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.