Goal-Concordant Care After Severe Acute Brain Injury

Background: Patients with severe acute brain injury (SABI) lack decision-making capacity, calling on families and clinicians to make goal-concordant decisions, aligning treatment with patient's presumed goals-of-care. Using the family perspective, this study aimed to (1) compare patient's goals-of-care with the care they were receiving in the acute setting, (2) identify patient and family characteristics associated with goal-concordant care, and (3) assess goals-of-care 6 months after SABI.Methods: Our cohort included patients with SABI in our Neuro-ICU and a Glasgow Coma Scale Score <12 after day 2. Socio-demographic and clinical characteristics were collected through surveys and chart review. At enrollment and again at 6 months, each family was asked if the patient would prefer medical care focused on extending life vs. care focused on comfort and quality of life, and what care the patient is currently receiving. We used multivariate regression to examine the characteristics associated with (a) prioritized goals (comfort/extending life/unsure) and (b) goal concordance.Results: Among 214 patients, families reported patients' goals-of-care to be extending life in 118 cases (55%), comfort in 71 (33%), and unsure for 25 (12%), while care received focused on extending life in 165 cases (77%), on comfort in 23 (11%) and families were unsure in 16 (7%). In a nominal regression model, prioritizing comfort over extending life was significantly associated with being non-Hispanic White and having worse clinical severity. Most patients who prioritized extending life were receiving family-reported goal-concordant care (88%, 104/118), while most of those who prioritized comfort were receiving goal-discordant care (73%, 52/71). The only independent association for goal concordance was having a presumed goal of extending life at enrollment (OR 23.62, 95% CI 10.19–54.77). Among survivors at 6 months, 1 in 4 family members were unsure about the patient's goals-of-care.Conclusion: A substantial proportion of patients are receiving unwanted aggressive care in the acute setting after SABI. In the first days, such aggressive care might be justified by prognostic uncertainty. The high rate of families unsure of patient's goals-of-care at 6 months suggests an important need for periodic re-evaluation of prognosis and goals-of-care in the post-acute setting.

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Early immunological defects in comatose patients after acute brain injury

Journal of Neurosurgery ◽

10.3171/jns.2001.94.5.0706 ◽

2001 ◽

Vol 94 (5) ◽

pp. 706-711 ◽

Cited By ~ 49

Author(s):

Baruch Wolach ◽

Leon Sazbon ◽

Ronit Gavrieli ◽

Arieh Broda ◽

Menachem Schlesinger

Keyword(s):

Immune System ◽

Brain Injury ◽

Vegetative State ◽

Persistent Vegetative State ◽

Acute Brain Injury ◽

High Rate ◽

Mechanical Trauma ◽

Severe Brain Injury ◽

Content Type ◽

Fine Print

Object. The aim of this prospective study was to evaluate the phagocytic, humoral, and cellular arms of the immune system in comatose patients shortly after severe brain injury and to compare the findings with those reported earlier in patients in a persistent vegetative state. The study was conducted in intensive care units and immunology laboratories of university-affiliated hospitals in central Israel. Methods. The study group consisted of 14 men aged 16 to 65 years who were comatose as a result of acute brain injury due to mechanical trauma. All were studied within 72 hours of injury. Brain damage was severe in all cases (Glasgow Coma Scale score < 8). Healthy age- and sex-matched volunteers served as simultaneous controls. Infections arose in nine (75%) of the 12 patients in whom data were available; the cumulative mortality rate was 38% (five of 13 patients in whom outcome data were available). Every patient exhibited one or more defects in at least one arm of the immune system. Significant deficiencies were noted in neutrophil superoxide release, immunoglobulin (Ig)G, IgG1, IgM, C1q, C2, properdin, alternate C pathway, T cells, T helper cells, T suppressor cells, and natural killer cells. In an earlier series of patients examined by the authors months after the primary insult, these impairments were absent in most of the patients in the vegetative state. Conclusions. Significant deficiencies of the immune system, particularly the cellular arm, are precipitated by severe brain injury within 72 hours of the event. These impairments probably play a role in the high rate of complicating infections and multiple organ failure. Together with earlier findings, the results of this study indicate that if brain-injured patients survive these hazards, their immune system will eventually recover.

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A methodology for detecting and exploring non-convulsive seizures in patients with acute brain injury

IEICE Proceeding Series ◽

10.15248/proc.2.396 ◽

2014 ◽

Vol 2 ◽

pp. 396-399 ◽

Cited By ~ 1

Author(s):

DJ Albers ◽

J Claassen ◽

M Schmidt ◽

G Hripcsak

Keyword(s):

Brain Injury ◽

Acute Brain Injury ◽

Convulsive Seizures

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Alterations of blood IL-8, TGF-beta1 and nitric oxide levels in relation to blood cells in patients with acute brain injury

Therapy ◽

10.1586/14750708.3.3.399 ◽

2006 ◽

Vol 3 (3) ◽

pp. 399-405

Author(s):

Elham Hadidi ◽

Mojtaba Mojtahedzadeh ◽

Mohammad Hassan Paknejad ◽

Shekoufeh Nikfar ◽

Mohammad Jafar Zamani ◽

...

Keyword(s):

Nitric Oxide ◽

Brain Injury ◽

Blood Cells ◽

Acute Brain Injury

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Faculty Opinions recommendation of Hypermetabolism following moderate to severe traumatic acute brain injury: a systematic review.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.1142036.599156 ◽

2009 ◽

Author(s):

Donald Marion

Keyword(s):

Systematic Review ◽

Brain Injury ◽

Acute Brain Injury

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Faculty Opinions recommendation of Simplifying the use of prognostic information in traumatic brain injury. Part 1: The GCS-Pupils score: an extended index of clinical severity.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.733027969.793562880 ◽

2019 ◽

Author(s):

Gregory Hawryluk

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Clinical Severity ◽

Prognostic Information

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Heart rate and blood pressure variability and baroreflex sensitivity in patients with acute brain injury

Journal of Critical Care ◽

10.1016/j.jcrc.2005.09.048 ◽

2005 ◽

Vol 20 (4) ◽

pp. 394 ◽

Cited By ~ 1

Author(s):

V. Papaioannou ◽

M. Giannakou ◽

N. Maglaveras ◽

E. Sofianos ◽

M. Giala

Keyword(s):

Blood Pressure ◽

Heart Rate ◽

Brain Injury ◽

Blood Pressure Variability ◽

Baroreflex Sensitivity ◽

Acute Brain Injury

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The Tangled History of Brain–Heart Pathways in Acute Brain Injury

Neurocritical Care ◽

10.1007/s12028-021-01193-5 ◽

2021 ◽

Author(s):

Eelco F. M. Wijdicks

Keyword(s):

Brain Injury ◽

Acute Brain Injury ◽

History Of

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Outcome Prognostication of Acute Brain Injury using the Neurological Pupil Index (ORANGE) study: protocol for a prospective, observational, multicentre, international cohort study

BMJ Open ◽

10.1136/bmjopen-2020-046948 ◽

2021 ◽

Vol 11 (5) ◽

pp. e046948

Author(s):

Mauro Oddo ◽

Fabio Taccone ◽

Stefania Galimberti ◽

Paola Rebora ◽

Giuseppe Citerio

Keyword(s):

Brain Injury ◽

Latent Class ◽

Acute Brain Injury ◽

Institutional Review ◽

Infrared Pupillometry ◽

Poor Neurological Outcome ◽

Registration Number ◽

Poor Outcomes ◽

Injured Patients ◽

Neurological Pupil Index

IntroductionThe pupillary examination is an important part of the neurological assessment, especially in the setting of acutely brain-injured patients, and pupillary abnormalities are associated with poor outcomes. Currently, the pupillary examination is based on a visual, subjective and frequently inaccurate estimation. The use of automated infrared pupillometry to measure the pupillary light reflex can precisely quantify subtle changes in pupillary functions. The study aimed to evaluate the association between abnormal pupillary function, assessed by the Neurological Pupil Index (NPi), and long-term outcomes in patients with acute brain injury (ABI).Methods and analysisThe Outcome Prognostication of Acute Brain Injury using the Neurological Pupil Index study is a prospective, observational study including adult patients with ABI requiring admission at the intensive care unit. We aimed to recruit at least 420 patients including those suffering from traumatic brain injury or haemorrhagic strokes, over 12 months. The primary aim was to assess the relationship between NPi and 6-month mortality or poor neurological outcome, measured by the Extended Glasgow Outcome Score (GOS-E, poor outcome=GOS-E 1–4). Supervised and unsupervised methods and latent class mixed models will be used to identify patterns of NPi trajectories and Cox and logistic model to evaluate their association with outcome.Ethics and disseminationThe study has been approved by the institutional review board (Comitato Etico Brianza) on 16 July 2020. Approved protocol V.4.0 dated 10 March 2020. The results of this study will be published in peer-reviewed journals and presented at conferences.Trial registration numberNCT04490005.

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