Abstract
BACKGROUND
The LACE index (Length of stay, Acuity of admission, Comorbidities, Emergency department use) quantifies the risk of mortality or unplanned readmission within 30 d after hospital ...discharge. The index was validated originally in a large, general population and, subsequently, in several specialties, not including neurosurgery.
OBJECTIVE
To determine if the LACE index accurately predicts mortality and unplanned readmission of neurosurgery patients within 30 d of discharge.
METHODS
We performed a retrospective, cohort study of consecutive neurosurgical procedures between January 1 and September 29, 2017 at our institution. The LACE index and other clinical data were abstracted. Data analysis included univariate and multivariate logistic regressions.
RESULTS
Of the 1,054 procedures on 974 patients, 52.7% were performed on females. Mean age was 54.2 ± 15.4 yr. At time of discharge, the LACE index was low (1-4) in 58.3% of patients, moderate (5-9) in 32.4%, and high (10-19) in 9.3%. Rates of readmission and mortality within 30 d were 7.0, 11.4, and 14.3% in the low-, moderate-, and high-risk groups, respectively. Moderate-risk (odds ratio OR 1.62, 95% CI 1.02-2.56, P = .04) and high-risk LACE indexes (OR 2.20, 95% CI 1.15-4.19, P = .02) were associated with greater odds of readmission or mortality, adjusting for all variables. Additionally, longer operations (OR 1.11, 95% CI 1.02-1.21, P = .02) had greater odds of readmission. Specificity of the high-risk score to predict 30-d readmission or mortality was 91.2%.
CONCLUSION
A moderate- or high-risk LACE index can be applied to neurosurgical populations to predict 30-d readmission and mortality. Longer operations are potential predictors of readmission or mortality.
Background
Among cardiac arrest survivors, about half remain comatose 72 h following return of spontaneous circulation (ROSC). Prognostication of poor neurological outcome in this population may ...result in withdrawal of life-sustaining therapy and death. The objective of this article is to provide recommendations on the reliability of select clinical predictors that serve as the basis of neuroprognostication and provide guidance to clinicians counseling surrogates of comatose cardiac arrest survivors.
Methods
A narrative systematic review was completed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Candidate predictors, which included clinical variables and prediction models, were selected based on clinical relevance and the presence of an appropriate body of evidence. The Population, Intervention, Comparator, Outcome, Timing, Setting (PICOTS) question was framed as follows: “When counseling surrogates of comatose adult survivors of cardiac arrest, should predictor, with time of assessment if appropriate be considered a reliable predictor of poor functional outcome assessed at 3 months or later?” Additional full-text screening criteria were used to exclude small and lower-quality studies. Following construction of the evidence profile and summary of findings, recommendations were based on four GRADE criteria: quality of evidence, balance of desirable and undesirable consequences, values and preferences, and resource use. In addition, good practice recommendations addressed essential principles of neuroprognostication that could not be framed in PICOTS format.
Results
Eleven candidate clinical variables and three prediction models were selected based on clinical relevance and the presence of an appropriate body of literature. A total of 72 articles met our eligibility criteria to guide recommendations. Good practice recommendations include waiting 72 h following ROSC/rewarming prior to neuroprognostication, avoiding sedation or other confounders, the use of multimodal assessment, and an extended period of observation for awakening in patients with an indeterminate prognosis, if consistent with goals of care. The bilateral absence of pupillary light response > 72 h from ROSC and the bilateral absence of N20 response on somatosensory evoked potential testing were identified as reliable predictors. Computed tomography or magnetic resonance imaging of the brain > 48 h from ROSC and electroencephalography > 72 h from ROSC were identified as moderately reliable predictors.
Conclusions
These guidelines provide recommendations on the reliability of predictors of poor outcome in the context of counseling surrogates of comatose survivors of cardiac arrest and suggest broad principles of neuroprognostication. Few predictors were considered reliable or moderately reliable based on the available body of evidence.
Critical care fellowship training in the United States differs based on specific specialty and includes medicine, surgery, anesthesiology, pediatrics, emergency medicine, and neurocritical care ...training pathways. We provide an update regarding the number and growth of US critical care fellowship training programs, on-duty residents and certified diplomates, and review the different critical care physician training pathways available to residents interested in pursuing a fellowship in critical care. Data were obtained from the Accreditation Council for Graduate Medical Education and specialty boards (American Board of Internal Medicine, American Board of Surgery, American Board of Anesthesiology, American Board of Pediatrics American Board of Emergency Medicine) and the United Council for Neurologic Subspecialties for the last 16 years (2001-2017). The number of critical care fellowship training programs has increased 22.6%, with a 49.4% increase in the number of on-duty residents annually, over the last 16 years. This is in contrast to the period of 1995 to 2000 when the number of physicians enrolled in critical care fellowship programs had decreased or remained unchanged. Although more than 80% of intensivists in the US train in internal medicine critical care Accreditation Council for Graduate Medical Education-approved fellowships, there has been a significant increase in the number of residents from surgery, anesthesiology, pediatrics, emergency medicine, and other specialties who complete specialty fellowship training and certification in critical care. Matriculation in neurocritical care fellowships is rapidly rising with 60 programs and over 1,200 neurocritical care diplomates. Critical care is now an increasingly popular fellowship in all specialties. This rapid growth of all critical care specialties highlights the magnitude of the heterogeneity that will exist between intensivists in the future.
Hydrocephalus and seizures greatly impact outcomes of patients with aneurysmal subarachnoid hemorrhage (aSAH); however, reliable tools to predict these outcomes are lacking. The authors used a ...volumetric quantitative analysis tool to evaluate the association of total aSAH volume with the outcomes of shunt-dependent hydrocephalus and seizures.
Total hemorrhage volume following aneurysm rupture was retrospectively analyzed on presentation CT imaging using a custom semiautomated computer program developed in MATLAB that employs intensity-based k-means clustering to automatically separate blood voxels from other tissues. Volume data were added to a prospectively maintained aSAH database. The association of hemorrhage volume with shunted hydrocephalus and seizures was evaluated through logistic regression analysis and the diagnostic accuracy through analysis of the area under the receiver operating characteristic curve (AUC).
The study population comprised 288 consecutive patients with aSAH. The mean total hemorrhage volume was 74.9 ml. Thirty-eight patients (13.2%) developed seizures. The mean hemorrhage volume in patients who developed seizures was significantly higher than that in patients with no seizures (mean difference 17.3 ml, p = 0.01). In multivariate analysis, larger hemorrhage volume on initial CT scan and hemorrhage volume > 50 ml (OR 2.81, p = 0.047, 95% CI 1.03-7.80) were predictive of seizures. Forty-eight patients (17%) developed shunt-dependent hydrocephalus. The mean hemorrhage volume in patients who developed shunt-dependent hydrocephalus was significantly higher than that in patients who did not (mean difference 17.2 ml, p = 0.006). Larger hemorrhage volume and hemorrhage volume > 50 ml (OR 2.45, p = 0.03, 95% CI 1.08-5.54) were predictive of shunt-dependent hydrocephalus. Hemorrhage volume had adequate discrimination for the development of seizures (AUC 0.635) and shunted hydrocephalus (AUC 0.629).
Hemorrhage volume is an independent predictor of seizures and shunt-dependent hydrocephalus in patients with aSAH. Further evaluation of aSAH quantitative volumetric analysis may complement existing scales used in clinical practice and assist in patient prognostication and management.
Optic nerve sheath diameter (ONSD) measurement with bedside ultrasound has been shown in many studies to accurately detect high intracranial pressure (ICP). The accuracy of point-in-time ONSD ...measurement in the presence of ongoing fluctuation of ICP between high and normal is not known. Recent laboratory investigation suggests that reversal of optic nerve sheath distension may be impaired following bouts of intracranial hypertension. Our objective was to compare the accuracy of ONSD measurement in the setting of fluctuating versus stable ICP.
This was a retrospective analysis of data from prospective study comparing ONSD to invasive ICP. Patients with invasive ICP monitors in the ICU underwent ONSD measurement with simultaneous blinded recording of ICP from the invasive monitor. Three measurements were made in each eye. Significant acute ICP fluctuation (SAIF) was defined in two different ways; as the presence of ICP both above and below 20 mmHg within a cluster of six measurements (Definition 1) and as a magnitude of fluctuation >10 mmHg within the cluster (Definition 2). The accuracy of point-in-time ONSD measurements for the detection of concurrent ICP >20 mmHg within clusters fulfilling a specific definition of SAIF was compared to the accuracy of ONSD measurements within clusters not fulfilling the particular definition by comparison of independent receiver operating characteristic (ROC) curves.
A total of 613 concurrent ONSD-ICP measurements in 109 clusters were made in 73 patients. Twenty-three (21%) clusters fulfilled SAIF Definition 1 and 17 (16%) SAIF Definition 2. For Definition 1, the difference in the area under the curve (AUC) of ROC curves for groups with and without fluctuation was 0.10 (P = 0.0001). There was a fall in the specificity from 98% (95% CI 96 to 99%) to 74% (63 to 83%) and in the positive predictive value from 89% (80 to 95%) to 76% (66 to 84%) with fluctuation. For Definition 2, also, there was a significant difference between the AUC of ROC curves of groups with fluctuation-magnitude >10 mmHg and those with fluctuation-magnitude 5 to 10 mmHg (0.06, P = 0.04) as well as <5 mmHg (0.07, P = 0.01).
Specificity and PPV of ONSD for ICP >20 mmHg are substantially decreased in patients demonstrating acute fluctuation of ICP between high and normal. This may be because of delayed reversal of nerve sheath distension.
Information regarding the histological structure of thromboemboli that cause acute stroke provides insight into pathogenesis and clinical management.
This report describes the histological analysis ...of thromboemboli retrieved by endovascular mechanical extraction from the middle cerebral artery (MCA) and intracranial carotid artery (ICA) of 25 patients with acute ischemic stroke.
The large majority (75%) of thromboemboli shared architectural features of random fibrin:platelet deposits interspersed with linear collections of nucleated cells (monocytes and neutrophils) and confined erythrocyte-rich regions. This histology was prevalent with both cardioembolic and atherosclerotic sources of embolism. "Red" clots composed uniquely of erythrocytes were uncommon and observed only with incomplete extractions, and cholesterol crystals were notably absent. The histology of thromboemboli that could not be retrieved from 29 concurrent patients may be different. No thrombus >3 mm wide caused stroke limited to the MCA, and no thrombus >5 mm wide was removed from the ICA. A mycotic embolus was successfully removed in 1 case, and a small atheroma and attached intima were removed without clinical consequence from another.
Thromboemboli retrieved from the MCA or intracranial ICA of patients with acute ischemic stroke have similar histological components, whether derived from cardiac or arterial sources. Embolus size determines ultimate destination, those >5 mm wide likely bypassing the cerebral vessels entirely. The fibrin:platelet pattern that dominates thromboembolic structure provides a foundation for both antiplatelet and anticoagulant treatment strategies in stroke prevention.
Abstract
BACKGROUND
Length of stay beyond medical readiness (LOS-BMR) leads to increased expenses and higher morbidity related to hospital-acquired conditions.
OBJECTIVE
To determine the proportion ...of admitted neurosurgical patients who have LOS-BMR and associated risk factors and costs.
METHODS
We performed a prospective, cohort analysis of all neurosurgical patients admitted to our institution over 5 mo. LOS-BMR was assessed daily by the attending neurosurgeon and neuro-intensivist with a standardized criterion. Univariate and multivariate logistic regressions were performed.
RESULTS
Of the 884 patients admitted, 229 (25.9%) had a LOS-BMR. The average LOS-BMR was 2.7 ± 3.1 d at an average daily cost of $9 148.28 ± $12 983.10, which resulted in a total cost of $2 076 659.32 over the 5-mo period. Patients with LOS-BMR were significantly more likely to be older and to have hemiplegia, dementia, liver disease, renal disease, and diabetes mellitus. Patients with a LOS-BMR were significantly more likely to be discharged to a subacute rehabilitation/skilled nursing facility (40.2% vs 4.1%) or an acute/inpatient rehabilitation facility (22.7% vs 1.7%, P < .0001). Patients with Medicare insurance were more likely to have a LOS-BMR, whereas patients with private insurance were less likely (P = .048).
CONCLUSION
The most common reason for LOS-BMR was inefficient discharge of patients to rehabilitation and nursing facilities secondary to unavailability of beds at discharge locations, insurance clearance delays, and family-related issues.
Subdural hematoma (SDH) is a common disease that is increasingly being managed nonoperatively. The all-cause readmission rate for SDH has not previously been described. This study seeks to describe ...the incidence of unexpected 30-day readmission in a cohort of patients admitted to an academic neurosurgical center. Additionally, the relationship between operative management, clinical outcome, and unexpected readmission is explored.
This is an observational study of 200 consecutive adult patients with SDH admitted to the neurosurgical ICU of an academic medical center. Demographic information, clinical characteristics, and treatment strategies were compared between readmitted and nonreadmitted patients. Multivariable logistic regression, weighted by the inverse probability of receiving surgery using propensity scores, was used to evaluate the association between operative management and unexpected readmission.
Of 200 total patients, 18 (9%) died during hospitalization and were not included in the analysis. Overall, 48 patients (26%) were unexpectedly readmitted within 30 days. Sixteen patients (33.3%) underwent SDH evacuation during their readmission. Factors significantly associated with unexpected readmission were nonoperative management (72.9% vs 54.5%, p = 0.03) and female sex (50.0% vs 32.1%, p = 0.03). In logistic regression analysis weighted by the inverse probability of treatment and including likely confounders, surgical management was not associated with likelihood of a good outcome at hospital discharge, but was associated with significantly reduced odds of unexpected readmission (OR 0.19, 95% CI 0.08-0.49).
Over 25% of SDH patients admitted to an academic neurosurgical ICU were unexpectedly readmitted within 30 days. Nonoperative management does not affect outcome at hospital discharge but is significantly associated with readmission, even when accounting for the probability of treatment by propensity score weighted logistic regression. Additional research is needed to validate these results and to further characterize the impact of nonoperative management on long-term costs and clinical outcomes.
Abstract Current guidelines recommend against the use of phenytoin following aneurysmal subarachnoid hemorrhage (aSAH) but consider other anticonvulsants, such as levetiracetam, acceptable. Our ...objective was to evaluate the risk of poor functional outcomes, delayed cerebral ischemia (DCI) and delayed seizures in aSAH patients treated with levetiracetam versus phenytoin. Medical records of patients with aSAH admitted between 2005–2012 receiving anticonvulsant prophylaxis with phenytoin or levetiracetam for >72 hours were reviewed. The primary outcome measure was poor functional outcome, defined as modified Rankin Scale (mRS) score >3 at first recorded follow-up. Secondary outcomes measures included DCI and the incidence of delayed seizures. The association between the use of levetiracetam and phenytoin and the outcomes of interest was studied using logistic regression. Medical records of 564 aSAH patients were reviewed and 259 included in the analysis after application of inclusion/exclusion criteria. Phenytoin was used exclusively in 43 (17%), levetiracetam exclusively in 132 (51%) while 84 (32%) patients were switched from phenytoin to levetiracetam. Six (2%) patients had delayed seizures, 94 (36%) developed DCI and 63 (24%) had mRS score >3 at follow-up. On multivariate analysis, only modified Fisher grade and seizure before anticonvulsant administration were associated with DCI while age, Hunt-Hess grade and presence of intraparenchymal hematoma were associated with mRS score >3. Choice of anticonvulsant was not associated with any of the outcomes of interest. There was no difference in the rate of delayed seizures, DCI or poor functional outcome in patients receiving phenytoin versus levetiracetam after aSAH. The high rate of crossover from phenytoin suggests that levetiracetam may be better tolerated.
NCS guidelines and projects to date Title Year Type GRADE Critical Care Management of Patients Following Aneurysmal Subarachnoid Hemorrhage 2011 Consensus statement + Guidelines for the Evaluation ...and Management of Status Epilepticus 2012 Guideline + Consensus Summary Statement of the International Multidisciplinary Consensus Conference on Multimodality Monitoring in Neurocritical Care 2014 Consensus statement + Evidence-Based Guidelines for the Management of Large Hemispheric Infarction 2015 Guideline + Guideline for Reversal of Antithrombotics in Intracranial Hemorrhage 2015 Guideline + Prophylaxis of Venous Thrombosis in Neurocritical Care Patients 2015 Guideline + Recommendations for the Critical Care Management of Devastating Brain Injury: Prognostication, Psychosocial, and Ethical Management 2015 Position statement + The Insertion and Management of External Ventricular Drains: An Evidence-based Consensus Statement 2016 Consensus statement + The Implementation of Targeted Temperature Management: An Evidence-Based Guideline from the Neurocritical Care Society 2017 Guideline + Standards for Neurologic Critical Care Units 2018 White paper − Clinical Performance Measures for Neurocritical Care 2019 White paper − Guidelines for the Acute Treatment of Cerebral Edema in Neurocritical Care Patients 2020 Guideline + Neurocritical Care Resource Utilization in Pandemics 2020 Position statement − Critical Care Management of Patients Following Aneurysmal Subarachnoid Hemorrhage Update Est 2021 Guideline + Antiepileptic Drug Prophylaxis in Neurocritical Care Est 2022 Guideline + Neuroprognostication in Neurocritical Care Est 2022 Guideline + Guidelines for the Evaluation and Management of Status Epilepticus Update Est 2023 Guideline + Est, Estimated completion date; GRADE, Grading of Recommendations Assessment, Development and Evaluation; NCS, Neurocritical Care Society; + , GRADE methodology consulted for product development; − , No GRADE methodology utilized The aim of this article is to introduce and explain the basis for these changes. On the basis of the lessons learned from an examination of our own published projects and those of other societies, we summarize the changes necessary to bring our guidelines up to the highest contemporary standards. ...between December 2019 and June 2020, the NCS GC undertook a project to review existing best practices for guideline development using a comprehensive survey. Organizations identified for GC survey Neurocritical care society Agency for Healthcare Research and Quality American Academy Neurologya American College of Chest Physicians American Academy of Family Physicians American Academy of Nurse Practitioners American Association of Critical Care Nursesa American Association of Neurological Surgeons/Congress of Neurological Surgeonsa American Association of Neuroscience Nursesa American College of Surgeons, Trauma Quality Improvement Program American Epilepsy Societya American Heart Associationa Brain Trauma Foundationa Centers for Disease Control and Preventionb Eastern Association for the Surgery of Traumaa,b Endocrine Societyb European Society of Intensive Care Medicinea European Stroke Organizationa Hospital Infection Control Practices Advisory Committee Latin American Brain Injury Consortiuma Society for Neuroscience in Anesthesia and Critical Carea Society of Critical Care Medicinea,b US Preventive Services Task Forcea World Health Organizationb GC guideline committee, GRADE grading of recommendations assessment, development and evaluation aOverlapping interest bKnown to use GRADE methodology GRADE Guideline Methodology Topic, Scope, and Panel Regardless of methodology, the success of a guideline project depends greatly on a systematic approach and planning at inception. ...the NCS GC aims for a balance among physicians, nurses, pharmacists, physician assistants, and advanced practice nurses.
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