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McGrath M, Sarhadi K, Harris MH, Baird-Daniel E, Greil M, Barrios-Anderson A, Robinson E, Fong CT, Walters AM, Lele AV, Wahlster S, Bonow R. Utility of Routine Surveillance Head Computed Tomography After Receiving Therapeutic Anticoagulation in Patients with Acute Traumatic Intracranial Hemorrhage. World Neurosurg 2024; 185:e1114-e1120. [PMID: 38490443 DOI: 10.1016/j.wneu.2024.03.031] [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: 10/26/2023] [Revised: 03/06/2024] [Accepted: 03/07/2024] [Indexed: 03/17/2024]
Abstract
INTRODUCTION Patients with traumatic intracranial hemorrhage (tICH) are at increased risk of venous thromboembolism and may require anticoagulation. We evaluated the utility of surveillance computed tomography (CT) in patients with tICH who required therapeutic anticoagulation. METHODS This single institution, retrospective study included adult patients with tICH who required anticoagulation within 4 weeks and had a surveillance head CT within 24 hours of reaching therapeutic anticoagulation levels. The primary outcome was hematoma expansion (HE) detected by the surveillance CT. Secondary outcomes included 1) changes in management in patients with HE on the surveillance head CT, 2) HE in the absence of clinical changes, and 3) mortality due to HE. We also compared mortality between patients who did and did not have a surveillance CT. RESULTS Of 175 patients, 5 (2.9%) were found to have HE. Most (n = 4, 80%) had changes in management including anticoagulation discontinuation (n = 4), reversal (n = 1), and operative management (n = 1). Two patients developed symptoms or exam changes prior to the head CT. Of the 3 patients (1.7%) without preceding exam changes, each had only very minor HE and did not require operative management. No patient experienced mortality directly attributed to HE. There was no difference in mortality between patients who did and those who did not have a surveillance scan. CONCLUSIONS Our findings suggest that most patients with tICH who are started on anticoagulation could be followed clinically, and providers may reserve CT imaging for patients with changes in exam/symptoms or those who have a poor clinical examination to follow.
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Affiliation(s)
- Margaret McGrath
- Department of Neurological Surgery, University of Washington, Seattle, Washington.
| | - Kasra Sarhadi
- Department of Neurology, University of Washington, Seattle, Washington
| | - Mark H Harris
- School of Medicine, University of California, Irvine, California
| | - Eliza Baird-Daniel
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Madeline Greil
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | | | - Ellen Robinson
- Quality Improvement, Harborview Medical Center, Seattle, Washington
| | - Christine T Fong
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Andrew M Walters
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Abhijit V Lele
- Department of Neurological Surgery, University of Washington, Seattle, Washington; Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington; Harborview Injury Prevention Research Center, University of Washington, Seattle, Washington
| | - Sarah Wahlster
- Department of Neurological Surgery, University of Washington, Seattle, Washington; Department of Neurology, University of Washington, Seattle, Washington; Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Robert Bonow
- Department of Neurological Surgery, University of Washington, Seattle, Washington; Harborview Injury Prevention Research Center, University of Washington, Seattle, Washington
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Lele AV, Liu J, Kunapaisal T, Chaikittisilpa N, Kiatchai T, Meno MK, Assad OR, Pham J, Fong CT, Walters AM, Nandate K, Chowdhury T, Krishnamoorthy V, Vavilala MS, Kwon Y. Early Cardiac Evaluation, Abnormal Test Results, and Associations with Outcomes in Patients with Acute Brain Injury Admitted to a Neurocritical Care Unit. J Clin Med 2024; 13:2526. [PMID: 38731055 PMCID: PMC11084203 DOI: 10.3390/jcm13092526] [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] [Received: 03/09/2024] [Revised: 04/17/2024] [Accepted: 04/23/2024] [Indexed: 05/13/2024] Open
Abstract
Background: to examine factors associated with cardiac evaluation and associations between cardiac test abnormalities and clinical outcomes in patients with acute brain injury (ABI) due to acute ischemic stroke (AIS), spontaneous subarachnoid hemorrhage (SAH), spontaneous intracerebral hemorrhage (sICH), and traumatic brain injury (TBI) requiring neurocritical care. Methods: In a cohort of patients ≥18 years, we examined the utilization of electrocardiography (ECG), beta-natriuretic peptide (BNP), cardiac troponin (cTnI), and transthoracic echocardiography (TTE). We investigated the association between cTnI, BNP, sex-adjusted prolonged QTc interval, low ejection fraction (EF < 40%), all-cause mortality, death by neurologic criteria (DNC), transition to comfort measures only (CMO), and hospital discharge to home using univariable and multivariable analysis (adjusted for age, sex, race/ethnicity, insurance carrier, pre-admission cardiac disorder, ABI type, admission Glasgow Coma Scale Score, mechanical ventilation, and intracranial pressure [ICP] monitoring). Results: The final sample comprised 11,822 patients: AIS (46.7%), sICH (18.5%), SAH (14.8%), and TBI (20.0%). A total of 63% (n = 7472) received cardiac workup, which increased over nine years (p < 0.001). A cardiac investigation was associated with increased age, male sex (aOR 1.16 [1.07, 1.27]), non-white ethnicity (aOR), non-commercial insurance (aOR 1.21 [1.09, 1.33]), pre-admission cardiac disorder (aOR 1.21 [1.09, 1.34]), mechanical ventilation (aOR1.78 [1.57, 2.02]) and ICP monitoring (aOR1.68 [1.49, 1.89]). Compared to AIS, sICH (aOR 0.25 [0.22, 0.29]), SAH (aOR 0.36 [0.30, 0.43]), and TBI (aOR 0.19 [0.17, 0.24]) patients were less likely to receive cardiac investigation. Patients with troponin 25th-50th quartile (aOR 1.65 [1.10-2.47]), troponin 50th-75th quartile (aOR 1.79 [1.22-2.63]), troponin >75th quartile (aOR 2.18 [1.49-3.17]), BNP 50th-75th quartile (aOR 2.86 [1.28-6.40]), BNP >75th quartile (aOR 4.54 [2.09-9.85]), prolonged QTc (aOR 3.41 [2.28; 5.30]), and EF < 40% (aOR 2.47 [1.07; 5.14]) were more likely to be DNC. Patients with troponin 50th-75th quartile (aOR 1.77 [1.14-2.73]), troponin >75th quartile (aOR 1.81 [1.18-2.78]), and prolonged QTc (aOR 1.71 [1.39; 2.12]) were more likely to be associated with a transition to CMO. Patients with prolonged QTc (aOR 0.66 [0.58; 0.76]) were less likely to be discharged home. Conclusions: This large, single-center study demonstrates low rates of cardiac evaluations in TBI, SAH, and sICH compared to AIS. However, there are strong associations between electrocardiography, biomarkers of cardiac injury and heart failure, and echocardiography findings on clinical outcomes in patients with ABI. Findings need validation in a multicenter cohort.
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Affiliation(s)
- Abhijit V. Lele
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA 98104, USA; (C.T.F.); (A.M.W.); (K.N.); (M.S.V.)
| | - Jeffery Liu
- Department of Biosciences, Wiess School of Natural Sciences, Rice University, Houston, TX 77005, USA;
| | - Thitikan Kunapaisal
- Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Hat-Yai 90110, Thailand;
| | - Nophanan Chaikittisilpa
- Department of Anesthesiology, Siriraj Hospital, Mahidol University, Bangkok 73170, Thailand; (N.C.); (T.K.)
| | - Taniga Kiatchai
- Department of Anesthesiology, Siriraj Hospital, Mahidol University, Bangkok 73170, Thailand; (N.C.); (T.K.)
| | - Michael K. Meno
- Department of Medicine, University of Washington, Seattle, WA 98104, USA; (M.K.M.); (O.R.A.); (J.P.)
| | - Osayd R. Assad
- Department of Medicine, University of Washington, Seattle, WA 98104, USA; (M.K.M.); (O.R.A.); (J.P.)
| | - Julie Pham
- Department of Medicine, University of Washington, Seattle, WA 98104, USA; (M.K.M.); (O.R.A.); (J.P.)
| | - Christine T. Fong
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA 98104, USA; (C.T.F.); (A.M.W.); (K.N.); (M.S.V.)
| | - Andrew M. Walters
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA 98104, USA; (C.T.F.); (A.M.W.); (K.N.); (M.S.V.)
| | - Koichiro Nandate
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA 98104, USA; (C.T.F.); (A.M.W.); (K.N.); (M.S.V.)
| | - Tumul Chowdhury
- Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University of Toronto, Toronto, ON M5S 1A1, Canada;
| | | | - Monica S. Vavilala
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA 98104, USA; (C.T.F.); (A.M.W.); (K.N.); (M.S.V.)
| | - Younghoon Kwon
- Department of Cardiology, Harborview Medical Center, University of Washington, Seattle, WA 98104, USA;
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Vail EA, Chun RH, Tsai SD, Souter MJ, Lele AV. Anesthetic Management of Organ Recovery Procedures: Opportunities to Increase Clinician Engagement and Disseminate Evidence-based Practice. J Neurosurg Anesthesiol 2024; 36:174-176. [PMID: 37000806 DOI: 10.1097/ana.0000000000000915] [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: 12/28/2022] [Accepted: 02/18/2023] [Indexed: 04/01/2023]
Affiliation(s)
| | - Rebekah H Chun
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | | | - Michael J Souter
- Departments of Anesthesiology and Pain Medicine and Neurological Surgery University of Washington, Seattle, WA
| | - Abhijit V Lele
- Departments of Anesthesiology and Pain Medicine and Neurological Surgery University of Washington, Seattle, WA
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Lele AV, Shiferaw AA, Theard MA, Vavilala MS, Tavares C, Han R, Assefa D, Dagne Alemu M, Mahajan C, Tandon MS, Karmarkar NV, Singhal V, Lamsal R, Athiraman U. A Global Review of the Perioperative Care of Patients With Aneurysmal Subarachnoid Hemorrhage Undergoing Microsurgical Repair of Ruptured Intracerebral Aneurysm. J Neurosurg Anesthesiol 2024; 36:164-171. [PMID: 37294597 PMCID: PMC10584987 DOI: 10.1097/ana.0000000000000913] [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: 10/19/2022] [Accepted: 02/20/2023] [Indexed: 06/10/2023]
Abstract
INTRODUCTION To describe the perioperative care of patients with aneurysmal subarachnoid hemorrhage (aSAH) who undergo microsurgical repair of a ruptured intracerebral aneurysm. METHODS An English language survey examined 138 areas of the perioperative care of patients with aSAH. Reported practices were categorized as those reported by <20%, 21% to 40%, 41% to 60%, 61% to 80%, and 81% to 100% of participating hospitals. Data were stratified by Worldbank country income level (high-income or low/middle-income). Variation between country-income groups and between countries was presented as an intracluster correlation coefficient (ICC) and 95% confidence interval (CI). RESULTS Forty-eight hospitals representing 14 countries participated in the survey (response rate 64%); 33 (69%) hospitals admitted ≥60 aSAH patients per year. Clinical practices reported by 81 to 100% of the hospitals included placement of an arterial catheter, preinduction blood type/cross match, use of neuromuscular blockade during induction of general anesthesia, delivering 6 to 8 mL/kg tidal volume, and checking hemoglobin and electrolyte panels. Reported use of intraoperative neurophysiological monitoring was 25% (41% in high-income and 10% in low/middle-income countries), with variation between Worldbank country-income group (ICC 0.15, 95% CI 0.02-2.76) and between countries (ICC 0.44, 95% CI 0.00-0.68). The use of induced hypothermia for neuroprotection was low (2%). Before aneurysm securement, variable in blood pressure targets was reported; systolic blood pressure 90 to 120 mm Hg (30%), 90 to 140 mm Hg (21%), and 90 to 160 mmHg (5%). Induced hypertension during temporary clipping was reported by 37% of hospitals (37% each in high and low/middle-income countries). CONCLUSIONS This global survey identifies differences in reported practices during the perioperative management of patients with aSAH.
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Affiliation(s)
- Abhijit V Lele
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | | | - Marie Angele Theard
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | - Monica S Vavilala
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | | | - Ruquan Han
- Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | | | - Mihret Dagne Alemu
- Department of Anesthesiology, University of Addis Ababa, Addis Ababa, Ethiopia
| | - Charu Mahajan
- All-India Institute of Medical Sciences, New Delhi, India
| | - Monica S Tandon
- G.B. Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | | | | | - Ritesh Lamsal
- Tribhuvan University Teaching Hospital, Institute of Medicine, Kathmandu, Nepal
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Pugazenthi S, Norris AJ, Lauzier DC, Lele AV, Huguenard A, Dhar R, Zipfel GJ, Athiraman U. Conditioning-based therapeutics for aneurysmal subarachnoid hemorrhage - A critical review. J Cereb Blood Flow Metab 2024; 44:317-332. [PMID: 38017387 PMCID: PMC10870969 DOI: 10.1177/0271678x231218908] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 11/08/2023] [Accepted: 11/19/2023] [Indexed: 11/30/2023]
Abstract
Aneurysmal subarachnoid hemorrhage (SAH) carries significant mortality and morbidity, with nearly half of SAH survivors having major cognitive dysfunction that impairs their functional status, emotional health, and quality of life. Apart from the initial hemorrhage severity, secondary brain injury due to early brain injury and delayed cerebral ischemia plays a leading role in patient outcome after SAH. While many strategies to combat secondary brain injury have been developed in preclinical studies and tested in late phase clinical trials, only one (nimodipine) has proven efficacious for improving long-term functional outcome. The causes of these failures are likely multitude, but include use of therapies targeting only one element of what has proven to be multifactorial brain injury process. Conditioning is a therapeutic strategy that leverages endogenous protective mechanisms to exert powerful and remarkably pleiotropic protective effects against injury to all major cell types of the CNS. The aim of this article is to review the current body of evidence for the use of conditioning agents in SAH, summarize the underlying neuroprotective mechanisms, and identify gaps in the current literature to guide future investigation with the long-term goal of identifying a conditioning-based therapeutic that significantly improves functional and cognitive outcomes for SAH patients.
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Affiliation(s)
- Sangami Pugazenthi
- Department of Neurological Surgery, Washington University, St. Louis MO, USA
| | - Aaron J Norris
- Department of Anesthesiology, Washington University, St. Louis MO, USA
| | - David C Lauzier
- Department of Neurological Surgery, University of California, Los Angeles, CA, USA
| | - Abhijit V Lele
- Department of Anesthesiology, University of Washington, Seattle, WA, USA
| | - Anna Huguenard
- Department of Neurological Surgery, Washington University, St. Louis MO, USA
| | - Rajat Dhar
- Department of Neurology, Washington University, St. Louis, MO, USA
| | - Gregory J Zipfel
- Departments of Neurological Surgery and Neurology, Washington University, St. Louis, MO, USA
| | - Umeshkumar Athiraman
- Department of Anesthesiology and Neurological Surgery, Washington University, St. Louis, MO, USA
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Raquer AP, Fong CT, Walters AM, Souter MJ, Lele AV. Delirium and Its Associations with Critical Care Utilizations and Outcomes at the Time of Hospital Discharge in Patients with Acute Brain Injury. Medicina (Kaunas) 2024; 60:304. [PMID: 38399591 PMCID: PMC10890045 DOI: 10.3390/medicina60020304] [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] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 01/30/2024] [Accepted: 02/08/2024] [Indexed: 02/25/2024]
Abstract
Background and Objectives: We analyzed delirium testing, delirium prevalence, critical care associations outcomes at the time of hospital discharge in patients with acute brain injury (ABI) due to acute ischemic stroke (AIS), non-traumatic subarachnoid hemorrhage (SAH), non-traumatic intraparenchymal hemorrhage (IPH), and traumatic brain injury (TBI) admitted to an intensive care unit. Materials and Methods: We examined the frequency of assessment for delirium using the Confusion Assessment Method for the intensive care unit. We assessed delirium testing frequency, associated factors, positive test outcomes, and their correlations with clinical care, including nonpharmacological interventions and pain, agitation, and distress management. Results: Amongst 11,322 patients with ABI, delirium was tested in 8220 (726%). Compared to patients 18-44 years of age, patients 65-79 years (aOR 0.79 [0.69, 0.90]), and those 80 years and older (aOR 0.58 [0.50, 0.68]) were less likely to undergo delirium testing. Compared to English-speaking patients, non-English-speaking patients (aOR 0.73 [0.64, 0.84]) were less likely to undergo delirium testing. Amongst 8220, 2217 (27.2%) tested positive for delirium. For every day in the ICU, the odds of testing positive for delirium increased by 1.11 [0.10, 0.12]. Delirium was highest in those 80 years and older (aOR 3.18 [2.59, 3.90]). Delirium was associated with critical care resource utilization and with significant odds of mortality (aOR 7.26 [6.07, 8.70] at the time of hospital discharge. Conclusions: In conclusion, we find that seven out of ten patients in the neurocritical care unit are tested for delirium, and approximately two out of every five patients test positive for delirium. We demonstrate disparities in delirium testing by age and preferred language, identified high-risk subgroups, and the association between delirium, critical care resource use, complications, discharge GCS, and disposition. Prioritizing equitable testing and diagnosis, especially for elderly and non-English-speaking patients, is crucial for delivering quality care to this vulnerable group.
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Affiliation(s)
- Alex P. Raquer
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA 99202, USA;
| | - Christine T. Fong
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA 98104, USA; (C.T.F.); (A.M.W.); (M.J.S.)
| | - Andrew M. Walters
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA 98104, USA; (C.T.F.); (A.M.W.); (M.J.S.)
| | - Michael J. Souter
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA 98104, USA; (C.T.F.); (A.M.W.); (M.J.S.)
- Neurocritical Care Service, Harborview Medical Center, Seattle, WA 98104, USA
| | - Abhijit V. Lele
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA 98104, USA; (C.T.F.); (A.M.W.); (M.J.S.)
- Neurocritical Care Service, Harborview Medical Center, Seattle, WA 98104, USA
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Kunapaisal T, Lele AV, Gomez C, Moore A, Theard MA, Vavilala MS. Effect of Increasing Blood Pressure on Brain Tissue Oxygenation in Adults After Severe Traumatic Brain Injury. Crit Care Med 2024:00003246-990000000-00284. [PMID: 38299970 DOI: 10.1097/ccm.0000000000006211] [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: 02/02/2024]
Abstract
OBJECTIVES To examine if increasing blood pressure improves brain tissue oxygenation (PbtO2) in adults with severe traumatic brain injury (TBI). DESIGN Retrospective review of prospectively collected data. SETTING Level-I trauma center teaching hospital. PATIENTS Included patients greater than or equal to 18 years of age and with severe (admission Glasgow Coma Scale [GCS] score < 9) TBI who had advanced neuromonitoring (intracranial blood pressure [ICP], PbtO2, and cerebral autoregulation testing). INTERVENTIONS The exposure was mean arterial pressure (MAP) augmentation with a vasopressor, and the primary outcome was a PbtO2 response. Cerebral hypoxia was defined as PbtO2 less than 20 mm Hg (low). MAIN RESULTS MAP challenge test results conducted between ICU admission days 1-3 from 93 patients (median age 31; interquartile range [IQR], 24-44 yr), 69.9% male, White (n = 69, 74.2%), median head abbreviated injury score 5 (IQR 4-5), and median admission GCS 3 (IQR 3-5) were examined. Across all 93 tests, a MAP increase of 25.7% resulted in a 34.2% cerebral perfusion pressure (CPP) increase and 16.3% PbtO2 increase (no MAP or CPP correlation with PbtO2 [both R2 = 0.00]). MAP augmentation increased ICP when cerebral autoregulation was impaired (8.9% vs. 3.8%, p = 0.06). MAP augmentation resulted in four PbtO2 responses (normal and maintained [group 1: 58.5%], normal and deteriorated [group 2: 2.2%; average 45.2% PbtO2 decrease], low and improved [group 3: 12.8%; average 44% PbtO2 increase], and low and not improved [group 4: 25.8%]). The average end-tidal carbon dioxide (ETCO2) increase of 5.9% was associated with group 2 when cerebral autoregulation was impaired (p = 0.02). CONCLUSIONS MAP augmentation after severe TBI resulted in four distinct PbtO2 response patterns, including PbtO2 improvement and cerebral hypoxia. Traditionally considered clinical factors were not significant, but cerebral autoregulation status and ICP responses may have moderated MAP and ETCO2 effects on PbtO2 response. Further study is needed to examine the role of MAP augmentation as a strategy to improve PbtO2 in some patients.
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Affiliation(s)
- Thitikan Kunapaisal
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA
| | - Abhijit V Lele
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA
| | - Courtney Gomez
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA
| | - Anne Moore
- Cerebrovascular Laboratory, Harborview Medical Center, Seattle, WA
| | - Marie Angele Theard
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA
| | - Monica S Vavilala
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA
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Abate Shiferaw A, Negash AY, Tirsit A, Kunapaisal T, Gomez C, Theard MA, Vavilala MS, Lele AV. Perioperative Care and Outcomes of Patients with Brain Tumors Undergoing Elective Craniotomy: Experience from an Ethiopian Tertiary-Care Hospital. World Neurosurg 2024; 181:e434-e446. [PMID: 37865195 DOI: 10.1016/j.wneu.2023.10.077] [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: 05/26/2023] [Revised: 10/13/2023] [Accepted: 10/14/2023] [Indexed: 10/23/2023]
Abstract
OBJECTIVE To describe patients, perioperative care, and outcomes undergoing supratentorial and infratentorial craniotomy for brain tumor resection in a tertiary-care hospital in Ethiopia. METHODS A retrospective cohort study of patients consecutively admitted between January 1, 2021, and December 31, 2021, was performed. We characterized patients, perioperative care, and outcomes. RESULTS The final sample comprised 153 patients; 144 (94%) were 18 years and over, females (n = 48, 55%) with primarily American Society of Anesthesiologists physical class II (n = 97, 63.4%) who underwent supratentorial (n = 114, 75%), or infratentorial (n = 39, 25%) tumor resection. Patients were routinely admitted (95%) to floor/wards before craniotomy; Inhaled anesthetic (isoflurane 88%/halothane 12%) was used for maintenance of general anesthesia. Propofol (n = 93, 61%), mannitol (n = 73, 48%), and cerebrospinal fluid drain (n = 28, 18%), were used to facilitate intraoperative brain relaxation, while the use of hyperventilation was rare (n = 1). The average estimated blood loss was 1040 ± 727 ml; 37 (24%) patients received tranexamic acid, and 57 (37%) received a blood transfusion. Factors associated with extubation were a) infratentorial tumor location: relative risk (RR) 0.45 (95% confidence interval [CI] 0.29-0.69), preoperative hydrocephalus: RR 0.51, (95% CI 0.34-0.79), shorter total anesthesia duration: 277.8 + 8.8 versus 426.77 + 13.1 minutes, P < 0.0001, lower estimated blood loss: 897 + 68 ml versus 1361.7 + 100 ml, P = 0.0002, and cerebrospinal fluid drainage to facilitate brain relaxation: RR 0.52, 95% CI 0.32-0.84). Approximately one in ten patients experienced postoperative obstructive hydrocephalus, surgical site infections, or pneumonia. CONCLUSIONS These findings suggest that certain factors may impact patient outcomes following craniotomy for tumor resection. By identifying these factors, health care providers may be better equipped to develop individualized treatment plans and improve patient outcomes. Additionally, the study highlights the importance of postoperative monitoring and management to prevent complications.
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Affiliation(s)
- Ananya Abate Shiferaw
- Department of Anesthesiology, Addis Ababa University School of Medicine, Addis Ababa, Ethiopia
| | - Amanuel Y Negash
- Department of Anesthesiology, Addis Ababa University School of Medicine, Addis Ababa, Ethiopia
| | - Abenezer Tirsit
- Department of Neurosurgery, Addis Ababa University School of Medicine, Addis Ababa, Ethiopia
| | - Thitikan Kunapaisal
- Harborview Injury Prevention and Research Center, Harborview Medical Center, Seattle, Washington, USA
| | - Courtney Gomez
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Marie A Theard
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA; Harborview Injury Prevention and Research Center, Harborview Medical Center, Seattle, Washington, USA
| | - Monica S Vavilala
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA; Harborview Injury Prevention and Research Center, Harborview Medical Center, Seattle, Washington, USA
| | - Abhijit V Lele
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA; Harborview Injury Prevention and Research Center, Harborview Medical Center, Seattle, Washington, USA.
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Lele AV, Bhananker AS, Fong CT, Imholt C, Walters A, Robinson EF, Souter MJ. Clinical Experience With a Dedicated Neurocritical Care Quality Improvement Program in an Academic Medical Center. Cureus 2024; 16:e52730. [PMID: 38384632 PMCID: PMC10880743 DOI: 10.7759/cureus.52730] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2024] [Indexed: 02/23/2024] Open
Abstract
Background Managing neurocritical care patients encompasses many complex challenges, necessitating specialized care and continuous quality improvement efforts. In recent years, the focus on enhancing patient outcomes in neurocritical care may have led to the development of dedicated quality improvement programs. These programs are designed to systematically evaluate and refine care practices, aligning them with the latest clinical guidelines and research findings. Objective To describe the structure, processes, and outcomes of a dedicated Neurocritical Care Quality Improvement Program (NCC-QIP) at Harborview Medical Center, United States; a quaternary academic medical center, level I trauma, and a comprehensive stroke center. Materials and methods We describe the development of the NCC-QIP, its structure, function, challenges, and evolution. We examine our performance with several NCC-QI quality measures as proposed by the Joint Commission, the American Association of Neurology, and the Neurocritical Care Society, self-reported quality improvement (QI) concerns and QI initiatives undertaken because of the information obtained during our event/measure reporting process for patients admitted between 1/1/2014 and 06/30/2023. Results The NCC-QI reviewed data from 20,218 patients; mean age 57.9 (standard deviation 18.1) years, 56% (n=11,326) males, with acute ischemic stroke (AIS; 22.3%, n=4506), spontaneous intracerebral hemorrhage (ICH; 14.8%, n=2,996), spontaneous subarachnoid hemorrhage (SAH; 8.9%, n=1804), and traumatic brain injury (TBI; 16.6%, n=3352) among other admissions, 37.4% (n=7,559) were mechanically ventilated, and 13.6% (n=2,753) received an intracranial pressure monitor. The median intensive care unit length of stay was two days (Quartile 1-Quartile 3: 2-5 days), and the median hospital length of stay was seven days (Quartile 1-Quartile 3: 3-14 days); 53.9% (n=10,907) were discharged home while 11.4% (2,309) died. The three most commonly reported QI concerns were related to care coordination/communication/handoff (40.4%, n=283), medication-related concerns (14.9%, n=104), and equipment/devices-related concerns (11.7%, n=82). Hospital-acquired infections were in the form of ventilator-associated pneumonia (16.3%, n=419/2562), ventriculostomy catheter-associated infections (4%, n=102/2246), and deep venous thrombosis/pulmonary embolism (3.2%, n=647). The quality metrics documentation was as follows: nimodipine after SAH (99.8%, 1802/1810), Hunt and Hess score (36%, n=650/1804), and ICH score (58.4% n=1752/2996). In comparison, 72% (n=3244/4506) of patients with AIS had a documented National Institute of Health Stroke Scale. Admission Glasgow Coma Score was recorded in 99% of patients with SAH, ICH, and TBI. Educational modules were implemented in response to event reporting. Conclusion A dedicated NCC-QIP can be successfully implemented at a quaternary medical medical center. It is possible to monitor and review a large volume of neurocritical care patients, The three most reported NCC-QI concerns may be related to care coordination-communication/handoff, medication-related concerns, and equipment/devices-related complications. The documentation of illness severity scores and stroke measures depends upon the type of measure and ability to reliably and accurately abstract and can be challenging. The quality improvement process can be enhanced by educational modules that reinforce quality and safety.
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Affiliation(s)
- Abhijit V Lele
- Neurocritical Care/Anesthesiology, Harborview Medical Center, Seattle, USA
| | | | - Christine T Fong
- Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, USA
| | - Christine Imholt
- Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, USA
| | - Andrew Walters
- Anesthesiology and Pain Medicine, Harborview Medical Center, Seattle, USA
| | | | - Michael J Souter
- Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, USA
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10
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Blacker SN, Lele AV. Response. J Neurosurg Anesthesiol 2024; 36:91-92. [PMID: 36069826 DOI: 10.1097/ana.0000000000000869] [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] [Indexed: 11/25/2022]
Affiliation(s)
- Samuel N Blacker
- Department of Anesthesiology University of North Carolina at Chapel Hill, NC
| | - Abhijit V Lele
- Department of Anesthesiology and Pain Medicine, University of Washington Seattle, WA
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11
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Blacker SN, Kang M, Chakraborty I, Chowdhury T, Williams J, Lewis C, Zimmer M, Wilson B, Lele AV. Utilizing Artificial Intelligence and Chat Generative Pretrained Transformer to Answer Questions About Clinical Scenarios in Neuroanesthesiology. J Neurosurg Anesthesiol 2023:00008506-990000000-00090. [PMID: 38124357 DOI: 10.1097/ana.0000000000000949] [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] [Received: 08/14/2023] [Accepted: 11/20/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE We tested the ability of chat generative pretrained transformer (ChatGPT), an artificial intelligence chatbot, to answer questions relevant to scenarios covered in 3 clinical guidelines, published by the Society for Neuroscience in Anesthesiology and Critical Care (SNACC), which has published management guidelines: endovascular treatment of stroke, perioperative stroke (Stroke), and care of patients undergoing complex spine surgery (Spine). METHODS Four neuroanesthesiologists independently assessed whether ChatGPT could apply 52 high-quality recommendations (HQRs) included in the 3 SNACC guidelines. HQRs were deemed present in the ChatGPT responses if noted by at least 3 of the 4 reviewers. Reviewers also identified incorrect references, potentially harmful recommendations, and whether ChatGPT cited the SNACC guidelines. RESULTS The overall reviewer agreement for the presence of HQRs in the ChatGPT answers ranged from 0% to 100%. Only 4 of 52 (8%) HQRs were deemed present by at least 3 of the 4 reviewers after 5 generic questions, and 23 (44%) HQRs were deemed present after at least 1 additional targeted question. Potentially harmful recommendations were identified for each of the 3 clinical scenarios and ChatGPT failed to cite the SNACC guidelines. CONCLUSIONS The ChatGPT answers were open to human interpretation regarding whether the responses included the HQRs. Though targeted questions resulted in the inclusion of more HQRs than generic questions, fewer than 50% of HQRs were noted even after targeted questions. This suggests that ChatGPT should not currently be considered a reliable source of information for clinical decision-making. Future iterations of ChatGPT may refine algorithms to improve its reliability as a source of clinical information.
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Affiliation(s)
- Samuel N Blacker
- Department of Anesthesiology, University of North Carolina at Chapel Hill
| | - Mia Kang
- Department of Anesthesiology, University of North Carolina at Chapel Hill
| | | | | | - James Williams
- Department of Anesthesiology, University of North Carolina at Chapel Hill
| | - Carol Lewis
- Department of Anesthesiology, University of North Carolina at Chapel Hill
| | - Michael Zimmer
- Department of Anesthesiology, University of North Carolina at Chapel Hill
| | - Brad Wilson
- Department of Anesthesiology, University of North Carolina at Chapel Hill
| | - Abhijit V Lele
- Department of Anesthesiology, University of Washington, Seattle, WA
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12
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Dhar R, Marklin GF, Klinkenberg WD, Wang J, Goss CW, Lele AV, Kensinger CD, Lange PA, Lebovitz DJ. Intravenous Levothyroxine for Unstable Brain-Dead Heart Donors. N Engl J Med 2023; 389:2029-2038. [PMID: 38048188 PMCID: PMC10752368 DOI: 10.1056/nejmoa2305969] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [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] [Indexed: 12/06/2023]
Abstract
BACKGROUND Hemodynamic instability and myocardial dysfunction are major factors preventing the transplantation of hearts from organ donors after brain death. Intravenous levothyroxine is widely used in donor care, on the basis of observational data suggesting that more organs may be transplanted from donors who receive hormonal supplementation. METHODS In this trial involving 15 organ-procurement organizations in the United States, we randomly assigned hemodynamically unstable potential heart donors within 24 hours after declaration of death according to neurologic criteria to open-label infusion of intravenous levothyroxine (30 μg per hour for a minimum of 12 hours) or saline placebo. The primary outcome was transplantation of the donor heart; graft survival at 30 days after transplantation was a prespecified recipient safety outcome. Secondary outcomes included weaning from vasopressor therapy, donor ejection fraction, and number of organs transplanted per donor. RESULTS Of the 852 brain-dead donors who underwent randomization, 838 were included in the primary analysis: 419 in the levothyroxine group and 419 in the saline group. Hearts were transplanted from 230 donors (54.9%) in the levothyroxine group and 223 (53.2%) in the saline group (adjusted risk ratio, 1.01; 95% confidence interval [CI], 0.97 to 1.07; P = 0.57). Graft survival at 30 days occurred in 224 hearts (97.4%) transplanted from donors assigned to receive levothyroxine and 213 hearts (95.5%) transplanted from donors assigned to receive saline (difference, 1.9 percentage points; 95% CI, -2.3 to 6.0; P<0.001 for noninferiority at a margin of 6 percentage points). There were no substantial between-group differences in weaning from vasopressor therapy, ejection fraction on echocardiography, or organs transplanted per donor, but more cases of severe hypertension and tachycardia occurred in the levothyroxine group than in the saline group. CONCLUSIONS In hemodynamically unstable brain-dead potential heart donors, intravenous levothyroxine infusion did not result in significantly more hearts being transplanted than saline infusion. (Funded by Mid-America Transplant and others; ClinicalTrials.gov number, NCT04415658.).
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Affiliation(s)
- Rajat Dhar
- From the Department of Neurology, Section of Neurocritical Care (R.D.), and the Center for Biostatistics and Data Science (J.W., C.W.G.), Washington University School of Medicine, and Mid-America Transplant (G.F.M., W.D.K.) - both in St. Louis; the Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, and LifeCenter Northwest, Bellevue - both in Washington (A.V.L.); LifeLink of Georgia, Norcross, and Piedmont Transplant Institute, Atlanta - both in Georgia (C.D.K.); Donor Alliance, Denver (P.A.L.); and Akron Children's Hospital, Akron, OH (D.J.L.)
| | - Gary F Marklin
- From the Department of Neurology, Section of Neurocritical Care (R.D.), and the Center for Biostatistics and Data Science (J.W., C.W.G.), Washington University School of Medicine, and Mid-America Transplant (G.F.M., W.D.K.) - both in St. Louis; the Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, and LifeCenter Northwest, Bellevue - both in Washington (A.V.L.); LifeLink of Georgia, Norcross, and Piedmont Transplant Institute, Atlanta - both in Georgia (C.D.K.); Donor Alliance, Denver (P.A.L.); and Akron Children's Hospital, Akron, OH (D.J.L.)
| | - W Dean Klinkenberg
- From the Department of Neurology, Section of Neurocritical Care (R.D.), and the Center for Biostatistics and Data Science (J.W., C.W.G.), Washington University School of Medicine, and Mid-America Transplant (G.F.M., W.D.K.) - both in St. Louis; the Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, and LifeCenter Northwest, Bellevue - both in Washington (A.V.L.); LifeLink of Georgia, Norcross, and Piedmont Transplant Institute, Atlanta - both in Georgia (C.D.K.); Donor Alliance, Denver (P.A.L.); and Akron Children's Hospital, Akron, OH (D.J.L.)
| | - Jinli Wang
- From the Department of Neurology, Section of Neurocritical Care (R.D.), and the Center for Biostatistics and Data Science (J.W., C.W.G.), Washington University School of Medicine, and Mid-America Transplant (G.F.M., W.D.K.) - both in St. Louis; the Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, and LifeCenter Northwest, Bellevue - both in Washington (A.V.L.); LifeLink of Georgia, Norcross, and Piedmont Transplant Institute, Atlanta - both in Georgia (C.D.K.); Donor Alliance, Denver (P.A.L.); and Akron Children's Hospital, Akron, OH (D.J.L.)
| | - Charles W Goss
- From the Department of Neurology, Section of Neurocritical Care (R.D.), and the Center for Biostatistics and Data Science (J.W., C.W.G.), Washington University School of Medicine, and Mid-America Transplant (G.F.M., W.D.K.) - both in St. Louis; the Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, and LifeCenter Northwest, Bellevue - both in Washington (A.V.L.); LifeLink of Georgia, Norcross, and Piedmont Transplant Institute, Atlanta - both in Georgia (C.D.K.); Donor Alliance, Denver (P.A.L.); and Akron Children's Hospital, Akron, OH (D.J.L.)
| | - Abhijit V Lele
- From the Department of Neurology, Section of Neurocritical Care (R.D.), and the Center for Biostatistics and Data Science (J.W., C.W.G.), Washington University School of Medicine, and Mid-America Transplant (G.F.M., W.D.K.) - both in St. Louis; the Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, and LifeCenter Northwest, Bellevue - both in Washington (A.V.L.); LifeLink of Georgia, Norcross, and Piedmont Transplant Institute, Atlanta - both in Georgia (C.D.K.); Donor Alliance, Denver (P.A.L.); and Akron Children's Hospital, Akron, OH (D.J.L.)
| | - Clark D Kensinger
- From the Department of Neurology, Section of Neurocritical Care (R.D.), and the Center for Biostatistics and Data Science (J.W., C.W.G.), Washington University School of Medicine, and Mid-America Transplant (G.F.M., W.D.K.) - both in St. Louis; the Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, and LifeCenter Northwest, Bellevue - both in Washington (A.V.L.); LifeLink of Georgia, Norcross, and Piedmont Transplant Institute, Atlanta - both in Georgia (C.D.K.); Donor Alliance, Denver (P.A.L.); and Akron Children's Hospital, Akron, OH (D.J.L.)
| | - Paul A Lange
- From the Department of Neurology, Section of Neurocritical Care (R.D.), and the Center for Biostatistics and Data Science (J.W., C.W.G.), Washington University School of Medicine, and Mid-America Transplant (G.F.M., W.D.K.) - both in St. Louis; the Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, and LifeCenter Northwest, Bellevue - both in Washington (A.V.L.); LifeLink of Georgia, Norcross, and Piedmont Transplant Institute, Atlanta - both in Georgia (C.D.K.); Donor Alliance, Denver (P.A.L.); and Akron Children's Hospital, Akron, OH (D.J.L.)
| | - Daniel J Lebovitz
- From the Department of Neurology, Section of Neurocritical Care (R.D.), and the Center for Biostatistics and Data Science (J.W., C.W.G.), Washington University School of Medicine, and Mid-America Transplant (G.F.M., W.D.K.) - both in St. Louis; the Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, and LifeCenter Northwest, Bellevue - both in Washington (A.V.L.); LifeLink of Georgia, Norcross, and Piedmont Transplant Institute, Atlanta - both in Georgia (C.D.K.); Donor Alliance, Denver (P.A.L.); and Akron Children's Hospital, Akron, OH (D.J.L.)
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13
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Lele AV, Vavilala MS. Cerebral Autoregulation-guided Management of Adult and Pediatric Traumatic Brain Injury. J Neurosurg Anesthesiol 2023; 35:354-360. [PMID: 37523326 DOI: 10.1097/ana.0000000000000933] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Received: 06/14/2023] [Accepted: 07/05/2023] [Indexed: 08/02/2023]
Abstract
Cerebral autoregulation (CA) plays a vital role in maintaining cerebral blood flow in response to changes in systemic blood pressure. Impairment of CA following traumatic brain injury (TBI) may exacerbate the injury, potentially impacting patient outcomes. This focused review addresses 4 key questions regarding the measurement, natural history of CA after TBI, and potential clinical implications of CA status and CA-guided management in adults and children with TBI. We examine the feasibility and safety of CA assessment, its association with clinical outcomes, and the potential for reversing deranged CA following TBI. Finally, we discuss how the knowledge of CA status may affect TBI management and outcomes.
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Affiliation(s)
- Abhijit V Lele
- Department of Anesthesiology and Pain Medicine
- Harborview Injury Prevention and Research Center
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, WA
| | - Monica S Vavilala
- Department of Anesthesiology and Pain Medicine
- Harborview Injury Prevention and Research Center
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, WA
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14
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Athiraman U, Norris AJ, Jayaraman K, Lele AV, Kentner R, Singh PM, Higo OM, Zipfel GJ, Dhar R. Intraoperative Blood Pressure and Carbon Dioxide Values during Aneurysmal Repair and the Outcomes after Aneurysmal Subarachnoid Hemorrhage. J Clin Med 2023; 12:5488. [PMID: 37685555 PMCID: PMC10488211 DOI: 10.3390/jcm12175488] [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] [Received: 07/11/2023] [Revised: 08/21/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023] Open
Abstract
Cerebral autoregulation impairment is a critical aspect of subarachnoid hemorrhage (SAH)-induced secondary brain injury and is also shown to be an independent predictor of delayed cerebral ischemia (DCI) and poor neurologic outcomes. Interestingly, intraoperative hemodynamic and ventilatory parameters were shown to influence patient outcomes after SAH. The aim of the current study was to evaluate the association of intraoperative hypotension and hypocapnia with the occurrence of angiographic vasospasm, DCI, and neurologic outcomes at discharge. Intraoperative data were collected for 390 patients with aneurysmal SAH who underwent general anesthesia for aneurysm clipping or coiling between January 2010 and May 2018. We measured the mean intraoperative blood pressure and end-tidal carbon dioxide (ETCO2), as well as the area under the curve (AUC) for the burden of hypotension: SBP below 100 or MBP below 65 and hypocapnia (ETCO2 < 30), during the intraoperative period. The outcome measures were angiographic vasospasm, DCI, and the neurologic outcomes at discharge as measured by the modified Rankin scale score (an mRS of 0-2 is a good outcome, and 3-6 is a poor outcome). Univariate and logistic regression analyses were performed to evaluate whether blood pressure (BP) and ETCO2 variables were independently associated with outcome measures. Out of 390 patients, 132 (34%) developed moderate-to-severe vasospasm, 114 (29%) developed DCI, and 46% (169) had good neurologic outcomes at discharge. None of the measured intraoperative BP and ETCO2 variables were associated with angiographic vasospasm, DCI, or poor neurologic outcomes. Our study did not identify an independent association between the degree of intraoperative hypotension or hypocapnia in relation to angiographic vasospasm, DCI, or the neurologic outcomes at discharge in SAH patients.
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Affiliation(s)
| | - Aaron J. Norris
- Department of Anesthesiology, Washington University, St. Louis, MO 63110, USA
| | - Keshav Jayaraman
- Department of Anesthesiology, Washington University, St. Louis, MO 63110, USA
| | - Abhijit V. Lele
- Department of Anesthesiology, University of Washington, Seattle, WA 98122, USA
| | - Rainer Kentner
- Department of Anesthesiology, Washington University, St. Louis, MO 63110, USA
| | | | - Omokhaye M. Higo
- Department of Anesthesiology, Washington University, St. Louis, MO 63110, USA
| | - Gregory J. Zipfel
- Departments of Neurological Surgery and Neurology, Washington University, St. Louis, MO 63110, USA
| | - Rajat Dhar
- Department of Neurology, Washington University, St. Louis, MO 63110, USA
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15
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Kunapaisal T, Phuong J, Liu Z, Stansbury LG, Vavilala MS, Lele AV, Tsang HC, Hess JR. Age, admission platelet count, and mortality in severe isolated traumatic brain injury: A retrospective cohort study. Transfusion 2023; 63:1472-1480. [PMID: 37515367 DOI: 10.1111/trf.17476] [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: 06/02/2023] [Accepted: 06/12/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND We asked whether patients >50 years of age with acute traumatic brain injury (TBI) present with lower platelet counts and whether lower platelet counts are independently associated with mortality. METHODS We combined trauma registry and laboratory data on a retrospective cohort of all patients ≥18 years of age admitted to our Level 1 US regional trauma center 2015-2021 with severe (Head Abbreviated Injury Score [AIS] ≥3), isolated (all other AIS <3) TBI who had a first platelet count within 1 h of arrival. Age and platelet count were assessed continuously and as groups (age 18-50 vs. >50, platelet normals, and at conventional transfusion thresholds). Outcomes such as mean admission platelet counts and in-hospital mortality were assessed categorically and with logistic regression. RESULTS Of 44,056 patients, 1298 (3%, median age: 52 [IQR 33,68], 76.1% male) met all inclusion criteria with no differences between younger and older age groups for (ISS; 18 [14,26] vs. 17 [14,26], p = .22), New ISS (NISS; 29 [19,50] vs. 28 [17,50], p = .36), or AIS-Head (4 [3,5] vs. 4 [3,5]; p = .87). Patients aged >50 had lower admission platelet counts (219,000 ± 93,000 vs. 242,000 ± 76,000/μL; p < .001) and greater in-hospital mortality (24.5% vs. 15.6%, p < .001) than those 18-50. In multivariable regression, firearms injuries (OR9.08), increasing age (OR1.004), NISS (OR1.007), and AIS-Head (OR1.05), and decreasing admission platelet counts (OR0.998) were independently associated with mortality (p < .001-.041). Platelet transfusion in the first 4 h of care was more frequent among older patients (p < .001). CONCLUSIONS Older patients with TBI had lower admission platelet counts, which were independently associated with greater mortality.
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Affiliation(s)
- Thitikan Kunapaisal
- Department of Anesthesiology and Pain Medicine, University of Washington (UW) School of Medicine (SOM), Seattle, Washington, USA
- Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
- Harborview Injury Prevention and Research Center, Harborview Medical Center, Seattle, Washington, USA
| | - Jim Phuong
- Harborview Injury Prevention and Research Center, Harborview Medical Center, Seattle, Washington, USA
| | - Zhinan Liu
- Harborview Injury Prevention and Research Center, Harborview Medical Center, Seattle, Washington, USA
- Transfusion Service, Harborview Medical Center, Seattle, Washington, USA
| | - Lynn G Stansbury
- Department of Anesthesiology and Pain Medicine, University of Washington (UW) School of Medicine (SOM), Seattle, Washington, USA
- Harborview Injury Prevention and Research Center, Harborview Medical Center, Seattle, Washington, USA
| | - Monica S Vavilala
- Department of Anesthesiology and Pain Medicine, University of Washington (UW) School of Medicine (SOM), Seattle, Washington, USA
- Harborview Injury Prevention and Research Center, Harborview Medical Center, Seattle, Washington, USA
- Department of Pediatrics, UW SOM, Seattle, Washington, USA
| | - Abhijit V Lele
- Department of Anesthesiology and Pain Medicine, University of Washington (UW) School of Medicine (SOM), Seattle, Washington, USA
- Harborview Injury Prevention and Research Center, Harborview Medical Center, Seattle, Washington, USA
| | - Hamilton C Tsang
- Harborview Injury Prevention and Research Center, Harborview Medical Center, Seattle, Washington, USA
- Transfusion Service, Harborview Medical Center, Seattle, Washington, USA
- Department of Laboratory Medicine and Pathology, UW SOM, Seattle, Washington, USA
| | - John R Hess
- Harborview Injury Prevention and Research Center, Harborview Medical Center, Seattle, Washington, USA
- Transfusion Service, Harborview Medical Center, Seattle, Washington, USA
- Department of Laboratory Medicine and Pathology, UW SOM, Seattle, Washington, USA
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16
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Kunapaisal T, Vavilala MS, Moore A, Theard MA, Lele AV. Critical Care Experience With Clinical Cerebral Autoregulation Testing in Adults With Traumatic Brain Injury. Cureus 2023; 15:e43451. [PMID: 37711917 PMCID: PMC10499057 DOI: 10.7759/cureus.43451] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND To describe the setting, feasibility, and safety of static cerebral autoregulation testing in critically injured adults with traumatic brain injury (TBI). Methods: We reviewed static autoregulation testing using transcranial Doppler (TCD) ultrasound in patients > 18 years with TBI ICD codes between January 1, 2014, and December 31, 2021. Adverse events during testing were defined as systemic hypertension (systolic blood pressure (SBP>180 mmHg), bradycardia (HR<40 bpm), and high ICP (>30 mmHg). Impaired and absent cerebral autoregulation was defined as an autoregulatory index (ARI) <0.4 and ARI 0, respectively. We characterized prescribed changes in intracranial pressure (ICP) and cerebral perfusion pressure (CPP) targets by autoregulation testing results. Results: A total of 135 patients, median age 31 (interquartile range (IQR) 24, 43) years, 71.9% male, admission Glasgow coma scale (GCS) score 3 (IQR 3, 5.5), and 70.9% with subdural hematoma from severe (GCS 3-8; 133 (98.5%)) and moderate (GCS 9-12; 2 (1.5%)) TBI, underwent 309 attempted testing. All patients were mechanically ventilated and had ICP monitoring; 246 (80%) had brain tissue oxygen monitoring, and 68 (22%) had an external ventricular drain. The median number of autoregulation tests was two (range 1-3) tests/patient, and the median admission to the first test time was two days (IQR 1, 3). Of 55 (17.8%) tests not completed, systemic hypertension (32, 10.4%), intracranial hypertension (10, 3.2%), and bradycardia (3, 0.9%) were transient. Fifty-three (51%) of the first (n=104) autoregulation tests showed impaired/absent cerebral autoregulation. Impaired/absent autoregulation results at the first test were associated with repeat cerebral autoregulation testing (RR 2.25, 95% CI [1.40-3.60], p=0.0007) than intact cerebral autoregulation results. Pre-testing cerebral hemodynamic targets were maintained (n=131; 86.8%) when cerebral autoregulation was impaired (n=151; RR 1.49, 95% CI [1.25-1.77], p<0.0001). However, 15 (9.9%) test results led to higher ICP targets (from 20 mmHg to 25 mmHg), 5 (3.3%) results led to an increase in CPP target (from 60 mmHg to 70 mmHg), and five out of 131 (3.8%) patients underwent decompressive craniectomy and placement of an external ventricular drain. Intact cerebral autoregulation results (n=43/103, 41.7%) were associated with a change in ICP targets from 20 mmHg to 25 mmHg (RR 3.15, 95% CI [1.97-5.03], p<0.0001). Conclusions: Static cerebral autoregulation testing was feasible, safe, and useful in individualizing the care of patients with moderate-severe TBI receiving multimodal neuromonitoring. Testing results guided future testing, cerebral hemodynamic targets, and procedural decisions. Impaired cerebral autoregulation was very common.
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Affiliation(s)
- Thitikan Kunapaisal
- Anesthesiology and Pain Medicine, University of Washington, Seattle, USA
- Anesthesiology, Prince of Songkla University, Songkhla, THA
| | - Monica S Vavilala
- Anesthesiology and Pain Medicine, University of Washington, Seattle, USA
| | - Anne Moore
- Cerebrovascular Laboratory, Harborview Medical Center, Seattle, USA
| | - Marie A Theard
- Anesthesiology and Pain Medicine, University of Washington, Seattle, USA
| | - Abhijit V Lele
- Anesthesia and Critical Care, University of Washington, Seattle, USA
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Yuwapattanawong K, Chanthima P, Thamjamrassri T, Keen J, Qiu Q, Fong C, Robinson EF, Dhulipala VB, Walters AM, Athiraman U, Kim LJ, Vavilala MS, Levitt MR, Lele AV. The Association Between Illness Severity Scores and In-hospital Mortality After Aneurysmal Subarachnoid Hemorrhage. J Neurosurg Anesthesiol 2023; 35:299-306. [PMID: 35297396 DOI: 10.1097/ana.0000000000000840] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Received: 10/27/2021] [Accepted: 02/13/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The purpose of this study was to examine the association with in-hospital mortality of 8 illness severity scores in patients with aneurysmal subarachnoid hemorrhage (aSAH). METHODS In a retrospective cohort study, we investigated the association with in-hospital mortality of admission Hunt and Hess (HH) score, Fisher grade, severity of illness and risk of mortality scores, and serial Glasgow coma scale (GCS) score in patients with aSAH. We also explored the changes in GCS between admission and discharge using a multivariate model adjusting for age, clinical vasospasm, and external ventricular drain status. RESULTS Data from 480 patients with aSAH, of which 383 (79.8%) aneurysms were in the anterior circulation, were included in analysis. Patients were female (n=340, 70.8%) with a median age of 56 (interquartile range: 48 to 66) years. The majority (n=332, 69.2%) had admission HH score 3 to 5, Fisher grade 3 to 4 (n=437, 91%), median severity of illness 3 (range: 1 to 4), median risk of mortality 3 (range: 1 to 4), and median admission GCS of 13 (interquartile range: 7 to 15). Overall, 406 (84.6%) patients received an external ventricular drain, 469 (97.7%) underwent aneurysm repair, and 60 died (12.5%). Compared with admission HH score, GCS 24 hours after admission (area under the curve: 0.84, 95% confidence interval [CI]: 0.79-0.88) and 24 hours after aneurysm repair (area under the curve: 0.87, 95% CI: 0.82-0.90) were more likely to be associated with in-hospital mortality. Among those who died, the greatest decline in GCS was noted between 24 hours after aneurysm repair and discharge (-3.38 points, 95% CI: -4.17, -2.58). CONCLUSIONS Compared with admission HH score, GCS 24 hours after admission (or 24 h after aneurysm repair) is more likely to be associated with in-hospital mortality after aSAH.
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Affiliation(s)
| | | | | | | | - Qian Qiu
- Harborview Injury Prevention and Research Center
| | - Christine Fong
- Anesthesiology and Pain Medicine, Harborview Medical Center
| | | | | | | | | | | | - Monica S Vavilala
- Harborview Injury Prevention and Research Center
- Anesthesiology and Pain Medicine, Harborview Medical Center
| | | | - Abhijit V Lele
- Harborview Injury Prevention and Research Center
- Departments of Neurological Surgery
- Anesthesiology and Pain Medicine, Harborview Medical Center
- Neurocritical Service, Harborview Medical Center, Seattle, WA
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18
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Lele AV, Wahlster S, Khadka S, Walters AM, Fong CT, Blissitt PA, Livesay SL, Jannotta GE, Gulek BG, Srinivasan V, Rosenblatt K, Souter MJ, Vavilala MS. Neurological Pupillary Index and Disposition at Hospital Discharge following ICU Admission for Acute Brain Injury. J Clin Med 2023; 12:jcm12113806. [PMID: 37298001 DOI: 10.3390/jcm12113806] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 05/26/2023] [Accepted: 05/30/2023] [Indexed: 06/12/2023] Open
Abstract
We examined the associations between the Neurological Pupillary Index (NPi) and disposition at hospital discharge in patients admitted to the neurocritical care unit with acute brain injury (ABI) due to acute ischemic stroke (AIS), spontaneous intracerebral hemorrhage (sICH), aneurysmal subarachnoid hemorrhage (SAH), and traumatic brain injury (TBI). The primary outcome was discharge disposition (home/acute rehabilitation vs. death/hospice/skilled nursing facility). Secondary outcomes were tracheostomy tube placement and transition to comfort measures. Among 2258 patients who received serial NPi assessments within the first seven days of ICU admission, 47.7% (n = 1078) demonstrated NPi ≥ 3 on initial and final assessments, 30.1% (n = 680) had initial NPI < 3 that never improved, 19% (n = 430) had initial NPi ≥ 3, which subsequently worsened to <3 and never recovered, and 3.1% (n = 70) had initial NPi < 3, which improved to ≥3. After adjusting for age, sex, admitting diagnosis, admission Glasgow Coma Scale score, craniotomy/craniectomy, and hyperosmolar therapy, NPi values that remained <3 or worsened from ≥3 to <3 were associated with poor outcomes (adjusted odds ratio, aOR 2.58, 95% CI [2.03; 3.28]), placement of a tracheostomy tube (aOR 1.58, 95% CI [1.13; 2.22]), and transition to comfort measures only (aOR 2.12, 95% CI [1.67; 2.70]). Our study suggests that serial NPi assessments during the first seven days of ICU admission may be helpful in predicting outcomes and guiding clinical decision-making in patients with ABI. Further studies are needed to evaluate the potential benefit of interventions to improve NPi trends in this population.
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Affiliation(s)
- Abhijit V Lele
- Neurocritical Care Service, Harborview Medical Center, University of Washington, Seattle, WA 98195, USA
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA 98195, USA
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, WA 98195, USA
- Harborview Injury Prevention and Research Center, Harborview Medical Center, University of Washington, Seattle, WA 98195, USA
| | - Sarah Wahlster
- Neurocritical Care Service, Harborview Medical Center, University of Washington, Seattle, WA 98195, USA
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA 98195, USA
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, WA 98195, USA
- Department of Neurology, Harborview Medical Center, University of Washington, Seattle, WA 98195, USA
| | - Sunita Khadka
- Neurocritical Care Service, Harborview Medical Center, University of Washington, Seattle, WA 98195, USA
| | - Andrew M Walters
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA 98195, USA
| | - Christine T Fong
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA 98195, USA
| | - Patricia A Blissitt
- Department of Nursing, Harborview Medical Center, University of Washington, Seattle, WA 98195, USA
| | - Sarah L Livesay
- Neurocritical Care Service, Harborview Medical Center, University of Washington, Seattle, WA 98195, USA
| | - Gemi E Jannotta
- Neurocritical Care Service, Harborview Medical Center, University of Washington, Seattle, WA 98195, USA
| | - Bernice G Gulek
- Neurocritical Care Service, Harborview Medical Center, University of Washington, Seattle, WA 98195, USA
| | - Vasisht Srinivasan
- Neurocritical Care Service, Harborview Medical Center, University of Washington, Seattle, WA 98195, USA
- Harborview Injury Prevention and Research Center, Harborview Medical Center, University of Washington, Seattle, WA 98195, USA
- Department of Emergency Medicine, Harborview Medical Center, University of Washington, Seattle, WA 98195, USA
| | - Kathryn Rosenblatt
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Michael J Souter
- Neurocritical Care Service, Harborview Medical Center, University of Washington, Seattle, WA 98195, USA
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA 98195, USA
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, WA 98195, USA
| | - Monica S Vavilala
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA 98195, USA
- Harborview Injury Prevention and Research Center, Harborview Medical Center, University of Washington, Seattle, WA 98195, USA
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Blacker SN, Woody N, Abate Shiferaw A, Burbridge M, Bustillo MA, Hazard SW, Heller BJ, Lamperti M, Mejia-Mantilla J, Nadler JW, Rath GP, Robba C, Vincent A, Admasu AK, Awraris M, Lele AV. Differences in Perioperative Management of Patients Undergoing Complex Spine Surgery: A Global Perspective. J Neurosurg Anesthesiol 2023; Publish Ahead of Print:00008506-990000000-00063. [PMID: 37192477 DOI: 10.1097/ana.0000000000000919] [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] [Received: 11/08/2022] [Accepted: 03/29/2023] [Indexed: 05/18/2023]
Abstract
BACKGROUND The aim of this survey was to understand institutional spine surgery practices and their concordance with published best practices/recommendations. METHODS Using a global internet-based survey examining perioperative spine surgery practice, reported institutional spine pathway elements (n=139) were compared with the level of evidence published in guideline recommendations. The concordance of clinical practice with guidelines was categorized as poor (≤20%), fair (21%-40%), moderate (41%-60%), good (61%-80%), or very good (81%-100%). RESULTS Seventy-two of 409 (17.6%) institutional contacts started the survey, of which 31 (7.6%) completed the survey. Six (19.4%) of the completed surveys were from respondents in low/middle-income countries, and 25 (80.6%) were from respondents in high-income countries. Forty-one incomplete surveys were not included in the final analysis, as most were less than 40% complete. Five of 139 (3.6%) reported elements had very good concordance for the entire cohort; hospitals with spine surgery pathways reported 18 elements with very good concordance, whereas institutions without spine surgery pathways reported only 1 element with very good concordance. Reported spine pathways included between 7 and 47 separate pathway elements. There were 87 unique elements in the reviewed pathways. Only 3 of 87 (3.4%) elements with high-quality evidence demonstrated very good practice concordance. CONCLUSIONS This global survey-based study identified practice variation and low adoption rates of high-quality evidence in the care of patients undergoing complex spine surgery.
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Affiliation(s)
- Samuel N Blacker
- Department of Anesthesiology, University of North Carolina, Chapel Hill, NC
| | - Nathan Woody
- Department of Anesthesiology, University of North Carolina, Chapel Hill, NC
| | | | - Mark Burbridge
- Department of Anesthesiology, Perioperative and Pain Management, Stanford University School of Medicine, Stanford, CA
| | - Maria A Bustillo
- Department of Anesthesiology, Weill Cornell Medical College, New York City, NY
| | - Sprague W Hazard
- Department of Anesthesiology and Critical Care Medicine, Penn State Health, PA
| | - Benjamin J Heller
- Department of Anesthesiology and Pain Medicine, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Massimo Lamperti
- Anesthesiology Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | - Jorge Mejia-Mantilla
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY
| | - Jacob W Nadler
- Department of Neuroanaesthesiology and Critical Care, Neurosciences Centre, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | | | - Chiara Robba
- Department of Anesthesiology and Critical Care Medicine, George Washington University Hospital, Washington, DC
| | | | - Azarias K Admasu
- Department of Neurology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Meron Awraris
- Department of Anesthesiology, Fundación Valle Del Lili, Cali, Colombia
| | - Abhijit V Lele
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA
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Kersey CB, Lele AV, Johnson MN, Pattock AM, Liu L, Huang GS, Kirkpatrick JN, Mazimba S, Jobarteh S, Kwon Y. The Quality and Safety of Sedation and Monitoring in Adults Undergoing Nonoperative Transesophageal Echocardiography. Am J Cardiol 2023; 194:40-45. [PMID: 36940560 PMCID: PMC10351909 DOI: 10.1016/j.amjcard.2023.02.008] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 02/03/2023] [Accepted: 02/08/2023] [Indexed: 03/23/2023]
Abstract
Sedation is an essential component of the transesophageal echocardiography (TEE) procedure for patient comfort. The use and the clinical implications of cardiologist-supervised (CARD-Sed) versus anesthesiologist-supervised sedation (ANES-Sed) are unknown. We reviewed nonoperative TEE records from a single academic center over a 5-year period and identified CARD-Sed and ANES-Sed cases. We evaluated the impact of patient co-morbidities, cardiac abnormalities on transthoracic echocardiogram, and the indication for TEE on sedation practice. We analyzed the use of CARD-Sed versus ANES-Sed in light of institutional guidelines; the consistency in the documentation of preprocedural risk stratification; and the incidence of cardiopulmonary events, including hypotension, hypoxia, and hypercarbia. A total of 914 patients underwent TEE, with 475 patients (52%) receiving CARD-Sed and 439 patients (48%) receiving ANES-Sed. The presence of obstructive sleep apnea (p = 0.008), a body mass index of >45 kg/m2 (p <0.001), an ejection fraction of <30% (p <0.001), and pulmonary artery systolic pressure of more than 40 mm Hg (p = 0.015) were all associated with the use of ANES-Sed. Of the 178 patients (19.5%) with at least 1 caution to nonanesthesiologist-supervised sedation by the institutional screening guideline, 65 patients (36.5%) underwent CARD-Sed. In the ANES-Sed group, where intraprocedural vital signs and medications were documented in all cases, hypotension (n = 91, 20.7%), vasoactive medication use (n = 121, 27.6%), hypoxia (n = 35, 8.0%), and hypercarbia (n = 50, 11.4%) were noted. This single-center study revealed that 48% of the nonoperative TEE used ANES-Sed over 5 years. Sedation-related hemodynamic changes and respiratory events were not infrequently encountered during ANES-Sed.
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Affiliation(s)
- Cooper B Kersey
- Division of Cardiology, University of Washington Medical Center, Seattle, Washington State
| | - Abhijit V Lele
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, Washington State
| | - Matthew N Johnson
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, Washington State
| | - Andrew M Pattock
- Division of Cardiology, University of Washington Medical Center, Seattle, Washington State
| | - Linda Liu
- Section of Cardiology, University of Chicago, Chicago, Illinois
| | - Gary S Huang
- Division of Cardiology, Harborview Medical Center, University of Washington, Seattle, Washington State
| | - James N Kirkpatrick
- Division of Cardiology, University of Washington Medical Center, Seattle, Washington State
| | - Sula Mazimba
- Division of Cardiology, University of Virginia, Charlottesville, Virginia
| | - Sulayman Jobarteh
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, Washington State
| | - Younghoon Kwon
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, Washington State.
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21
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Zirpe KG, Alunpipatthanachai B, Matin N, Gulek BG, Blissitt PA, Palmieri K, Rosenblatt K, Athiraman U, Gollapudy S, Theard MA, Wahlster S, Vavilala MS, Lele AV. Benchmarking Hospital Practices and Policies on Intrahospital Neurocritical Care Transport: The Safe-Neuro-Transport Study. J Clin Med 2023; 12:jcm12093183. [PMID: 37176625 PMCID: PMC10179223 DOI: 10.3390/jcm12093183] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 04/07/2023] [Accepted: 04/26/2023] [Indexed: 05/15/2023] Open
Abstract
An electronic survey was administered to multidisciplinary neurocritical care providers at 365 hospitals in 32 countries to describe intrahospital transport (IHT) practices of neurocritically ill patients at their institutions. The reported IHT practices were stratified by World Bank country income level. Variability between high-income (HIC) and low/middle-income (LMIC) groups, as well as variability between hospitals within countries, were expressed as counts/percentages and intracluster correlation coefficients (ICCs) with a 95% confidence interval (CI). A total of 246 hospitals (67% response rate; n = 103, 42% HIC and n = 143, 58% LMIC) participated. LMIC hospitals were less likely to report a portable CT scanner (RR 0.39, 95% CI [0.23; 0.67]), more likely to report a pre-IHT checklist (RR 2.18, 95% CI [1.53; 3.11]), and more likely to report that intensive care unit (ICU) physicians routinely participated in IHTs (RR 1.33, 95% CI [1.02; 1.72]). Between- and across-country variation were highest for pre-IHT external ventricular drain clamp tolerance (reported by 40% of the hospitals, ICC 0.22, 95% CI 0.00-0.46) and end-tidal carbon dioxide monitoring during IHT (reported by 29% of the hospitals, ICC 0.46, 95% CI 0.07-0.71). Brain tissue oxygenation monitoring during IHT was reported by only 9% of the participating hospitals. An IHT standard operating procedure (SOP)/hospital policy (HP) was reported by 37% (n = 90); HIC: 43% (n= 44) vs. LMIC: 32% (n = 46), p = 0.56. Amongst the IHT SOP/HPs reviewed (n = 13), 90% did not address the continuation of hemodynamic and neurophysiological monitoring during IHT. In conclusion, the development of a neurocritical-care-specific IHT SOP/HP as well as the alignment of practices related to the IHT of neurocritically ill patients are urgent unmet needs. Inconsistent standards related to neurophysiological monitoring during IHT warrant in-depth scrutiny across hospitals and suggest a need for international guidelines for neurocritical care IHT.
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Affiliation(s)
- Kapil G Zirpe
- Neurotrauma Unit, Ruby Hall Clinic, Pune 411040, India
| | | | - Nassim Matin
- Neurocritical Care Service, Department of Neurology, Harborview Medical Center, University of Washington, Seattle, WA 98104, USA
| | - Bernice G Gulek
- Neurocritical Care Service, Department of Neurology, Harborview Medical Center, University of Washington, Seattle, WA 98104, USA
| | - Patricia A Blissitt
- Harborview Medical Center, University of Washington School of Nursing, Seattle, WA 98104, USA
| | - Katherine Palmieri
- Department of Anesthesiology, University of Kansas Health System, Kansas City, KS 66160, USA
| | - Kathryn Rosenblatt
- Department of Anesthesiology, Johns Hopkins Medical Institutions, Baltimore, MD 21287, USA
| | | | | | - Marie Angele Theard
- Department of Anesthesiology and Pain Medicine, Harborview Injury Prevention and Research Center, Harborview Medical Center, University of Washington, Seattle, WA 98122, USA
| | - Sarah Wahlster
- Neurocritical Care Service, Department of Neurology, Harborview Medical Center, University of Washington, Seattle, WA 98104, USA
- Neurocritical Care Service, Department of Anesthesiology and Pain Medicine, Harborview Injury Prevention and Research Center, Harborview Medical Center, University of Washington, Seattle, WA 98122, USA
| | - Monica S Vavilala
- Department of Anesthesiology and Pain Medicine, Harborview Injury Prevention and Research Center, Harborview Medical Center, University of Washington, Seattle, WA 98122, USA
| | - Abhijit V Lele
- Neurocritical Care Service, Department of Anesthesiology and Pain Medicine, Harborview Injury Prevention and Research Center, Harborview Medical Center, University of Washington, Seattle, WA 98122, USA
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22
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Lele AV, Takala RSK, Athiraman U, Schloemerkemper N, Gollapudy S, Vagnerova K, Vincent A, Roberts KE, Wahlster S, Vavilala MS. Implementation of an Online External Ventricular Drain Training Module-An Educational Initiative to Improve Proficiency of Perioperative Health Care Providers: Results of a Retrospective Study. J Neurosurg Anesthesiol 2023; 35:201-207. [PMID: 34881561 DOI: 10.1097/ana.0000000000000815] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Received: 06/04/2021] [Accepted: 09/07/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND An external ventricular drain (EVD) training module may improve the knowledge and proficiency of perioperative health care providers (HCPs). METHODS We examined knowledge gaps, self-reported comfort in managing EVDs, and improvement in self-assessment scores among HCPs from 7 academic medical centers based on an online EVD training module. RESULTS Of the 326 HCPs who completed the module, 207 (70.6%) reported being uncomfortable managing EVDs. The median pretest scores were 6 (interquartile range=2), and posttest scores were 8 (interquartile range=1), out of a maximum possible score of 9. The most frequent incorrectly answered questions were: (a) maximum allowed hourly cerebrospinal fluid volume drainage (51%), (b) the components of a normal intracranial pressure waveform (41%), and (c) identifying the correct position of the stopcock for accurate measurement of intracranial pressure (41%). The overall gain in scores was 2 (interquartile range=2) and highest among HCPs who had managed 1 to 25 EVDs (2.51, 95% confidence interval: 2.23-2.80), and without self-reported comfort in managing EVDs (2.26, 95% confidence interval: 1.96-2.33, P <0.0001). The majority of participants (312, 95.7%) reported that the training module helped them understand how to manage EVDs, and 276 (84.7%) rated the module 8 or more out of 10 in recommending it to their colleagues. CONCLUSIONS This online EVD training module was well-received by participants. Overall, improved scores reflect enhanced knowledge among HCPs following completion of the module. The greatest benefit was observed in those reporting less experience and feeling uncomfortable in managing EVDs. The impact on the reduction in EVD-associated adverse events deserves further examination.
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Affiliation(s)
- Abhijit V Lele
- Neurocritical Care Service, Department of Anesthesiology, Pain Medicine, and Neurological Surgery
| | - Riikka S K Takala
- Department of Anesthesiology, Perioperative Services, Intensive Care Medicine, and Pain Management, Turku University Hospital
- Department of Anaesthesiology, Intensive Care, Emergency Care, and Pain Medicine, University of Turku, Turku, Finland
| | | | | | - Suneeta Gollapudy
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
| | - Kamila Vagnerova
- Department of Anesthesiology, Oregon Health Sciences University, Portland, OR
| | - Anita Vincent
- Department of Anesthesiology, George Washington University, Washington, DC
| | - Katherine E Roberts
- Neurocritical Care Service, Department of Anesthesiology, Pain Medicine, and Neurological Surgery
| | - Sarah Wahlster
- Departments of Neurology, Anesthesiology, and Neurological Surgery
| | - Monica S Vavilala
- Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington
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23
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Lele AV, Brooks A, Miyagawa LA, Tesfalem A, Lundgren K, Cano RE, Ferro-Gonzalez N, Wongelemegist Y, Abdullahi A, Christianson JT, Huong JS, Nash PL, Wang WY, Fong CT, Theard MA, Wahlster S, Jannotta GE, Vavilala MS. Caseworker Cultural Mediator Involvement in Neurocritical Care for Patients and Families With Non-English Language Preference: A Quality Improvement Project. Cureus 2023; 15:e37687. [PMID: 37214078 PMCID: PMC10195074 DOI: 10.7759/cureus.37687] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2023] [Indexed: 05/23/2023] Open
Abstract
Objective To describe Harborview Medical Center's experience with the involvement of caseworker cultural mediators (CCM) for patients requiring neurocritical care. Methods Using univariate and multivariate analysis (model adjusted for age, Glasgow Coma Scale score (GCS), Sequential Organ Failure Assessment (SOFA) Scores, mechanical ventilation, transition to comfort measures only (CMO), and death by neurologic criteria), we examined CCM team members' involvement in the care of Amharic/Cambodian/Khmer/Somali/Spanish/Vietnamese patients admitted to our neurocritical care service between 2014-2022, factors associated with CCM utilization, and changes in CCM utilization after a QI initiative was implemented in 2020 to encourage healthcare providers to consult the CCM team. Results Compared to eligible patients (n=827) who did not receive CCM referral, patients with CCM involvement (n=121) were younger (49 [interquartile range, IQR 38,63] vs. 56 [IQR 42,68] years, p = 0.002), had greater illness severity (admission GCS 8.5 [IQR 3,14] vs. 14 [IQR 7,15], p < 0.001, SOFA scores (5 [IQR 2,8] vs. 4 [IQR2,6], p = 0.007), and more frequently required mechanical ventilation (67% vs. 40%, odds ratio, OR 3.07, 95% CI 2.06,4.64), with higher all-cause mortality (20% vs. 12%, RR 1.83, 95% CI 1.09, 2.95), and with a higher rate of transition to CMO (11.6% vs. 6.2%, OR 2.00, 95% CI 1.03;3.66). The CCM QI initiative was independently associated with increased CCM involvement (aOR 4.22, 95% CI [2.32;7.66]). Overall, 4/10 attempts made by CCMs to reach out to the family to provide support were declined by the family. CCMs reported providing cultural/emotional support (n=96, 79%), end-of-life counseling (n=16, 13%), conflict mediation (n=15, 12.4%), and facilitating goals of care meetings (n=4, 3.3%). Conclusions Among eligible patients, CCM consultations appeared to occur in patients with higher disease severity. Our QI initiative increased CCM involvement.
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Affiliation(s)
- Abhijit V Lele
- Anesthesiology and Pain Medicine, Harborview Injury Prevention and Research Center, Harborview Medical Center, University of Washington, Seattle, USA
- Neurological Surgery, Harborview Injury Prevention and Research Center, Harborview Medical Center, University of Washington, Seattle, USA
| | - Anna Brooks
- Medicine, Harborview Injury Prevention and Research Center, Harborview Medical Center, University of Washington, Seattle, USA
| | | | | | - Kim Lundgren
- Interpreter Services, Harborview Medical Center, Seattle, USA
| | - Rosemary E Cano
- Interpreter Services, Harborview Medical Center, Seattle, USA
| | | | | | - Anab Abdullahi
- Interpreter Services, Harborview Medical Center, Seattle, USA
| | | | | | - Piper L Nash
- Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, USA
| | - Wei-Yun Wang
- Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, USA
| | - Christine T Fong
- Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, USA
| | - Marie-Angele Theard
- Anesthesiology and Pain Medicine, Harborview Injury Prevention and Research Center, Harborview Medical Center, University of Washington, Seattle, USA
| | - Sarah Wahlster
- Neurology, Harborview Medical Center, University of Washington, Seattle, USA
- Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, USA
- Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, USA
| | - Gemi E Jannotta
- Neurocritical Care Service, Harborview Medical Center, University of Washington, Seattle, USA
| | - Monica S Vavilala
- Anesthesiology and Pain Medicine, Harborview Injury Prevention and Research Center, Harborview Medical Center, University of Washington, Seattle, USA
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24
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Lele AV, Fong CT, Newman SF, O’Reilly-Shah V, Walters AM, Athiraman U, Souter MJ, Levitt MR, Vavilala MS. Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) Quality Metrics in Patients Undergoing Decompressive Craniectomy and Endoscopic Clot Evacuation after Spontaneous Supratentorial Intracerebral Hemorrhage: A Retrospective Observational Study. J Neurosurg Anesthesiol 2023; Publish Ahead of Print:00008506-990000000-00057. [PMID: 36941123 PMCID: PMC10511654 DOI: 10.1097/ana.0000000000000912] [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] [Received: 09/08/2022] [Accepted: 02/15/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND We report adherence to 6 Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) quality metrics (QMs) relevant to patients undergoing decompressive craniectomy or endoscopic clot evacuation after spontaneous supratentorial intracerebral hemorrhage (sICH). METHODS In this retrospective observational study, we describe adherence to the following ASPIRE QMs: acute kidney injury (AKI-01); mean arterial pressure < 65 mm Hg for less than 15 minutes (BP-03); myocardial injury (CARD-02); treatment of high glucose (> 200 mg/dL, GLU-03); reversal of neuromuscular blockade (NMB-02); and perioperative hypothermia (TEMP-03). RESULT The study included 95 patients (70% male) with median (interquartile range) age 55 (47 to 66) years and ICH score 2 (1 to 3) undergoing craniectomy (n=55) or endoscopic clot evacuation (n=40) after sICH. In-hospital mortality attributable to sICH was 23% (n=22). Patients with American Society of Anesthesiologists physical status class 5 (n=16), preoperative reduced glomerular filtration rate (n=5), elevated cardiac troponin (n=21) and no intraoperative labs with high glucose (n=71), those who were not extubated at the end of the case (n=62) or did not receive a neuromuscular blocker given (n=3), and patients having emergent surgery (n=64) were excluded from the analysis for their respective ASPIRE QM based on predetermined ASPIRE exclusion criteria. For the remaining patients, the adherence to ASPIRE QMs were: AKI-01, craniectomy 34%, endoscopic clot evacuation 1%; BP-03, craniectomy 72%, clot evacuation 73%; CARD-02, 100% for both groups; GLU-03, craniectomy 67%, clot evacuation 100%; NMB-02, clot evacuation 79%, and; TEMP-03, clot evacuation 0% with hypothermia. CONCLUSION This study found variable adherence to ASPIRE QMs in sICH patients undergoing decompressive craniectomy or endoscopic clot evacuation. The relatively high number of patients excluded from individual ASPIRE metrics is a major limitation.
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Affiliation(s)
- Abhijit V. Lele
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA
- Harborview Injury and Research Center, Seattle, Washington, USA
| | - Christine T. Fong
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Shu-Fang Newman
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Vikas O’Reilly-Shah
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Andrew M. Walters
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | | | - Michael J. Souter
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Michael R. Levitt
- Department of Neurological Surgery, Radiology, Mechanical Engineering, and Stroke & Applied Neuroscience Center, University of Washington, Seattle, WA, USA
| | - Monica S. Vavilala
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA
- Harborview Injury and Research Center, Seattle, Washington, USA
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Kunapaisal T, Guo S, Gomez C, Theard MA, Lynch JB, Lele AV, King MA, Buckley R, Vavilala MS. Bacterial Brain Abscess and Life-Threatening Intracranial Hypertension Requiring Emergent Decompressive Craniectomy After SARS-CoV-2 Infection in a Healthy Adolescent. Cureus 2023; 15:e36258. [PMID: 37073194 PMCID: PMC10105642 DOI: 10.7759/cureus.36258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2023] [Indexed: 03/18/2023] Open
Abstract
Acute coronavirus 2 (SARS-CoV-2) infection usually results in mild symptoms, but secondary infections after SARS-CoV-2 infection can occur, particularly with comorbid conditions. We present the clinical course of a healthy adolescent with a brain abscess and life-threatening intracranial hypertension requiring emergent decompressive craniectomy after a SARS-CoV-2 infection. A 13-year-old healthy immunized male presented with invasive frontal, ethmoid, and maxillary sinusitis and symptoms of lethargy, nausea, headache, and photophobia due to a frontal brain abscess diagnosed three weeks after symptoms and 11 days of oral amoxicillin treatment. Coronavirus disease 2019 (COVID-19) reverse transcription-polymerase chain reaction (RT-PCR) was negative twice but then positive on amoxicillin day 11 (symptom day 21), when magnetic resonance imaging revealed a 2.5-cm right frontal brain abscess with a 10-mm midline shift. The patient underwent emergent craniotomy for right frontal epidural abscess washout and functional endoscopic sinus surgery with ethmoidectomy. On a postoperative day one, his neurological condition showed new right-sided pupillary dilation and decreased responsiveness. His vital signs showed bradycardia and systolic hypertension. He underwent an emergent decompressive craniectomy for signs of brain herniation. Bacterial PCR was positive for Streptococcus intermedius, for which he received intravenous vancomycin and metronidazole. He was discharged home on hospital day 14 without neurological sequelae and future bone flap replacement. Our case highlights the importance of timely recognition and treatment of brain abscess and brain herniation in patients with neurological symptoms after SARS-CoV-2 infection, even in otherwise healthy patients.
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Pan J, Bonow RH, Temkin N, Robinson EF, Sekhar LN, Levitt MR, Lele AV. Incidence and Risk Model of Venous Thromboembolism in Patients with Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2023; 172:e418-e427. [PMID: 36657716 DOI: 10.1016/j.wneu.2023.01.045] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/11/2023] [Accepted: 01/12/2023] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Venous thromboembolism (VTE) is a significant source of morbidity and mortality in hospitalized patients. We describe our experience with VTE prophylaxis and treatment in patients with aneurysmal subarachnoid hemorrhage (aSAH), risk factors for VTE, and a hazard model describing the daily risk of VTE. METHODS A retrospective cohort study was performed on patients with aSAH admitted from 2014 to 2018. Patients were screened for VTE based on clinical suspicion. Demographics, perioperative data, and in-hospital data were assessed as risk factors for VTE using survival analysis with death as a competing risk. RESULTS Among 485 patients, the overall incidence of VTE, deep vein thrombosis, and pulmonary embolism were 5.6%, 4.3%, and 2.3%, respectively. Increasing length of stay in the intensive care unit (hazard ratio [HR], 1.79; P < 0.0001; 95% confidence interval [CI], 1.49-2.16) and ventilation immediately after aneurysm treatment was associated with VTE (HR, 8.87; P < 0.01; 95% CI, 1.86-42.38). Hunt and Hess grade was negatively associated with VTE (HR, 0.61; P = 0.045; 95% CI, 0.37-1.00) due to its increased association with the competing risk of death (HR, 2.57; P < 0.0001; 95% CI, 1.89-3.49). The adjusted 4-year cumulative incidence for VTE is 11.1% and at mean day of hospital discharge is 5.4%. Treatment of VTEs with anticoagulation and/or inferior vena cava filter placement was not associated with immediate complications. CONCLUSIONS We describe the largest single-institution cohort of VTEs in aSAH patients. Our hazard model quantifies the cumulative incidence of VTEs during the course of hospitalization. We suggest a standardized protocol for screening, prophylaxis, and treatment of VTEs in this patient population.
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Affiliation(s)
- James Pan
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Robert H Bonow
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA; Harborview Injury Prevention Research Center, University of Washington School of Medicine, Seattle, Washington, USA
| | - Nancy Temkin
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA; Harborview Injury Prevention Research Center, University of Washington School of Medicine, Seattle, Washington, USA
| | - Ellen F Robinson
- Quality Improvement, Harborview Medical Center, Seattle, Washington, USA
| | - Laligam N Sekhar
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Michael R Levitt
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Abhijit V Lele
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA; Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, Washington, USA; Harborview Injury Prevention Research Center, University of Washington School of Medicine, Seattle, Washington, USA.
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Lin V, Lele AV, Fong CT, Jannotta GE, Livesay S, Sharma M, Bonow RH, Town JA, Chou SH, Creutzfeldt CJ, Wahlster S. Impact of COVID-19 on neurocritical care delivery and outcomes in patients with severe acute brain injury - Assessing the initial response in the first US epicenter. J Clin Neurosci 2022; 106:135-140. [PMID: 36308868 PMCID: PMC9556940 DOI: 10.1016/j.jocn.2022.10.009] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 09/06/2022] [Accepted: 10/10/2022] [Indexed: 11/05/2022]
Abstract
To investigate the pandemic’s impact on critically ill patients with neurological emergencies, we compared care metrics and outcomes of patients with severe acute brain injury (SABI) before and during the initial COVID-19 surge at our institution. We included adult patients with SABI during two separate three-month time periods: 'pre-COVID vs COVID'. We further stratified the COVID cohort to characterize outcomes in patients requiring COVID-19 precautions (Patient Under Investigation, ‘PUI’). The primary endpoint was in-hospital mortality; secondary endpoints included length of stay (LOS), diagnostic studies performed, time to emergent decompressive craniectomies (DCHC), ventilator management, and end-of-life care. We included 394 patients and found the overall number of admissions for SABI declined by 29 % during COVID (pre-COVID n = 231 vs COVID, n = 163). Our primary outcome of mortality and most secondary outcomes were similar between study periods. There were more frequent extubation attempts (72.1 % vs 76 %) and the mean time to extubation was shorter during COVID (55.5 h vs 38.2 h). The ICU LOS (6.10 days vs 4.69 days) and hospital LOS (15.32 days vs 11.74 days) was shorter during COVID. More PUIs died than non-PUIs (51.7 % vs 11.2 %), but when adjusted for markers of illness severity, this was not significant. We demonstrate the ability to maintain a consistent care delivery for patients with SABI during the pandemic at our institution. PUIs represent a population with higher illness severity at risk for delays in care. Multicenter, longitudinal studies are needed to explore the impact of the pandemic on patients with acute neurological emergencies.
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Affiliation(s)
- Victor Lin
- Department of Neurology, Harborview Medical Center, University of Washington, Seattle, WA, USA.
| | - Abhijit V Lele
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA; Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Christine T Fong
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Gemi E Jannotta
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Sarah Livesay
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA; College of Nursing, Rush University, Chicago, IL, USA
| | - Monisha Sharma
- Department of Global Health, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Robert H Bonow
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - James A Town
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Sherry H Chou
- Ken and Ruth Davee Dept of Neurology, Northwestern University Feinberg School of Medicine, Chicago IL, USA
| | - Claire J Creutzfeldt
- Department of Neurology, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Sarah Wahlster
- Department of Neurology, Harborview Medical Center, University of Washington, Seattle, WA, USA; Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA; Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, WA, USA
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Alinani A, Mills B, Gause E, Vavilala MS, Lele AV. National Institutes of Health Clinical Research Funding and All-Cause In-Hospital Traumatic Brain Injury-Related Mortality. Cureus 2022. [DOI: 10.7759/cureus.c77] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Thamjamrassri T, Watanitanon A, Moore A, Chesnut RM, Vavilala MS, Lele AV. A Pilot Prospective Observational Study of Cerebral Autoregulation and 12-Month Outcomes in Children With Complex Mild Traumatic Brain Injury: The Argument for Sufficiency Conditions Affecting TBI Outcomes. J Neurosurg Anesthesiol 2022; 34:384-391. [PMID: 34009858 PMCID: PMC8563492 DOI: 10.1097/ana.0000000000000775] [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: 01/22/2021] [Accepted: 03/25/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND The relationship between cerebral autoregulation and outcomes in pediatric complex mild traumatic brain injury (TBI) is unknown, and explored in this study. METHODS We conducted a prospective observational study of patients aged 0 to 18 years hospitalized with complex mild TBI (admission Glasgow Coma Scale score 13 to 15 with either abnormal computerized tomogram of the head or history of loss of consciousness). Cerebral autoregulation was tested using transcranial Doppler ultrasonography, and impaired autoregulation defined as autoregulation index<0.4. We collected Glasgow Outcome Scale Extended-Pediatrics score and health-related quality of life data at 3, 6, and 12 months after discharge. RESULTS Twenty-four patients aged 1.8 to 16.6 years (58.3% male) with complete 12-month outcome data were included in the analysis. Median admission Glasgow Coma Scale score was 15 (range: 13 to 15), median injury severity score was 12 (range: 4 to 29) and 23 patients (96%) had isolated TBI. Overall, 10 (41.7%) patients had impaired cerebral autoregulation. Complete recovery was observed in 6 of 21 (28.6%) children at 3 months, in 4 of 16 (25%) children at 6 months, and in 8 of 24 (33.3%) children at 12 months. There was no difference in median (interquartile range) Glasgow Outcome Scale Extended-Pediatrics score (2 [2.3] vs. 2 [interquartile range 1.3]) or health-related quality of life scores (91.5 [21.1] vs. 90.8 [21.6]) at 12 months between those with intact and impaired autoregulation, respectively. Age-adjusted hypotension occurred in 2/24 (8.3%) patients. CONCLUSION Two-thirds of children with complex mild TBI experienced incomplete functional recovery at 1 year. The co-occurrence of hypotension and cerebral autoregulation may be a sufficiency condition needed to affect TBI outcomes.
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Affiliation(s)
| | | | - Anne Moore
- Department of Neurological Surgery, University of Washington, Harborview Medical Center
| | - Randall M. Chesnut
- Department of Neurological Surgery, University of Washington, Harborview Medical Center
- Orthopedics and Sport Medicine, Seattle, WA
| | - Monica S. Vavilala
- Harborview Injury Prevention and Research Center
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle
| | - Abhijit V. Lele
- Harborview Injury Prevention and Research Center
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle
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Alinani A, Mills B, Gause E, Vavilala MS, Lele AV. National Institutes of Health Clinical Research Funding and All-Cause In-Hospital Traumatic Brain Injury-Related Mortality. Cureus 2022; 14:e27228. [PMID: 36035060 PMCID: PMC9400552 DOI: 10.7759/cureus.27228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2022] [Indexed: 11/05/2022] Open
Abstract
Introduction Higher federal research funding levels may improve patient outcomes. We examined this relationship between traumatic brain injury (TBI) funding and all-cause in-hospital TBI-related mortality. Methods Using an ecological series analysis, we examined the linear trend in both clinical TBI research funding in year 2000 United States dollars ($) (National Institutes of Health [NIH] RePORTER) and in-hospital isolated TBI mortality among patients aged 15 and older (National Trauma Data Bank [NTDB], TBI-related ICD-9 or ICD-10 code, abbreviated head injury score >2 and body region score <2 with ICU admission) between 2007-2015 with data from centers contributing all years of data for the study period. Linear regression was used to assess the relationship between mortality rate and total funding, lagged one to three years, both overall and within ten-year age groups. Results The mean annual NIH-TBI research funding was $64.36 million (lowest: 2008; $48.79 million, highest: 2015; $71.42 million). 192,597 encounters of patients 15 years and older, predominantly male (67.5%) and with polytrauma (59.9%), were included. There was no statistically significant reduction in in-hospital TBI-related mortality (14.15% in 2007 to 13.36% in 2015) for the cohort overall, but the mortality rate decreased for patients over 55 years. The greatest mortality reduction occurred in patients 85 years and older (-62.35, 95% CI -92.45-32.25), followed by patients 75-84 years (-44.41, 95% CI -61.72, -27.09), patients 65-74 years (-47.60, 95% CI -67.39, -27.81), and patients 55-64 years of age (-15.15, 95% CI -27.59, -2.72). During the study period, annual NIH funding for TBI varied from the lowest level of $48.79 million (in 2007) to the highest level of $77.34.43 million (in 2005). There was no association between funding in the previous three years and the in-hospital TBI-related mortality rate. Conclusion This study found a variable pattern in NIH funding for clinical TBI research and a contemporaneous reduction in moderate-severe TBI-related deaths only for those aged 55 years and older, but no association between funding and mortality.
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Lele AV, Wahlster S, Alunpipachathai B, Awraris Gebrewold M, Chou SHY, Crabtree G, English S, Der-Nigoghossian C, Gagnon DJ, Kim-Tenser M, Karanjia N, Kirkman MA, Lamperti M, Livesay SL, Mejia-Mantilla J, Melmed K, Prabhakar H, Tumino L, Venkatasubba Rao CP, Udy AA, Videtta W, Moheet AM. Perceptions Regarding the SARS-CoV-2 Pandemic's Impact on Neurocritical Care Delivery: Results From a Global Survey. J Neurosurg Anesthesiol 2022; 34:209-220. [PMID: 34882104 PMCID: PMC8900891 DOI: 10.1097/ana.0000000000000825] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 10/29/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND The SARS-CoV-2 (COVID-19) pandemic has impacted many facets of critical care delivery. METHODS An electronic survey was distributed to explore the pandemic's perceived impact on neurocritical care delivery between June 2020 and March 2021. Variables were stratified by World Bank country income level, presence of a dedicated neurocritical care unit (NCCU) and experiencing a COVID-19 patient surge. RESULTS Respondents from 253 hospitals (78.3% response rate) from 47 countries (45.5% low/middle income countries; 54.5% with a dedicated NCCU; 78.6% experienced a first surge) participated in the study. Independent of country income level, NCCU and surge status, participants reported reductions in NCCU admissions (67%), critical care drug shortages (69%), reduction in ancillary services (43%) and routine diagnostic testing (61%), and temporary cancellation of didactic teaching (44%) and clinical/basic science research (70%). Respondents from low/middle income countries were more likely to report lack of surge preparedness (odds ratio [OR], 3.2; 95% confidence interval [CI], 1.8-5.8) and struggling to return to prepandemic standards of care (OR, 12.2; 95% CI, 4.4-34) compared with respondents from high-income countries. Respondents experiencing a surge were more likely to report conversion of NCCUs and general-mixed intensive care units (ICUs) to a COVID-ICU (OR 3.7; 95% CI, 1.9-7.3), conversion of non-ICU beds to ICU beds (OR, 3.4; 95% CI, 1.8-6.5), and deviations in critical care and pharmaceutical practices (OR, 4.2; 95% CI 2.1-8.2). Respondents from hospitals with a dedicated NCCU were less likely to report conversion to a COVID-ICU (OR, 0.5; 95% CI, 0.3-0.9) or conversion of non-ICU to ICU beds (OR, 0.5; 95% CI, 0.3-0.9). CONCLUSION This study reports the perceived impact of the COVID-19 pandemic on global neurocritical care delivery, and highlights shortcomings of health care infrastructures and the importance of pandemic preparedness.
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Affiliation(s)
- Abhijit V. Lele
- Departments of Anesthesiology and Pain Medicine, and Neurological Surgery
| | - Sarah Wahlster
- Neurology, Anesthesiology and Pain Medicine, and Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, WA
| | | | - Meron Awraris Gebrewold
- Department of Neurology, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Sherry H.-Y. Chou
- Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh, Pittsburgh, PA
| | - Gretchen Crabtree
- Neurocritical Care, OhioHealth Riverside Methodist Hospital, Columbus, OH
| | - Shane English
- Department of Medicine (Critical Care), University of Ottawa, Ottawa, ON, Canada
| | - Caroline Der-Nigoghossian
- Department of Pharmacy, Neurosciences Intensive Care Unit, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York City, NY
| | - David J. Gagnon
- Maine Medical Center, Tufts University School of Medicine, Maine Medical Center Research Institute, Portland, ME
| | - May Kim-Tenser
- University of Southern California/Keck School of Medicine, Los Angeles
| | | | - Matthew A. Kirkman
- Atkinson Morley Regional Neurosciences Centre, St George’s Hospital, London, UK
| | - Massimo Lamperti
- Anesthesiology Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | | | | | - Kara Melmed
- Department of Neurology and Neurosurgery at NYU Grossman School of Medicine, Langone Health, New York City, NY
| | - Hemanshu Prabhakar
- Departments of Neuroanesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Leandro Tumino
- HIGA San Martín de La Plata y Clinica San Camilo, Argentina
| | - Chethan P. Venkatasubba Rao
- Division of Vascular Neurology and Neurocritical Care, Baylor College of Medicine and St. Luke’s Medical Center, Houston, TX
| | - Andrew A. Udy
- Department of Intensive Care & Hyperbaric Medicine, The Alfred Hospital, and Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Vic., Australia
| | | | - Asma M. Moheet
- Neurocritical Care, OhioHealth Riverside Methodist Hospital, Columbus, OH
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Athiraman U, Lele AV, Karanikolas M, Dhulipala VB, Jayaraman K, Fong C, Kentner R, Sheolal R, Vellimana A, Gidday JM, Dhar R, Zipfel GJ. Inhalational Versus Intravenous Anesthetic Conditioning for Subarachnoid Hemorrhage-Induced Delayed Cerebral Ischemia. Stroke 2022; 53:904-912. [PMID: 34732071 PMCID: PMC8885765 DOI: 10.1161/strokeaha.121.035075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Inhalational anesthetics were associated with reduced incidence of angiographic vasospasm and delayed cerebral ischemia (DCI) in patients with aneurysmal subarachnoid hemorrhage (SAH). Whether intravenous anesthetics provide similar level of protection is not known. METHODS Anesthetic data were collected retrospectively for patients with SAH who received general anesthesia for aneurysm repair between January 1, 2014 and May 31, 2018, at 2 academic centers in the United States (one employing primarily inhalational and the other primarily intravenous anesthesia with propofol). We compared the outcomes of angiographic vasospasm, DCI, and neurological outcome (measured by disposition at hospital discharge), between the 2 sites, adjusting for potential confounders. RESULTS We compared 179 patients with SAH receiving inhalational anesthetics at one institution to 206 patients with SAH receiving intravenous anesthetics at the second institution. The rates of angiographic vasospasm between inhalational versus intravenous anesthetic groups were 32% versus 52% (odds ratio, 0.49 [CI, 0.32-0.75]; P=0.001) and DCI were 21% versus 40% (odds ratio, 0.47 [CI, 0.29-0.74]; P=0.001), adjusting for imbalances between sites/groups, Hunt-Hess and Fisher grades, type of aneurysm treatment, and American Society of Anesthesiology status. No impact of anesthetics on neurological outcome at time of discharge was noted with rates of good discharge outcome between inhalational versus intravenous anesthetic groups at (78% versus 72%, P=0.23). CONCLUSIONS Our data suggest that those who received inhalational versus intravenous anesthetic for ruptured aneurysm repair had significant protection against SAH-induced angiographic vasospasm and DCI. Although we cannot fully disentangle site-specific versus anesthetic effects in this comparative study, these results, when coupled with preclinical data demonstrating a similar protective effect of inhalational anesthetics on vasospasm and DCI, suggest that inhalational anesthetics may be preferable for patients with SAH undergoing aneurysm repair. Additional investigations examining the effect of inhalational anesthetics on other SAH outcomes such as early brain injury and long-term neurological outcomes are warranted.
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Affiliation(s)
| | - Abhijit V. Lele
- Department of Anesthesiology and Pain Medicine, University of
Washington, Seattle, WA, USA
| | | | - Vasu Babu Dhulipala
- Department of Anesthesiology and Pain Medicine, University of
Washington, Seattle, WA, USA
| | - Keshav Jayaraman
- Department of Neurological surgery, Washington University, St.
Louis MO, 63110
| | - Chrsitine Fong
- Department of Anesthesiology and Pain Medicine, University of
Washington, Seattle, WA, USA
| | - Rainer Kentner
- Department of Anesthesiology, Washington University, St. Louis MO,
63110
| | - Ravitha Sheolal
- Department of Anesthesiology, Washington University, St. Louis MO,
63110
| | - Ananth Vellimana
- Department of Neurological surgery, Washington University, St.
Louis MO, 63110
| | - Jeffrey M. Gidday
- Neuroscience, Physiology, Biochemistry and Molecular Biology, LSU
Health Science Center, New Orleans, LA 70112
| | - Rajat Dhar
- Department of Neurology, Washington University, St. Louis MO,
63110
| | - Gregory J. Zipfel
- Departments of Neurological surgery and Neurology, Washington
University, St. Louis MO, 63110
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Ershova K, Savin I, Khomenko O, Wong D, Danilov G, Shifrin M, Sokolova E, O'Reilly-Shah VN, Lele AV, Ershova O. The incidence and outcomes of healthcare-associated respiratory tract infections in non-ventilated neurocritical care patients: Results of a 10-year cohort study. J Clin Neurosci 2022; 97:32-41. [PMID: 35033779 DOI: 10.1016/j.jocn.2021.12.035] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 11/25/2021] [Accepted: 12/29/2021] [Indexed: 11/17/2022]
Abstract
The incidence of healthcare-associated respiratory tract infections in non-ventilated patients (NVA-HARTI) in neurosurgical intensive care units (ICUs) is unknown. The impact of NVA-HARTI on patient outcomes and differences between NVA-HARTI and ventilator-associated healthcare-associated respiratory tract infections (VA-HARTI) are poorly understood. Our objectives were to report the incidence, hospital length of stay (LOS), ICU LOS, and mortality in NVA-HARTI patients and compare these characteristics to VA-HARTI in neurocritical care patients. This cohort study was conducted in a neurosurgical ICU in Moscow. From 2011 to 2020, all patients with an ICU LOS > 48 h were included. A competing risk model was used for survival and risk analysis. A total of 3,937 ICU admissions were analyzed. NVA-HARTI vs VA-HARTI results were as follows: cumulative incidence 7.2 (95%CI: 6.4-8.0) vs 15.4 (95%CI: 14.2-16.5) per 100 ICU admissions; incidence rate 4.2 ± 2.0 vs 9.5 ± 3.0 per 1000 patient-days in the ICU; median LOS 32 [Q1Q3: 21, 48.5] vs 46 [Q1Q3: 28, 76.5] days; median ICU LOS 15 [Q1Q3: 10, 28.75] vs 26 [Q1Q3: 17, 43] days; mortality 12.3% (95%CI: 7.9-16.8) vs 16.7% (95%CI: 13.6-19.7). The incidence of VA-HARTI decreased over ten years while NVA-HARTI incidence did not change. VA-HARTI was an independent risk factor of death, OR 1.54 (1.11-2.14), while NVA-HARTI was not. Our findings suggest that NVA-HARTI in neurocritical care patients represents a significant healthcare burden with relatively high incidence and associated poor outcomes. Unlike VA-HARTI, the incidence of NVA-HARTI remained constant despite preventive measures. This suggests that extrapolating VA-HARTI research findings to NVA-HARTI should be avoided.
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Affiliation(s)
- Ksenia Ershova
- Department of Anesthesiology and Pain Medicine, University of Washington, 1959 Pacific Street, Box 356540, Seattle, WA 98195, USA.
| | - Ivan Savin
- Burdenko National Medical Research Center of Neurosurgery, 4-Ya Tverskaya-Yamskaya Ulitsa, 16, Moscow 125047, Russia
| | - Oleg Khomenko
- Department of Computer Science, Skolkovo Institute of Science and Technology, Bolshoy Bulvar, 30, Moscow Oblast, 143026, Russia
| | - Darren Wong
- Division of Infectious Diseases, Keck School of Medicine, University of Southern California, 1975 Zonal Ave, Los Angeles, CA 90033, USA
| | - Gleb Danilov
- Burdenko National Medical Research Center of Neurosurgery, 4-Ya Tverskaya-Yamskaya Ulitsa, 16, Moscow 125047, Russia
| | - Michael Shifrin
- Burdenko National Medical Research Center of Neurosurgery, 4-Ya Tverskaya-Yamskaya Ulitsa, 16, Moscow 125047, Russia
| | - Ekaterina Sokolova
- Burdenko National Medical Research Center of Neurosurgery, 4-Ya Tverskaya-Yamskaya Ulitsa, 16, Moscow 125047, Russia
| | - Vikas N O'Reilly-Shah
- Department of Anesthesiology and Pain Medicine, University of Washington, 1959 Pacific Street, Box 356540, Seattle, WA 98195, USA
| | - Abhijit V Lele
- Department of Anesthesiology and Pain Medicine, University of Washington, 1959 Pacific Street, Box 356540, Seattle, WA 98195, USA
| | - Olga Ershova
- Burdenko National Medical Research Center of Neurosurgery, 4-Ya Tverskaya-Yamskaya Ulitsa, 16, Moscow 125047, Russia
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Kunapaisal T, Moore A, Theard MA, King MA, Chesnut RM, Vavilala MS, Lele AV. Experience with clinical cerebral autoregulation testing in children hospitalized with traumatic brain injury: Translating research to bedside. Front Pediatr 2022; 10:1072851. [PMID: 36704136 PMCID: PMC9871541 DOI: 10.3389/fped.2022.1072851] [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] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 12/23/2022] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE To report our institutional experience with implementing a clinical cerebral autoregulation testing order set with protocol in children hospitalized with traumatic brain injury (TBI). METHODS After IRB approval, we examined clinical use, patient characteristics, feasibility, and safety of cerebral autoregulation testing in children aged <18 years between 2014 and 2021. A clinical order set with a protocol for cerebral autoregulation testing was introduced in 2018. RESULTS 25 (24 severe TBI and 1 mild TBI) children, median age 13 years [IQR 4.5; 15] and median admission GCS 3[IQR 3; 3.5]) underwent 61 cerebral autoregulation tests during the first 16 days after admission [IQR1.5; 7; range 0-16]. Testing was more common after implementation of the order set (n = 16, 64% after the order set vs. n = 9, 36% before the order set) and initiated during the first 2 days. During testing, patients were mechanically ventilated (n = 60, 98.4%), had invasive arterial blood pressure monitoring (n = 60, 98.4%), had intracranial pressure monitoring (n = 56, 90.3%), brain-tissue oxygenation monitoring (n = 56, 90.3%), and external ventricular drain (n = 13, 25.5%). Most patients received sedation and analgesia for intracranial pressure control (n = 52; 83.8%) and vasoactive support (n = 55, 90.2%) during testing. Cerebral autoregulation testing was completed in 82% (n = 50 tests); 11 tests were not completed [high intracranial pressure (n = 5), high blood pressure (n = 2), bradycardia (n = 2), low cerebral perfusion pressure (n = 1), or intolerance to blood pressure cuff inflation (n = 1)]. Impaired cerebral autoregulation on first assessment resulted in repeat testing (80% impaired vs. 23% intact, RR 2.93, 95% CI 1.06:8.08, p = 0.03). Seven out of 50 tests (14%) resulted in a change in cerebral hemodynamic targets. CONCLUSION Findings from this series of children with TBI indicate that: (1) Availability of clinical order set with protocol facilitated clinical cerebral autoregulation testing, (2) Clinicians ordered cerebral autoregulation tests in children with severe TBI receiving high therapeutic intensity and repeatedly with impaired status on the first test, (3) Clinical cerebral autoregulation testing is feasible and safe, and (4) Testing results led to change in hemodynamic targets in some patients.
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Affiliation(s)
- Thitikan Kunapaisal
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States.,Harborview Injury Prevention, and Research Center, University of Washington, Seattle, WA, United States
| | - Anne Moore
- Cerebrovascular Laboratory, Harborview Medical Center, Seattle, WA, United States
| | - Marie A Theard
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States.,Harborview Injury Prevention, and Research Center, University of Washington, Seattle, WA, United States
| | - Mary A King
- Department of Pediatrics, University of Washington, Seattle, WA, United States
| | - Randall M Chesnut
- Harborview Injury Prevention, and Research Center, University of Washington, Seattle, WA, United States.,Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, WA, United States
| | - Monica S Vavilala
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States.,Harborview Injury Prevention, and Research Center, University of Washington, Seattle, WA, United States.,Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, WA, United States
| | - Abhijit V Lele
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States.,Harborview Injury Prevention, and Research Center, University of Washington, Seattle, WA, United States.,Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, WA, United States
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Thamjamrassri T, Yuwapattanawong K, Chanthima P, Vavilala MS, Lele AV. A Narrative Review of the Published Literature, Hospital Practices, and Policies Related to External Ventricular Drains in the United States: The External Ventricular Drain Publications, Practices, and Policies (EVDPoP) Study. J Neurosurg Anesthesiol 2022; 34:21-28. [PMID: 32467476 PMCID: PMC9014964 DOI: 10.1097/ana.0000000000000694] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 04/20/2020] [Indexed: 01/03/2023]
Abstract
External ventricular drain (EVD) placement and management pose risks to neurocritically ill patients. Yet, little is known about EVD management or hospital EVD management practices and policies in US hospitals. A narrative review was conducted to describe EVD-related publications reported in PubMed and Embase between 1953 and 2019, and a survey was used to examine US hospital EVD practices and policies, including adherence to EVD guideline recommendations. Overall, 912 relevant articles were published between 1953 and 2019 (average 21; range, 0 to 102 articles, per year), primarily related to indications for EVD placement (n=275, 30.2%), EVD-associated complications (n=206, 22.6%), and EVD care (n=200, 21.9%). The number of EVD publications increased over time (R2=0.7), and most publications addressed EVD-associated infection (n=296, 73.4%) and EVD insertion (n=195, 45.2%). Survey responses were received from 30 hospitals (37.5% response rate), and reported use of antimicrobial-impregnated catheters in 80% of hospitals, preinsertion antibiotic administration in 70%, collection of cerebrospinal fluid samples for suspicion of ventriculitis in 73.3%, tracking of EVD-associated infection in 86.7%, routine EVD clamping during transport in 66.7%, and monitoring of intracranial pressure during transport in 33.3%. Adherence to hospital policies was high for recommendations related to flushing an EVD and changing cerebrospinal fluid drainage systems (100% [range, 0% to 100%] each), but low for intrahospital transportation (16.7% [0% to 83.3%]), EVD removal (0% [0% to 66.7%]), patient and family education (0% [0% to 100%]), and administration of intraventricular medication (0% [0% to 100%]). In summary, the published literature related to EVD insertion and maintenance, and reported EVD hospital practices and policies, primarily focus on reducing EVD-associated infections. Still, overall adherence of hospital EVD policies to guideline recommendations is modest. To promote a culture of EVD safety, clinicians should focus on reducing all EVD-associated adverse events.
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Affiliation(s)
| | | | | | - Monica S Vavilala
- Harborview Injury Prevention and Research Center, Harborview Medical Center
- Department of Anesthesiology and Pain Medicine, Harborview Injury Prevention and Research Center, Harborview Medical Center, University of Washington, Seattle, WA
| | - Abhijit V Lele
- Harborview Injury Prevention and Research Center, Harborview Medical Center
- Neurocritical Care Service
- Department of Anesthesiology and Pain Medicine, Harborview Injury Prevention and Research Center, Harborview Medical Center, University of Washington, Seattle, WA
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Lele AV, Nair BG, Fong C, Walters AM, Souter MJ. Anesthetic Management of Brain-dead Adult and Pediatric Organ Donors: The Harborview Medical Center Experience. J Neurosurg Anesthesiol 2022; 34:e34-e39. [PMID: 32149890 DOI: 10.1097/ana.0000000000000683] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Accepted: 02/10/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The exposure of anesthesiologists to organ recovery procedures and the anesthetic technique used during organ recovery has not been systematically studied in the United States. METHODS A retrospective cohort study was conducted on all adult and pediatric patients who were declared brain dead between January 1, 2008, and June 30, 2019, and who progressed to organ donation at Harborview Medical Center. We describe the frequency of directing anesthetic care by attending anesthesiologists, anesthetic technique, and donor management targets during organ recovery. RESULTS In a cohort of 327 patients (286 adults and 41 children), the most common cause of brain death was traumatic brain injury (51.1%). Kidneys (94.4%) and liver (87.4%) were the most common organs recovered. On average, each year, an attending anesthesiologist cared for 1 (range: 1 to 7) brain-dead donor during organ retrieval. The average anesthetic time was 127±53.5 (mean±SD) minutes. Overall, 90% of patients received a neuromuscular blocker, 63.3% an inhaled anesthetic, and 33.9% an opioid. Donor management targets were achieved as follows: mean arterial pressure ≥70 mm Hg (93%), normothermia (96%), normoglycemia (84%), urine output >1 to 3 mL/kg/h (61%), and lung-protective ventilation (58%). CONCLUSIONS During organ recovery from brain-dead organ donors, anesthesiologists commonly administer neuromuscular blockers, inhaled anesthetics, and opioids, and strive to achieve donor management targets. While infrequently being exposed to these cases, it is expected that all anesthesiologists be cognizant of the physiological perturbations in brain-dead donors and achieve physiological targets to preserve end-organ function. These findings warrant further examination in a larger multi-institutional cohort.
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Affiliation(s)
- Abhijit V Lele
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA
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Lele AV, To-Adithep P, Chanthima P, Lakireddy V, Vavilala MS. Correlation Between Brain Trauma Foundation Guidelines and Published Severe Traumatic Brain Injury Research. J Neurosurg Anesthesiol 2021; 33:323-328. [PMID: 32149889 DOI: 10.1097/ana.0000000000000684] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 02/09/2020] [Indexed: 11/27/2022]
Abstract
Four editions of the Brain Trauma Foundation's (BTF) evidence-based guidelines have been published to guide clinical management after severe traumatic brain injury (TBI) and increase TBI research. We reviewed the association between published clinical severe TBI research and BTF guideline year of publication and guideline chapter topics. Using PubMed, we searched for peer-reviewed articles on severe TBI research published between 1975 and 2019. The frequency and study design of publications on chapter topics included in all 4 BTF guideline editions was collected and the relationship with published TBI research examined using linear regression and the coefficient of determination (r2). A total of 845 relevant articles were identified, with an average of 19 articles published per year. There was an increase in the overall number of publications (r2=0.72), with the largest increase occurring between the third and the fourth guideline editions (r2=0.70, 31 articles/y). Across all 4 guideline editions, 54% (n=460) of publications were retrospective studies, 27.2% (n=230) prospective studies, 12% (n=101) randomized controlled trials, and 7.6% (n=64) meta-analyses/systematic reviews. Publication of retrospective study numbers increased the most (r2=0.61), followed by prospective observational studies and meta-analyses/systematic reviews (r2=0.47 each), and randomized controlled trials (r2=0.39). The 3 most highly published guideline chapter topic areas were ventilator-associated pneumonia (r2=0.70), hyperosmolar therapy (r2=0.47), and decompressive craniectomy (r2=0.41). In summary, the TBI research output increased over time and was associated with BTF guideline release. However, the increase in published TBI research was not consistent between serial editions of the BTF guidelines, and many studies did not incorporate high-quality prospective research designs.
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Affiliation(s)
- Abhijit V Lele
- Neurocritical Care Service, Harborview Medical Center
- Departments of Anesthesiology and Pain Medicine
| | - Puriwat To-Adithep
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA
- Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Phuriphong Chanthima
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA
| | - Viharika Lakireddy
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA
| | - Monica S Vavilala
- Anesthesiology and Pediatrics, Harborview Injury Prevention and Research Center, University of Washington
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Athiraman U, Dhar R, Jayaraman K, Karanikolas M, Helsten D, Yuan J, Lele AV, Rath GP, Tempelhoff R, Roth S, Zipfel GJ. Conditioning Effect of Inhalational Anesthetics on Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage. Neurosurgery 2021; 88:394-401. [PMID: 32860066 DOI: 10.1093/neuros/nyaa356] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 06/19/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (SAH) has been identified as an independent predictor of poor outcome in numerous studies. OBJECTIVE To investigate the potential protective role of inhalational anesthetics against angiographic vasospasm, DCI, and neurologic outcome in SAH patients. METHODS After Institutional Review Board approval, data were collected retrospectively for SAH patients who received general anesthesia for aneurysm repair between January 1st, 2010 and May 31st, 2018. Primary outcomes were angiographic vasospasm, DCI, and neurologic outcome as measured by modified Rankin scale at hospital discharge. Univariate and logistic regression analysis were performed to identify independent predictors of these outcomes. RESULTS The cohort included 390 SAH patients with an average age of 56 ± 15 (mean ± SD). Multivariate logistic regression analysis identified inhalational anesthetic only technique, Hunt-Hess grade, age, anterior circulation aneurysm and average intraoperative mean blood pressure as independent predictors of angiographic vasospasm. Inhalational anesthetic only technique and modified Fishers grade were identified as independent predictors of DCI. No impact on neurological outcome at time of discharge was noted. CONCLUSION Our data provide additional evidence that inhalational anesthetic conditioning in SAH patients affords protection against angiographic vasospasm and new evidence that it exerts a protective effect against DCI. When coupled with similar results from preclinical studies, our data suggest further investigation into the impact of inhalational anesthetic conditioning on SAH patients, including elucidating the most effective dosing regimen, defining the therapeutic window, determining whether a similar protective effect against early brain injury, and on long-term neurological outcome exists.
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Affiliation(s)
| | - Rajat Dhar
- Department of Neurology, Washington University, St. Louis, Missouri
| | - Keshav Jayaraman
- Department of Neurological surgery, Washington University, St. Louis, Missouri
| | | | - Daniel Helsten
- Department of Anesthesiology , Washington University, St. Louis, Missouri
| | - Jane Yuan
- Department of Neurological surgery, Washington University, St. Louis, Missouri
| | - Abhijit V Lele
- Neurocritical Care Service, Harborview Medical Center, Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Girija Prasad Rath
- Department of Neuroanaesthesiology & Critical Care, Neurosciences Centre, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Rene Tempelhoff
- Department of Anesthesiology , Washington University, St. Louis, Missouri.,Department of Neurological surgery, Washington University, St. Louis, Missouri
| | - Steven Roth
- Department of Anesthesiology; Ophthalmology and Visual Sciences, College of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Gregory J Zipfel
- Department of Neurology, Washington University, St. Louis, Missouri.,Department of Neurological surgery, Washington University, St. Louis, Missouri
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Jannotta GE, Gulek BG, Dempsey JS, Blissitt PA, Sullivan HC, Tran K, Joffe A, Lele AV. Administration of 3% Sodium Chloride Through Peripheral Intravenous Access: Development and Implementation of a Protocol for Clinical Practice. Worldviews Evid Based Nurs 2021; 18:147-153. [PMID: 33783949 DOI: 10.1111/wvn.12501] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Patients with traumatic brain injury, cerebral edema, and severe hyponatremia require rapid augmentation of serum sodium levels. Three percent sodium chloride is commonly used to normalize or augment serum sodium level, yet there are limited data available concerning the most appropriate route of administration. Traditionally, 3% sodium chloride is administered through a central venous catheter (CVC) due to the attributed theoretical risk of phlebitis and extravasation injuries when hyperosmolar solution is administered peripherally. CVCs are associated with numerous complications, including arterial puncture, pneumothorax, infection, thrombosis, and air embolus. Peripherally infused 3% sodium chloride may bypass these concerns. AIMS To explore the evidence for peripherally infused 3% sodium chloride and to implement the findings. METHODS The Iowa Model of Evidence-Based Practice (EBP) was used to guide the project. A multidisciplinary team was established, and they developed an evidence-based protocol for the administration of 3% sodium chloride using peripheral intravenous catheters (PIVs), identified potential barriers to implementation, and developed targeted education to implement this practice change in a large academic medical center. RESULTS Of the 103 patients in this project, only three (2.9%) identified adverse events. Two were associated with continuous infusions, and one was associated with a bolus infusion. LINKING ACTION TO EVIDENCE This is the first study to describe a multidisciplinary protocol development and implementation process for the administration of 3% sodium chloride peripherally. Utilizing a multidisciplinary team is critical to the success of an EBP project. Implementing an evidence-based PIV protocol with stringent monitoring criteria for the administration of 3% sodium chloride has the potential to reduce adverse events related to CVC injury.
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Affiliation(s)
- Gemi E Jannotta
- Neurocritical Care Service, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Bernice G Gulek
- Neurocritical Care Service, Harborview Medical Center, University of Washington, Seattle, WA, USA.,Graduate School, College of Nursing, Washington State University, Spokane, WA, USA
| | - John S Dempsey
- Department of Pharmacy, Harborview Medical Center, Seattle, WA, USA
| | - Patricia A Blissitt
- Professional Development and Nursing Excellence, Harborview Medical Center, Seattle, WA, USA.,Department of Biobehavioral Nursing and Health Informatics, University of Washington School of Nursing, Seattle, WA, USA
| | - Helen C Sullivan
- Professional Development and Nursing Excellence, Harborview Medical Center, Seattle, WA, USA
| | - Kim Tran
- Department of Pharmacy, Harborview Medical Center, Seattle, WA, USA
| | - Aaron Joffe
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Abhijit V Lele
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA
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Barkley AS, Medina-Beckwith J, Sothea S, Pak S, Durfy SJ, Lele AV. Teaching the Emergency Neurologic Life Support Course at Two Major Hospitals in Phnom Penh, Cambodia. World Neurosurg 2020; 141:e686-e690. [PMID: 32525088 DOI: 10.1016/j.wneu.2020.05.275] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 05/29/2020] [Accepted: 05/30/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To determine the effect of offering a subset of the Emergency Neurological Life Support (ENLS) course modules on provider knowledge and self-reported confidence in acute management of neurocritically ill patients in a low-middle income country (LMIC). METHODS Eight ENLS modules were provided by in-person lecture using English to Khmer translated slides and a medical translator to physicians and nurses of 2 hospitals in Phnom Penh, Cambodia in May 2019. Providers included emergency, neurology, neurologic surgery, and general intensive care. Demographics, pre- and postcourse knowledge of ENLS content areas, and pre- and postcourse confidence in managing neurocritically ill patients were assessed. Data were pooled across both hospitals for analysis. RESULTS A total of 57 health care providers were approached for participation: 52 (25 physicians, 27 nurses) participated; 45 completed all study instruments. Pre- and postcourse knowledge scores showed no significant differences between providers. Postcourse, 37/45 (82.2%) participants reported that the content had prepared them for acute management of neurocritically ill patients. Satisfaction with module content ranged from 77.8%-80.0% per module. For the 8 modules, a majority of participants agreed that course material had provided them with knowledge and skills to provide acute care for patients' neurologic emergencies (68.4%-88.6%). CONCLUSIONS Provision of ENLS course module content increased LMIC provider self-reported knowledge and confidence in acute management of neurocritically ill patients immediately postcourse. Tailoring ENLS course presentation to a particular LMIC setting warrants additional investigation, as does the effect of ENLS course training on neurocritically ill patient outcomes in the LMIC setting.
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Affiliation(s)
- Ariana S Barkley
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA.
| | | | - Seang Sothea
- Technical Office, University of Health Sciences, Phnom Penh, Cambodia
| | - Sopheak Pak
- Technical Office, University of Health Sciences, Phnom Penh, Cambodia
| | - Sharon J Durfy
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Abhijit V Lele
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
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Alali AS, Temkin N, Vavilala MS, Lele AV, Barber J, Dikmen S, Chesnut RM. Matching early arterial oxygenation to long-term outcome in severe traumatic brain injury: target values. J Neurosurg 2020; 132:537-544. [PMID: 30738409 DOI: 10.3171/2018.10.jns18964] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Accepted: 10/02/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to examine the relationship between early arterial oxygenation thresholds and long-term outcome after severe traumatic brain injury (TBI). METHODS In a post hoc analysis of a randomized trial, adults with severe TBI were classified based on exposure to different levels of arterial oxygenation as measured using the average of arterial partial pressure of oxygen (PaO2) values obtained within 24 hours of admission. Potentially important PaO2 thresholds were defined a priori. The primary outcome was Glasgow Outcome Scale-Extended (GOSE) score at 6 months. Secondary outcomes were cognitive outcomes measured using a battery of 9 neuropsychological tests administered at 6 months, and 6-month mortality. RESULTS In adjusted analyses, oxygenation thresholds of 150 and 200 mm Hg were associated with better functional outcome at 6 months (adjusted OR for better functional outcome on GOSE 1.82 [95% CI 1.12-2.94] and 1.59 [95% CI 1.06-2.37], respectively) and improved cognitive outcome at 6 months (adjusted beta coefficients for better cognitive percentile across 9 neuropsychological tests: 6.9 [95% CI 1.3-12.5] and 6.8 [95% CI 2.4-11.3], respectively). There was no significant association between oxygenation level and 6-month mortality except at a PaO2 threshold of 200 mm Hg (OR for death 0.36, 95% CI 0.18-0.71). Higher or lower oxygenation thresholds were not associated with functional or cognitive outcome. CONCLUSIONS In this observational study, the relationship between early arterial oxygenation and long-term functional and cognitive TBI outcomes appears to be U-shaped. Mild levels of hyperoxemia within the first 24 hours after injury were associated with better long-term functional and cognitive outcomes. These findings highlight the importance of examining balanced oxygen supplementation as a potential strategy to improve TBI outcomes in future research.
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Affiliation(s)
- Aziz S Alali
- 1Department of Neurological Surgery, University of Washington, Harborview Medical Center; and
| | - Nancy Temkin
- 1Department of Neurological Surgery, University of Washington, Harborview Medical Center; and.,Departments of2Biostatistics
| | | | | | - Jason Barber
- 1Department of Neurological Surgery, University of Washington, Harborview Medical Center; and
| | - Sureyya Dikmen
- 1Department of Neurological Surgery, University of Washington, Harborview Medical Center; and.,4Rehabilitation Medicine, University of Washington, Seattle, Washington
| | - Randall M Chesnut
- 1Department of Neurological Surgery, University of Washington, Harborview Medical Center; and
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Lele AV, Alunpipatthanachai B, Clark-Bell C, Watanitanon A, Min Xu M, Anne Moore RVT, Zimmerman JJ, Portman MA, Chesnut RM, Vavilala MS. Cardiac-cerebral-renal associations in pediatric traumatic brain injury: Preliminary findings. J Clin Neurosci 2020; 76:126-133. [PMID: 32299773 DOI: 10.1016/j.jocn.2020.04.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 04/04/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The clinical epidemiology of organ outcomes in pediatric traumatic brain injury (TBI) has not been examined. We describe associated markers of cerebral, cardiac and renal injury after pediatric TBI. DESIGN Prospective observational study. PATIENTS Children 0-18 years who were hospitalized with TBI. MEASUREMENTS Measures of myocardial (at least one elevated plasma troponin [cTnI] ≥ 0.4 ng/ml) and multiorgan (hemodynamic variables, cerebral perfusion, and renal) function were examined within the first ten days of hospital admission and within 24 h of each other. MAIN RESULTS Data from 28 children who were 11[IQR 10.3] years, male (64.3%), with isolated TBI (67.9%), injury severity score (ISS) 25[10], and admission Glasgow coma score (GCS) 11[9] were examined. Overall, 50% (14 children) had elevated cTnI, including those with isolated TBI (57.9%; 11/19), polytrauma (33.3%; 3/9), mild TBI (57.1% 8/14), and severe TBI (42.9%; 6/11). Elevated cTnI occurred within the first six days of admission and across all age groups, in both sexes, and regardless of TBI lesion type, GCS, and ISS. Age-adjusted admission tachycardia was associated with cTnI elevation (AUC 0.82; p < 0.001). Reduced urine output occurred more commonly in patients with isolated TBI (27.3% elevated cTnI vs. 0% normal cTnI). CONCLUSIONS Myocardial injury commonly occurs during the first six days after pediatric TBI irrespective of injury severity, age, sex, TBI lesion type, or polytrauma. Age-adjusted tachycardia may be a clinical indicator of myocardial injury, and elevated troponin may be associated with cardio-cerebro-renal dysfunction.
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Affiliation(s)
- Abhijit V Lele
- Department of Anesthesiology and Pain Medicine, Harborview Injury Prevention and Research Center, Harborview Medical Center, Seattle, WA, United States.
| | - Bhunyawee Alunpipatthanachai
- Department of Anesthesiology and Pain Medicine, Harborview Injury Prevention and Research Center, Harborview Medical Center, Seattle, WA, United States
| | - Crystalyn Clark-Bell
- Department of Anesthesiology and Pain Medicine, Harborview Injury Prevention and Research Center, Harborview Medical Center, Seattle, WA, United States
| | - Arraya Watanitanon
- Department of Anesthesiology and Pain Medicine, Harborview Injury Prevention and Research Center, Harborview Medical Center, Seattle, WA, United States
| | - M Min Xu
- Department of Laboratories, Seattle Children's Hospital, Department of Laboratory Medicine, University of Washington, Seattle, WA, United States
| | - R V T Anne Moore
- Department of Neurological Surgery, Harborview Medical Center, Seattle, WA, United States
| | - Jerry J Zimmerman
- Professor of Pediatrics and Anesthesiology, Seattle Children's Hospital, Harborview Medical Center, University of Washington, Seattle, WA, United States
| | - Michael A Portman
- Department of Pediatrics, Seattle Children's Hospital, Seattle, WA, United States
| | - Randall M Chesnut
- Department of Neurological Surgery and Orthopedics, Harborview Medical Center, Seattle, WA, United States
| | - Monica S Vavilala
- Department of Anesthesiology and Pain Medicine, Harborview Injury Prevention and Research Center, Harborview Medical Center, Seattle, WA, United States
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Krishnamoorthy V, Chaikittisilpa N, Lee J, Mackensen GB, Gibbons EF, Laskowitz D, Hernandez A, Velazquez E, Lele AV, Vavilala MS. Speckle Tracking Analysis of Left Ventricular Systolic Function Following Traumatic Brain Injury: A Pilot Prospective Observational Cohort Study. J Neurosurg Anesthesiol 2020; 32:156-161. [PMID: 30676403 PMCID: PMC6646112 DOI: 10.1097/ana.0000000000000578] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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] [Indexed: 02/03/2023]
Abstract
BACKGROUND Systolic dysfunction and reduction in left ventricular ejection fraction (LVEF) has been documented after traumatic brain injury (TBI). Speckle tracking is an emerging technology for myocardial strain assessment which has been utilized to identify subclinical myocardial dysfunction, and is most commonly reported as global longitudinal strain (GLS). We examined myocardial strain and regional strain patterns following moderate-severe TBI. MATERIALS AND METHODS We conducted a prospective cohort study of moderate-severe TBI patients (Glasgow Coma Scale≤12) and age/sex-matched controls. Transthoracic echocardiography was performed within the first day and 1 week following TBI. Myocardial function was assessed using both GLS and LVEF, and impaired systolic function was defined as GLS >-16% or LVEF ≤50%. Regional strain patterns and individual strain trajectories were examined. RESULTS Thirty subjects were included, 15 patients with TBI and 15 age/sex-matched controls. Among patients with adequate echocardiographic windows, systolic dysfunction was observed in 2 (17%) patients using LVEF and 5 (38%) patients using GLS within the first day after TBI. Mean GLS was impaired in patients with TBI compared with controls (-16.4±3.8% vs. -20.7±1.8%, P=0.001). Regional myocardial examination revealed impaired strain primarily in the basal and mid-ventricular segments. There was no improvement in GLS from day 1 to day 7 (P=0.81). CONCLUSIONS Myocardial strain abnormalities are common and persist for at least 1 week following moderate-severe TBI. Speckle tracking may be useful for the early diagnosis and monitoring of systolic dysfunction following TBI.
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Affiliation(s)
- Vijay Krishnamoorthy
- Department of Anesthesiology, Duke University
- Harborview Injury Prevention & Research Center, University of Washington
| | | | - James Lee
- Department of Internal Medicine, Division of Cardiology, Henry Ford Health System
| | | | - Edward F. Gibbons
- Harborview Injury Prevention & Research Center, University of Washington
- Department of Cardiology, University of Washington
| | | | - Adrian Hernandez
- Department of Internal Medicine, Division of Cardiology, Duke University
| | - Eric Velazquez
- Department of Internal Medicine, Division of Cardiology, Yale University
| | - Abhijit V. Lele
- Department of Anesthesiology & Pain Medicine, University of Washington
| | - Monica S. Vavilala
- Department of Anesthesiology & Pain Medicine, University of Washington
- Harborview Injury Prevention & Research Center, University of Washington
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Wu VKS, Fong C, Walters AM, Lele AV. Prevalence, Clinical Characteristics, and Outcomes Related to Ventilator-Associated Events in Neurocritically Ill Patients. Neurocrit Care 2020; 33:499-507. [PMID: 31974871 PMCID: PMC7223985 DOI: 10.1007/s12028-019-00910-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background The prevalence, characteristics, and outcomes related to the ventilator-associated event(s) (VAE) in neurocritically ill patients are unknown and examined in this study. Methods A retrospective study was performed on neurocritically ill patients at a 413-bed level 1 trauma and stroke center who received three or more days of mechanical ventilation to describe rates of VAE, describe characteristics of patients with VAE, and examine the association of VAE on ventilator days, mortality, length of stay, and discharge to home. Results Over a 5-year period from 2014 through 2018, 855 neurocritically ill patients requiring mechanical ventilation were identified. A total of 147 VAEs occurred in 130 (15.2%) patients with an overall VAE rate of 13 per 1000 ventilator days and occurred across age, sex, BMI, and admission Glasgow Coma Scores. The average time from the start of ventilation to a VAE was 5 (range 3–48) days after initiation of mechanical ventilation. Using Centers for Disease Control and Prevention definitions, VAEs met criteria for a ventilator-associated condition in 58% of events (n = 85), infection-related VAE in 22% of events (n = 33), and possible ventilator-associated pneumonia in 20% of events (n = 29). A most common trigger for VAE was an increase in positive end-expiratory pressure (84%). Presence of a VAE was associated with an increase in duration of mechanical ventilation (17.4[IQR 20.5] vs. 7.9[8.9] days, p < 0.001, 95% CI 7.86–13.92), intensive care unit (ICU) length of stay (20.2[1.1] vs. 12.5[0.4] days, p < 0.001 95% CI 5.3–10.02), but not associated with in-patient mortality (34.1 vs. 31.3%. 95% CI 0.76–1.69) or discharge to home (12.7% vs. 16.3%, 95% 0.47–1.29). Conclusions VAE are prevalent in the neurocritically ill. They result in an increased duration of mechanical ventilation and ICU length of stay, but may not be associated with in-hospital mortality or discharge to home. Electronic supplementary material The online version of this article (10.1007/s12028-019-00910-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Christine Fong
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Andrew M Walters
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Abhijit V Lele
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA. .,Neurocritical Care Service, Neuroscience ICU, Seattle, USA. .,Department of Neurological Surgery, University of Washington, Seattle, WA, USA. .,Associate Faculty, Harborview Injury Prevention and Research Center, Harborview Medical Center, Seattle, WA, 98104, USA.
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45
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Krishnamoorthy V, Hough CL, Vavilala MS, Komisarow J, Chaikittisilpa N, Lele AV, Raghunathan K, Creutzfeldt CJ. Tracheostomy After Severe Acute Brain Injury: Trends and Variability in the USA. Neurocrit Care 2020; 30:546-554. [PMID: 30919303 DOI: 10.1007/s12028-019-00697-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND/OBJECTIVE Severe acute brain injury (SABI) is responsible for 12 million deaths annually, prolonged disability in survivors, and substantial resource utilization. Little guidance exists regarding indication or optimal timing of tracheostomy after SABI. Our aims were to determine national trends in tracheostomy utilization among mechanically ventilated patients with SABI in the USA, as well as to examine factors associated with tracheostomy utilization following SABI. METHODS We conducted a population-based retrospective cohort study using the National Inpatient Sample from 2002 to 2011. We identified adult patients with SABI, defined as a primary diagnosis of stroke, traumatic brain injury or post-cardiac arrest who received mechanical ventilation for greater than 96 h. We analyzed trends in tracheostomy utilization over time and used multilevel mixed-effects logistic regression to analyze factors associated with tracheostomy utilization. RESULTS There were 94,082 hospitalizations for SABI during the study period, with 30,455 (32%) resulting in tracheostomy utilization. The proportion of patients with SABI who received a tracheostomy increased during the study period, from 28.0% in 2002 to 32.1% in 2011 (p < 0.001). Variation in tracheostomy utilization was noted based on patient and facility characteristics, including higher odds of tracheostomy in large hospitals (OR 1.34, 95% CI 1.18-1.53, p < 0.001, compared to small hospitals), teaching hospitals (OR 1.15, 95% CI 1.06-1.25, p = 0.001, compared to non-teaching hospitals), and urban hospitals (OR 1.60, 95% CI 1.33-1.92, p < 0.001, compared to rural hospitals). CONCLUSIONS Tracheostomy utilization has increased in the USA among patients with SABI, with wide variation by patient and facility-level factors.
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Affiliation(s)
- Vijay Krishnamoorthy
- Department of Anesthesiology, Duke University, 2301 Erwin Rd., Durham, NC, 27710, USA. .,Harborview Injury Prevention and Research Center, University of Washington, Seattle, USA.
| | - Catherine L Hough
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, USA.,Harborview Injury Prevention and Research Center, University of Washington, Seattle, USA
| | - Monica S Vavilala
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, USA.,Harborview Injury Prevention and Research Center, University of Washington, Seattle, USA
| | | | | | - Abhijit V Lele
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, USA.,Harborview Injury Prevention and Research Center, University of Washington, Seattle, USA
| | - Karthik Raghunathan
- Department of Anesthesiology, Duke University, 2301 Erwin Rd., Durham, NC, 27710, USA
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46
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Barkley AS, Spece LJ, Barros LM, Bonow RH, Ravanpay A, Ellenbogen R, Huoy P, Thy T, Sothea S, Pak S, LoGerfo J, Lele AV. A mixed-methods needs assessment of traumatic brain injury care in a low- and middle-income country setting: building neurocritical care capacity at two major hospitals in Cambodia. J Neurosurg 2019; 134:244-250. [PMID: 31860819 PMCID: PMC7372920 DOI: 10.3171/2019.10.jns192118] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [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] [Received: 08/14/2019] [Accepted: 10/11/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The high global burden of traumatic brain injury (TBI) disproportionately affects low- and middle-income countries (LMICs). These settings also have the greatest disparity in the availability of surgical care in general and neurosurgical care in particular. Recent focus has been placed on alleviating this surgical disparity. However, most capacity assessments are purely quantitative, and few focus on concomitantly assessing the complex healthcare system needs required to care for these patients. The objective of the present study was to use both quantitative and qualitative assessment data to establish a comprehensive approach to inform capacity-development initiatives for TBI care at two hospitals in an LMIC, Cambodia. METHODS This mixed-methods study used 3 quantitative assessment tools: the World Health Organization Personnel, Infrastructure, Procedures, Equipment, Supplies (WHO PIPES) checklist, the neurosurgery-specific PIPES (NeuroPIPES) checklist, and the Neurocritical Care (NCC) checklist at two hospitals in Phnom Penh, Cambodia. Descriptive statistics were obtained for quantitative results. Qualitative semistructured interviews of physicians, nurses, and healthcare administrators were conducted by a single interviewer. Responses were analyzed using a thematic content analysis approach and coded to allow categorization under the PIPES framework. RESULTS Of 35 healthcare providers approached, 29 (82.9%) participated in the surveys, including 19 physicians (65.5%) and 10 nurses (34.5%). The majority had fewer than 5 years of experience (51.7%), were male (n = 26, 89.7%), and were younger than 40 years of age (n = 25, 86.2%). For both hospitals, WHO PIPES scores were lowest in the equipment category. However, using the NCC checklist, both hospitals scored higher in equipment (81.2% and 62.7%) and infrastructure (78.6% and 69.6%; hospital 1 and 2, respectively) categories and lowest in the training/continuing education category (41.7% and 33.3%, hospital 1 and 2, respectively). Using the PIPES framework, analysis of the qualitative data obtained from interviews revealed a need for continuing educational initiatives for staff, increased surgical and critical care supplies and equipment, and infrastructure development. The analysis further elucidated barriers to care, such as challenges with time availability for experienced providers to educate incoming healthcare professionals, issues surrounding prehospital care, maintenance of donated supplies, and patient poverty. CONCLUSIONS This mixed-methods study identified areas in supplies, equipment, and educational/training initiatives as areas for capacity development for TBI care in an LMIC such as Cambodia. This first application of the NCC checklist in an LMIC setting demonstrated limitations in its use in this setting. Concomitant qualitative assessments provided insight into barriers otherwise undetected in quantitative assessments.
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Affiliation(s)
| | - Laura J. Spece
- Department of Medicine, University of Washington
- Department of Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington
| | | | - Robert H. Bonow
- Department of Neurological Surgery, University of Washington
| | - Ali Ravanpay
- Department of Neurological Surgery, University of Washington
- Department of Neurological Surgery, VA Puget Sound Health Care System, Seattle, Washington
| | | | - Phearum Huoy
- Department of Neurological Surgery, Khmer Soviet Friendship Hospital
| | - Try Thy
- Department of Neurological Surgery, University of Health Sciences, Phnom Penh, Cambodia
| | - Seang Sothea
- Department of Neurological Surgery, University of Health Sciences, Phnom Penh, Cambodia
| | - Sopheak Pak
- Technical Office, University of Health Sciences, Phnom Penh, Cambodia
| | - James LoGerfo
- Department of Medicine, Division of General Internal Medicine, University of Washington, Seattle, Washington
- Department of Global Health, University of Washington, Seattle, Washington
| | - Abhijit V. Lele
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
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47
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Lele AV, Alunpipatthanachai B, Qiu Q, Clark-Bell C, Watanitanon A, Moore A, Chesnut RM, Armstead W, Vavilala MS. Plasma Levels, Temporal Trends and Clinical Associations between Biomarkers of Inflammation and Vascular Homeostasis after Pediatric Traumatic Brain Injury. Dev Neurosci 2019; 41:177-192. [PMID: 31553988 DOI: 10.1159/000502276] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 07/22/2019] [Indexed: 01/22/2023] Open
Abstract
Expression of inflammatory (interleukin-6 [IL-6]) and vascular homeostatic (angiopoietin-2 [AP-2], endothelin-1 [ET-1], endocan-2 [EC-2]) biomarkers in pediatric traumatic brain injury (TBI) was examined in this prospective, observational cohort study of 28 children hospitalized with mild, moderate, and severe TBI by clinical measures (age, sex, Glasgow Coma Scale score [GCS], Injury Severity Score [ISS], and cerebral autoregulation status). Biomarker patterns suggest an inverse relationship between GCS and AP-2, GCS and IL-6, ISS and ET-1, but a direct relationship between GCS and ET-1 and ISS and AP-2. Biomarker patterns suggest an inverse relationship between AP-2 and ET-1, AP-2 and EC-2, but a direct relationship between AP-2 and IL-6, IL-6 and EC-2, and IL-6 and ET-1. Plasma concentrations of inflammatory and vascular homeostatic biomarkers suggest a role for inflammation and disruption of vascular homeostasis during the first 10 days across the severity spectrum of pediatric TBI. Although not statistically significant, without impact on cerebral autoregulation, biomarker patterns suggest a relationship between inflammation and alterations in vascular homeostasis. The large variation in biomarker levels within TBI severity and age groups, and by sex suggests other contributory factors to biomarker expression.
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Affiliation(s)
- Abhijit V Lele
- Department of Anesthesiology and Pain Medicine, Harborview Injury Prevention and Research Center, Harborview Medical Center, Seattle, Washington, USA, .,Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington, USA,
| | | | - Qian Qiu
- Department of Anesthesiology and Pain Medicine, Harborview Injury Prevention and Research Center, Harborview Medical Center, Seattle, Washington, USA
| | - Crystalyn Clark-Bell
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington, USA
| | - Arraya Watanitanon
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington, USA
| | - Anne Moore
- Department of Neurological Surgery and Orthopedics, Harborview Medical Center, Seattle, Washington, USA
| | - Randall M Chesnut
- Department of Neurological Surgery and Orthopedics, Harborview Medical Center, Seattle, Washington, USA
| | - William Armstead
- Department of Anethesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Monica S Vavilala
- Department of Anesthesiology and Pain Medicine, Harborview Injury Prevention and Research Center, Harborview Medical Center, Seattle, Washington, USA.,Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington, USA
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48
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Chaikittisilpa N, Vavilala MS, Lele AV, Moore AE, Bethel J, Krishnamoorthy V. Early cardiovascular function and associated hemodynamics in adults with isolated moderate-severe traumatic brain injury: A pilot study. J Clin Neurosci 2019; 69:97-103. [PMID: 31477465 DOI: 10.1016/j.jocn.2019.08.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 08/05/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND While cardiac dysfunction has been described following traumatic brain injury (TBI), its association with systemic and cerebral hemodynamics is not known. We examined the contemporaneous relationship between early cardiac function with systemic and cerebral hemodynamic parameters after moderate-severe TBI. METHODS Bedside transthoracic echocardiography (TTE) and transcranial Doppler (TCD) ultrasonography were performed within 24 h in patients > 18 years with isolated moderate-severe TBI. Systemic hemodynamic parameters were quantified using routine monitoring [heart rate and mean arterial pressures (MAP)] and calculation from echocardiographic data [stroke volume index (SVI), cardiac index (CI), and systemic vascular resistance index (SVRI)]. Systolic dysfunction was defined using TTE as global longitudinal strain (GLS) > -16%. Mean middle cerebral artery velocity (FVm) was the measure of cerebral hemodynamics and quantified using TCD. RESULTS Among 15 patients [mean age 43 ± 13 years, GCS 5 ± 3, 73% male], 15 TTE and 15 TCD exams were performed simultaneously. Five (33%) patients had systolic dysfunction, with significantly worse GLS (median [IQR] -12.1% [-14.1, -12] vs. -19.1% [-19.9, -17.7], p = 0.004). Median (IQR) MAP was 97 (89, 107) mmHg, SVI (29.0 [20.5, 31.0] mL m-2), and CI (2.83 [2.05, 3.10] L/min m-2) were low to normal, while SVRI (2704 dyne sec/cm5 m-2 [2210, 4084]) was normal to high. None of the patients had abnormal TCDs. Higher GLS (reduced systolic function) was associated with lower SVI (r2 = 0.274, p = 0.03) but not other parameters. CONCLUSION Systemic hemodynamic parameters were consistent with an early catecholamine-excess state. While reduced systolic function was associated with lower SVI, there was no relationship with reduced cerebral perfusion, possibly due to normal MAP.
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Affiliation(s)
- Nophanan Chaikittisilpa
- Department of Anesthesiology, Siriraj Hospital, Mahidol University, Bangkok, Thailand; Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA, United States.
| | - Monica S Vavilala
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA, United States; Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA, United States
| | - Abhijit V Lele
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA, United States; Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA, United States
| | - Anne E Moore
- Department of Neurological Surgery, University of Washington, Seattle, WA, United States
| | - Justin Bethel
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA, United States
| | - Vijay Krishnamoorthy
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA, United States; Department of Anesthesiology, Duke University, Durham, NC, United States
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49
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Yang JT, Erickson SL, Killien EY, Mills B, Lele AV, Vavilala MS. Agreement Between Arterial Carbon Dioxide Levels With End-Tidal Carbon Dioxide Levels and Associated Factors in Children Hospitalized With Traumatic Brain Injury. JAMA Netw Open 2019; 2:e199448. [PMID: 31418806 PMCID: PMC6704750 DOI: 10.1001/jamanetworkopen.2019.9448] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
IMPORTANCE Alterations in the partial pressure of carbon dioxide, arterial (Paco2) can affect cerebral perfusion after traumatic brain injury. End-tidal carbon dioxide (EtCO2) monitoring is a noninvasive tool used to estimate Paco2 values. OBJECTIVE To examine the agreement between Paco2 and EtCO2 and associated factors in children with traumatic brain injury. DESIGN, SETTING, AND PARTICIPANTS A secondary analysis was conducted using data from a prospective cohort study of 137 patients younger than 18 years with traumatic brain injury who were admitted to the pediatric intensive care unit of a level I trauma center between May 1, 2011, and July 31, 2017. Analysis was performed from December 17, 2018, to January 10, 2019. MAIN OUTCOMES AND MEASURES The closest EtCO2 value obtained within 30 minutes of a Paco2 value and the closest systolic blood pressure value obtained within 60 minutes prior to a Paco2 value during the first 24 hours after admission were recorded. The main outcome of Paco2-EtCO2 agreement was defined as Paco2 between 0 and 5 mm Hg greater than the paired EtCO2 value, and it was determined using Bland-Altman analysis, Passing and Bablok regression, and the Pearson correlation coefficient. Multivariable regression models determined which factors were associated with agreement. RESULTS The analysis included 137 patients (34 girls and 103 boys; mean [SD] age, 10.0 [6.3] years) and 445 paired Paco2-EtCO2 data points. On average, Paco2 was 2.7 mm Hg (95% limits of agreement, -11.3 to 16.7) higher than EtCO2. Overall, 187 of all Paco2-EtCO2 pairs (42.0%) agreed. There was larger variation in the Paco2-EtCO2 difference during the first 8 hours compared with 9 to 24 hours after admission to the pediatric intensive care unit. Development of pediatric acute respiratory distress syndrome within 24 hours of admission was associated with a lower likelihood of Paco2-EtCO2 agreement (adjusted odds ratio, 0.20; 95% CI, 0.08-0.51) compared with no development of pediatric acute respiratory distress syndrome. A diagnosis of pediatric acute respiratory distress syndrome 1 to 7 days after admission was associated with a larger first-day Paco2-EtCO2 difference compared with those who never developed pediatric acute respiratory distress syndrome (mean [SD] difference, 4.48 [3.70] vs 0.46 [5.50] mm Hg). CONCLUSIONS AND RELEVANCE In this study of pediatric traumatic brain injury, Paco2-EtCO2 agreement was low, especially among patients with pediatric acute respiratory distress syndrome. Low Paco2-EtCO2 agreement early in hospitalization may be associated with future development of pediatric acute respiratory distress syndrome. Data on EtCO2 should not be substituted for data on Paco2 during the first 24 hours.
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Affiliation(s)
- Jen-Ting Yang
- Harborview Injury Prevention and Research Center, University of Washington, Seattle
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle
| | - Scott L. Erickson
- Harborview Injury Prevention and Research Center, University of Washington, Seattle
- Department of Epidemiology, University of Washington, Seattle
| | - Elizabeth Y. Killien
- Harborview Injury Prevention and Research Center, University of Washington, Seattle
- Department of Pediatrics, University of Washington, Seattle
| | - Brianna Mills
- Harborview Injury Prevention and Research Center, University of Washington, Seattle
| | - Abhijit V. Lele
- Harborview Injury Prevention and Research Center, University of Washington, Seattle
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle
| | - Monica S. Vavilala
- Harborview Injury Prevention and Research Center, University of Washington, Seattle
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle
- Department of Pediatrics, University of Washington, Seattle
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50
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Lele AV, Vavilala MS, Gupta D. In Reply: Patients Who Benefit From Intracranial Pressure Monitoring Without Cerebrospinal Fluid Drainage After Severe Traumatic Brain Injury. Neurosurgery 2019; 84:E261. [PMID: 30566692 DOI: 10.1093/neuros/nyy620] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Abhijit V Lele
- Department of Anesthesiology & Pain Medicine University of Washington Seattle, Washington
| | - Monica S Vavilala
- Department of Anesthesiology & Pain Medicine University of Washington Seattle, Washington
| | - Deepak Gupta
- Department of Neurosurgery Jai Prakash Narayan Apex Trauma Center New Delhi, India
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