Algorithm plus medication distribution system reverses herniation, lowers intracranial pressure.

A California neurocritical care team reported a significant improvement in medication administration for acute intracranial hypertension with its “brain code” algorithm and medication distribution system.

When neurological problems arise, they can increase the pressure inside the head, explained Jamie LaBuzetta, MD, of the University of California San Diego (UCSD) Medical Center, to MedPage Today.

LaBuzetta and colleagues presented the results of a retrospective study of the brain code at the American Academy of Neurology annual meeting.

With the system, a physician team and pharmacists collaborate at the patient’s bedside. The goal is to reverse the herniation by lowering the intracranial pressure and to “buy us time” to think about other possible interventions such as surgery, she said.

The brain code box contains:

• Sodium chloride 23.4% 30 mL vial (240 mOsm/vial)
• Sodium chloride 3% 500 mL IVPB
• Mannitol 20% 500 mL IVPB
• Pre-mixed phenylephrine 1,000 mcg/10 mL syringe
• Syringes and needles
• Gloves, alcohol swabs, labels, and emergency “code” record sheet

LaBuzetta and colleagues compiled 33 months of data, following implementation of the new brain code in May 2012. They compared the time it took to administer medications from March 1, 2011, to April 30, 2012, with recorded times from May 1, 2012, to Jan. 31, 2015.

The data showed the new protocol had been activated 77 times, and the authors were able to access code data for 50 of those cases. Data showed that 67% of the patients were male and with a mean age of 59.

With the protocol, the average time from activation of the brain code to medication administration plummeted from over 40 minutes to 11 minutes (P=0.001), which LaBuzetta called “highly statistically significant.”

The majority of herniations were caused by intraparenchymal hemorrhage (44.2%), followed by subarachnoid hemorrhage (11.7%). Other causes were mass, stroke, cardiac arrest, and subdural hemorrhage.

The most common initial medication was sodium chloride 3% (47%).

LaBuzetta noted that the protocol can be activated by any provider, anywhere in the hospital. During the study period, it was most often used in the emergency department (39.4%) followed by the neurological and medical ICU (36.6%).

While neurocritical care teams are becoming more common in hospitals, many institutions still do not have neurocritical ICUs, and still others do not have the kind of infrastructure where an entire team, including specialized nurses and other providers, are working in one place, LaBuzetta stated. This was the situation at the authors’ institution a few years ago, said co-author Navaz Karanjia, MD.

“When I came to start the program, our patients were scattered throughout the hospital,” explained Karanjia, director of UCSD Neurocritical Care.

“So I had to figure out how to get them the standard of care even though they weren’t in our little neck of the woods,” she explained to MedPage Today.

Study limitations included the retrospective design, lack of data on standard administration times for medications for comparison, and lack of data on whether the improvement in administration time led to better patient outcomes.

LaBuzetta said she hopes other institutions will adopt a similar algorithm, potentially confirming whether the brain code improves the time to medication administration and patient outcomes, she said.

“Ultimately, that’s what we’re talking about,” she stated. “We’re talking about the patient outcome and how to give the patient the best chance.”