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Cascio A, Ferrand A, Racine E, St-Hilaire M, Sanon PN, Gorgos A, Wintermark P. Discussing brain magnetic resonance imaging results for neonates with hypoxic-ischemic encephalopathy treated with hypothermia: A challenge for clinicians and parents. eNeurologicalSci 2022; 29:100424. [PMID: 36147866 PMCID: PMC9485039 DOI: 10.1016/j.ensci.2022.100424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 09/04/2022] [Accepted: 09/06/2022] [Indexed: 11/27/2022] Open
Abstract
Context Clinicians use brain magnetic resonance imaging (MRI) to discuss neurodevelopmental prognosis with parents of neonates with hypoxic-ischemic encephalopathy (HIE) treated with therapeutic hypothermia (TH). Purpose To investigate how clinicians and parents discuss these MRI results in the context of HIE and TH and how these discussions could be facilitated and more meaningful for parents. Procedures Mixed-methods surveys with open-ended and closed-ended questions were completed by two independent groups. (1) Clinicians responded to clinical vignettes of neonates with HIE treated with TH with various types of clinical features, evolution and extent of brain injury and questions about how they discuss brain MRI results in this context. (2) Parents of children with HIE treated with TH responded to questions about the discussion of MRI that they had while still in the neonatal intensive care unit and were asked to place it in perspective with the outcomes of their child when he/she reached at least 2 years of age. Open-ended responses were analyzed using a thematic analysis approach. Closed-ended responses are presented descriptively. Results Clinicians reported uncertainty, lack of confidence, and limitations when discussing brain MRI results in the context of HIE and TH. Brain MRI results were "usually" (53%) used in the prognostication discussion. When dealing with day-2 brain MRIs performed during TH, most clinicians (40%) assumed that the results of these early MRIs were only "sometimes" accurate and only used them "sometimes" (33%) to discuss prognosis; a majority of them (66%) would "always" repeat imaging at a later time-point to discuss prognosis. Parents also struggled with this uncertainty, but did not discuss limitations of MRI as often. Parents raised the importance of the setting where the discussion took place and the importance to inform them as quickly as possible. Clinicians identified strategies to improve these discussions, including interdisciplinary approach, formal training, and standardized approach to report brain MRI. Parents highlighted the importance of communication skills, the stress, the hope surrounding their situation, and the need to receive answers as soon as possible. The importance of showing the pictures or making representative drawing of the injury, but also highlighting the not-injured brain, was also highlighted by parents. Conclusions Discussing brain MRI results for neonates with HIE treated with TH are challenging tasks for clinicians and daunting moments for parents.
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Affiliation(s)
- Ariel Cascio
- College of Medicine, Central Michigan University, Mount Pleasant, USA
| | - Amaryllis Ferrand
- Pragmatic Health Ethics Research Unit, Montreal Clinical Research Institute, Montreal, Canada
- Division of Newborn Medicine, Department of Pediatrics, Jewish General Hospital, McGill University, Montreal, Canada
- Faculty of Medicine, Department of Biomedical Sciences, University of Montreal, Montreal, Canada
| | - Eric Racine
- Pragmatic Health Ethics Research Unit, Montreal Clinical Research Institute, Montreal, Canada
- Departments of Medicine and Social and Preventive Medicine, University of Montreal, Montreal, Canada
- Departments of Neurology and Neurosurgery, Medicine, and Biomedical Ethics Unit, McGill University. Montreal, Canada
| | - Marie St-Hilaire
- Research Institute of the McGill University Health Centre, McGill University, Montreal, Canada
| | - Priscille-Nice Sanon
- Research Institute of the McGill University Health Centre, McGill University, Montreal, Canada
| | - Andreea Gorgos
- Division of Newborn Medicine, Department of Pediatrics, Montreal Children's Hospital, McGill University, Montreal, Canada
| | - Pia Wintermark
- Research Institute of the McGill University Health Centre, McGill University, Montreal, Canada
- Division of Newborn Medicine, Department of Pediatrics, Montreal Children's Hospital, McGill University, Montreal, Canada
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Ull C, Hamsen U, Weckwerth C, Schildhauer TA, Gaschler R, Jansen O, Waydhas C. The use of predefined scales and scores with eye-tracking devices for symptom identification in critically ill nonverbal patients. J Trauma Acute Care Surg 2022; 92:640-647. [PMID: 34908025 DOI: 10.1097/ta.0000000000003494] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Eye tracking (ET) may be a novel tool to enable nonverbal communication. We hypothesized that ET could be used successfully by intensive care unit (ICU) patients with artificial airways to express their levels of pain and mood, quality of life, and self-esteem with predefined scales and scores. METHODS Prospective, monocentric, observational study, including patients with an endotracheal tube or tracheostomy tube and a history of mechanical ventilation for more than 48 hours without delirium, and inadequate nonverbal communication skills. The ICU patients' pain was assessed with a numeric rating scale, their mood was tested with a smiley analog scale. Quality of life and self-esteem were measured with the European quality of life-5 dimensions-5 levels-score and the visual analog self-esteem scale. RESULTS A total of 75 patients with a mean age of 58.3 years were included. Main diagnoses for ICU admission were major trauma (45.3%), nonabdominal sepsis (22.6%), and acute abdomen (13.3%). Patients showed moderate levels of pain and sadness with a median of 4 (interquartile range, 3-5.5) on the numeric rating scale and a median of 4 (interquartile range, 3-4) on the smiley analog scale. The general health status on the European quality of life-5 dimensions-5 levels-score was rated as poor. Reporting on the visual analog self-esteem scale, most of the included patients felt trapped (90.7%) and not confident (72%), were frustrated (64%) or did not feel understood (56%). However, despite their severe illness, many patients classified themselves as intelligent (30.6%), not mixed up (38.6%), outgoing (38.6%), and optimistic (44%). CONCLUSION Eye tracking enables symptom identification in critically ill voiceless patients with impaired communication options. The results of our study may provide guidance for improvement measures in the care of voiceless ICU patients. We believe that ET is useful for symptom identification and therefore may be capable of improving patient-medical team interaction and patient satisfaction. LEVEL OF EVIDENCE Diagnostic Test or Criteria, Level III.
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Affiliation(s)
- Christopher Ull
- From the Department of General and Trauma Surgery (C.U., U.H., T.A.S., O.J., C.Wa.), BG University Hospital Bergmannsheil, Bürkle-de-la-Camp-Platz 1, Bochum, Germany; Faculty of Psychology (C.We., R.G.), FernUniversität of Hagen, Hagen, Germany; and Medical Faculty University Duisburg-Essen (C.Wa.), Essen, Germany
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Bracken-Roche D, Shevell M, Racine E. Understanding and addressing barriers to communication in the context of neonatal neurologic injury: Exploring the ouR-HOPE approach. HANDBOOK OF CLINICAL NEUROLOGY 2019; 162:511-528. [PMID: 31324327 DOI: 10.1016/b978-0-444-64029-1.00024-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Predicting neurologic outcomes for neonates with acute brain injury is essential for guiding the development of treatment goals and appropriate care plans in collaboration with parents and families. Prognostication helps parents imagine their child's possible future and helps them make ongoing treatment decisions in an informed way. However, great uncertainty surrounds neurologic prognostication for neonates, as well as biases and implicit attitudes that can impact clinicians' prognoses, all of which pose significant challenges to evidence-based prognostication in this context. In order to facilitate greater attention to these challenges and guide their navigation, this chapter explores the practice principles captured in the ouR-HOPE approach. This approach proposes the principles of Reflection, Humility, Open-mindedness, Partnership, and Engagement and related self-assessment questions to encourage clinicians to reflect on their practices and to engage with others in responding to challenges. We explore the meaning of each principle through five clinical cases involving neonatal neurologic injury, decision making, and parent-clinician communication. The ouR-HOPE approach should bring more cohesion to the sometimes disparate concerns reported in the literature and encourage clinicians and teams to consider its principles along with other guidelines and practices they find to be particularly helpful in guiding communication with parents and families.
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Affiliation(s)
- Dearbhail Bracken-Roche
- Neuroethics Research Unit, Institut de recherches cliniques de Montréal, Montréal, QC, Canada
| | - Michael Shevell
- Department of Pediatrics and Department of Neurology and Neurosurgery, McGill University, Montréal, QC, Canada.
| | - Eric Racine
- Neuroethics Research Unit, Institut de recherches cliniques de Montréal, Montréal, QC, Canada
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Racine E, Bell E, Farlow B, Miller S, Payot A, Rasmussen LA, Shevell MI, Thomson D, Wintermark P. The 'ouR-HOPE' approach for ethics and communication about neonatal neurological injury. Dev Med Child Neurol 2017; 59:125-135. [PMID: 27915463 DOI: 10.1111/dmcn.13343] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/21/2016] [Indexed: 11/26/2022]
Abstract
Predicting neurological outcomes of neonates with acute brain injury is an essential component of shared decision-making, in order to guide the development of treatment goals and appropriate care plans. It can aid parents in imagining the child's future, and guide timely and ongoing treatment decisions, including shifting treatment goals and focusing on comfort care. However, numerous challenges have been reported with respect to evidence-based practices for prognostication such as biases about prognosis among clinicians. Additionally, the evaluation or appreciation of living with disability can differ, including the well-known disability paradox where patients self-report a good quality of life in spite of severe disability. Herein, we put forward a set of five practice principles captured in the "ouR-HOPE" approach (Reflection, Humility, Open-mindedness, Partnership, and Engagement) and related questions to encourage clinicians to self-assess their practice and engage with others in responding to these challenges. We hope that this proposal paves the way to greater discussion and attention to ethical aspects of communicating prognosis in the context of neonatal brain injury.
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Affiliation(s)
- Eric Racine
- Institut de recherches cliniques de Montréal, Montréal, Canada.,Université de Montréal, Montréal, Canada.,McGill University, Montréal, Canada
| | - Emily Bell
- Institut de recherches cliniques de Montréal, Montréal, Canada
| | - Barbara Farlow
- The DeVeber Institute for Bioethics and Social Research, Toronto, Canada.,Patients for Patient Safety Canada, Edmonton, Canada
| | - Steven Miller
- Hospital for Sick Children, Toronto, Canada.,University of Toronto, Toronto, Canada
| | - Antoine Payot
- Université de Montréal, Montréal, Canada.,CHU Sainte-Justine, Montréal, Canada
| | | | - Michael I Shevell
- McGill University, Montréal, Canada.,Montreal Children's Hospital, Montréal, Canada
| | - Donna Thomson
- NeuroDevNet/Kids Brain Health Network, Vancouver, Canada
| | - Pia Wintermark
- McGill University, Montréal, Canada.,Montreal Children's Hospital, Montréal, Canada
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Demirel İ, Kavak BS, Özer AB, Bayar MK, Erhan ÖL. An intensive care approach to posterior reversible encephalopathy syndrome (PRES): An analysis of 7 cases. J Turk Ger Gynecol Assoc 2014; 15:217-21. [PMID: 25584029 DOI: 10.5152/jtgga.2014.14072] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 09/19/2014] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE The aim of this study was to retrospectively evaluate the intensive care unit treatments applied to obstetrics patients with a diagnosis of posterior reversible encephalopathy syndrome (PRES). MATERIAL AND METHODS The cases of 7 pregnant patients who had been diagnosed with PRES between July 2011 and July 2013 were retrospectively reviewed. The patients' clinical data, brain magnetic resonance imaging (MRI) images before and after treatment, and neuropsychological tests were evaluated. RESULTS Five out of 7 patients had eclampsia, 1 patient had severe preeclampsia, and 1 patient developed HELLP syndrome secondary to PRES. Calcium channel blockers and β-blockers were used as antihypertensive treatment. All patients were treated with parenteral magnesium sulfate. In addition, sodium thiopental was given to control sedation and convulsions in all patients except 1. The neurological and radiological findings of all cases treated in the intensive care unit improved. CONCLUSION Posterior reversible encephalopathy syndrome is a clinical condition with a multifactorial etiology and can result in different clinical findings. Radiological imaging techniques can be used for the diagnosis of PRES. Pregnancy and the postpartum period often lead to this syndrome. In some cases, PRES can cause irreversible neurological deficits or death. For patients with severe radiological findings, early diagnosis and thiopental infusion, in addition to treatment with antihypertensive agents and magnesium sulfate, may lead to quicker and more effective recovery from clinical manifestations. We suggest supplementation of standard treatment with early thiopental infusion.
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Affiliation(s)
- İsmail Demirel
- Department of Anesthesiology and Reanimation, Fırat University Faculty of Medicine, Elazığ, Turkey
| | - Burçin Salih Kavak
- Department of Obstetric and Gynecology, Fırat University Faculty of Medicine, Elazığ, Turkey
| | - Ayşe B Özer
- Department of Anesthesiology and Reanimation, Fırat University Faculty of Medicine, Elazığ, Turkey
| | - Mustafa K Bayar
- Department of Anesthesiology and Reanimation, Fırat University Faculty of Medicine, Elazığ, Turkey
| | - Ömer L Erhan
- Department of Anesthesiology and Reanimation, Fırat University Faculty of Medicine, Elazığ, Turkey
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Le EM, Loghin ME. Posterior Reversible Encephalopathy Syndrome: A Neurologic Phenomenon in Cancer Patients. Curr Oncol Rep 2014; 16:383. [DOI: 10.1007/s11912-014-0383-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Pragmatic neuroethics. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/b978-0-444-53501-6.00030-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Rodrigue C, Riopelle RJ, Bernat JL, Racine E. Perspectives and Experience of Healthcare Professionals on Diagnosis, Prognosis, and End-of-Life Decision Making in Patients with Disorders of Consciousness. NEUROETHICS-NETH 2011. [DOI: 10.1007/s12152-011-9142-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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Michalek J, Svetlikova P, Fedora M, Klimovic M, Klapacova L, Bartosova D, Elbl L, Hrstkova H, Hubacek JA. Bactericidal permeability increasing protein gene variants in children with sepsis. Intensive Care Med 2007; 33:2158-64. [PMID: 17898994 DOI: 10.1007/s00134-007-0860-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2007] [Accepted: 08/18/2007] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To evaluate the role of genetic polymorphisms of the bactericidal permeability increasing protein (BPI) in pediatric patients with sepsis. DESIGN Prospective, single-center, case-control study at the pediatric intensive care unit (PICU) of a university hospital. PATIENTS 345 consecutive pediatric patients admitted to the PICU with fever, systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, septic shock, or multiple organ distress syndrome (MODS). INTERVENTIONS DNA was isolated and two BPI gene polymorphisms BPI (G545 > C) Taq and BPI (A645[ > G) 216 were studied in patients and compared with healthy controls. MEASUREMENTS AND RESULTS Genetic analysis of the BPI Taq gene revealed significant differences between healthy controls and the subgroup of febrile patients (p = 0.0243), the subgroup of SIRS and sepsis (p = 0.0101), and the subgroup of severe sepsis, septic shock, and MODS (p = 0.0027), respectively. No statistically significant differences for the BPI 216 gene polymorphism were found between patient and healthy control groups. A statistically significant predisposition to Gram-negative sepsis in patients carrying the BPI Taq GG variant together with the BPI 216 AG or GG variant was revealed (p = 0.0081), and these haplotypes were also associated with death due to sepsis-related complications. CONCLUSION BPI Taq gene polymorphism is the accurate predictor of the severity of sepsis in children admitted to the PICU.
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Affiliation(s)
- Jaroslav Michalek
- University Hospital Brno, First Department of Pediatrics, Cernopolni 9, 61300 Brno, Czech Republic.
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Jenq CC, Tsai MH, Tian YC, Lin CY, Yang C, Liu NJ, Lien JM, Chen YC, Fang JT, Chen PC, Yang CW. RIFLE classification can predict short-term prognosis in critically ill cirrhotic patients. Intensive Care Med 2007; 33:1921-30. [PMID: 17605129 DOI: 10.1007/s00134-007-0760-6] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2007] [Accepted: 06/04/2007] [Indexed: 12/14/2022]
Abstract
OBJECTIVE End-stage liver disease is frequently complicated by renal function disturbances. Cirrhotic patients with renal failure admitted to intensive care units (ICUs) have high mortality rates. This study analyzed the outcomes of critically ill cirrhotic patients and identified the association between prognosis and RIFLE (risk of renal failure, injury to kidney, failure of kidney function, loss of kidney function, and end-stage renal failure) classification, in comparison with other five scoring systems. DESIGN Prospective, clinical study. SETTING Ten-bed specialized hepatogastroenterology ICU in a university hospital in Taiwan. PATIENTS AND PARTICIPANTS One hundred and thirty-four cirrhotic patients consecutively admitted to ICU during a 1.5-year period. INTERVENTIONS Thirty-two demographic, clinical and laboratory variables were analyzed as predictors of survival. MEASUREMENTS AND MAIN RESULTS Overall hospital mortality was 65.7%. There was a progressive and significant increase (chi2 for trend: p<0.001) in mortality based on RIFLE classification severity. Multiple logistic regression analysis indicated that RIFLE classification and Sequential Organ Failure Assessment (SOFA) score on the first day of ICU admission were independent risk factors for hospital mortality. By using the areas under the receiver operating characteristic curve (AUROC), the RIFLE category and SOFA both indicated a good discriminative power (AUROC 0.837+/-0.036 and 0.917+/-0.025; p<0.001). Cumulative survival rates at 6-month follow-up differed significantly (p<0.05) for non-ARF vs. RIFLE-R, RIFLE-I, and RIFLE-F. CONCLUSION Both SOFA and RIFLE category showed high discriminative power in predicting hospital mortality in critically ill patients with cirrhosis. The RIFLE classification is a simple and easily applied evaluative tool with good prognostic abilities.
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Affiliation(s)
- Chang-Chyi Jenq
- Chang Gung University College of Medicine, Department of Nephrology, Chang Gung Memorial Hospital, 199 Tung Hwa North Road, 105 Taipei, Taiwan
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Brenmoehl J, Herfarth H, Glück T, Audebert F, Barlage S, Schmitz G, Froehlich D, Schreiber S, Hampe J, Schölmerich J, Holler E, Rogler G. Genetic variants in the NOD2/CARD15 gene are associated with early mortality in sepsis patients. Intensive Care Med 2007; 33:1541-8. [PMID: 17558494 DOI: 10.1007/s00134-007-0722-z] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2006] [Accepted: 05/07/2007] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Genetic variants in the NOD2/CARD15 gene resulting in a diminished capacity to activate NF-kappaB in response to bacterial cell wall products have been associated with Crohn's disease (CD). Recently, we found an association between the variant Leu1007fsinsC of the NOD2/CARD15 gene (SNP13) and a significantly increased rate of transplant related mortality (TRM) due to intestinal and pulmonary complications in stem cell transplantation (SCT). To assess a possible contribution of variants in the NOD2/CARD15 gene to sepsis related mortality (SRM) we investigated 132 prospectively characterised, consecutive patients with sepsis. DESIGN AND PATIENTS The three most common NOD2/CARD15 variants (Arg702Trp, Gly908Arg, and Leu1007fsinsC) were determined in 132 prospectively characterised patients with sepsis attended to three intensive care units at the University of Regensburg by Taqman PCR. NOD2/CARD15 genotype and major patients' characteristics were correlated with SRM. RESULTS Patient groups with and without NOD2/CARD15 variants did not differ in their clinical characteristics such as median age, gender, reason for admission or APACHE score; however, SRM (day 30) was increased in patients with NOD2/CARD15 coding variants (42 vs. 31%) and was highest (57%) in 8 patients carrying the Leu1007fsinsC variant (p < 0.05). Multivariate analysis demonstrated the Leu1007fsinsC genetic variant as an independent risk factor for SRM. CONCLUSION Our findings indicate a major role of NOD2/CARD15 coding variants for SRM. This may be indicative for a role of impaired barrier function and bacterial translocation in the pathophysiology of early sepsis related death.
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Affiliation(s)
- Julia Brenmoehl
- University Hospital of Regensburg, Department of Internal Medicine I, 93042 Regensburg, Germany
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Boer KR, Mahler CW, Unlu C, Lamme B, Vroom MB, Sprangers MA, Gouma DJ, Reitsma JB, De Borgie CA, Boermeester MA. Long-term prevalence of post-traumatic stress disorder symptoms in patients after secondary peritonitis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2007; 11:R30. [PMID: 17319937 PMCID: PMC2151910 DOI: 10.1186/cc5710] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/19/2006] [Revised: 01/10/2007] [Accepted: 02/23/2007] [Indexed: 12/15/2022]
Abstract
Introduction The aim of this study was to determine the long-term prevalence of post-traumatic stress disorder (PTSD) symptomology in patients following secondary peritonitis and to determine whether the prevalence of PTSD-related symptoms differed between patients admitted to the intensive care unit (ICU) and patients admitted only to the surgical ward. Method A retrospective cohort of consecutive patients treated for secondary peritonitis was sent a postal survey containing a self-report questionnaire, namely the Post-traumatic Stress Syndrome 10-question inventory (PTSS-10). From a database of 278 patients undergoing surgery for secondary peritonitis between 1994 and 2000, 131 patients were long-term survivors (follow-up period at least four years) and were eligible for inclusion in our study, conducted at a tertiary referral hospital in Amsterdam, The Netherlands. Results The response rate was 86%, yielding a cohort of 100 patients; 61% of these patients had been admitted to the ICU. PTSD-related symptoms were found in 24% (95% confidence interval 17% to 33%) of patients when a PTSS-10 score of 35 was chosen as the cutoff, whereas the prevalence of PTSD symptomology when borderline patients scoring 27 points or more were included was 38% (95% confidence interval 29% to 48%). In a multivariate analyses controlling for age, sex, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, number of relaparotomies and length of hospital stay, the likelihood of ICU-admitted patients having PTSD symptomology was 4.3 times higher (95% confidence interval 1.11 to 16.5) than patients not admitted to the ICU, using a PTSS-10 score cutoff of 35 or greater. Older patients and males were less likely to report PTSD symptoms. Conclusion Nearly a quarter of patients receiving surgical treatment for secondary peritonitis developed PTSD symptoms. Patients admitted to the ICU were at significantly greater risk for having PTSD symptoms after adjusting for baseline differences, in particular age.
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Affiliation(s)
- Kimberly R Boer
- Department of Clinical Epidemiology & Biostatistics, Academic Medical Center, Amsterdam, The Netherlands
| | - Cecilia W Mahler
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Cagdas Unlu
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Bas Lamme
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Margreeth B Vroom
- Department of Intensive Care Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Mirjam A Sprangers
- Department of Medical Psychology, Academic Medical Center, Amsterdam, The Netherlands
| | - Dirk J Gouma
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Johannes B Reitsma
- Department of Clinical Epidemiology & Biostatistics, Academic Medical Center, Amsterdam, The Netherlands
| | - Corianne A De Borgie
- Department of Clinical Epidemiology & Biostatistics, Academic Medical Center, Amsterdam, The Netherlands
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Schieveld JNM, Leroy PLJM, van Os J, Nicolai J, Vos GD, Leentjens AFG. Pediatric delirium in critical illness: phenomenology, clinical correlates and treatment response in 40 cases in the pediatric intensive care unit. Intensive Care Med 2007; 33:1033-40. [PMID: 17457571 PMCID: PMC1915613 DOI: 10.1007/s00134-007-0637-8] [Citation(s) in RCA: 124] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2006] [Accepted: 03/26/2007] [Indexed: 12/16/2022]
Abstract
Objective To study the phenomenology, clinical correlates, and response to treatment of delirium in critically ill children in the pediatric intensive care unit (PICU). Design, setting and patients Descriptive study of a cohort of child psychiatric consultations from a tertiary PICU between January 2002 and December 2005. Demographic data, clinical presentation, and response to treatment of children subsequently diagnosed with delirium were analyzed. Results Out of 877 admissions (age distribution 0–18 years) arose 61 requests for psychiatric assessment. Of the 61 children, 40 (15 girls and 25 boys) were diagnosed with delirium (cumulative incidence 5%; mean age 7.6 years). Age-specific incidence rates varied from 3% (0–3 years) to 19% (16–18 years). In addition to the classical hypoactive and hyperactive presentations, a third presentation was apparent, characterized mainly by anxiety, with a higher prevalence in boys. All but 2 of the 40 children received antipsychotic medication: 27 (68%) haloperidol, 10 (25%) risperidone, and 1 both in succession. Two children treated with haloperidol experienced an acute torticollis as side effect. All children made a complete recovery from the delirium; five, however, died of their underlying disease. Conclusion The rate of delirium in critically ill children on a PICU is not negligible, yet prospective studies of the phenomenology, risk factors and treatment of childhood delirium are very rare. Once pediatric delirium has been recognized, it generally responds well to treatment.
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Affiliation(s)
- Jan N M Schieveld
- University Hospital Maastricht, Division of Child and Adolescent Psychiatry, Department of Psychiatry, 5800, 6202, AZ Maastricht, The Netherlands.
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Servillo G, Bifulco F, De Robertis E, Piazza O, Striano P, Tortora F, Striano S, Tufano R. Posterior reversible encephalopathy syndrome in intensive care medicine. Intensive Care Med 2006; 33:230-6. [PMID: 17119920 DOI: 10.1007/s00134-006-0459-0] [Citation(s) in RCA: 94] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2006] [Accepted: 10/19/2006] [Indexed: 02/08/2023]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is a well-recognized clinico-neuroradiological transient condition. Early recognition is of paramount importance for prompt control of blood pressure or removal of precipitating factors and treatment of epileptic seizures or status epilepticus. Delay in the diagnosis and treatment may in fact results in death or in irreversible neurological sequelae. DISCUSSION PRES is characterized by headache, altered mental status, seizures, and visual disturbances and is associated with a number of different causes, most commonly acute hypertension, preeclampsia/eclampsia, and immunosuppressive agents. Clinical symptoms and neuroradiological findings are typically indistinguishable among the cases of PRES, regardless of underlying cause. Magnetic resonance studies typically show edema involving the white matter of cerebral posterior regions, especially parieto-occipital lobes but frontal and temporal lobes, and other encephalic structures may be involved. CONCLUSIONS Intensivists and other physicians involved in the evaluation of patients with presumed PRES must be aware of the clinical spectrum of the associated conditions, the diagnostic modalities, and the correct treatment.
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Affiliation(s)
- Giuseppe Servillo
- Medical Intensive Care Unit, Department of Surgical and Anesthesiological Sciences, Naples, Italy.
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Murch O, Collin M, Hinds CJ, Thiemermann C. Lipoproteins in inflammation and sepsis. I. Basic science. Intensive Care Med 2006; 33:13-24. [PMID: 17093985 DOI: 10.1007/s00134-006-0432-y] [Citation(s) in RCA: 115] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2005] [Accepted: 09/18/2006] [Indexed: 02/07/2023]
Abstract
BACKGROUND High-density lipoproteins (HDL) have been shown to bind and neutralize lipopolysaccharide (LPS) and are regarded as possible therapeutic agents for sepsis and conditions associated with local or systemic inflammation. However, in recent years, a multitude of possible immunomodulatory properties other than LPS neutralization have become evident. DISCUSSION This review highlights the advances in the understanding of how HDL is protective in both in vitro and in vivo inflammatory settings, including the ability of HDL to modulate adhesion molecule expression, upregulate endothelial nitric oxide synthase and counteract oxidative stress. Also, the active components of HDL and the recent discovery of novel lipid modulators of inflammation are discussed.
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Affiliation(s)
- Oliver Murch
- St. Bartholomew's and The Royal London School of Medicine and Dentistry, Queen Mary University of London, Centre for Experimental Medicine, Nephrology and Critical Care, William Harvey Research Institute, London, UK
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Brivet FG, Ducuing S, Jacobs F, Chary I, Pompier R, Prat D, Grigoriu BD, Nordmann P. Accuracy of clinical presentation for differentiating bacterial from viral meningitis in adults: a multivariate approach. Intensive Care Med 2005; 31:1654-60. [PMID: 16244879 DOI: 10.1007/s00134-005-2811-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2004] [Accepted: 08/11/2005] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To determine whether bacterial (BM) and viral (VM) meningitis can be differentiated based on initial clinical presentation. DESIGN AND SETTING Retrospective cohort study in a medical emergency department and intensive care unit in a university hospital. PATIENTS 144 adults, including 90 with confirmed BM and 54 unpretreated VM. MEASUREMENTS AND RESULTS Symptoms, examination findings, paraclinical data, and clinical outcome were assessed. Severity was defined by the presence at referral of one of the following criteria: altered consciousness, seizures, focal neurological findings, and shock. After univariate analyses we performed stepwise logistic regression to determine predictors for BM available at referral (except for CSF Gram stain) and logistic regression using previously validated CSF cutoffs. Univariate methods identified the presence of one sign of severity as the most important predictor for BM (sensitivity 0.989, specificity 0.981, positive predictive value 0.989, negative predictive value 0.981, odds ratio 4,770) and showed that CSF results differ in BM and in VM (except for CSF glucose). Logistic regression analysis revealed severity and CSF absolute neutrophil count as the two predictors of BM (R2=0.876). Logistic analysis showed that BM was related to severity (beta=6.46+/-1.27) and a CSF absolute neutrophil count above 1,000/mm3 whereas CSF glucose below 2 mmol/l and CSF protein higher than 2 g/l were not predictive. CONCLUSIONS The presence of at least one sign of severity at referral and a CSF absolute neutrophil count above 1,000/mm3 mm are predictive of BM.
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Affiliation(s)
- François G Brivet
- Medical Intensive Care Unit, Antoine Béclère Hospital, Assistance Publique Hôpitaux de Paris, 157 Rue de la Porte de Trivaux, 92141, Clamart, France.
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Brochard L. Intensive Care Medicine: what we offer to our readers and what the readers think of it. Intensive Care Med 2005; 31:609-10. [PMID: 15846480 DOI: 10.1007/s00134-005-2651-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2005] [Accepted: 04/10/2005] [Indexed: 12/25/2022]
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