Early mobilization in neurocritical care patients.

PURPOSE OF REVIEW: To examine the potential benefits of early mobilization in neurocritically ill patients and to summarize the recent evidence for and against early mobilization. RECENT FINDINGS: Early ICU mobilization in medically critically ill patients may decrease ICU and hospital length of stay, increase discharge-to-home, and reduce medical costs. Whether these benefits apply to neurologically critically ill patients remains unclear, as neuro ICU patients are often excluded from trials of early mobility. Neurocritically ill patients may present with hemodynamic instability, acute hemiplegia, altered consciousness and visual field deficits which complicate mobilization, or have cerebral ischemia, which may be exacerbated when upright or active. Results of early mobilization in neurocritical care are mixed. For example, a randomized trial in acute ischemic stroke demonstrated that very early mobilization was associated with worse outcomes. However, many smaller intervention trials in neurocritical care demonstrate safety and feasibility with early mobilization, including those in patients with invasive devices, for example, external ventricular drains. SUMMARY: Given successes in other critically ill populations, early mobility of neurocritically ill patients may be warranted. However, caution should be exercised given the results in acute stroke trials. In addition, before routine use, the character, quality, dose, duration, and timing of early mobilization therapies requires further definition.

Medical Training and the Brain Death Exam: A Single Institution's Experience.

BACKGROUND: Clinicians may have limited opportunities to perform neurological determination of death (NDD, or brain death) certification during their training. This study aimed to evaluate the level of resident exposure to the brain death exam at a large-volume donor hospital. METHODS: In March 2014, we adapted a dual-physician model for NDD certification at our institution to improve resident education regarding NDD. To evaluate the incidence of resident exposure, we collected examiner information from all brain death exams conducted between January 2014 and July 2015. Organ procurement, family authorization, and brain death intervals were also collected to evaluate the impact of NDD timeliness on organ donation. RESULTS: A total of 68 patients who met NDD criteria were included in this study. For these patients, 127 brain death exams were performed, 108 (85%) by a critical care attending physician or fellow, 9 (7%) by a neurology resident, and 7 (6%) by a neurosurgery resident. Exposure rates for neurology and neurosurgery residents were approximately 0.22 and 0.20 exams/resident/year, respectively. The median brain death interval between exams was 1.0 hours (interquartile range, 0.0-2.5) hours. Resident involvement, time between exams, and dual exams were all found to be nonsignificant correlates of organ authorization and family refusal. CONCLUSIONS: Neurology and neurosurgery residents may be limited in their exposure to the brain death exam during training. High-volume donor hospitals may be able to complete 2 exams for NDD certification in a timely manner without detrimentally influencing organ authorization or family refusal rates.