Faculty Bibliography

Background: Surgical resection of pituitary adenomas is associated with a 10 to 30% rate of temporary diabetes insipidus with ~50% resolving within 1 week and 80% resolving at 3 months.[1] Adrenal insufficiency occurs in ~ 5 % of patients and can result in an Addisonian crisis if left undiagnosed postoperatively.[1] [2] Many studies have been performed looking at readmission rates after pituitary surgery. A review of over 1,200 cases demonstrated a readmission rate of 8.5% with the most common cause being hyponatremia (29.5%).[3] To reduce the rate of readmission for hyponatremia, some groups have demonstrated the effective use of outpatient fluid restriction criteria during the first week post-op.[4] These guidelines are intended for the management of standard postoperative hormonal fluctuations which do not necessitate endocrine consultation during hospitalization.
Objective(s): Retrospectively evaluate patients undergoing endoscopic endonasal resection of pituitary adenomas to identify areas for quality improvement through the development of more standardized postoperative guidelines.
Method(s): A retrospective review of 75 patients who underwent endoscopic endonasal resection of pituitary adenomas at a single academic center from 2013 to 2018. We evaluated the average length of stay, number of laboratory studies performed, need for hormone supplementation long term and short term, rate of gross-total resection, rate of cerebrospinal fluid leak, rate of infection, and 30-day readmission rate ([Table 1]). From this, we have developed a change in guidelines aimed at reducing length of stay, redundant laboratory studies, and reduced rate of readmission.
Conclusion(s): Although our current outcomes for resection of pituitary adenoma are on par with published data, we have identified areas of possible quality improvement which have since been implemented

BACKGROUND:There have been a number of recent prominent lawsuits challenging the use of neurologic criteria to declare death in the United States. METHODS:To put these lawsuits into perspective, we conducted a search of Nexis Uni® to identify cases from the past 50 years that involved objections to the use of neurologic criteria to declare death in the United States. RESULTS:We identified lawsuits about 67 decedents (59 state and 8 federal) from 34 different regions which were filed for crime related issues (n=42), hospital related issues (n=20), insurance related issues (n=2) and other issues related to time of death (n=3). The judicial opinions about the lawsuits addressed: 1) acceptance of the use of neurologic criteria to declare death (n=55), 2) criteria to declare death (n=3), 3) management of decedents after death by neurologic criteria (n=13), 4) identification of the time of death (n=4) and 5) rights of the dead (n=3). The outcomes of these cases were heterogeneous. CONCLUSION/CONCLUSIONS:Since the incorporation of neurologic criteria into the medical practice of declaration of death, there have been a number of legal objections to its use. To avoid the rendering of variable opinions by the courts, there is a need for consistent legislative modification throughout the country to address 1) the specific criteria to employ when declaring death by neurologic criteria, 2) management of religious objections to use of neurologic criteria to declare death and 3) management after declaration of death by neurologic criteria.

The American Academy of Neurology holds the following positions regarding brain death and its determination, and provides the following guidance to its members who encounter resistance to brain death, its determination, or requests for accommodation including continued use of organ support technology despite neurologic determination of death.

BACKGROUND AND PURPOSE/OBJECTIVE:Patients with intracerebral hemorrhage (ICH) frequently present with hypertension, but it is unclear if this is due to pre-existing hypertension (prHTN) or to the bleed itself or associated pain. We sought to assess the relationship between prHTN and admission systolic blood pressure (aBP) and bleed severity. METHODS:We retrospectively assessed the relationship between prHTN and aBP and NIHSS in patients with ICH at 3 institutions. RESULTS:Of 251 patients, 170 (68%) had prHTN based on history of hypertension/antihypertensive use. Median aBP was significantly higher in those with prHTN (155 mm Hg (IQR 135-181) versus 139 mm Hg (IQR 124-158), P < .001). Patients with left ventricular hypertrophy (LVH) on electrocardiogram (ECG) or transthoracic echocardiogram (TTE) had significantly higher aBP than those without LVH (median aBP 195 mm Hg (IQR 155-216) for patients with LVH on ECG versus 147 mm Hg (IQR 129-163) for patients with no LVH on ECG, P < .001; median aBP 181 mm Hg (IQR 153-214) for patients with LVH on TTE versus 152 mm Hg (IQR 137-169) for patients with no LVH on TTE, P = .01). prHTN was associated with a higher median NIHSS (11 (IQR 3-20) for patients with history of hypertension/antihypertensive use versus 6 (IQR 1-14) for patients without this history (P = .02); 9 (IQR 3-19) versus 5 (IQR 2-13) for patients with/without LVH on ECG (P = .085); and 10 (IQR 5-18) versus 5 (IQR 1-13) for patients with/without LVH on TTE (P = .046). CONCLUSIONS:Patients with ICH who have prHTN have higher aBP and NIHSS, suggesting that prHTN may worsen reactive hypertension in the setting of ICH.

Hospital-acquired infections are common in neurointensive care units. We sought to review interventions which may reduce infection rates in neurocritically ill populations. We conducted a systematic review of studies targeting adult patients in neuro-intensive care units (neuro-ICUs) with an intervention designed to prevent ICU-acquired infections. Our outcome of interest was change in the prevalence or rates of infection between active and control arms of these studies. We excluded studies based on the following criteria: no English full-text version available; pediatric population; non-neurosciences ICU population; pre- or intraoperative methods to prevent infection; lack of discrete data for infection rates/prevalence; studies that were purely observational in nature and did not test an intervention; and studies performed in resource limited settings. We initially retrieved 3716 results by searching the following databases: PubMed/MEDLINE, EMBASE via Ovid, and Cochrane CENTRAL via Ovid. No date or language limits were used in the search. Computerized deduplication was conducted using EndNote followed by a confirmatory manual review resulting in 3414 citations. An additional 19 manuscripts were identified through review of references. The screening process followed a standard protocol, using two screeners at the title/abstract level to determine relevance and at the full-text level to determine eligibility for inclusion. The 3427 titles/abstracts were independently screened by two board-certified neurointensivists to determine relevance for full-text review, and 3248 were rejected. The remaining 179 abstracts were reviewed in full text using predetermined inclusion/exclusion criteria. Ultimately, 75 articles met our inclusion criteria and were utilized in the final analysis. The reviewed literature highlights the need for collaborative, multi-disciplinary, and multi-pronged approaches to reduce infections. Rates of VRI, SSI, VAP, CAUTI, and CLABSI can approach zero with persistence and a team-based approach.

Introduction Brain death is accepted as medically and legally equivalent to cardiopulmonary death throughout much of the world. However, families sometimes make "requests for accommodation" based on refusal to accept an established brain death declaration or desire to avert an examination for determination of brain death. We sought to evaluate the medical literature to identify the demographics and management of these requests. Methods We performed a comprehensive literature review of Cochrane, Embase and Medline for documents published between 1/1/92 and 7/15/17 that addressed requests for accommodation. Results We identified 19 documents for inclusion. In addition to the large number of requests (~1,000) described in two surveys of practitioners in the USA, we found 28 distinct requests for accommodation for persons of all ages (range: infancy to 87-years-old), nine of whom were children. Nearly every (25/28) request was made in the past 15 years. With the exception of one case from the United Kingdom, every request for accommodation was made in the USA. Requests for accommodation were made for a variety of reasons including belief that neurologic recovery could occur, desire to await arrival of additional family members prior to discontinuation of support, lack of conceptual acceptance of death with a beating heart and religious beliefs. Management of requests varied from continuation of support until cardiopulmonary arrest, withdrawal of organ support with a family's authorization, withdrawal of organ support against a family's wishes, transfer to another hospital or country or discharge home for continuation of organ support. In some cases, healthcare teams acted independently, but in others, they relied on recommendations from an ethics team or instructions from a court. Conclusions Requests for accommodation are increasing. This trend is particularly evident in the USA. Although the rationales for requests vary, uniform management guidelines are needed

Introduction Hypothermia can blunt brainstem reflexes and impair the elimination of sedatives and analgesics. As a result, it can be challenging to perform a brain death (BD) evaluation after treatment with therapeutic hypothermia. We sought to review the literature to determine when it is appropriate to do a BD evaluation after therapeutic hypothermia. Methods We reviewed Cochrane, Embase and Medline for documents published between 1/1/92 and 7/15/17 that addressed BD determination after use of therapeutic hypothermia. Results We identified 24 documents, all of which were published between 2008 and 2017. Two case studies on patients treated with therapeutic hypothermia who had findings consistent with BD, but subsequently demonstrated return of some brainstem activity, have garnered much attention in the literature: 1) A 10-month-old boy was cooled to 32-33degreeC and sedated for 24 hours then declared BD 10 hours after being rewarmed and 6 hours after discontinuation of sedation, but subsequently began breathing again; 2) A 55-year-old man was cooled to 33degreeC and sedated for 36 hours, then was declared BD 22 hours after being rewarmed and 28 hours after being taken off sedation, but later was found to breathe spontaneously and have corneal and cough reflexes. While the literature consistently questions when it is appropriate to conduct a BD evaluation after hypothermia, there is no answer based on high level evidence. Because it can be challenging to determine when a condition is irreversible after hypothermia, it has been noted that it can be helpful to augment a clinical evaluation for BD determination with ancillary testing to assess for cerebral blood flow. Conclusions There is a need for clear guidelines and expert consensus on timing of the clinical exam for BD determination and both the role for, and modality of, ancillary testing after therapeutic hypothermia