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Bakgrund: Både kateteranvändning och residualurin kan leda till flera komplikationer i efterförloppet. Att studera detta ansågs betydelsefullt ur ett kvalitetssäkerhetsperspektiv. Syfte: Att beskriva förekomst av postoperativ residualurin efter neurokirurgi relaterat till kateteranvändning. Syftet var även att belysa hur sjuksköterskor dokumenterade detta och om eventuella riktlinjer fanns och hur de i så fall följdes. Metod: Kvantitativ, retrospektiv studie med deskriptiv ansats. En journalgranskning genomfördes och de 144 patientjournaler som studerades på den aktuella vårdenheten valdes ut genom ett konsekutivt urval. Resultat: Nästan samtliga patienter vars journaler studerades hade haft urinkateter under operationen. För de patienter där residualurin hade förekommit var detta dokumenterat i standardvårdplanen hos samtliga. Bland några få patienter fanns detta även dokumenterat i en individuell vårdplan under sökord elimination. Sju av 10 patienter som hade mer än 400 ml urin i blåsan vid ultraljudsundersökning urintappades med hjälp av ren intermittent kateterisering. 3 patienter blev urintappade trots mindre än 400 ml urin i blåsan. Dokumentationen av residualurin var delvis bristfällig och de riktlinjer som fanns följdes inte fullt ut. Slutsats: Tydliga riktlinjer för dokumentation av residualurin är något som gynnar både patient och vårdgivare. Det leder sannolikt till att omvårdnadsåtgärder kan utföras i rätt tid och att komplikationer av olika slag kan undvikas.

Bakgrund: Ur patientsäkerhetssynpunkt är det viktigt att hitta rätt tidpunkt för extubering av intensivvårdspatienter. Inför extubering av neurointensivvårdspatienter behövs speciella överväganden. Samma bedömning som görs på allmän intensivvård kan inte direkt överföras till neurointensivvård, då den neurologiska skadan kan påverka patientens förmåga att andas. Syfte: Syftet var att genom journalgranskning utvärdera parametrar som tidigare forskning visat leder till lyckad extubation av neurointensivvårdspatienter. Metod: En prospektiv studie med jämförande kvantitativ design. Studien utfördes på en NIVA i Sverige, där patienterna inkluderades fortlöpande då de extuberats. Via journalgranskning samlades det in parametrar i samband med extuberingen av de 108 inkluderade neurointensivvårdspatienterna. Utvärdering av de insamlade parametrarna utfördes  genom deskriptiv och analytisk statistik med signifikansanalys i statistikprogrammet IBM SPSS statistics 20. Resultat: Denna studie visade att parametern sekretkonsistens påverkade extubationsutgången för neurointensivvårdspatienter. Det sågs även en trend att medvetandegraden påverkar extubations-utgången. För de övriga insamlade parametrarna inom andning och cirkulation, hostkraft, svalgfunktion och sekretmängd fanns inga signifikanta skillnader mellan grupperna lyckade respektive misslyckade extubationer. Gällande värden på parametrar inom andning och cirkulation uppfyllde majoriteten av patienterna, oavsett extubationsutgång, de rekommendationer som finns. Konklusion: Parametrar inom andning och cirkulation kan inte förutsäga extubationsutgång för neurointensivvårdspatienter. Av klinisk betydelse sågs en signifikant skillnad mellan grupperna lyckade och misslyckade extubationer för parametern sekretkonsistens och en trend att medvetandegraden påverkar extubationsutgång. För att öka patientsäkerheten vid extubation av neurointensivvårdspatienter behövs ytterligare forskning för att intensivvårdssjuksköterskan ska kunna göra en kvalitativ och säker bedömning. / Background: In the interest of patient safety it is of importance to extubate intensive care patients at the exact right moment. In the case of intensive care patients in neurocritical care special considerations have to be taken into account. Assessments done in general intensive care is not directly applicable to neurocritical care, since the neurologic injury can affect the patients ability to breathe. Objective: Through the examination of medical records this study aims to evaluate parameters that prior research has found to be conductive to a successful extubation of patients in neurocritical care. Method: A prospective study with inferential quantitative design. The study was performed in a neurocritical care ward in Sweden. The patients were included continuously as they were extubated. Medical records were examined in order to gather parameters in connection to the extubation of the 108 included neurocritical care patients.  Descriptive and analytical statistics, including significance analysis, was performed using IBM SPSS Statistics 20.Result: The study showed that the parameter “secretion texture” affected the extubation outcome for the patients in neurocritical care. There was also a tendency that the level of consciousness influenced extubation outcome. The other gathered parameters concerning breathing and circulation, cough strength, swallowing function and secretion volume showed no significant differences between the groups ”successful” and ”failed” extubation. Regarding the parameters for breathing and circulation, the majority of the patients, irrespective of extubation outcome, were extubated with conditions that generally complied with established recommendations. Conclusion: Parameters concerning breathing and circulation do not predict extubation outcome in a neurocritical care setting. There was however a significant difference between the groups for the parameter secretion texture. The tendency that the level of consciousness affected extubation outcome is of clinical relevance. To increase the level of patient safety concerning extubation of neurocritical care patients further research is required to enable the intensive care nurse to make an assessment of high quality and safety.

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ABSTRACT Background: An acquired brain injury can be classified as either a primary brain injury or a secondary brain injury. A secondary brain injury can also be caused by secondary clinical insults, such as epileptic seizures. To date, there have been no studies conducted on whether nursing interventions, such as bathing, oral care and suctioning the endotracheal tube, can cause epileptic seizures when caring for neurosurgical patients in the intensive care ward. Aim: The aim of this study was to explore whether nursing interventions can cause changes in a neurosurgical intensive care ward patient’s EEG pattern. Methods: Qualitative prospective observational study, using descriptive design (non-experimental). There was a total of 12 patients included in this study, all from a neurointensive care ward in the middle of Sweden. The patients were observed using continuous EEG monitoring with video recording all nursing interventions during 48 hours for each patient. The nursing interventions that were conducted were marked and categorised on a data log. The EEG was then analysed by a neurophysiologist, the results of which were also documented on the data log. Results: The total number of nursing interventions that have been observed for all 12 patients are 1170. Of these, 55 percent resulted in a change in the EEG pattern. The changes in an EEG pattern were categorized into one of four categories. The category with the largest percentage of documented changes was muscle artifact. The nursing interventions that resulted in the highest percentage of EEG pattern changes were – Everything at once, Oral care, Hygiene, Change of position and Suctioning the endotracheal tube. A correlation between the duration of nursing interventions and the occurrence of EEG pattern changes was detected. The longer the nursing intervention lasted the more EEG changes were generated. Conclusion: The results of the study show that nursing-related EEG changes can occur. This suggests that nursing interventions may be stressful for the neurosurgical intensive care patient. It is possible that this stress could be palliated by raising awareness among nursing staff of the importance of using sedatives and analgesics before performing nursing interventions.

<p>Radio-frequency (RF) lesioning is a method utilising high frequency currents for thermal coagulation of pathological tissue or signal pathways. The current is delivered from an electrode with a temperature sensor, permitting control of the current at a desired target temperature. In the brain RF-lesioning can e.g. be used for severe chronic pain and movement disorders such as Parkinson’s disease. This thesis focuses on modelling and simulation with the aim of gaining better understanding and predictability of the lesioning process in deep brain structures. The finite element method (FEM) together with experimental comparisons was used to study the effects of electrode dimensions, electrode target temperature, electric and thermal conductivity of the brain tissue, blood perfusion and cerebrospinal fluid (CSF) filled cysts. Equations for steady current, thermal transport and incompressible flow were used together with statistical factorial design and regression analysis for this purpose.</p><p>Increased target temperature, electrode tip length and electrode diameter increased the simulated lesion size, which is in accordance with experimental results. The influence of blood perfusion, modelled as an increase in thermal conductivity in non-coagulated tissue, gave smaller simulated lesions with increasing blood perfusion as heat was more efficiently conducted from the rim of the lesion. If no consideration was taken to the coagulation the lesion became larger with increased thermal conductivity instead, as the increase in conducted heat was compensated for through an increased power output in order to maintain the target temperature. Simulated lesions corresponded well to experimental in-vivo lesions.</p><p>The electric conductivity in a homogeneous surrounding had little impact on lesion development. However this was not valid for a heterogeneous surrounding. CSF-filled cysts have a much higher electric conductivity than brain tissue focussing the current to them if the electrode tip is in contact with both. Heating of CSF can also cause considerable convective flow and as a result a very efficient heat transfer. This affected simulated as well as experimental lesion sizes and shapes resulting in both very large lesions if sufficient power compared to the cysts size was supplied and very small lesions if the power was low, mitigating the heat over a large volume.</p><p>In conclusion especially blood perfusion and CSF can greatly affect the lesioning process and appear to be important to consider when planning surgical procedures. Hopefully this thesis will help improve knowledge about and predictability of clinical lesioning.</p>

The overall aim of the research presented here was to expand the knowledge on metabolic course and nutritional outcome in patients with severe traumatic brain injury and to analyze the use and accuracy of different methods of assessment. Study I, a systematic review of 30 articles demonstrated consistent data on increased metabolic rate, of catabolism and of upper gastrointestinal intolerance in the majority of the patients during early post injury period. Data also indicated a tendency of less morbidity and mortality in early fed patients. Study II, a retrospective survey, based on medical records of 64 patients from three regions in Sweden, showed that the majority of patients regained their independence in eating within six months post injury. However, energy intake was set at a low level and 68 % of the patients developed malnutrition with 10 to 29 % loss of initial body mass during the first and second month post injury. Study III, a questionnaire based study addressed to 74 care units caring for patients with severe traumatic brain injury showed that resources in terms of qualified staff members were reportedly good, but nutritional guidelines were adopted in less than half of the units, screening for malnutrition at admission was rarely performed and surveillance of energy intake declined when oral intake began. Moreover, assessment of energy requirements relied on calculations and the profession in charge to estimate energy requirement varied depending on nutritional route and unit speciality. At transferral between units nutritional information was lost. Study IV and V, a prospective descriptive study on metabolic course, energy balance and methods of assessment in six patients showed that patients were in negative energy balance from 3rd week post injury and lost 8-19 % of their initial body weight. Concurrent nutritional problems were difficulties in retaining enteral and/or parenteral nutrition delivery routes until oral feeding was considered satisfactory. The majority of methods for predicting energy expenditure agreed poorly with measured energy expenditure.  The Penn-State equation from 1998 was the only valid predictive method during mechanical ventilation. This thesis concludes that patients with moderate or severe traumatic brain injury exhibit a wide range of increased metabolic rate, catabolism and upper gastrointestinal intolerance during the early post-injury period. Most patients regain independence in eating, but develop malnutrition. Suggested explanations, other than the systemic disturbances early post injury, could be the use of inaccurate predictions of energy expenditure, deficient nutritional routines and difficulties in securing alternative nutritional routes until oral feeding is satisfactory. The impact of timing, content and ways of administration of nutritional support on neurological outcome after a severe traumatic brain injury remains to be demonstrated.

Subarachnoid hemorrhage (SAH) is a disease with high risk of mortality and morbidity. Elderly patients have an even higher risk of poor outcome. The incidence of SAH increases with age and the elderly constitute a substantial and increasing proportion of the population. Thus, the management of elderly SAH patients is an imminent clinical challenge. Time trends in clinical management and outcome were investigated in 281 SAH patients aged ≥65 years admitted over an 18-year period. The volume of elderly patients, especially patients ≥70 years and patients in worse clinical condition increased over time. The proportion of patients with favorable outcome increased over time, without an increase in severely disabled patients. Technical results and clinical outcome of endovascular aneurysm treatment (EVT) was investigated in 62 elderly SAH patients. EVT can be performed in elderly SAH patients with high technical success, acceptable aneurysm occlusion degree, acceptable procedural complication rate, and fair outcome results. EVT was compared to neurosurgical clipping (NST) in 278 elderly SAH patients in the International Subarachnoid Aneurysm Trial. In good grade elderly SAH patients, EVT should probably be the favored treatment for internal carotid and posterior communicating artery aneurysms, while elderly patients with middle cerebral artery aneurysms appear to benefit from NST. Occurrence of secondary insults and their impact on clinical deterioration were studied in 99 patients with severe SAH. High intracranial pressure increased and high cerebral perfusion pressure decreased the risk of clinical deterioration. Elderly patients had less intracranial hypertension insults and more hypertensive, hypotensive and hypoxemic insults. Good outcome was achieved in 24% of elderly patients with severe SAH, and the proportion of severe disability was similar to that of younger patients. Patient age was not a significant predictor for vasospasm in 413 SAH patients when admission and treatment variables were adjusted for with multiple logistic regression.

Bakgrund: Många av patienterna på en neurointensivvårdsavdelning (NIVA) vårdas med respirator under en längre eller kortare period av vårdtiden. Neurointensivvårdspatienterna bedöms ibland utifrån de kriterier för urträning och extubering som används på allmänna intensivvårdspatienter. Detta kan leda till för tidig extubation med reintubation som följd. Syfte: Redogöra för vilka kriterier som ska bedömas hos neurointensivvårdspatienter inför en extubering. Metod: Litteraturstudie. Resultat och slutsats: Neurointensivvårdspatienter behöver uppfylla en kombination av kriterier inför extubation. Hänsyn ska tas till de generella extubationskriterierna avseende andning och cirkulation. Dessutom ska patienten ha en tillräckligt hög medvetandegrad för att kunna följa någon form av uppmaning. Till sist ska patientens förmåga att hålla fri luftväg bedömas genom observation av hostkraft, sekretmängd/konsistens och svalgfunktion. Det behövs ytterligare forskning för att utröna i hur hög grad neurointensivvårdspatienterna behöver vara medvetna inför extubering och på vilket sätt detta bäst bedöms. Forskning behövs kring ett enhetligt tillvägagångssätt för bedömning av hostkraft, sekretmängd/konsistens och svalgfunktion. / Background: Many of the patients cared for in a neurocritical unit are treated with mechanical ventilation for a longer or shorter period of time during their stay in the unit. When weaning or extubating neurocritical patients, they are sometimes assessed according to the criteria for weaning and extubation used in general intensive care patients. This can cause premature extubation, resulting in re-intubation. Aim: Describe the criteria to be assessed in neurocritical patients prior to extubation. Method: Literature review. Results and conclusion: Neurocritical patients need to fulfil a combination of criteria prior to extubation. The general criteria in terms of respiration and circulation must be taken in to consideration, as well as the patient’s level of consciousness. The patient has to be conscious enough to be able to take directions. Lastly the patient’s ability to protect the airway must be assessed by observation of cough strength, the quantities and viscosity of the secretions and the patient’s swallowing function. Further research is required to ascertain the level of consciousness required in the neurocritical patients prior to extubation and in which way the assessment is best carried out. There is also need for further research considering a standardized measurement for assessing cough strength, the quantities and viscosity of secretions and swallowing function in these patients.

Traumatic Brain Injury (TBI) mainly affects young persons in traffic accidents and the elderly in fall accidents. Improvements in the clinical management have significantly improved the outcome following TBI but survivors still suffer from depression, memory problems, personality changes, epilepsy and fatigue. The initial injury starts a series of events that give rise to a secondary injury process and despite several clinical trials there is no drug available for clinical use that targets secondary brain injury mechanisms. Some recovery of function is seen during the first months following injury but is usually limited and there are no drugs that stimulate the recovery of lost function. Some of the recovery is attributed to plasticity, the brains ability to adapt to new circumstances, and enhancing plasticity via increased axonal growth has the potential to partly restore lost function. In this thesis mice were subjected to the controlled cortical impact model of TBI and functional outcome was evaluated using Morris water maze, the cylinder test and the rotarod. Brain tissue loss was measured in all Papers but the additional histological analyses differ among the Papers. Attempts to increase axonal growth were made by interfering with Nogo receptor function in Paper I and by conditional knockout of ephA4 in Paper II. Contrary to the hypothesis cognition was impaired in Paper I but otherwise no effects of treatment were detected in Paper I and II. Much is still unknown about plasticity and despite the discouraging results of Papers I and II this treatment approach is still worth further exploration. It is firmly established that TBI results in an inflammatory response and some aspects of it may damage brain tissue. In Papers III and IV the inflammatory response was attenuated using an IL-1β directed antibody which resulted in reduced tissue loss and edema while improving cognitive function. The results from Papers III and IV are encouraging and the possibility to find a treatment based on IL-1β inhibition appears promising.