Adam Webb

Impact of a Dedicated Neurocritical Care Team in Treating Patients with Aneurysmal Subarachnoid Hemorrhage

BackgroundIntensivist staffing of intensive care units (ICUs) has been associated with a reduction in in-hospital mortality. These improvements in patient outcomes have been extended to neurointensivist staffing of neuroscience ICUs for patients with intracranial hemorrhage and traumatic brain injury.ObjectiveThe primary objective of this study is to determine if hospital outcomes (measured by discharge status) for patients admitted with aneurysmal subarachnoid hemorrhage changed after the introduction of a neurointensivist-led multidisciplinary neurocritical care team.MethodsThe authors retrospectively identified 703 patients admitted to the neuroscience ICU with a diagnosis of aneurysmal subarachnoid hemorrhage at a single academic tertiary care hospital between January 1, 1995 and December 31, 2002. It was compared with discharge outcomes for those patients treated prior to and following the development of a multidisciplinary neurocritical care team.ResultsPatients treated after the introduction of a neurocritical care team were significantly more likely to be discharged to home (25.2% vs. 36.5%) and less likely to be discharged to a rehab facility (25.2% vs. 36.5%). Patients treated after introduction of a neurocritical care team were also more likely to receive definitive aneurysm treatment (10.9% vs. 18%).ConclusionThe implementation of a neurointensivist-led neurocritical care team is associated with improved hospital discharge disposition for patients with aneurysmal subarachnoid hemorrhage.

Reversible brain death after cardiopulmonary arrest and induced hypothermia.

Objective: To describe a patient with transient reversal of findings of brain death after cardiopulmonary arrest and attempted therapeutic hypothermia. Design: Case report. Setting: Intensive care unit of an academic tertiary care hospital. Patient: A 55-yr-old man presented with cardiac arrest preceded by respiratory arrest. Cardiopulmonary resuscitation was performed, spontaneous perfusion restored, and therapeutic hypothermia was attempted for neural protection. After rewarming to 36.5°C, neurologic examination showed no eye opening or response to pain, spontaneous myoclonic movements, sluggishly reactive pupils, absent corneal reflexes, and intact gag and spontaneous respirations. Over 24 hrs, remaining cranial nerve function was lost. The neurologic examination was consistent with brain death. Apnea test and repeat clinical examination after a duration of 6 hrs confirmed brain death. Death was pronounced and the family consented to organ donation. Twenty-four hrs after brain death pronouncement, on arrival to the operating room for organ procurement, the patient was found to have regained corneal reflexes, cough reflex, and spontaneous respirations. The care team faced the challenge of offering an adequate explanation to the patients family and other healthcare professionals involved. Interventions: Induced hypothermia and brain death determination. Measurements and Main Results: This represents the first published report in an adult patient of reversal of a diagnosis of brain death made in full adherence to American Academy of Neurology guidelines. Although the reversal was transient and did not impact the patients prognosis, it impacted his eligibility for organ donation and cast doubt about the ability to determine irreversibility of brain death findings in patients treated with hypothermia after cardiac arrest. Conclusions: We strongly recommend caution in the determination of brain death after cardiac arrest when induced hypothermia is used. Confirmatory testing should be considered and a minimum observation period after rewarming before brain death testing ensues should be established.

Effect of antiplatelet therapy and platelet function testing on hemorrhagic and thrombotic complications in patients with cerebral aneurysms treated with the pipeline embolization device: a review and meta-analysis.

Purpose The pipeline embolization device (PED) necessitates dual antiplatelet therapy (APT) to decrease thrombotic complications while possibly increasing bleeding risks. The role of APT dose, duration, and response in patients with hemorrhagic and thromboembolic events warrants further analysis. Methods A PubMed and Google Scholar search from 2009 to 2014 was performed using the following search terms individually or in combination: pipeline embolization device, aneurysm(s), and flow diversion, excluding other flow diverters. Review of the bibliographies of the retrieved articles yielded 19 single and multicenter studies. A statistical meta-analysis between aspirin (ASA) dose (low dose ≤160 mg, high dose ≥300 mg), loading doses of APT agents, post-PED APT regimens, and platelet function testing (PFT) with hemorrhagic or thrombotic complications was performed. Results ASA therapy for ≤6 months post-PED was associated with increased hemorrhagic events. High dose ASA ≤6 months post-PED was associated with fewer thrombotic events compared with low dose ASA. Post-PED clopidogrel for ≤6 months demonstrated an increased incidence of symptomatic thrombotic events. Loading doses of ASA plus clopidogrel demonstrated a decreased incidence of permanent symptomatic hemorrhagic events. PFT did not show a statistically significant relationship with symptomatic hemorrhagic or thrombotic complications. Conclusions High dose ASA >6 months is associated with fewer permanent thrombotic and hemorrhagic events. Clopidogrel therapy ≤6 months is associated with higher rates of thrombotic events. Loading doses of ASA and clopidogrel were associated with a decreased incidence of hemorrhagic events. PFT did not have any significant association with symptomatic events.

Avoidable 30-Day Readmissions Among Patients With Stroke and Other Cerebrovascular Disease

Background: There are limited data on factors associated with 30-day readmissions and the frequency of avoidable readmissions among patients with stroke and other cerebrovascular disease. Methods: University HealthSystem Consortium (UHC) database records were used to identify patients discharged with a diagnosis of stroke or other cerebrovascular disease at a university hospital from January 1, 2007 to December 31, 2009 and readmitted within 30 days to the index hospital. Logistic regression models were used to identify patient and clinical characteristics associated with 30-day readmission. Two neurologists performed chart reviews on readmissions to identify avoidable cases. Results: Of 2706 patients discharged during the study period, 174 patients had 178 readmissions (6.4%) within 30 days. The only factor associated with 30-day readmission was the index length of stay >10 days (vs <5 days; odds ratio [OR] 2.3, 95% CI [1.4, 3.7]). Of 174 patients readmitted within 30 days (median time to readmission 10 days), 92 (53%) were considered avoidable readmissions including 38 (41%) readmitted for elective procedures within 30 days of discharge, 27 (29%) readmitted after inadequate outpatient care coordination, 15 (16%) readmitted after incomplete initial evaluations, 8 (9%) readmitted due to delayed palliative care consultation, and 4 (4%) readmitted after being discharged with inadequate discharge instructions. Only 5% of the readmitted patients had outpatient follow-up recommended within 1 week. Conclusions: More than half of the 30-day readmissions were considered avoidable. Coordinated timing of elective procedures and earlier outpatient follow-up may prevent the majority of avoidable readmissions among patients with stroke and other cerebrovascular disease.

Pharmacokinetic and Other Considerations for Drug Therapy During Targeted Temperature Management.

Objective:To synthesize an emerging body of literature describing pharmacokinetic alterations and related pharmacodynamic implications affecting drugs commonly used in patients receiving targeted temperature management following cardiac arrest. Data Sources:Peer-reviewed articles indexed in PubMed. Study Selection:A systematic search of the PubMed database for relevant preclinical studies and clinical and observational trials of physiologic changes and drug pharmacokinetic and pharmacodynamic alterations, especially during targeted temperature management/therapeutic hypothermia, but also from cardiac surgery and acute stroke hypothermia models. Data Extraction:Detailed review of information contained in published scientific work. Data Synthesis:Physiologic changes during targeted temperature management significantly alter both the pharmacokinetic and the pharmacodynamic parameters of medications. Current literature describes these alterations and provides practical considerations for management of medications. Medication selection should center on the pharmacokinetics and pharmacodynamics of agents in an attempt to ameliorate potential adverse effects. Conclusions:This review provides an overview of physiologic changes associated with targeted temperature management and practical considerations for the management of medications. Clinicians should understand and anticipate potential drug-therapy interactions of targeted temperature management and mitigate adverse outcomes by appropriate medication selection, dosing, and monitoring. We discuss complications of hypothermia including shivering, electrolyte abnormalities, hemodynamic changes, arrhythmias, and seizures. We review management of these complications as well as considerations for sedation, analgesia, anticoagulation, and prognostication. Approach to interpretation of the clinical significance of drug interactions during targeted temperature management therapy is also addressed.

493: EVALUATION OF PROTHROMBIN COMPLEX REVERSAL STRATEGIES IN PATIENTS WITH WARFARIN-ASSOCIATED ICH

Crit Care Med 2015 • Volume 43 • Number 12 (Suppl.) brain injured patients. The aim of this study was to evaluate the efficacy and safety of intravenous (IV) infusion of 4°C Normal Saline (NS) for fever control in brain injured patients. Methods: Patients with brain injury and fever (core temperature > 38 °C) despite acetaminophen, Ibuprofen(if not contraindicated) and cooling blanket, were given either 500 cc or 1000 cc IV bolus of 4°C NS. In addition to core temperature before and after the infusion, the following were measured before the infusion (T0), directly after (T1) and at 24 hr (T2): Serum Sodium (Na), Serum Chloride (Cl), and Serum Bicarbonate (Bicarb) levels. Ratio of arterial oxygen partial pressure to fractional inspired oxygen (P/F) was also measured before and directly after the infusion to determine effect of infusion on oxygenation. Shivering was assessed by bedside nurse. Results: Thirty boluses (divided equally between 500 cc and 1000cc) were given to 25 patients. Average volume given was 750 cc (9.1 cc/ Kg) ± 254 cc (3.5 cc/Kg). Average Temperature decreased from 39.2 (±0.6) °C to 38.3 (±0.6) °C (p < 0.0001). Serum Na levels were 140 (±6) mmol/L at T0, 140 (±5) mmol/L at T1 (p = 1.0), and 141 (±6) mmol/L at T2 (p = 0.5). Serum Cl levels were 106 (±6) mmol/L at T0, 108 (±6) mmol/L at T1 (p = 0.2), and 107 (±7) mmol/L at T2 (p = 0.6). Bicarb levels were 21 (±4) mmol/L at T0, 21 (±4) mmol/L at T1 (p = 1.0), and 22 (±4) mmol/L at T2 (p = 0.3). P/F ratio was 344 (± 164) before and 344 (± 186) after the infusion (p = 1.0). There were 4 episodes of shivering (13%). Conclusions: Infusion of chilled (4°C) Normal Saline for fever control in brain injured patients was found to be effective and well tolerated. We propose that the effect of this cooling method on fever control and neurologic outcome be studied in a prospective randomized study with larger numbers of patients.