Combining Observational and Physiologic Sedation Assessment Tools

Purpose: This study was designed to test the hypothesis that bispectral index (BIS) monitoring, when used as an adjunct to current sedation assessment, reduces the amount of sedation used. Background/Significance: ICU patients frequently experience episodes of oversedation. A wide array of sedation scales have been proposed and tested with varying results. There is some confusion about BIS monitoring both in literature and practice; BIS is neither adequate, nor designed, to replace observational assessments of the patient's response to sedation. This study is unique in that it explores how a specific outcome variable (the amount of sedation) is impacted by augmenting (not replacing) current methods of sedation assessment. Methods: This prospective randomized controlled trial blinded nurses to the primary purpose of the study. Following informed consent by the subject's legally authorized representative, for this institutional review board approved study, 51 subjects were randomized to receive sedation assessment with either the standard of care alone (Ramsay-alone group; n = 25), or the standard of care plus BIS (BIS-augmentation group; n = 26). The study period began at 8:00 a.m. on the day of study and lasted 12 hours. Nurses were instructed to adjust sedation to a Ramsay score of 4 (both groups) and a BIS value between 60 and 70 (BIS-augmentation group). Results: The results represent data from 51 subjects included in the interim analysis of a planned enrollment of 90 subjects. The interim analysis was performed using a significance level of .025 to explore the primary research question. Upon rejecting the null hypothesis for the primary research question, the remaining research questions were explored using a significance level of .05. Data were analyzed using SAS v9.1 (Cary, NC). The mean infused volumes for the Ramsay-alone group (175.36 ml) and the BIS-augmentation group (97.51 ml) were significantly different (F=6.00, p=.018, r2=.011). The mean infusion rates for the Ramsay-alone group (30.19 mcg/kg/min) and BIS-augmentation group (15.35 mcg/kg/min) were significantly different (F=8.63, p=.005, r2=.15). The length of time for subjects in the Ramsay-alone group (9.47 minutes) compared to the BIS-augmentation group (1.44 minutes) to awaken (recovery rate) when the sedation was discontinued was significantly different (F=24.48, p<.0001). There were no undersedation events reported in either group. Conclusions: BIS augmentation of current observational assessment resulted in a reduction in the sedation use and a shorter time to recovery from sedation; no increase in undersedation associated with the reduced use of sedation in the BIS augmented group. Physiologic sedation assessment tools with EEG-derived parameters such as BIS provide useful information that may decrease the incidence of oversedation in critically ill patients

Pilotażowy test interwencji świadomej medytacji w redukcji stresu u młodszych pacjentów z udarem mózgu

Introduction. The population of younger people having strokes is growing. Persons who are younger and have a stroke have specific stressors after a stroke that those over 60 may not experience (e.g., ability to earn an income, provide for a family, returning to work, etc.).Aim. In order to address some of these age-specific stressors, new and novel approaches to stress mediation are needed. In order to address this gap in the literature this study piloted a mindfulness meditation with younger in hospital stroke survivors.Material and Methods. Prospective non-randomized pilot study of in-hospital stroke patients &lt; 60 years of age. Baseline assessment included the Perceived Stress Scale (PSS), heart rate (HR), blood pressure (BP), and respiratory rate (RR). Patients received a 10-minute mindfulness training session with instructions for home use. PSS, HR, BP, and RR were collected immediately after training and telephone assessments of PSS were collected 30-day post discharge.Results. The mean age of the 21 patients included in the final analysis was 47.4 years. Paired t-test showed statistically significant differences in heart rate (p &lt; 0.001) and respiratory rate (p &lt; 0.001) before and after the intervention, but no statistically significant differences in pre and post training blood pressure (p = 0.480). There was no statistically significant difference in PSS scores before and after the training.Conclusions. The findings of this study suggest that the mindfulness intervention is feasible for in-hospital stroke patients and shows promise for reducing stress, as indicated by physiologic changes such as lowering heart and blood pressure rates. (JNNN 2019;8(2):48–53)Wstęp. Wzrasta populacja młodych ludzi zapadających na udary mózgu. Osoby młodsze w wyniku udaru odczuwają określone czynniki stresogenne, których osoby powyżej 60. roku życia mogą nie doświadczyć (np. zdolność do zarabiania pieniędzy, utrzymanie rodziny, powrót do pracy itp.).Cel. Aby odnieść się do niektórych z tych specyficznych dla danego wieku czynników stresogennych, potrzebne są nowe i nowatorskie podejścia do mediacji w zakresie stresu. W celu zajęcia się tą luką w literaturze, w badaniu tym przeprowadzono pilotażową świadomą medytację w szpitalu z młodszymi osobami, które przeżyły udar mózgu.Materiał i metody. Prospektywne, nierandomizowane badanie pilotażowe u pacjentów po udarze mózgu w wieku poniżej 60 lat przeprowadzono w warunkach szpitalnych. Ocena stanu wyjściowego obejmowała skalę postrzeganego stresu (PSS), częstość akcji serca (HR), ciśnienie krwi (BP) i częstość oddechową (RR). Pacjenci otrzymali 10-minutowy trening świadomego myślenia oraz instrukcje wykonywania w warunkach domowych. PSS, HR, BP i RR zebrano natychmiast po przeszkoleniu, a oceny telefoniczne PSS zebrano 30 dni po wypisie ze szpitala.Wyniki. Średni wiek 21 pacjentów objętych finalną analizą wynosił 47,4 lat. Analiza t-testem wykazała istotne statystycznie różnice w częstości akcji serca (p &lt; 0,001) i częstości oddechu (p &lt; 0,001) przed i po interwencji, jednakże nie wykazano istotnych statystycznie różnic w ciśnieniu krwi przed i po instruktażu (p = 0,480). Nie odnotowano statystycznie istotnej różnicy w wynikach PSS przed i po szkoleniu.Wnioski. Wyniki tego badania sugerują, że interwencja w zakresie świadomego myślenia jest wykonalna dla pacjentów po udarze mózgu w warunkach szpitalnych i wskazuje na obiecujące możliwości zmniejszenia stresu, na co wskazują zmiany fizjologiczne, takie jak obniżenie częstości akcji serca i ciśnienia krwi. (PNN 2019;8(2):48–53

Różnice wartości zautomatyzowanej pupilometrii służą jako wskaźnik prognostyczny, nawet gdy mieszczą się w normalnym zakresie

Introduction. The pupillary light reflex (PLR) is an integral aspect of the neurologic exam. With the enhancement of automated infrared pupillometry (AIP), the Neurological Pupil index (NPi) is being increasingly used when performing a neurological examination. NPi difference (the absolute difference between paired NPi readings from the left and right eye) is a relatively unexplored variable in AIP assessment.Aim. This study evaluates the association between Glasgow Coma Scale (GCS) scores and NPi differences between the left and right eyes, when the NPi is normal, in patients enrolled in a multi-center prospective database.Material and Methods. Restricting observations to only include NPi values ≥ 3 (normal), there were 2,572 qualifying patients with 3,519 pupillometer readings linked to GCS values. Linear regression and ANOVA models were developed to investigate the relationship between GCS and NPi difference.Results. Subject mean age was 55.88 (16.95) years and 54.5% were female. Mean NPi difference was 0.36 and mean GCS was 12.06. Regression analysis indicated a slight negative association between NPi difference and GCS (r2 = 0.0696, P &lt; .0001). When observations were dichotomized as either NPi difference ≥ 0.7 (large) or &lt; 0.7 (small), there was a statistically significant difference in the mean GCS (10.76 [3.90]) for large NPi difference vs. small NPi difference (13.15 [2.68]; P &lt; .0001).Conclusions. Even among patients with normal PLR, a large NPi difference is associated with lower GCS scores. Trending and evaluating the NPi difference may become an important aspect of patient assessment. (JNNN 2021;10(4):168–174)Wstęp. Odruch źreniczny na światło (PLR) jest integralną częścią badania neurologicznego. Wraz z udoskonaleniem automatycznej pupilometrii w podczerwieni (AIP), wskaźnik neurologiczny źrenicy (NPi) jest coraz częściej używany podczas wykonywania badań neurologicznych. Różnica NPi (bezwzględna różnica między sparowanymi odczytami NPi z lewego i prawego oka) jest stosunkowo niezbadaną zmienną w ocenie AIP.Cel. Niniejsze badanie ocenia związek między wynikami w skali Glasgow (GCS) a różnicami NPi między lewym i prawym okiem, gdy NPi jest prawidłowe, u pacjentów włączonych do wieloośrodkowej prospektywnej bazy danych.Materiał i metody. Ograniczając obserwacje tylko do wartości NPi ≥ 3 (normalne), zakwalifikowano 2572 pacjentów z 3519 odczytami z pupilometru powiązanymi z wartościami GCS. Opracowano modele regresji liniowej i ANOVA w celu zbadania związku między różnicami między GCS a NPi.Wyniki. Średnia wieku badanych wynosiła 55,88 (16,95) lat i 54,5% stanowiły kobiety. Średnia różnica NPi wynosiła 0,36, a średnia GCS 12,06. Analiza regresji wykazała niewielki negatywny związek między różnicą NPi a GCS (r2 = 0,0696, P &lt; 0,0001). Gdy obserwacje zostały rozdzielone jako różnica NPi ≥ 0,7 (duża) lub &lt; 0,7 (mała), wystąpiła statystycznie istotna różnica w średniej GCS (10,76 [3,90]) dla dużej różnicy NPi vs małej różnicy NPi (13,15 [2,68]); P &lt; 0,0001).Wnioski. Nawet wśród pacjentów z prawidłowym PLR duża różnica w NPi wiąże się z niższymi wynikami GCS. Trendy i ocena różnicy NPi mogą stać się ważnym aspektem oceny pacjenta. (PNN 2021;10(4):168–174

Rola zarejestrowanej objętości wyrzutu płynu mózgowo-rdzeniowego w przewidywaniu wyniku w zmodyfikowanej skali Rankina przy wypisie ze szpitala u pacjentów z krwawieniami podpajęczynówkowymi (DROPSS)

Introduction. External ventricular drain (EVD) placement is common among aneurysmal subarachnoid hemorrhage (aSAH). Draining cerebrospinal fluid (CSF) from the EVD is also common, yet little is known about how much to drain, the length of time to drain, or how drainage impacts patient outcomes. Aim. The purpose of this study is to correlate amount of CSF drainage to patient outcomes, via modified Rankin Score (mRS). Material and Methods. This retrospective review of data located in a local hospital-based registry and electronic medical record. A linear mixed effects model was constructed to examine CSF drainage volume as a predictor of mRS at discharge. Results. Data from 82 patients was included in this analysis. There was no statistically significant relationship between CSF totals and mRS at hospital discharge (p = 0.3614, r² = 0.01). After controlling for age, Hunt and Hess score, and subject as random effect, there was still no significant relationship between CSF drained and mRS score at hospital discharge (p = .9042). Conclusions. There is no correlation between the total volume of CSF drained and mRS at discharge. Future research should explore CSF drainage documentation practices. (JNNN 2022;11(2):43–48) Key Words: acute care, aneurysmal subarachnoid hemorrhage, cerebrospinal fluid, external ventricular drain, patient outcomesWstęp. Założenie drenu komorowego zewnętrznego (EVD) jest powszechne w przypadku tętniakowatego krwotoku podpajęczynówkowego (aSAH). Drenaż płynu mózgowo-rdzeniowego (cerebrospinal fluid, CSF) z EVD jest również powszechny, jednak niewiele wiadomo na temat ilości płynu, czasu trwania drenażu i wpływu drenażu na wyniki leczenia. Cel. Celem tego badania jest korelacja ilości drenażu płynu mózgowo-rdzeniowego z wynikami leczenia pacjentów w zmodyfikowanej skali Rankina (modified Rankin Score, mRS). Materiał i metody. Retrospektywny przegląd danych znajdujących się w lokalnym rejestrze szpitalnym i elektronicznej dokumentacji medycznej. W celu zbadania objętości drenażu płynu mózgowo-rdzeniowego jako predyktora mRS przy wypisie ze szpitala skonstruowano liniowy model efektów mieszanych. Wyniki. Do analizy włączono dane od 82 pacjentów. Nie stwierdzono istotnej statystycznie zależności między całkowitą objętością płynu mózgowo-rdzeniowego a mRS przy wypisie ze szpitala (p = 0,3614, r² = 0,01). Po uwzględnieniu wieku, punktacji w skali Hunta i Hessa oraz podmiotu jako efektu losowego, nadal nie było istotnej zależności między odsączonym płynem mózgowo-rdzeniowym a wynikiem mRS przy wypisie ze szpitala (p = .9042). Wnioski. Nie ma korelacji między całkowitą objętością zdrenowanego płynu mózgowo-rdzeniowego a mRS przy wypisie ze szpitala. W przyszłych badaniach należy przeanalizować sposób prowadzenia dokumentacji drenażu płynu mózgowo-rdzeniowego. (PNN 2022;11(2):43–48)

Anesthesia and Sedation Practices Among Neurointerventionalists during Acute Ischemic Stroke Endovascular Therapy

Background and Purpose: Intra-arterial reperfusion therapies are expanding frontiers in acute ischemic stroke (AIS) management but there is considerable variability in clinical practice. The use of general anesthesia (GA) is one example. We aimed to better understand sedation practices in AIS. Methods: An online survey was distributed to the 68 active members of the Society of Vascular and Interventional Neurology (SVIN). Survey development was based on discussions at the SVIN Endovascular Stroke Round Table Meeting (Chicago, IL, 2008). The final survey contained 12 questions. Questions were developed as single and multiple-item responses; with an option for a free-text response. Results: There was a 72% survey response rate (N = 49/68). Respondents were interventional neurologists in practice 1–5 years (71.4%, N = 35). The mean (±SD) AIS interventions performed per year at the respondents’ institutions was 42.5 ± 25, median 35.0 (IQR 20, 60). The most frequent anesthesia type used was GA (anesthesia team), then conscious sedation (nurse administered), monitored anesthesia care (anesthesia team), and finally local analgesia alone. There was a preference for GA because of eliminating movement (65.3% of respondents; N = 32/49), perceived procedural safety (59.2%, N = 29/49), and improved procedural efficacy (42.9%, N = 21/49). However, cited limitations to GA included risk of time delay (69.4%, N = 34), of propagating cerebral ischemia due to hypoperfusion or other complications (28.6%, N = 14), and lack of adequate anesthesia workforce (20.4%, N = 7). Conclusions: The most frequent type of anesthesia used by Neurointerventionalists for AIS interventions is GA. Prior to making GA standard of care during AIS intervention, more data are needed about effects on clinical outcomes

A Randomized Evaluation of Bispectral Index-Augmented Sedation Assessment in Neurological Patients

To assess whether monitoring sedation status using bispectral index (BIS) as an adjunct to clinical evaluation was associated with a reduction in the total amount of sedative drug used in a 12 h period

Patterns, predictors, variations, and temporal trends in emergency medical service hospital prenotification for acute ischemic stroke.

BACKGROUND#ENTITYSTARTX02014;: Emergency medical services (EMS) hospital prenotification of an incoming stroke patient is guideline recommended as a means of increasing the timeliness with which stroke patients are evaluated and treated. Still, data are limited with regard to national use of, variations in, and temporal trends in EMS prenotification and associated predictors of its use. METHODS AND RESULTS#ENTITYSTARTX02014;: We examined 371 988 patients with acute ischemic stroke who were transported by EMS and enrolled in 1585 hospitals participating in Get With The Guidelines-Stroke from April 1, 2003, through March 31, 2011. Prenotification occurred in 249 197 EMS-transported patients (67.0%) and varied widely by hospital (range, 0% to 100%). Substantial variations by geographic regions and by state, ranging from 19.7% in Washington, DC, to 93.4% in Montana, also were noted. Patient factors associated with lower use of prenotification included older age, diabetes mellitus, and peripheral vascular disease. Prenotification was less likely for black patients than for white patients (adjusted odds ratio 0.94, 95% confidence interval 0.92-0.97, P&lt;0.0001). Hospital factors associated with greater EMS prenotification use were absence of academic affiliation, higher annual volume of tissue plasminogen activator administration, and geographic location outside the Northeast. Temporal improvements in prenotification rates showed a modest general increase, from 58.0% in 2003 to 67.3% in 2011 (P temporal trend &lt;0.0001). CONCLUSIONS#ENTITYSTARTX02014;: EMS hospital prenotification is guideline recommended, yet among patients transported to Get With The Guidelines-Stroke hospitals it is not provided for 1 in 3 EMS-arriving patients with acute ischemic stroke and varies substantially by hospital, state, and region. These results support the need for enhanced implementation of stroke systems of care. (J Am Heart Assoc. 2012;1:e002345 doi: 10.1161/JAHA.112.002345.)

Relationship of national institutes of health stroke scale to 30-day mortality in medicare beneficiaries with acute ischemic stroke.

BackgroundThe National Institutes of Health Stroke Scale (NIHSS), a well-validated tool for assessing initial stroke severity, has previously been shown to be associated with mortality in acute ischemic stroke. However, the relationship, optimal categorization, and risk discrimination with the NIHSS for predicting 30-day mortality among Medicare beneficiaries with acute ischemic stroke has not been well studied.Methods and resultsWe analyzed data from 33102 fee-for-service Medicare beneficiaries treated at 404 Get With The Guidelines-Stroke hospitals between April 2003 and December 2006 with NIHSS documented. The 30-day mortality rate by NIHSS as a continuous variable and by risk-tree determined or prespecified categories were analyzed, with discrimination of risk quantified by the c-statistic. In this cohort, mean age was 79.0 years and 58% were female. The median NIHSS score was 5 (25th to 75th percentile 2 to 12). There were 4496 deaths in the first 30 days (13.6%). There was a strong graded relation between increasing NIHSS score and higher 30-day mortality. The 30-day mortality rates for acute ischemic stroke by NIHSS categories were as follows: 0 to 7, 4.2%; 8 to 13, 13.9%; 14 to 21, 31.6%; 22 to 42, 53.5%. A model with NIHSS alone provided excellent discrimination whether included as a continuous variable (c-statistic 0.82 [0.81 to 0.83]), 4 categories (c-statistic 0.80 [0.79 to 0.80]), or 3 categories (c-statistic 0.79 [0.78 to 0.79]).ConclusionsThe NIHSS provides substantial prognostic information regarding 30-day mortality risk in Medicare beneficiaries with acute ischemic stroke. This index of stroke severity is a very strong discriminator of mortality risk, even in the absence of other clinical information, whether used as a continuous or categorical risk determinant. (J Am Heart Assoc. 2012;1:42-50.)

Considering Causes for Hypoactive Delirium

Delirium is defined as a mental disorder characterized by an abnormal state of cognition and awareness. Delirium is associated with an annual cost of $350 billion between the United States and Europe. Approximately 80% of delirium cases are either not identified or misdiagnosed. Older adults have the highest incidence due to the consequences of aging. Hypoactive delirium or “quite delirium” is the most common delirium subtype experienced by older adults. Hypoactive delirium, is difficult to recognize and has worse outcomes than other subtypes. If detected, symptoms of hypoactive delirium are frequently dismissed as depression or dementia. Therefore, nurses need heightened vigilance in assessment and identification of hypoactive delirium. This article seeks to assist nurses in identifying hypoactive delirium by outlining factors that increase an individual’s potential for developing hypoactive delirium