Abstract P868: Clinical Challenges of the ICU Complex Stroke Patient

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Mary P Amatangelo
Keyword(s):  
Critical Care ◽  
Ischemic Stroke ◽  
Brain Injury ◽  
Stroke Patient ◽  
Complex Interventions ◽  
Cost Of Care ◽  
Current Evidence ◽  
Secondary Brain Injury ◽  
Stroke Patients ◽  
Neurosurgical Patients

Ischemic stroke accounts for approximately 85% of all strokes. Reperfusion therapy with intravenous Alteplase and/or endovascular thrombectomy is mainstay of acute stroke management. Approximately 30% of ischemic stroke patients will deteriorate in the first 24 hours regardless of pharmacologic and/or mechanical intervention. 15%-20% will require care in an intensive care unit (ICU). Severe strokes constitute a minority of cases though are associated with a majority of subsequent disability and death. The complex stroke patient presents many clinical challenges for the ICU nurse. This presentation will review nursing clinical challenges of the complex stroke patient in the ICU. The ICU Nurse is challenged with a variety of complex interventions caring for the ICU stroke patient. There is a significant subset of ischemic stroke patients at risk for secondary brain injury who may benefit from critical care monitoring and intervention. Nursing assessment, treatments, goals of care, and collaboration with the interdisciplinary ICU team will be addressed. There is evidence that care in a neuroscience-specific ICU leads to improved outcomes in traumatic brain injury, intraparenchymal hemorrhage, and subarachnoid hemorrhage and reduced cost of care for neurosurgical patients. There is less direct evidence to support benefit of ICU care in ischemic stroke, but the association between care at a specialized stroke center and outcome is well established. Recognizing nursing’s role in the care of the ICU stroke patient is key. The assessment and identification of subtle changes are imperative. Intervening with a variety of timely treatment options to eliminate complications must occur. Implementing current evidence-based practice allows for the best patient outcomes. The ICU nurse is challenged with the early recognition and appropriate management of neurological and non-neurological complications of the stroke patient in the ICU. This can be a significant factor in reducing mortality during the acute hospitalization. Standardized care implemented by the collaboration of nursing, neurointensivist and a critical care team, can not only decrease the length of stay, though also offer a greater chance of being discharged to home.

Abstract 3418: Acute Care Nurse Practicioner Led Critical Care Transport Team Leads to Improved Door to Imaging Time in Acute Ischemic Stroke Patients

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Michelle M Winfield ◽  
Julie A McNeil ◽  
Stephanie L Steiner ◽  
Christopher F Manacci ◽  
Damon Kralovic ◽  
...  
Keyword(s):  
Critical Care ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Patient Outcomes ◽  
Care Transitions ◽  
Cleveland Clinic ◽  
Stroke Patients ◽  
Time Intervals ◽  
Care Nurse ◽  
Transport Team

Background: In evaluating the acute ischemic stroke (AIS) patient, targeting time intervals for imaging and treatment times are paramount in optimizing outcomes. Initial evaluation by skilled providers who can facilitate the extension of a tertiary care facility can positively influence patient outcomes. A collaborative approach with a hospital based Critical Care Transport (CCT) Team can extend primary stroke program care out to a referring facility’s bedside. In the Cleveland Clinic Health System, the suspicion of a large vessel occlusion causing AIS in patients at an outside hospital triggers an “Auto Launch” process, bypassing typical transfer processes to expedite care transitions for patients with time sensitive emergencies. Referring facilities contact a CCT Coordinator, with immediate launching of the transport team that consists of an Acute Care Nurse Practitioner (ACNP) who evaluates the patient at outside facility, performs NIHSS and transitions the patient directly to CT/MRI upon return to Cleveland Clinic facility. Patient is met by the Stroke Neurology Team at CT scanner for definitive care. A CCT Team with an ACNP on board can augment not only door to CT and MRI times, but also time to evaluation by a stroke neurologist and time to intervention, bypassing the Emergency Department upon their arrival and proceeding directly to studies and/or time sensitive intervention as appropriate. Objective: To describe a stroke program with a coordinated approach with a CCT Team to facilitate rapid care transitions as well as decreased time to imaging in patients with AIS by having an ACNP on board during transport and throughout the continuum of care. Methods: A retrospective audit of a database of patients undergoing hyperacute evaluation of acute ischemic stroke symptoms from April 30, 2010 to July 31, 2011 was performed. Demographic information, types of imaging performed, hyperacute therapies administered and time intervals to imaging modalities and treatment were collected and analyzed. Results: 107 patients total, 28 males, and 36 females with a mean age of 70 were included in the analysis. 60% [64] of patients transferred via the CCT Team over 26.42 average nautical miles. The mean time of call to arrival was 1 hr and 19 min. The CCT Team monitored tPA infusion in 27 patients and initiated tPA infusion in 2 patients. 64 patients had CT imaging performed and 64 had MRI performed following the CT. [The average door to CT completion was 22 min, the average door to MRI completion was 1 hr and 29 min, compared to 1 hr and 8 min and 2 hr and 36 min, respectively, in patients not arriving by CCT Team], p<0.05. Conclusion: Collaboration between the Stroke Neurology Team and CCT Team has allowed acute ischemic stroke patients to be taken directly to CT/MRI scanner, allowing for rapid evaluation, definitive treatment decisions, and the potential for improved patient outcomes by decreasing the door to imaging time.

scholarly journals Critical Update on the Third Edition of the Guidelines for Managing Severe Traumatic Brain Injury in Children

2020 ◽  
Vol 29 (1) ◽  
pp. e13-e18
Author(s):  
Karin Reuter-Rice ◽  
Elise Christoferson
Keyword(s):  
Traumatic Brain Injury ◽  
Critical Care ◽  
Brain Injury ◽  
Severe Traumatic Brain Injury ◽  
Current Evidence ◽  
Care Providers ◽  
The Third ◽  
Guideline Document ◽  
Severe Tbi ◽  
Pediatric Tbi

Background Severe traumatic brain injury (TBI) is associated with high rates of death and disability. As a result, the revised guidelines for the management of pediatric severe TBI address some of the previous gaps in pediatric TBI evidence and management strategies targeted to promote overall health outcomes. Objectives To provide highlights of the most important updates featured in the third edition of the guidelines for the management of pediatric severe TBI. These highlights can help critical care providers apply the most current and appropriate therapies for children with severe TBI. Methods and Results After a brief overview of the process behind identifying the evidence to support the third edition guidelines, both relevant and new recommendations from the guidelines are outlined to provide critical care providers with the most current management approaches needed for children with severe TBI. Recommendations for neuroimaging, hyperosmolar therapy, analgesics and sedatives, seizure prophylaxis, ventilation therapies, temperature control/hypothermia, nutrition, and corticosteroids are provided. In addition, the complete guideline document and its accompanying algorithm for recommended therapies are available electronically and are referenced within this article. Conclusions The evidence base for treating pediatric TBI is increasing and provides the basis for high-quality care. This article provides critical care providers with a quick reference to the current evidence when caring for a child with a severe TBI. In addition, it provides direct access links to the comprehensive guideline document and algorithms developed to support critical care providers.

Abstract 9115: Determining Optimal Hemoglobin Transfusion Threshold for Patients With Severe Traumatic Brain Injury: A Systematic Review and Meta-Analysis

Circulation ◽  
2021 ◽  
Vol 144 (Suppl_2) ◽  
Author(s):  
Nitish Sood ◽  
Arnav Goyal ◽  
Dayton Grogan ◽  
Vamsi Reddy
Keyword(s):  
Systematic Review ◽  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Length Of Stay ◽  
Severe Traumatic Brain Injury ◽  
Meta Analysis ◽  
Cost Of Care ◽  
Current Evidence ◽  
Transfusion Threshold ◽  
Significant Difference

Introduction: Multiple randomized controlled trials have found that a conservative approach to transfusing critically ill patients reduces mortality, with current guidelines recommending a hemoglobin (HgB) transfusion threshold of 7 g/dL. However, little work has examined whether this transfusion threshold reduces mortality in patients with severe traumatic brain injury (TBI). Here, we present a systematic review and meta-analysis of the literature. Methods: A systematic search was conducted on PubMed, Ovid, and Web of Science. Full-text articles were eligible if patients with TBI, defined as Glasgow Coma Score <= 8, were divided into multiple groups with varying hemoglobin transfusion thresholds and reported any outcome of interest including mortality, number of packed red blood cell (PRBC) units transfused, length of stay in ICU, and length of stay in the hospital. Eight studies were eligible (n = 3663). We compared mortality rates at HgB transfusion thresholds of < 7 g/dL, < 8 g/dL, < 9 g/dL, and < 10 g/dL. Results: We found that traditionally ‘conservative’ approaches to anemia management (HgB < 7 g/dL, < 8 g/dL, and < 9 g/dL) were associated with decreased mortality when compared to traditionally ‘liberal’ approaches (HgB < 10 g/dL), with p < 0.05. Results were robust across both frequentist and Bayesian analysis. As a surrogate for cost of care and use of hospital resources, the total number of PRBC units transfused to patients, length of stay in ICU, and length of stay in hospital were analyzed. We found that using a transfusion threshold < 7 g/dL compared to < 10 g/dL substantially decreased the number of PRBC units transfused. In three of five cohorts, the cohort with the lower HgB transfusion threshold or no transfusion had a significantly shorter length of stay in the ICU and in the hospital. The remaining two cohorts found no significant difference in the length of stays in ICU or hospital. Conclusion: This study demonstrates that conservative approaches to transfusions ( < 7 g/dL, < 8 g/dL, or < 9 g/dL) significantly reduce mortality and the number of PRBC units transfused when compared to more liberal approaches ( < 10 g/dL). Current evidence is unclear on the benefits of conservative approaches in reduction of ICU or hospital length of stay.

Abstract WP378: Use of Code Head Bleed to Promote Hemorrhagic Stroke Awareness in the Emergency Department

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Candace J McAlpine ◽  
Rocio Garcia ◽  
Pablo Rojas
Keyword(s):  
Emergency Department ◽  
Ischemic Stroke ◽  
Patient Care ◽  
Stroke Patient ◽  
Hemorrhagic Stroke ◽  
Stroke Patients ◽  
Care Coordinator ◽  
Staff Members ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background and Purpose: Providers recognize the need for quick recognition and allocation of resources when ischemic stroke patients arrive at the emergency department. Hemorrhagic stroke patients have not been always given the same priority. One Comprehensive Stroke Center noticed a deficiency in timely recognition, documentation and mobilization of resources for hemorrhagic stroke patients. The initiation of “code head bleed” in the emergency department was created to correct this deficiency. The purpose of this study was to bring awareness and education to the team initially caring for the hemorrhagic stroke patient. Methods: Using Lean methodology, to bring about quality patient care while reducing wasted time, the “code head bleed” was born. Education was provided for all emergency department staff members and physicians regarding “code head bleed.” When a code head bleed notification is paged out it mobilizes all required resources to the patient’s bedside (Faculty physician, Medical Resuscitation team, Patient Care Coordinator, Respiratory Therapy, Stroke Coordinators and Emergency Department leadership). Results: Since its inception in May, the “code head bleed” is the most used code notification in the hospital (n=163 ), surpassing ischemic stroke alerts (n= 89 ) in the same period. An increase of traumatic hemorrhages has been noticed since they are also included in the notification; which has led to an increased awareness in this population of patients as well. Code head bleed has improved neuro-check documentation by 21 % and documentation of vasoactive drip titration by 15% in the hemorrhagic stroke population. Conclusions: In conclusion, having all essential staff, services and resources lends to optimizing the hemorrhagic stroke patient’s care. The “code head bleed” initiative has been attributed to an increased awareness of the needs of the hemorrhagic stroke patient in the emergency department and an improvement in the documentation of care provided.

Tenecteplase utility in acute ischemic stroke patients: A clinical review of current evidence

2019 ◽  
Vol 37 (2) ◽  
pp. 344-348 ◽  
Author(s):  
Amelia Nelson ◽  
Gregory Kelly ◽  
Richard Byyny ◽  
Catherine Dionne ◽  
Candice Preslaski ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Clinical Review ◽  
Current Evidence ◽  
Stroke Patients

scholarly journals Effect of Body Position on Oxygenation and Hemodynamic Status among Patients with Traumatic Brain Injury

2021 ◽  
Vol 3 (2) ◽  
pp. 15
Author(s):  
Abdullah Sh. Ismail ◽  
Sahar Y. Mohammad ◽  
Amira H. Mourad
Keyword(s):  
Blood Pressure ◽  
Traumatic Brain Injury ◽  
Critical Care ◽  
Brain Injury ◽  
Oxygen Saturation ◽  
Body Position ◽  
Lateral Position ◽  
Secondary Brain Injury ◽  
Hemodynamic Parameters ◽  
Hemodynamic Status

Context: Positioning is one of the most frequently performed nursing activities in the critical care unit. It is often providing a central pivotal focus for planning other nursing activities. Therapeutic positioning of the patient's head, different degrees of the head of the bed elevation has been suggested as a low-cost and simple approach to preventing secondary brain injury. Aim: determine the effect of body position on oxygenation and hemodynamic status among patients with traumatic brain injury. Methods: Quasi-experiments (single group pre/posttest design). The study was conducted in the Critical Care Units in El-Mansoura general hospital at El-Mansoura city. A purposive sample of (67) adult patients diagnosed with traumatic brain injuries was recruited in this study. A structured socio-demographic interview questionnaire, patients’ medical records to elicit clinical variables and record cardiorespiratory assessment findings, Glasgow Coma Scale, and Richmond Agitation Sedation Scale were used to either include or exclude the patient according to the study criteria. Results: There was a significant increase in oxygen saturation in post right lateral position from (94.93 ± 1.25 to 95.37 ± 1.17) and the semi fowler position from (95.37 ± 1.17 to 97.31 ± 11.13) compared to pre-positioning. The hemodynamic parameters (heart rate, respiratory rate, systolic blood pressure, diastolic blood pressure, and mean arterial pressure) were significantly decreased in the post-semi-fowler position and then right lateral position compared to pre. Besides, the CVP is significantly increased in the semi-fowler position. Conclusion: Oxygen saturation and all hemodynamic parameters were significantly improved compared to their normal range in post-semi-fowler position, then right lateral position. Develop nursing practice protocol for critical care nurses to position patients at the semi-fowler position after traumatic brain injury can improve oxygenation and hemodynamic parameters. Moreover, further studies should be carried out to assess the effect of other body positions in other medical conditions.

Abstract TP151: Association of Splenic Contraction And Development of Systemic Inflammatory Response Syndrome After Acute Ischemic Stroke

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Alicia M Zha ◽  
Bhargav Tippinayani ◽  
Jaskaren Randhawa ◽  
Nicole J Pariseau ◽  
Farhaan S Vahidy ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Systemic Inflammatory Response Syndrome ◽  
Inflammatory Response ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Care Center ◽  
Tertiary Care ◽  
Systemic Inflammatory Response ◽  
Secondary Brain Injury ◽  
Stroke Patients

Background: Animal models have demonstrated the deleterious contribution that immunocytes from the spleen exert on secondary brain injury after stroke. While previous work has demonstrated that there is splenic contraction (SC) in patients with acute ischemic stroke (AIS) and intracranial hemorrhage (ICH), no clinical studies have connected the systemic inflammatory response syndrome (SIRS) with SC. We aim to associate SIRS and its individual components with SC in acute stroke Methods: This is a retrospective analysis of a previous prospective observational study where daily spleen sizes were evaluated in 178 acute stroke patients in a tertiary care center from 2010-2013. Spleen contraction was defined compared to previously established normograms of healthy volunteers from the same study. SIRS was defined as the presence of 2 or more of the following: body temperature <36 or >38C, heart rate >90 beats, respiratory rate >20, and serum white blood cell count >12,000 or <4000 mm3 in the absence of infection. SC was evaluated in patients at 24 and 72 hrs after AIS with SIRS as a primary outcome. Results: 91 patients had verified AIS without concurrent infection at admission and 70 of these patients remained inpatient at 72 hrs. SIRS was not associated with admission SC at 24hr and 72 hrs. Patients with SIRS at 24 and 72 hrs were more likely to have higher admission NIHSS. SIRS was associated with higher discharge mRS (OR 4.24, 95% CI 1.64-10.9, p=0.0028) and PEG placement (OR 3.70, 95% CI 0.95-15.11, p=0.05). 16 patients (22.9%) developed SIRS by 72hrs, only 5 of whom had SC initially. 28 patients (47%) had SIRS on admission that persisted, 12 of whom had SC. SC was not associated with SIRS at 72 hrs (OR 1.05, 95% CI 0.35-2.79, p = 0.92). 14 patients (15%) developed infections while hospitalized, of which 85% had SIRS on admission. Conclusion: Based on our initial evaluation, SC detected within 24 hrs of stroke onset is not associated with SIRS suggesting that the relationship between the two may be more complicated in humans. Consistent with prior studies, however, SIRS is associated with worse outcome. Further studies and additional time points are necessary to further clarify the role of the spleen in the development of SIRS in stroke patients.

Abstract TMP24: Soluble St2 Links Innate Inflammation to Secondary Injury After Stroke and Subarachnoid Hemorrhage

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Matthew Bevers ◽  
Cristina Sastre ◽  
India Lissak ◽  
Eric Rosenthal ◽  
W. Taylor Kimberly
Keyword(s):  
Flow Cytometry ◽  
Immune Response ◽  
Ischemic Stroke ◽  
Subarachnoid Hemorrhage ◽  
Brain Injury ◽  
Innate Immune ◽  
Stroke Onset ◽  
Secondary Brain Injury ◽  
Midline Shift ◽  
Soluble St2

Background: We recently found that soluble ST2 (sST2) is a plasma marker that predicts neurological outcome after ischemic stroke and aneurysmal subarachnoid hemorrhage. We sought to extend these findings by studying sST2 associations with markers of secondary brain injury and peripheral innate immunity. Methods: We studied 241 acute ischemic stroke (AIS) patients with sST2 level measured on admission (7.4 ± 3.7 hrs after stroke onset) and at least one follow-up brain imaging study, obtained at a mean of 2.2 ± 1.4 days after stroke onset. A subgroup (n=147) had a second sST2 measurement at a mean of 2.1 ± 1.7 days after stroke onset. A separate cohort of 110 subarachnoid hemorrhage (SAH) patients were studied who had plasma sST2 measured at approximately 3.5 ± 1.2 days after ictus. Markers of secondary brain injury included edema after AIS (midline shift), and delayed cerebral ischemia (DCI) or epileptiform discharges on EEG after SAH. The relationships between sST2 level and outcome measures were assessed. Primary blood mononuclear cells from SAH patients and elective aneurysm controls were analyzed by multiparameter flow cytometry to phenotype the peripheral immune response. Results: In the AIS cohort, baseline plasma sST2 level was associated with the presence of midline shift (46.1 vs. 41.8 ng/mL, p=0.017), which further increased at 48 hr after stroke onset (50.6 vs. 38.4 ng/mL, p=0.006). In the SAH cohort, median sST2 in patients who developed new epileptiform abnormalities was higher compared to patients who did not (114.8 ng/ml vs. 74.7 ng/ml, p=0.024). Higher median sST2 concentration was also observed in those patients with DCI (90.8 vs 53.7ng/mL, p=0.003). In patients with high sST2, flow cytometry identified a peripheral monocyte population with decreased expression of CD14 (4.27x105 ± 2950 A.U. vs. 5.64x105 ± 1290 A.U., p<0.001), and increased expression of CD16 (39,960 ± 272 A.U. vs. 34,869 ± 183 A.U., p<0.001). Conclusion: Plasma sST2 independently predicts edema after stroke, and DCI and epileptiform abnormalities after subarachnoid hemorrhage. Elevated sST2 is also associated with changes in peripheral innate immune cells. These data suggest that sST2 links the innate immune response to secondary brain injury.

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