Faculty Bibliography

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.

External ventricular drains (EVDs) are commonly used to facilitate removal of cerebrospinal fluid in patients with neurologic dysfunction. Despite a high risk for infection (upward of 45%), many hospitals lack strict protocols for EVD placement and maintenance. In addition, EVD infections are typically not tracked with the same diligence as central-line catheter infections, because there are no widely accepted standards for routine management of EVDs. The purpose of this review is to provide a guide for the development of a standardized, best practice EVD protocol for catheter insertion, care, and maintenance to reduce ventriculostomy-related infections. A secondary goal of this review is to provide support for the future development of guidelines for the consistent tracking of EVD insertion and maintenance practices.At an academic medical center, an interdisciplinary team of nurses, advanced practice nurses, and neurointensivists reviewed recent medical and nursing literature as well as research-based institutional protocols on EVD insertion and maintenance from the United States and abroad to determine global best practices. The goal of this literature review was to identify key areas of focus in EVD insertion and maintenance as well as to identify recent studies that have shown success in managing EVDs with low rates of infection. The following terms were used in this search: EVD, externalized ventricular drains, EVD infections, EVD insertion, EVD Care and Maintenance, Nursing and EVDS. The following databases were utilized by each member of the interdisciplinary team to establish a state of the science on EVD management: American Association of Neurosurgical Surgeons, CINAHL, Cochrane, National Guidelines Clearinghouse, and PubMed. The following common EVD themes were identified: preinsertion hair removal and skin preparation, aseptic technique, catheter selection, monitoring of EVD insertion technique using a "bundle" approach, postinsertion dressing type and frequency of dressing changes, techniques for maintenance and cerebrospinal fluid sampling, duration of catheter placement, staff education/competence, and surveillance.

BACKGROUND: The manner in which brain death protocols in the United States address family objection to death by neurologic criteria has not been explored. METHODS: Institutional brain death protocols from hospitals in the United States were reviewed to identify if and how the institution addressed situations in which families object to determination of brain death or discontinuation of organ support after brain death. RESULTS: Protocols from 331 institutions in 25 different states and the District of Columbia were reviewed. There was no mention of how to handle a family's objections in 77.9 % (258) of the protocols. Of those that allowed for accommodation, reasons to defer brain death declaration or prolong organ support after brain death declaration included: (1) religion; (2) moral objection; (3) nonspecific social reasons; or (4) awaiting arrival of family. Recommendations to handle these situations included: (1) seek counsel; (2) maintain organ support until cardiac cessation; (3) extubate against the family's wishes; (4) obtain a second opinion; or (5) transfer care of the patient to another practitioner or facility. Protocols differed on indications and length of time to continue organ support, code status while support was continued, and time of death. CONCLUSIONS: The majority of protocols reviewed did not mention how to handle circumstances in which families object to determination of brain death or discontinuation of organ support after brain death. The creation of guidelines on management of these complex situations may be helpful to prevent distress to families and hospital staff.

INTRODUCTION: Comparison of rates of ventriculostomy-related infections (VRIs) across institutions is difficult due to the lack of a standard definition. We sought to review published definitions of VRI and apply them to a test cohort to determine the degree of variability in VRI diagnosis. MATERIALS AND METHODS: We conducted a PubMed search for definitions of VRI using the search strings "ventriculostomy-related infection" and "ventriculostomy-associated infection." We applied these definitions to a test cohort of 18 positive cerebrospinal fluid (CSF) cultures taken from ventriculostomies at two institutions to compare the frequency of infection using each definition. RESULTS: We found 16 unique definitions of VRI. When the definitions were applied to the test cohort, the frequency of infection ranged from 22 to 94% (median 61% with interquartile range (IQR) 56-74%). The concordance between VRI diagnosis and treatment with VRI-directed antibiotics for at least seven days ranged from 56 to 89% (median: 72%, IQR: 71-78%). CONCLUSIONS: The myriad of definitions in the literature produce widely different frequencies of infection. In order to compare rates of VRI between institutions for the purposes of qualitative metrics and research, a consistent definition of VRI is needed.

The diagnosis of brain death has generated numerous medical, legal, social and ethical controversies. The recent highly publicized case of Jahi McMath, a 13-year-old who was declared brain dead and transferred to a long-term care facility, illustrates these issues and raises new challenges and questions about the management of brain dead patients