Mary Jo Kocan

Risk of infection with prolonged ventricular catheterization.

OBJECTIVE:The relationship between extended ventricular catheterization and infection remains controversial. Although studies have substantiated an increasing infection rate with prolonged catheterization, there has been less agreement on whether this trend continues beyond 10 days. Our study reviews the daily infection rate of 595 patients, 213 of whom underwent more than 10 days of catheterization. METHODS:All patients who underwent ventricular monitoring in the neurological intensive care unit from 1995 to 2003 at the University of Michigan Health System were reviewed retrospectively. Infection was defined as a positive cerebrospinal fluid culture. Life-table analysis was used to calculate daily hazard (infection) rates. Patient age, sex, diagnosis, catheter exchanges, location of patient during catheter insertion, and cerebrospinal fluid leak were evaluated as risk factors for infection. RESULTS:The average patient age was 51.3 years, and 51.3% were male. Duration of catheterization averaged 8.6 days. The overall infection rate was 8.6%. Daily infection rates increased from the onset of catheter insertion but reached a plateau after Day 4, with subsequent rates ranging predominantly between 1 and 2%, even with extended catheterization beyond 10 days. Only ventricular catheters that had been placed at other institutions significantly affected the infection rate. CONCLUSION:A relationship between duration of catheterization and infection seems to be present. However, this relationship is not linear. There is an extremely low daily infection rate that rises over the initial 4 days but then remains relatively constant even with prolonged catheter use. Clinical decisions to continue ventricular catheterization should reflect this low daily risk of infection, which does not seem to increase with extended catheter use.

A comparison of continuous and intermittent enteral nutrition in NICU patients.

&NA; Tube feedings are frequently used for the nutritional support of neurologically impaired patients. Feedings may be delivered either continuously or intermittently. There is little evidence for advantages of one method over the other in patients with neurologic problems. In this study, a convenience sample of 34 adult neurological intensive care unit (NICU) patients were randomly assigned to either continuous or intermittent administration No significant differences were found in number or consistency of stools per day, presence of blue dye in pulmonary secretions as evidence of aspiration, or in caloric intake as a percent of the patients nutritional goal. Also, there was no correlation between patients level of consciousness, based on Glasgow Coma Scale (GCS), and the incidence of aspiration. Implications for nursing practice are discussed.

Intrahospital transport of neuro ICU patients.

&NA; Neuroscience intensive care unit (NICU) patients are frequently transported out of the critical care environment for diagnostic and interventional procedures. Four hundred and seventy‐one such transports from seventeen clinical centers were studied to identify the characteristics of intrahospital transport. Data collected included the destination and duration of transport, number and type of personnel involved, changes in monitoring and treatment during transport, adverse patient responses and the impact on patients left in the unit. Differences between transports characterized as elective or emergent in nature were noted. Results validate that intrahospital transport of NICU patients is both time and labor intensive. The study also suggests that the optimal process for safe and efficient transport is yet to be designed.

Improved outcomes in patients with head and neck cancer using a standardized care protocol for postoperative alcohol withdrawal.

OBJECTIVE To show clinical benefit in the main outcome measures by the use of a standardized protocol for identification, characterization, and treatment of alcohol withdrawal syndrome (AWS) in postoperative patients with head and neck cancer. DESIGN Prospective cohort study with a retrospective cohort control. SETTING Tertiary care university. PATIENTS A total of 26 consecutive postoperative patients with AWS were selected from among 652 patients with head and neck cancer to be enrolled in the protocol from March 2003 through March 2005. Controls consisted of 14 of 981 consecutive patients with AWS from March 2000 through December 2002. INTERVENTION Application of a standardized care protocol. MAIN OUTCOME MEASURES Sensitivity and specificity of preoperative screening for AWS risk, predictability of outcomes, length of stay, transfers to the intensive care unit (ICU), AWS symptoms, postoperative morbidity and mortality, doses of pharmacotherapy required, and charges. RESULTS Protocol patients demonstrated significantly fewer AWS-related ICU transfers and less delirium and violence than preprotocol patients. Mortality, wound complications, hospital charges, and doses of benzodiazepines, clonidine, and haloperidol were not significantly different between these 2 groups. Preoperative medical history correlated poorly with AWS outcomes. Screening was 87.5% sensitive and 99.7% specific. Late enrollees to the protocol (false-negative screening results) showed many significantly worse outcomes than immediate enrollees. CONCLUSION Use of the standardized AWS symptom-triggered protocol decreased delirium, violence, and AWS-related ICU transfers without significantly increasing hospital charges.

Flow-regulated continuous spinal drainage: Technical note with case report

A new method for continuous external drainage of cerebrospinal fluid (CSF) for the treatment of CSF fistulas is described. In this system, CSF is withdrawn continuously from the lumbar subarachnoid space at a controlled flow rate calculated to be slightly less than the natural absorption rate of CSF. Controlled spinal drainage can be achieved using equipment readily available in most intensive care units. This system was developed to prevent pneumocephalus during CSF drainage, as illustrated in the case presentation.

The brain-heart connection: cardiac effects of acute ischemic stroke.

Cerebrovascular events are known to produce changes in the electrocardiogram (ECG). Whether or not these changes are actually reflective of myocardial damage has been the topic of much research. There are indications that these ECG changes result from an imbalance in the autonomic nervous system, resulting in a relative excess of sympathetic activity. This article provides an overview of the ECG and physiologic changes noted in patients with acute ischemic stroke and identifies subgroups that may be at high risk for developing these changes. Implications for nursing care are discussed.

Efficacy of antibiotic-impregnated external ventricular drains in reducing ventriculostomy-associated infections

Use of an external ventricular drain (EVD) is essential for managing patients with hydrocephalus or intracranial hypertension. While this procedure is safe and efficacious, ventriculostomy-associated infections (VAI) continue to cause significant morbidity. In this study, we evaluated the efficacy of antibiotic-coated EVD (AC-EVD) in reducing the occurrence of VAI. Between July 2007 and July 2009, 203 patients underwent placement of an EVD. A total of 145 of these patients met the inclusion criteria, with 76 patients (52.4%) receiving AC-EVD and 69 patients (47.6%) receiving uncoated EVD. Ten patients (6.9%) developed VAI, of whom three were in the AC-EVD group and seven were in the uncoated EVD group (p=0.19). The mean duration between catheter insertion and positive cerebrospinal fluid culture was significantly greater in the AC-EVD group versus the uncoated EVD group (15±4days versus 4±2days, respectively; p=0.001). In the uncoated EVD group, 17 of 69 patients (24.6%) were dead at 3years versus 12 of 76 (15.8%) patients in the AC-EVD group (p=0.21). The overall VAI rate was 6.9% with a trend toward lower infection rates in the AC-EVD group compared to the uncoated EVD group (3.9% versus 10.1%, respectively; p>0.05).

Special considerations for mobilizing patients in the neurointensive care unit.

Patients with neurologic illness or injury benefit from early interventions to increase physical activity and mobility, but they also have special needs related to hemodynamic stability and intracranial pressure dynamics. After brain injury, moving paralyzed limbs—even passively—helps promote neural plasticity, “rerouting” signals around the injured area and forming new connections, resulting in improved functional recovery. Neurologic deficits may impede a patients functional and language abilities, so a mobility program must take into account the need for assistive devices, communication strategies, and additional personnel. Because cerebral autoregulation may be impaired, stability of blood pressure and intracranial pressure must be considered when planning mobility activities. The clinical team must consider the full spectrum of mobility for the neuroscience patient, from having the bed in the chair position for a comatose patient to ambulation of the patient with ventriculostomy whose intracranial pressure will tolerate having drainage clamped for a short period of time. Those involved with mobility need to understand the patients disease process, the implications of increasing activity levels, and the monitoring required during activity.

Stroke Awareness Among Inpatient Nursing Staff at an Academic Medical Center

Background and Purpose— Because 10% of strokes occur in hospitalized patients, we sought to evaluate stroke knowledge and predictors of stroke knowledge among inpatient and emergency department nursing staff. Methods— Nursing staff completed an online stroke survey. The survey queried outcome expectations (the importance of rapid stroke identification), self-efficacy in recognizing stroke, and stroke knowledge (to name 3 stroke warning signs or symptoms). Adequate stroke knowledge was defined as the ability to name ≥2 stroke warning signs. Logistic regression was used to identify the association between stroke symptom knowledge and staff characteristics (education, clinical experience, and nursing unit), stroke self-efficacy, and outcome expectations. Results— A total of 875 respondents (84% response rate) completed the survey and most of the respondents were nurses. More than 85% of respondents correctly reported ≥2 stroke warning signs or symptoms. Greater self-efficacy in identifying stroke symptoms (odds ratio, 1.13; 95% confidence interval, 1.01–1.27) and higher ratings for the importance of rapid identification of stroke symptoms (odds ratio, 1.23; 95% confidence interval, 1.002–1.51) were associated with stroke knowledge. Clinical experience, educational experience, nursing unit, and personal knowledge of a stroke patient were not associated with stroke knowledge. Conclusions— Stroke outcome expectations and self-efficacy are associated with stroke knowledge and should be included in nursing education about stroke.

Use of Simulation in Stroke Unit Education

Approximately 795,000 people in the United States experience a stroke each year; 610,000 of these are new and 185,000 are recurrent attacks (American Heart Association, 2010). Stroke is the third leading cause of death and the leading cause of long-term disability in this country and will cost an es