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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5783_Библиотеки_им_академика_М_И_Перельмана.pdf
6
G. HerasLaCalle and J. M. V. Bueno
8
7
Humanised
infraestructure
6
Prevention,
management and
monitoring of post-
intensive care
syndrome
End-of-life care
Care for the
healthcare
professional
5
Open-door
Policy in ICUs
Presence &
participation of
relatives in
intensive care
4
1
Communication
2
Wellbeing of
the patient
3
Fig. 1.1 The HU-CI project research lines
• Emotional exhaustion
• ICU structure problems
• Family interference in medical care
• Security
• Infection control
• Lack of communication skills
Currently, there is sufcient evidence in the literature to promote a change in this
policy [8]. The experience in this regard of pediatric and neonatal ICUs, where parents and usual caregivers are considered fundamental in the comprehensive care of
the patient, has much to contribute to adult therapies. Flexible schedules are benecial for patients, families, and professionals.
The existing barriers to change in this sense are related to the physical structure
of the units and the mental structure of the professionals. The solution must come
1 Neurocritical Patient in ICU: An Humanized View of Our Medical Care as a Gold…
7
from dissemination and training based on the successful experiences of other units,
new attitudes, and habits that allow a modication of the visiting policy and that are
adapted to each unit. Likewise, it is essential to value the family as a “companion in
care,” thus eradicating the concept of “visit.” Thus, family members can collaborate
in basic care together with the staff: cleaning, rehabilitation, feeding, training, and
supervised learning opportunities are encouraged for them. Giving the family the
opportunity to contribute to the patient’s recovery can have positive effects on the
patient, themselves, and professionals by reducing emotional stress and facilitating
closeness and communication between the parties involved.
Many critically ill patients are subjected to aggressive or interventional techniques. The presence of family members, also during certain procedures, is accompanied by changes in the attitude of professionals, in terms of privacy, dignity, and
pain management, during such procedures. In addition, greater satisfaction of the
families and a greater acceptance of the situation have been achieved by favoring
the mourning process in the case of cardiopulmonary resuscitation. The presence
and participation of the family members [9] in the daily rounds also contribute to the
improvement of communication and favor the opportunity to ask questions and
clarify information, increasing their satisfaction.
1.2.2 Communication
Communication is the key element in human relations, and improving it is one of
the basic and priority pillars of HU-CI project.
With an effective communication (complete, clear, opportune, and concise)
shared by the whole team, we avoid mistakes and we agree on treatments and care.
The moments of transfer of information in the ICUs are frequent and very important
since in them relevant information can be omitted or misinterpreted [10].
The use of tools such as working by daily objectives, checklists, briengs, random analysis of real-time security (RARTS), or the situation/background/assessment/recommendation (SBAR) technique facilitates multidisciplinary participation
and makes these processes more effective and safe.
Team cohesion can be improved through support strategies and the acquisition of
“non-technical” skills (human tools) that minimize the occurrence of conicts
related to communication problems. These conicts affect the team and directly
inuence the well-being of the patient and the family, generate professional wear
and tear, and have an impact on the results.
Many of the problems that are generated in hospitals stem from poor communication, and in critical care, from poor information to families and patients.
Historically, professionals have not been taught at university in these skills, if it is
known that proper communication with patients and families helps to foster a climate of trust and respect, and facilitates joint decision-making. Furthermore, on
many occasions, the information demands of families and patients have little to do
with the information provided by health professionals. The participation of the
8
nurse in the information is, in general, insufcient and not clearly dened, despite
the fundamental role they play in the care of the critically ill patient and his/her family members.
The use of augmentative and/or alternative communication systems in those
patients who cannot speak for different reasons and which replace oral language
when it is not understandable or absent, is very useful as tools to facilitate communication, putting technology at the service of people.
G. HerasLaCalle and J. M. V. Bueno
1.2.3 Well-Being ofthePatient
Although it is perhaps the most obvious line and one of the basic objectives of the
critics’ units, it is not always developed with excellence. The disease itself and the
procedures necessary to achieve cure generate discomfort and pain in patients [11].
And on many occasions, the scales that ensure the well-being of the patient are not
applied routinely.
Both physical and emotional factors generate suffering in critical patients: they
suffer from pain, thirst, heat, and cold; difculty in resting due to excessive noise or
lighting; and are limited in their mobilization, often due to the use of unnecessary
restraints and other sequelae generated in the ICU, such as polyneuropathy of the
critical patient. Continuous assessment and pain control, dynamic sedation appropriate to the patient’s condition [12], and prevention and management of acute delirium [13] are essential to improve patient’s comfort.
In addition, patients and their families also experience feelings of loneliness,
isolation, fear, loss of identity, intimacy, and dignity, feelings of dependency, uncertainty due to lack of information, and misunderstanding, among others [14]. The
assessment and support of these needs must be considered a key element of quality
care. Ensuring adequate training of professionals and promoting measures aimed at
treating or mitigating these problems, ensuring the well-being of patients, is a major
objective in the care of the critically ill [15].
1.2.4 Care oftheProfessional
Healthcare professionals, and more so in the critical care eld, are exposed to human
suffering on a daily basis. We achieve great miracles when patients who would have
died survive thanks to our knowledge and its technical application. However, when
various personal, group, and organizational factors come together, the personal
wear and tear is very considerable, and the well-known burnout syndrome can
appear. Recently, a 54% professional burnout rate has been published among intensivists in the United States.
1 Neurocritical Patient in ICU: An Humanized View of Our Medical Care as a Gold…
9
The burnout syndrome is a disorder that encompasses different aspects: emotional exhaustion, depersonalization, and feelings of low professional self-esteem.
This problem affects both personally and professionally and can lead to posttraumatic stress syndrome and other serious psychological disorders and even to suicide. The presence of these problems inuences the quality of care, patient outcomes,
and patient satisfaction, and is related to the lack of involvement of professionals in
organizations [16].
Having a healthy organization where professionals feel cared for should become
an essential requirement for any organization [17], which must set itself a series of
objectives oriented toward the execution of preventive and therapeutic actions.
Different scientic societies have tried to give diffusion and visibility to this problem, offering recommendations to reduce its appearance and to mitigate its consequences; establishing concrete strategies that allow to give an appropriate answer to
the physical, emotional, and psychological needs of the professionals of intensive
care, derived from their dedication and effort in the performance of their work.
1.2.5 Post-ICU Syndrome
A very high percentage of patients (more than 35%) go through the ICU with a
series of possible complications that since 2010 are known as post-ICU syndrome:
• Physical problems (persistent pain, weakness acquired during hospitalization,
malnutrition, pressure ulcers, sleep disturbances, and need for use of devices)
• Neuropsychological disorders (cognitive decits, memory disorders, attention,
and speed of mental process)
• Emotional disorders (anxiety, depression, or posttraumatic stress)
Their medium- and long-term consequences affect the quality of life of patients
and families by increasing healthcare expenditure.
Minimizing the appearance of post-ICU syndrome requires preventive activities,
as well as correct treatment and follow-up of known disorders. This requires sensitized and trained multidisciplinary teams that begin their work during admission to
the unit and continue it once the unit has been abandoned.
Family members and relatives can be a fundamental part of the management of
post-ICU syndrome, participating in the care of the patient and helping him/her to
remain oriented [18]. In fact, it is known that primary caregivers bear a huge share
of the overall health care costs of a country. Caregivers can also be affected by feelings of worry and confusion that can lead them to neglect their own health, and they
can suffer from the post-ICU syndrome of the family member. The health care team
must be aware of this in order to recognize and also provide support to the family
members who need it: This is where the care of the patient-family pairing takes on
fundamental importance.
10
G. HerasLaCalle and J. M. V. Bueno
1.2.6 Humanized Infrastructure
The architectural and structural design of the ICUs is one of the main arguments that
hinder a humanized provision of care. In many parts of the world, there are still
units with open spaces in which several patients are located, separated by screens or
curtains, which do not respect the right to privacy. This makes the possibility of
family accompaniment difcult; patients who are admitted feel exposed to others in
moments of great weakness and vulnerability. On the other hand, these distributions
do not contribute to the establishment of personalized relationships between the
professionals and the patients they attend.
This strategic line proposes and promotes the creation of spaces where technical
efciency goes hand in hand with quality of care and the comfort of all users:
patients, families, and professionals. There are recommendations focused on reducing stress and promoting comfort by focusing on architectural and structural
improvements to ICUs [19], which often require signicant economic resources,
especially in those places built long ago and which require comprehensive reforms.
Other changes consider an appropriate location, as well as adaptation to users
and workows in adequate environmental conditions of light, temperature, noise,
materials and nishes, furniture, and decoration. The incorporation of vinyl, articial windows where natural light is not available, decorative elements, and others
that facilitate the temporal and spatial orientation of patients requires minimal
investment and can considerably increase the comfort and satisfaction of all
involved. These modications can have a positive inuence on feelings and emotions by favoring human spaces adapted to the functionality of the units.
These concepts are equally applicable to waiting rooms, which must be redesigned to become “living rooms” and offer greater comfort and functionality to
families, and equally to staff’s work and rest spaces.
1.2.7 End-of-Life Care
Between 10% and 15% of the time, depending on the country, it is impossible to
restore the patient’s previous situation and achieve a cure. In these situations, we
must be able to reconsider the objectives in order to direct them toward reducing
suffering and providing the best possible care, especially at the end of life [20]. To
allow a death free of discomfort and suffering for the patient and family members,
according to their wishes and clinical, cultural, and ethical standards, is another of
the objectives of the H-ICU project, starting from the idea that palliative and intensive care are not exclusive options, but should coexist during the whole process of
care of the critically ill patient.
The limitation of life support, frequently in the critically ill patient, must be carried out following the guidelines and recommendations established by the scientic
societies [21]. It should be applied as part of a global palliative care plan [22], in a
1 Neurocritical Patient in ICU: An Humanized View of Our Medical Care as a Gold…
11
multidisciplinary manner, with the aim of covering the needs—physical, psychosocial, and spiritual—of the patients and their families. The existence of specic protocols and the periodic evaluation of the care offered should be considered basic
requirements.
Decisions at the end of life are not exempt from discrepancies between health
professionals and between health professionals and family members [23].
Professionals must have the necessary skills and tools for the resolution of these
conicts, incorporating open and constructive discussion in these situations, as coping strategies to reduce the emotional burden derived from them.
1.3 Conclusion: How toGive anHumanized Attention
toaNeurocritical Patient?
In December 2017, the HU-CI project certication working group [24] prepared the
Manual of Good Practices for the Humanization of Intensive Care Units (Fig.1.2),
which contains 159 tangible measures to make critical care units more friendly to all
Fig. 1.2 Manual of Good Practices for the Humanization of Intensive Care Units
12
G. HerasLaCalle and J. M. V. Bueno
their stakeholders. In May 2019, this document was revised and one more measure
was added [25].
It is an exportable method that can be reproduced anywhere in the world, free to
download, with the aim of betting on a revolution written with ¨H¨ [26] (the
H-evolution of intensive care units) that will facilitate the reunion with those reasons why one day we decided to dedicate our lives to the service of others: People
who help people.
Now then, how can we humanize the care of the neurocritical patient? [27]. Well,
that, dear reader, depends on you.
Without a doubt, from our point of view, the fundamental tool will be listening
to the protagonists: patients with neurological diseases and patient associations
(multiple in the case of diseases with some kind of neurological decit); the opinion
and experience of the relatives, who in large part become the real caretakers of neurocritical patients once they leave the ICU, often victims of states of high dependency; and of course the professionals in the therapies, the real motors of the change
that humanizes.
And to design together the health care we deserve wherever we are: The one we
always wanted to have, not the one we have inherited from health systems that do
not work. Rewriting this history is an exercise in responsibility, not only professional but also personal and social toward our children.
Sometimes utopia is not really different from reality, and of course, HU-CI project has shown that passion moves the world and that if you want to and work you
can [28].
In many occasions, a thousand excuses and obstacles will be put to the change:
this is also human. But on the other hand, you cannot put doors to the sea, and anyone who still does not understand this blessed madness, perhaps will understand it
when he is a user of the system from another role. In the meantime, the question
remains:
And you: What can you do to humanize the neurocritical patient units?
References
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13
Chapter 2
Neuro-ICU: Monitoring andManagement
ofIntracranial Pressure. APractical
Review
PeterLeRoux
Key Points
1. Increased ICP, especially when refractory to treatment, is associated with
increased mortality.
2. Total “ICP dose,” “area under the ICP curve,” temporal evolution of ICP, how
ICP responds to treatment, or individualized ICP thresholds may be more important parameters associated with outcome than a simple numeric threshold.
3. Noninvasive technologies to monitor ICP are evolving but currently none are
robust enough to allow continuous monitoring in routine practice. Consequently,
invasive monitors such as parenchymal ICP monitors or an external ventricular
drain are recommended.
4. Rather than treat the ICP number per se, it may be more important to regard this
value as a marker of altered physiology and instead nd the reason why ICP is
elevated and treat that rather than the numeric value alone.
5. Interventions to manage increased ICP include optimizing normal patient physi-
ology; sedation and analgesia; appropriate uid therapy; blood pressure and
hemoglobin management; ventilation; osmotherapy; cerebral spinal uid (CSF)
drainage; metabolic suppression; and surgery ideally performed according to a
tiered approach and in a patient-specic targeted approach.
P. LeRoux (*)
Division of Neurosurgery, Main Line Health, Wynnewood, PA, USA
Lankenau Institute of Medical Research, Wynnewood, PA, USA
C. N. Rodríguez et al. (eds.), Neurosonology in Critical Care,
https://doi.org/10.1007/978-3-030-81419-9_2
15© Springer Nature Switzerland AG 2022
16
vv
()
P. Le Roux
2.1 Introduction
The prevention and management of increased intracranial pressure (ICP) along with
avoiding secondary insults, for example, hypotension and hypoxia, is fundamental
to neurocritical care management of acute brain injury including traumatic brain
injury (TBI), subarachnoid hemorrhage (SAH), and intracerebral hemorrhage (ICH)
among other pathologies. This is important since untreated increased ICP, particularly when refractory to treatment, can reduce cerebral perfusion pressure (CPP)
and so contribute to brain ischemia, hypoxia, alter metabolism, and hence, cause or
aggravate brain damage [1–5]. In addition, increased ICP can cause herniation and
is an important marker of disease severity. The Monro-Kellie doctrine (Eq.2.1) provides a conceptual framework to understand ICP. Normal adult ICP is between 5
and 15mmHg. It is lower in children (3–7mmHg) and in adults will vary with age
and body posture. The increase in ICP that results from an increase in intracranial
volume follows an exponential curve, so that initial increases in volume are well
compensated but further increases will lead to a sharp ICP increase. This compensatory reserve is known as cerebral compliance dened as the change in cerebral volume per unit change in pressure. Hence, the absolute ICP number is less important
than the rate of rise and the pressure gradient between compartments. Patients can
have a normal ICP and still herniate, and patients with slow, longstanding increases
in ICP may be asymptomatic. This emphasizes the role of cerebral autoregulation
(CA) and other parameters when considering how best to manage ICP [6].
IV BrainCSF Blood Mass lesion
=+++
vv
(2.1)
IV: intracranial volume, Brainv: brain volume, CSFv: cerebral spinal uid volume,
Bloodv: blood volume, Mass lesionv: mass lesion volume.
There are a variety of causes for increased ICP (Table2.1) [7]. Several clinical
and imaging factors may help predict increased ICP and so guide treatment decisions (Table2.2) [8, 9]. However, management of ICP is best accomplished with use
of an ICP monitor [10–15]. ICP monitoring was introduced in the 1950s and today
is the most frequently used neuromonitor. ICP has been most frequently studied in
TBI, where despite much research and a variety of multidisciplinary consensus
statements and guidelines [10–15], there remains much variation in the practice of
ICP monitoring and management [16, 17], and debate about use [18]. In part, this is
associated with inconsistency in reporting variables or heterogeneity in methodology [19]. Important clinical questions that are still being elucidated include:
1. Which patients should undergo ICP monitoring and for how long?
2. What denes intracranial hypertension?/What threshold should ICP be treated?
3. How should intracranial pressure be monitored?
4. How best to manage increased ICP?
5. Does control of ICP inuence outcome?
6. Other monitors necessary to fully understand ICP?