[derelys9]

Since a loved one has been in the NeuroICU for the past month (TBI, multiple broken bones and internal injuries due to motorcycle accident) I (as well as other family members) have been told off and on "oh don't talk to him, don't touch him, etc because it will overstimulate him and that isn't good" But yet no one has been able to explain just what "overstimulation" is and why it isn't good. I am a nurse(long term care) and I feel that I have a pretty good grasp of the siutation at hand, yet this whole concept of overstimulation is new to me and I can't seem to find much information on the subject that I can relate to. I asked one of the nurses at the hospital where I work and she said "well it can cause seizures in some patients" but didn't go into any further detail or explanation. So, if anyone could please shed some light on this for me I would greatly appreciate it.

Also, while some of the staff are stern with the family about "overstimulation" and NOT talking, touching etc, others encourage the family to talk to him, touch him, etc and this has caused quite a bit of confusion between family and staff because the family isn't sure just what to do!

[gwenith]

I would challenge the ones asking you not to overstimulate to explain why. There are times when we want only the most minimal stimulation and that is when the pressure within the brain (ICP) is still high and fragile. In the early days of head injury it is important to manage the ICP so that minimal secondary damage can occur but after that there is some schools of thought that suggest certain specific stimulations are therapuetic and can accelerate recovery.

[derelys9]

Right, I understand in relation to the ICP. When he arrived his ICP was>50 and it took about two weeks to get the pressure and drainage to a "normal" level. At that time, the drains were clamped and once it was deemed his body was actually processing the pressure and drainage flucuations normally the drains were removed after 24 hours. Some of the staff has continued with the 'overstimulation" bit since that time. When in the room, he tends to relax a great deal when talking to him and touching him: his body is less tense and rigid, he opens his eyes more, his BP, pulse, respirations are more even and steady and on occassion he will squeeze with his hand. But even with this (and it is only certain ones) some staff still basically make the family to feel like all they can do is stand at the door and peak inside while holding their breath.

[hollyster]

I cannot speak for those nurses but I would, on occasion, ask family members to keep stimulation to a minimum. We try to cluster care to prevent continous stimulation and I would ask family members to keep visits short or very quiet if the pt had just come back from a road trip, had a bedside procedure or if the pt was having a rough day. I always explained to the families why I was asking for them to keep stimulation down to a minimum.

[pfitz1079]

There may be a case where the nurse warns a family against "over stimulation", when what she means is: "let him rest." Insults to the brain are often devastating to the patient's family as well as the patient. I've seen families spend hours trying to get a response out of a loved one in hopes that any sign is a good sign. It is often difficult to for a desperate family member to hold his or her tounge, often the nurse has to place limits on these folks.

The first step should always be honest teaching about the value of rest, but in their grief, many families refuse to listen. Sometimes the fear of doing harm works a little better. It's not really being dishonest, too little rest (resulting from too much stimulation) will do harm, but it's not completely upfront either. It's a case of the ends (patient rest) justifing the means.

I wish your loved one a quick recovery.

Pete Fitzpatrick

[bellehill]

I had a patient last week that I had to ask the family to stop stimulating because her ICP was >40, elevated HR and elevated BP. Keep in mind that if he is in the Neuro ICU he is being assessed very frequently which can interrupt any sleep pattern. I actually wonder how many of our "neuro changes" are sleep deprivation. The best thing for you to do is ask the nurse what they want and why. If you are getting conflicting info ask for a clarification.

[derelys9]

Thanks a mint for the input, I do appreciate all of your thoughts. He has been moved to a neuro rehab clinic the other day. He is doing much better, still in a coma as far as I know (I live in another state and visit when I can)

I was thinking that perhaps by using the term overstimulation the staff was mainly concerned about getting him in a state of agitation or anxiety (I know how detrimental that can be in any situation towards healing) I certainly understand wanting to keep things as quiet and relaxed as possible for him. I guess I mainly didn't quite grasp at the way some of the staff expressed the need for not overstimulating him without explaining the possible "whys" for it.

As for the thought about the neuro changes occurring as a response to sleep deprivation, that is an interesting idea!

Again, thanks for the information.

[TNNURSE]

icp over 50.....the nurses were right.I havent seen anyone who can process an ICP of 50.When a crani is that tight...with ICPs that high...it literally compresses the arterial flow to that brain tissue.When the patient is stimulated...what happens...?The sbp goes up...right?And what does that do to the ICP?Its shoots it up even higher.Which...in turn causes an even further extension of the anoxic brain injury. In patients with ICP's over 22...you have swelling that is impairing the blood flow to that braintissue...so you try to keep these patients cold....and quiet to attempt to maintain any....any...long term brain function in the future> Be there for the patient...your friend...your family member.hold their hand...put photos at the bedside...etc etc....but there is a rationale behind not overstimulating these patients and it is to simply (hopefully) preserve any/as much cerebral function as possible in the long term by not inducing more swelling.hope this helps....my heart goes out to you... .

Originally Posted by derelys9

Right, I understand in relation to the ICP. When he arrived his ICP was>50 and it took about two weeks to get the pressure and drainage to a "normal" level. At that time, the drains were clamped and once it was deemed his body was actually processing the pressure and drainage flucuations normally the drains were removed after 24 hours. Some of the staff has continued with the 'overstimulation" bit since that time. When in the room, he tends to relax a great deal when talking to him and touching him: his body is less tense and rigid, he opens his eyes more, his BP, pulse, respirations are more even and steady and on occassion he will squeeze with his hand. But even with this (and it is only certain ones) some staff still basically make the family to feel like all they can do is stand at the door and peak inside while holding their breath.

[ADDnurse]

Originally Posted by TNNURSE

icp over 50.....the nurses were right.I havent seen anyone who can process an ICP of 50.When a crani is that tight...with ICPs that high...it literally compresses the arterial flow to that brain tissue.When the patient is stimulated...what happens...?The sbp goes up...right?And what does that do to the ICP?Its shoots it up even higher.Which...in turn causes an even further extension of the anoxic brain injury. In patients with ICP's over 22...you have swelling that is impairing the blood flow to that braintissue...so you try to keep these patients cold....and quiet to attempt to maintain any....any...long term brain function in the future> Be there for the patient...your friend...your family member.hold their hand...put photos at the bedside...etc etc....but there is a rationale behind not overstimulating these patients and it is to simply (hopefully) preserve any/as much cerebral function as possible in the long term by not inducing more swelling.hope this helps....my heart goes out to you... .

Sorry TNN but as Derelys9 stated, this was after a month and the patient was moved to rehab shortly after. I think we all agree with your comments in the early stages when cerebral perfusion is a serious concern, but not one month out in a patient who's ICP is so stable that the ventriculostomy has been clamped. I do however disagree with your comment that in patients with ICP's >22mmHg "you try to keep these patients cold". First of all apatient with an ICP of 22mmHg means nothing if an adequate cerebral perfusion pressure is maintained and there is good cerebral compliance. Secondly since when has hypothermia treatment become the norm for treating elevated ICP, the complications associated with this therapy are extremely grave and should not be taken lightly. When I left Neurosurgical Nursing in 2000, the NHI multicenter Hypothermia study (for the treatment of Cerebral trauma) had just been stopped due to unacceptably high complications associated with the therapy. I know that the use of hypothermia has been shown to be beneficial in the pediatric population but I am not aware of the treatment being shown to have the same success in adults. The principle investigator for the NIH study that I mentioned was Dr Guy Cooper. I'll double check that and see if I can get a reference for you, and please if you have a study to show the benefits of hypothermia I would be grateful for the name.
Thanks TNN, have to go to bed now, I'm up at 4.
Tony

[TNNURSE]

Originally Posted by ADDnurse

Sorry TNN but as Derelys9 stated, this was after a month and the patient was moved to rehab shortly after. I think we all agree with your comments in the early stages when cerebral perfusion is a serious concern, but not one month out in a patient who's ICP is so stable that the ventriculostomy has been clamped. I do however disagree with your comment that in patients with ICP's >22mmHg "you try to keep these patients cold". First of all apatient with an ICP of 22mmHg means nothing if an adequate cerebral perfusion pressure is maintained and there is good cerebral compliance. Secondly since when has hypothermia treatment become the norm for treating elevated ICP, the complications associated with this therapy are extremely grave and should not be taken lightly. When I left Neurosurgical Nursing in 2000, the NHI multicenter Hypothermia study (for the treatment of Cerebral trauma) had just been stopped due to unacceptably high complications associated with the therapy. I know that the use of hypothermia has been shown to be beneficial in the pediatric population but I am not aware of the treatment being shown to have the same success in adults. The principle investigator for the NIH study that I mentioned was Dr Guy Cooper. I'll double check that and see if I can get a reference for you, and please if you have a study to show the benefits of hypothermia I would be grateful for the name.
Thanks TNN, have to go to bed now, I'm up at 4.
Tony

Hmm...I didnt see the part about it being a month afterward. I read the first 4 posts and went from there.A month later is a lil different.And....I think alot has changed since you left NeuroICU then.Bc......many many NeuroICU's are utilizing medically induced hypothermia on adults.From the last few years I can tell you it has been extremely beneficial on like the Grade 5's from what I have seen ...and I dont even think it is considered as "research"...its utilized alot. Still...highly controversial amongst physicians still....but neverthe less still being widely utilized.As far as peds usage of hypothermia...I am not familiar with it as I dont do "peds". The patients you actually are trying to maintain hypothermic...are......pretty grave as far as their prognosis.I know you havent been in neuro for 6 years......but....alot has changed in 6 years.An ICP above 50....they should "never" have pulled that EVD. ...unless they placed a VP shunt. If that patient was able to shunt that CSF appropriately,,...the ICP wouldnt be 50.He/she needed a VPS with an ICP at 50.T