Intra-hospital transport of brain-injured patients: a prospective, observational study

Method for detection of cerebral blood flow in neurointensive care using longitudinal arterial spin labeling MRI

Cerebral blood flow (CBF) is carefully monitored in the Neurointensive Care Unit (NICU) to prevent secondary brain insults in patients who have suffered subarachnoid hemorrhage. Including absolute MRI measurements of CBF in the NICU monitoring protocol could add valuable information and potentially improve patient outcomes. This is particularly feasible at Linköping University Hospital, which uniquely has an MRI scanner located in the NICU, enabling longitudinal CBF measurements while eliminating medical transportation risks. Arterial spin labeling is a subtraction-based MRI technique that can measure CBF globally in the brain without the use of contrast agents, and thus is suitable for repeated measurements over short time periods. Therefore, this work aims to develop and implement a methodological workflow for the acquisition, analysis, absolute quantification, and visualization of longitudinal arterial spin labeling MRI measurements acquired in the clinical NICU setting. At this initial stage, the workflow was implemented and tested using acquired test-retest data and longitudinal data from two healthy participants. Subsequently, the workflow was tested in clinical practice on an intubated and ventilated patient monitored in the NICU after suffering a subarachnoid hemorrhage. To ensure accurate day-to-day comparisons between the repeated measurements, the selection of processing and analysis methods aimed to obtain CBF maps in absolute units of ml/min/100g. These CBF maps were quantified using both the FMRIB Software Library and an openly available flow territory atlas. The test-retest data showed small variations (4.4 ml/min/100g between sessions), and the longitudinal measurement resulted in low CBF variability over 12 days. Despite the greater complexity of clinical data, the quantification and chosen visualization tools proved helpful in interpreting the results. In conclusion, this workflow including repeated MRI measurements could help detect changes in CBF between different measurement days and complement other conventional monitoring techniques in the NICU.

Developing and Validating a Bundle for Safe Intra-Hospital Transporting of the Critically Ill Patients: Mixed Qualitative Design With Delphi Approach

The aim of this study was to develop a bundle to increase safety of intra-hospital transport in critically ill patients. A qualitative design with Delphi approach was conducted for creation of an intra-hospital transport bundle in 3 steps. First, doctors and nurses were questioned about their encounters with intra-hospital transport incidents. Second, several databases were looked through to find published checklists and recommendations for intra-hospital transport. Third, using this strategy, a bundle was created and reviewed with subject matter experts. The content validity index (CVI), which assesses the degree of expert agreement, was utilized to evaluate each item in the generated bundle. Two evaluation cycles were required before a minimal index could be reached. We looked at the content validity and important weighting of the items. The scale-CVI was calculated using the average of all the elements, and it was 1. The created bundle serves as a framework for directing doctors and nurses during intra-hospital transportation and offers continuity of care to improve patient safety. The techniques suggested in this study can be used to adapt this bundle to the needs of other hospitals.

Dynamics of Intracranial Pressure and Cerebrovascular Reactivity During Intrahospital Transportation of Traumatic Brain Injury Patients in Coma

BACKGROUND

Intrahospital transportation (IHT) of patients with traumatic brain injury (TBI) is common and may have adverse consequences, incurring inherent risks. The data on the frequency and severity of clinical complications linked with IHT are contradictory, and there is no agreement on whether it is safe or potentially challenging for neurocritical care unit patients. Continuous intracranial pressure (ICP) monitoring is essential in neurointensive care. The role of ICP monitoring and management of cerebral autoregulation impairments in IHT of patients with severe TBI is underinvestigated. The purpose of this nonrandomized retrospective single-center study was to assess the dynamics of ICP and an improved pressure reactivity index (iPRx) as a measure of autoregulation during IHT.

METHODS

Seventy-seven men and fourteen women with severe TBI admitted in 2012-2022 with a mean age of 33.2 ± 5.2 years were studied. ICP and arterial pressure were invasively monitored, and cerebral perfusion pressure and iPRx were calculated from the measured parameters. All patients were subjected to dynamic helical computed tomography angiography using a 64-slice scanner Philips Ingenuity computed tomography scan 1-2 days after TBI. Statistical analysis of all results was done using a paired t-test, and p was preset at < 0.05. The logistic regression analysis was performed for cerebral ischemia development dependent on intracranial hypertension and cerebrovascular reactivity.

RESULTS

IHT led to an increase in ICP in all the patients, especially during vertical movement in an elevator (maximum 75.2 mm Hg). During the horizontal transportation on the floor, ICP remained increased (p < 0.05). The mean ICP during IHT was significantly higher (26.1 ± 13.5 mm Hg, p < 0.001) than that before the IHT (19.9 ± 5.3 mm Hg). The mean iPRx after and before IHT was 0.52 ± 0.04 and 0.23 ± 0.14, respectively (p < 0.001).

CONCLUSIONS

Both horizontal and vertical transportation causes a significant increase in ICP and iPRx in patients with severe TBI, potentially leading to the outcome worsening.

Brain metabolism response to intrahospital transfers in neurocritical ill patients and the impact of microdialysis probe location

Intrahospital transfer (IHT), a routine in the management of neurocritical patients requiring imaging or interventions, might affect brain metabolism. Studies about IHT effects using microdialysis (MD) have produced conflicting results. In these studies, only the most damaged hemisphere was monitored, and those may not reflect the impact of IHT on overall brain metabolism, nor do they address differences between the hemispheres. Herein we aimed to quantify the effect of IHT on brain metabolism by monitoring both hemispheres with bilateral MD. In this study, 27 patients with severe brain injury (10 traumatic brain injury and 17 subarachnoid hemorrhage patients) were included, with a total of 67 IHT. Glucose, glycerol, pyruvate and lactate were measured by MD in both hemispheres for 10 h pre- and post-IHT. Alterations in metabolite levels after IHT were observed on both hemispheres; although these changes were more marked in hemisphere A (most damaged) than B (less damaged). Our results suggest that brain metabolism is altered after an IHT of neurocritical ill patients particularly but not limited to the damaged hemisphere. Bilateral monitorization may be more sensitive than unilateral monitorization for detecting metabolic disturbances not directly related to the course of the disease.

Current role of portable MRI in diagnosis of acute neurological conditions

Neuroimaging is an inevitable component of the assessment of neurological emergencies. Magnetic resonance imaging (MRI) is the preferred imaging modality for detecting neurological pathologies and provides higher sensitivity than other modalities. However, difficulties such as intra-hospital transport, long exam times, and availability in strict access-controlled suites limit its utility in emergency departments and intensive care units (ICUs). The evolution of novel imaging technologies over the past decades has led to the development of portable MRI (pMRI) machines that can be deployed at point-of-care. This article reviews pMRI technologies and their clinical implications in acute neurological conditions. Benefits of pMRI include timely and accurate detection of major acute neurological pathologies such as stroke and intracranial hemorrhage. Additionally, pMRI can be potentially used to monitor the progression of neurological complications by facilitating serial measurements at the bedside.

Serum biomarkers for risk assessment of intrahospital transports in neurosurgical intensive care unit patients

BACKGROUND

Intrahospital transport (IHT) of Neurosurgical Intensive Care Unit (NICU) patients for cranial computed tomography (CCT) scans is associated with a high rate of complications. The potential of serum biomarkers to estimate the risk for complications associated with IHT and improve their safety remains underexplored. The present study investigated the influence of several serum biomarkers on IHT-associated complications in brain-injured NICU patients.

METHODS

A total of 523 IHTs in 223 NICU patients were prospectively analyzed (05/2019-05/2020). Hemoglobin, hematocrit, serum sodium, and albumin levels were evaluated as serum biomarkers. Each patient's demographic data, CCT scan, NICU parameters and modified Rankin Scale at discharge as well as indications, consequences, and complications of IHTs were analyzed.

RESULTS

In 58.7% of all IHTs, at least one IHT-associated complication was observed with 60.1% of all IHTs having no therapeutic consequence. Significantly lower rates of increased intracranial pressure (ICP; P<0.0001), decreased cerebral perfusion pressure (CPP; P=0.03) as well as hemodynamic (P<0.0001) and pulmonary events (P=0.01) were observed in patients with higher hemoglobin levels prior to IHT. Additionally, higher hematocrit levels before IHT were associated with a fewer rate of hemodynamic (P<0.0001), pulmonary (P=0.006), ICP (P<0.0001), and CPP (P=0.01) events.

CONCLUSIONS

Higher levels of hemoglobin and hematocrit are associated with less complications with respect to ICP, CPP, hemodynamic and pulmonary events during IHT in NICU patients. Therefore, these biomarkers may be helpful for risk assessment of potential complications prior to IHT.

First Experience With Postoperative Transcranial Ultrasound Through Sonolucent Burr Hole Covers in Adult Hydrocephalus Patients

BACKGROUND

Managing patients with hydrocephalus and cerebrospinal fluid (CSF) disorders requires repeated head imaging. In adults, it is typically computed tomography (CT) or less commonly magnetic resonance imaging (MRI). However, CT poses cumulative radiation risks and MRI is costly. Ultrasound is a radiation-free, relatively inexpensive, and optionally point-of-care alternative, but is prohibited by very limited windows through an intact skull.

OBJECTIVE

To describe our initial experience with transcutaneous transcranial ultrasound through sonolucent burr hole covers in postoperative hydrocephalus and CSF disorder patients.

METHODS

Using cohort study design, infection and revision rates were compared between patients who underwent sonolucent burr hole cover placement during new ventriculoperitoneal shunt placement and endoscopic third ventriculostomy over the 1-year study time period and controls from the period 1 year before. Postoperatively, trans-burr hole ultrasound was performed in the clinic, at bedside inpatient, and in the radiology suite to assess ventricular anatomy.

RESULTS

Thirty-seven patients with sonolucent burr hole cover were compared with 57 historical control patients. There was no statistically significant difference in infection rates between the sonolucent burr hole cover group (1/37, 2.7%) and the control group (0/57, P = .394). Revision rates were 13.5% vs 15.8% (P = 1.000), but no revisions were related to the burr hole or cranial hardware.

CONCLUSION

Trans-burr hole ultrasound is feasible for gross evaluation of ventricular caliber postoperatively in patients with sonolucent burr hole covers. There was no increase in infection rate or revision rate. This imaging technique may serve as an alternative to CT and MRI in the management of select patients with hydrocephalus and CSF disorders.

Effectiveness of the graded transport mode for the intrahospital transport of critically ill patients: A retrospective study

Aim

The purpose of this study was to evaluate the effectiveness of the graded transport mode in the intrahospital transport (IHT) of critically ill patients.

Methods

This is a retrospective study, including 800 patients and categorized them into control and observation groups. The control group included 420 critically ill patients who were transported via conventional methods from our emergency resuscitation unit from June 2017 to December 2017. The observation group included 380 critically ill patients who were transported through a graded transport mode from January 2018 to June 2018. We performed intergroup comparisons of the incidence rates and causes of adverse events (AEs), transport time, length of stay, and mortality rate.

Results

The observation group had significantly lower transport time and AE incidence rates than the control group. However, no significant differences were observed in terms of the length of stay and mortality rate between the two groups.

Conclusion

The most notable merits of the graded transport mode in the IHT of critical care patients include the fact that it significantly reduces the incidence of AEs during IHT, shortens the transport time, and improves transport efficiency, thereby ensuring the safety of critically ill patients.

Implementation of portable head CT imaging in patients with severe acute brain injury in a French ICU: a prospective before-after design pilot study

Head-CT-scanning is a cornerstone procedure during the management of patients admitted for acute brain injury (ABI) in intensive care unit (ICU). But intrahospital transfer for these procedure is known to increase the rate of severe adverse events potentially worsening the brain injuries. Portable head-CT (pCTH) may facilitate pCTH performance in safer conditions for the patients avoiding transfer out of the ICU. To evaluate the safety and the time duration required to use a portable head CT (pCTH) scanner in the intensive care unit (ICU) in the French healthcare system in ICU patients admitted for acute brain injury, we prospectively included all ICU-patients admitted for severe ABI over a 2-year period following before-after design. As the main outcome, we compared the time required to perform a scan with pCTH to that with conventional head CT (cCTH) and reported adverse events and reactions. In total, forty-six patients were included and finally, 41 patients were analyzed (21 in the pCTH group and 20 in the cCTH group). The median (interquartile) time required to perform a scan with pCTH was 28 (23-48) minutes compared to 30 (25-36) minutes with cCTH (p = 0.825). The duration time required to perform a pCTH was similar to that with cCTH in an ICU of the French healthcare system without significant difference in adverse events reactions.

Methodology for Low-Field, Portable Magnetic Resonance Neuroimaging at the Bedside

Neuroimaging is a critical component of triage and treatment for patients who present with neuropathology. Magnetic resonance imaging and non-contrast computed tomography are the gold standard for diagnosis and prognostication of patients with acute brain injuries. However, these modalities require intra-hospital transport to strict, access-controlled environments, which puts critically ill patients at risk for complications and secondary injuries. A novel, portable MRI (pMRI) device that can be deployed at the patient's bedside provides a needed solution. In a dual-center investigation, Yale New Haven Hospital has obtained regular neuroimaging on patients using the pMRI as part of routine clinical care in the Emergency Department and Intensive Care Unit (ICU) since August of 2020. Massachusetts General Hospital has begun using pMRI in the Neuroscience Intensive Care Unit since January 2021. This technology has expanded the population of patients who can receive MRI imaging by increasing accessibility and timeliness for scan completion by eliminating the need for transport and increasing the potential for serial monitoring. Here we describe our methods for screening, coordinating, and executing pMRI exams and provide further detail on how to scan specific patient populations.

Detrimental effects of intrahospital transport on cerebral metabolism in patients suffering severe aneurysmal subarachnoid hemorrhage

OBJECTIVE

Intrahospital transport for CT scans is routinely performed for neurosurgical patients. Particularly in the sedated and mechanically ventilated patient, intracranial hypertension and blood pressure fluctuations that might impair cerebral perfusion are frequently observed during these interventions. This study quantifies the impact of intrahospital patient transport on multimodality monitoring measurements, with a particular focus on cerebral metabolism.

METHODS

Forty intrahospital transports in 20 consecutive patients suffering severe aneurysmal subarachnoid hemorrhage (SAH) under continuous intracranial pressure (ICP), brain tissue oxygen tension (pbtO2), and cerebral microdialysis monitoring were prospectively included. Changes in multimodality neuromonitoring data during intrahospital transport to the CT scanner and the subsequent 10 hours were evaluated using linear mixed models. Furthermore, the impact of risk factors at transportation, such as cerebral vasospasm, cerebral hypoxia (pbtO2 < 15 mm Hg), metabolic crisis (lactate-pyruvate ratio [LPR] > 40), and transport duration on cerebral metabolism, was analyzed.

RESULTS

During the transport, the mean ICP significantly increased from 7.1 ± 3.9 mm Hg to 13.5 ± 6.0 mm Hg (p < 0.001). The ICP exceeded 20 mm Hg in 92.5% of patients; pbtO2 showed a parallel rise from 23.1 ± 13.3 mm Hg to 28.5 ± 23.6 mm Hg (p = 0.02) due to an increase in the fraction of inspired oxygen during the transport. Both ICP and pbtO2 returned to baseline values thereafter. Cerebral glycerol significantly increased from 71.0 ± 54.9 µmol/L to 75.3 ± 56.0 µmol/L during the transport (p = 0.01) and remained elevated for the following 9 hours. In contrast, cerebral pyruvate and lactate levels were stable during the transport but showed a significant secondary increase 1-8 hours and 2-9 hours, respectively, thereafter (p < 0.05). However, the LPR remained stable over the entire observation period. Patients with extended transport duration (more than 25 minutes) were found to have significantly higher levels of cerebral pyruvate and lactate as well as lower glutamate concentrations in the posttransport period.

CONCLUSIONS

Intrahospital transport and horizontal positioning during CT scans induce immediate intracranial hypertension and an increase in cerebral glycerol, suggesting neuronal injury. Afterward, sustained impairment of neuronal metabolism for several hours could be observed, which might increase the risk of secondary ischemic events. Therefore, intrahospital transport for neuroradiological imaging should be strongly reconsidered and only indicated if the expected benefit of imaging results outweighs the risks of transportation.

Routine postoperative computed tomography scan after craniotomy: systematic review and evidence-based recommendations

Over the last few years, the role of early postoperative computed tomography (EPOCT) after cranial surgery has been repeatedly questioned, but there is yet no consensus on the practice. We conducted a systematic review to address the usefulness of EPOCT in association with neurological examination after elective craniotomies compared to the neurological examination alone. Studies were eligible if they provided information about the number of patients scanned, how many were asymptomatic or presented neurological deterioration before the scan and how many of each of those groups had their management changed due to imaging findings. CTs had to be performed in the first 48 h following surgery to be considered early. Eight studies were included. The retrospective studies enrolled a total of 3639 patients, with 3737 imaging examinations. Out of the 3696 CT scans performed in asymptomatic patients, less than 0.8% prompted an intervention, while 100% of patients with neurological deterioration were submitted to emergency surgery. Positive predictive values of altered scans were 0.584 for symptomatic patients and 0.125 for the asymptomatic. The number of altered scans necessary to predict (NNP) one change in management for the asymptomatic patients was 8, while for the clinically evident cases, it was 1.71. The number of scans needed to diagnose one clinically silent alteration is 134.75, and postoperative imaging of neurologically intact patients is 132 times less likely to issue an emergency intervention than an altered neurological examination alone. EPOCT following elective craniotomy in neurologically preserved patients is not supported by current evidence, and CT scanning should be performed only in particular conditions. The authors have developed an algorithm to help the judgment of each patient by the surgeon in a resource-limited context.

Dealing with the Sick Rural Surgery Patient in Need of Transfer

Care for rural and urban surgical patients is increasingly more complex due to advancing knowledge and technology. Interhospital transfers occur in approximately 10% of index encounters at rural hospitals secondary to mismatch of patient needs and local resources. Due to the recent expansion of air transport to rural areas, distance and geography are less of a barrier. The interhospital transfer process is understudied and far from standardized. Interhospital transfer status is associated with increase in mortality, complications, length of stay, and costs. The cost, price to patients, and safety of air ambulance transports cannot be ignored.

Intracranial Pressure and Intracranial Elastance Monitoring in Neurocritical Care

Patients with acute brain injuries tend to be physiologically unstable and at risk of rapid and potentially life-threatening decompensation due to shifts in intracranial compartment volumes and consequent intracranial hypertension. Invasive intracranial pressure (ICP) monitoring therefore remains a cornerstone of modern neurocritical care, despite the attendant risks of infection and damage to brain tissue arising from the surgical placement of a catheter or pressure transducer into the cerebrospinal fluid or brain tissue compartments. In addition to ICP monitoring, tracking of the intracranial capacity to buffer shifts in compartment volumes would help in the assessment of patient state, inform clinical decision making, and guide therapeutic interventions. We review the anatomy, physiology, and current technology relevant to clinical management of patients with acute brain injury and outline unmet clinical needs to advance patient monitoring in neurocritical care.

Safety of Early MRI Examinations in Severe TBI: A Test Battery for Proper Patient Selection

Introduction: Early magnetic resonance imaging (MRI) provides important information for management and prognosis in patients with severe traumatic brain injury (sTBI). Yet, optimal timing of MRI remains unknown. The aim of our study was to evaluate the safety of early MRI and to identify a method for appropriate patient selection to minimize adverse events related to the intrahospital transport (IHT) and the MRI examination.

Methods: Twenty-six patients with sTBI [mean Glasgow Coma Scale (GCS) 6, range 3–8] admitted to our neurosurgical ICU from 03/2015 to 12/2017 and receiving at least one MRI within the first 14 days after initial traumatic event were prospectively included in the study. The following requirements were fulfilled for at least 4 h prior to anticipated MRI: MAP > 70 mmHg, aPCO₂ 30–40 mmHg, stable ICP < 25 mmHg. All relevant cardiopulmonary and cerebral parameters and medication were recorded. The following MRI sequences were performed: DWI, FLAIR, 3D T2-space, 3D T1 MPRAGE, 3D SWI, 3D TOF, pASL, and ¹H/³¹P-MRS.

Results: Four females and 22 males (aged 23–78 years, mean 46.4 years) with a median GCS on admission of 5 (range 3–8) were analyzed. In total, 40 IHTs were performed within the first 14 days (mean 6 days, range 1–14 days). Mean pre-MRI ICP was 14.1 mmHg (range 3–32 mmHg). The mean post-MRI ICP was 14.3 mmHg (range 3–29 mmHg), decreasing to a mean ICP of 13.2 mmHg after 1 h (range 3–29 mmHg). There were no significant differences in ICP measurements before and after MRI (p = 0.30). MAP remained stable with no significant changes during the entire IHT and MRI. No other adverse events were observed as well.

Conclusion: Early MRI in acute severe TBI is feasible and safe. Yet, careful patient selection with prior adequate testing of cardiopulmonary and cerebral parameters is crucial to minimize transport- or examination-related morbidity.

Bedside Sonographic Duplex Technique as a Monitoring Tool in Patients after Decompressive Craniectomy: A Single Centre Experience

Background and objectives: Bedside sonographic duplex technique (SDT) may be used as an adjunct to cranial computed tomography (CCT) to monitor brain-injured patients after decompressive craniectomy (DC). The present study aimed to assess the value of SDT in repeated measurements of ventricle dimensions in patients after DC by comparing both techniques. Materials and Methods: Retrospective assessment of 20 consecutive patients after DC for refractory intracranial pressure (ICP) increase following subarachnoid hemorrhage (SAH), bleeding and trauma which were examined by SDT and CCT in the context of routine clinical practice. Whenever a repeated CCT was clinically indicated SDT examinations were performed within 24 hours and correlated via measurement of the dimensions of all four cerebral ventricles. Basal cerebral arteries including pathologies such as vasospasms were also evaluated in comparison to selected digital subtraction angiography (DSA). Results: Repeated measurements of all four ventricle diameters showed high correlation between CCT and SDT (right lateral r = 0.997, p < 0.001; left lateral r = 0.997, p < 0.001; third r = 0.991, p < 0.001, fourth ventricle r = 0.977, p < 0.001). SDT performed well in visualizing basal cerebral arteries including pathologies (e.g., vasospasms) as compared to DSA. Conclusions: Repeated SDT measurements of the dimensions of all four ventricles in patients after DC for refractory ICP increase delivered reproducible results comparable to CCT. SDT may be considered as a valuable bedside monitoring tool in patients after DC.

Neuroanesthesiology Update

This review is intended to provide a summary of the literature pertaining to the perioperative care of neurosurgical patients and patients with neurological diseases. General topics addressed in this review include general neurosurgical considerations, stroke, neurological monitoring, and perioperative disorders of cognitive function.

Serum Biomarkers for Risk Assessment of Intrahospital Transports in Mechanically Ventilated Neurosurgical Intensive Care Unit Patients

OBJECTIVE

Intrahospital transports (IHTs) of neurosurgical intensive care unit (NICU) patients can be hazardous. Increasing intracranial pressure (ICP) and/or decreasing cerebral perfusion pressure (CPP) as well as cardiopulmonary alterations are common complications of an IHTs, which can lead to secondary brain injury. This study was performed to assess several serum biomarkers concerning their potential to improve safety of IHTs in mechanically ventilated NICU patients.

METHODS

All IHTs of mechanically ventilated and sedated NICU patients from 03/2017 to 01/2018 were retrospectively analyzed. Intracranial pressure and CPP measurements were performed in all patients. Serum hemoglobin, hematocrit, and serum sodium were defined as serum biomarkers. Demographic data, computed tomography scan on admission, Simplified Acute Physiology Score and Acute Physiology and Chronic Health Evaluation II, modified Rankin Scale, indication and consequence of IHTs were analyzed. Alteration of ICP/CPP, hemodynamic and pulmonary events were defined as complications. The study population was stratified into patients with the occurrence of a complication and absence of a complication.

RESULTS

We analyzed a total number of 184 IHTs in 70 NICU patients with an overall complication rate of 57.6%. Of all, 32.1% IHTs had no direct therapeutic consequence. In patients with higher hemoglobin values prior to IHT less complications occurred, concerning ICP (P = .001), CPP (P = .001), hemodynamic (P = .005), and pulmonary (P < .0001) events. In addition, complications concerning ICP (P = .001), CPP (P = .001), hemodynamic (P = .005), and pulmonary problems (P = .002) were significantly lower in patients with higher hematocrit values before IHT.

CONCLUSION

Intrahospital transports of mechanically ventilated NICU patients carry a high risk of increased ICP and hemodynamic complications and should be performed restrictively. Higher values of hemoglobin and hematocrit prior to IHT were associated with less complications with regard to ICP, CPP as well as hemodynamic and pulmonary events and could be helpful to assess the potential risk of complications prior to IHTs.

From the ICU to the operating room: how to manage the patient?

PURPOSE OF REVIEW

To outline key points for perioperative ICU optimization of nutrition, airway management, blood product preparation and transfusion, antibiotic prophylaxis and transport.

RECENT FINDINGS

Optimization entails glycemic control for all, with specific attention to type-1 diabetic patients. Transport-related adverse events may be averted with surgery in the ICU. If moving the patient is unavoidable, transport guidelines should be followed and hemodynamic optimization, airway control, and stabilization of mechanical ventilation ensured before transport. Preinduction preparation includes assessment of the airway and the provision of high-flow oxygen to prolong apneic oxygenation. Postintubation, a protective positive ventilation strategy should be employed. Ideal transfusion thresholds are 7 g/dl for hemodynamically stable adult patients, 8 g/dl in orthopedic or cardiac surgery patients as well as those with underlying cardiovascular disease. Higher transfusions thresholds may be required in specific disease states. Antimicrobial prophylaxis within 120 min of incision prevents most surgical site infections. Antibiotic therapy depends on the antibiotics being received in the ICU, the time elapsed since ICU admission, local epidemiology and the type of surgery. Tailored antimicrobial regimens may be continued periprocedurally. If more than 70% of the nutritional requirement cannot be met enterally, parenteral nutrition should be initiated within 5-7 days of surgery or earlier if the patient is malnourished.

SUMMARY

ICU patients who require surgery may benefit from appropriate perioperative management.

Low-Dose versus Therapeutic Range Intravenous Unfractionated Heparin Prophylaxis in the Treatment of Patients with Severe Aneurysmal Subarachnoid Hemorrhage After Aneurysm Occlusion

BACKGROUND

While prophylaxis with intravenous unfractionated heparin (UFH) can effectively prevent venous thromboembolism (VTE) during the neurocritical care of patients with severe aneurysmal subarachnoid hemorrhage (aSAH), the risk for intracranial bleeding complications might increase. Owing to this therapeutic dilemma, the UFH administration regimen in this critical patient population remains highly controversial.

METHODS

We performed a retrospective analysis of patients with severe aSAH (Fisher grade 3-4) receiving either low-dose (activated partial thromboplastin time [aPTT] <40 seconds) or therapeutic range (aPTT 50-60 seconds) UFH during intensive care unit (ICU) treatment after complete surgical/endovascular aneurysm occlusion. The primary outcome was the rate of bleeding/VTE complications and the investigation of potential risk factors.

RESULTS

This study series comprised 410 patients with aneurysmal SAH (aSAH), with a mean age of 54.7 ± 12.6 years, a male:female ratio of 1:2.2, and aSAH-associated intracerebral hemorrhage (ICH) in 33.2%. After complete aneurysm occlusion, 112 patients (27.3%) received therapeutic dose UFH and 298 patients (72.7%) received low-dose UFH. VTE events occurred in 5.4% of the low-dose UFH cohort and in 6.3% of the therapeutic dose UFH cohort, with no significant differences in the rate and severity of VTE events. However, an increase in initial SAH-associated ICH was significantly (P = 0.007) more frequent in the therapeutic dose cohort (18.8% vs. 3.4%). Heparin-induced thrombocytopenia (HIT) was the sole risk factor for VTE (P < 0.001), and both an aPTT ≥50 seconds under UFH administration (P = 0.007) and the initial presence of SAH-associated ICH (P = 0.035) were significant risk factors for intracranial bleeding complications.

CONCLUSIONS

Even in high-risk neurocritical patients with severe SAH and prolonged ICU treatment, low-dose UFH-administration for VTE prophylaxis is equally effective as therapeutic UFH administration and carries a lower risk of bleeding complications.

Risks of Routinely Clamping External Ventricular Drains for Intrahospital Transport in Neurocritically Ill Cerebrovascular Patients

BACKGROUND

Current guidelines recommend routine clamping of external ventricular drains (EVD) for intrahospital transport (IHT). The aim of this project was to describe intracranial hemodynamic complications associated with routine EVD clamping for IHT in neurocritically ill cerebrovascular patients.

METHODS

We conducted a retrospective review of cerebrovascular adult patients with indwelling EVD admitted to the neurocritical care unit (NICU) during the months of September to December 2015 at a tertiary care center. All IHTs from the NICU of the included patients were examined. Main outcomes were incidence and risk factors for an alteration in intracranial pressure (ICP) and cerebral perfusion pressure after IHT.

RESULTS

Nineteen cerebrovascular patients underwent 178 IHTs (79.8 % diagnostic and 20.2 % therapeutic) with clamped EVD. Twenty-one IHTs (11.8 %) were associated with post-IHT ICP ≥ 20 mmHg, and 33 IHTs (18.5 %) were associated with escalation of ICP category. Forty IHTs (26.7 %) in patients with open EVD status in the NICU prior to IHT were associated with IHT complications, whereas no IHT complications occurred in IHTs with clamped EVD status in the NICU. Risk factors for post-IHT ICP ≥ 20 mmHg were IHT for therapeutic procedures (adjusted relative risk [aRR] 5.82; 95 % CI, 1.76-19.19), pre-IHT ICP 15-19 mmHg (aRR 3.40; 95 % CI, 1.08-10.76), pre-IHT ICP ≥ 20 mmHg (aRR 12.94; 95 % CI, 4.08-41.01), and each 1 mL of hourly cerebrospinal fluid (CSF) drained prior to IHT (aRR 1.11; 95 % CI, 1.01-1.23).

CONCLUSIONS

Routine clamping of EVD for IHT in cerebrovascular patients is associated with post-IHT ICP complications. Pre-IHT ICP ≥ 15 mmHg, increasing hourly CSF output, and IHT for therapeutic procedures are risk factors.

Safety First! Using a Checklist for Intrafacility Transport of Adult Intensive Care Patients

BACKGROUND

Adult critical care patients in an academic medical center experienced adverse events during intrafacility transport resulting from lack of preparation. An intervention was needed to help keep patients safe during intrafacility transport.

OBJECTIVE

To develop a checklist for transport that is easy to use and effective in preparing patients for transport.

METHOD

A checklist was developed and implemented. Elements of the checklist include preparation of the patient before transport, screening of patients for criteria that may place them at higher risk during transport, and a checklist for the procedural site.

RESULTS

From May 2011 through July 2014, 2506 transports were conducted. Of these, 97.6% (n = 2445) involved no reported complications.

CONCLUSION

This tool is suitable for bedside clinicians to use when preparing patients for transport.

Intracranial Pressure Changes During Intrahospital Transports of Neurocritically Ill Patients

BACKGROUND

Intrahospital transport is associated with a high rate of complications. Investigations of this problem using neuromonitoring remain scarce.

METHODS

This is a monocentric, prospective observational study. Patients with severe brain diseases and intracranial pressure (ICP) monitoring were included. Continuous monitoring of ICP, cerebral perfusion pressure (CPP), oxygen saturation (SpO2), heart rate, and mean arterial pressure was measured during seven different periods of intrahospital transport (baseline for 30 min, I = preparation, II = transport I, III = CT scan, IV = transport II, V = postprocessing, and follow-up for another 30 min). All complications were documented.

RESULTS

Between July 2013 and December 2013, a total number of 56 intrahospital transports of 43 patients were performed from ICU to CT. Data recording was incomplete in six cases. Fifty transports have been taken into account for statistical analysis. Forty-two percent were emergency transports. Mean duration of the procedure was 17' (preparation), 6' (transport I), 9' (CT scan), 6' (transport II), and 15' (postprocessing), respectively. Mean ICP at baseline was 8.53 mmHg. Comparing all periods of intrahospital transport and the follow-up period to the baseline showed a significant increase of ICP only during CT scan (15.83 mmHg, p < 0.01), not during the transport to and from the radiology department. An overall complication rate of 36 % (n = 18) was observed. In 26 % (n = 13), additional ICP therapy was necessary due to an elevation of ICP above 20 mmHg.

CONCLUSION

There is a considerable rate of complications during intrahospital transport of critically ill patients with severe brain diseases, with a significant increase of ICP during transport and CT scan. In one-fifth of all patients, additional therapy was necessary. From our point of view, transport of critically ill patients should only be performed by trained staff and under monitoring of ICP and CPP.

Detection of Cerebral Vasospasm Following Aneurysmal Subarachnoid Hemorrhage Using Motor Evoked Potentials

BACKGROUND

Early detection of vasospasm (VS) following aneurysmal subarachnoid hemorrhage (aSAH) is vital to trigger therapy and to prevent infarction and subsequent permanent neurological deficit. Although motor evoked potentials (MEPs) are a well-established method for intraoperative detection of cerebral VS and cerebral ischemia during aneurysm surgery, there are no studies investigating the diagnostic value of MEPs for detecting delayed VS following aSAH in an intensive care unit.

OBJECTIVE

A prospective study was conceived to assess the diagnostic accuracy of MEPs in comparison with digital subtraction angiography.

METHODS

MEP threshold changes were determined in patients both with and without angiographic VS following high-grade aSAHs. Sensitivity, specificity, and the positive and negative predictive values of significant MEP threshold increases, which indicate angiographic VS, were calculated.

RESULTS

In all patients experiencing VS of the arteries supplying cerebral motor areas, a minimal MEP threshold increase of 50 mA (mean 66.25 mA) was observed, whereas a maximum MEP threshold increase of 30 mA was observed in patients without VS. Therefore, an increase from a baseline of ≥50 mA was considered significant and resulted in a sensitivity of 0.83, a specificity of 0.92, a positive predictive value of 0.83, and a negative predictive value of 0.92.

CONCLUSION

VS following aSAH can be detected accurately by using MEPs. MEPs are a feasible bedside tool for online VS detection in an intensive care unit and, therefore, may complement existing diagnostic tools.

Complications during intrahospital transport of critically ill patients: Focus on risk identification and prevention

Intrahospital transportation of critically ill patients is associated with significant complications. In order to reduce overall risk to the patient, such transports should well organized, efficient, and accompanied by the proper monitoring, equipment, and personnel. Protocols and guidelines for patient transfers should be utilized universally across all healthcare facilities. Care delivered during transport and at the site of diagnostic testing or procedure should be equivalent to the level of care provided in the originating environment. Here we review the most common problems encountered during transport in the hospital setting, including various associated adverse outcomes. Our objective is to make medical practitioners, nurses, and ancillary health care personnel more aware of the potential for various complications that may occur during patient movement from the intensive care unit to other locations within a healthcare facility, focusing on risk reduction and preventive strategies.

High incidence of adverse events during intra-hospital transport of critically ill patients and new related risk factors: a prospective, multicenter study in China

BACKGROUND

The aim of the present study was to investigate the incidence of adverse events (AEs) during intra-hospital transport (IHT) of critically ill patients and evaluate the risk factors associated with these events.

METHODS

This prospective multicenter observational study was performed in 34 intensive care units in China during 20 consecutive days from 5 November to 25 November 2012. All consecutive patients who required IHT for diagnostic testing or therapeutic procedures during the study period were included. All AEs that occurred during IHT were recorded. The incidence of AEs was defined as the rate of transports with at least one AE. The statistical analysis included a description of demographic and clinical characteristics of the cohort as well as identification of risk factors for AEs during IHT by univariate and multivariate logistic regression analyses.

RESULTS

In total, 441 IHTs of 369 critically ill patients were analyzed. The overall incidence of AEs was 79.8% (352 IHTs). The proportion of equipment- and staff-related adverse events was 7.9% (35 IHTs). The rate of patient-related adverse events (P-AEs) was 79.4% (349 IHTs). The rates of vital sign-related P-AEs and arterial blood gas analysis-related P-AEs were 57.1% (252 IHTs) and 46.9% (207 IHTs), respectively. The incidence of critical P-AEs was 33.1% (146 IHTs). The rates of vital sign-related critical P-AEs and arterial blood gas analysis-related critical P-AEs were 22.9% (101 IHTs) and 15.0% (66 IHTs), respectively. All data collected in our study were considered potential risk factors. In the multivariate analysis, predictive factors for P-AEs were pH, partial pressure of carbon dioxide in arterial blood, lactate level, glucose level, and heart rate before IHT. Furthermore, the Acute Physiology and Chronic Health Evaluation II score, partial pressure of oxygen in arterial blood, lactate level, glucose level, heart rate, respiratory rate, pulse oximetry, and sedation before transport were independent influential factors for critical P-AEs during IHT.

CONCLUSIONS

The incidence of P-AEs during IHT of critically ill patients was high. Risk factors for P-AEs during IHT were identified. Strategies are needed to reduce their frequency.

TRIAL REGISTRATION

Chinese Clinical Trial Register identifier ChiCTR-OCS-12002661. Registered 5 November 2012.

Intrahospital transport of mechanically ventilated intensive care patients using new equipment attached to a transfer board

Aim

Multiple lines and tubes often complicate bed transfer in critically ill patients. To solve this problem, the authors developed medical equipment attached to a transfer board ("transfer board tree") that integrates the patient, transfer board, and medical equipment. The objective of this study was to evaluate the efficiency and safety of the transfer board tree.

Methods

Forty mechanically ventilated patients (20 transfer board tree, 20 conventional) in the intensive care unit who were transported for computed tomography were enrolled. Transfer times and adverse events were recorded.

Results

Transfer board tree patients had significantly shorter transfer times. There were two adverse events only in the conventional group.

Conclusions

The transfer board tree enables rapid intrahospital transport of intensive care patients with sufficient monitoring.

Neuroanesthesiology update

We review topics pertinent to the perioperative care of patients with neurological disorders. Our review addresses topics not only in the anesthesiology literature, but also in basic neurosciences, critical care medicine, neurology, neurosurgery, radiology, and internal medicine literature. We include literature published or available online up through December 8, 2013. As our review is not able to include all manuscripts, we focus on recurring themes and unique and pivotal investigations. We address the broad topics of general neuroanesthesia, stroke, traumatic brain injury, anesthetic neurotoxicity, neuroprotection, pharmacology, physiology, and nervous system monitoring.

Safety of percutaneous endoscopic gastrostomy after trauma laparotomy

BACKGROUND

Trauma patients frequently require long-term enteral access because of injuries to the head, neck, or gastrointestinal tract. Noninvasive methods for gastrostomy placement include percutaneous endoscopic gastrostomy (PEG) and percutaneous radiographic gastrostomy (PRG). In patients with recent trauma laparotomy, PEG placement is felt to be relatively contraindicated because of the concerns about altered anatomy. We hypothesize that there is no increased rate of complications related to PEG placement in patients with trauma laparotomy compared with those without laparotomy provided that basic safety principles are followed.

MATERIALS AND METHODS

This retrospective study evaluates all percutaneous gastrostomies (both PEG and PRG) placed in trauma patients admitted at a level I trauma center between January 1, 2007 and March 30, 2010. The electronic medical records of the 354 patients were reviewed through 30 days after procedure, and patients were further subdivided by the history of laparotomy. Statistical analysis was performed using Fisher exact test or two-tailed t-test, as appropriate.

RESULTS

In patients with no prior trauma laparotomy, successful PEG placement occurred in 92.2% of patients, the remainder underwent PRG placement. Of patients with prior trauma laparotomy, 82.4% had successful PEG placement. Two percent of attempted PEG placements failed in patients with no previous trauma laparotomy, whereas 11.8% failed in patients with recent trauma laparotomy. The overall complication rate was 2.0%, with no recorded complications in patients with trauma laparotomy before PEG placement.

CONCLUSIONS

These data suggest that surgeons should not consider recent trauma laparotomy a contraindication to PEG placement.