Assessing Outcome Measurements and Impact of Simulation in Neurocritical Care Training: A Systematic Review.

ABSTRACT: AIM: The use of simulation training in neurocritical care is increasing. Yet, the pooled impact on patient and trainee outcomes remains unclear. This systematic review aims to determine the outcome measurements used after simulation training in neurocritical care and to synthesize the current evidence about the impact of simulation training on these outcomes. METHODS: A 3-step search was conducted in CINAHL, Cochrane, MEDLINE, PsychINFO, and Scopus. The inclusion criteria were composed of studies exploring simulation training in neurocritical care, published in English between 2000 and 2023. Two reviewers independently conducted screening, critical appraisal, and data extraction, using standardized Joanna Briggs Institute tools. Meta-analysis was precluded because of clinical, methodological, and statistical heterogeneity. RESULTS: Nine relevant studies were found: 1 quality improvement project and 8 quasi-experimental studies. The overall quality of the relevant studies was moderate to high (61.1%-77.8%). Three types of outcome measurements for simulation in neurocritical care were identified: knowledge and clinical performance; confidence and comfort; and teamwork, communication, and leadership skills. Simulation training was associated with a significant improvement in knowledge and clinical performance, and confidence and comfort, but not in communication and leadership skills. CONCLUSION: Significant improvement in trainees' outcomes was observed. The current literature includes significant heterogeneity in the methods of evaluating simulation outcomes, although no patient outcomes were observed. Investigating the effect of simulation in neurocritical care training on patient outcomes in future studies is warranted.

Valproate-induced Periorbital Edema.

INTRODUCTION: Valproate is an antiepileptic medication that can be used to manage behavioral symptoms associated with Alzheimer's dementia. We present a rare case of valproate-induced periorbital edema. CASE: A 76-year-old man came to the emergency room with agitation and aggression. He was medically cleared and referred to a psychiatric facility where he was treated with haloperidol. When he developed drug-induced parkinsonism, the haloperidol was stopped, and the patient was started on valproate 250 mg twice daily. The day after valproate administration, the patient developed periorbital edema. After ruling out other causes of periorbital edema, adverse drug reaction was suspected. Valproate was discontinued, and the edema rapidly resolved within five days. CONCLUSION: Periorbital edema is a rare side effect of valproate. It can occur in patients who are being treated with valproate for behavioral changes in Alzheimer's disease. The edema resolves with discontinuation of the medication.

Internal Bleeding Extending to the Retroperitoneum and Right Psoas With Severe Acute Respiratory Syndrome Coronavirus 2 Infection.

Coronavirus disease 2019 (COVID-19 - severe acute respiratory syndrome coronavirus 2 {SARS-CoV-2}) infection has been associated with thromboembolic events and coagulopathy, leading to a surge in the use of anticoagulants. The dose and duration of therapy differ according to the followed protocol. Several case reports documented fatal bleeding as an adverse effect of anticoagulation. We report a case of nearly fatal retroperitoneal bleed in an otherwise healthy 60-year-old man who developed severe COVID-19 requiring ICU stay and mechanical ventilation. The development of retroperitoneal bleed led to a 50% drop in his hemoglobin. The patient happens to be a Jehovah's Witness, and the family refused blood transfusion, which added to the complexity of the situation. Anticoagulation is associated with a potential risk of fatal bleed in critically ill COVID-19 patients. There are different protocols of anticoagulation in the management of SARS-CoV-2. The risk of bleeding vs thrombosis should be weighed on a case-by-case basis. A high degree of suspicion, early intervention, and knowledge of alternatives to blood transfusion can improve outcomes.

Rhino-Orbital Cerebral Mucormycosis in Non-Diabetic Patients with COVID-19.

Rhino-orbital Cerebral Mucormycosis (ROCM), a rare invasive fungal infection, affects diabetic and immunocompromised individuals. Recent reports have raised the alarm for invasive ROCM associated with SARS-CoV-2 infection. SARS-CoV-2 infection causes immune cell dysregulation, cytokine dysregulation, and is associated with invasive fungal infections. Immunosuppressive treatment of COVID-19 with corticosteroids increases the risk of opportunistic infection. We present a series of 3 cases of invasive ROCM with different outcomes in immunocompetent nondiabetic patients who all received corticosteroids at doses higher than those recommended by the World Health Organization, and who received oxygen during their SARS-CoV-2 treatment course. Immune dysregulatory effects of COVID-19 and high-dose corticosteroids may both have caused predisposition to ROCM in these cases. Additionally, health system stress caused by responding to COVID-19 surges may have predisposed patients to exposure to mucormycosis-causing fungi through use of non-sterilized water for oxygen humidification. In light of these cases, we encourage guideline-based corticosteroid dosing in the management of COVID-19 as well as vigilance for invasive mucormycosis and prompt treatment in corticosteroid-treated patients.

Self-Report Assessment of Nurses' Risk for Infection After Exposure to Patients With Coronavirus Disease (COVID-19) in the United Arab Emirates.

PURPOSE: Nurses have an increased risk for acquiring COVID-19 infection. This study assessed levels of risk for exposure to COVID-19 among nurses, and determined those at the greatest risk. DESIGN: A cross-sectional design was used to assess risk for exposure to COVID-19 in nurses from five randomly selected governmental hospitals in the United Arab Emirates. Participants completed an online survey (including the World Health Organization survey) to assess their risk for exposure to COVID-19. Descriptive statistics were used to describe classes of risk for exposure, and logistic regression was used to identify factors associated with greater risk. FINDINGS: Of the 552 participants, 284 nurses (51.4%) were classified at high risk for COVID-19 exposure as they did not report adherence to infection control and prevention (ICP) guidelines at all times during healthcare interactions and when performing aerosol procedures, or had accidental exposure to biological fluid and respiratory secretions. Compared with adherence to wearing medical masks, gloves, and hand hygiene practices, adherence to wearing face shields or goggles and disposable gowns and decontaminating high-touch surfaces was less frequent. Shifting to work in critical care units, not having adequate critical care experience, and reporting a need for training in ICP practices were factors that contributed to high-risk exposure (p values for Ex (Bs) = 2.60, 2.16, 1.75, ≤ 0.05, consecutively). CONCLUSIONS: A considerable number of nurses were classified at high risk for COVID-19 exposure. Critical care work experience and adequate evidence-based training in ICP practices related to COVID-19 must be considered to mitigate the risk for exposure to COVID-19 in nurses. CLINICAL RELEVANCE: This study provided a strong message regarding protecting nurses at high risk for exposure to COVID-19. Clinical leaders must stay vigilant to ensure nurses' adherence to ICP practices in the context of COVID-19, and to proactively address any related deficits.