scholarly journals Neurologic Assessment of the Neurocritical Care Patient: The Neurologic Wake-Up Test

2020 ◽  
Author(s):  
Shane Musick ◽  
Anthony Alberico
Keyword(s):  
Gold Standard ◽  
Acute Stress ◽  
Cerebral Metabolism ◽  
Relevant Information ◽  
Hemodynamic Instability ◽  
Rapid Onset ◽  
Care Patient ◽  
Cerebral Microdialysis ◽  
Propofol Infusion Syndrome ◽  
Oxygen Monitoring

Sedation is a ubiquitous practice in ICUs and NCCUs. It has the benefit of reducing cerebral energy demands, but also precludes an accurate neurologic assessment. Because of this, sedation is intermittently stopped for the purposes of a neurologic assessment, which is termed a neurologic wake-up test (NWT). NWTs are considered to be the gold-standard in continued assessment of brain-injured patients under sedation. NWTs also produce an acute stress response that is accompanied by elevations in blood pressure, respiratory rate, heart rate, and ICP. Utilization of cerebral microdialysis and brain tissue oxygen monitoring indicates that this is not mirrored by alterations in overall cerebral metabolism, and seldom affects oxygenation. The hard contraindications for the NWT are preexisting intracranial hypertension, barbiturate treatment, status epilepticus, and hyperthermia. However, hemodynamic instability, sedative use for primary ICP control, and sedative use for severe agitation or respiratory distress are considered significant safety concerns. Despite ubiquitous recommendation, it is not clear if additional clinically relevant information is gleaned through its use, especially with the contemporaneous utilization of multimodality monitoring. Various monitoring modalities provide unique and pertinent information about neurologic function, however, their role in improving patient outcomes and guiding treatment plans has not been fully elucidated. There is a paucity of information pertaining to the optimal frequency of NWTs, and if it differs based on type of injury. Only one concrete recommendation was found in the literature, exemplifying the uncertainty surrounding its utility. The most common sedative used and recommended is propofol because of its rapid onset, short duration, and reduction of cerebral energy requirements. Dexmedetomidine may be employed to facilitate serial NWTs, and should always be used in the non-intubated patient or if propofol infusion syndrome (PRIS) develops. Midazolam is not recommended due to tissue accumulation and residual sedation confounding a reliable NWT. Thus, NWTs are well tolerated in most patients and remain recommended as the gold-standard for continued neuromonitoring. Predicated upon one expert panel, they should be performed at least one time per day. Propofol or dexmedetomidine are the main sedative choices, both enabling a rapid awakening and consistent NWT.

scholarly journals Neurologic Assessment of the Neurocritical Care Patient

2021 ◽  
Vol 12 ◽  
Author(s):  
Shane Musick ◽  
Anthony Alberico
Keyword(s):  
Gold Standard ◽  
Acute Stress ◽  
Cerebral Metabolism ◽  
Relevant Information ◽  
Hemodynamic Instability ◽  
Rapid Onset ◽  
Cerebral Microdialysis ◽  
Propofol Infusion Syndrome ◽  
Brain Injured ◽  
Injured Patients

Sedation is a ubiquitous practice in ICUs and NCCUs. It has the benefit of reducing cerebral energy demands, but also precludes an accurate neurologic assessment. Because of this, sedation is intermittently stopped for the purposes of a neurologic assessment, which is termed a neurologic wake-up test (NWT). NWTs are considered to be the gold-standard in continued assessment of brain-injured patients under sedation. NWTs also produce an acute stress response that is accompanied by elevations in blood pressure, respiratory rate, heart rate, and ICP. Utilization of cerebral microdialysis and brain tissue oxygen monitoring in small cohorts of brain-injured patients suggests that this is not mirrored by alterations in cerebral metabolism, and seldom affects oxygenation. The hard contraindications for the NWT are preexisting intracranial hypertension, barbiturate treatment, status epilepticus, and hyperthermia. However, hemodynamic instability, sedative use for primary ICP control, and sedative use for severe agitation or respiratory distress are considered significant safety concerns. Despite ubiquitous recommendation, it is not clear if additional clinically relevant information is gleaned through its use, especially with the contemporaneous utilization of multimodality monitoring. Various monitoring modalities provide unique and pertinent information about neurologic function, however, their role in improving patient outcomes and guiding treatment plans has not been fully elucidated. There is a paucity of information pertaining to the optimal frequency of NWTs, and if it differs based on type of injury. Only one concrete recommendation was found in the literature, exemplifying the uncertainty surrounding its utility. The most common sedative used and recommended is propofol because of its rapid onset, short duration, and reduction of cerebral energy requirements. Dexmedetomidine may be employed to facilitate serial NWTs, and should always be used in the non-intubated patient or if propofol infusion syndrome (PRIS) develops. Midazolam is not recommended due to tissue accumulation and residual sedation confounding a reliable NWT. Thus, NWTs are well-tolerated in selected patients and remain recommended as the gold-standard for continued neuromonitoring. Predicated upon one expert panel, they should be performed at least one time per day. Propofol or dexmedetomidine are the main sedative choices, both enabling a rapid awakening and consistent NWT.

scholarly journals Revered but Poorly Understood: A Case Report of Dendroaspis polylepis (Black Mamba) Envenomation in Watamu, Malindi Kenya, and a Review of the Literature

2018 ◽  
Vol 3 (3) ◽  
pp. 104 ◽  
Author(s):  
Valentine Erulu ◽  
Mitchel Okumu ◽  
Francis Ochola ◽  
Joseph Gikunju
Keyword(s):  
Mechanical Ventilation ◽  
Oxygen Saturation ◽  
South African ◽  
Artificial Ventilation ◽  
Clinical Course ◽  
Clinical Manifestations ◽  
Hemodynamic Instability ◽  
Rapid Onset ◽  
Sub Saharan Africa ◽  
Sub Saharan

The black mamba (Dendroaspis polylepis) ranks consistently as one of the most revered snakes in sub-Saharan Africa. It has potent neurotoxic venom, and envenomation results in rapid onset and severe clinical manifestations. This report describes the clinical course and reversal of effects of black mamba envenomation in a 13-year-old boy in the Jimba area of Malindi. The victim presented to Watamu Hospital, a low resource health facility with labored breathing, frothing at the mouth, severe ptosis and pupils non-responsive to light. His blood pressure was unrecordable, heart rate was 100 beats per minute but thready, his temperature was 35.5 °C, and oxygen saturation was 83%. Management involved suction to clear salivary secretions, several hours of mechanical ventilation via ambu-bagging, oxygen saturation monitoring, and the use of South African Vaccine Producers (SAVP) polyvalent antivenom. Subcutaneous adrenaline was used to stave off anaphylaxis. The victim went into cardiac arrest on two occasions and chest compressions lasting 3–5 min was used to complement artificial ventilation. Hemodynamic instability was corrected using IV infusion of ringers lactate and normal saline (three liters over 24 h). Adequate mechanical ventilation and the use of specific antivenom remain key in the management of black mamba envenomation.

scholarly journals Improving the quality of GP referrals to the Croydon Assessment & Liaison Team

BJPsych Open ◽  
2021 ◽  
Vol 7 (S1) ◽  
pp. S205-S205
Author(s):  
Gabriella Lewis ◽  
Lucia Chaplin ◽  
Gareth Knott ◽  
Alexandra Coull ◽  
Lamide Sobamowo
Keyword(s):  
Random Sample ◽  
Gold Standard ◽  
Relevant Information ◽  
Post Intervention ◽  
Significant Difference ◽  
Referral Form ◽  
Patient Assessments ◽  
New Form ◽  
Intervention Uptake

AimsTo increase the percentage of GP referrals to the Croydon Assessment & Liaison (A&L) Team deemed to be of ‘good quality’. The A&L Team receives a large number of referrals daily from GPs, and it was identified that many of these referrals did not include important and relevant information, leading to delays in patient assessments.MethodA questionnaire was distributed to A&L MDT members to collect information about what information they consider important in a GP referral. The project team reviewed the results of the questionnaire, along with current policies and guidelines, to create a set of criteria by which to assess the quality of GP referrals, as there was no pre-existing gold standard available. A random sample of 6 GP referrals per week stratified by locality was collected and assessed against these criteria.Using Plan-Do-Study-Act (PDSA) methodology change ideas were generated, and a GP referral form was identified as an important intervention to adopt. A previously-developed draft form was updated after a round of consultations with various stakeholders including Assessment & Liaison staff, GPs and the CCG. The new GP referral form was uploaded to the GP DSX electronic referrals platform and GP practices were also emailed directly to encourage them to use the new form.The proportion of GP referrals deemed to be of good quality was compared pre and post-intervention. Uptake of the new GP referral form was recorded as a process measure, and the length of time taken to discuss referrals at A&L daily referrals meetings as a counterbalance measure.ResultAt baseline 33% of GP referrals were deemed to be of good quality using the developed criteria. This improved to 58% after implementation of the new referral form in January 2021. There was poor overall uptake of the form, with only 32.5% of GP referrals utilising the new form so far, however of the referrals received on the new form 69% fulfilled the criteria for good quality. Comparison of length of discussion required for referrals with and without the new form showed no significant difference (7.7 and 7.6 minutes respectively).ConclusionImplementation of a standardised GP referral form was effective at increasing the proportion of referrals deemed to be of good quality. However, further PDSA cycles focused on improving uptake of the form will be required.

Diverticulitis

2016 ◽  
Author(s):  
Bharati Kocher
Keyword(s):  
Abdominal Pain ◽  
Diverticular Disease ◽  
Gold Standard ◽  
Hemodynamic Instability ◽  
Immunocompetent Patient ◽  
Indications For Surgery ◽  
Oral Antibiotics ◽  
Uncomplicated Diverticulitis ◽  
Generalized Peritonitis ◽  
Colon Diverticulosis

Diverticular disease includes two conditions: diverticulosis and diverticulitis. Both involve saclike protrusions of the mucosal and submucosal walls, typically in the colon. Diverticulosis is the presence of multiple diverticula, which may or may not be symptomatic. Symptomatic diverticulosis presents with indistinct symptoms and, less commonly, with severe symptoms, such as slow bleeding (causing anemia) or rapid bleeding (causing frank hematochezia and even hemodynamic instability). Diverticulitis is acute or chronic inflammation of the diverticula, possibly leading to abscesses and even perforation. Classic diverticulitis includes fever, leukocytosis, and left-sided abdominal pain, with localized tenderness and guarding. Incidence of disease increases with age. CT is the gold standard for diagnosis, which rules out other abdominal pathology and detects any diverticular complications. An outpatient course of oral antibiotics is prescribed for uncomplicated diverticulitis in an immunocompetent patient. Indications for surgery are generalized peritonitis or large abscesses that cannot be drained.

scholarly journals 0306 Corticotropin-Releasing Hormone Receptor 1 Gene Polymorphism Modulates Cognitive Flexibility Following Acute Stress and Total Sleep Deprivation

SLEEP ◽  
2020 ◽  
Vol 43 (Supplement_1) ◽  
pp. A115-A116
Author(s):  
B C Satterfield ◽  
I Anlap ◽  
S L Esbit ◽  
W D Killgore
Keyword(s):  
Stress Response ◽  
Sleep Deprivation ◽  
Cognitive Flexibility ◽  
Acute Stress ◽  
Relevant Information ◽  
Corticotropin Releasing Hormone ◽  
Reversal Performance ◽  
Releasing Hormone ◽  
Total Sleep Deprivation ◽  
Stimulus Response

Abstract Introduction Dynamic decision processes requiring flexible updating of information are impaired by stress and sleep loss, both of which activate the hypothalamic-pituitary-adrenal (HPA) stress response. Corticotropin-releasing hormone (CRH) initiates the HPA pathway. The CRH receptor (CRHR1) gene contains a single nucleotide polymorphism that modulates this response. We investigated whether cognitive flexibility is affected by CRHR1 polymorphism following a night of acute stress and total sleep deprivation (TSD). Methods N=46 healthy, young adults (21.8±3.4y; 21 females) participated in an in-laboratory 31h sleep deprivation study. Beginning at 19:30 until 07:30, the Maastricht Acute Stress Test (MAST) was administered every 4h. The MAST alternates a cold pressor task with an oral subtraction task five times in a single bout. At 29h wakefulness, subjects performed a novel go/no-go reversal learning task. Stimulus-response rules were presented at the beginning of the task, and subjects were asked to either respond or withhold a response to the presented stimuli while receiving accuracy feedback. Halfway through the task, the stimulus-response rules were reversed. Performance was assessed by discriminability index (d’), hit rate (HR), and false alarm rate (FAR). Saliva samples were collected immediately prior, immediately after, and 30min after each MAST and assayed for cortisol. One saliva sample from each subject was assayed for CRHR1 genotype. Results CRHR1 genotypes were in Hardy-Weinberg equilibrium (χ 2=2.97, p=0.08). Mixed effects ANOVA with fixed effects of CRHR1 genotype, pre/post-reversal, and their interaction found a significant CRHR1 by reversal interaction for d’ (F2,319=3.88, p=0.022) and HR (F2,319=3.16, p=0.044) following a night of stress and TSD. No such interaction was found at well-rested baseline (d’: F2,319=2.51, p=0.083; HR: F2,319=1.55, p=0.213). Subjects homozygous for the T allele had higher mean post-MAST cortisol levels (0.40±0.06 µg/dL) with better pre-reversal performance, but worse post-reversal performance compared to heterozygous and homozygous G allele carriers. Conclusion CRHR1 genotype modulates dynamic decision making following a night of acute stress and TSD. A higher cortisol stress response (T/T genotype) is beneficial to maintaining task relevant information (stability), but significantly impairs the ability to update task-relevant information following a change in situational demands (flexibility). Support CDMRP grant W81XWH-17-C-0088

scholarly journals Neural therapy approach in a hospitalized patient with acute stress disorder. Case report

Case reports ◽  
2020 ◽  
Vol 6 (1) ◽  
pp. 25-32
Author(s):  
Alba Fernanda Ruiz-Mejía ◽  
Eduardo Humberto Beltrán-Dussán ◽  
Leonardo Alfonso Morales-Hernandez ◽  
Laura Bibiana Pinilla-Bonilla
Keyword(s):  
Stress Disorder ◽  
Acute Stress ◽  
Traumatic Event ◽  
Abdominal Mass ◽  
Clinical History ◽  
Rapid Onset ◽  
Acute Stress Disorder ◽  
Organ Function ◽  
Neural Therapy ◽  
Therapy Approach

Introduction: Acute stress disorder is a picture of rapid onset that follows a traumatic event. It is characterized by dissociative, intrusive, avoidance and activation symptoms that affect the quality of life of the patient. To date, there is no evidence of a relationship between altered organ function and this disorder, and there is no literature on its treatment with neural therapy on an inpatient basis.Case presentation: 53-year-old woman, who developed symptoms compatible with acute stress disorder after the resection of an intra- abdominal mass diagnosed as lymphoma. The patient was assessed by the neural therapy department, which applied procaine into specific skin zones —determined by the clinical history and physical examination—, with improvement of dissociated symptoms.Discussion: The neural therapy approach allowed identifying the relationship between the dissociative symptoms of the patient and the associated alteration in organ function, as well as applying a therapy that led to the resolution of the symptoms.Conclusions: The neural therapy approach allows for a comprehensive perspective and treatment of the patient, taking into account the close functional relationship between mindemotions- body. This type of treatment also offers therapeutic strategies to hospitals, which can accompany the treatment established by other health specialists.

Cerebral microdialysis and intracranial pressure monitoring in patients with idiopathic normal-pressure hydrocephalus: association with clinical response to extended lumbar drainage and shunt surgery

2010 ◽  
Vol 112 (2) ◽  
pp. 414-424 ◽  
Author(s):  
Per K. Eide ◽  
Milo Stanisic
Keyword(s):  
Intracranial Pressure ◽  
Normal Pressure Hydrocephalus ◽  
Wave Amplitude ◽  
Cerebral Metabolism ◽  
Normal Pressure ◽  
Idiopathic Normal Pressure Hydrocephalus ◽  
Clinical Severity ◽  
Cerebral Microdialysis ◽  
Shunt Surgery ◽  
Lumbar Drainage

Object This study was performed in patients with idiopathic normal-pressure hydrocephalus (iNPH) to monitor cerebral metabolism with microdialysis (MD) and intracranial pressure (ICP) readings, and relate to the clinical responses to extended lumbar drainage (ELD) and shunt surgery. Methods The baseline levels of MD metabolites and ICP were monitored overnight in 40 consecutive patients with iNPH. In a subset of 28 patients, monitoring was continued during 3 days of ELD. Thirty-one patients received a ventriculoperitoneal shunt. The clinical severity of iNPH was determined before and then 3 and 6–12 months after shunt surgery. Results Altered levels of MD markers (lactate, pyruvate, lactate/pyruvate ratio, glutamate, and/or glycerol) were seen in all patients at baseline; these improved during ELD. Despite normal static ICP (mean ICP), the pulsatile ICP (the ICP wave amplitude) was increased in 24 patients (60%). Only the level of the ICP wave amplitude differentiated the ELD and/or shunt responders from nonresponders. Conclusions The MD monitoring indicated low-grade cerebral ischemia in patients with iNPH; during ELD, cerebral metabolism improved. The pulsatile ICP (the ICP wave amplitude) was the only variable differentiating the clinical responders from the nonresponders. The authors suggest that the pulsatile ICP reflects the intracranial compliance and that CSF diversion improves the biophysical milieu of the nerve cells, which subsequently may improve their biochemical milieu.

Continuous monitoring of cerebral metabolism in traumatic brain injury: a focus on cerebral microdialysis

2006 ◽  
Vol 12 (2) ◽  
pp. 112-118 ◽  
Author(s):  
Lars Hillered ◽  
Lennart Persson ◽  
Pelle Nilsson ◽  
Elisabeth Ronne-Engstrom ◽  
Per Enblad
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Continuous Monitoring ◽  
Cerebral Metabolism ◽  
Cerebral Microdialysis

scholarly journals Educational intervention reduces complications and re-hospitalizations after heart surgery.

2021 ◽  
Author(s):  
Suzanne Fredericks ◽  
Terrence M. Yau
Keyword(s):  
Hospital Discharge ◽  
Heart Surgery ◽  
Controlled Trial ◽  
Hospital Readmissions ◽  
Self Care ◽  
Relevant Information ◽  
Preliminary Evidence ◽  
Care Patient ◽  
Chi Square ◽  
The Impact

The effectiveness of in-hospital self-care patient education, delivered to patients following heart surgery, is questionable, as evidence indicates individuals are not able to absorb and/or retain information at this time. In the absence of adequate instruction, individuals will not have the relevant information to engage in specific self-care behaviors, resulting in the onset of complications and/or hospital readmissions. The purpose of this pilot study was to collect preliminary evidence to demonstrate the impact of an individualized education intervention given above and beyond usual care, delivered, at two points in time, following hospital discharge. A randomized controlled trial was used in which 34 patients were randomly assigned to one of two groups. Chi-square analyses to examine differences between groups on complications and hospital readmission rates were conducted. Findings point to the impact of the intervention in reducing the number of hospital readmissions and complications at 3 months following hospital discharge.

scholarly journals Educational intervention reduces complications and re-hospitalizations after heart surgery.

2021 ◽  
Author(s):  
Suzanne Fredericks ◽  
Terrence M. Yau
Keyword(s):  
Hospital Discharge ◽  
Heart Surgery ◽  
Controlled Trial ◽  
Hospital Readmissions ◽  
Self Care ◽  
Relevant Information ◽  
Preliminary Evidence ◽  
Care Patient ◽  
Chi Square ◽  
The Impact

The effectiveness of in-hospital self-care patient education, delivered to patients following heart surgery, is questionable, as evidence indicates individuals are not able to absorb and/or retain information at this time. In the absence of adequate instruction, individuals will not have the relevant information to engage in specific self-care behaviors, resulting in the onset of complications and/or hospital readmissions. The purpose of this pilot study was to collect preliminary evidence to demonstrate the impact of an individualized education intervention given above and beyond usual care, delivered, at two points in time, following hospital discharge. A randomized controlled trial was used in which 34 patients were randomly assigned to one of two groups. Chi-square analyses to examine differences between groups on complications and hospital readmission rates were conducted. Findings point to the impact of the intervention in reducing the number of hospital readmissions and complications at 3 months following hospital discharge.

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