Neurocritical care
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The Full Outline of UnResponsiveness (FOUR) score was developed to overcome the limitations of the Glasgow Coma Scale (GCS) when assessing individuals with impaired consciousness. We sought to review the evidence regarding the predictive validity of the GCS and FOUR score in intensive care unit (ICU) settings. This review was prospectively registered in PROSPERO (CRD42023420528). ⋯ The FOUR score may be superior to the GCS for predicting mortality in ICU settings. Further adequately powered studies with clear, reliable methods for assessment of index and outcome scores are required to clarify the predictive performance of both coma scales in ICUs. Inclusion of sedated patients may improve generalizability of findings in general ICU populations.
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Although evaluation of disorders of consciousness (DoC) following brain injury has traditionally relied on bedside behavioral examination, advances in neurotechnology have elucidated novel approaches to detecting and predicting recovery of consciousness. Professional society guidelines now recommend that clinicians integrate these neurotechnologies into clinical practice as part of multimodal evaluations for some patients with DoC but have not crafted concrete protocols for this translation. Little is known about the experiences and ethical perspectives held by key stakeholder groups around the clinical implementation of advanced neurotechnologies to detect and predict recovery of consciousness. ⋯ Ethical themes of prognostic uncertainty, nihilism, and access also permeated multiple domains. Considerations surrounding access, knowledge base, results interpretation, and communication with surrogates are cross-cutting ethical threads shaping the clinical translation of advanced neurotechnologies for DoC. These components represent opportunities for implementation science work focused on democratizing access to neurotechnologies, educating clinicians on the use of novel techniques and interpretation of results, conducting multisite validation studies, and standardizing approaches to communicating test results.
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Severe traumatic brain injury (TBI) can lead to transient changes in autonomic nervous system (ANS) functioning and development of paroxysmal sympathetic hyperactivity (PSH) syndrome. Clinical manifestation of ANS disorders may be obscured by therapeutic interventions in TBI. This study aims to analyze ANS metrics and cerebral autoregulation in patients with PSH syndrome to determine their significance in early prognostication. ⋯ Elevated HRV in the LF and decreased HR may serve as early predictors of PSH syndrome development, particularly in patients with diffuse axonal trauma. Further research is needed to investigate the utility of the cerebral autoregulation-ANS relationship in PSH prognostication.