological injury have been described extensively, fewer studies have examined cognitive, mental health, health-related quality of life (HRQoL), and employment outcomes. This scoping review describes the publication landscape beyond physical and/or motor sequelae in neurocritical care survivors. Databases were searched for terms related to critical illness, intensive care, and outcomes from January 1970 to March 2022. English-language studies of critically ill adults with a primary neurological diagnosis were included if they reported on at least one outcome of interest: cognition, mental health, HRQoL or employment. Data extraction was performed in duplicate for prespecified variables related to study outcomes. Of 16,036 abstracts screened, 74 citations were identified for inclusion. The studies encompassed seven worldwide regions and eight neurocritical diagnosis categories. Publications reporting outcomes of interest increased from 3 before the year 2000 to 71 after. Follow-up time points included ≤ 1 (n = 15 [20%] citations), 3 (n = 28 [38%]), 6 (n = 28 [38%]), and 12 (n = 21 [28%]) months and 1 to 5 (n = 19 [26%]) and > 5 years (n = 8 [11%]), with 28 (38%) citations evaluating outcomes at multiple time points. Sixty-six assessment tools were used to evaluate the four outcomes of interest: 22 evaluating HRQoL (56 [76%] citations), 21 evaluating cognition (20 [27%] citations), 21 evaluating mental health (18 [24%] citations), and 2 evaluating employment (9 [12%] citations). This scoping review aimed to better understand the literature landscape regarding nonphysical outcomes in survivors of neurocritical care. Although a rising number of publications highlight growing awareness, future efforts are needed to improve study consistency and comparability and characterize outcomes in a disease-specific manner, including outlining of a minimum core outcomes set and associated assessment tools.

The Pathogenesis of Central and Complex Sleep Apnea.

PURPOSE: The purpose of this article is to review the recent literature on central apnea. Sleep disordered breathing (SDB) is characterized by apneas (cessation in breathing), and hypopneas (reductions in breathing), that occur during sleep. Central sleep apnea (CSA) is sleep disordered breathing in which there is an absence or diminution of respiratory effort during breathing disturbances while asleep. In obstructive sleep apnea (OSA), on the other hand, there is an absence of flow despite ongoing ventilatory effort. RECENT FINDINGS: Central sleep apnea is a heterogeneous disease with multiple clinical manifestations. OSA is by far the more common condition; however, CSA is highly prevalent among certain patient groups. Complex sleep apnea (CompSA) is defined as the occurrence/emergence of CSA upon treatment of OSA. Similarly, there is considerable overlap between CSA and OSA in pathogenesis as well as impacts. Thus, understanding sleep disordered breathing is important for many practicing clinicians.

Practices and Patterns of Hourly Neurochecks: Analysis of 8,936 Patients With Neurological Injury.

BACKGROUND: Patients experiencing acute neurological injury often receive hourly neurological assessments ("neurochecks") to capture signs of deterioration. While commonly utilized in the intensive care unit (ICU) setting, little is known regarding practices (i.e., variations by age and ordering services) and patterns (i.e., duration and post-discontinuation plans) of hourly neurochecks. To inform future quality improvement intervention efforts, we performed an analysis of hourly neurochecks using an electronic health record-based dataset. STUDY DESIGN AND METHODS: Our 75-month retrospective dataset consisted of all health system ICU patients who received hourly neurochecks. Variables included age, admission diagnosis category, ordering provider, post-discontinuation order, and discharge destination. Multivariable Cox regression was used to evaluate factors associated with hourly neurocheck duration. RESULTS: We evaluated 9,513 first admission hourly neurocheck orders in 8,936 patients. The trauma, neurosurgery, and neurocritical care services were responsible for 4,067 (43%), 2,071 (22%) and 1,697 (18%) hourly neurocheck orders, respectively. Median (interquartile range) hourly neurocheck duration was 1.09 (0.69, 2.35) days, and was greater than 3 and 7 days, respectively, for 1,773 (19%) and 640 (7%) patients. Median hourly neurocheck duration ranged from 0.87 (0.65, 1.68) to 1.60 (0.83, 2.97) days for neurosurgical and non-neurological ICU services, respectively. Upon discontinuation, 2,225 (23%) of hourly neurochecks were transitioned to no neurochecks. CONCLUSION: Substantial differences exist between ICU services and practice patterns surrounding hourly neurochecks. Understanding these differences will help inform intervention efforts aimed at streamlining hourly neurocheck practices and outcomes for patients with acute neurological injury.

A unique case of Miller Fisher-Guillain-Barré overlap syndrome in a liver transplant recipient.

Guillain-Barré syndrome (GBS) is an ascending demyelinating polyneuropathy often associated with recent infection. Miller Fisher syndrome represents a variant with predominant facial and cranial nerve involvement, although Miller Fisher and Guillain-Barré overlap syndromes can occur. Guillain-Barré spectrum syndromes have been thought to be rare among solid organ transplant recipients. We describe an immunocompromised patient with a liver transplant who presented with ophthalmoplegia and bulbar deficits. His symptoms rapidly progressed to a state of descending paralysis involving the diaphragm; he then developed acute respiratory failure and eventually developed quadriparesis. Electromyography and a nerve conduction study demonstrated a severe sensorimotor axonal polyneuropathy consistent with Miller Fisher variant Guillain-Barré syndrome. Despite several negative nasopharyngeal swabs for COVID-19 polymerase chain reaction, a serology for SARS-CoV-2 IgG was positive. He was diagnosed with Miller Fisher-Guillain-Barré overlap syndrome with rapid recovery following treatment with plasma exchange. Although Guillain-Barré is a rare complication in solid organ transplant recipients, this case highlights the importance of rapid diagnosis and treatment of neurologic complications in transplant patients. Furthermore, it demonstrates a possible case of neurological complications from COVID-19 infection.

Identifying disincentives to ethics consultation requests among physicians, advance practice providers, and nurses: a quality improvement all staff survey at a tertiary academic medical center.

BACKGROUND: Ethics consult services are well established, but often remain underutilized. Our aim was to identify the barriers and perceptions of the Ethics consult service for physicians, advance practice providers (APPs), and nurses at our urban academic medical center which might contribute to underutilization. METHODS: This was a cross-sectional single-health system, anonymous written online survey, which was developed by the UCSD Health Clinical Ethics Committee and distributed by Survey Monkey. We compare responses between physicians, APPs, and nurses using standard parametric and non-parametric statistical methods. Satisfaction with ethics consult and likelihood of calling Ethics service again were assessed using a 0-100 scale using a 5-likert response structured (0 being "not helpful at all" to 100 being "extremely helpful") and results presented using box plots and interquartile ranges (IQR). RESULTS: From January to July 2019, approximately 3800 surveys were sent to all physicians, APPs and nurses with a return rate of 5.5-10%. Although the majority of respondents had encountered an ethical dilemma (85-92.1%) only approximately half had ever requested an Ethics consult. The primary reason for physicians never having requested a consult was that they never felt the need for help (41%). For APPs the primary reasons were not knowing an Ethics consult service was available (33.3%) or not knowing how to contact Ethics (27.8%). For nurses, it was not knowing how to contact the Ethics consult service (30.8%) or not feeling the need for help (26.2%). The median satisfaction score (IQR) for Ethics consult services rated on a 0-100 scale, from physicians was 76 (29), for AAPs 89 (49), and nurses 70 (40) (p = 0.62). The median (IQR) of likelihood of consulting Ethics in the future also on a 0-100 scale was 71 (47) for physicians, 69 (45) for APPs, and 61 (45) for nurses (p = 0.79). APP's and nurses were significantly more likely than physicians to believe that the team did not act on the Ethics consult's recommendations. CONCLUSIONS: Based on the results presented, we were able to identify actionable steps to better engage healthcare providers-and in particular APPs and nurses-and scale up institutional educational efforts to increase awareness of the role of the Ethics consult service at our institution. Actionable steps included implementing a system of ongoing feedback that is critical for the sustainability of the Ethics service role. We hope this project can serve as a blueprint for other hospital-based Ethics consult services to improve the quality of their programs.

Review: Post-Intensive Care Syndrome: Unique Challenges in the Neurointensive Care Unit.

Within the last couple of decades, advances in critical care medicine have led to increased survival of critically ill patients, as well as the discovery of notable, long-term health challenges in survivors and their loved ones. The terms post-intensive care syndrome (PICS) and PICS-family (PICS-F) have been used in non-neurocritical care populations to characterize the cognitive, psychiatric, and physical sequelae associated with critical care hospitalization in survivors and their informal caregivers (e.g., family and friends who provide unpaid care). In this review, we first summarize the literature on the cognitive, psychiatric, and physical correlates of PICS and PICS-F in non-neurocritical patient populations and draw attention to their long-term negative health consequences. Next, keeping in mind the distinction between disease-related neurocognitive changes and those that are associated directly with the experience of a critical illness, we review the neuropsychological sequelae among patients with common neurocritical illnesses. We acknowledge the clinical factors contributing to the difficulty in studying PICS in the neurocritical care patient population, provide recommendations for future lines of research, and encourage collaboration among critical care physicians in all specialties to facilitate continuity of care and to help elucidate mechanism(s) of PICS and PICS-F in all critical illness survivors. Finally, we discuss the importance of early detection of PICS and PICS-F as an opportunity for multidisciplinary interventions to prevent and treat new neuropsychological deficits in the neurocritical care population.

Determinants of early outcomes in patients with acute ischemic stroke and proximal artery occlusion.

BACKGROUND: Proximal artery occlusions (PAO) recanalize in only a small percentage of acute ischemic stroke (AIS) patients treated with intravenous tissue plasminogen activator (IV tPA) alone, yet the benefits of adjunctive or substitutive intra-arterial therapy (IAT) in this patient subgroup are not well established. We evaluated early poststroke outcomes in a cohort of AIS patients with PAO categorized as "likely to benefit" (LTB) from IAT using prespecified criteria. METHODS: Using a prespecified protocol, 193 patients from our institutional stroke database admitted between January 1, 2007, and December 31, 2011, were prospectively deemed LTB from IAT. Logistic regression was used to determine independent predictors of favorable (discharge to home or acute rehabilitation) versus unfavorable (discharge to skilled nursing facility, hospice, or in-hospital mortality) outcome. RESULTS: Of the patients included, 29.5% received IV tPA only, 11.4% underwent IAT only, and 37.8% had both. Overall in-hospital mortality was 19.2%. In a univariate analysis, age (odds ratio [OR], .95; 95% confidence interval [CI], .93-.98), IV tPA (OR, 2.3; 95% CI, 1.2-4.3), and history of atrial fibrillation (OR, .5; 95% CI, .28-.97) were associated with outcome. Effect of IAT was not statistically significant (OR, 1.3; 95% CI, .7-2.3; P = .4). In multivariate analysis, the only independent predictor of favorable outcome was IV tPA administration (OR, 2.4; 95% CI, 1.2-5.0). The odds of favorable poststroke outcome were significantly lowered (OR, .3; 95% CI, .1-.6; P = .0006) in those receiving neither IV tPA nor IAT. CONCLUSIONS: In AIS patients with PAO thought most likely to benefit from IAT, IV tPA independently predicted favorable outcomes. These data reinforce the recommendation to provide early IV tPA to all eligible patients.

Reporting on Neurological Decline as Identified by Hourly Neuroassessments.

ABSTRACT: BACKGROUND: Hourly neurological examinations (neuro exam) have been widely used to monitor for a decline in neurological status, allowing for timely intervention. There are, however, limited data behind this common practice. The objective of this study was to identify how frequently neurological decline occurred across various diagnoses and whether that decline (1) was identified by a scheduled neurocheck and (2) altered management. METHODS: A cross-sectional survey was performed in a neurological intensive care unit at a tertiary care academic medical center. Clinical neuroscience nurses caring for patients with hourly neurological assessments completed a brief survey at 12-hour shift completion. RESULTS: Data were collected from 212 nurse's shifts. Neurological changes were identified by nurses in 14% (n = 30) of shifts. The neurological change was identified during a scheduled neurocheck 67% of the time, with the detection of changes more likely to occur during a scheduled neuro exam than at other times (P < .05). There was no change to the care plan in 55% of the cases of neurological decline. Patients with subarachnoid hemorrhage were more likely to have a decline detected. CONCLUSION: Findings suggest that many patients undergo hourly neurological exams without ever identifying a neurological deterioration. In many instances of neurodeterioration, there was no change to the treatment plan pursued. Primary diagnoses and neurological changes may not be entirely independent, and therefore, hourly neuro exams may have greater yield in some diagnoses than others. Replication is warranted with a larger sample to evaluate the risks and benefits of neuroassessments.

Reassessing hourly neurochecks.

Following acute brain injury, frequent neurological examinations ("neurochecks") are commonly prescribed and form the cornerstone of many care protocols and guidelines (e.g., for intracranial hemorrhage). While these assessments are intended to identify and mitigate secondary injury, they may unintentionally contribute to additional injury related to neurocheck-associated sleep disruption. Data are lacking to define patterns of neurological decline following acute brain injury, as are data to define the short- and long-term consequences (e.g., neuropsychological sequelae) of frequent and prolonged neurochecks. A critical need exists for rigorous evaluation of neurocheck practices, perceptions, benefits and risks, along with interventions to optimize neurocheck frequency and duration.

Clinical Reasoning: A 67-Year-Old Man With Multiple Intracranial Lesions.

A wide variety of diseases present with intracranial lesions. In this case report, a 67-year-old man initially presented to an outside hospital with nausea, headache, and ataxia and was found to have multiple intracranial lesions. Diagnostic workup was ultimately unrevealing, and his condition improved after a course of steroids and antibiotics. Unfortunately, symptoms returned 3 months later. MRI of the brain revealed progression of his intracranial lesions. This case highlights a diagnostic approach and general management strategy for patients presenting with undifferentiated intracranial pathology. A final diagnosis is ultimately reached and raises further discussion.

COVID-19-associated AMPA-R and CRMP-5 autoimmune encephalitis in a patient with thymoma and myasthenia gravis.

Thymomas are associated with autoimmune disease, most commonly myasthenia gravis, and rarely with autoimmune encephalitis. More recently, viral triggers including COVID-19 have also been implicated in autoimmunity. We present a case of antibody-positive autoimmune encephalitis that developed in the setting of COVID-19 in a patient with thymomatous myasthenia gravis.

Massage Therapy May be Safe and Reduce Pain in Critically Ill Patients with Acute Neurological Injury: a Case Control Study.

Purpose: Massage therapy is an important adjunctive treatment for physiologic and psychologic symptoms and has been shown to benefit patients among a wide variety of patient populations. Setting: Few studies have investigated the utility of massage therapy in the general ICU setting, and even fewer have done so in the neurological ICU (NeuroICU). Research Design: If massage therapy was determined to improve objective outcomes-or even subjective outcomes in the absence of harm-massage may be more readily employed as a complementary therapy, particularly in the ICU setting or in patients with acute neurological injury. Intervention: This pilot study aimed to assess the safety of massage in the neurocritical care unit and its impact on patient vital signs, subjective pain assessment, and other clinical outcomes. Participants: Twenty-one patients who received massage therapy during admission to the neurocritical care service were compared to matched controls in a retrospective case control study design. Results: We found a statistically significant reduction in pain scores among patients with acute neurological injury who received massage therapy. There was no statistical difference in hospital length of stay, discharge destination, in-hospital mortality, adverse events, or incidence/duration of delirium between patients who received massage therapy and those who did not. No adverse events were ascribed to the massage therapy when evaluated by blinded neurocritical care specialists. Conclusion: This study found that massage therapy may be safe for many patients in the NeuroICU and may offer additional subjective benefits.

Neurocheck Frequency: Determining Perceptions and Barriers to Implementation of Evidence-Based Practice.

BACKGROUND: Following acute brain injury, patients in the intensive care unit often undergo hourly or every-other-hour exams ("neurochecks") to monitor for neurodeterioration. We assessed health care provider attitudes towards neurocheck frequency and evaluated providers' ideal neurocheck frequency. METHODS: This was a cross-sectional, online survey distributed in Spring 2021 at a tertiary care academic medical center. Providers from multiple intensive care unit and neuroscience clinical specialties including attending faculty, medical trainees, advanced practice providers, and bedside nurses were invited to participate. RESULTS: Among 177 participants, 61 (34%) and 116 (66%) were self-identified as ordering and performing providers, respectively. The survey response rate was 58% among physicians and 51% among bedside nurses with neurological expertise. The most common medical and non-medical reasons for ordering hourly neurochecks were "a specific diagnosis with anticipated course" and "standard of care," respectively. Compared with ordering providers, performing providers felt guidelines regarding neurocheck frequency ( P <0.01) and duration ( P <0.01) should be proscriptive. Conversely, ordering providers felt hourly neurochecks were detrimental to patients with acute brain injury ( P =0.02) and believed they would not utilize hourly neurochecks if there was another mode of monitoring available ( P =0.03). Performing providers identified multiple patient-related factors impacting the difficulty of and their willingness to perform frequent neurochecks, and only 70% of neurochecks were perceived to be performed as ordered. Both ordering and performing providers preferred every-other-hour neurochecks following acute brain injury. CONCLUSIONS: This survey revealed clinically relevant differences in ordering versus performing provider attitudes about frequent neurochecks. Providers preferred every-other-hour rather than hourly neurochecks.

Development and Validation of an ICU Delirium Playbook for Provider Education.

Although delirium detection and prevention practices are recommended in critical care guidelines, there remains a persistent lack of effective delirium education for ICU providers. To address this knowledge-practice gap, we developed an "ICU Delirium Playbook" to educate providers on delirium detection (using the Confusion Assessment Method for the ICU) and prevention. DESIGN: Building on our previous ICU Delirium Video Series, our interdisciplinary team developed a corresponding quiz to form a digital "ICU Delirium Playbook." Playbook content validity was evaluated by delirium experts, and face validity by an ICU nurse focus group. Additionally, focus group participants completed the quiz before and after video viewing. Remaining focus group concerns were evaluated in semi-structured follow-up interviews. SETTING: Online validation survey, virtual focus group, and virtual interviews. SUBJECTS: The validation group included six delirium experts in the fields of critical care, geriatrics, nursing, and ICU education. The face validation group included nine ICU nurses, three of whom participated in the semi-structured feedback interviews. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The 44-question quiz had excellent content validity (average scale-level content validity index [S-CVI] of individual items = 0.99, universal agreement S-CVI = 0.93, agreement κ ≥ 0.75, and clarity p ≥ 0.8). The focus group participants completed the Playbook in an average (sd) time of 53 (14) minutes, demonstrating significant improvements in pre-post quiz scores (74% vs 86%; p = 0.0009). Verbal feedback highlighted the conciseness, utility, and relevance of the Playbook, with all participants agreeing to deploy the digital education module in their ICUs. CONCLUSIONS: The ICU Delirium Playbook is a novel, first-of-its-kind asynchronous digital education tool aimed to standardize delirium detection and prevention practices. After a rigorous content and face validation process, the Playbook is now available for widespread use.

Optimizing Sleep and Circadian Health in the NeuroICU.

Purpose of Review: This article introduces fundamental concepts in circadian biology and the neuroscience of sleep, reviews recent studies characterizing circadian rhythm and sleep disruption among critically ill patients and potentially links to functional outcomes, and draws upon existing literature to propose therapeutic strategies to mitigate those harms. Particular attention is given to patients with critical neurologic conditions and the unique environment of the neuro-intensive care unit. Recent Findings: Circadian rhythm disruption is widespread among critically ill patients and sleep time is reduced and abnormally fragmented. There is a strong association between the degree of arousal suppression observed at the bedside and the extent of circadian disruption at the system (e.g., melatonin concentration rhythms) and cellular levels (e.g., core clock gene transcription rhythms). There is a paucity of electrographically normal sleep, and rest-activity rhythms are severely disturbed. Common care interventions such as neurochecks introduce unique disruptions in neurologic patients. There are no pharmacologic interventions proven to normalize circadian rhythms or restore physiologically normal sleep. Instead, interventions are focused on reducing pharmacologic and environmental factors that perpetuate disruption. Summary: The intensive care environment introduces numerous potent disruptors to sleep and circadian rhythms. Direct neurologic injury and neuro-monitoring practices likely compound those factors to further derange circadian and sleep functions. In the absence of direct interventions to induce normalized rhythms and sleep, current therapy depends upon normalizing external stimuli.

Focused Management of Patients With Severe Acute Brain Injury and ARDS.

Considering the COVID-19 pandemic where concomitant occurrence of ARDS and severe acute brain injury (sABI) has increasingly coemerged, we synthesize existing data regarding the simultaneous management of both conditions. Our aim is to provide readers with fundamental principles and concepts for the management of sABI and ARDS, and highlight challenges and conflicts encountered while managing concurrent disease. Up to 40% of patients with sABI can develop ARDS. Although there are trials and guidelines to support the mainstays of treatment for ARDS and sABI independently, guidance on concomitant management is limited. Treatment strategies aimed at managing severe ARDS may at times conflict with the management of sABI. In this narrative review, we discuss the physiological basis and risks involved during simultaneous management of ARDS and sABI, summarize evidence for treatment decisions, and demonstrate these principles using hypothetical case scenarios. Use of invasive or noninvasive monitoring to assess brain and lung physiology may facilitate goal-directed treatment strategies with the potential to improve outcome. Understanding the pathophysiology and key treatment concepts for comanagement of these conditions is critical to optimizing care in this high-acuity patient population.