Monitoring in Neurocritical Care

Monitoring in Neurocritical Care......Page 4
Copyright page......Page 5
Dedication......Page 6
Preface......Page 7
Contributors......Page 9
Abbreviations......Page 14
Physiology of Cerebral Blood Flow and Cerebral Blood Volume......Page 20
Cerebral Autoregulation......Page 21
Intracranial Pressure and  Cerebral Hemodynamics......Page 22
Primary and Secondary Injury......Page 23
Conclusion......Page 24
References......Page 25
References......Page 26
Scope of Practice of the  Modern Neurointensivist......Page 28
Neurocritical Care Delivery  and Patient Outcome......Page 29
Primary and Secondary Brain Injury......Page 31
Rationale for Neurologic Monitoring......Page 32
References......Page 33
References......Page 35
Limiting Infection, Traffic, and Noise......Page 37
Patient Room Layout......Page 38
Hospital-Acquired Infections......Page 39
Staff Work and Support Area Location  and Layout......Page 40
Staff Stress and Effectiveness......Page 41
Family Space in Patient Rooms......Page 42
Odors and Aromas......Page 43
Evidence for a Better Way......Page 44
A Dynamic Design Process......Page 45
Proposal Becomes Reality......Page 46
References......Page 47
References......Page 49
Introduction......Page 51
Planning......Page 52
Overview......Page 53
Collecting Data from Individual Bedside Patient Monitors or Devices......Page 54
Linking Patients to Their Data......Page 55
Clinical Decision Support......Page 56
References......Page 57
References......Page 59
Immediate Past......Page 60
Nursing Theory—Practice  and Process......Page 61
Evidence-Based Practice......Page 63
Invasive Monitoring......Page 64
Nursing and Monitoring......Page 65
Phase II—Maintenance at the  Intrahospital Destination......Page 66
Nurse and Physician......Page 67
References......Page 68
References......Page 70
History of and Impetus for Qualitative Initiatives......Page 71
Process Quality Indicators......Page 72
Ventilator-Associated Pneumonia......Page 73
Glycemic Control (See Also Chapter 14)......Page 74
Physician Staffing Models......Page 75
Intensive Care Unit Physician Staffing Plan......Page 76
Telemedicine......Page 77
Does Benchmarking  Influence Outcome?......Page 78
How to Ensure a Successful  Quality Assurance or  Benchmarking Initiative......Page 79
References......Page 80
References......Page 82
Cerebral Blood Flow......Page 85
Brain Tissue Oxygen......Page 86
Pressure Autoregulation......Page 87
References......Page 88
References......Page 90
History......Page 93
A Closer Look at the Definition: “Total” and “Irreversible”......Page 94
Loosening Brain Death Criteria to Include Other Disorders of Consciousness: Issues in Diagnostics and Prognostics......Page 96
Futility......Page 97
Ethically Weighted by Prognostic Ambiguity and Futility......Page 99
When and How to Use Neuromonitoring in the Context  of Patients’ and Their Families’ Needs and Wants......Page 100
Conclusion......Page 101
References......Page 102
References......Page 103
Anesthetic Agents......Page 105
Inhalational Anesthetics......Page 106
Intravenous Anesthetics......Page 107
Somatosensory Evoked Potential Monitoring......Page 108
Motor Evoked Potentials......Page 109
Anesthetic Effects......Page 110
Near Infrared Spectroscopy......Page 112
Intravenous Anesthetics......Page 113
References......Page 114
References......Page 116
Anatomy of Brain Circuits  Involved in Arousal, Alertness,  and Conscious Behavior......Page 119
Coma Etiology......Page 120
Level of Consciousness......Page 121
Pupillary Examination......Page 122
Resting Eye Position and Eye Movements......Page 123
Breathing Patterns......Page 124
Glasgow Coma Scale......Page 125
Full Outline of Unresponsiveness Score......Page 126
Subarachnoid Hemorrhage......Page 128
Clinical Scores That Reflect Overall Disease Severity......Page 129
Prognosis of the Comatose Patient......Page 130
The Vegetative and Minimally Conscious State......Page 131
References......Page 132
References......Page 134
Indications for Analgesia  and Sedation......Page 137
Delirium......Page 138
Confusion Assessment Method  for Intensive Care Unit......Page 139
Strategies to Optimize the Delivery of Analgesia and Sedation......Page 140
Selection of Analgesia and Sedation for Critically Ill Patients......Page 141
Management of Delirium......Page 142
Conclusion......Page 143
References......Page 144
References......Page 145
Functional Outcome Scales......Page 148
Barthel Index......Page 149
Sickness Impact Profile......Page 150
Mini-Mental Status Examination......Page 151
Cognistat......Page 152
References......Page 153
References......Page 155
Brain Death Medical Criteria......Page 157
Brainstem Reflexes......Page 158
Tests of Cerebral Blood Flow......Page 159
Controversies in Brain Death......Page 160
Brain Death and Organ Donation......Page 161
References......Page 162
References......Page 164
Point-of-Care Testing......Page 166
Microdialysis......Page 167
Insulin Therapy in Critical Care......Page 168
Insulin Therapy in Neurocritical Care......Page 169
Nutrition......Page 170
Route of Acute Nutritional Delivery......Page 171
Formulas to Determine Caloric Requirements......Page 172
Biochemical Measurements......Page 173
References......Page 174
References......Page 176
Erythropoiesis and Blood Counts......Page 179
Causes of Anemia in the Intensive  Care Unit......Page 180
Anemia in the Neurocritical Care Unit......Page 181
Drug-Induced Immune Thrombocytopenia......Page 182
Thrombotic Microangiopathies: Thrombotic Thrombocytopenic Purpura......Page 183
Disseminated Intravascular Coagulation......Page 184
Efficacy of Transfusion......Page 185
Strategies to Prevent Anemia......Page 186
Venous Thromboembolism in the Intensive Care Unit......Page 187
Venous Thromboembolism Prophylaxis  in Stroke Patients......Page 188
Cerebral Venous Thrombosis......Page 189
Hyperhomocysteinemia......Page 190
Fondaparinux......Page 191
Vitamin K Antagonists......Page 192
Thromboelastography......Page 193
References......Page 194
References......Page 196
Basic Science of Inflammation......Page 202
The Febrile State: Monitoring Brain and Body Temperature......Page 203
Cerebrospinal Fluid  Inflammatory Markers......Page 204
Further Understanding of the Dual Effects of Cytokines Following Acute Brain Injury......Page 205
References......Page 206
References......Page 208
Epidemiology......Page 211
Management of Space-Occupying Infections......Page 212
Management......Page 213
Characteristics of the West Nile Virus......Page 214
External Ventricular Drains......Page 215
Surveillance and Evaluating  the Febrile Neurocritical  Care Unit Patient......Page 216
Sepsis......Page 217
Infection Prevention  in the Intensive Care Unit......Page 218
Human Immunodeficiency Virus......Page 219
References......Page 220
References......Page 222
Introduction......Page 225
Current Status of  Surrogate Markers......Page 226
S100β......Page 227
Spectrin......Page 228
Novel Approaches to Identify Potential Surrogate Markers  for Brain Damage......Page 229
Neuron-Enriched Proteins Released During Neurodegeneration Are Markers for Acute Brain Damage  in Experimental Models......Page 230
Novel CSF Neurodegeneration Markers Provide Evidence for Acute Central Nervous System Damage  in Humans......Page 231
Future Directions......Page 233
References......Page 234
References......Page 236
Physical Examination and Laboratory Determination  of Effective Circulating Volume......Page 239
Invasive......Page 240
Pulse Pressure and Stroke  Volume Variability......Page 241
Monitoring Flow and Volume......Page 242
Central Venous Pressure:  What It Does and Does Not Do......Page 243
Lithium Dilution......Page 244
Other Devices......Page 245
Right Heart Catheterization  and Pulmonary Artery  Pressure Monitoring......Page 246
The Current Role of Echocardiography  in Critical Care......Page 247
Assessment of Cardiac Output......Page 248
Lactate......Page 249
Key Points......Page 250
References......Page 251
References......Page 252
Imaging and Diagnostic Studies......Page 255
ARDS and ALI......Page 256
Indications for Use......Page 257
Information Provided  and Troubleshooting......Page 258
Engineering and Technology......Page 259
Indications for Use......Page 260
Information Provided  and Troubleshooting......Page 261
Therapy Based on Respiratory  Mechanics and Ventilator Variables  and the Effect on Outcome......Page 262
Weaning and Liberation from Mechanical Ventilation......Page 263
References......Page 264
References......Page 266
Practicalities of Endocrine Assessment in the Critical Care Unit......Page 268
Etiology......Page 269
Monitoring the Hypothalamic-Pituitary-Adrenal Axis in the ICU......Page 270
Etiology and Presentation......Page 271
Nonthyroidal Illness Syndrome......Page 272
Monitoring Somatotroph and Gonatroph Function in the ICU......Page 273
Syndrome of Inappropriate  Antidiuretic Hormone......Page 274
Endocrine Consequences  of Traumatic Brain Injury......Page 275
References......Page 276
References......Page 278
Renin-Angiotensin-Aldosterone System......Page 280
Plasma Osmolality......Page 281
RIFLE and AKIN Criteria......Page 283
Prerenal AKI and ATN......Page 284
AKI in Cirrhosis......Page 285
Drugs and AKI......Page 286
ACE Inhibitors......Page 287
Pigment-Induced AKI......Page 288
Renal Replacement Therapy in AKI......Page 289
Normal Gas Exchange......Page 290
Acute Respiratory Acidosis......Page 291
Anion Gap......Page 292
Alcohols......Page 293
Methanol......Page 294
References......Page 295
References......Page 297
Gastrointestinal Bleeding......Page 299
Hepatic Encephalopathy  and Hyperammonemia......Page 302
Cerebral Edema......Page 303
Pancreatitis......Page 304
References......Page 305
References......Page 307
Recording......Page 309
Somtatosensory Evoked Potentials......Page 310
Brainstem Auditory Evoked Potentials......Page 311
Postanoxic Coma (Hypoxic-Ischemic Encephalopathy)......Page 312
Acute Ischemic Stroke......Page 313
Subarachnoid Hemorrhage......Page 315
Medication Effects......Page 316
References......Page 317
References......Page 319
Pathologic Electroencephalogram Activity......Page 322
Types of Seizures, Related Phenomena, and Differential Diagnosis......Page 323
Electrode Placement and Montage......Page 325
Data Analysis......Page 326
Aneurysmal Subarachnoid Hemorrhage......Page 327
Hypoxic-Ischemic Encephalopathy......Page 328
Refractory Status Epilepticus......Page 329
References......Page 330
References......Page 332
A Brief Comparison  with Other Techniques......Page 335
Computed Tomography Perfusion......Page 336
Intracranial Hemorrhage......Page 337
Herniation......Page 338
Infarct......Page 339
Computed Tomography Angiography......Page 340
Subarachnoid Hemorrhage......Page 341
Acute Cerebral Infarction......Page 344
Computed Tomography Angiography......Page 345
References......Page 346
References......Page 348
Theory and Physiology......Page 352
Devices and Engineering......Page 356
Xe-CT Cerebral Blood Flow Procedure......Page 357
Subarachnoid Hemorrhage and Vasospasm......Page 358
Ischemic Stroke......Page 359
Conclusion......Page 360
References......Page 361
References......Page 363
MRI Sequences......Page 366
Ischemic Stroke......Page 367
Anoxic Brain Injury......Page 368
Traumatic Brain Injury......Page 370
Reversibility of Traumatic  Brain Injury Lesions......Page 372
Conclusion......Page 373
References......Page 374
References......Page 375
Methodologic Issues......Page 377
Positron Emission Tomography......Page 378
Single Photon Emission  Computed Tomography......Page 379
Imaging of Cerebral Blood Flow and Volume......Page 380
Imaging of Oxygen  and Glucose Metabolism......Page 381
References......Page 383
References......Page 385
Transcranial Doppler and TCCS Techniques......Page 388
Nonthermal Effects......Page 389
Assessment of Cerebral Blood Flow Regulation with Ultrasound......Page 390
Limitations of TCD and TCCS......Page 392
Diagnosis and Monitoring  of Cerebral Vasospasm......Page 393
Vasospasm of Other Arteries......Page 394
Selection of Patients for Extracranial  to Intracranial Bypass Surgery......Page 395
Balloon Occlusion Test......Page 396
Traumatic Brain Injury......Page 397
Microembolic Signals and Monitoring During Vascular Procedures......Page 398
Therapeutic Use of Ultrasound  in Acute Stroke......Page 399
References......Page 400
References......Page 402
Laser Doppler Flowmetry......Page 408
Thermal Diffusion Flowmetry......Page 409
Orthogonal Polarizing  Spectral Imaging......Page 411
References......Page 412
References......Page 414
Insertion Technique......Page 416
Site of Cannulation......Page 417
Interpretation of the Measurements......Page 418
Intraoperative Management of Patients Undergoing Intracranial Aneurysm Surgery......Page 419
As a Guide to Clinical Management  in the Intensive Care Unit......Page 420
References......Page 421
References......Page 423
Basic Principles......Page 425
Instrumentation......Page 426
Clinical Application......Page 427
Evaluation of the NIRO 300 as a Monitor of Cerebral Ischemia......Page 428
Cerebral Blood Volume  and Cerebral Blood Flow......Page 429
Indocyanine Green......Page 430
Conclusion......Page 431
References......Page 432
References......Page 434
Mass Lesion......Page 437
Cerebral Blood Volume......Page 438
Is High Intracranial Pressure Associated with Poor Outcome?......Page 439
An Intracranial Pressure Threshold......Page 440
Intracranial Pressure  Monitoring Technology......Page 441
Technical Issues......Page 442
Insertion of ICP Monitors  in Patients with Abnormal Coagulation Studies......Page 443
Cerebral Compliance and Compensatory Reserve......Page 444
References......Page 445
References......Page 447
Technology......Page 451
Regional Versus Global Measurement......Page 453
Observational Data......Page 454
Safety......Page 455
PbtO2 Reactivity......Page 456
References......Page 457
References......Page 459
Principles of Microdialysis......Page 463
Microdialysis Markers......Page 465
Markers of Glucose Metabolism......Page 466
Excitotoxicity......Page 467
Monitoring Evolution of Brain Injury......Page 468
Assessment of Adequacy of Cerebral Perfusion......Page 469
Hyperventilation......Page 470
Novel Biomarkers......Page 471
References......Page 472
References......Page 474
Brain Temperature Is Heterogeneous......Page 477
Fever Is Associated with Worse Outcomes After Severe Brain Injury......Page 478
Systemic and Core Temperature......Page 479
Conclusion......Page 480
References......Page 481
References......Page 482
Idea Generation......Page 484
Extent of Business Activities......Page 485
Financing Product Development......Page 486
Government Research Funds......Page 487
State Commercialization Funds......Page 488
Angel and Venture Funding......Page 489
What Equity Investors Are Seeking......Page 490
Pros and Cons of an Equity Investment......Page 491
Conclusion......Page 492
References......Page 493
The Ideal Monitor......Page 494
Tunneling......Page 495
Primary Sensors......Page 496
Intensity Modulation......Page 497
Doppler......Page 498
The Regulatory Environment......Page 499
References......Page 500
Rationale......Page 501
Communicative Monitoring......Page 502
The Role of Artificial Intelligence......Page 504
University-Developed Systems......Page 506
Commercial Systems......Page 507
The Future......Page 508
Sensors......Page 509
Unified Information Architecture......Page 510
References......Page 511
References......Page 513
Introduction......Page 515
What Is Crisis Resource Management?......Page 516
Simulation as a Strategy for CRM Training in Critical Care......Page 517
Does CRM Work in Medicine?......Page 519
References......Page 520
References......Page 522
Physician Response Paradigms......Page 524
Robotic Telepresence Technology......Page 525
Rapid Response to Unstable Intensive Care Unit Patient Condition......Page 526
Improving Efficiency of Care......Page 527
Emergency Department Triage  and Consultation......Page 528
References......Page 529
Information Technology......Page 531
Data Acquisition......Page 532
Mathematical Models......Page 535
Artificial Neural Network......Page 536
Bayesian Approach to Neural  Network Training......Page 537
Conclusion......Page 539
References......Page 541
ICU Outcomes with an Intensivist Model......Page 542
Evolution of VISICU......Page 543
eICU Technology......Page 544
eICU Team Responsibilities......Page 545
The Impact Beyond the ICU......Page 546
Possibilities for the Practice of Neurocritical Care with an eICU Program......Page 547
References......Page 548
References......Page 550
What Is Not Known......Page 552
Are More Data Better? The Example of Defining “Dose” of Secondary Brain Insults......Page 553
Advanced Critical Care  Informatics I: Data-Driven  Methods for Prediction......Page 554
Neural Networks......Page 555
Decision Trees......Page 556
Dynamic Bayesian Networks......Page 557
Medical Informatics and Decision Support—Enhancing Expertise......Page 558
References......Page 559
References......Page 561
Noninvasive Intracranial  Pressure and Cerebral  Perfusion Pressure Monitoring......Page 563
Intracranial Pressure Monitors Based  on the Optic Nerve......Page 564
System Analysis: Phase Shift and Transfer Function Between Arterial Pressure and Flow Velocity Waves......Page 566
Time Correlation Method (Mx Index)......Page 567
Wavelet Analysis......Page 568
Brain Oxygenation......Page 569
Magnetic Resonance Imaging......Page 570
EEG and BIS......Page 571
References......Page 572
References......Page 574
Pathophysiology of Detectable Brain Injury......Page 576
Initial Studies......Page 577
Current Status......Page 578
BAM Measurements in Normal Volunteers and Traumatic Brain Injury Patients......Page 579
Example of the Acoustic Response  of a Stroke Patient......Page 583
Initial Issues and Challenges......Page 584
Delay of Initial Acoustic Response?......Page 585
The Brain Acoustic Monitor  as a Leading Indicator......Page 586
Sensitivity and Specificity Verification......Page 587
References......Page 588
The Basics: Glasgow Coma Scale and Physical Examination......Page 590
PbtO2......Page 591
Noninvasive Monitoring of Brain  Oximetry: NIRS......Page 592
Devices Based on Light  Scattering Measurements......Page 593
Brainstem Auditory Evoked Potentials......Page 594
Pupillometer......Page 595
Nanotechnology, Microprocessing, and Long-Term Projections......Page 596
References......Page 598
References......Page 600