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Battaglini D, Delpiano L, Masuello D, Leme Silva P, Rocco PRM, Matta B, Pelosi P, Robba C. Effects of positive end-expiratory pressure on brain oxygenation, systemic oxygen cascade and metabolism in acute brain injured patients: a pilot physiological cross-sectional study. J Clin Monit Comput 2024; 38:165-175. [PMID: 37453007 DOI: 10.1007/s10877-023-01042-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 06/02/2023] [Indexed: 07/18/2023]
Abstract
Patients with acute brain injury (ABI) often require the application of positive end-expiratory pressure (PEEP) to optimize mechanical ventilation and systemic oxygenation. However, the effect of PEEP on cerebral function and metabolism is unclear. The primary aim of this study was to evaluate the effects of PEEP augmentation test (from 5 to 15 cmH2O) on brain oxygenation, systemic oxygen cascade and metabolism in ABI patients. Secondary aims include to determine whether changes in regional cerebral oxygenation are reflected by changes in oxygenation cascade and metabolism, and to assess the correlation between brain oxygenation and mechanical ventilation settings. Single center, pilot cross-sectional observational study in an Academic Hospital. Inclusion criteria were: adult (> 18 y/o) patients with ABI and stable intracranial pressure, available gas exchange and indirect calorimetry (IC) monitoring. Cerebral oxygenation was monitored with near-infrared spectroscopy (NIRS) and different derived parameters were collected: variation (Δ) in oxy (O2)-hemoglobin (Hb) (ΔO2Hbi), deoxy-Hb(ΔHHbi), total-Hb(ΔcHbi), and total regional oxygenation (ΔrSO2). Oxygen cascade and metabolism were monitored with arterial/venous blood gas analysis [arterial partial pressure of oxygen (PaO2), arterial saturation of oxygen (SaO2), oxygen delivery (DO2), and lactate], and IC [energy expenditure (REE), respiratory quotient (RQ), oxygen consumption (VO2), and carbon dioxide production (VCO2)]. Data were measured at PEEP 5 cmH2O and 15 cmH2O and expressed as delta (Δ) values. Ten patients with ABI [median age 70 (IQR 62-75) years, 6 (60%) were male, median Glasgow Coma Scale at ICU admission 5.5 (IQR 3-8)] were included. PEEP augmentation from 5 to 15 cmH2O did not affect cerebral oxygenation, systemic oxygen cascade parameters, and metabolism. The arterial component of cerebral oxygenation was significantly correlated with DO2 (ΔO2HBi, rho = 0.717, p = 0.037). ΔrSO2 (rho = 0.727, p = 0.032), ΔcHbi (rho = 0.797, p = 0.013), and ΔHHBi (rho = 0.816, p = 0.009) were significantly correlated with SaO2, but not ΔO2Hbi. ΔrSO2 was significantly correlated with VCO2 (rho = 0.681, p = 0.049). No correlation between brain oxygenation and ventilatory parameters was found. PEEP augmentation test did not affect cerebral and systemic oxygenation or metabolism. Changes in cerebral oxygenation significantly correlated with DO2, SaO2, and VCO2. Cerebral oxygen monitoring could be considered for individualization of mechanical ventilation setting in ABI patients without high or instable intracranial pressure.
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Affiliation(s)
| | - Lara Delpiano
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università degli Studi di Genova, Genoa, Italy
| | - Denise Masuello
- Hospital Donaciòn Francisco Santojanni, Buenos Aires, Argentina
| | - Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Centro de Ciências da Saúde, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Centro de Ciências da Saúde, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- Rio de Janeiro Network on Neuroinflammation, Carlos Chagas Filho Foundation for Supporting Research in the State of Rio de Janeiro (FAPERJ), Rio de Janeiro, Brazil
| | - Basil Matta
- Neurocritical Care Unit, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Paolo Pelosi
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università degli Studi di Genova, Genoa, Italy
| | - Chiara Robba
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università degli Studi di Genova, Genoa, Italy
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Wang C, Xing D, Zhou S, Fang F, Fu Y, Xu F. Electrical bioimpedance measurement and near-infrared spectroscopy in pediatric postoperative neurocritical care: a prospective observational study. Front Neurol 2023; 14:1190140. [PMID: 37416310 PMCID: PMC10322191 DOI: 10.3389/fneur.2023.1190140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 05/30/2023] [Indexed: 07/08/2023] Open
Abstract
Background To investigate the clinical significance of the disturbance coefficient (DC) and regional cerebral oxygen saturation (rSO2) as obtained through the use of electrical bioimpedance and near-infrared spectroscopy (NIRS) in pediatric neurocritical care. Participants and methods We enrolled 45 pediatric patients as the injury group and 70 healthy children as the control group. DC was derived from impedance analysis of 0.1 mA-50 kHz current via temporal electrodes. rSO2 was the percentage of oxyhemoglobin measured from reflected NIR light on the forehead. DC and rSO2 were obtained at 6, 12, 24, 48 and 72 h after surgery for the injury group and during the health screening clinic visit for the control group. We compared DC and rSO2 between the groups, their changes over time within the injury group and their correlation with intracranial pressure (ICP), cerebral perfusion pressure (CPP), Glasgow coma scale (GCS) score, Glasgow outcome scale (GOS) score, and their ability to diagnose postoperative cerebral edema and predict poor prognosis. Results DC and rSO2 were significantly lower in the injury group than in the control group. In the injury group, ICP increased over the monitoring period, while DC, CPP and rSO2 decreased. DC was negatively correlated with ICP and positively correlated with GCS score and GOS score. Additionally, lower DC values were observed in patients with signs of cerebral edema, with a DC value of 86.5 or below suggesting the presence of brain edema in patients aged 6-16 years. On the other hand, rSO2 was positively correlated with CPP, GCS score, and GOS score, with a value of 64.4% or below indicating a poor prognosis. Decreased CPP is an independent risk factor for decreased rSO2. Conclusion DC and rSO2 monitoring based on electrical bioimpedance and near-infrared spectroscopy not only reflect the degree of brain edema and oxygenation, but also reflect the severity of the disease and predict the prognosis of the patients. This approach offers a real-time, bedside, and accurate method for assessing brain function and detecting postoperative cerebral edema and poor prognosis.
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Affiliation(s)
- Chenhao Wang
- Department of Critical Care Medicine, Children’s Hospital of Chongqing Medical University, Chongqing, China
- National Clinical Research Center for Child Health and Disorders, Chongqing, China
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Dianwei Xing
- Department of Critical Care Medicine, Children’s Hospital of Chongqing Medical University, Chongqing, China
- National Clinical Research Center for Child Health and Disorders, Chongqing, China
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Shuoyan Zhou
- Department of Critical Care Medicine, Children’s Hospital of Chongqing Medical University, Chongqing, China
- National Clinical Research Center for Child Health and Disorders, Chongqing, China
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Fang Fang
- Department of Critical Care Medicine, Children’s Hospital of Chongqing Medical University, Chongqing, China
- National Clinical Research Center for Child Health and Disorders, Chongqing, China
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Yueqiang Fu
- Department of Critical Care Medicine, Children’s Hospital of Chongqing Medical University, Chongqing, China
- National Clinical Research Center for Child Health and Disorders, Chongqing, China
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Feng Xu
- Department of Critical Care Medicine, Children’s Hospital of Chongqing Medical University, Chongqing, China
- National Clinical Research Center for Child Health and Disorders, Chongqing, China
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
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Giardina A, Cardim D, Ciliberti P, Battaglini D, Ball L, Kasprowicz M, Beqiri E, Smielewski P, Czosnyka M, Frisvold S, Groznik M, Pelosi P, Robba C. Effects of positive end-expiratory pressure on cerebral hemodynamics in acute brain injury patients. Front Physiol 2023; 14:1139658. [PMID: 37200838 PMCID: PMC10185889 DOI: 10.3389/fphys.2023.1139658] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 04/14/2023] [Indexed: 05/20/2023] Open
Abstract
Background: Cerebral autoregulation is the mechanism that allows to maintain the stability of cerebral blood flow despite changes in cerebral perfusion pressure. Maneuvers which increase intrathoracic pressure, such as the application of positive end-expiratory pressure (PEEP), have been always challenged in brain injured patients for the risk of increasing intracranial pressure (ICP) and altering autoregulation. The primary aim of this study is to assess the effect of PEEP increase (from 5 to 15 cmH2O) on cerebral autoregulation. Secondary aims include the effect of PEEP increase on ICP and cerebral oxygenation. Material and Methods: Prospective, observational study including adult mechanically ventilated patients with acute brain injury requiring invasive ICP monitoring and undergoing multimodal neuromonitoring including ICP, cerebral perfusion pressure (CPP) and cerebral oxygenation parameters obtained with near-infrared spectroscopy (NIRS), and an index which expresses cerebral autoregulation (PRx). Additionally, values of arterial blood gases were analyzed at PEEP of 5 and 15 cmH2O. Results are expressed as median (interquartile range). Results: Twenty-five patients were included in this study. The median age was 65 years (46-73). PEEP increase from 5 to 15 cmH2O did not lead to worsened autoregulation (PRx, from 0.17 (-0.003-0.28) to 0.18 (0.01-0.24), p = 0.83). Although ICP and CPP changed significantly (ICP: 11.11 (6.73-15.63) to 13.43 (6.8-16.87) mm Hg, p = 0.003, and CPP: 72.94 (59.19-84) to 66.22 (58.91-78.41) mm Hg, p = 0.004), these parameters did not reach clinically relevant levels. No significant changes in relevant cerebral oxygenation parameters were observed. Conclusion: Slow and gradual increases of PEEP did not alter cerebral autoregulation, ICP, CPP and cerebral oxygenation to levels triggering clinical interventions in acute brain injury patients.
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Affiliation(s)
- Alberto Giardina
- Dipartimento di Scienze Chirurgiche e Diagnostiche, University of Genoa, Genova, Italy
| | - Danilo Cardim
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, United States
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas, TX, United States
| | - Pietro Ciliberti
- Dipartimento di Scienze Chirurgiche e Diagnostiche, University of Genoa, Genova, Italy
| | | | - Lorenzo Ball
- Dipartimento di Scienze Chirurgiche e Diagnostiche, University of Genoa, Genova, Italy
- IRCCS Policlinico San Martino, Genova, Italy
| | - Magdalena Kasprowicz
- Department of Biomedical Engineering, Faculty of Fundamental Problems of Technology, Wroclaw University of Science and Technology, Wroclaw, Poland
| | - Erta Beqiri
- Brain Physics Laboratory, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Peter Smielewski
- Brain Physics Laboratory, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Marek Czosnyka
- Brain Physics Laboratory, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
- Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
| | - Shirin Frisvold
- Anesthesia and Intensive Care, University Hospital of Northern Norway, Tromsø, Norway
| | - Matjaž Groznik
- Traumatology Department of the University Clinical Center Ljubljana, Ljubljana, Slovenia
| | - Paolo Pelosi
- Dipartimento di Scienze Chirurgiche e Diagnostiche, University of Genoa, Genova, Italy
- IRCCS Policlinico San Martino, Genova, Italy
| | - Chiara Robba
- Dipartimento di Scienze Chirurgiche e Diagnostiche, University of Genoa, Genova, Italy
- IRCCS Policlinico San Martino, Genova, Italy
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Datzmann T, Münz F, Hoffmann A, Moehrke E, Binzenhöfer M, Gröger M, Kapapa T, Mathieu R, Mayer S, Zink F, Gässler H, Wolfschmitt EM, Hogg M, Merz T, Calzia E, Radermacher P, Messerer DAC. An exploratory study investigating the effect of targeted hyperoxemia in a randomized controlled trial in a long-term resuscitated model of combined acute subdural hematoma and hemorrhagic shock in cardiovascular healthy pigs. Front Immunol 2023; 14:1123196. [PMID: 37114041 PMCID: PMC10126345 DOI: 10.3389/fimmu.2023.1123196] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 03/14/2023] [Indexed: 04/29/2023] Open
Abstract
Severe physical injuries and associated traumatic brain injury and/or hemorrhagic shock (HS) remain leading causes of death worldwide, aggravated by accompanying extensive inflammation. Retrospective clinical data indicated an association between mild hyperoxemia and improved survival and outcome. However, corresponding prospective clinical data, including long-term resuscutation, are scarce. Therefore, the present study explored the effect of mild hyperoxemia for 24 hours in a prospective randomized controlled trial in a long-term resuscitated model of combined acute subdural hematoma (ASDH) and HS. ASDH was induced by injecting 0.1 ml × kg-1 autologous blood into the subdural space and HS was triggered by passive removal of blood. After 2 hours, the animals received full resuscitation, including retransfusion of the shed blood and vasopressor support. During the first 24 hours, the animals underwent targeted hyperoxemia (PaO2 = 200 - 250 mmHg) or normoxemia (PaO2 = 80 - 120 mmHg) with a total observation period of 55 hours after the initiation of ASDH and HS. Survival, cardiocirculatory stability, and demand for vasopressor support were comparable between both groups. Likewise, humoral markers of brain injury and systemic inflammation were similar. Multimodal brain monitoring, including microdialysis and partial pressure of O2 in brain tissue, did not show significant differences either, despite a significantly better outcome regarding the modified Glasgow Coma Scale 24 hours after shock that favors hyperoxemia. In summary, the present study reports no deleterious and few beneficial effects of mild targeted hyperoxemia in a clinically relevant model of ASDH and HS with long-term resuscitation in otherwise healthy pigs. Further beneficial effects on neurological function were probably missed due to the high mortality in both experimental groups. The present study remains exploratory due to the unavailability of an a priori power calculation resulting from the lack of necessary data.
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Affiliation(s)
- Thomas Datzmann
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University, Ulm, Germany
| | - Franziska Münz
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University, Ulm, Germany
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Ulm, Ulm, Germany
| | - Andrea Hoffmann
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University, Ulm, Germany
| | - Elena Moehrke
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University, Ulm, Germany
| | - Martha Binzenhöfer
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University, Ulm, Germany
| | - Michael Gröger
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University, Ulm, Germany
| | - Thomas Kapapa
- Department of Neurosurgery, University Hospital Ulm, Ulm, Germany
| | - René Mathieu
- Department of Neurosurgery, German Federal Armed Forces Hospital Ulm, Ulm, Germany
| | - Simon Mayer
- Department of Neurosurgery, German Federal Armed Forces Hospital Ulm, Ulm, Germany
| | - Fabian Zink
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University, Ulm, Germany
| | - Holger Gässler
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, German Armed Forces Hospital Ulm, Ulm, Germany
| | - Eva-Maria Wolfschmitt
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University, Ulm, Germany
| | - Melanie Hogg
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University, Ulm, Germany
| | - Tamara Merz
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University, Ulm, Germany
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Ulm, Ulm, Germany
| | - Enrico Calzia
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University, Ulm, Germany
| | - Peter Radermacher
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University, Ulm, Germany
| | - David Alexander Christian Messerer
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University, Ulm, Germany
- Department of Transfusion Medicine and Hemostaseology, Friedrich-Alexander University Erlangen-Nuremberg, University Hospital Erlangen, Erlangen, Germany
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Robba C, Camporota L, Citerio G. Acute respiratory distress syndrome complicating traumatic brain injury. Can opposite strategies converge? Intensive Care Med 2023; 49:583-586. [PMID: 37017697 DOI: 10.1007/s00134-023-07043-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 03/16/2023] [Indexed: 04/06/2023]
Affiliation(s)
- Chiara Robba
- Anesthesia and Intensive Care, IRCCS Policlinico San Martino, Genoa, Italy.
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Viale Benedetto XV 16, Genoa, Italy.
| | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
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Beqiri E, Smielewski P, Guérin C, Czosnyka M, Robba C, Bjertnæs L, Frisvold SK. Neurological and respiratory effects of lung protective ventilation in acute brain injury patients without lung injury: brain vent, a single centre randomized interventional study. Crit Care 2023; 27:115. [PMID: 36941683 PMCID: PMC10026451 DOI: 10.1186/s13054-023-04383-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 02/25/2023] [Indexed: 03/23/2023] Open
Abstract
INTRODUCTION Lung protective ventilation (LPV) comprising low tidal volume (VT) and high positive end-expiratory pressure (PEEP) may compromise cerebral perfusion in acute brain injury (ABI). In patients with ABI, we investigated whether LPV is associated with increased intracranial pressure (ICP) and/or deranged cerebral autoregulation (CA), brain compensatory reserve and oxygenation. METHODS In a prospective, crossover study, 30 intubated ABI patients with normal ICP and no lung injury were randomly assigned to receive low VT [6 ml/kg/predicted (pbw)]/at either low (5 cmH2O) or high PEEP (12 cmH2O). Between each intervention, baseline ventilation (VT 9 ml/kg/pbw and PEEP 5 cmH2O) were resumed. The safety limit for interruption of the intervention was ICP above 22 mmHg for more than 5 min. Airway and transpulmonary pressures were continuously monitored to assess respiratory mechanics. We recorded ICP by using external ventricular drainage or a parenchymal probe. CA and brain compensatory reserve were derived from ICP waveform analysis. RESULTS We included 27 patients (intracerebral haemorrhage, traumatic brain injury, subarachnoid haemorrhage), of whom 6 reached the safety limit, which required interruption of at least one intervention. For those without intervention interruption, the ICP change from baseline to "low VT/low PEEP" and "low VT/high PEEP" were 2.2 mmHg and 2.3 mmHg, respectively, and considered clinically non-relevant. None of the interventions affected CA or oxygenation significantly. Interrupted events were associated with high baseline ICP (p < 0.001), low brain compensatory reserve (p < 0.01) and mechanical power (p < 0.05). The transpulmonary driving pressure was 5 ± 2 cmH2O in both interventions. Partial arterial pressure of carbon dioxide was kept in the range 34-36 mmHg by adjusting the respiratory rate, hence, changes in carbon dioxide were not associated with the increase in ICP. CONCLUSIONS The present study found that most patients did not experience any adverse effects of LPV, neither on ICP nor CA. However, in almost a quarter of patients, the ICP rose above the safety limit for interrupting the interventions. Baseline ICP, brain compensatory reserve, and mechanical power can predict a potentially deleterious effect of LPV and can be used to personalize ventilator settings. Trial registration NCT03278769 . Registered September 12, 2017.
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Affiliation(s)
- Erta Beqiri
- Department of Clinical Neurosciences, Neurosurgery Department, University of Cambridge, Cambridge, UK
| | - Peter Smielewski
- Department of Clinical Neurosciences, Neurosurgery Department, University of Cambridge, Cambridge, UK
| | - Claude Guérin
- University of Lyon, Lyon, France
- INSERM955, Créteil, France
| | - Marek Czosnyka
- Department of Clinical Neurosciences, Neurosurgery Department, University of Cambridge, Cambridge, UK
| | - Chiara Robba
- IRCCS for Oncology and Neuroscience, Policlinico San Martino, Genoa, Italy
- Department of Surgical Science Diagnostic and Integrated, University of Genova, Genoa, Italy
| | - Lars Bjertnæs
- Department of Anaesthesia and Intensive Care, University Hospital of North Norway, Tromsø, Norway
- Department of Clinical Medicine, UiT the Arctic University of Norway, Tromsø, Norway
| | - Shirin K Frisvold
- Department of Anaesthesia and Intensive Care, University Hospital of North Norway, Tromsø, Norway.
- Department of Clinical Medicine, UiT the Arctic University of Norway, Tromsø, Norway.
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Mechanical Ventilation in Patients with Traumatic Brain Injury: Is it so Different? Neurocrit Care 2023; 38:178-191. [PMID: 36071333 DOI: 10.1007/s12028-022-01593-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 08/16/2022] [Indexed: 10/14/2022]
Abstract
Patients with traumatic brain injury (TBI) frequently require invasive mechanical ventilation and admission to an intensive care unit. Ventilation of patients with TBI poses unique clinical challenges, and careful attention is required to ensure that the ventilatory strategy (including selection of appropriate tidal volume, plateau pressure, and positive end-expiratory pressure) does not cause significant additional injury to the brain and lungs. Selection of ventilatory targets may be guided by principles of lung protection but with careful attention to relevant intracranial effects. In patients with TBI and concomitant acute respiratory distress syndrome (ARDS), adjunctive strategies include sedation optimization, neuromuscular blockade, recruitment maneuvers, prone positioning, and extracorporeal life support. However, these approaches have been largely extrapolated from studies in patients with ARDS and without brain injury, with limited data in patients with TBI. This narrative review will summarize the existing evidence for mechanical ventilation in patients with TBI. Relevant literature in patients with ARDS will be summarized, and where available, direct data in the TBI population will be reviewed. Next, practical strategies to optimize the delivery of mechanical ventilation and determine readiness for extubation will be reviewed. Finally, future directions for research in this evolving clinical domain will be presented, with considerations for the design of studies to address relevant knowledge gaps.
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Weaning Outcomes in Patients with Brain Injury. Neurocrit Care 2022; 37:649-659. [PMID: 36050534 DOI: 10.1007/s12028-022-01584-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 05/18/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Despite the need for specific weaning strategies in neurological patients, evidence is generally insufficient or lacking. We aimed to describe the evolution over time of weaning and extubation practices in patients with acute brain injury compared with patients who are mechanically ventilated (MV) due to other reasons. METHODS We performed a secondary analysis of three prospective, observational, multicenter international studies conducted in 2004, 2010, and 2016 in adults who had need of invasive MV for more than 12 h. We collected data on baseline characteristics, variables related to management ventilator settings, and complications while patients were ventilated or until day 28. RESULTS Among the 20,929 patients enrolled, we included 12,618 (60%) who started the weaning from MV, of whom 1722 (14%) were patients with acute brain injury. In the acutely brain-injured cohort, 538 patients (31%) did not undergo planned extubation, defined as the need for a tracheostomy without an attempt of extubation, accidental extubation, and death. Among the 1184 planned extubated patients with acute brain injury, 202 required reintubation (17%). Patients with acute brain injury had a higher odds for unplanned extubation (odds ratio [OR] 1.35, confidence interval for 95% [CI 95%] 1.19-1.54; p < 0.001), a higher odds of failure after the first attempt of weaning (spontaneous breathing trial or gradual reduction of ventilatory support; OR 1.14 [CI 95% 1.01-1.30; p = 0.03]), and a higher odds for reintubation (OR 1.41 [CI 95% 1.20-1.66; p < 0.001]) than patients without brain injury. Patients with hemorrhagic stroke had the highest odds for unplanned extubation (OR 1.47 [CI 95% 1.22-1.77; p < 0.001]), of failed extubation after the first attempt of weaning (OR 1.28 [CI 95% 1.06-1.55; p = 0.009]), and for reintubation (OR 1.49 [CI 95% 1.17-1.88; p < 0.001]). In relation to weaning evolution over time in patients with acute brain injury, the risk for unplanned extubation showed a downward trend; the risk for reintubation was not associated to time; and there was a significant increase in the percentage of patients who underwent extubation after the first attempt of weaning from MV. CONCLUSIONS Patients with acute brain injury, compared with patients without brain injury, present higher odds of undergoing unplanned extubated after weaning was started, lower odds of being extubated after the first attempt, and a higher risk of reintubation.
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Association between Traumatic Subarachnoid Hemorrhage and Acute Respiratory Failure in Moderate-to-Severe Traumatic Brain Injury Patients. J Clin Med 2022; 11:jcm11143995. [PMID: 35887760 PMCID: PMC9318973 DOI: 10.3390/jcm11143995] [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: 05/01/2022] [Revised: 06/27/2022] [Accepted: 07/05/2022] [Indexed: 01/25/2023] Open
Abstract
Acute respiratory failure (ARF) with a high incidence among moderate-to-severe traumatic brain injury (M-STBI) patients plays a pivotal role in worsening neurological outcomes. Traumatic subarachnoid hemorrhage (tSAH) is highly prevalent in M-STBI, which is associated with significant adverse outcomes. In this retrospective cohort study, we aimed to explore the association between the severity of the tSAH and ARF in the M-STBI population. A total of 771 subjects were reviewed. Clinical and neuroimaging data of M-STBI patients were retrospectively collected, and ARF was ascertained retrospectively based on their electronic medical record. The degree of tSAH was classified according to Fisher’s criteria, and the grade of tSAH was dichotomized to a low Fisher grade (Fisher grade 1–2) and a high Fisher grade (Fisher grade 3–4). After exclusion procedures, the data of 695 M-STBI patients were analyzed. A total of 284 (30.8%) had a high Fisher grade on admission. The overall rate of ARF within 48 h upon admission was 34.4% (239/695); it was 29.5% (142/481) and 46.3% (99/214) for the low and high Fisher groups, respectively. In a full cohort, a high Fisher grade was associated with ARF after adjusting for age, gender, GCS, smoking history, comorbidities, multiple injuries, characteristics of TBI, and pulmonary factors (OR 1.78; 95% CI, 1.11–2.85, p = 0.016). This result remained robust in the comparisons after PSM (71/132, 42.8% vs. 53/132, 31.9%; OR, 1.59; 95% CI, 1.02–2.49, p = 0.042). A high Fisher SAH grade exposure on admission is associated with ARF in M-STBI patients.
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Robba C, Ball L, Nogas S, Battaglini D, Messina A, Brunetti I, Minetti G, Castellan L, Rocco PRM, Pelosi P. Effects of Positive End-Expiratory Pressure on Lung Recruitment, Respiratory Mechanics, and Intracranial Pressure in Mechanically Ventilated Brain-Injured Patients. Front Physiol 2021; 12:711273. [PMID: 34733173 PMCID: PMC8558243 DOI: 10.3389/fphys.2021.711273] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 09/09/2021] [Indexed: 01/17/2023] Open
Abstract
Background: The pathophysiological effects of positive end-expiratory pressure (PEEP) on respiratory mechanics, lung recruitment, and intracranial pressure (ICP) in acute brain-injured patients have not been completely elucidated. The primary aim of this study was to assess the effects of PEEP augmentation on respiratory mechanics, quantitative computed lung tomography (qCT) findings, and its relationship with ICP modifications. Secondary aims included the assessment of the correlations between different factors (respiratory mechanics and qCT features) with the changes of ICP and how these factors at baseline may predict ICP response after greater PEEP levels. Methods: A prospective, observational study included mechanically ventilated patients with acute brain injury requiring invasive ICP and who underwent two-PEEP levels lung CT scan. Respiratory system compliance (Crs), arterial partial pressure of carbon dioxide (PaCO2), mean arterial pressure (MAP), data from qCT and ICP were obtained at PEEP 5 and 15 cmH2O. Results: Sixteen examinations (double PEEP lung CT and neuromonitoring) in 15 patients were analyzed. The median age of the patients was 54 years (interquartile range, IQR = 39–65) and 53% were men. The median Glasgow Coma Scale (GCS) at intensive care unit (ICU) admission was 8 (IQR = 3–12). Median alveolar recruitment was 2.5% of total lung weight (−1.5 to 4.7). PEEP from 5 to 15 cmH2O increased ICP [median values from 14.0 (11.2–17.5) to 23.5 (19.5–26.8) mmHg, p < 0.001, respectively]. The amount of recruited lung tissue on CT was inversely correlated with the change (Δ) in ICP (rho = −0.78; p = 0.0006). Additionally, ΔCrs (rho = −0.77, p = 0.008), ΔPaCO2 (rho = 0.81, p = 0.0003), and ΔMAP (rho = −0.64, p = 0.009) were correlated with ΔICP. Baseline Crs was not predictive of ICP response to PEEP. Conclusions: The main factors associated with increased ICP after PEEP augmentation included reduced Crs, lower MAP and lung recruitment, and increased PaCO2, but none of these factors was able to predict, at baseline, ICP response to PEEP. To assess the potential benefits of increased PEEP in patients with acute brain injury, hemodynamic status, respiratory mechanics, and lung morphology should be taken into account.
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Affiliation(s)
- Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) for Oncology and Neurosciences, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Lorenzo Ball
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) for Oncology and Neurosciences, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Stefano Nogas
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) for Oncology and Neurosciences, Genoa, Italy
| | - Denise Battaglini
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) for Oncology and Neurosciences, Genoa, Italy
| | - Antonio Messina
- Humanitas Clinical and Research Center-Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rozzano, Italy
| | - Iole Brunetti
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) for Oncology and Neurosciences, Genoa, Italy
| | - Giuseppe Minetti
- Radiology Department San Martino Policlinico Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) for Oncology and Neurosciences, Genoa, Italy
| | - Lucio Castellan
- Radiology Department San Martino Policlinico Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) for Oncology and Neurosciences, Genoa, Italy
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) for Oncology and Neurosciences, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
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11
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Robba C, Citerio G, Taccone FS, Galimberti S, Rebora P, Vargiolu A, Pelosi P. Multicentre observational study on practice of ventilation in brain injured patients: the VENTIBRAIN study protocol. BMJ Open 2021; 11:e047100. [PMID: 34380722 PMCID: PMC8359464 DOI: 10.1136/bmjopen-2020-047100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Mechanical ventilatory is a crucial element of acute brain injured patients' management. The ventilatory goals to ensure lung protection during acute respiratory failure may not be adequate in case of concomitant brain injury. Therefore, there are limited data from which physicians can draw conclusions regarding optimal ventilator management in this setting. METHODS AND ANALYSIS This is an international multicentre prospective observational cohort study. The aim of the 'multicentre observational study on practice of ventilation in brain injured patients'-the VENTIBRAIN study-is to describe the current practice of ventilator settings and mechanical ventilation in acute brain injured patients. Secondary objectives include the description of ventilator settings among different countries, and their association with outcomes. Inclusion criteria will be adult patients admitted to the intensive care unit (ICU) with a diagnosis of traumatic brain injury or cerebrovascular diseases (intracranial haemorrhage, subarachnoid haemorrhage, ischaemic stroke), requiring intubation and mechanical ventilation and admission to the ICU. Exclusion criteria will be the following: patients aged <18 years; pregnant patients; patients not intubated or not mechanically ventilated or receiving only non-invasive ventilation. Data related to clinical examination, neuromonitoring if available, ventilator settings and arterial blood gases will be recorded at admission and daily for the first 7 days and then at day 10 and 14. The Glasgow Outcome Scale Extended on mortality and neurological outcome will be collected at discharge from ICU, hospital and at 6 months follow-up. ETHICS AND DISSEMINATION The study has been approved by the Ethic committee of Brianza at the Azienda Socio Sanitaria Territoriale-Monza. Data will be disseminated to the scientific community by abstracts submitted to the European Society of Intensive Care Medicine annual conference and by original articles submitted to peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT04459884.
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Affiliation(s)
- Chiara Robba
- Anesthesia and Intensive Care, Policlinico San Martino, IRCCS for Oncology and Neuroscience, Genova, Italy
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, University of Genoa, Genova, Italy
| | - Giuseppe Citerio
- School of Medicine and Surgery, Università Miano - Bicocca, Milano, Italy
- Neuroscience Department, NeuroIntensive Care Unit, Hospital San Gerardo, ASST Monza, Monza, Italy
| | - Fabio S Taccone
- Dpt of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Stefania Galimberti
- School of Medicine and Surgery, Università Miano - Bicocca, Milano, Italy
- Bicocca Bioinformatics Biostatistics and Bioimaging B4 Center, School of Medicine and Surgery, University of Milano - Bicocca, Monza, Italy
| | - Paola Rebora
- School of Medicine and Surgery, Università Miano - Bicocca, Milano, Italy
- Bicocca Bioinformatics Biostatistics and Bioimaging B4 Center, School of Medicine and Surgery, University of Milano - Bicocca, Monza, Italy
| | - Alessia Vargiolu
- School of Medicine and Surgery, Università Miano - Bicocca, Milano, Italy
| | - Paolo Pelosi
- Anesthesia and Intensive Care, Policlinico San Martino, IRCCS for Oncology and Neuroscience, Genova, Italy
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, University of Genoa, Genova, Italy
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12
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Shi ZH, Jonkman AH, Tuinman PR, Chen GQ, Xu M, Yang YL, Heunks LMA, Zhou JX. Role of a successful spontaneous breathing trial in ventilator liberation in brain-injured patients. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:548. [PMID: 33987246 PMCID: PMC8105847 DOI: 10.21037/atm-20-6407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 12/18/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND Spontaneous breathing trials (SBTs) have been shown to improve outcomes in critically ill patients. However, in patients with brain injury, indications for intubation and mechanical ventilation are different from those of non-neurological patients, and the role of an SBT in patients with brain injury is less established. The aim of the present study was to compare key respiratory variables acquired during a successful SBT between patients with successful ventilator liberation versus failed ventilator liberation. METHODS In this prospective study, patients with brain injury (≥18 years of age), who completed a 30-min SBT, were enrolled. Airway pressure, flow, esophageal pressure, and diaphragm electrical activity (ΔEAdi) were recorded before (baseline) and during the SBT. Respiratory rate (RR), tidal volume, inspiratory muscle pressure (ΔPmus), ΔEAdi, and neuromechanical efficiency (ΔPmus/ΔEAdi) of the diaphragm were calculated breath by breath and compared between the liberation success and failure groups. Failed liberation was defined as the need for invasive ventilator assistance within 48 h after the SBT. RESULTS In total, 46 patients (51.9±13.2 years, 67.4% male) completed the SBT. Seventeen (37%) patients failed ventilator liberation within 48 h. Another 11 patients required invasive ventilation within 7 days after completing the SBT. There were no differences in baseline characteristics between the success and failed groups. In-depth analysis showed similar changes in patterns and values of respiratory physiological parameters between the groups. CONCLUSIONS In patients with brain injury, ventilator liberation failure was common after successful SBT. In-depth physiological analysis during the SBT did not provide data to predict successful liberation in these patients. TRIAL REGISTRATION The trial was registered at ClinicalTrials.gov (No. NCT02863237).
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Affiliation(s)
- Zhong-Hua Shi
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Intensive Care, Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
- Research VUmc Intensive Care (REVIVE), Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
| | - Annemijn H. Jonkman
- Department of Intensive Care, Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
- Research VUmc Intensive Care (REVIVE), Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
| | - Pieter Roel Tuinman
- Department of Intensive Care, Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
- Research VUmc Intensive Care (REVIVE), Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
| | - Guang-Qiang Chen
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ming Xu
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yan-Lin Yang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Leo M. A. Heunks
- Department of Intensive Care, Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
- Research VUmc Intensive Care (REVIVE), Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
| | - Jian-Xin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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13
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Robba C, Ball L, Battaglini D, Cardim D, Moncalvo E, Brunetti I, Bassetti M, Giacobbe DR, Vena A, Patroniti N, Rocco PRM, Matta BF, Pelosi P. Early effects of ventilatory rescue therapies on systemic and cerebral oxygenation in mechanically ventilated COVID-19 patients with acute respiratory distress syndrome: a prospective observational study. Crit Care 2021; 25:111. [PMID: 33741052 PMCID: PMC7978164 DOI: 10.1186/s13054-021-03537-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 03/05/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND In COVID-19 patients with acute respiratory distress syndrome (ARDS), the effectiveness of ventilatory rescue strategies remains uncertain, with controversial efficacy on systemic oxygenation and no data available regarding cerebral oxygenation and hemodynamics. METHODS This is a prospective observational study conducted at San Martino Policlinico Hospital, Genoa, Italy. We included adult COVID-19 patients who underwent at least one of the following rescue therapies: recruitment maneuvers (RMs), prone positioning (PP), inhaled nitric oxide (iNO), and extracorporeal carbon dioxide (CO2) removal (ECCO2R). Arterial blood gas values (oxygen saturation [SpO2], partial pressure of oxygen [PaO2] and of carbon dioxide [PaCO2]) and cerebral oxygenation (rSO2) were analyzed before (T0) and after (T1) the use of any of the aforementioned rescue therapies. The primary aim was to assess the early effects of different ventilatory rescue therapies on systemic and cerebral oxygenation. The secondary aim was to evaluate the correlation between systemic and cerebral oxygenation in COVID-19 patients. RESULTS Forty-five rescue therapies were performed in 22 patients. The median [interquartile range] age of the population was 62 [57-69] years, and 18/22 [82%] were male. After RMs, no significant changes were observed in systemic PaO2 and PaCO2 values, but cerebral oxygenation decreased significantly (52 [51-54]% vs. 49 [47-50]%, p < 0.001). After PP, a significant increase was observed in PaO2 (from 62 [56-71] to 82 [76-87] mmHg, p = 0.005) and rSO2 (from 53 [52-54]% to 60 [59-64]%, p = 0.005). The use of iNO increased PaO2 (from 65 [67-73] to 72 [67-73] mmHg, p = 0.015) and rSO2 (from 53 [51-56]% to 57 [55-59]%, p = 0.007). The use of ECCO2R decreased PaO2 (from 75 [75-79] to 64 [60-70] mmHg, p = 0.009), with reduction of rSO2 values (59 [56-65]% vs. 56 [53-62]%, p = 0.002). In the whole population, a significant relationship was found between SpO2 and rSO2 (R = 0.62, p < 0.001) and between PaO2 and rSO2 (R0 0.54, p < 0.001). CONCLUSIONS Rescue therapies exert specific pathophysiological mechanisms, resulting in different effects on systemic and cerebral oxygenation in critically ill COVID-19 patients with ARDS. Cerebral and systemic oxygenation are correlated. The choice of rescue strategy to be adopted should take into account both lung and brain needs. Registration The study protocol was approved by the ethics review board (Comitato Etico Regione Liguria, protocol n. CER Liguria: 23/2020).
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Affiliation(s)
- Chiara Robba
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
- IRCCS for Oncology and Neuroscience, Ospedale Policlinico San Martino, Genoa, Italy
| | - Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
- IRCCS for Oncology and Neuroscience, Ospedale Policlinico San Martino, Genoa, Italy
| | - Denise Battaglini
- IRCCS for Oncology and Neuroscience, Ospedale Policlinico San Martino, Genoa, Italy
| | - Danilo Cardim
- Department of Neurology, University of Texas, Austin, USA
| | - Emanuela Moncalvo
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Iole Brunetti
- IRCCS for Oncology and Neuroscience, Ospedale Policlinico San Martino, Genoa, Italy
| | - Matteo Bassetti
- Department of Health Sciences (DISSAL), University of Genoa, Genoa , Italy
- Infectious Diseases Unit, IRCCS for Oncology and Neuroscience, Ospedale Policlinico San Martino, Genoa, Italy
| | - Daniele R. Giacobbe
- Department of Health Sciences (DISSAL), University of Genoa, Genoa , Italy
- Infectious Diseases Unit, IRCCS for Oncology and Neuroscience, Ospedale Policlinico San Martino, Genoa, Italy
| | - Antonio Vena
- Infectious Diseases Unit, IRCCS for Oncology and Neuroscience, Ospedale Policlinico San Martino, Genoa, Italy
| | - Nicolò Patroniti
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
- IRCCS for Oncology and Neuroscience, Ospedale Policlinico San Martino, Genoa, Italy
| | - Patricia R. M. Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio De Janeiro, Brazil
| | - Basil F. Matta
- Neurocritical Care Unit, Addenbrooke’s Hospital, Cambridge, UK
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
- IRCCS for Oncology and Neuroscience, Ospedale Policlinico San Martino, Genoa, Italy
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14
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Evolution Over Time of Ventilatory Management and Outcome of Patients With Neurologic Disease. Crit Care Med 2021; 49:1095-1106. [PMID: 33729719 DOI: 10.1097/ccm.0000000000004921] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To describe the changes in ventilator management over time in patients with neurologic disease at ICU admission and to estimate factors associated with 28-day hospital mortality. DESIGN Secondary analysis of three prospective, observational, multicenter studies. SETTING Cohort studies conducted in 2004, 2010, and 2016. PATIENTS Adult patients who received mechanical ventilation for more than 12 hours. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Among the 20,929 patients enrolled, we included 4,152 (20%) mechanically ventilated patients due to different neurologic diseases. Hemorrhagic stroke and brain trauma were the most common pathologies associated with the need for mechanical ventilation. Although volume-cycled ventilation remained the preferred ventilation mode, there was a significant (p < 0.001) increment in the use of pressure support ventilation. The proportion of patients receiving a protective lung ventilation strategy was increased over time: 47% in 2004, 63% in 2010, and 65% in 2016 (p < 0.001), as well as the duration of protective ventilation strategies: 406 days per 1,000 mechanical ventilation days in 2004, 523 days per 1,000 mechanical ventilation days in 2010, and 585 days per 1,000 mechanical ventilation days in 2016 (p < 0.001). There were no differences in the length of stay in the ICU, mortality in the ICU, and mortality in hospital from 2004 to 2016. Independent risk factors for 28-day mortality were age greater than 75 years, Simplified Acute Physiology Score II greater than 50, the occurrence of organ dysfunction within first 48 hours after brain injury, and specific neurologic diseases such as hemorrhagic stroke, ischemic stroke, and brain trauma. CONCLUSIONS More lung-protective ventilatory strategies have been implemented over years in neurologic patients with no effect on pulmonary complications or on survival. We found several prognostic factors on mortality such as advanced age, the severity of the disease, organ dysfunctions, and the etiology of neurologic disease.
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15
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Robba C, Poole D, McNett M, Asehnoune K, Bösel J, Bruder N, Chieregato A, Cinotti R, Duranteau J, Einav S, Ercole A, Ferguson N, Guerin C, Siempos II, Kurtz P, Juffermans NP, Mancebo J, Mascia L, McCredie V, Nin N, Oddo M, Pelosi P, Rabinstein AA, Neto AS, Seder DB, Skrifvars MB, Suarez JI, Taccone FS, van der Jagt M, Citerio G, Stevens RD. Mechanical ventilation in patients with acute brain injury: recommendations of the European Society of Intensive Care Medicine consensus. Intensive Care Med 2020; 46:2397-2410. [PMID: 33175276 PMCID: PMC7655906 DOI: 10.1007/s00134-020-06283-0] [Citation(s) in RCA: 114] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 10/05/2020] [Indexed: 12/29/2022]
Abstract
Purpose To provide clinical practice recommendations and generate a research agenda on mechanical ventilation and respiratory support in patients with acute brain injury (ABI). Methods An international consensus panel was convened including 29 clinician-scientists in intensive care medicine with expertise in acute respiratory failure, neurointensive care, or both, and two non-voting methodologists. The panel was divided into seven subgroups, each addressing a predefined clinical practice domain relevant to patients admitted to the intensive care unit (ICU) with ABI, defined as acute traumatic brain or cerebrovascular injury. The panel conducted systematic searches and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method was used to evaluate evidence and formulate questions. A modified Delphi process was implemented with four rounds of voting in which panellists were asked to respond to questions (rounds 1–3) and then recommendation statements (final round). Strong recommendation, weak recommendation, or no recommendation were defined when > 85%, 75–85%, and < 75% of panellists, respectively, agreed with a statement. Results The GRADE rating was low, very low, or absent across domains. The consensus produced 36 statements (19 strong recommendations, 6 weak recommendations, 11 no recommendation) regarding airway management, non-invasive respiratory support, strategies for mechanical ventilation, rescue interventions for respiratory failure, ventilator liberation, and tracheostomy in brain-injured patients. Several knowledge gaps were identified to inform future research efforts. Conclusions This consensus provides guidance for the care of patients admitted to the ICU with ABI. Evidence was generally insufficient or lacking, and research is needed to demonstrate the feasibility, safety, and efficacy of different management approaches. Electronic supplementary material The online version of this article (10.1007/s00134-020-06283-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Chiara Robba
- San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Daniele Poole
- Anesthesia and Intensive Care Operative Unit, S. Martino Hospital, Belluno, Italy
| | - Molly McNett
- Implementation Science, The Helene Fuld Health Trust National Institute for EBP, College of Nursing, The Ohio State University, Columbus, OH, USA
| | - Karim Asehnoune
- Department of Anaesthesia and Critical Care, Hôtel Dieu, University Hospital of Nantes, Nantes, France
| | - Julian Bösel
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
- Department of Neurology, Klinikum Kassel, Kassel, Germany
| | - Nicolas Bruder
- Anesthesiology-Intensive Care Department, Aix-Marseille University, APHM, CHU Timone, Marseille, France
| | - Arturo Chieregato
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Raphael Cinotti
- Department of Anaesthesia and Critical Care, Hôpital Guillaume et René Laennec, University Hospital of Nantes, Saint-Herblain, France
| | - Jacques Duranteau
- Department of Anesthesiology and Perioperative Intensive Care Medicine, Bicêtre Hospital, Assistance Publique Hôpitaux de Paris, Paris-Saclay University, Paris, France
| | - Sharon Einav
- Faculty of Medicine, Intensive Care Unit of the Shaare Zedek Medical Centre and Hebrew University, Jerusalem, Israel
| | - Ari Ercole
- University of Cambridge Division of Anaesthesia, Addenbrooke's Hospital, Cambridge, UK
| | - Niall Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Physiology, University of Toronto, Toronto, ON, Canada
| | - Claude Guerin
- Medecine Intensive-Réanimation, Hopital Edouard Herriot, University of Lyon, Lyon, France
- INSERM 955, Créteil, France
| | - Ilias I Siempos
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, New York-Presbyterian Hospital-Weill Cornell Medical Center, Weill Cornell Medicine, New York, NY, USA
| | - Pedro Kurtz
- Department of Neurointensive Care, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Nicole P Juffermans
- Department of Intensive Care Medicine, Olvg Hospital, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Jordi Mancebo
- Servei Medicina Intensiva, Hospital Sant Pau, Barcelona, Spain
| | - Luciana Mascia
- Alma Mater Studiorum, Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy
| | - Victoria McCredie
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Nicolas Nin
- Department of Intensive Care Medicine, Hospital Español, Montevideo, Uruguay
| | - Mauro Oddo
- Department of Intensive Care Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), University of Lausanne, Lausanne, Switzerland
| | - Paolo Pelosi
- San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | | | - Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Critical Care Medicine, Hospital Israelita Alberto Einstein, São Paulo, Brazil
| | - David B Seder
- Department of Critical Care Services, Neuroscience Institute, Maine Medical Center, 22 Bramhall Street, Portland, ME, 04102, USA
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Meilahden sairaala, Haartmaninkatu 4, 00029 HUS, Helsinki, Finland
| | - Jose I Suarez
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Phipps 455, Baltimore, MD, 21287, USA
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fabio Silvio Taccone
- Department of Intensive Care Medicine, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Mathieu van der Jagt
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano - Bicocca, Milan, Italy
| | - Robert D Stevens
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Phipps 455, Baltimore, MD, 21287, USA.
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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16
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Mazeraud A, Robba C, Rebora P, Iaquaniello C, Vargiolu A, Rass V, Bogossian EG, Helbok R, Taccone FS, Citerio G. Acute Distress Respiratory Syndrome After Subarachnoid Hemorrhage: Incidence and Impact on the Outcome in a Large Multicenter, Retrospective Cohort. Neurocrit Care 2020; 34:1000-1008. [PMID: 33083966 PMCID: PMC7575216 DOI: 10.1007/s12028-020-01115-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 09/14/2020] [Indexed: 11/28/2022]
Abstract
Background Respiratory complications are frequently reported after aneurismal subarachnoid hemorrhage (aSAH), even if their association with outcome remains controversial. Acute respiratory distress syndrome (ARDS) is one of the most severe pulmonary complications after aSAH, with a reported incidence ranging from 11 to 50%. This study aims to assess in a large cohort of aSAH patients, during the first week after an intensive care unit (ICU) admission, the incidence of ARDS defined according to the Berlin criteria and its effect on outcome. Methods This is a multicentric, retrospective cohort study in 3 European intensive care units. We collected data between January 2009 and December 2017. We included adult patients (≥ 18 years) with a diagnosis of aSAH admitted to the ICU. Results A total of 855 patients fulfilled the inclusion criteria. ARDS was assessable in 851 patients. The cumulative incidence of ARDS was 2.2% on the first day since ICU admission, 3.2% on day three, and 3.6% on day seven. At the univariate analysis, ARDS was associated with a poor outcome (p = 0.005) at ICU discharge, and at the multivariable analysis, patients with ARDS showed a worse neurological outcome (Odds ratio = 3.00, 95% confidence interval 1.16–7.72; p = 0.023). Conclusions ARDS has a low incidence in the first 7 days of ICU stay after aSAH, but it is associated with worse outcome. Electronic supplementary material The online version of this article (10.1007/s12028-020-01115-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Aurélien Mazeraud
- Neurointensive Care Unit, GHU Paris - Psychiatrie et neurosciences, rue Cabanis 1, 75014, Paris, France.,School of Medicine and Surgery, University of Milano - Bicocca, Via Cadore 48, 20900, Monza, Italy
| | - Chiara Robba
- Department of Anaesthesia and Intensive Care, Policlinico San Martino IRCCS for Oncology and Neuroscience, Largo R.Benzi 10, 16132, Genova, Italy
| | - Paola Rebora
- School of Medicine and Surgery, University of Milano - Bicocca, Via Cadore 48, 20900, Monza, Italy
| | - Carolina Iaquaniello
- School of Medicine and Surgery, University of Milano - Bicocca, Via Cadore 48, 20900, Monza, Italy
| | - Alessia Vargiolu
- School of Medicine and Surgery, University of Milano - Bicocca, Via Cadore 48, 20900, Monza, Italy
| | - Verena Rass
- Department of Neurology, Neurological Intensive Care Unit, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Elisa Gouvea Bogossian
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium
| | - Raimund Helbok
- Department of Neurology, Neurological Intensive Care Unit, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano - Bicocca, Via Cadore 48, 20900, Monza, Italy. .,Neurointensive Care Unit, San Gerardo Hospital, ASST-Monza, Via G. B. Pergolesi 33, 20835, Monza, Italy.
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17
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Robba C, Asgari S, Gupta A, Badenes R, Sekhon M, Bequiri E, Hutchinson PJ, Pelosi P, Gupta A. Lung Injury Is a Predictor of Cerebral Hypoxia and Mortality in Traumatic Brain Injury. Front Neurol 2020; 11:771. [PMID: 32849225 PMCID: PMC7426476 DOI: 10.3389/fneur.2020.00771] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 06/23/2020] [Indexed: 12/19/2022] Open
Abstract
Background: A major contributor to unfavorable outcome after traumatic brain injury (TBI) is secondary brain injury. Low brain tissue oxygen tension (PbtO2) has shown to be an independent predictor of unfavorable outcome. Although PbtO2 provides clinicians with an understanding of the ischemic and non-ischemic derangements of brain physiology, its value does not take into consideration systemic oxygenation that can influence patients' outcomes. This study analyses brain and systemic oxygenation and a number of related indices in TBI patients: PbtO2, partial arterial oxygenation pressure (PaO2), PbtO2/PaO2, ratio of PbtO2 to fraction of inspired oxygen (FiO2), and PaO2/FiO2. The primary aim of this study was to identify independent risk factors for cerebral hypoxia. Secondary goal was to determine whether any of these indices are predictors of mortality outcome in TBI patients. Materials and Methods: A single-centre retrospective cohort study of 70 TBI patients admitted to the Neurocritical Care Unit (NCCU) at Cambridge University Hospital in 2014-2018 and undergoing advanced neuromonitoring including invasive PbtO2 was conducted. Three hundred and three simultaneous measurements of PbtO2, PaO2, PbtO2/PaO2, PbtO2/FiO2, PaO2/FiO2 were collected and mortality at discharge from NCCU was considered as outcome. Generalized estimating equations were used to analyse the longitudinal data. Results: Our results showed PbtO2 of 28 mmHg as threshold to define cerebral hypoxia. PaO2/FiO2 found to be a strong and independent risk factor for cerebral hypoxia when adjusting for confounding factor of intracranial pressure (ICP) with adjusted odds ratio of 1.78, 95% confidence interval of (1.10-2.87) and p-value = 0.019. With respect to TBI outcome, compromised values of PbtO2, PbtO2/PaO2, PbtO2/FiO2, and PaO2/FiO2 were all independent predictors of mortality while considered individually and adjusting for confounding factors of ICP, age, gender, and cerebral perfusion pressure (CPP). However, when considering all the compromised values together, only PaO2/FiO2 became an independent predictor of mortality with adjusted odds ratio of 3.47 (1.20-10.04) and p-value = 0.022. Conclusions: Brain and Lung interaction in TBI patients is a complex interrelationship. PaO2/FiO2 seems to be a major determinant of cerebral hypoxia and mortality. These results confirm the importance of employing ventilator strategies to prevent cerebral hypoxia and improve the outcome in TBI patients.
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Affiliation(s)
- Chiara Robba
- Anaesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Shadnaz Asgari
- Biomedical Engineering Department, California State University, Long Beach, CA, United States.,Computer Engineering and Computer Science Department, California State University, Long Beach, CA, United States
| | - Amit Gupta
- Emergency Department, Broomfield Hospital, Mid-Essex Hospital Trust, Essex, United Kingdom
| | - Rafael Badenes
- Department of Surgery, University of Valencia, Valencia, Spain
| | - Mypinder Sekhon
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Erta Bequiri
- Department of Neurosurgery, Addenbrooke's Hospital, Hills University of Cambridge, Cambridge, United Kingdom.,Department of Physiology and Transplantation, Milan University, Milan, Italy
| | - Peter J Hutchinson
- Department of Neurosurgery, Addenbrooke's Hospital, Hills University of Cambridge, Cambridge, United Kingdom
| | - Paolo Pelosi
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università Degli Studi di Genova, Genoa, Italy
| | - Arun Gupta
- Neurocritical Care Unit, Addenbrooke's Hospital, Cambridge, United Kingdom
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18
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Picetti E, Pelosi P, Taccone FS, Citerio G, Mancebo J, Robba C. VENTILatOry strategies in patients with severe traumatic brain injury: the VENTILO Survey of the European Society of Intensive Care Medicine (ESICM). CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:158. [PMID: 32303255 PMCID: PMC7165367 DOI: 10.1186/s13054-020-02875-w] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 04/06/2020] [Indexed: 12/16/2022]
Abstract
Background Severe traumatic brain injury (TBI) patients often develop acute respiratory failure. Optimal ventilator strategies in this setting are not well established. We performed an international survey to investigate the practice in the ventilatory management of TBI patients with and without respiratory failure. Methods An electronic questionnaire, including 38 items and 3 different clinical scenarios [arterial partial pressure of oxygen (PaO2)/inspired fraction of oxygen (FiO2) > 300 (scenario 1), 150–300 (scenario 2), < 150 (scenario 3)], was available on the European Society of Intensive Care Medicine (ESICM) website between November 2018 and March 2019. The survey was endorsed by ESICM. Results There were 687 respondents [472 (69%) from Europe], mainly intensivists [328 (48%)] and anesthesiologists [206 (30%)]. A standard protocol for mechanical ventilation in TBI patients was utilized by 277 (40%) respondents and a specific weaning protocol by 198 (30%). The most common tidal volume (TV) applied was 6–8 ml/kg of predicted body weight (PBW) in scenarios 1–2 (72% PaO2/FIO2 > 300 and 61% PaO2/FiO2 150–300) and 4–6 ml/kg/PBW in scenario 3 (53% PaO2/FiO2 < 150). The most common level of highest positive end-expiratory pressure (PEEP) used was 15 cmH2O in patients with a PaO2/FiO2 ≤ 300 without intracranial hypertension (41% if PaO2/FiO2 150–300 and 50% if PaO2/FiO2 < 150) and 10 cmH2O in patients with intracranial hypertension (32% if PaO2/FiO2 150–300 and 33% if PaO2/FiO2 < 150). Regardless of the presence of intracranial hypertension, the most common carbon dioxide target remained 36–40 mmHg whereas the most common PaO2 target was 81–100 mmHg in all the 3 scenarios. The most frequent rescue strategies utilized in case of refractory respiratory failure despite conventional ventilator settings were neuromuscular blocking agents [406 (88%)], recruitment manoeuvres [319 (69%)] and prone position [292 (63%)]. Conclusions Ventilatory management, targets and practice of adult severe TBI patients with and without respiratory failure are widely different among centres. These findings may be helpful to define future investigations in this topic.
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Affiliation(s)
- Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Via Gramsci 14, 43100, Parma, Italy.
| | - Paolo Pelosi
- Department of Anesthesia and Intensive Care, IRCCS for Oncology and Neurosciences, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan - Bicocca, Monza, Italy
| | - Jordi Mancebo
- Department of Intensive Care, Sant Pau Hospital, Barcelona, Spain
| | - Chiara Robba
- Department of Anesthesia and Intensive Care, IRCCS for Oncology and Neurosciences, Genoa, Italy
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19
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Robba C, Sonneville R, Meyfroidt G. Focus on neuro-critical care: combined interventions to improve relevant outcomes. Intensive Care Med 2020; 46:1027-1029. [PMID: 32206844 DOI: 10.1007/s00134-020-06014-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 03/16/2020] [Indexed: 12/20/2022]
Affiliation(s)
- Chiara Robba
- Anesthesia and Intensive Care, Policlinico San Martino, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Romain Sonneville
- INSERM UMR1148, Team 6, Université de Paris, 75018, Paris, France.,Department of Intensive Care Medicine and Infectious Diseases, AP-HP, Bichat-Claude Bernard Hospital, 75018, Paris, France
| | - Geert Meyfroidt
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium. .,Laboratory of Intensive Care Medicine, University of Leuven (KU Leuven), Leuven, Belgium.
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