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Hwang DY, Bannon SM, Meurer K, Kubota R, Baskaran N, Kim J, Zhang Q, Reichman M, Fishbein NS, Lichstein K, Motta M, Muehlschlegel S, Reznik ME, Jaffa MN, Creutzfeldt CJ, Fehnel CR, Tomlinson AD, Williamson CA, Vranceanu AM. Thematic Analysis of Psychosocial Stressors and Adaptive Coping Strategies Among Informal Caregivers of Patients Surviving ICU Admission for Coma. Neurocrit Care 2024; 40:674-688. [PMID: 37523110 DOI: 10.1007/s12028-023-01804-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 07/10/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND Family caregivers of patients with severe acute brain injury (SABI) admitted to intensive care units (ICUs) with coma experience heightened emotional distress stemming from simultaneous stressors. Stress and coping frameworks can inform psychosocial intervention development by elucidating common challenges and ways of navigating such experiences but have yet to be employed with this population. The present study therefore sought to use a stress and coping framework to characterize the stressors and coping behaviors of family caregivers of patients with SABI hospitalized in ICUs and recovering after coma. METHODS Our qualitative study recruited a convenience sample from 14 US neuroscience ICUs. Participants were family caregivers of patients who were admitted with ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, traumatic brain injury, or hypoxic-ischemic encephalopathy; had experienced a comatose state for > 24 h; and completed or were scheduled for tracheostomy and/or gastrostomy tube placement. Participants were recruited < 7 days after transfer out of the neuroscience ICU. We conducted live online video interviews from May 2021 to January 2022. One semistructured interview per participant was recorded and subsequently transcribed. Recruitment was stopped when thematic saturation was reached. We deductively derived two domains using a stress and coping framework to guide thematic analysis. Within each domain, we inductively derived themes to comprehensively characterize caregivers' experiences. RESULTS We interviewed 30 caregivers. We identified 18 themes within the two theory-driven domains, including ten themes describing practical, social, and emotional stressors experienced by caregivers and eight themes describing the psychological and behavioral coping strategies that caregivers attempted to enact. Nearly all caregivers described using avoidance or distraction as an initial coping strategy to manage overwhelming emotions. Caregivers also expressed awareness of more adaptive strategies (e.g., cultivation of positive emotions, acceptance, self-education, and soliciting social and medical support) but had challenges employing them because of their heightened emotional distress. CONCLUSIONS In response to substantial stressors, family caregivers of patients with SABI attempted to enact various psychological and behavioral coping strategies. They described avoidance and distraction as less helpful than other coping strategies but had difficulty engaging in alternative strategies because of their emotional distress. These findings can directly inform the development of additional resources to mitigate the long-term impact of acute psychological distress among this caregiver population.
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Affiliation(s)
- David Y Hwang
- Division of Neurocritical Care, Department of Neurology, University of North Carolina School of Medicine, 170 Manning Drive, CB# 7025, Chapel Hill, NC, 27599-7025, USA.
| | - Sarah M Bannon
- Department of Psychiatry, Center for Health Outcomes and Interdisciplinary Research, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Kate Meurer
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Rina Kubota
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Nithyashri Baskaran
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Jisoo Kim
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Qiang Zhang
- David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA, USA
| | - Mira Reichman
- Department of Psychology, University of Washington, Seattle, WA, USA
| | - Nathan S Fishbein
- Department of Psychiatry, Center for Health Outcomes and Interdisciplinary Research, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Kaitlyn Lichstein
- Department of Psychiatry, Center for Health Outcomes and Interdisciplinary Research, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Melissa Motta
- Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Susanne Muehlschlegel
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Michael E Reznik
- Department of Neurology, Alpert Medical School, Brown University, Providence, RI, USA
| | - Matthew N Jaffa
- Department of Neurointensive Care, Hartford Hospital, Hartford, CT, USA
| | - Claire J Creutzfeldt
- Department of Neurology, University of Washington and Harborview Medical Center, Seattle, WA, USA
| | - Corey R Fehnel
- Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Amanda D Tomlinson
- Department of Critical Care Medicine, College of Medicine, Mayo Clinic, Jacksonville, FL, USA
| | | | - Ana-Maria Vranceanu
- Department of Psychiatry, Center for Health Outcomes and Interdisciplinary Research, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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Jaffa MN, Kirschen MP, Tuppeny M, Reynolds AS, Lim-Hing K, Hargis M, Choi RK, Schober ME, LaBuzetta JN. Response to "Some Contributions on Standardized Education for Brain Death Determination". Neurocrit Care 2023; 39:742-743. [PMID: 37752297 DOI: 10.1007/s12028-023-01851-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 08/28/2023] [Indexed: 09/28/2023]
Affiliation(s)
- Matthew N Jaffa
- Division of Neurocritical Care, Department of Neurology, Ayer Neuroscience Institute, Hartford Hospital, Hartford, CT, USA
| | - Matthew P Kirschen
- Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Misti Tuppeny
- Division of Neuroscience and Behavioral Health, Department of Nursing Education and Quality, Advent Health, Orlando, FL, USA
| | - Alexandra S Reynolds
- Departments of Neurosurgery and Neurology, Mount Sinai Health System, New York, NY, USA
| | - Krista Lim-Hing
- Neurocritical Care Division, Department of Neurosurgery, Northwell Health, Bay Shore, NY, USA
| | - Mitch Hargis
- Division of Neurocritical Care, Department of Neurosciences, Novant Health Forsyth Medical Center, Winston-Salem, NC, USA
| | - Richard K Choi
- Division of Neurosciences, ChristianaCare, Newark, DE, USA
| | - Michelle E Schober
- Pediatric Critical Care Medicine, University of Utah, Salt Lake City, UT, USA
| | - Jamie Nicole LaBuzetta
- Division of Neurocritical Care, Department of Neurosciences, University of California, San Diego Health, 9444 Medical Center Dr., East Campus Office Building 3-028, La Jolla, CA, 92037-7740, USA.
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Jaffa MN, Kirsch HL, Creutzfeldt CJ, Guanci M, Hwang DY, LeTavec D, Mahanes D, Natarajan G, Steinberg A, Zahuranec DB, Muehlschlegel S. Common Data Elements for Disorders of Consciousness: Recommendations from the Working Group on Goals-of-Care and Family/Surrogate Decision-Maker Data. Neurocrit Care 2023; 39:600-610. [PMID: 37704937 DOI: 10.1007/s12028-023-01796-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 06/22/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND To facilitate comparative research, it is essential for the fields of neurocritical care and rehabilitation to establish common data elements (CDEs) for disorders of consciousness (DoC). Our objective was to identify CDEs related to goals-of-care decisions and family/surrogate decision-making for patients with DoC. METHODS To achieve this, we formed nine CDE working groups as part of the Neurocritical Care Society's Curing Coma Campaign. Our working group focused on goals-of-care decisions and family/surrogate decision-makers created five subgroups: (1) clinical variables of surrogates, (2) psychological distress of surrogates, (3) decision-making quality, (4) quality of communication, and (5) quality of end-of-life care. Each subgroup searched for existing relevant CDEs in the National Institutes of Health/CDE catalog and conducted an extensive literature search for additional relevant study instruments to be recommended. We classified each CDE according to the standard definitions of "core", "basic", "exploratory", or "supplemental", as well as their use for studying the acute or chronic phase of DoC, or both. RESULTS We identified 32 relevant preexisting National Institutes of Health CDEs across all subgroups. A total of 34 new instruments were added across all subgroups. Only one CDE was recommended as disease core, the "mode of death" of the patient from the clinical variables subgroup. CONCLUSIONS Our findings provide valuable CDEs specific to goals-of-care decisions and family/surrogate decision-making for patients with DoC that can be used to standardize studies to generate high-quality and reproducible research in this area.
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Affiliation(s)
- Matthew N Jaffa
- Department of Neurology, Ayer Neuroscience Institute, Hartford Hospital, Hartford, CT, USA
| | - Hannah L Kirsch
- Department of Neurology, Stanford University School of Medicine, 453 Quarry Road, MC 5235, Palo Alto, CA, USA.
| | - Claire J Creutzfeldt
- Department of Neurology, Division of Stroke and Palliative Care, University of Washington, Seattle, WA, USA
| | - Mary Guanci
- Department of Neuroscience Nursing, Massachusetts General Hospital, Boston, MA, USA
| | - David Y Hwang
- Division of Neurocritical Care, Department of Neurology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | | | - Dea Mahanes
- Departments of Neurology and Neurosurgery, UVA Health, Charlottesville, VA, USA
| | - Girija Natarajan
- Department of Pediatrics, Children's Hospital of Michigan, Detroit Medical Center, Detroit, MI, USA
| | - Alexis Steinberg
- Department of Neurology, Critical Care Medicine, and Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Darin B Zahuranec
- Department of Neurology, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Susanne Muehlschlegel
- Departments of Neurology, Anesthesiology/Critical Care and Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
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Jaffa MN, Kirschen MP, Tuppeny M, Reynolds AS, Lim-Hing K, Hargis M, Choi RK, Schober ME, LaBuzetta JN. Enhancing Understanding and Overcoming Barriers in Brain Death Determination Using Standardized Education: A Call to Action. Neurocrit Care 2023; 39:294-303. [PMID: 37434103 DOI: 10.1007/s12028-023-01775-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 06/02/2023] [Indexed: 07/13/2023]
Affiliation(s)
- Matthew N Jaffa
- Division of Neurocritical Care, Department of Neurology, Ayer Neuroscience Institute, Hartford Hospital, Hartford, CT, USA
| | - Matthew P Kirschen
- Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Misti Tuppeny
- Division of Neuroscience and Behavioral Health, Department of Nursing Education and Quality, Advent Health, Orlando, FL, USA
| | - Alexandra S Reynolds
- Departments of Neurosurgery and Neurology, Mount Sinai Health System, New York, NY, USA
| | - Krista Lim-Hing
- Neurocritical Care Division, Department of Neurosurgery, Northwell Health, Bay Shore, NY, USA
| | - Mitch Hargis
- Division of Neurocritical Care, Department of Neurosciences, Novant Health Forsyth Medical Center, Winston-Salem, NC, USA
| | - Richard K Choi
- Division of Neurosciences, ChristianaCare, Newark, DE, USA
| | - Michelle E Schober
- Pediatric Critical Care Medicine, University of Utah, Salt Lake City, UT, USA
| | - Jamie Nicole LaBuzetta
- Division of Neurocritical Care, Department of Neurosciences, University of California San Diego Health, 9444 Medical Center Dr., East Campus Office Building 3-028, La Jolla, CA, 92037-7740, USA.
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Mistry EA, Hart KW, Davis LT, Gao Y, Prestigiacomo CJ, Mittal S, Mehta T, LaFever H, Harker P, Wilson-Perez HE, Beasley KA, Krothapalli N, Lippincott E, Stefek H, Froehler M, Chitale R, Fusco M, Grossman A, Shirani P, Smith M, Jaffa MN, Yeatts SD, Albers GW, Wanderer JP, Tolles J, Lindsell CJ, Lewis RJ, Bernard GR, Khatri P. Blood Pressure Management After Endovascular Therapy for Acute Ischemic Stroke: The BEST-II Randomized Clinical Trial. JAMA 2023; 330:821-831. [PMID: 37668620 PMCID: PMC10481231 DOI: 10.1001/jama.2023.14330] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 07/11/2023] [Indexed: 09/06/2023]
Abstract
Importance The effects of moderate systolic blood pressure (SBP) lowering after successful recanalization with endovascular therapy for acute ischemic stroke are uncertain. Objective To determine the futility of lower SBP targets after endovascular therapy (<140 mm Hg or 160 mm Hg) compared with a higher target (≤180 mm Hg). Design, Setting, and Participants Randomized, open-label, blinded end point, phase 2, futility clinical trial that enrolled 120 patients with acute ischemic stroke who had undergone successful endovascular therapy at 3 US comprehensive stroke centers from January 2020 to March 2022 (final follow-up, June 2022). Intervention After undergoing endovascular therapy, participants were randomized to 1 of 3 SBP targets: 40 to less than 140 mm Hg, 40 to less than 160 mm Hg, and 40 to 180 mm Hg or less (guideline recommended) group, initiated within 60 minutes of recanalization and maintained for 24 hours. Main Outcomes and Measures Prespecified multiple primary outcomes for the primary futility analysis were follow-up infarct volume measured at 36 (±12) hours and utility-weighted modified Rankin Scale (mRS) score (range, 0 [worst] to 1 [best]) at 90 (±14) days. Linear regression models were used to test the harm-futility boundaries of a 10-mL increase (slope of 0.5) in the follow-up infarct volume or a 0.10 decrease (slope of -0.005) in the utility-weighted mRS score with each 20-mm Hg SBP target reduction after endovascular therapy (1-sided α = .05). Additional prespecified futility criterion was a less than 25% predicted probability of success for a future 2-group, superiority trial comparing SBP targets of the low- and mid-thresholds with the high-threshold (maximum sample size, 1500 with respect to the utility-weighted mRS score outcome). Results Among 120 patients randomized (mean [SD] age, 69.6 [14.5] years; 69 females [58%]), 113 (94.2%) completed the trial. The mean follow-up infarct volume was 32.4 mL (95% CI, 18.0 to 46.7 mL) for the less than 140-mm Hg group, 50.7 mL (95% CI, 33.7 to 67.7 mL), for the less than 160-mm Hg group, and 46.4 mL (95% CI, 24.5 to 68.2 mL) for the 180-mm Hg or less group. The mean utility-weighted mRS score was 0.51 (95% CI, 0.38 to 0.63) for the less than 140-mm Hg group, 0.47 (95% CI, 0.35 to 0.60) for the less than 160-mm Hg group, and 0.58 (95% CI, 0.46 to 0.71) for the high-target group. The slope of the follow-up infarct volume for each mm Hg decrease in the SBP target, adjusted for the baseline Alberta Stroke Program Early CT score, was -0.29 (95% CI, -0.81 to ∞; futility P = .99). The slope of the utility-weighted mRS score for each mm Hg decrease in the SBP target after endovascular therapy, adjusted for baseline utility-weighted mRS score, was -0.0019 (95% CI, -∞ to 0.0017; futility P = .93). Comparing the high-target SBP group with the lower-target groups, the predicted probability of success for a future trial was 25% for the less than 140-mm Hg group and 14% for the 160-mm Hg group. Conclusions and Relevance Among patients with acute ischemic stroke, lower SBP targets less than either 140 mm Hg or 160 mm Hg after successful endovascular therapy did not meet prespecified criteria for futility compared with an SBP target of 180 mm Hg or less. However, the findings suggested a low probability of benefit from lower SBP targets after endovascular therapy if tested in a future larger trial. Trial Registration ClinicalTrials.gov Identifier: NCT04116112.
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Affiliation(s)
- Eva A. Mistry
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Kimberly W. Hart
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Larry T. Davis
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Yue Gao
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Shilpi Mittal
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Tapan Mehta
- Ayer Neuroscience Institute, Department of Neurology, Hartford Hospital, Hartford, Connecticut
| | - Hayden LaFever
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Pablo Harker
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio
| | | | - Kalli A. Beasley
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Neeharika Krothapalli
- Ayer Neuroscience Institute, Department of Neurology, Hartford Hospital, Hartford, Connecticut
| | - Emily Lippincott
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Heather Stefek
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael Froehler
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rohan Chitale
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew Fusco
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Aaron Grossman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Peyman Shirani
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Matthew Smith
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Matthew N. Jaffa
- Ayer Neuroscience Institute, Department of Neurology, Hartford Hospital, Hartford, Connecticut
| | - Sharon D. Yeatts
- Department of Public Health Sciences, Medical University of South Carolina, Charleston
| | | | - Jonathan P. Wanderer
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Juliana Tolles
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Los Angeles, California
| | - Christopher J. Lindsell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
- Duke Clinical Research Institute, Durham, North Carolina
| | - Roger J. Lewis
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Los Angeles, California
- Statistical Editor, JAMA
| | - Gordon R. Bernard
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Pooja Khatri
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio
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Jaffa MN, Hwang DY. Goals of Care for Severe Acute Brain Injury Patients: When a Choice Is Not a Choice. Crit Care Med 2023; 51:978-980. [PMID: 37318295 DOI: 10.1097/ccm.0000000000005879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Affiliation(s)
- Matthew N Jaffa
- Department of Neurology, Ayer Neuroscience Institute, Hartford Hospital, Hartford, CT
| | - David Y Hwang
- Division of Neurocritical Care, Department of Neurology, University of North Carolina School of Medicine, Chapel Hill, NC
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Jaffa MN, Podell JE, Foroutan A, Motta M, Chang WTW, Cherian J, Pergakis MB, Parikh GY, Simard JM, Armahizer MJ, Badjatia N, Morris NA. Steroids Provide Temporary Improvement of Refractory Pain Following Subarachnoid Hemorrhage. Neurohospitalist 2023; 13:236-242. [PMID: 37441219 PMCID: PMC10334057 DOI: 10.1177/19418744231172350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/15/2023] Open
Abstract
Introduction Evidence for optimal analgesia following subarachnoid hemorrhage (SAH) is limited. Steroid therapy for pain refractory to standard regimens is common despite lack of evidence for its efficacy. We sought to determine if steroids reduced pain or utilization of other analgesics when given for refractory headache following SAH. Methods We performed a retrospective within-subjects cohort study of SAH patients who received steroids for refractory headache. We compared daily pain scores, total daily opioid, and acetaminophen doses before, during, and after steroids. Repeated measures were analyzed with a multivariable general linear model and generalized estimating equations. Results Included 52 patients treated with dexamethasone following SAH, of whom 11 received a second course, increasing total to 63 treatment epochs. Mean pain score on the first day of therapy was 7.92 (standard error of the mean [SEM] .37) and decreased to 6.68 (SEM .36) on the second day before quickly returning to baseline levels, 7.36 (SEM .33), following completion of treatment. Total daily analgesics mirrored this trend. Mean total opioid and acetaminophen doses on days one and two and two days after treatment were 47.83mg (SEM 6.22) and 1848mg (SEM 170.66), 34.24mg (SEM 5.12) and 1809mg (SEM 150.28), and 46.38mg (SEM 11.64) and 1833mg (SEM 174.23), respectively. Response to therapy was associated with older age, decreasing acetaminophen dosing, and longer duration of steroids. Hyperglycemia and sleep disturbance/delirium effected 28.6% and 55.6% of cases, respectively. Conclusion Steroid therapy for refractory pain in SAH patients may have modest, transient effects in select patients.
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Affiliation(s)
- Matthew N. Jaffa
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Jamie E. Podell
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Arshom Foroutan
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Melissa Motta
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Wan-Tsu W. Chang
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jacob Cherian
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Melissa B. Pergakis
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Gunjan Y. Parikh
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - J. Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Physiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Michael J. Armahizer
- Department of Pharmacy Services, University of Maryland Medical Center, Baltimore, MD, USA
| | - Neeraj Badjatia
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Nicholas A. Morris
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
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Jaffa MN, Kirsch HL, Creutzfeldt CJ, Guanci M, Hwang DY, LeTavec D, Mahanes D, Steinberg A, Natarajan G, Zahuranec DB, Muehlschlegel S. Common Data Elements for Disorders of Consciousness: Recommendations from the Working Group on Goals-of-care and Family/Surrogate Decision-Maker Data. Res Sq 2023:rs.3.rs-3084539. [PMID: 37461521 PMCID: PMC10350109 DOI: 10.21203/rs.3.rs-3084539/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
INTRODUCTION In order to facilitate comparative research, it is essential for the fields of neurocritical care and rehabilitation to establish common data elements (CDE) for disorders of consciousness (DoC). Our objective was to identify CDEs related to goals-of-care decisions and family/surrogate decision-making for patients with DoC. METHODS To achieve this, we formed nine CDE working groups as part of the Neurocritical Care Society's Curing Coma Campaign. Our working group focused on goals-of-care decisions and family/surrogate decision-makers created five subgroups: (1) clinical variables of surrogates, (2) psychological distress of surrogates, (3) decision-making quality, (4) quality of communication, and (5) quality of end-of-life care. Each subgroup searched for existing relevant CDEs in the NIH/CDE catalog and conducted an extensive literature search for additional relevant study instruments to be recommended. We classified each CDE according to the standard definitions of "core," "basic," "exploratory," or "supplemental," as well as their utility for studying the acute or chronic phase of DoC, or both. RESULTS We identified 32 relevant pre-existing NIH CDEs across all subgroups. A total of 34 new instruments were added across all subgroups. Only one CDE was recommended as disease core, the "mode of death" of the patient from the clinical variables subgroup. CONCLUSIONS Our findings provide valuable CDEs specific to goals-of-care decisions and family/surrogate decision-making for patients with DoC that can be used to standardize studies to generate high-quality and reproducible research in this area.
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Affiliation(s)
| | | | | | | | - David Y Hwang
- The University of North Carolina at Chapel Hill School of Medicine
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Salasky V, Jaffa MN, Motta M, Parikh GY. Neurocritical Care Recovery Clinics: An Idea Whose Time Has Come. Curr Neurol Neurosci Rep 2023; 23:159-166. [PMID: 36929481 DOI: 10.1007/s11910-023-01256-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2023] [Indexed: 03/18/2023]
Abstract
PURPOSE OF REVIEW Purposes were to identify evidence for post-intensive care syndrome (PICS) and post-intensive care syndrome-family (PICS-F), defined as the psychological impact on families from exposure to critical care, in the neurologically injured population and to characterize existing models for neurorecovery clinics and the evidence to support their use. RECENT FINDINGS There has been an explosion of post-ICU clinics among the general critical care population, with their use largely justified based on the management of PICS and PICS-F, terminology which excludes brain injured patients. In contrast, neurocritical care recovery clinics are not common and not well-described. There is however evidence in the neuro-ICU population supporting the provision of "dyadic" care, whereby the patient and caregiver are treated as one unit. Brain injured populations likely experience many of the same PICS phenomena as medically ill patients but are not represented in this body of literature. These patients deserve the same level of follow-up as other patients who have experienced critical illness. We propose a neuro-ICU transitional care clinic that addresses PICS-like symptoms and is modeled after transitional care provided to other brain injured populations. Future investigations should be targeted toward understanding the sequalae of a neuro-ICU admission, mechanisms for providing dyadic care, and the impact of neurorecovery clinics on long-term outcomes.
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Affiliation(s)
- Vanessa Salasky
- Department of Neurology, University of Maryland School of Medicine, 22 S. Greene St., Baltimore, MD, 21201, USA
- Program in Trauma, Baltimore, MD, USA
| | - Matthew N Jaffa
- Department of Neurology, Hartford Hospital, Ayer Neuroscience Institute, Hartford, CT, USA
| | - Melissa Motta
- Department of Neurology, University of Maryland School of Medicine, 22 S. Greene St., Baltimore, MD, 21201, USA
- Program in Trauma, Baltimore, MD, USA
| | - Gunjan Y Parikh
- Department of Neurology, University of Maryland School of Medicine, 22 S. Greene St., Baltimore, MD, 21201, USA.
- Program in Trauma, Baltimore, MD, USA.
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10
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Jaffa MN, Morris N. Maximal Care After Intracerebral Hemorrhage: Giving Patients a Chance. Neurology 2023; 100:891-892. [PMID: 36927879 DOI: 10.1212/wnl.0000000000207206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 02/03/2023] [Indexed: 03/18/2023] Open
Affiliation(s)
- Matthew N Jaffa
- Department of Neurology, Ayer Neuroscience Institute, Hartford Hospital, Hartford, CT
| | - Nicholas Morris
- Department of Neurology, Program in Trauma, University of Maryland School of Medicine, Baltimore, MD
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11
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Kardon A, Elmer J, Elsaesser D, Dickinson K, Podell J, Jaffa MN, Maciel C, Jha R, Busl KM, Morris N. Abstract WMP66: Early Rising Pain Scores Predict Cerebral Vasospasm After Aneurysmal Subarachnoid Hemorrhage. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.wmp66] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Introduction:
Persistent pain following subarachnoid hemorrhage (SAH) is common and follows distinct trajectories. Cerebral vasospasm (CV) and delayed cerebral ischemia are late complications of SAH and may represent modifiable causes of secondary brain injury. Headache and CV share common risk factors including age, blood burden and cigarette smoking, however the relationship between pain and CV is unknown. We hypothesize that patients with increasing pain will be at increased risk for developing CV.
Methods:
We conducted a retrospective review of patients with non-traumatic SAH at two large academic medical centers from 2015-2022. Pain scores were recorded for 14 days. We excluded patients with onset of CV before post-bleed day (PBD) 4. We employed group-based trajectory modeling to identify distinct trajectories of 24 q2h pain scores during PBDs 2 and 3. Pain scores prior to PBD 2 were omitted due to the large amount of missing data. The incidence of CV was compared between trajectory groups using chi-squared analysis.
Results:
We identified 442 patients (median [IQR] age 56 [47-64] years, 294 (66%) women, 33 (7.4%) peri-mesencephalic, 330 (75%) Hunt-Hess 1-3, 393 (88%) modified Fisher 3-4) for analysis. We considered 3 through 8-group models and compared model fit by comparing AIC, BIC, and visual inspection of trajectories between models. Ultimately, a 4-group model fit the data best with four distinct trajectories of pain: persistently low (41% of patients), persistently high (24%), falling (18%) and rising (16%). Baseline clinical variables were comparable between trajectory groups. The median [IQR] day of CV onset was PBD 7 [5-10]. Patients with rising pain had significantly higher rates of vasospasm than those with persistently high or falling pain (54% vs 34% and 36%, respectively, Chi2 P = 0.02). Results were similar in a sensitivity analysis limited to patients with verbally reported pain scores.
Conclusion:
Distinct pain trajectories exist in the early hospital course following SAH. Our multicenter, retrospective cohort found that an initial rising pain trajectory is associated with development of CV. Future studies should validate this finding in separate cohorts and explore the pathophysiological mechanisms of this association.
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12
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Elmashad A, Emmerson D, Gorseth A, Jaffa MN. Ticagrelor Induced Angioedema Following Carotid Artery Stenting. Neurohospitalist 2022; 12:550-552. [DOI: 10.1177/19418744221097353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Ticagrelor is a frequent component of dual antiplatelet therapy (DAPT) following carotid artery stent placement. Hemorrhagic complications remain the focus of most reports, however, other adverse events must also be known to the prescribing physician. Angioedema is a rare and potentially life-threatening complication reported following ticagrelor administration and we present 1 such case here with a review of the existing literature.
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Affiliation(s)
- Ahmed Elmashad
- Department of Neurology, University of Connecticut, Farmington, CT, USA
- Department of Neurology, Ayer Neuroscience Institute, Hartford Hospital, Hartford, CT, USA
| | - Danison Emmerson
- Department of Neurology, University of Connecticut, Farmington, CT, USA
- Department of Neurology, Ayer Neuroscience Institute, Hartford Hospital, Hartford, CT, USA
| | - Allison Gorseth
- Department of Pharmacy Services, Hartford Hospital, Hartford, CT, USA
| | - Matthew N. Jaffa
- Department of Neurology, Ayer Neuroscience Institute, Hartford Hospital, Hartford, CT, USA
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13
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Podell JE, Krause EM, Rector R, Hassan M, Reddi A, Jaffa MN, Morris NA, Herr DL, Parikh GY. Neurologic Outcomes After Extracorporeal Cardiopulmonary Resuscitation: Recent Experience at a Single High-Volume Center. ASAIO J 2022; 68:247-254. [PMID: 33927083 DOI: 10.1097/mat.0000000000001448] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Extracorporeal cardiopulmonary resuscitation (ECPR)-veno-arterial extracorporeal membrane oxygenation (ECMO) for refractory cardiac arrest-has grown rapidly, but its widespread adoption has been limited by frequent neurologic complications. With individual centers developing best practices, utilization may be increasing with an uncertain effect on outcomes. This study describes the recent ECPR experience at the University of Maryland Medical Center from 2016 through 2018, with attention to neurologic outcomes and predictors thereof. The primary outcome was dichotomized Cerebral Performance Category (≤2) at hospital discharge; secondary outcomes included rates of specific neurologic complications. From 429 ECMO runs over 3 years, 57 ECPR patients were identified, representing an increase in ECPR utilization compared with 41 cases over the previous 6 years. Fifty-two (91%) suffered in-hospital cardiac arrest, and 36 (63%) had an initial nonshockable rhythm. Median low-flow time was 31 minutes. Overall, 26 (46%) survived hospitalization and 23 (88% of survivors, 40% overall) had a favorable discharge outcome. Factors independently associated with good neurologic outcome included lower peak lactate, initial shockable rhythm, and higher initial ECMO mean arterial pressure. Neurologic complications occurred in 18 patients (32%), including brain death in 6 (11%), hypoxic-ischemic brain injury in 11 (19%), ischemic stroke in 6 (11%), intracerebral hemorrhage in 1 (2%), and seizure in 4 (7%). We conclude that good neurologic outcomes are possible for well-selected ECPR patients in a high-volume program with increasing utilization and evolving practices. Markers of adequate peri-resuscitation tissue perfusion were associated with better outcomes, suggesting their importance in neuroprognostication.
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Affiliation(s)
- Jamie E Podell
- From the Section of Neurocritical Care and Emergency Neurology, Department of Neurology, Program in Trauma, University of Maryland School of Medicine, Baltimore, Maryland
| | - Eric M Krause
- Division of Thoracic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Raymond Rector
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Mubariz Hassan
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Ashwin Reddi
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Matthew N Jaffa
- From the Section of Neurocritical Care and Emergency Neurology, Department of Neurology, Program in Trauma, University of Maryland School of Medicine, Baltimore, Maryland
| | - Nicholas A Morris
- From the Section of Neurocritical Care and Emergency Neurology, Department of Neurology, Program in Trauma, University of Maryland School of Medicine, Baltimore, Maryland
| | - Daniel L Herr
- Division of Surgical Critical Care, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Gunjan Y Parikh
- From the Section of Neurocritical Care and Emergency Neurology, Department of Neurology, Program in Trauma, University of Maryland School of Medicine, Baltimore, Maryland
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14
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Jaffa MN, Jha RM, Elmer J, Kardon A, Podell JE, Zusman BE, Smith MC, Marc Simard J, Parikh GY, Armahizer MJ, Badjatia N, Morris NA. Correction to: Pain Trajectories Following Subarachnoid Hemorrhage are Associated with Continued Opioid Use at Outpatient Follow-Up. Neurocrit Care 2021; 35:928. [PMID: 34661862 PMCID: PMC8895053 DOI: 10.1007/s12028-021-01370-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Matthew N Jaffa
- Department of Neurology, School of Medicine, University of Maryland, Baltimore, MD, USA.,Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Ruchira M Jha
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Neurology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Neurosurgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Safar Center for Resuscitation Research, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Clinical and Translational Science Institute, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jonathan Elmer
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Neurology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Emergency Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Adam Kardon
- Department of Neurology, School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Jamie E Podell
- Department of Neurology, School of Medicine, University of Maryland, Baltimore, MD, USA.,Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Benjamin E Zusman
- Department of Neurology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Madeleine C Smith
- Department of Neurology, School of Medicine, University of Maryland, Baltimore, MD, USA
| | - J Marc Simard
- Department of Neurosurgery, School of Medicine, University of Maryland, Baltimore, MD, USA.,Department of Pathology, School of Medicine, University of Maryland, Baltimore, MD, USA.,Department of Physiology, School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Gunjan Y Parikh
- Department of Neurology, School of Medicine, University of Maryland, Baltimore, MD, USA.,Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Michael J Armahizer
- Department of Pharmacy Services, University of Maryland Medical Center, Baltimore, MD, USA
| | - Neeraj Badjatia
- Department of Neurology, School of Medicine, University of Maryland, Baltimore, MD, USA.,Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Nicholas A Morris
- Department of Neurology, School of Medicine, University of Maryland, Baltimore, MD, USA. .,Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA.
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15
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Affiliation(s)
- Matthew N Jaffa
- Neurocritical Care, Program in Trauma, Department of Neurology, University of Maryland School of Medicine, 22 South Greene St., Rm G7K18, Baltimore, MD, 21201, USA.
| | - Jamie E Podell
- Neurocritical Care, Program in Trauma, Department of Neurology, University of Maryland School of Medicine, 22 South Greene St., Rm G7K18, Baltimore, MD, 21201, USA
| | - Melissa Motta
- Neurocritical Care, Program in Trauma, Department of Neurology, University of Maryland School of Medicine, 22 South Greene St., Rm G7K18, Baltimore, MD, 21201, USA
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16
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Jaffa MN, Jha RM, Elmer J, Kardon A, Podell JE, Zusman BE, Smith MC, Simard JM, Parikh GY, Armahizer MJ, Badjatia N, Morris NA. Pain Trajectories Following Subarachnoid Hemorrhage are Associated with Continued Opioid Use at Outpatient Follow-up. Neurocrit Care 2021; 35:806-814. [PMID: 34109554 PMCID: PMC8189709 DOI: 10.1007/s12028-021-01282-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 05/20/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Subarachnoid hemorrhage (SAH) is characterized by the worst headache of life and associated with long-term opioid use. Discrete pain trajectories predict chronic opioid use following other etiologies of acute pain, but it is unknown whether they exist following SAH. If discrete pain trajectories following SAH exist, it is uncertain whether they predict long-term opioid use. We sought to characterize pain trajectories after SAH and determine whether they are associated with persistent opioid use. METHODS We reviewed pain scores from patients admitted to a single tertiary care center for SAH from November 2015 to September 2019. Group-based trajectory modeling identified discrete pain trajectories during hospitalization. We compared outcomes across trajectory groups using χ2 and Kruskal-Wallis tests. Multivariable regression determined whether trajectory group membership was an independent predictor of long-term opioid use, defined as continued use at outpatient follow-up. RESULTS We identified five discrete pain trajectories among 305 patients. Group 1 remained pain free. Group 2 reported low scores with intermittent spikes and slight increase over time. Group 3 noted increasing pain severity through day 7 with mild improvement until day 14. Group 4 experienced maximum pain with steady decrement over time. Group 5 reported moderate pain with subtle improvement. In multivariable analysis, trajectory groups 3 (odds ratio [OR] 3.5; 95% confidence interval [CI] 1.5-8.3) and 5 (OR 8.0; 95% CI 3.1-21.1), history of depression (OR 3.6; 95% CI 1.3-10.0) and racial/ethnic minority (OR 2.3; 95% CI 1.3-4.1) were associated with continued opioid use at follow-up (median 62 days following admission, interquartile range 48-96). CONCLUSIONS Discrete pain trajectories following SAH exist. Recognition of pain trajectories may help identify those at risk for long-term opioid use.
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Affiliation(s)
- Matthew N Jaffa
- Department of Neurology, School of Medicine, University of Maryland, Baltimore, MD, USA.,Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Ruchira M Jha
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Neurology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Neurosurgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Safar Center for Resuscitation Research, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Clinical and Translational Science Institute, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jonathan Elmer
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Neurology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Emergency Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Adam Kardon
- Department of Neurology, School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Jamie E Podell
- Department of Neurology, School of Medicine, University of Maryland, Baltimore, MD, USA.,Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Benjamin E Zusman
- Department of Neurology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Madeleine C Smith
- Department of Neurology, School of Medicine, University of Maryland, Baltimore, MD, USA
| | - J Marc Simard
- Department of Neurosurgery, School of Medicine, University of Maryland, Baltimore, MD, USA.,Department of Pathology, School of Medicine, University of Maryland, Baltimore, MD, USA.,Department of Physiology, School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Gunjan Y Parikh
- Department of Neurology, School of Medicine, University of Maryland, Baltimore, MD, USA.,Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Michael J Armahizer
- Department of Pharmacy Services, University of Maryland Medical Center, Baltimore, MD, USA
| | - Neeraj Badjatia
- Department of Neurology, School of Medicine, University of Maryland, Baltimore, MD, USA.,Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Nicholas A Morris
- Department of Neurology, School of Medicine, University of Maryland, Baltimore, MD, USA. .,Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA.
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17
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Jaffa MN, Podell JE, Smith MC, Foroutan A, Kardon A, Chang WTW, Motta M, Parikh GY, Sheth KN, Badjatia N, Armahizer MJ, Simard JM, Morris NA. Association of Refractory Pain in the Acute Phase After Subarachnoid Hemorrhage With Continued Outpatient Opioid Use. Neurology 2021; 96:e2355-e2362. [PMID: 33766993 DOI: 10.1212/wnl.0000000000011906] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 02/05/2021] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE Little is known about the prevalence of continued opioid use following aneurysmal subarachnoid hemorrhage (aSAH) despite guidelines recommending their use during the acute phase of disease. We sought to determine prevalence of opioid use following aSAH and test the hypothesis that acute pain and higher inpatient opioid dose increased outpatient opioid use. METHODS We reviewed consecutively admitted patients with aSAH from November 2015 through September 2019. We retrospectively collected pain scores and daily doses of analgesics. Pain burden was calculated as area under the pain-time curve. Univariate and multivariable regression models determined risk factors for continued opioid use at discharge and outpatient follow-up. RESULTS We identified 234 patients with aSAH with outpatient follow-up. Continued opioid use was common at discharge (55% of patients) and follow-up (47% of patients, median 63 [interquartile range 49-96] days from admission). Pain burden, craniotomy, and racial or ethnic minority status were associated with discharge opioid prescription in multivariable analysis. At outpatient follow-up, pain burden (odds ratio [OR] 1.88, 95% confidence interval [CI] 1.5-2.4), depression (OR 3.1, 95% CI 1.1-8.8), and racial or ethnic minority status (OR 2.1, 95% CI 1.1-4.0) were independently associated with continued opioid use; inpatient opioid dose was not. CONCLUSION Continued opioid use following aSAH is prevalent and related to refractory pain during acute illness, but not inpatient opioid dose. More efficacious analgesic strategies are needed to reduce continued opioid use in patients following aSAH. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that continued opioid use following aSAH is associated with refractory pain during acute illness but not hospital opioid exposure.
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Affiliation(s)
- Matthew N Jaffa
- From the Departments of Neurology (M.N.J., J.E.P., A.K., W.-T.W.C., M.M., G.Y.P., N.B., N.A.M.), Emergency Medicine (W.-T.W.C.), Pharmacy Services (M.J.A.), Neurosurgery (J.M.S.), Pathology (J.M.S.), and Physiology (J.M.S.), and Program in Trauma, R. Adams Cowley Shock Trauma Center (M.N.J., J.E.P., W.-T.W.C., M.M., G.Y.P., N.B., N.A.M.), University of Maryland School of Medicine (M.C.S., A.F., A.K.), Baltimore; and Department of Neurology, Division of Neurocritical Care and Emergency Neurology (K.N.S.), Yale School of Medicine, New Haven, CT
| | - Jamie E Podell
- From the Departments of Neurology (M.N.J., J.E.P., A.K., W.-T.W.C., M.M., G.Y.P., N.B., N.A.M.), Emergency Medicine (W.-T.W.C.), Pharmacy Services (M.J.A.), Neurosurgery (J.M.S.), Pathology (J.M.S.), and Physiology (J.M.S.), and Program in Trauma, R. Adams Cowley Shock Trauma Center (M.N.J., J.E.P., W.-T.W.C., M.M., G.Y.P., N.B., N.A.M.), University of Maryland School of Medicine (M.C.S., A.F., A.K.), Baltimore; and Department of Neurology, Division of Neurocritical Care and Emergency Neurology (K.N.S.), Yale School of Medicine, New Haven, CT
| | - Madeleine C Smith
- From the Departments of Neurology (M.N.J., J.E.P., A.K., W.-T.W.C., M.M., G.Y.P., N.B., N.A.M.), Emergency Medicine (W.-T.W.C.), Pharmacy Services (M.J.A.), Neurosurgery (J.M.S.), Pathology (J.M.S.), and Physiology (J.M.S.), and Program in Trauma, R. Adams Cowley Shock Trauma Center (M.N.J., J.E.P., W.-T.W.C., M.M., G.Y.P., N.B., N.A.M.), University of Maryland School of Medicine (M.C.S., A.F., A.K.), Baltimore; and Department of Neurology, Division of Neurocritical Care and Emergency Neurology (K.N.S.), Yale School of Medicine, New Haven, CT
| | - Arshom Foroutan
- From the Departments of Neurology (M.N.J., J.E.P., A.K., W.-T.W.C., M.M., G.Y.P., N.B., N.A.M.), Emergency Medicine (W.-T.W.C.), Pharmacy Services (M.J.A.), Neurosurgery (J.M.S.), Pathology (J.M.S.), and Physiology (J.M.S.), and Program in Trauma, R. Adams Cowley Shock Trauma Center (M.N.J., J.E.P., W.-T.W.C., M.M., G.Y.P., N.B., N.A.M.), University of Maryland School of Medicine (M.C.S., A.F., A.K.), Baltimore; and Department of Neurology, Division of Neurocritical Care and Emergency Neurology (K.N.S.), Yale School of Medicine, New Haven, CT
| | - Adam Kardon
- From the Departments of Neurology (M.N.J., J.E.P., A.K., W.-T.W.C., M.M., G.Y.P., N.B., N.A.M.), Emergency Medicine (W.-T.W.C.), Pharmacy Services (M.J.A.), Neurosurgery (J.M.S.), Pathology (J.M.S.), and Physiology (J.M.S.), and Program in Trauma, R. Adams Cowley Shock Trauma Center (M.N.J., J.E.P., W.-T.W.C., M.M., G.Y.P., N.B., N.A.M.), University of Maryland School of Medicine (M.C.S., A.F., A.K.), Baltimore; and Department of Neurology, Division of Neurocritical Care and Emergency Neurology (K.N.S.), Yale School of Medicine, New Haven, CT
| | - Wan-Tsu W Chang
- From the Departments of Neurology (M.N.J., J.E.P., A.K., W.-T.W.C., M.M., G.Y.P., N.B., N.A.M.), Emergency Medicine (W.-T.W.C.), Pharmacy Services (M.J.A.), Neurosurgery (J.M.S.), Pathology (J.M.S.), and Physiology (J.M.S.), and Program in Trauma, R. Adams Cowley Shock Trauma Center (M.N.J., J.E.P., W.-T.W.C., M.M., G.Y.P., N.B., N.A.M.), University of Maryland School of Medicine (M.C.S., A.F., A.K.), Baltimore; and Department of Neurology, Division of Neurocritical Care and Emergency Neurology (K.N.S.), Yale School of Medicine, New Haven, CT
| | - Melissa Motta
- From the Departments of Neurology (M.N.J., J.E.P., A.K., W.-T.W.C., M.M., G.Y.P., N.B., N.A.M.), Emergency Medicine (W.-T.W.C.), Pharmacy Services (M.J.A.), Neurosurgery (J.M.S.), Pathology (J.M.S.), and Physiology (J.M.S.), and Program in Trauma, R. Adams Cowley Shock Trauma Center (M.N.J., J.E.P., W.-T.W.C., M.M., G.Y.P., N.B., N.A.M.), University of Maryland School of Medicine (M.C.S., A.F., A.K.), Baltimore; and Department of Neurology, Division of Neurocritical Care and Emergency Neurology (K.N.S.), Yale School of Medicine, New Haven, CT
| | - Gunjan Y Parikh
- From the Departments of Neurology (M.N.J., J.E.P., A.K., W.-T.W.C., M.M., G.Y.P., N.B., N.A.M.), Emergency Medicine (W.-T.W.C.), Pharmacy Services (M.J.A.), Neurosurgery (J.M.S.), Pathology (J.M.S.), and Physiology (J.M.S.), and Program in Trauma, R. Adams Cowley Shock Trauma Center (M.N.J., J.E.P., W.-T.W.C., M.M., G.Y.P., N.B., N.A.M.), University of Maryland School of Medicine (M.C.S., A.F., A.K.), Baltimore; and Department of Neurology, Division of Neurocritical Care and Emergency Neurology (K.N.S.), Yale School of Medicine, New Haven, CT
| | - Kevin N Sheth
- From the Departments of Neurology (M.N.J., J.E.P., A.K., W.-T.W.C., M.M., G.Y.P., N.B., N.A.M.), Emergency Medicine (W.-T.W.C.), Pharmacy Services (M.J.A.), Neurosurgery (J.M.S.), Pathology (J.M.S.), and Physiology (J.M.S.), and Program in Trauma, R. Adams Cowley Shock Trauma Center (M.N.J., J.E.P., W.-T.W.C., M.M., G.Y.P., N.B., N.A.M.), University of Maryland School of Medicine (M.C.S., A.F., A.K.), Baltimore; and Department of Neurology, Division of Neurocritical Care and Emergency Neurology (K.N.S.), Yale School of Medicine, New Haven, CT
| | - Neeraj Badjatia
- From the Departments of Neurology (M.N.J., J.E.P., A.K., W.-T.W.C., M.M., G.Y.P., N.B., N.A.M.), Emergency Medicine (W.-T.W.C.), Pharmacy Services (M.J.A.), Neurosurgery (J.M.S.), Pathology (J.M.S.), and Physiology (J.M.S.), and Program in Trauma, R. Adams Cowley Shock Trauma Center (M.N.J., J.E.P., W.-T.W.C., M.M., G.Y.P., N.B., N.A.M.), University of Maryland School of Medicine (M.C.S., A.F., A.K.), Baltimore; and Department of Neurology, Division of Neurocritical Care and Emergency Neurology (K.N.S.), Yale School of Medicine, New Haven, CT
| | - Michael J Armahizer
- From the Departments of Neurology (M.N.J., J.E.P., A.K., W.-T.W.C., M.M., G.Y.P., N.B., N.A.M.), Emergency Medicine (W.-T.W.C.), Pharmacy Services (M.J.A.), Neurosurgery (J.M.S.), Pathology (J.M.S.), and Physiology (J.M.S.), and Program in Trauma, R. Adams Cowley Shock Trauma Center (M.N.J., J.E.P., W.-T.W.C., M.M., G.Y.P., N.B., N.A.M.), University of Maryland School of Medicine (M.C.S., A.F., A.K.), Baltimore; and Department of Neurology, Division of Neurocritical Care and Emergency Neurology (K.N.S.), Yale School of Medicine, New Haven, CT
| | - J Marc Simard
- From the Departments of Neurology (M.N.J., J.E.P., A.K., W.-T.W.C., M.M., G.Y.P., N.B., N.A.M.), Emergency Medicine (W.-T.W.C.), Pharmacy Services (M.J.A.), Neurosurgery (J.M.S.), Pathology (J.M.S.), and Physiology (J.M.S.), and Program in Trauma, R. Adams Cowley Shock Trauma Center (M.N.J., J.E.P., W.-T.W.C., M.M., G.Y.P., N.B., N.A.M.), University of Maryland School of Medicine (M.C.S., A.F., A.K.), Baltimore; and Department of Neurology, Division of Neurocritical Care and Emergency Neurology (K.N.S.), Yale School of Medicine, New Haven, CT
| | - Nicholas A Morris
- From the Departments of Neurology (M.N.J., J.E.P., A.K., W.-T.W.C., M.M., G.Y.P., N.B., N.A.M.), Emergency Medicine (W.-T.W.C.), Pharmacy Services (M.J.A.), Neurosurgery (J.M.S.), Pathology (J.M.S.), and Physiology (J.M.S.), and Program in Trauma, R. Adams Cowley Shock Trauma Center (M.N.J., J.E.P., W.-T.W.C., M.M., G.Y.P., N.B., N.A.M.), University of Maryland School of Medicine (M.C.S., A.F., A.K.), Baltimore; and Department of Neurology, Division of Neurocritical Care and Emergency Neurology (K.N.S.), Yale School of Medicine, New Haven, CT.
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