Salt steps and sugar checks - Making arterial line use safer in our trust

Introduction: Arterial lines are used within our intensive care unit to allow invasive blood pressure monitoring and regular blood gas analysis. Inadvertent use of dextrose containing fluids in the flush have been associated with falsely high glucose readings. When these are acted on with insulin, it can cause devastating hypoglycaemic brain injury. There have been a number of deaths and other incidents relating to the wrong fluid being used in arterial line set up reported within the UK in recent years. In 2014 the AAGBI released a safety guideline on the use of arterial lines specifically to reduce to the risk of hypoglycaemic brain injury. Objective(s): Our objective was to ensure that 100% of arterial lines in use within Royal Victoria Hospital's intensive care unit were compliant with our trust policy on the management of arterial lines. Method(s): We audited our intensive care unit's compliance with our trust policy and found that we were 80% compliant. We formed a multi-disciplinary arterial line working group in order to tackle the problem. Our quality improvement project consisted of two main approaches: 1. To educate staff on how to manage arterial lines correctly. We divided the management of arterial lines into S.A.L.T steps (a 7 step bundle on "Setting up an Arterial Line Transducer") and SUGAR checks ( a series of red flag moments to prompt staff to review the patient prior to starting or increasing insulin administration).We developed educational posters for key areas in ICU and presented our findings at departmental meetings. 2. To change the system, in order to make it easier to do the right thing. We developed a Universal Adult Arterial Pack (UAAP) containing key components in the setup of an arterial line. This also included aide memoires for the S.A.L.T steps and SUGAR checks. In order to measure the effect of these changes, we: 1. Audited compliance on a regular basis. 2. Monitored serious bundle breaches ( for example no label, wrong fluid used) 3. Assessed usage of the UAAP. Result(s): 1. Bundle compliance improved during the first half of 2021, however then reduced in the second half with the number of serious bundle breaches increasing. This coincided with COVID surge 4 - associated with reduced nursing ratios and staff redeployment. 2. UAAP usage increased throughout the project, from an average of 6 to 9 per day. 86% of staff found the packs useful and 85% thought that they reduced the potential for error. Conclusion(s): The presence of a policy does not ensure that staff will know about it or adhere to it. Although we have not yet achieved our target of 100% compliance, we have seen evidence of how our project has the potential to do so in the near future. We aim to roll out our new e-learning module for staff education, manufacture our UAAP on a bigger scale, and disseminate the project to other departments within the trust.

Use of Living Systematic Reviews (LSRS) Beyond COVID-19

Objectives: A LSR is a systematic review that is continually updated, incorporating new evidence as it becomes available. They are conducted in research areas where new evidence is constantly emerging on diagnostic methods, treatments, and outcomes. The objective of this study was to understand the current application of LSRs across research areas. Method(s): Embase, MEDLINE, and the Cochrane Database of Systematic Reviews were searched to identify LSRs. Only the most recent update of a LSR was included. Data regarding the indication, intervention, methods, frequency of updates, and funding were extracted. Result(s): Of the 1,243 records identified, 126 LSRs were included for analysis. The first LSR was published in 2015, with a significant increase in the number of LSRs published starting in 2020, coinciding with the COVID-19 pandemic. The most common indication represented by LSRs was COVID-19 (72%), followed by oncology (10%). Other indications with LSRs included chronic pain, traumatic brain injury, and skin disorders, among others. While most oncology LSRs identified interventional randomized-controlled trials (RCTs) (85%), only 54% of COVID-19 LSRs were restricted to interventional studies, including a combination of RCTS and real-world observational studies. Oncology LSRs included common cancers such as prostate, renal, or multiple myeloma. Of the reviews that reported update frequency, 28% planned monthly, 12% yearly, and 12% weekly updates. Only 46% of LSRs were registered. The majority of LSRs were funded by government or research organizations. Objectives of LSRs varied, with most stating the need to maintain up-to-date databases;however, several studies used LSRs to facilitate network meta-analysis or mixed treatment comparisons. Conclusion(s): While LSRs were introduced over five years ago, their frequency increased during the COVID-19 pandemic. Apart from COVID-19, LSRs are commonly used in oncology settings. LSRs provide high-level, relevant, and up-to-date evidence, making them a useful tool for clinical and real-world research.Copyright © 2023

A Case Report on Heart Rate Variability Biofeedback and Postconcussion Syndrome: Healing the Autonomic Nervous System

Postconcussion syndrome is a devastating condition of the mind, body, and even personality. Mounting research demonstrates that heart rate variability biofeedback can help the concussed individual in three critical ways: (a) eliciting high amplitude oscillations in cardiovascular functions and thereby strengthening self-regulatory control mechanisms;(b) restoring autonomic balance;and (c) increasing the afferent impulse stream from the baroreceptors to restore balance between inhibitory and excitatory processes in the brain.

Big data approach on the impact of COVID-19 lockdown on pediatric neurosurgery

Objective: COVID-19 lockdowns in 2020 limited activities of daily life. Data on the impact on healthcare systems is ambiguous. So far no data has been published for pediatric neurosurgery in Germany. We present the results of a big data approach. Method(s): We obtained anonymous data from the nationwide database of hospital statistics (German Federal Statistical Office, www. desta tis. de) in August 2022. For the age group <18 years in 2016- 2020, the following diagnoses (ICD-10 code) were analysed: Intracranial injury (S06), malignant (C71), benign (D33) and unspecified (D43) neoplasia, abuse (T74), violent attack (Y09) and, for comparison, forearm fracture (S52). The following operations (OPS code) were chosen: Operation of the central nervous system (CNS, 5-01- 05), excision of intracranial lesion (5-015), shunt insertion (5-023), shunt revision (5-024), plastic operations of the spinal cord (5-036) and, for comparison, overall number of operations (OPS-5), spondylodesis (5-836) and functional neurosurgery (5-028) at all ages. Result(s): The number of operations declined from 17.23 million in 2019 to 15.82 million in 2020 (8.2%). CNS operations declined by 5%. Shunt insertion declined by 8.1%, revision by 5.1% and spinal cord operations by 6.6%, whereas excisions of intracranial lesions increased by 1.7%. Spondylodesis and functional operations both decreased by 11.9%. The hospitalisations for intracranial neoplasia declined by 8.8% compared to previous years. The number of inpatients with intracranial injury declined by 16%. Violent attack was also documented less often (-13.2%), but child abuse increased by 3.3%. Forearm fractures declined by 5.6%. Conclusion(s): The COVID-19 lockdown in 2020 lead to reduction of operations. Neuro-oncological operations were not affected. Intracranial injury even declined by 16%, reflecting limited activities and mobility. An increase in documented child abuse by 3.3% compared to the average of previous years was observed. These results help understand the impact of pandemics and political decisions and guide future decision-making.

'Online therapy' to reduce caregiver's distress and to stimulate post-severe acquired brain injury motor and cognitive recovery: A Sicilian hospital experience in the COVID era.

INTRODUCTION: Severe acquired brain injury(SABI) often results in the deterioration of physical, cognitive and emotional functions in the patient and a significant caregiver's distress syndrome, which is now amplified by the social isolation, depression and financial difficulties related to the COVID-19 pandemic. The use of web-based online-therapy has been shown to be useful to overcome caregiver's distress syndrome and further stimulate cognitive-motor recovery of SABI-patients. Our study aimed to investigate whether a systematic online Skype-therapy(OLST) may be of support in favoring global cognitive and sensory-motor recovery in SABI-patients and reducing caregiver distress. METHODS: Twenty-five SABI-subjects in inpatient regimen were provided with intensive OLST with the caregiver for 12 weeks in addition to standard neurorehabilitation. Each subject and caregiver was evaluated before and after the treatment by administering an ad hoc battery. Furthermore, 18 of 27 patients were provided with EEG recording in resting state. RESULTS: We found a significant reduction in caregiver's anxiety (p<0.0001) and burden(p<0.0001). Patients showed significant improvement in trunk control (p<0.0001), functional independence (p = 0.005), functional (p = 0.01) and global communication (p = 0.004), cognitive functioning (p = 0.001), and behavioral responsiveness (p = 0.0004). The training yielded a significant connectivity change within the fronto-centro-parietal areas in the delta frequency band (p<0.0001) and the centro-parieto-occipital areas in the alpha range (p = 0.004). DISCUSSION: OLST may be a useful and complementary treatment to optimize global cognitive and functional recovery in SABI-subjects and reduce caregivers' concerns in the Covid-era. OLST can foster cognitive-motor recovery potentially by favoring the plasticity-dependent functional recovery. Therefore, OLST could be proposed as a tool allowing social conversations also in the hospital setting.

Neurotrauma: 2021 update.

Despite the interruptions and restrictions to the progress of science that the COVID-19 pandemic has introduced, 2020 was marked by a number of important advances in the field of neurotrauma. Here, I will highlight what I believe are among the most important contributions. This year there were notable advances towards providing clinically useful information on neurotrauma outcome through the use of fluid biomarkers. I also introduce fascinating approaches to studying the role of microglia in nervous system repair and neuroinflammatory mechanisms leading to dysfunction through the use of colony-stimulating factor 1 receptor inhibitors, especially Plexxikon 5622 (PLX5622). Oral administration of this compound is able to deplete microglial elements and then, following withdrawal from the drug, a new population of microglia then repopulates the brain. Use of this approach in traumatic brain injury experimental models has produced important insights into the pathogenetic role of microglia in responding to this process. Important new data on the nature and distribution of tau involvement of neurons and astrocytes in cases of chronic traumatic encephalopathy (CTE) also appeared suggesting differences and similarities to Alzheimer s disease. Additionally, the use of tau-specific PET scan ligands in at-risk populations has suggested that this approach may be able to identify cases with CTE. Lastly, we note the death in the past year of a major contributor to the field of neurotrauma neuropathology, Professor J. Hume Adams.

Automated screening of computed tomography using weakly supervised anomaly detection.

BACKGROUND: Current artificial intelligence studies for supporting CT screening tasks depend on either supervised learning or detecting anomalies. However, the former involves a heavy annotation workload owing to requiring many slice-wise annotations (ground truth labels); the latter is promising, but while it reduces the annotation workload, it often suffers from lower performance. This study presents a novel weakly supervised anomaly detection (WSAD) algorithm trained based on scan-wise normal and anomalous annotations to provide better performance than conventional methods while reducing annotation workload. METHODS: Based on surveillance video anomaly detection methodology, feature vectors representing each CT slice were trained on an AR-Net-based convolutional network using a dynamic multiple-instance learning loss and a center loss function. The following two publicly available CT datasets were retrospectively analyzed: the RSNA brain hemorrhage dataset (normal scans: 12,862; scans with intracranial hematoma: 8882) and COVID-CT set (normal scans: 282; scans with COVID-19: 95). RESULTS: Anomaly scores of each slice were successfully predicted despite inaccessibility to any slice-wise annotations. Slice-level area under the curve (AUC), sensitivity, specificity, and accuracy from the brain CT dataset were 0.89, 0.85, 0.78, and 0.79, respectively. The proposed method reduced the number of annotations in the brain dataset by 97.1% compared to an ordinary slice-level supervised learning method. CONCLUSION: This study demonstrated a significant annotation reduction in identifying anomalous CT slices compared to a supervised learning approach. The effectiveness of the proposed WSAD algorithm was verified through higher AUC than existing anomaly detection techniques.

Neurodegeneration: 2022 update.

Here, we review a collection of recent manuscripts and research trends on the neuropathology of neurodegeneration that are considered by the author to be among the potentially most impactful. To the greatest extent possible, we chose to focus on histopathological studies that are most relevant to experimental and diagnostic neuropathology. While there has been an abundance of important recent discoveries and developments in neurodegenerative disease research, there was a deliberate effort here to provide balance to prevent disease categories and experimental approaches from overshadowing the others. The result is a diverse series of outstanding studies, together showing the landscape of progress across neurodegenerative disorders. One is a stereological study examining dystrophic microglia in aging. We highlight the first large genetic study of primary age-related tauopathy, showing convergence and divergence from classical Alzheimer's disease. There were further advances in the neuropathological criteria and staging of chronic traumatic encephalopathy. Links suggesting a causal role for TMEM106B in TDP-43 proteinopathy emerged. Attempts to subtype Alzheimer's disease on the molecular level were made. Evidence for a role for the VEGF family in cognitive impairment was advanced. Comparison of gene expression profiles from myeloid cells in peripheral blood and brain tissues from Parkinson's disease patients revealed pathways that may lead to new mechanistic insights and biomarkers. A large autopsy series identified an increased frequency of central nervous system developmental malformations in Huntington's disease. A robust and reliable system for assessing Lewy body pathology was proposed. Finally, we continue to be plagued by the COVID-19 pandemic, with lingering concerns of a long-term link with neurodegeneration.

The impact of the South African Covid-19 lockdown on incidence and severity of traumatic brain injury at Tshepong hospital: A multivariate retrospective cohort study.

Background: Globally traumatic brain injuries (TBIs) are the leading cause of death in people under the age of 45. 2020 saw a series of social lockdowns as a response to the COVID-19 pandemic. We aimed to unveil the impact of the different levels of lockdown on TBI incidence at Tshepong Hospital. Method: A retrospective review of patients with TBIs during the first 30 days of each of the 5 lockdown levels, between 1st of April -20th October 2020 was conducted. Each lockdown level was compared to a control of a similar period in 2019. Results: Level 5 lockdown resulted in a 66% reduction in total incidence of TBI, with a decrease in the daily incidence median value to 0 when compared to its control group median of 1 (P-value 0.004). However, Level 3 and 2 resulted in a significant 133% and 200% increase respectively in TBI incidence for similar period the year before.There was a 0,75% decrease in total trauma during the non-lockdown periods in relation to the lock down periods with a lockdown mean incidence of 53,4 (std Dev. 26.6) and non-lockdown mean of 53 (std Dev 20.8). Conclusion: The cumulative effect of the lockdowns made miniscule changes in the overall TBI incidence but led to significant variation in TBI incidence in the comparative months. A "rebound trauma" phenomena is observed in transitioning from severe social restrictions to milder ones with unemployment and unbanning of alcohol as possible contributary factors. Further studies are needed to investigate these complex interactions.

Synthesis Strategy of Tetrapyrrolic Photosensitizers for Their Practical Application in Photodynamic Therapy

This review presents a wide range of tetrapyrrole photosensitizers used for photodynamic therapy (PDT), antimicrobial photodynamic therapy, photoinactivation of pathogens. Methods of synthesis and design of new photosensitizers with greater selectivity of accumulation in tumor tissue and increased photoinduced antitumor activity are considered. The issues of studying the properties of new photosensitizers, their photoactivity, the ability to generate singlet oxygen, and the possibility of using targeted photodynamic therapy in clinical practice are discussed. The review examines the work on PDT by national and foreign researchers.

Trauma: a stress during pandemic?

Introduction: Coronavirus disease 2019 pandemic significantly impacted on trauma systems, since emergency departments (ED) suddenly were overwhelmed by patients requiring intensive care unit (ICU) admission. Once, trauma volume was supposed to decrease due to lockdown policies, we aimed to describe ICU trauma admissions during this period. Method(s): Retrospective observational study of all trauma patients admitted to the ICU of a Portuguese Trauma Center between January 2020 and December 2021. Data were collected from clinical hospital records. Result(s): 437 trauma patients (15% of all admissions), mostly male (71%), with a median age of 59 years-old (42-74) were included. At least one comorbidity was present in 71% of the patients. Median severity scores were: SAPS II 26 (19-38), SOFA 3 (1-6), ISS 13 (9-22), RTS 8 (6-8) and TRISS 96,75 (81.1-98.6). The most frequent mechanisms of injury were falls (59%) and road traffic accidents (25%). The majority consisted of blunt trauma (88%), 65% of brain trauma and 35% of musculoeskeletal trauma. Trauma Team assessment was started in < 3 min in all cases and median length of stay (LOS) in the ED was 261 min (154-418). Surgical intervention was performed in < 4 h in 56% of surgical brain trauma injuries, in < 6 h in 67% of extremity open fractures and in < 1 h in 6% of a penetrating trauma. Shock, mainly hemorrhagic, was present in 8% of the patients on hospital admission. 38% were submitted to invasive mechanical ventilation and 34% to vasopressors. The most common complication was nosocomial infection (18%). The median LOS in the UCI was 12 days (5-24). Only 8% of the patients died in the ICU and 11% in the hospital. Conclusion(s): During pandemic, trauma persisted a major health problem with a significant consumption of time and critical care resources. The high influx of patients may have influenced the LOS in the ED before ICU admission and the time until the surgical intervention. Despite it, mortality remained low.

COVID-19's impact on a community-based physical activity program for adults with moderate-to-severe TBI.

PURPOSE: Physical activity (PA) is proposed for long-term problems after traumatic brain injury (TBI) with mood, quality of life, and participation. However, COVID-19 mitigation strategies resulted in widespread closures of community-based fitness centres, including one housing a peer-assisted PA program (TBI-Health). The purpose of this study was to provide an in-depth exploration of COVID-19's impact on the TBI-Health program for adults with moderate-to-severe TBI and determine how their PA behaviours could be supported in the pandemic. METHODS: Interpretative phenomenological analysis was employed to collect and analyze data from semi-structured Zoom-facilitated interviews with seven female and nine male adults with moderate-to-severe TBI (including program participants and mentors). RESULTS: Three major themes were identified. Need for PA after TBI included specific benefits of PA after TBI and desire for an adapted PA program. Lasting Impacts of the TBI-Health Program identified belonging to the TBI-Health community, benefits, and knowledge transfer from the program. Resilience and Loss through the Pandemic comprised the repercussions of COVID-19, loss of the PA program, adapting PA to the pandemic, and resilience after TBI. CONCLUSION: This study provides insights about impacts of participating in community-based peer-assisted PA programs after moderate-to-severe TBI and ways to support PA in unforeseen circumstances.IMPLICATIONS FOR REHABILITATIONOur community-based peer-assisted physical activity program for adults with moderate-to-severe traumatic brain injury (TBI) promoted a range of daily and social activities.Outdoor group-based physical activity programs provide physical activity and social opportunities for adults with moderate-to-severe TBI when indoor physical activity is restricted.Community-based peer-assisted physical activity programs can assist with posttraumatic growth after moderate-to-severe TBI.

Telerehabilitation Implementation: Perspectives from Physiotherapists Working in Complex Care

Purpose:The COVID-19 pandemic resulted in a rapid change in ways clinicians deliver physiotherapy services, leading to an important uprise in telerehabilitation implementation. Sharing the experiences of physiotherapists in clinically adopting this technology during this initial wave of the pandemic can influence future implementation. This mixed-method study aimed to identify the barriers and new facilitators of telerehabilitation clinical implementation. Methods:Canadian physiotherapists with and without telerehabilitation experience, working in various clinical settings, were recruited during the first wave of the COVID-19 pandemic. Participants completed the Assessing Determinants of Prospective Uptake of Virtual Reality instrument (ADOPT-VR) adapted for telerehabilitation and participated in online focus groups to explore their experiences with telerehabilitation implementation. Demographic data and ADOPT-VR responses were analyzed descriptively. Qualitative data were analyzed using content analysis. Results:Sixteen physiotherapists completed the study. Scores on the Likert scale showed that physiotherapists enjoyed telerehabilitation (7.5/10) and perceived it as being useful (7.3/10). Physiotherapists disagreed with the necessity to use only minimal mental efforts (4.4/10) and feeling familiar with the evidence (4.7/10). Limited access to telerehabilitation implementation evidence, a reduced hands-on approach, and a lack of validated remote assessments were reported as barriers. Discussion:Clinical practice guidelines, validated remote neurological assessments, changes in physiotherapy curriculum and policymaking are critical to improving telerehabilitation implementation within physiotherapy practices. Conclusion:Participants positively experienced the quick use of telerehabilitation from the beginning of the COVID-19 pandemic, but some important barriers remain.

Impact of Covid-19 lockdown on the mood, behaviour, and social activities of people with brain injury in the UK: Results of a survey of brain injury professionals' reports

The Covid-19 related lockdown of March–June 2020 in the United Kingdom (UK) may have negatively affected mood and behaviour of people with brain injuries. Conversely, there may have been beneficial effects due to reduced demand on cognition and emotional regulation. In this online survey study, care coordinators (n=19) assessed the consequences of lockdown on 130 individuals with ABI (range 3–29 clients per care co-ordinator;10–65years+;and mostly living in residential care). The majority of reports were of no change to mood, behaviour, or social functioning (105 ratings). However, respondents reported that 88 (68 per cent) clients presented with changes: 63 clients (48 per cent) had lower mood, higher distress, and agitation, and were less engaged in usual activities;while 25 clients (19 per cent) were reported to have improved. Moreover, 13/19 (68 per cent) of respondents reported increased vulnerabilities in their clients, and 5/19 (26 per cent) reported online exploitation, controlling behaviour from partner and financial scams. These data present a mixed picture of how the first national lockdown affected people with ABI. [ FROM AUTHOR] Copyright of Neuropsychologist is the property of British Psychological Society and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Comorbidity of purulent meningitis with COVID‐19: A case report

To date, only a few cases of intracranial infection related to severe acute respiratory syndrome‐coronavirus‐2 (SARS‐CoV‐2) were reported. Here we describe a case of coronavirus disease 2019 (COVID‐19) that was comorbid with purulent meningitis. A 62‐year‐old male patient was diagnosed with moderate COVID‐19 and had no fever or cough after treatment. However, he suffered from a head injury and experienced headache and fever immediately after the accident. Computed tomography (CT) of the brain showed bilateral frontal lobe contusion, subdural hematoma, and subarachnoid hemorrhage. In the following days, the patient suffered from recurrent fever, although chest CT did not show evidence of worsening of infection. Several lumbar punctures were made, confirming increased cerebrospinal fluid (CSF) pressure and karyocyte count. SARS‐CoV‐2 nucleic acid was not detected in CSF but revealed the presence of Escherichia coli. Thus, the patient was diagnosed with purulent meningitis, presumably caused by brain trauma or the immunologic dysfunction caused by COVID‐19, which was supported by the significant reduction of all kinds of immune cells. Since immunologic dysfunction is commonly presented in COVID‐19 patients, comorbidity with meningitis should be considered when a COVID‐19 patient presents with headache and fever. Lumbar punctures and CSF cultures may help in the diagnosis.

Changes in the State of Vital Systems with Long COVID-19

—Long COVID-19 is a chronic disease that continues to be studied. Data on epidemiology and the main symptoms typical for long COVID-19 are presented. Issues related to the pathogenesis of the disease are discussed. At the same time, special attention is paid to the inflammation process (including of the vascular wall endothelium), the state of the immune system (cytokine storm), the hemostasis system (the mechanism for the development of microangiopathy and thrombosis), and oxidative stress. During the analysis, a special place is given to central nervous system disorders (including organic brain damage) and disorders of cognitive functions. In addition, currently known complications from the cardiovascular system and respiratory organs are described. The treatment and rehabilitation of patients with long COVID-19 is not only a medical, but also a significant social problem.

Narcolepsy due to a medical condition

"Narcolepsy due to a medical condition” (symptomatic or secondary narcolepsy) results from a specific underlying medical or neurological condition. Common causes are inherited disorders, tumors, head trauma, demyelinating diseases and stroke. Similar to idiopathic narcolepsy, aberrant T cell mediated cytotoxicity to host antigens in hypocretin neurons might be the underlying pathophysiology. Secondary narcolepsy cases have varying ages of onset, typically following a specific underlying medical or neurological disorder. Primary sleep disorders, mental disorders, or drug/substance use needs to be ruled out. Although the main treatment should be controlling underlying pathologic processes, use of wake promoting medications are often warranted. © 2023 Elsevier Inc. All rights reserved

Po251 / #854 Noninvasive Closed Loop Diaphragm Stimulation for Ventilated Icu Patients: E-Poster Viewing

Introduction: Many COVID-19 patients need prolonged artificial ventilation. Skeletal muscle wastes rapidly when deprived of neural activation, and in ventilated patients the diaphragm muscle begins to atrophy within 24 hours (ventilator induced diaphragmatic dysfunction, VIDD). This profoundly weakens the diaphragm, complicating the weaning of the patient off the ventilator, and increasing the risk of complications such as bacterial pneumonia. 40% of the total duration of mechanical ventilation in ITU patients is accounted for by the weaning period, after the initial illness has resolved. Prevention of VIDD would therefore both improve individual outcomes, and also release ITU capacity. We aim to prevent VIDD by exercising the diaphragm with electrical stimulation of the nerves that control it. Evidence suggests that muscle wasting can be prevented by quite low levels of exercise (e.g. 200 contractions per day). Materials / Methods: The diaphragm is activated by the phrenic nerves, formed from branches of the C3-C5 nerve roots in the neck. These nerves may be electrically stimulated in the lower neck. An electrode array is positioned on each side of the neck using surface landmarks. The system automatically determines the best electrode to use in each array. Sensors built into the ventilatory circuit are monitored both to match stimulation to the respiratory cycle and to determine the effects of stimulation. Result(s): We have designed and built a prototype system for unsupervised noninvasive phrenic nerve stimulation. The system delivers one contraction every 7 minutes, synchronised to early inspiration so as not to disrupt ventilation. Electrode impedances are measured before each stimulus, and the closed loop system continuously monitors the effects of stimulation on airflow and adjusts stimulation parameters to compensate for changes in coupling, for example due to head movement. Discussion(s): This stimulator system overcomes several limitations of existing solutions, namely the resource implications and risk profile of invasive electrodes, and the requirement for supervised operation. While invasive systems are applied selectively for these reasons, routine use of our system can be envisaged. This system was inspired by COVID-19 patients but is not limited to them, and has broad applicability to ventilated intensive care patients in general, for example patients with traumatic brain injury. Conclusion(s): Non-invasive stimulation of the phrenic nerves using pressure-free skin surface electrodes is feasible and safe. It offers the potential for prevention of VIDD and thereby faster ventilator weaning and shorter stay on ITU. Clinical trials are planned in 2022. Learning Objectives: After this presentation delegates should be aware of: 1. Ventilation induced diaphragm dysfunction (VIDD) and its importance in patients having lengthy periods of ventilation, as in many cases of COVID-19. 2. The fact that low levels of activity can maintain the condition of skeletal muscles including the diaphragm muscle 3. The potential for noninvasive stimulation of the phrenic nerves to provide 'diaphragm exercise' and prevent VIDD. Keywords: phrenic nerve stimulation, diaphragm, ventilation, COVID-19Copyright © 2022