Selecting patients for early interdisciplinary rehabilitation during neurointensive care after moderate to severe traumatic brain injury.

BACKGROUND: Early interdisciplinary rehabilitation (EIR) in neurointensive care is a limited resource reserved for patients with moderate to severe traumatic brain injury (TBI) believed to profit from treatment. We evaluated how key parameters related to injury severity and patient characteristics were predictive of receiving EIR, and whether these parameters changed over time. METHODS: Among 1003 adult patients with moderate to severe TBI admitted over 72 h to neurointensive care unit during four time periods between 2005 and 2020, EIR was given to 578 and standard care to 425 patients. Ten selection criteria thought to best represent injury severity and patient benefit were evaluated (Glasgow Coma Scale, Head Abbreviated Injury Scale, New-Injury-Severity-Scale, intracranial pressure monitoring, neurosurgery, age, employment, Charlson Comorbidity Index, severe psychiatric disease, and chronic substance abuse). RESULTS: In multivariate regression analysis, patients who were employed (adjOR 1.99 [95% CI 1.41, 2.80]), had no/mild comorbidity (adjOR 3.15 [95% CI 1.72, 5.79]), needed neurosurgery, had increasing injury severity and were admitted by increasing time period were more likely to receive EIR, whereas receiving EIR was less likely with increasing age (adjOR 0.97 [95% CI 0.96, 0.98]) and chronic substance abuse. Overall predictive ability of the model was 71%. Median age and comorbidity increased while employment decreased from 2005 to 2020, indicating patient selection became less restrictive with time. CONCLUSION: Injury severity and need for neurosurgery remain important predictors for receiving EIR, but the importance of age, employment, and comorbidity have changed over time. Moderate prediction accuracy using current clinical criteria suggest unrecognized factors are important for patient selection.

Impact of Norepinephrine on Regional Cerebral Oxygenation During Cardiopulmonary Bypass.

OBJECTIVES: Norepinephrine is used to increase mean arterial pressure during cardiopulmonary bypass. However, it has been suggested that norepinephrine could constrict cerebral arteries, reducing cerebral blood flow. The aim of this study, therefore, was to explore whether there was an association between doses of norepinephrine to maintain mean arterial pressure at ≈80 mmHg during cardiopulmonary bypass and cerebral oxygen saturation measured using near-infrared spectroscopy. DESIGN: Observational study. SETTING: University hospital. PARTICIPANTS: Patients undergoing cardiac surgery (n = 45) using cardiopulmonary bypass. INTERVENTIONS: Norepinephrine was administered to maintain mean arterial pressure ≈80 mmHg during cardiopulmonary bypass. MEASUREMENTS AND MAIN RESULTS: From initiation of cardiopulmonary bypass to removal of the aortic cross-clamp, norepinephrine dose, mean arterial pressure, partial pressure of arterial carbon dioxide, partial pressure of arterial oxygen, hemoglobin, and pump flow values were averaged over 1 minute, giving a total of 3,460 data points entered as covariates in a linear mixed model for repeated measurements, with cerebral oxygen saturation measured using near-infrared spectroscopy as outcome. There was no statistically significant association between norepinephrine dose to maintain mean arterial pressure and cerebral oxygen saturation (p = 0.46) in this model. CONCLUSIONS: Administration of norepinephrine to maintain mean arterial pressure ≈80 mmHg during cardiopulmonary bypass was not associated with statistically significant changes in cerebral oxygen saturation. These results indicated that norepinephrine could be used to increase mean arterial pressure during cardiopulmonary bypass without reducing cerebral oxygen saturation.

Sudden survival improvement in critical neurotrauma: An exploratory analysis using a stratified statistical process control technique.

BACKGROUND: Outcome after trauma depends on patient characteristics, quality of care, and random events. The TRISS model predicts probability of survival (Ps) adjusted for Injury Severity Score (ISS), Revised Trauma Score (RTS), mechanism of injury, and age. Quality of care is often evaluated by calculating the number of "excess" survivors, year by year. In contrast, the Variable Life-Adjusted Display (VLAD) technique allows rapid detection of altered survival. VLAD adjusts each death or survival by the patient's risk status and graphically displays accumulated number of unexpected survivors over time. We evaluated outcome changes and their time relation to trauma service improvements. METHODS: Observational, retrospective study of the total 2001-2011 trauma population from a Level I trauma centre. Outcome was 30-day survival. Ps was calculated with the TRISS model, 2005 coefficients. VLAD graphs were created for the entire population and for subpopulations stratified by ISS level, ISS body region (Head/Neck, Face, Chest, Abdomen/Pelvic contents, Extremities/Pelvic girdle, External), and maximum Abbreviated Injury Scale (maxAIS) score in each region. Piecewise linear regression identified VLAD graph breakpoints. RESULTS: 12,191 consecutive trauma patients (median age 35 years, 72% males, 91% blunt injury, 41% ISS≥16) formed the dataset. Their VLAD graph indicated performance equal to TRISS predicted survival until a sudden improvement in late 2004. From then survival remained improved but unchanged through 2011. Total number of excess survivors was 141. Inspection of subgroup VLAD graphs showed that the increased survival mainly occurred in patients having at least one Head/Neck AIS 5 injury. The effect was present in both isolated and multitraumatised maxAIS 5 Head/Neck trauma. The remaining trauma population showed unchanged survival, superior to TRISS predicted, throughout the study period. Important general and neurotrauma-targeted improvements in our trauma service could underlie our findings: A formalised trauma service, damage control resuscitation protocols, structured training, increased helicopter transfer capacity, consultant-based neurosurgical assessment, a doubling of emergency neurosurgical procedures, and improved neurointensive care. CONCLUSIONS: Stratified VLAD enables continuous, high-resolution system analysis. We encourage trauma centres to explore their data and to monitor future system changes.

No difference in self reported health among coalminers in two different shift schedules at Spitsbergen, Norway, a two years follow-up.

This study was performed among coal miners in the remote location Svea, Spitsbergen. The shift schedule used to be 7 d on and 7 d off. The aim of this study was to investigate possible changes in health after a voluntary implementation of a new shift schedule, with periods of 14 d on and 14 d off, for 74 percent of the workers in 2007. A questionnaire was distributed to all employees before and two times after the new shift schedule, comprising questions on type of work, shift schedule, pain, sleep, stress and coping. Ninety nine percent of the employees responded; 274 in 2006, 307 in 2007 and 312 in 2008. Work neither in the 14/14 shift nor 7/7 shift was related to any change in the health after these two years. The coping index for workers in the 14/14 shift improved.

[Vascular surgical patients and patient rights legislation]. / Karkirurgiske pasienter og pasientrettighetsloven.

BACKGROUND: From 1 January 2001, a new Patients Rights' Act came into force in Norway that regulates many aspects of clinical work, including patients' right to be adequately informed, the right to a second opinion, the right to choose hospital, the right to refuse a blood transfusion, and the terminally ill patient's right to refuse further treatment. This study aims at assessing the impact of the new legislation on given cases in vascular surgery and to clarify in what ways work procedures in a vascular surgical department should be changed in view of the new rules. MATERIAL AND METHODS: Ten cases drawn from our department between autumn 2000 and January 2001 were analysed in relation to the new legislation, each case representing a specific medico-legal issue regulated by the new act. RESULT: By and large, established practice in our department is in line with the new legislation. However, better documentation is required, as well as more emphasis on integrity in relation to competing hospitals. INTERPRETATION: Surgeons should be well informed on regulations directly affecting the practice of surgery.