Faculty Bibliography

Introduction Infections are common inpatient complications after intracerebral hemorrhage (ICH), but little is known about risk of infection after hospital discharge. Methods We performed a retrospective cohort study of patients discharged from non-federal acute-care hospitals in California with a primary diagnosis of ICH between 2006 and 2010. ICH was defined as a primary ICD-9CM discharge diagnosis code of 431. Only the first eligible ICH admission was included for each patient. Exclusion criteria were discharge against medical advice, in-hospital death, and non-California residency. After discharge from index admission, we assessed the proportion of readmissions to an acute-care hospital within 30 days that were related to infection. Clinical Classification Software (CCS) categorization of ICD-9CM codes was utilized for etiology of readmission. Inter-hospital transfers and readmission for likely planned procedures (craniotomy, embolization) were not included. Log-binomial regression was used to assess relationship between baseline characteristics and readmission mortality. Results There were 24,540 index ICH visits from 2006 to 2010. Unplanned readmissions occurred in 14.8% (n=3,269) of index patients. Of the 3,269 revisits, 934 (26%) had an infection-related primary diagnosis code. When evaluating all available revisit diagnosis codes, infection was associated with 1,945 (54%) of readmissions. Other common primary causes for readmission included stroke-related codes (n=894, 24.6%) and complications of medical/surgical care (n=92, 2.5%). The most common infection-related primary diagnosis codes were septicemia (n=422, 11.6%), respiratory infections/aspiration (n=292, 8.0%), urinary tract infection (n=141, 3.9%), and gastrointestinal infection (n=90, 2.5%). Patients with primary infection-related readmissions had higher in-hospital mortality compared to other types of readmission (15.7% vs. 7.7%, p< 0.001). After controlling for other predictors of mortality, primary infection-related readmissions remained associated with in-hospital mortality (RR=1.5, 95% CI 1.2-1.8). Conclusions Readmission for infection after ICH is common and associated with in-hospital death. Efforts should be made to identify ways to reduce infection-related complications in ICH patients after hospital discharge

Introduction The death of Marlise Munoz, a pregnant woman who suffered an anoxic brain injury in the setting of a presumed pulmonary embolus, instigated a national discussion on management of brain death in pregnancy. We sought to evaluate whether institutions in the United States are prepared to handle the unfortunate situation in which a pregnant woman suffers a catastrophic brain injury. Methods Institutional brain death protocols were procured 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 225 unique protocols from 21 different states were reviewed. In 3.56% (8) of protocols, it was noted that a pregnant patient could not be diagnosed as brain dead if the fetus could be preserved. Of the protocols that permitted brain death evaluation, 91.71% (199) did not provide guidance as to whether or not protracted somatic support should be provided to a brain dead mother. There was no indication of who was responsible for making decisions for the fetus in 98.67% (222) of protocols. Conclusions Very few institutional brain death policies address the issue of pregnancy.The creation of national guidelines on management of the social and ethical challenges associated with brain death in pregnancy may be helpful

Introduction The prominent case of Jahi McMath highlights the social and ethical controversies that emerge in the setting of brain death diagnosis. While it is well-established that there is significant variability between brain death protocols throughout the United States, the manner in which protocols address a family's objection to discontinuation of the ventilator after diagnosis of brain death has not been explored. Methods Institutional brain death protocols were procured in cooperation with local and regional organ procurement agencies. Each protocol was reviewed to determine if and how it addressed situations in which families object to discontinuation of the ventilator after diagnosis of brain death. Results 225 unique protocols from 21 different states were reviewed. Indications for prolonged ventilator support after diagnosis of brain death described in institutional protocols included family's religious beliefs (8.44%, 19), family's moral beliefs (1.78%, 4), desire to await arrival of family members (4.44%, 10), and nonspecific social reasons/desire to give family members time to accept the patient's death (1.33%, 3). However, 80.44% (181) of protocols made no mention of how to handle situations in which families request ventilator support be continued after diagnosis of brain death. The remainder of the protocols included recommendations to: 1) seek counsel from administrative/ethical/legal/religious/risk management resources; 2) transfer care of the patient to another practitioner or another facility; 3) obtain a second opinion regarding diagnosis of brain death; 4) extubate against the family's wishes; or 5) defer to the family's request and maintain organ support until cardiac death. Conclusions The majority of protocols reviewed did not include mention of how to handle circumstances in which families object to discontinuation of ventilator support after diagnosis of brain death. The creation of national guidelines on management of these socially and ethically complex situations may be helpful to prevent distress to families and hospital staff

Introduction Comparison of rates of ventriculostomy-related infections (VRI) 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. 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 22-94% (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 56-89% (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

Objective. Hydrocephalus after subarachnoid hemorrhage (SAH) requires temporary cerebrospinal fluid (CSF) drainage using an external ventricular drain (EVD). This drain is removed if patients pass a clamp trial, or a ventriculoperitoneal shunt (VPS) is placed. Little is known about the risk factors for delayed VPS placement in patients who pass a clamp trial and have their EVD removed. In order to explore the risk factors associated with delayed VPS placement, we studied a retrospective cohort of SAH patients at our institution. Methods. We performed a retrospective analysis of SAH patients who had an EVD placed between January 2008 and June 2012 at our institution. We extracted demographic, imaging, and CSF data from the medical record and analyzed risk factors associated with delayed VPS placement. Results. Of 91 patients who passed a clamp trial and had their EVD removed, 12 (13%) required delayed VPS placement at a median of 54 (interquartile range: 15-75) days after EVD removal. After multivariate analysis, risk factors for delayed VPS placement included increased CSF protein concentration within the first 7 days of EVD placement (OR: 1.02, CI: 1-1.04, p = 0.023) and increased third ventricular diameter prior to EVD removal (OR: 1.59, CI: 1.11-2.6, p = 0.026). Conclusion. Patients with increased CSF protein concentration at time of EVD placement and those with increased third ventricular diameter at time of EVD removal should be carefully monitored for development of delayed hydrocephalus.

OBJECTIVE: There are multiple etiologies for failure while weaning an external ventricular drain (EVD) after subarachnoid hemorrhage (SAH), but there is little data on the relationship between etiology of wean failure and ventriculoperitoneal shunt (VPS) placement. METHODS: We performed a retrospective analysis of SAH patients who had an EVD placed between January 2008 and June 2012 at our institution. For each wean step (defined as raising or clamping the EVD), we recorded success or failure. We categorized failure as lowering or opening the EVD due to elevated intracranial pressure (ICP), clinical failure (due to headache or vomiting or altered mental status), leakage from the EVD site, or development of radiographic hydrocephalus. We evaluated the relationship between etiology of wean failure and subsequent need for VPS. RESULTS: Of 116 patients with an EVD placed, 35 required VPS placement (30%). Patients who required VPS placement had a median of 2 (interquartile range (IQR) 1-4) wean failures and those who did not require VPS placement had a median of 1 (IQR 0-1) wean failure (p=0.001). There was no significant relationship between age, sex, Hunt Hess score, Fisher score, Glasgow coma scale, aneurysm location, aneurysm size, aneurysm treatment method, vasospasm and need for VPS. There was a significant relationship between patients with at least one wean failure due to clinical changes or radiographic hydrocephalus and need for VPS (p=0.007 and p=0.029, respectively). After multivariate analysis, there was only a significant relationship between clinical changes and need for VPS (OR 2.76, CI 1.03-7.36, p=0.04). CONCLUSION: There is a significant association between wean failure due to clinical changes and requirement for VPS placement after SAH.

Stroke is one of the leading causes of death. Hyperlipidemia is a major risk factor for stroke. The United States Preventive Service Task Force defines lipid screening guidelines. Treatment options of hyperlipidemia include lifestyle modifications and medical management. Statins have been shown to decrease lipids and exert a pleiotropic effect on intracranial vasculature and inflammatory modulators, leading to neuroprotection. Lower low-density lipoprotein and higher high-density lipoprotein levels are associated with decreased risk of stroke. Despite screening guidelines and evidence of the efficacy of statins, there are numerous barriers to maintaining adequate control of lipids.

In this double-blinded randomized study, we sought to confirm that patients undergoing general anesthesia who were exposed to a hemispheric synchronization (Hemi-Sync) musical recording during surgery had a smaller analgesia requirement, as was suggested in a previous study. Bispectral index monitoring was used to adjust depth of hypnosis, and hemodynamic variables were used to determine analgesia administration. Consented patients underwent either laparoscopic bariatric or one-level lumbar disk surgery. After endotracheal intubation and application of headphones, baseline heart rate and arterial blood pressure were established. Isoflurane was titrated to maintain sedation on the basis of a target bispectral index range of 40-60, and 25-microg increments of fentanyl were administered in response to increases in heart rate and systolic arterial blood pressure. Bariatric patients who listened to Hemi-Sync required one-third less fentanyl than the control group (mean [SD]: 0.015 [0.01] vs 0.024 microg.kg(-1).min(-1) [0.01]) (P = 0.009). It is interesting to note that lumbar patients in the experimental and control groups required similar amounts of fentanyl (0.012 [0.01] vs 0.015 microg.kg(-1).min(-1) [0.01]). End-tidal isoflurane concentration was similar for Hemi-Sync and blank-tape patients (bariatric, 0.74% (0.14) vs 0.77% (0.21); lumbar, 0.36% [0.16] vs 0.39% [0.12]). The bariatric patients in this study demonstrated that Hemi-Sync may be an innovative intraoperative supplement to analgesia. IMPLICATIONS: The purpose of this study was to determine the decrease in analgesia requirement for patients listening to hemispheric synchronization (musical tones) while under general anesthesia. We demonstrated that bariatric patients who listened to hemispheric synchronization had a smaller analgesia requirement than those who listened to a blank tape.