Dea Mahanes

Recommendations for the Critical Care Management of Devastating Brain Injury: Prognostication, Psychosocial, and Ethical Management

Devastating brain injuries (DBIs) profoundly damage cerebral function and frequently cause death. DBI survivors admitted to critical care will suffer both intracranial and extracranial effects from their brain injury. The indicators of quality care in DBI are not completely defined, and despite best efforts many patients will not survive, although others may have better outcomes than originally anticipated. Inaccuracies in prognostication can result in premature termination of life support, thereby biasing outcomes research and creating a self-fulfilling cycle where the predicted course is almost invariably dismal. Because of the potential complexities and controversies involved in the management of devastating brain injury, the Neurocritical Care Society organized a panel of expert clinicians from neurocritical care, neuroanesthesia, neurology, neurosurgery, emergency medicine, nursing, and pharmacy to develop an evidence-based guideline with practice recommendations. The panel intends for this guideline to be used by critical care physicians, neurologists, emergency physicians, and other health professionals, with specific emphasis on management during the first 72-h post-injury. Following an extensive literature review, the panel used the GRADE methodology to evaluate the robustness of the data. They made actionable recommendations based on the quality of evidence, as well as on considerations of risk: benefit ratios, cost, and user preference. The panel generated recommendations regarding prognostication, psychosocial issues, and ethical considerations.

Recommendations for the critical care management of devastating brain injury: prognostication, psychosocial, and ethical management : a position statement for healthcare professionals from the neurocritical care society

Devastating brain injuries (DBIs) profoundly damage cerebral function and frequently cause death. DBI survivors admitted to critical care will suffer both intracranial and extracranial effects from their brain injury. The indicators of quality care in DBI are not completely defined, and despite best efforts many patients will not survive, although others may have better outcomes than originally anticipated. Inaccuracies in prognostication can result in premature termination of life support, thereby biasing outcomes research and creating a self-fulfilling cycle where the predicted course is almost invariably dismal. Because of the potential complexities and controversies involved in the management of devastating brain injury, the Neurocritical Care Society organized a panel of expert clinicians from neurocritical care, neuroanesthesia, neurology, neurosurgery, emergency medicine, nursing, and pharmacy to develop an evidence-based guideline with practice recommendations. The panel intends for this guideline to be used by critical care physicians, neurologists, emergency physicians, and other health professionals, with specific emphasis on management during the first 72-h post-injury. Following an extensive literature review, the panel used the GRADE methodology to evaluate the robustness of the data. They made actionable recommendations based on the quality of evidence, as well as on considerations of risk: benefit ratios, cost, and user preference. The panel generated recommendations regarding prognostication, psychosocial issues, and ethical considerations.

Multicenter pilot study: Safety of automated chest percussion in patients at risk for intracranial hypertension

In the critical care setting, the focus of care during the first few weeks following acute brain injury is prevention of secondary brain injury by optimizing cerebral perfusion. Ensuring adequate oxygenation and perfusion of cerebral tissues requires attention to all of the body systems. Chest percussion therapy (CPT) promotes pulmonary hygiene and optimizes gas exchange by opening the alveoli. However, many patients with brain injury have intracranial pressure (ICP) monitoring, and conventional wisdom supports limiting activities such as CPT that may stimulate the patient and increase ICP. The purpose of this study was to explore the effects of CPT on ICP. Thirty participants were enrolled over a 6-month period. Data were collected at 1-minute intervals for 1 hour. Each patient was randomized to receive automated CPT (using specialty beds) for 10 minutes, starting at 10, 20, 30, or 40 minutes into the hour. There were no differences in mean ICP values before, during, or after CPT. This study provides evidence that it is safe to perform CPT in patients with ICP monitoring in situ.

APN-led nursing rounds: An emphasis on evidence-based nursing care

In todays healthcare environment, nursing staff are challenged to care for patients with increasingly complex needs in an ever-changing environment. Nurses are expected to stay up to date on a tremendous number of institutional initiatives, best practice guidelines, and policies and procedures. These practice imperatives are often disseminated through passive means of information-sharing such as staff meetings and electronic mail. In this setting, it is difficult for nurses to simultaneously focus on incorporating practice updates while continuing to value basic nursing functions such as oral care, skin care, and incontinence management. The concept of Interventional Patient Hygiene emphasises that basic nursing functions are not only tasks, but also important evidence-based interventions that contribute to improved health for the patient. Interventional Patient Hygiene facilitates the integration of science and practice. This article describes a quality improvement intervention, Advanced practice nurse-led nursing rounds, which supports Interventional Patient Hygiene and be used to help staff integrate best practices while balancing the multiple priorities inherent in nursing care.

Is Broader Better

In their article “A Broader Understanding of Moral Distress,” Campbell, Ulrich, and Grady (2016) correctly assert that moral distress is well established in the nursing literature and is gaining attention in other health care professions. These are significant points. For decades, moral distress simmered quietly in the health care professions—unstudied, unacknowledged, and insidiously damaging careers. Today, the phenomenon is finally receiving the attention it deserves at the bedside, in institutional boardrooms, in the classroom, and on research priority lists. As the authors state, “Moral distress is, first and foremost, a practical problem.” The current understanding of moral distress has identifiable boundaries, and, while not perfect, has utility in practice and evolving research. We argue that the authors’ broader definition of moral distress dilutes the concept to such a degree as to render it impractical—too nebulous to be effectively taught, studied, used in practice, or, frankly, respected any longer as a powerful phenomenon in bioethics. The authors are not the first to attempt to redefine moral distress. At least 13 previous articles have offered new definitions since Jameton first coined the term in the 1980s (e.g., Hamric 2014; McCarthy and Deady 2008; Thomas and McCullough 2015; Varcoe et al. 2012). Nearly all of the earlier attempts have maintained the same core element: being compelled to act in a way that one believes is morally wrong but feels powerless to change. Campbell, Ulrich, and Grady move away from this central understanding into

Brain Death and Organ Donation

Death by neurologic criteria, also called brain death, is a difficult concept for families and even some healthcare professionals to understand. Standards for determination of brain death specify an irreversible cause of coma, exclusion of confounding factors, brainstem areflexia, and apnea in response to hypercarbia. Ancillary tests can be helpful when confounding variables are present or the clinical exam cannot be satisfactorily completed. Declaration of brain death is typically completed by the attending physician, but neurocritical care APCs play an important role in identifying patients who may progress to brain death, supporting physiologic stability of the patient throughout the process, ordering or performing some of the tests required, and communicating with the patient’s family. Many patients who are declared brain dead are able to donate organs, and the APC is often involved in the management surrounding this process.

The Code of Professional Conduct for the Neurocritical Care Society

Part of the responsibility of a professional society is to establish the expectations for appropriate behavior for its members. Some codes are so essential to a society that the code itself becomes the central document defining the organization and its tenets, as we see with the Hippocratic Oath. In that tradition, we have revised the code of professional conduct for the Neurocritical Care Society into its current version, which emphasizes guidelines for personal behavior, relationships with fellow members, relationships with patients, and our interactions with society as a whole. This will be a living document and updated as the needs of our society change in time.Available online: http://www.neurocriticalcare.org/about-us/bylaws-procedures-and-code-professional-conduct(1)Code of professional conduct (this document)(2)Leadership code of conduct(3)Disciplinary policy

Recommendations for the Critical Care Management of Devastating Brain Injury

Devastating brain injuries (DBIs) profoundly damage cerebral function and frequently cause death. DBI survivors admitted to critical care will suffer both intracranial and extracranial effects from their brain injury. The indicators of quality care in DBI are not completely defined, and despite best efforts many patients will not survive, although others may have better outcomes than originally anticipated. Inaccuracies in prognostication can result in premature termination of life support, thereby biasing outcomes research and creating a self-fulfilling cycle where the predicted course is almost invariably dismal. Because of the potential complexities and controversies involved in the management of devastating brain injury, the Neurocritical Care Society organized a panel of expert clinicians from neurocritical care, neuroanesthesia, neurology, neurosurgery, emergency medicine, nursing, and pharmacy to develop an evidence-based guideline with practice recommendations. The panel intends for this guideline to be used by critical care physicians, neurologists, emergency physicians, and other health professionals, with specific emphasis on management during the first 72-h post-injury. Following an extensive literature review, the panel used the GRADE methodology to evaluate the robustness of the data. They made actionable recommendations based on the quality of evidence, as well as on considerations of risk: benefit ratios, cost, and user preference. The panel generated recommendations regarding prognostication, psychosocial issues, and ethical considerations.

Dax's Case Redux: When Comes the End of the Day?

Forty years after Dax Cowart fought to have his voice heard regarding his medical treatment, patient autonomy and rights are at the heart of patient care today. Yet, despite its centrality in patient care, the tension between a severely burned patient’s right to stop treatment and the physician’s role in saving a life has not abated. As this case study explores, barriers remain to hearing and respecting a patient’s treatment decisions. Dismantling these barriers involves dispelling the myths that burn patients must grin and bear intense pain to recover and that a patient’s choice to discontinue treatment equals physician failure. Moreover, in these situations, sustained, direct engagement between physician and patient can reduce the moral distress of all involved and enable physicians to hear and better accept when a patient is calling for the end of the day.

Neurologic Assessment After Fibrinolytic Therapy for Myocardial Infarction

in the neuroscience intensive care unit at the University of Virginia Health System in Charlottesville. properties of the fibrinolytic agent and the impact of adjuvant therapies such as antiplatelet and anticoagulant agents must also be considered. Tenecteplase is a variant of tissue plasminogen activator (t-PA) that is genetically engineered to have increased fibrin specificity, a longer half-life (20-24 minutes vs 3-5 min for recombinant t-PA), and resistance to plasminogen activator inhibitor (PAI-1), an endogenous substance that inhibits thrombolysis. The longer half-life allows tenecteplase to be administered as a single bolus, whereas other agents require more complex dosing regimens. In addition, in a large clinical trial, patients treated with tenecteplase had less noncerebral bleeding than patients treated with recombinant t-PA, although the risk of ICH was similar.