Intensive care unit admission

Intensive care unit admission

Currently evidence do not allow to define standardized protocol to guide ICUadmission for acute neurological patients (TBI) patients, postoperative neurosurgical procedures and stroke 1).

Kim et al., enrolled 322 patients with severe trauma and TBI from January 2015 to December 2016. Clinical factors, indexes, and outcomes were compared before and after trauma center establishment (September 2015). The outcome was the Glasgow outcome scale classification at 3 months post-trauma.

Of the 322 patients, 120 (37.3%) and 202 (62.7%) were admitted before and after trauma center establishment, respectively. The two groups were significantly different in age (p=0.038), the trauma location within the city (p=0.010), the proportion of intensive care unit (ICUadmissions (p=0.001), and the emergency room stay time (p<0.001). Mortality occurred in 37 patients (11.5%). Although the preventable death rate decreased from before to after center establishment (23.1% vs. 12.5%), the difference was not significant. None of the clinical factors, indexes, or outcomes were different from before to after center establishment for patients with severe TBI (Glasgow coma scale score ≤8). However, the proportion of inter-hospital transfers increased and the time to emergency room arrival was longer in both the entire cohort and patients with severe TBI after versus before trauma center establishment.

They confirmed that for patients with severe trauma and TBI, establishing a trauma center increased the proportion of ICU admissions and decreased the emergency room stay time and preventable death rate. However, management strategies for handling the high proportion of inter-hospital transfers and long times to emergency room arrival will be necessary 2).


In the United States, 20% of patients with mild traumatic brain injury, defined as those with a Glasgow Coma Scale (GCS) of 13-15, presenting to the Emergency Department are admitted to the ICU 3).


Within a prospectiveobservationalmulticenter cohort study 68 hospitals (of which 66 responded), mostly academic (n = 60, 91%) level I trauma centers (n = 44, 67%) in 20 countries were asked to complete questionnaires regarding the “standard of care” for severe neurotrauma patients in their hospitals. From the questionnaire pertaining to ICU management, 12 questions related to admission criteria were selected for this analysis. The questionnaires were completed by 66 centers. The median number of TBI patients admitted to the ICU was 92 [interquartile range (IQR): 52-160] annually. Admission policy varied; in 45 (68%) centers, patients with a Glasgow Come Score (GCS) between 13 and 15 without CT abnormalities but with other risk factors would be admitted to the ICU while the rest indicated that they would not admit these patients routinely to the ICU.

Volovici et al. found no association between ICU admission policy and the presence of a dedicated neuro ICU, the discipline in charge of rounds, the presence of step down beds or geographic location (North- Western Europe vs. South – Eastern Europe and Israel). Variation in admission policy, primarily of mild TBI patients to ICU exists, even among high-volume academic centers and seems to be largely independent of other center characteristics. The observed variation suggests a role for comparative effectiveness research to investigate the potential benefit and cost-effectiveness of a liberal versus more restrictive admission policies 4).


The aim of study was to describe current approaches and to quantify variability between European intensive care units (ICU)s in patients with traumatic brain injury (TBI). Therefore, Huijben et al. conducted a provider profiling survey as part of the ‘Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury‘ (CENTER-TBI) study. The ICU Questionnaire was sent to 68 centers from 20 countries across Europe and Israel. For this study, they used ICU questions focused on 1) hemoglobin target level (Hb-TL), 2) coagulation management, and 3) deep venous thrombosis (DVT) prophylaxis. Sixty-six centers completed the ICU questionnaire. For ICU-patients, half of the centers (N= 34; 52%) had a defined Hb-TL in their protocol. For patients with TBI, 26 centers (41%) indicated a Hb-TL between 70 and 90 g/l and 38 centers (59%) above 90 g/l. To treat trauma related hemostatic abnormalities the use of fresh frozen plasma (N= 48; 73%) or platelets (N= 34; 52%) was most often reported, followed by the supplementation of vitamin K (N= 26; 39%). Most centers reported using DVT prophylaxis with anticoagulants frequently or always (N= 62; 94%). In the absence of hemorrhagic brain lesions, 14 centers (21%) delayed DVT prophylaxis until 72 hours after trauma. If hemorrhagic brain lesions were present, the number of centers delaying DVT prophylaxis for 72 hours increased to 29 (46%). Overall, a lack of consensus exists between European ICUs on blood transfusion and coagulation management. The results provide a baseline for the CENTER-TBI study and the large between-center variation indicates multiple opportunities for comparative effectiveness research 5).

References

1)

Badenes R, Robba C, Taccone FS, Bilotta F. Neuro-ICU patient disposition: optimal venue for acute needs. Curr Opin Crit Care. 2018 Jan 23. doi: 10.1097/MCC.0000000000000482. [Epub ahead of print] PubMed PMID: 29369064.
2)

Kim JS, Jeong SW, Ahn HJ, Hwang HJ, Kyoung KH, Kwon SC, Kim MS. Effects of Trauma Center Establishment on the Clinical Characteristics and Outcomes of Patients with Traumatic Brain Injury : A Retrospective Analysis from a Single Trauma Center in Korea. J Korean Neurosurg Soc. 2019 Mar;62(2):232-242. doi: 10.3340/jkns.2018.0037. Epub 2019 Feb 27. PubMed PMID: 30840979.
3)

Ratcliff JJ, Adeoye O, Lindsell CJ, et al.: ED disposition of the Glasgow Coma Scale 13 to 15 traumatic brain injury patient: analysis of the Transforming Research and Clinical Knowledge in TBI study. Am J Emerg Med 32:844-850, 2014
4)

Volovici V, Ercole A, Citerio G, Stocchetti N, Haitsma IK, Huijben JA, Dirven CMF, van der Jagt M, Steyerberg EW, Nelson D, Cnossen MC, Maas AIR, Polinder S, Menon DK, Lingsma HF. Intensive care admission criteria for traumatic brain injury patients across Europe. J Crit Care. 2018 Nov 8;49:158-161. doi: 10.1016/j.jcrc.2018.11.002. [Epub ahead of print] PubMed PMID: 30447560.
5)

Huijben JA, van der Jagt M, Cnossen MC, Kruip MJHA, Haitsma I, Stocchetti N, Maas A, Menon D, Ercole A, Maegele M, Stanworth SJ, Citerio G, Polinder S, Steyerberg EW, Lingsma H. Variation in blood transfusion and coagulation management in Traumatic Brain Injury at the Intensive Care Unit: A survey in 66 neurotrauma centers participating in the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. J Neurotrauma. 2017 Aug 21. doi: 10.1089/neu.2017.5194. [Epub ahead of print] PubMed PMID: 28825511.

Book: Neurosurgical Intensive Care

Neurosurgical Intensive Care

Neurosurgical Intensive Care

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Decompression is still the mainstay of surgical intervention for neurosurgeons treating neurocritical care patients. However, during the last 20 years, an evolution away from a mechanistic approach has transformed neurocritical care into an increasingly multidisciplinary field. Neurosurgical Intensive Care, 2nd Edition reflects this new paradigm, authored by a neurosurgeon with contributions from experts in the fields of neurology, vascular neurology, interventional neuroradiology, anesthesiology, critical care, traumatology, nutrition, and advanced practice nursing.
Neuromonitoring advances have enabled customized interventions tailored to each patient’s unique circumstances. The critical care of neurosurgical patients has evolved from an emphasis on pulmonary care (ventilation and oxygenation) to a more nuanced understanding of cerebral protection measures required to manage a disrupted blood-brain-barrier. This edition encompasses advances in the use of ICP monitors, external ventricular devices, brain tissue oxygen monitoring devices, cerebral microdialysis, fluid and electrolyte correction, as well as the increasing use of continuous EEG in the ICU.
Key Features

  • Straightforward summaries for each stage of patient care including bedside exams, neuroimaging, lab work, triage procedures, sedation and pain management, neuropharmacology, nutritional needs, administration of fluids, and more.
  • 159 tables and figures facilitate rapid evaluation and decision making.
  • Clinical pearls on a wide range of ICU scenarios – from pathophysiology and management of coma – to interventions for spinal cord injury, multisystem injuries, acute ischemic stroke, and pediatric cases.
  • Insights on how to handle family communication and spiritual needs, medical-legal issues, and discharge planning

This compact, highly practical handbook provides a stellar reference for managing critically ill neurosurgical patients in the ICU. It is a must-have resource for nurses, medical students, residents, fellows, and attending physicians who treat these patients.


Product Details

  • Published on: 2017-05-01
  • Original language: English
  • Dimensions: 5.00″ h x .0″ w x 8.00″ l,
  • Binding: Paperback
  • 576 pages
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