Faculty Bibliography

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

Management of patients with terminal brain disorders can be medically, socially, and ethically complex. Although a growing number of feasible treatment options may exist, there are times when further treatment can no longer meaningfully improve either quality or length of life. Clinicians and patients should discuss goals of care while patients are capable of making their own decisions. However, because such discussions can be challenging, they are often postponed. These discussions are then conducted with patients' health care proxies after patients lose the capacity to make their own decisions. Disagreements may arise when a patient's surrogate desires continued aggressive interventions that are either biologically futile (incapable of producing the intended physiologic result) or potentially inappropriate (potentially capable of producing the patient's intended effect but in conflict with the medical team's ethical principles). This article explores best practices in addressing these types of conflicts in the critical care unit, but these concepts also broadly apply to other sites of care.