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  • 1. Brain Trauma: Translating the Guidelines to Practice Presented by: Mary Kay Bader RN, MSN, CCNS Neuro/Critical Care CNS Mission Hospital [email_address]
  • 2. The Main Subject: BTF Guidelines Surgical Guidelines 2006
  • 3. Facilitating Implementation: What does it take?
  • 4. Facilitating Implementation: What does it take?
    • Barriers to Implementation
      • Macro environment
      • Structural factors and Organizational factors
      • Professional and personal factors
  • 5. Facilitating Implementation: What does it take?
    • Barriers to Implementation
    • Macro environment
      • Financial, regulatory and organizations context of trauma care
      • Payment structures do not match the costs of trauma care
      • Low volume makes it difficult to cover the high standby costs
      • High volume of uninsured trauma patients justify standby costs but still generate losses for the center
  • 6. Facilitating Implementation: What does it take?
    • Barriers to Implementation
      • Structural factors and Organizational factors
        • Segmentation of trauma care
          • Different providers making treatment decisions at different stages of care is antithetical to achievement of integrated TBI care
        • Boundaries between units, disciplines and departments contribute to breakdown of care
  • 7. Facilitating Implementation: What does it take?
    • Barriers to Implementation
      • Professional and Personal factors
        • Some physicians assume leadership role in aligning clinical practice with TBI guidelines
        • But…some have been the locus of resistance
          • Less reimbursement for trauma call
          • MD experience conflict between treating trauma patients and conducting and the rest of their practice if it impinges on their private practice
  • 8. Facilitating Implementation: What does it take?
    • Effective Implementation
      • Invest in nursing and physician roles that possess
        • Strong integration
        • Coordination
        • Communication
        • Leadership Champions
          • Physician
          • Administration
          • High level medical support
          • Hands on change agents
  • 9. Facilitating Implementation: What does it take?
    • EB Literature: BTF Guidelines
    • Champions: Physician, Administrative, & Nursing (Director, APN, Manager, & Staff)
    • Culture of Innovation/Mutual Respect
    • Data
      • What was?
      • What will be?
      • Comparative with a Data Base
    • Organizational
      • Losing territorial framework
      • Cultivating teamwork and ownership
    • Patient and Family Centered Care
  • 10. Pathological Changes Secondary Injury Coordinated ICU Multidisciplinary Care Critical Care Management of Severe TBI Evidence Based Practice Dynamics of Injury & Monitoring Technologies
  • 11. The Problem: Brain Injury
    • Primary Injury
      • Skull integrity
      • Brain integrity
        • Focal injuries
        • Diffuse injuries
  • 12. Secondary Injury: Alteration in CBF
    • Numerous studies have found low CBF in early hours after TBI
    • CBF in TBI
      • 1 st 12 to 24 hours: Hypoperfusion/decrease in CBF
      • 24 hours to Day 5: CBF exceeding CMRO2
      • Days 5/6 to 14: Slow flow due to vasospasm
    • CBF altered but it must be balanced with metabolism and oxygenation
  • 13. Secondary Injury
    • Arise from traumatic event and changes to brain/vasculature
      • Impaired autoregulation
        • Pressure autoregulation: the ability of brain to maintain constant CBF in face of changing BP or CPP
        • CPP : Optimal CPP differs in patients due to whether pressure autoregulation is intact
  • 14. Secondary Injury
    • Events arising from extracerebral causes
      • Hypotension
      • Hypoxia
      • Hypocapnia/Hypercapnia
      • Anemia
      • Cellular changes
      • Hyperthermia
  • 15. Translational Practice: Implementing the Guidelines
    • Level II: BP should be monitored and hypotension (SBP mm Hg) avoided
    • Level III: Oxygenation should be monitored and hypoxia (PaO2<60 mm Hg or O2 sat <90%) avoided
  • 16. Translational Practice: Implementing the Guidelines
    • Level II:
      • Prophylactic hyperventilation (PaCO2 M 25 mm Hg is not recommended
    • Level III:
      • Hyperventilation is recommended as a temporizing measure for the reduction of elevated ICP
        • HV should be avoided during the 1 st 24 hours when CBF is often critically reduced
        • If hyperventilation is used, SjO2 or PbtO2 measurements are recommended to monitor oxygen delivery to the brain
  • 17. Severe TBI Patient: GCS 3-8 CT+ Injury Arrival: Emergency Department Trauma Bay Assess A-B-C: Oxygenation and Ventilation Airway: Secured with RSI Breathing: Connect to Ventilator Avoid hyperventilation Use Capnography to monitor ET CO2 Assess Circulation: Assess Pulse, ECG and BP IV fluids to maintain adequate MAP
  • 18. Translational Practice: Implementing the Guidelines Treatment of ICP should be initiated with ICP > 20 mm Hg Combination of ICP, clinical & Brain CT findings should determine need for Tx
  • 19. Translational Practice: Implementing the Guidelines
    • Level III: SjO2 < 50% or PbtO2 < 15 mm Hg are treatment thresholds
    CPP Level II: Do not use aggressive attempts to maintain CPP >70 mm Hg Level III: Avoid CPP < 50 mm Hg; Target CPP 50-70 mm Hg Ancillary monitoring of Cerebral parameters including CBF, oxygenation, or metabolism can help to target appropriate CPP levels
  • 20. Severe TBI Patient: GCS 3-8 CT+ Injury Diagnostic Tests, Insertion of Monitoring Devices & OR Radiographic Evaluation –Confirmation Placement of ICP/Ancillary Monitoring Operative Intervention Needed Surgical Guidelines
  • 21. Severe TBI Patient: GCS 3-8 CT+ Injury Surgery
  • 22. Severe TBI Patient: GCS 3-8 CT+ Injury Surgery
  • 23. Translational Practice: Implementing the Guidelines ICU Care
  • 24. Severe TBI Patient: GCS 3-8 CT+ Injury ICU Care: Primary Interventions Admit to ICU A & B: Oxygenation/Ventilation Optimization Circulation: Maintain CPP 50-60 mm Hg as initial target Autoregulation Testing: Intact – may need CPP up to 70 mm Hg ICP Management : Draining CSF and Providing Sedation/Analgesia
  • 25. Translational Practice: Implementing the Guidelines ICU Care
  • 26. Translational Practice: Implementing the Guidelines ICU Care DON’T USE THEM
  • 27. Translational Practice: Implementing the Guidelines Tertiary Interventions
  • 28. Translational Practice: Implementing the Guidelines Tertiary Interventions Recent Research
  • 29. Latest Conversations on Hypothermia in TBI
  • 30.  
  • 31.  
  • 32. Should Normothermia be considered part of the Core Interventions of TBI?
  • 33. Putting It All Together
  • 34. Core TBI Interventions
      • Place ICP and monitor of metabolism
      • Maintain CO2 35-45 mm Hg
      • Provide Sedation/Analgesia
      • Maintain Normothermia T 37
      • Optimize CPP 50-60 mm Hg with fluids
  • 35. Core/Foundation TBI Management
    • Place ICP/Ventriculostomy and cerebral ischemia monitor
    • Core interventions
      • Drain CSF
      • CO2 35-45 mm Hg
      • Sedation/Analgesia
      • Normothermia T 37
      • CPP 50-60 mm Hg
    • Scenarios
      • 1: Elevated ICP without cerebral ischemia monitor
      • 2:Elevated ICP with normal PbtO2
      • 3: Normal ICP with cerebral ischemia present (PbtO2 < 20 mm Hg or ↓CBF or microdialysis +ischemia
      • 4: Elevated ICP with cerebral ischemia present
  • 36. TBI Management
    • Core Intervention
      • Place ICP ( Ventriculostomy )
      • CO2 35-45 mm Hg
      • Sedation/Analgesia
      • Normothermia T 37
      • CPP 50-60 mm Hg
    • Elevated ICP without cerebral ischemia monitor
      • CSF Drainage (1)
      • Mannitol 0.25-1 gm/kg (1)
      • Mannitol >1 gm/kg (2)
      • Hypertonic Saline bolus(2) or Hypertonic Saline infusion continuous (2)
      • *PaCO2 30-35 mm Hg (2)
      • Neuromuscular blocker (3)
      • Decompressive hemicraniectomy (3)
      • Mild Hypothermia 32-34 (3)
      • Barbiturate coma (3)
    • Avoid using the following interventions
      • CPP > 70 mm Hg
      • Lumbar CSF Drainage
      • PaCO2 < 30 mm Hg
  • 37. TBI Management
    • Core Intervention
      • Place ICP
      • (Ventriculostomy) and cerebral ischemia monitor
      • CO2 35-45 mm Hg
      • Sedation/Analgesia
      • Normothermia T 37
      • CPP 50-60 mm Hg
    • Scenario 2: Elevated ICP without cerebral ischemia (normal PbtO2)
      • CSF Drainage (1)
      • Mannitol 0.25-1 gm/kg (1)
      • Mannitol >1 gm/kg (2)
      • Hypertonic Saline bolus(2) or Hypertonic Saline infusion continuous (2)
      • PaCO2 30-35 mm Hg (2)
      • Decompressive hemicraniectomy (3)
      • Neuromuscular blocker (3)
      • Mild Hypothermia 32-34 (3)
      • Barbiturate coma (3)
    • Avoid using the following interventions
      • CPP > 70 mm Hg
      • Lumbar CSF Drainage
      • PaCO2 < 30 mm Hg
  • 38. TBI Management
    • Core Intervention
      • Place ICP and cerebral ischemia monitor
      • CO2 35-45 mm Hg
      • Sedation/Analgesia
      • Normothermia T 37
      • CPP 50-60 mm Hg
    • Scenario 3: Normal ICP with cerebral ischemia (PbtO2 < 20 mm Hg)
      • Titrate CPP 50-70 mm Hg(1)
      • Temperature 35-37 (1)
      • Ventilator manipulation to keep PaO2 >90 mm Hg (2)
        • Increase PaCO2
    • Avoid using the following interventions
      • PaCO2 < 35 OR > 45 mm Hg
      • FIO2 100%
      • Hypothermia 32-34° C
  • 39. TBI Management
    • Core Intervention
      • Place ICP and cerebral ischemia monitor
      • CO2 35-45 mm Hg
      • Sedation/Analgesia
      • Normothermia T 37
      • CPP 50-60 mm Hg
    • Scenario 4: ↑ICP+ Cerebral Ischemia (PbtO2 < 20 mm Hg)
      • CSF Drainage (1)
      • Mannitol 0.25-1 gm/kg (1)
      • Titrate CPP 50-70 mm Hg(1)
      • Mannitol >1 gm/kg (2)
      • Hypertonic Saline bolus(2) or infusion continuous (2)
      • Temperature 35-37 (2)
      • Decompressive Hemicraniectomy(3)
      • Neuromuscular Blocker (3)
      • Temperature 32-34 C (3)
      • Barbiturate coma (3)
    • Avoid using the following interventions
      • FIO2 100%
      • PaCO2 < 35 OR > 45 mm Hg
  • 40. Strategies for Success
    • Timing and organizational readiness
  • 41. Strategies for Success
    • Comprehensive Change: Systemic/Systematic
  • 42. Strategies for Success
    • Leadership and Change Agents
      • Nurses, Physicians, higher level administrators and clinicians (chiefs, department heads and medical directors)
      • Powerful and credible physician champions from at least 2 services
        • Change agent must be hands on leader
        • Trauma and Neurosurgery
  • 43. Strategies for Success
    • Clinical Nurse Specialist as hands-on change agent
      • Roles of a CNS is a near perfect match for translating EB guidelines
        • Expert clinician – rounds/communication
        • Taskmaster of the process/develops protocols
        • Change agent for improving performance
        • Researcher and authors publications with team
        • Teacher and mentor for neuro/critical care practice
        • An enforcer who ensures the protocols are followed
  • 44. Strategies for Success
    • Integrators, Coordinators, and Communicators
      • Program manager
        • Works with medical director to make everything click
        • Pulls information together for regulatory bodies
        • Generates policies/procedures
        • Manage database for quality data
        • Key liaison with team/nurses
  • 45. Strategies for Success
    • Develop Protocols
      • Guideline implementation “shorthand” for what it takes to translate a set of recommendations from standard, everyday practice for a network of independent clinicians
  • 46. Strategies for Success
    • Pathway and Protocol Design
      • Standardized routine matters but built with ability to flex and use judgment
      • Gives clinician “zones of latitude” with clearly defined limits where consultation is available
      • Aim to reduce the workload of the physicians…when MD called they are provided more focused, higher level conversations with empowered nurses
  • 47. Strategies for Success
    • Staff redeployment
      • Multidisciplinary rounds
      • Trauma nurse deployed to ED to stay with the patient through resuscitation
        • Advocate for the patient and the guidelines
        • Ensures consistency across disciplines, boundaries, and venues
  • 48. Strategies for Success
    • Research Framing
      • Implementation of guidelines
        • Use before and after data to evaluate impact at center
        • Studied the literature
        • Careful data collection prospectively
        • Analyze team processes across venues
  • 49. Strategies for Success
    • Organization and Management of ICUs
      • Ensure neurosurgical and trauma input is equal and valued
      • Bring nurses, residents, and managers on board with the guidelines/care priorities
      • Develop a “New ICU” – combine trauma/neuro services into one unit
      • Deploying intensivists who are supportive of guidelines/collaborative practice
  • 50. Strategies for Success
    • Comprehensive and Tailored Education
      • Start with core team then spread
      • Comprehensive, evidence based with hands on component
        • Context “Situation, person, and moment”
    • Organize for continuous improvement
      • Never done…never taken for granted
      • Reinvent constantly…
  • 51. Protocol Revisions
    • Revisions
      • At least yearly
      • Team learning + new changes in practice must be integrated
      • Example
        • Analgesia
        • Sedation
  • 52. Choice of Analgesia and Vasopressor Use in Severe TBI
  • 53. Change of Sedation Approach
  • 54. Change of Sedation Approach
  • 55. Case Application
  • 56. Event
    • 24 year old male involved in bike accident
      • Field
        • GCS 4-6-4
        • Vomiting
      • ED
        • GCS 4-6-3
        • PERRL
        • Vomiting with ? Aspiration of thick brown fluid and food
      • CT
        • Vomits again
        • Loses consciousness: GCS 1-3-1
        • Emergently intubated
  • 57. Admit CT scan TO OR
  • 58.  
  • 59.
    • OR
    • SICU
      • ICP 20s
      • PbtO2 24 drops to 11 mm Hg
      • Pulmonary worsens
    • NPE
    • Low PbtO2 correlating with low PaO2
  • 60. Progress Days 2-3
    • Pulmonary Issues resolve x 4 days
    • ICP controllable
    • Hemodynamically improved
    • Neurosurgeon elects to begin rewarm 0.05 degrees per hour on Day 4
  • 61. Days 1-3
  • 62. Day 4
  • 63. Abort
    • ICP increases with attempted rewarm
  • 64. Rewarm….ICP shoots up
    • Cooled for 72 hours then neurosurgical decision to rewarm
      • ICP increases to 35 mm Hg by 34.5 degrees
      • Phone conference call
      • MD decision to begin barbs
    • ICP increases from 30 to 60mm Hg
      • Decompressive hemicraniectomy
      • ICP to 20s then back up
    • Recool after 48 hours
  • 65. Rewarm and the Lungs
  • 66. Recool x 7 days
  • 67. Day 7
  • 68. ARDS
    • PaO2 50 and PbtO2 12
    • Proning 4 hour down and Supine 2 hours
      • Loses effectiveness after 2 days
    • Order to start Nitric Oxide
    • Improvement
  • 69. ARDS Lungs worsen while on Barbs/Hypothemia: Nitric Oxide x 12 days Decision to Prone
  • 70. Outcome
    • Outcome
      • Nitric Oxide/Inverse x 12 days
      • Prone/Supine x 14 days
      • Weaned from ventilator
      • Day 30
        • Opens eyes
        • Moving all 4 extremities spontaneously
      • Day 45
        • To Floor
        • Ambulating/Follows commands
        • Trache downsized
        • To ARU
      • Day 64: D/C Home
    • Was the cause of ARDS
      • Barbs + Hypothermia
      • Posterior Fossa Injury/NPE + Aspiration
  • 71. Book on Adam’s Story