Aaron E. Bunnell

Peer Support as a Novel Strategy to Mitigate Post-Intensive Care Syndrome.

ABSTRACT Post‐intensive care syndrome, a condition defined by new or worsening impairment in cognition, mental health, and physical function after critical illness, has emerged in the past decade as a common and life‐altering consequence of critical illness. New strategies are urgently needed to mitigate the risk of neuropsychological and functional impairment common after critical illness and to prepare and support survivors on their road toward recovery. The present state of critical care survivorship is described, and postdischarge care delivery in the United States and the potential impact of the present‐day fragmented model of care delivery are detailed. A novel strategy that uses peer support groups could more effectively meet the needs of survivors of critical illness and mitigate post‐intensive care syndrome.

Quantitative neuromuscular ultrasound in intensive care unit–acquired weakness: A systematic review

Intensive care unit–acquired weakness (ICU‐AW) causes significant morbidity and impairment in critically ill patients. Recent advances in neuromuscular ultrasound (NMUS) allow evaluation of neuromuscular pathology early in critical illness. Here we review application of ultrasound in ICU‐AW. MEDLINE‐indexed articles were searched for terms relevant to ultrasound and critical illness. Two reviewers evaluated the resulting abstracts (n = 218) and completed full‐text review (n = 13). Twelve studies and 1 case report were included. Ten studies evaluated muscle thickness or cross‐sectional area (CSA): 8 reported a decrease, and 2 reported no change. Two studies reported preservation of muscle thickness in response to neuromuscular electrical stimulation, and 1 found no preservation. One study found decreases in gray‐scale standard deviation, but no change in echogenicity. One study described increases in echogenicity and fasciculations. Ultrasound reliability in ICU‐AW is not fully established. Further investigation is needed to identify ultrasound measures that reliably predict clinical, electrodiagnostic, and pathologic findings of ICU‐AW. Muscle Nerve 52: 701–708, 2015

A retrospective review of safety using a nursing driven protocol for autonomic dysreflexia in patients with spinal cord injuries

Objective/Background: Autonomic dysreflexia is a potentially life-threatening condition which afflicts a significant proportion of individuals with spinal cord injuries (SCI). To date, the safety and efficacy of several commonly used interventions for this condition have not been studied. Design: A retrospective chart review of the safety of a previously implemented nursing driven inpatient autonomic dysreflexia protocol. Methods: Seventy-eight male patients with SCI who experienced autonomic dysreflexia while inpatient at our Veterans Affairs SCI unit over a 3–1/2-year period were included. The safety of a nursing driven protocol utilizing conservative measures, nitroglycerin paste, and oral hydralazine was evaluated. Outcome Measures: Occurrence of adverse events and relative hypotensive events during all episodes treated with the protocol, and efficacy of attaining target blood pressure for all episodes with protocol adherence and for initial episode experienced by each patient. Results: Four hundred forty-five episodes of autonomic dysreflexia were recorded in the study period, with 92% adherence to the protocol. When the protocol was followed, target blood pressure was achieved for 97.6% of all episodes. Twenty-three total adverse events occurred (5.2% of all episodes). All adverse events were due to hypotension and only 0.9% required interventions beyond clinical monitoring. Of each patients initial autonomic dysreflexia episode, 97.3% resolved using the protocol without need for further escalation of care. Conclusion: This inpatient nursing driven-protocol for treating autonomic dysreflexia utilizing conservative measures, nitroglycerin paste and oral hydralazine achieved target blood pressure with a high success rate and a low incidence of adverse events.

Pharmacodynamics and effectiveness of topical nitroglycerin at lowering blood pressure during autonomic dysreflexia

Study design:Secondary analysis of prospectively collected observational data assessing the safety of an autonomic dysreflexia (AD) management protocol.Objectives:To estimate the time to onset of action, time to full clinical effect (sustained systolic blood pressure (SBP) <160 mm Hg) and effectiveness of nitroglycerin ointment at lowering blood pressure for patients with spinal cord injuries experiencing AD.Setting:US Veterans Affairs inpatient spinal cord injury (SCI) unit.Methods:Episodes of AD recalcitrant to nonpharmacologic interventions that were given one to two inches of 2% topical nitroglycerin ointment were recorded. Pharmacodynamics as above and predictive characteristics (through a mixed multivariate logistic regression model) were calculated.Results:A total of 260 episodes of pharmacologically managed AD were recorded in 56 individuals. Time to onset of action for nitroglycerin ointment was 9–11 min. Time to full clinical effect was 14–20 min. Topical nitroglycerin controlled SBP <160 mm Hg in 77.3% of pharmacologically treated AD episodes with the remainder requiring additional antihypertensive medications. A multivariate logistic regression model was unable to identify statistically significant factors to predict which patients would respond to nitroglycerin ointment (odds ratios 95% confidence intervals 0.29–4.93). The adverse event rate, entirely attributed to hypotension, was 3.6% with seven of the eight events resolving with close observation alone and one episode requiring normal saline.Conclusions:Nitroglycerin ointment has a rapid onset of action and time to full clinical effect with high efficacy and relatively low adverse event rate for patients with SCI experiencing AD.

Planning Interventions to Treat Brachial Plexopathies

This article reviews the electrodiagnosis of brachial plexus injury, factors that predict outcome, the utility electrodiagnostic evaluation of potential nerve donors, and commonly used surgical interventions. Electrodiagnostic evaluation begins with a detailed understanding of brachial plexus anatomy and uses a complement of motor and sensory nerve conduction studies and needle electromyography to determine the location of injury and predict severity. Several factors are used to predict prognosis. In injuries with poor prognosis, surgical intervention is indicated. Nerve transfers are increasingly employed to improve functional outcomes. Electrodiagnosis is key to evaluating the viability of potential nerve donors.

Poster 2: Prognostic Values of Electrodiagnostic Studies in Traumatic Brachial Plexus Injury

valvular heart disease). At baseline, 24 (40%) were classified as frail based on any of the following criteria: 6-minute walk distance (6MWD) <300m, gait speed (GS) <1m/s, timed up and go (TUG) >15s, tandem stand (TS) <10s. Interventions: Completing at least 24 sessions of CR including individualized exercise training and risk factor education. Main Outcome Measures: Change in 6MWD, GS, TUG, and TS from preto post-assessment in frail and non-frail patients. Results: Frail and non-frail CR patients improved significantly in 6MWD (274 70m vs. 331 69m, p<.001; 379 54m vs. 411 62m, p1⁄4.001, respectively). The magnitude of change was significantly greater for frail vs. non-frail (58 49m vs. 31 52m, p1⁄4.050). Improvements in GS, TUG, and TS were demonstrated in frail and non-frail patients, but statistical significance was only evident in the non-frail for GS and TUG (GS: 0.01 0.25m/s, p1⁄4.805 vs. 0.11 0.24m/s, p1⁄4.014; TUG: e0.9 2.8s, p1⁄4.136 vs. e0.8 1.6s, p1⁄4.004; TS: 4.8 5.9s, p1⁄40.152 vs. 1.4 6.4s, p1⁄4.189; frail vs. non-frail, respectively). Of the 24 patients classified as “frail” at enrollment, 13 (54%) were no longer classified as frail at completion of CR. Conclusions: Frail and non-frail patients in CR achieved multiple domains of functional enhancement. These results provide strong rationale for referring frail adults to CR. Additional modifications to CR that specifically address balance, strength, cognition, and other frailty hazards may further enhance its utility for today’s growing population of frail CVD patients. Level of Evidence: Level III

Rehabilitation of a patient with overlap of acute transverse myelitis and Bickerstaff’s brainstem encephalitis: a case report

We report on one patient with Bickerstaff’s brainstem encephalitis (BBE) and associated flaccid weakness. Counter to previous studies with BBE which indicate weakness due to Guillain–Barre syndrome, our patient’s presentation of paraplegia following BBE is consistent with concomitant acute transverse myelitis. Her findings of BBE largely resolved, although she remained with T6 American Spinal Injury Association (ASIA) A paraplegia. Motor functional impairment measure scores improved from 20 at admission to 66 before discharge home with assistance. This case presents the first potential overlapping case of acute transverse myelitis with BBE and describes how acute inpatient rehabilitation can be effective in facilitating transition back to independence following tetraplegia with BBE.

Poster 299 Pharmacokinetics and Efficacy of Nitroglycerin Paste for Autonomic Dysreflexia Following Spinal Cord Injury

adverse events (AEs) included dysphagia and muscle weakness. Five patients discontinued due to AEs. Conclusions: This study demonstrates the usual clinical practice of botulinum toxin injectors across multiple sites and demonstrates a consistent approach to abobotulinumtoxinA injection patterns and doses. Use of EMG guidance was variable, with less than half of the injections using this technique. Level of Evidence: Level II

Quantitative neuromuscular ultrasound in intensive care unit-acquired weakness

Intensive care unit–acquired weakness (ICU‐AW) causes significant morbidity and impairment in critically ill patients. Recent advances in neuromuscular ultrasound (NMUS) allow evaluation of neuromuscular pathology early in critical illness. Here we review application of ultrasound in ICU‐AW. MEDLINE‐indexed articles were searched for terms relevant to ultrasound and critical illness. Two reviewers evaluated the resulting abstracts (n = 218) and completed full‐text review (n = 13). Twelve studies and 1 case report were included. Ten studies evaluated muscle thickness or cross‐sectional area (CSA): 8 reported a decrease, and 2 reported no change. Two studies reported preservation of muscle thickness in response to neuromuscular electrical stimulation, and 1 found no preservation. One study found decreases in gray‐scale standard deviation, but no change in echogenicity. One study described increases in echogenicity and fasciculations. Ultrasound reliability in ICU‐AW is not fully established. Further investigation is needed to identify ultrasound measures that reliably predict clinical, electrodiagnostic, and pathologic findings of ICU‐AW. Muscle Nerve 52: 701–708, 2015

Quantitative neuromuscular ultrasound in intensive care unit-acquired weakness: A systematic review: US in ICU-AW

Intensive care unit–acquired weakness (ICU‐AW) causes significant morbidity and impairment in critically ill patients. Recent advances in neuromuscular ultrasound (NMUS) allow evaluation of neuromuscular pathology early in critical illness. Here we review application of ultrasound in ICU‐AW. MEDLINE‐indexed articles were searched for terms relevant to ultrasound and critical illness. Two reviewers evaluated the resulting abstracts (n = 218) and completed full‐text review (n = 13). Twelve studies and 1 case report were included. Ten studies evaluated muscle thickness or cross‐sectional area (CSA): 8 reported a decrease, and 2 reported no change. Two studies reported preservation of muscle thickness in response to neuromuscular electrical stimulation, and 1 found no preservation. One study found decreases in gray‐scale standard deviation, but no change in echogenicity. One study described increases in echogenicity and fasciculations. Ultrasound reliability in ICU‐AW is not fully established. Further investigation is needed to identify ultrasound measures that reliably predict clinical, electrodiagnostic, and pathologic findings of ICU‐AW. Muscle Nerve 52: 701–708, 2015