A comprehensive view on the consensus statement Multimodality Monitoring in Neurocritical Care

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Few days ago a joint commission published a consensus on neuromonitoring in Neurocritical Care. There was no such explicit guideline before. This lead to a wide variety of approaches and opinions how to perform that crucial task. Some of these recommendations were rather surprising for me. An example is the recommendation against the use of serum NSE for prognostication in hypoxic-ischemic encephalopathy in patients treated with therapeutic hypothermia. In the following days I try to comment every subchapter of the consensus agenda. Today I start reviewing the subchapter “Clinical Evaluation”

1. We recommend that assessments with either the GCS (combined with assessment of pupils) or the FOUR score be routinely performed in comatose adult patients with acute brain injury.

The FOUR Score is not widely used in Germany and even among neurologist not wide known. The score is quiet more powerful assessing the comatose patient taking in account the pattern of breathing und pupillar reaction.

2. We recommend using the NRS 0–10 to elicit patient’s self-report of pain in all neurocritical care patients wakeful enough to attempt this. This is the gateway to a concept of analgosedation with a clear emphasis on analgesia.

If you do not asses pain, you don´t treat it proper. Be sure to asses this in a somnolent or even comatose patient. These are the next two points.

3. We recommend in the absence of a reliable NRS patient self-report, clinicians use a behavior-based scale to estimate patient pain such as the BPS or CCPOT.

4. We recommend use of the revised NCS-R to estimate pain for patients with severely impaired consciousness such as VS or MCS, using a threshold score of 4.

I will link all scales used in the show notes.

5. We recommend monitoring sedation with a validated and reliable scale such as the SAS or RASS.

RASS should be the next tool to do a reasonable sedation especially in ventilated patients. In a protocol controlled analgesia and sedation these two parameters should be assessed every shift by the nurse. We should turn our back to a one size fits all analgesia.

6. We recommend against performing sedation interruption or wake-up tests among brain-injured patients with intracranial hypertension, unless benefit out-weighs the risk.

This goes along with my personal experience. Brain injured go freaking if you wham-bam turn off analgesia and sedation. ICP is sure to sky rocket. So this should be a gradual process. I prefer to quarter analgesia and sedation every quarter of an hour and hold this maneuver in case of severe ICP reaction and vegetative instability.

7. We suggest assessment of delirium among neurocritical care patients include a search for new neurologic insults as well as using standard delirium assessment tools.

8. We recommend attention to level of wakefulness, as used in the ICDSC, during delirium screening to avoid confounding due to residual sedative effect. Delirium in NICU is associated with increased mortality and long-term cognitive impairment.

Scores like the CAM-ICU test have been validated for a general ICU population. In one trial the CAM-ICU was feasible only in some patients on a stroke unit. 55% of patients where excluded due to higher NIH stroke scales and lower GCS. Of the remaining patient there was a delirium incidence of 43%. I guess delirium screening should only be performed in awake patients. In particular testing takes time.

Le Roux, Peter, et al., “Consensus summary statement of the International Multidisciplinary Consensus Conference on Multimodality Monitoring in Neurocritical Care.” Intensive care medicine 40.9 (2014): 1189-1209.

Mitasova, Adela, et al., “Poststroke delirium incidence and outcomes: Validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU)*.” Critical care medicine 40.2 (2012): 484-490.

CAM-ICU:

http://www.icudelirium.org/docs/CAM_ICU_training_German.pdf http://geriatriceducation.duke.edu/resources/resource/cam-icu-assessment-demonstration-videos

GCS:

http://www.mdcalc.com/glasgow-coma-scale-score/

FOUR Score:

http://www.coma.ulg.ac.be/images/four_e.pdf

RASS:

http://www.icudelirium.org/docs/RASS.pdf

NRS:

http://en.wikipedia.org/wiki/Pain_scale

BPS:

http://www.fruehmobilisierung.de/Fruehmobilisierung/Algorithmen_files/BPS.pdf

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Do it Right – Vancomycin Dosing

bioniche_vancomycin

  After a discussion at work I’ve been looking to current recommendations for proper vancomycin dosing in the ICU and ER.

Drug monitoring should be performed. Through serum concentrations just before the next dose at steady state are recommended. Steady state is achieved normally just before the fourth dose. The minimum through serum concentration should be above 10mg/L to avoid the resistance and at least moderate concentration at the infection theatre. If you have a MRSA with a Minimal Inhibition Concentration (MIC) of 1mg/L or above minimum through concentrations of 15-20mg/L should be targeted. To achieve optimal through concentrations doses of 15-20mg/kg actual body weight (ABW) should be given every 8-12 hours with normal renal function. In case of a MIC of 2 or above conventional dosing regimes fail. If you have a serious ill patient the authors recommend a loading dose of 25-30mg/kg ABW.  Vancomycin Induced Nephrotoxicity is defined as two or three increases in serum creatinine concentrations (0,5mg/dL or 50% above baseline) after several days of therapy. Frequent monitoring is not recommended if there is no risk for renal failure. The authors suggest a weekly monitoring for stable patients. Every patient should receive at least one through serum level and repeated as deemed clinically appropriate.

So dose right, know your MIC.

Rybak, Michael, et al. “Therapeutic monitoring of vancomycin in adult patients: a consensus review of the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, and the Society of Infectious Diseases Pharmacists.” American Journal of Health-System Pharmacy 66.1 (2009): 82-98.

MarylandCC Project - Vanc & Zosyn is NOT the Answer to Everything

EMCrit – Proper Vancomycin Dosing

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PRINCIPLE – First details published

As a part of the poster presentation first details were published.
PRINCIPLE – Predictors of Re-Intubation in Neurological Criticall Ill Planned for Extubation found these predictors and could calculate a significant score to use in daily business. Strengest predictor for itself was tracheal secretion.

http://www.dgni.de/forschung/ignite-initiative-klinischer-multizenter-studien/aktuelle-forschungsprojekte/allgemeine-intensivmedizin/115-principle-predictors-of-re-intubation-in-neurological-criticall-ill-planned-for-extubation.html

We are hoping on an interview with Dr. Steidl.

There is already an article about PRINCIPLE on the site of the Department of Neurology, here is the link.

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Another failed neuroprotective agent – ALIAS part 2

Today i give a little review about ALBUMIN 25% as a neuroprotective agent in case of ischemic stroke. Ginsberg et. all. published in the LANCET NEUROLOGY a placebo controlled double blinded phase 3 trial  where they looked for a favourable outcome for the use of ALBUMIN in the early treatment of stroke. ALIAS part 1 showed a trend to a favourable outcome. So about 800 patients were enrolled. Patients in the verum group received 25% ALBUMIN (2g per kg/KG). Favourable outcome was defined as NIH-SS of 0 and 1 or/and mRS of 0 and 1 at 90 days. About 85% in both groups received thrombolysis. The investigation was stopped due to futility in september 2012. There was no outcome differ after 841 patients enrolled. During the early phase of the trial there was promissing data in favour of ALB treatment.
Pulmonary oedema was more common as well as intracerebral hemorrhage in the ALB group.
I personally exspected a different result. In the light of SAFE-TBI there could have been even a different result showing harm if using ALB.
So standard fluid for resus a patient with ischemic insult remains cristalloid. But i think that you have an option for ALB in selected cases.

Notes:
SAFE-TBI, Cooper et all., J Neurotrauma. 2013 Apr 1;30(7):512-8. doi: 10.1089/neu.2012.2573. Epub 2013 Mar 21.
ALIAS part 1, Hill et all., Stroke. 2011 Jun;42(6):1621-5. doi: 10.1161/STROKEAHA.110.610980. Epub 2011 May 5.
ALIAS part 2, Ginsberg et all., Lancet Neurol. 2013 Sep 26. pii: S1474-4422(13)70223-0. doi: 10.1016/S1474-4422(13)70223-0. [Epub ahead of print]

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Cerebral Vasospasm in Intraventricular Hemorrhage

Just read an intresting artivel about vasospasms in ICB in case of IVH. Method of Detection was ultrasound. DCI was confirmd by CCT. Functional outcom finally fixed by mRS. Regual et al. scaned about 130 Patients and of whom 62 entered the study. 37% had vasospasm. Outcome did not differ. In case of early vasospasm there is a significant worsened outcome.

http://rd.springer.com/article/10.1007%2Fs12028-013-9897-z

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Malignant neuroleptic syndorme

Yesterday a young male patient with history of autism and aggressive behaviour was presented at our ER and directly admissioned to our ICU. In a community hospital the question was raised, cloud that be a malignant neuroleptic syndrome. I took that as an opportunity to think a about this entity.

With the help of my dear colleague Sascha Berning we have sketched a possible SOP for malignant neuroleptic syndrome.

MNS

There is a very good score in uptodate

Malignant neuroleptic syndrome

Neurointensivmedizin – kompakt 2012, Altenburg : J. Berrouschot, Klinikum Altenburger Land, 978-3-00-036912-4, http://d-nb.info/1022768417

Neuroleptic malignant syndrome, Wijdicks et al., 2013, http://www.uptodate.com/contents/neuroleptic-malignant-syndrome?detectedLanguage=en&source=search_result&search=neuroleptic+malignant+hyperthermia&selectedTitle=1%7E150&provider=noProvider#H31

 

 

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