Faculty Bibliography

Introduction: Practice guidelines recommend that practitioners should not prescribe prolonged prophylactic systemic antibiotics (PPSA) after neurosurgical procedures, even if drains are left in place. We sought to evaluate 1) current practice patterns related to PPSA administration to neurosurgical patients with drains and devices and 2) practitioner perception about the need for PPSA in this population. Methods: We surveyed members of the Neurocritical Care Society on use of PPSA (defined as maintenance antibiotics after the time of insertion) and personal perception about the need for PPSA in patients with intraparenchymal monitors, subdural drains, subgaleal drains, Jackson-Pratt spinal drains, and lumbar drains. Results: Of 52 respondents, routine institutional use of PPSA was reported by 29-52% for each drain/device. The fewest respondents reported use with subgaleal drains and the most respondents reported use with Jackson-Pratt spinal drains with instrumentation. Respondents had varying personal opinions on the need for PPSA with each drain/device. Only fifteen respondents strongly disagreed/disagreed with the need for PPSA for every drain/device. The highest percentage of respondents who agreed/strongly agreed with the need for PPSA (35%) for a given drain/device was for patients with spinal drains with instrumentation while the lowest (19%) was for patients with subgaleal drains. Conclusions: It is clear that adherence to, and knowledge of, practice guidelines varies. Because antibiotic use is associated with risk of nosocomial infections and growth of resistant bacteria, education about guidelines on the use of PPSA in patients with neurosurgical drains is necessary to optimize patient care

People die either when their heart and respiration stop or when their brain irreversibly stops functioning. This latter mode of death by neurologic criteria (also called brain death) emerged after the development of ventilators and intensive care units in the late 1950s and 1960s. Brain death is universally accepted as a modern entity, but the complex process for declaring a patient brain dead is not uniformly followed across country and state lines or even hospital policies, creating unacceptable variability and risks for falsely pronouncing a patient dead. If, however, the declaring physician has expertise and diligently follows the steps that have been published in guidelines, this risk is mitigated. In this article, the authors describe the steps for brain death declaration, discuss how to avoid pitfalls, and examine the modern controversies regarding this medical reality.

OBJECTIVE: We sought to evaluate how neurologists approach situations in which families request prolonged organ support after declaration of death by neurologic criteria (DNC). METHODS: We surveyed 938 members of the American Academy of Neurology (AAN) who treat critically ill patients, including 50% who practice in states with accommodation exceptions (states that require religious or moral beliefs to be taken into consideration when declaring death or discontinuing organ support: California, Illinois, New Jersey, New York), and 50% who practice in nonaccommodation states. RESULTS: The survey was completed by 201/938 individuals (21% response rate), 96 of whom were from accommodation states and 105 of whom were from nonaccommodation states. Both groups reported encountering situations in which families requested continuation of organ support after DNC (48% from accommodation states and 46% from nonaccommodation states). In a hypothetical scenario where a request is made to continue organ support after DNC (outside of organ donation), 48% of respondents indicated they would continue support due to fear of litigation. In reply to an open-ended question, respondents requested that the AAN generate guidelines and advocate to codify laws regarding organ support after DNC, and to improve public and physician education on DNC. CONCLUSIONS: Our findings suggest that it is relatively common for neurologists who treat critically ill patients to encounter families who object to discontinuation of organ support after DNC at some point during their career. It would be beneficial for physicians, families, and society to rely on clear medicolegal guidelines on management of this situation.

BACKGROUND: External ventricular drains (EVDs) are used to manage acute hydrocephalus and facilitate brain relaxation after subarachnoid hemorrhage (SAH). We conducted a retrospective study on the relationship between CSF drainage volume and requirement and timing (early vs. late) for ventriculoperitoneal shunt (VPS) placement after EVD removal. We also sought to examine what factors were associated with volume of CSF drainage. METHODS: We performed a retrospective analysis of SAH patients who had an EVD placed between January 2008 and June 2012 at Massachusetts General Hospital. Clinical and laboratory variables were abstracted from the medical record. RESULTS: Of 97 patients, 19 failed an EVD clamp trial and had an early VPS placed and 10 had their EVD removed but subsequently required late VPS placement. Average CSF drainage volume per day was highest in patients who required early VPS (median of 201cc, interquartile range [IQR] 186-236) compared to those who did not require a VPS (median of 162cc, IQR 131-202) and those who required late VPS (median of 151cc, IQR 121-171) (P=0.002). There was a significant relationship between average CSF drainage volume per day and age (P=0.005) and sonographic vasospasm (P=0.006). After multivariate analysis, there was a significant relationship between VPS placement/timing and age (P=0.03) and average CSF output/day (P=<0.0001), and a trend towards significance with sonographic vasospasm (P=0.06). CONCLUSIONS: High CSF output is associated with early VPS placement. Prospective research on targeted CSF drainage volume is warranted.

BACKGROUND AND PURPOSE: Infections are common after intracerebral hemorrhage, but little is known about the risk of serious infection requiring readmission after hospital discharge. METHODS: To determine if infections are prevalent in patients readmitted within 30 days of discharge, we performed a retrospective cohort study of patients discharged from nonfederal acute care hospitals in California with a primary diagnosis of intracerebral hemorrhage between 2006 and 2010. We excluded patients who died during the index admission, were discharged against medical advice, or were not California residents. Our main outcome was 30-day unplanned readmission with primary infection-related International Classification of Diseases, Ninth Revision, Clinical Modification code. RESULTS: There were 24 540 index intracerebral hemorrhage visits from 2006 to 2010. Unplanned readmissions occurred in 14.5% (n=3550) of index patients. Of 3550 readmissions, 777 (22%) had an infection-related primary diagnosis code. When evaluating primary and all secondary diagnosis codes, infection was associated with 1826 (51%) of readmissions. Other common diagnoses associated with readmission included stroke-related codes (n=840, 23.7%) and aspiration pneumonitis (n=154, 4.3%). The most common infection-related primary diagnosis codes were septicemia (n=420, 11.8%), pneumonia (n=124, 3.5%), urinary tract infection (n=141, 4.0%), and gastrointestinal infection (n=42, 1.2%). Patients with a primary infection-related International Classification of Diseases, Ninth Revision, Clinical Modification code on readmission had higher in-hospital mortality compared with other types of readmission (15.6% versus 8.0%, P<0.001). After controlling for other predictors of mortality, primary infection-related readmissions remained associated with in-hospital mortality (relative risk, 1.7; 95% confidence interval, 1.3-2.2). CONCLUSIONS: Infections are associated with a majority of 30-day readmissions after intracerebral hemorrhage and increased mortality. Efforts should be made to reduce infection-related complications after hospital discharge.

INTRODUCTION: We sought to evaluate the caliber of education mainstream media provides the public about brain death. METHODS: We reviewed articles published prior to July 31, 2015 on the most shared/heavily trafficked mainstream media websites of 2014 using the names of patients from two highly publicized brain death cases, 'Jahi McMath' and 'Marlise Munoz.' RESULTS: We reviewed 208 unique articles. The subject was referred to as being 'alive' or on 'life support' in 72% (149) of the articles, 97% (144) of which also described the subject as being brain dead. A definition of brain death was provided in 4% (9) of the articles. Only 7% (14) of the articles noted that organ support should be discontinued after brain death declaration unless a family has agreed to organ donation. Reference was made to well-known cases of patients in persistent vegetative states in 16% (34) of articles and 47% (16) of these implied both patients were in the same clinical state. CONCLUSIONS: Mainstream media provides poor education to the public on brain death. Because public understanding of brain death impacts organ and tissue donation, it is important for physicians, organ procurement organizations, and transplant coordinators to improve public education on this topic

Objective The death of Marlise Munoz, a pregnant woman who suffered an anoxic brain injury in November 2013, highlights the social, ethical, legal, and medical controversies associated with brain death in pregnancy. We sought to evaluate whether institutions in the United States have policies in place for situations in which a pregnant woman is declared brain dead. Study Design Institutional brain-death protocols from hospitals in the United States were obtained in cooperation with local and regional organ procurement agencies. Each protocol was reviewed to determine if and how it addressed brain death in pregnancy. Results We reviewed 317 unique brain-death protocols. In eight protocols (2.5%), it was noted that a pregnant patient could not be evaluated for brain death if the fetus could be preserved. Of the protocols that permitted brain-death evaluation, 289 (93.8%) did not include guidance about fetal management after maternal brain death and 305 (99%) did not indicate who was responsible for making decisions for the fetus. Conclusion Very few institutional brain-death policies address the issue of pregnancy. The creation of guidelines on management of the social and ethical challenges associated with brain death in pregnancy may be helpful.