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SCCM Pod-498 Current Concepts: New Initiatives, Diagnostics, and Management in Coma

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Dive into the inaugural episode of SCCM’s Current Concepts Series, in which authors unveil exclusive insights into the 2024 Current Concepts Course. Samantha Gambles Farr, MSN, NP-C, CCRN, RNFA, is joined by Diane C. McLaughlin, DNP, AGACNP-BC, CCRN, FCCM, as they discuss the latest developments in the coma, delving into essential aspects vital for the intricacies of critical care management. Don't miss this riveting exploration of cutting-edge knowledge in the field.

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This educational activity is supported by the SCCM Current Concepts Committee.

Dr. Gambles Farr: Hello and welcome to the Society of Critical Care Medicine podcast. I’m your host, Samantha Gambles Farr. Today, we’re joined by Diane C. McLaughlin, DNP, AGACNP-BC, CCRN, FCCM, to kick off our multipart series, introducing the Current Concepts course and text available at the 2024 Critical Care Congress. Get ready to dive into each chapter as we chat with the authors, providing an exclusive sneak peek into their expertise and course content.

Dr. McLaughlin is a neurocritical care nurse practitioner at Baptist Health Lyerly Neurosurgery and Mayo Clinic in Jacksonville, Florida. She is active within SCCM, serving on both the Strategic Planning and Annual Congress Planning committees, and is a social media ambassador for SCCM. She is also the only advanced practice provider to hold fellowship in both SCCM and the Neurocritical Care Society. Welcome, Dr. McLaughlin. Before we start, do you have any disclosures to report?

Dr. McLaughlin: I do not.

Dr. Gambles Farr: Thank you so much. It’s so exciting to have you here today with your vast knowledge of neurocritical care. I guess the best question we can start out with is: What exactly is neuroprognostication?

Dr. McLaughlin: Neuroprognostication is essentially the science of predicting neurologic outcomes. Rather than just looking into a crystal ball, how do we use science to predict what the future will look like? It’s a critical aspect in both neurology and critical care because it can guide life-or-death decisions for patients and their family members.

Dr. Gambles Farr: We know that prognostication is often something that’s not specifically asked of advanced practice providers. Were you surprised that they chose an APP to write this chapter?

Dr. McLaughlin: I was, honestly, but it kind of fits with SCCM as very multidisciplinary. I was thrilled that they did it because I think, honestly, that most people don’t realize how much influence nursing has on patients and their family members. They’re the ones who are at the bedside all the time. If you have one of those nurses who has been doing this for 30 or 40 years, even though we’re seeing less of those in the last couple years, these are patients that all died. Now, after doing all this research, we found out that the number one reason that these patients die is because we withdraw life support. It’s very easy for somebody who’s been doing this 30 or 40 years to say, Oh, well, I’ve been doing this for this long and all these patients die. Well, yeah, it’s because we’re telling people to withdraw.

So I feel like, on one hand, advanced practice providers can bridge the knowledge that physicians have gained with what nursing knows and put those together. The other part is, we’re the ones having these conversations now. I know I have these conversations all the time. I’m primarily a nocturnist. That’s the first question every family asks: How are they going to be? What are they going to look like? Are they going to do okay? Now, after reading everything that’s come out, the answer, and we’ll talk more about this obviously is, we don’t really know, and we need time to see what the trajectory is going to be.

I’m not saying that it really only should be APPs doing the neuroprognostication, I’m nowhere near saying that, but it’s a whole team together that is not only gathering the data, interpreting it, putting it into this scientific framework, but also having these conversations with families. So I was really excited that SCCM is willing to branch out and let multiple disciplines write these chapters and have these conversations.

Dr. Gambles Farr: Yeah. And understanding the importance of what this means to the families and how that can translate in overall patient outcomes. Understanding how this affects providers, can you share with us what makes this a topic, a current concept in critical care, as we like to call it?

Dr. McLaughlin: Neuroprognostication has been a hot topic for a few years. Some of this is we’re seeing the release from the Neurocritical Care Society of guidelines based on different neurologic pathologies coming out, but also technology has continued to evolve, and we’re not really sure how that all fits in with how patients are going to do. The more data that we’ve collected on this, the more questions come up.

We know that somebody on ECMO, you can’t pronounce him brain dead the same way as somebody who comes in on a standard ventilator. We know that this new concept of normothermic regional perfusion and the questions that have been generated just from that, we’re now seeing these discrepancies in how brain death is determined, variable by region, institution, country. We’re seeing this huge push to decrease length of stay when all these guidelines and all this science is telling us that we need to do the opposite, and more and more research looking into this. Very much not only is this a current concept now, I anticipate this is going to continue to be a current concept for years to come.

Dr. Gambles Farr: Those are very pivotal thoughts. People want answers pretty quickly because there’s this fear of what’s going to happen, and staying in alignment with what patients’ wishes are and helping our families translate that information. In everything that you said as far as how we’ve been managing patients and doing the research and writing this specific current concept in critical care, was there anything that really surprised you as you went through this body of work in preparation for this particular topic?

Dr. McLaughlin: Honestly, a lot surprised me. I’m going to start by confessing that I’ve been in healthcare a very long time so there is a part of me that will always be one of those old-school nurses who thinks everyone’s going to die. It’s hard to let go of that. But now I’m seeing more and more information that’s saying to pause and give patients a chance to show you their trajectory. I was really surprised, especially reading some of the TBI research, how well some of these patients do that come in, GCS of 3, pentobarb coma, frequent ICP crises, and these are walking, talking patients a year later that you would never know everything they had been through. We’re looking at it through a lens of seeing them in their worst moment. Doing the research and seeing how patients do after they leave the ICU was kind of surprising to me. It did make me wish that I had more interactions with these patients after they left so that I could follow up on how they do.

One of the other aspects that surprised me about writing this chapter was looking at how technology has changed that lens that I was talking about that we look through. One of the things that really I found interesting, and this was less critical care and a little bit more basic science, was this whole concept of reanimation, which has come out in the last two years. It’s basically ECMO for the brain, extracorporeal pulsatile perfusion; they were able to restore cellular brain function in pig brains hours after death. This is groundbreaking, and it challenges this concept of irreversibility of brain death and even puts this maybe nugget of thought that maybe in the future we’ll be able to resuscitate brain function in some way. So we’re at the start of something that we don’t know what it’s going to turn into yet.

The last thing that I’ll say is, we really think we do a good job with certain things, and prognostication is one of them. But there are a couple people who went back and looked at what we thought the patient was going to do and then how things actually turned out, and we’re really not that great at it. I know that’s a hard concept for people who work in critical care to acknowledge, but we’re not so great at predicting the future. Maybe we should do it a little bit less often or less freely than some people are doing it now.

Dr. Gambles Farr: Yes, I agree a hundred percent. The prognostication that we give patients at times does not align with who actually presents a year later. At times, patients will present one way clinically in their acute phase, but we’re not there as acute care providers as they transition in their care in that outpatient setting. Sometimes we don’t even really see their overall outcome until a year or two later, and they are completely opposite of what we prognosticated. So I can completely understand why you would think that we need to do a better job at prognostication and also, at times, taking our time in doing that job and giving the patients an opportunity to declare themselves as you stated. What are some of the top key points that you would like the listeners to know as a result of this current concept?

Dr. McLaughlin: The number one point to make, and to take from this, is to take time. Don’t even start thinking about prognostication in the first 72 hours. That’s pretty consistent in every pathology, though you’ll see some of them, like trauma, are actually saying to wait two weeks before thinking about neuroprognostication. I think we’re going to see some of these other pathologies push out as well. Of course, there are always going to be exceptions to this. If a patient is obviously brain dead and you’ve removed confounders, we’re not saying not to pursue diagnosis. Or if somebody is walking and talking, I think you could look at that pretty optimistically in your prognostication.

Two would be to be very cautious with your communication with family; that’s something that I haven’t really talked about yet in our discussion here, but you have to be transparent that there’s not a very clear answer to how someone’s going to do. We might be able to say: Based on this specific area of injury, we would expect the patient to have issues with language or expect that they might have some right-sided weakness. But in terms of life or death, I would be very cautious making those definitive statements. Even though families, I think, find it easier when you’re clear, you can be clear with still allowing that little bit of uncertainty that we know now does exist.

The third thing would be, this is a rapidly progressing field and we’re getting new information all the time. We have experts who are trying to put together guidelines to help people who don’t do neuroprognostication every day. Follow them, but really follow them, because we found even something like brain death should be pretty black and white, I would say, but we found that it’s not. Even though these guidelines have existed for over 10 years, people don’t do a great job following them. So when you have resources, use them, but realize that new things are coming out every single day, and the pressure is on you to keep up with this and get new information and stay current, which is pretty relevant in current concepts to the new information that’s coming out to aid you in these conversations.

Dr. Gambles Farr: In having those conversations with patients, family members, or their surrogate decision-makers, as you progress through that discussion, because typically those discussions can start from the very beginning and go day to day, what do you feel is the role of auxiliary testing or other tests that we use to quantify prognostication in patients as we attempt to give the best answers that we can in taking care of patients?

Dr. McLaughlin: All of these ancillary tests are supplementary to a clinical exam. When possible, clinical examination is always first and foremost. Where they’re especially useful is when the clinical exam is inconclusive, often because it’s compromised by some type of confounding factor or when certain criteria, and this is pretty specific for brain death determination, but something like an apnea test can’t be performed safely.

There’s also more of a role for ancillary testing in some of these patients who are on advanced technologies like ECMO. As we’re trying to figure out what the standard brain death determination process is going to be, then ancillary testing is likely going to play a role. It also helps to give some objective, quantifiable data that can be seen by family and sometimes makes the prognosis or determination a little bit easier to digest or understand. But in general, I would not say that every single patient requires an ancillary test, and you’ll see, as some of these guidelines have come out, that some are more reliable than others, but it does provide that objective measurement to support, validate, or even challenge what your clinical findings are.

Dr. Gambles Farr: As you’ve gone through this process of doing this research or examining the research that’s out there to help with neuroprognostication, how would you apply the most recent evidence into your practice? Have you had any difficulties? Do you find that your fellow colleagues are accepting of these new thought processes?

Dr. McLaughlin: I think we all carry certain bias into our clinical practice and you see this, some cultures or religions are less likely to support removal of life support. You see laws are a little bit different now in every state. The most important thing is to stay updated and to remember it’s not about what you think. It should be a patient-centered approach, which means that you prioritize the preferences of the patient and their family member over your own and, again, to avoid any type of rush judgment or putting our opinions onto these families. You do that by being completely transparent, trying to work collaboratively, not only with the family, but among the team, and that sometimes can help, and also to try to document clearly what are the pieces of data that helped you lead the family down a certain path. Really, it’s collaborating with everybody to make sure that everybody’s comfortable with wherever the patient ends up.

Dr. Gambles Farr: Given where we’ve come from in the past with certain diagnoses that we just automatically attributed to patient death to where we are now, in understanding what this neuroprognostication means and applying it in the current practice of medicine, what do you think the future of neuroprognostication is going to look like?

Dr. McLaughlin: I have completely bought in, after doing all this research, reading all of these articles, that if we give patients more time, we will have a lot more of them with reasonable to good outcomes. That is immediately in discord with this push for decreased length of stay. The only place I could see this going is this brand-new corner of critical care that is the long-term acute care hospital, where these patients are still critically ill patients. I think everybody listening to this can probably agree that most patients in a hospital period now are much sicker than they were 20 years ago, a lot of these patients who are managed at home that previously might have been in a med-surg unit. But now we have these patients who are going to require higher levels of support that could take weeks to months to know how they’re actually going to do.

You have to find a way to take care of these patients without utilizing all of your critical care resources. I think there’s going to be a niche here that hasn’t been filled yet. The more of these that we do, I suspect, again, we’re going to have better outcomes and patients that, years from now, are going to be able to look back and say, I’m glad that I’m alive, I might have a certain degree of disability that I’m okay living with. Thank goodness that I’ve had the opportunity and the support to get where I am today.

Dr. Gambles Farr: I agree completely with the fact that there is this segue or, like you said, a niche population or a healthcare gap that we have right now for these patients who will need continued support while they transition through that area of getting better or not getting better. That is a healthcare or research gap that we’re going to have to quantify and change as neuroprognostication continues to change in healthcare. Given that fact, do you feel like this process is more of an art, or is it more of a science that we’re working through, or is it a combination of both? I know how I feel about it, but what are your thoughts on it?

Dr. McLaughlin: It’s funny because that was the question that kept replaying in my mind while I was working on the chapter is that this has become much more of a science. But it’s not that simple, because, again, you have all these data points that you’re trying to fit to complete a puzzle. This is how I explain it to families: Every day, we’re getting more pieces of data, and each piece is a piece of a puzzle. At the end of the day, we’re trying to figure out what this puzzle is going to show us. So that part is becoming more and more science, as it should.

But, and maybe two buts, there’s certainly an art to communication and the way that we’re able to express this and help people who aren’t medical understand the amount of uncertainty when you’re trying to gain trust, that we know which direction things are going, is really a challenge and something that we aren’t taught. I don’t think a lot of med schools have a lot of communication courses. I know that my NP program didn’t have a lot of leadership or communication education. I know nursing has theories, but that doesn’t necessarily apply to these types of talks.

So it really is both. It’s like a science wrapped in an art. Then there’s always that one patient who will surprise us either for good or bad. So there’s still this one mystery component that is almost, for me, I tell families that we can do everything right and something bad can still happen, or we can do everything wrong and that patient will walk out. There’s still that piece that we can’t explain with science. So I think it’s important to allow for all things. But if I had to pick a final answer, I think I’d say it’s a science wrapped in an art.

Dr. Gambles Farr: I agree. I agree a thousand percent. As healthcare providers, we are not organized or taught that, how to effectively communicate, how to have family communication, how to have family meetings, and how to organize those thoughts in a way that is not necessarily our medical jargon that we’re giving them, but to make it applicable to patients’ families who are not experts in medicine and have never seen their loved one like this. There’s an added level of stress that goes into neuroprognostication for the person who’s actually receiving the information that sometimes I think we underestimate. So I agree with you. I think that that description of it being a science wrapped in an art, because there is an art form that has to be perfected within ourselves in order to give the best information that we can at the time with all the puzzle pieces, as you said.

One more question: Is there anything else that you feel like the audience needs to really concentrate on as we move forward, or best practices that you have learned or would like for your additional healthcare providers to work on knowing what is coming down the pipeline for neuroprognostication?

Dr. McLaughlin: I’m going to do a little plug or teaser for reading the chapter or coming to the precourse because we’ve mentioned some of the science but haven’t gone into detail. When I say to stay current in what’s coming out, I’ll actually, in the chapter, go through relevant studies and how they’ve shaped guidelines and how you should utilize this to approach prognostication specific to disease process. For a 20- or 30-minute podcast, it’s hard to go into that degree of detail, but I think it’s important to actually have that in order to use it.

Then, to continue to try to improve your own practice with communication is huge. That’s among the team, being very honest with yourself, and then obviously with the family. The precourse is going to also go into more detail with some of these things. It was a great opportunity to get specific studies and guidelines to become a resource for practice and even practice some of these skills. I’ll just use that as a little plug, to get more information. We have it wrapped up for you if you’d like to utilize the resources that we put together with this Current Concepts.

Dr. Gambles Farr: Thank you so much, Dr. McLaughlin. The information within this Current Concepts in Critical Care is one that’s timely, one that’s needed, and one that will hopefully propel medicine and nursing into a deep and thoughtful process as we continue to care for these extremely complex patients. We really appreciate you taking time to discuss this with us on this podcast.

Dr. McLaughlin: Thank you so much for having me. I’m always happy to talk about pretty much anything related to neurocritical care, APP practice or, now you’ve been learning about AI, anything you want to talk about. Thanks for having me.

Dr. Gambles Farr: Thank you so much. We appreciate all your hard work and dedication to the Society. With that, this concludes another episode of the Society of Critical Care Medicine Podcast. For more information on Current Concepts, please listen to the series and sign up for the 2024 Current Concepts precourse at Congress.

Don’t forget, if you’re listening to your favorite podcast app and you like what you hear, please consider giving us a rating and leaving a comment for review. For the Society of Critical Care Podcast, I’m Samantha Gambles Farr. Thank you for tuning in.

This educational activity is supported by the SCCM Current Concepts Committee. Samantha Gambles Farr, MSN, NP-C, CCRN, RNFA, is a nurse practitioner intensivist at University of California San Diego Health in the Department of Trauma, Surgical Critical Care, Burns and Acute Care Surgery. She also serves as adjunct faculty at University of San Diego Hahn School of Nursing and Health Science in its nurse practitioner program.

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Knowledge Area: Neuroscience