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Su Y, Teng J, Pan S, Jiang W, Wang F, Tian F, Jing J, Huang H, Cao J, Hu H, Liu L, Li W, Liang C, Ma L, Meng X, Tian L, Wang C, Wang L, Wang Y, Wang Z, Wang Z, Xie Z, You M, Yuan J, Zeng C, Zeng L, Zhang L, Zhang L, Zhang X, Zhang Y, Zhao B, Zhou S, Zhou Z. The development of the neurocritical care specialty in China based on the analysis of neurocritical care unit volume and quality. Brain Circ 2024; 10:67-76. [PMID: 38655441 PMCID: PMC11034439 DOI: 10.4103/bc.bc_71_23] [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: 08/25/2023] [Revised: 12/08/2023] [Accepted: 12/22/2023] [Indexed: 04/26/2024] Open
Abstract
PURPOSE Through three neurocritical care unit (NCCU) surveys in China, we tried to understand the development status of neurocritical care and clarify its future development. METHODS Using a cross-sectional survey method and self-report questionnaires, the number and quality of NCCUs were investigated through three steps: administering the questionnaire, sorting the survey data, and analyzing the survey data. RESULTS At the second and third surveys, the number of NCCUs (76/112/206) increased by 47% and 84%, respectively. The NCCUs were located in tertiary grade A hospitals or teaching hospitals (65/100/181) in most provinces (24/28/29). The numbers of full-time doctors (359/668/1337) and full-time nurses (904/1623/207) in the NCCUs increased, but the doctor-bed ratio and nurse-bed ratio were still insufficient (0.4:1 and 1.3:1). CONCLUSION In the past 20 years, the growth rate of NCCUs in China has accelerated, while the allocation of medical staff has been insufficient. Although most NCCU hospital bed facilities and instruments and equipment tend to be adequate, there are obvious defects in some aspects of NCCUs.
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Affiliation(s)
- Yingying Su
- Departments of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Junfang Teng
- The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Suyue Pan
- Nanfang Hospital of Southern Medical University, Guangzhou, China
| | - Wen Jiang
- Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Furong Wang
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Fei Tian
- Departments of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jing Jing
- The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Huijin Huang
- Departments of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jie Cao
- The First Hospital of Jilin University, Changchun, China
| | - Huaiqiang Hu
- The 960(th) Hospital of Joint Logistics Support, PLA, Jinan, China
| | - Liping Liu
- Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wei Li
- Daping Hospital, The Army Military Medical University, Chongqing, China
| | - Cheng Liang
- The Second Hospital of Lanzhou University, Lanzhou, China
| | - Liansheng Ma
- The First Hospital of Shanxi Medical University, Taiyuan, China
| | - Xuegang Meng
- The Xinjiang Uygur Autonomous Region People's Hospital, Urumqi, China
| | - Linyu Tian
- West China Hospital, Sichuan University, Chengdu, China
| | - Changqing Wang
- The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Lihua Wang
- The Second Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Yan Wang
- Tangshan People's Hospital of Hebei Province, Tangshan, China
| | - Zhenhai Wang
- Neurology Center, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Zhiqiang Wang
- The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Zunchun Xie
- The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Mingyao You
- The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Jun Yuan
- Inner Mongolia People's Hospital, Hohhot, China
| | - Chaosheng Zeng
- The Second Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Li Zeng
- The Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Le Zhang
- Xiangya Hospital, Central South University, Changsha, China
| | - Lei Zhang
- The First People's Hospital of Yunnan Province, Kunming, China
| | - Xin Zhang
- Nanjing Drum Tower Hospital, Nanjing, China
| | - Yongwei Zhang
- Department of Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Bin Zhao
- Tianjin Medical University General Hospital, Tianjin, China
| | - Saijun Zhou
- The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zhonghe Zhou
- General Hospital of Northern Theater Command, Shenyang, China
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Schoene D, Hartmann C, Winzer S, Moustafa H, Günther A, Puetz V, Barlinn K. [Postoperative management following decompressive hemicraniectomy for malignant middle cerebral artery infarction-A German nationwide survey study]. DER NERVENARZT 2023; 94:934-943. [PMID: 37140605 PMCID: PMC10157548 DOI: 10.1007/s00115-023-01486-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/26/2023] [Indexed: 05/05/2023]
Abstract
BACKGROUND Malignant middle cerebral artery infarction is a potentially life-threatening disease. Decompressive hemicraniectomy constitutes an evidence-based treatment practice, especially in patients under 60 years of age; however, recommendations with respect to postoperative management and particularly duration of postoperative sedation lack standardization. OBJECTIVE This survey study aimed to analyze the current situation of patients with malignant middle cerebral artery infarction following hemicraniectomy in the neurointensive care setting. MATERIAL AND METHODS From 20 September 2021 to 31 October 2021, 43 members of the initiative of German neurointensive trial engagement (IGNITE) network were invited to participate in a standardized anonymous online survey. Descriptive data analysis was performed. RESULTS Out of 43 centers 29 (67.4%) participated in the survey, including 24 university hospitals. Of the hospitals 21 have their own neurological intensive care unit. While 23.1% favored a standardized approach regarding postoperative sedation, the majority utilized individual criteria (e.g., intracranial pressure increase, weaning parameters, complications) to assess the need and duration. The timing of targeted extubation varied widely between hospitals (≤ 24 h 19.2%, ≤ 3 days in 30.8%, ≤ 5 days in 19.2%, > 5 days in 15.4%). Early tracheotomy (≤ 7 days) is performed in 19.2% and 80.8% of the centers aim for tracheotomy within 14 days. Hyperosmolar treatment is used on a regular basis in 53.9% and 22 centers (84.6%) agreed to participate in a clinical trial addressing the duration of postoperative sedation and ventilation. CONCLUSION The results of this nationwide survey among neurointensive care units in Germany reflect a remarkable heterogeneity in the treatment practices of patients with malignant middle cerebral artery infarction undergoing hemicraniectomy, especially with respect to the duration of postoperative sedation and ventilation. A randomized trial in this matter seems warranted.
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Affiliation(s)
- D Schoene
- Klinik und Poliklinik für Neurologie, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland.
- Dresdner Neurovaskuläres Centrum, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Deutschland.
| | - C Hartmann
- Institut und Poliklinik für Diagnostische und Interventionelle Neuroradiologie, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Deutschland
| | - S Winzer
- Klinik und Poliklinik für Neurologie, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland
- Dresdner Neurovaskuläres Centrum, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Deutschland
| | - H Moustafa
- Klinik und Poliklinik für Neurologie, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland
- Dresdner Neurovaskuläres Centrum, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Deutschland
| | - A Günther
- Klinik für Neurologie, Universitätsklinikum Jena, Jena, Deutschland
| | - V Puetz
- Klinik und Poliklinik für Neurologie, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland
- Dresdner Neurovaskuläres Centrum, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Deutschland
| | - K Barlinn
- Klinik und Poliklinik für Neurologie, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland
- Dresdner Neurovaskuläres Centrum, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Deutschland
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IGNITE Status Epilepticus Survey: A Nationwide Interrogation about the Current Management of Status Epilepticus in Germany. J Clin Med 2022; 11:jcm11051171. [PMID: 35268262 PMCID: PMC8910893 DOI: 10.3390/jcm11051171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 02/16/2022] [Accepted: 02/18/2022] [Indexed: 01/22/2023] Open
Abstract
We aimed to evaluate the current management of status epilepticus (SE) in intensive care units (ICUs) in Germany, depending on the different hospital levels of care and the ICU specialty. We performed a nationwide web-based anonymized survey, including all German ICUs registered with the German Society for Neurointensive and Emergency Care (Deutsche Gesellschaft für Neurointensiv- und Notfallmedizin; DGNI). The response rate was 83/232 (36%). Continuous EEG monitoring (cEEG) was available in 86% of ICUs. Regular written cEEG reports were obtained in only 50%. Drug management was homogeneous with a general consensus regarding substance order: benzodiazepines—anticonvulsants—sedatives. Thereunder first choice substances were lorazepam (90%), levetiracetam (91%), and propofol (73%). Data suggest that network structures for super-refractory SE are not permeable, as 75% did not transfer SE patients. Our survey provides “real world data” concerning the current management of SE in Germany. Uniform standards in the implementation of cEEG could help further improve the overall quality. Initial therapy management is standardized. For super-refractory SE, a concentration of highly specialized centers establishing network structures analogous to neurovascular diseases seems desirable to apply rescue therapies with low evidence carefully, ideally collecting data on this rare condition in registries and clinical trials.
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Luger S, Koerbel K, Martinez Oeckel A, Schneider H, Maurer CJ, Hintereder G, Wagner M, Hattingen E, Foerch C. Role of S100B Serum Concentration as a Surrogate Outcome Parameter After Mechanical Thrombectomy. Neurology 2021; 97:e2185-e2194. [PMID: 34635559 PMCID: PMC8641970 DOI: 10.1212/wnl.0000000000012918] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 09/20/2021] [Indexed: 11/24/2022] Open
Abstract
Background and Objectives To establish serum concentration of protein S100B as an objective biomarker surrogate for astroglial tissue damage after mechanical thrombectomy in patients with acute ischemic stroke. Methods This prospective 2-center study recruited patients with acute middle cerebral artery infarctions caused by large vessel occlusion treated with mechanical thrombectomy. Blood samples were collected at day 2 after intervention and analyzed for S100B serum concentrations using ELISA techniques. Infarct size was determined on follow-up brain imaging and functional outcome according to modified Rankin Scale (mRS) was assessed at 90 days. Results A total of 171 patients were included (mean age ± SD: 70 ± 14 years, 42% female). S100B levels correlated with infarct size. Median S100B concentrations at day 2 after intervention were lower in patients with favorable outcome (mRS score 0–1) at 90 days compared to patients with unfavorable outcome (mRS score 2–6) (median 0.10 µg/L [interquartile range 0.07–0.14] vs 0.20 µg/L [0.11–0.48], p < 0.001). Younger age (odds ratio [OR] 1.120 [confidence interval (CI) 1.068–1.174]; p < 0.001), lower National Institutes of Health Stroke Scale score 24 hours after symptom onset (OR 1.232 [CI 1.106–1.372]; p < 0.001), and lower S100B serum concentrations (OR 1.364 [CI 1.105–1.683]; p = 0.004) were independently associated with a favorable outcome. S100B was able to eliminate the lateralization bias associated with the use of mRS for functional outcome assessment at 90 days after stroke. Discussion S100B serum concentrations after mechanical thrombectomy indicate the extent of ischemic tissue damage. This can be assessed rapidly, independent of brain imaging and clinical outcome scales. Following prospective validation in further studies, this may provide an objective surrogate outcome measure both in clinical routine and interventional trials. Classification of Evidence This study provides Class I evidence that S100B 2 days following mechanical thrombectomy for acute ischemic stroke accurately distinguishes favorable from unfavorable functional outcome.
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Affiliation(s)
- Sebastian Luger
- From the Department of Neurology (S.L., K.K., A.M.O., C.F.), Central Laboratory (G.H.), and Institute of Neuroradiology (M.W., E.H.), University Hospital Frankfurt / Goethe University Frankfurt; and Departments of Neurology (H.S.) and Diagnostic and Interventional Radiology and Neuroradiology (C.J.M.), University Hospital Augsburg, Germany.
| | - Kimberly Koerbel
- From the Department of Neurology (S.L., K.K., A.M.O., C.F.), Central Laboratory (G.H.), and Institute of Neuroradiology (M.W., E.H.), University Hospital Frankfurt / Goethe University Frankfurt; and Departments of Neurology (H.S.) and Diagnostic and Interventional Radiology and Neuroradiology (C.J.M.), University Hospital Augsburg, Germany
| | - Ariane Martinez Oeckel
- From the Department of Neurology (S.L., K.K., A.M.O., C.F.), Central Laboratory (G.H.), and Institute of Neuroradiology (M.W., E.H.), University Hospital Frankfurt / Goethe University Frankfurt; and Departments of Neurology (H.S.) and Diagnostic and Interventional Radiology and Neuroradiology (C.J.M.), University Hospital Augsburg, Germany
| | - Hauke Schneider
- From the Department of Neurology (S.L., K.K., A.M.O., C.F.), Central Laboratory (G.H.), and Institute of Neuroradiology (M.W., E.H.), University Hospital Frankfurt / Goethe University Frankfurt; and Departments of Neurology (H.S.) and Diagnostic and Interventional Radiology and Neuroradiology (C.J.M.), University Hospital Augsburg, Germany
| | - Christoph J Maurer
- From the Department of Neurology (S.L., K.K., A.M.O., C.F.), Central Laboratory (G.H.), and Institute of Neuroradiology (M.W., E.H.), University Hospital Frankfurt / Goethe University Frankfurt; and Departments of Neurology (H.S.) and Diagnostic and Interventional Radiology and Neuroradiology (C.J.M.), University Hospital Augsburg, Germany
| | - Gudrun Hintereder
- From the Department of Neurology (S.L., K.K., A.M.O., C.F.), Central Laboratory (G.H.), and Institute of Neuroradiology (M.W., E.H.), University Hospital Frankfurt / Goethe University Frankfurt; and Departments of Neurology (H.S.) and Diagnostic and Interventional Radiology and Neuroradiology (C.J.M.), University Hospital Augsburg, Germany
| | - Marlies Wagner
- From the Department of Neurology (S.L., K.K., A.M.O., C.F.), Central Laboratory (G.H.), and Institute of Neuroradiology (M.W., E.H.), University Hospital Frankfurt / Goethe University Frankfurt; and Departments of Neurology (H.S.) and Diagnostic and Interventional Radiology and Neuroradiology (C.J.M.), University Hospital Augsburg, Germany
| | - Elke Hattingen
- From the Department of Neurology (S.L., K.K., A.M.O., C.F.), Central Laboratory (G.H.), and Institute of Neuroradiology (M.W., E.H.), University Hospital Frankfurt / Goethe University Frankfurt; and Departments of Neurology (H.S.) and Diagnostic and Interventional Radiology and Neuroradiology (C.J.M.), University Hospital Augsburg, Germany
| | - Christian Foerch
- From the Department of Neurology (S.L., K.K., A.M.O., C.F.), Central Laboratory (G.H.), and Institute of Neuroradiology (M.W., E.H.), University Hospital Frankfurt / Goethe University Frankfurt; and Departments of Neurology (H.S.) and Diagnostic and Interventional Radiology and Neuroradiology (C.J.M.), University Hospital Augsburg, Germany
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Lozada-Martínez ID, Camargo-Martínez W, Agrawal A, Mishra R, Murlimanju BV, Shrivastava A, Moscote-Salazar LR. Letter to the Editor. Intrahospital transport and SAH: possible impact on low- and middle-income countries. J Neurosurg 2021; 135:1587-1588. [PMID: 34243162 DOI: 10.3171/2021.3.jns21734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Ivan David Lozada-Martínez
- 1Medical and Surgical Research Center, University of Cartagena, Colombia
- 2Latinamerican Council of Neurocritical Care (CLaNi), Cartagena, Colombia
- 3Colombian Clinical Research Group in Neurocritical Care, University of Cartagena, Colombia
| | | | - Amit Agrawal
- 4All India Institute of Medical Sciences, Saket Nagar, Bhopal, Madhya Pradesh, India
| | - Rakesh Mishra
- 5Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Bukkambudhi V Murlimanju
- 6Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Adesh Shrivastava
- 4All India Institute of Medical Sciences, Saket Nagar, Bhopal, Madhya Pradesh, India
| | - Luis Rafael Moscote-Salazar
- 1Medical and Surgical Research Center, University of Cartagena, Colombia
- 2Latinamerican Council of Neurocritical Care (CLaNi), Cartagena, Colombia
- 3Colombian Clinical Research Group in Neurocritical Care, University of Cartagena, Colombia
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Chen K, Yang YL, Li HL, Xiao D, Wang Y, Zhang L, Zhou JX. A gap existed between physicians' perceptions and performance of pain, agitation-sedation and delirium assessments in Chinese intensive care units. BMC Anesthesiol 2021; 21:61. [PMID: 33627067 PMCID: PMC7905610 DOI: 10.1186/s12871-021-01286-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 02/15/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pain, agitation-sedation and delirium management are crucial elements in the care of critically ill patients. In the present study, we aimed to present the current practice of pain, agitation-sedation and delirium assessments in Chinese intensive care units (ICUs) and investigate the gap between physicians' perception and actual clinical performance. METHODS We sent invitations to the 33 members of the Neuro-Critical Care Committee affiliated with the Chinese Association of Critical Care Physicians. Finally, 24 ICUs (14 general-, 5 neuroscience-, 3 surgical-, and 2 emergency-ICUs) from 20 hospitals participated in this one-day point prevalence study combined with an on-site questionnaire survey. We enrolled adult ICU admitted patients with a length of stay ≥24 h, who were divided into the brain-injured group or non-brain-injured group. The hospital records and nursing records during the 24-h period prior to enrollment were reviewed. Actual evaluations of pain, agitation-sedation and delirium were documented. We invited physicians on-duty during the 24 h prior to the patients' enrollment to complete a survey questionnaire, which contained attitude for importance of pain, agitation-sedation and delirium assessments. RESULTS We enrolled 387 patients including 261 (67.4%) brain-injured and 126 (32.6%) non-brain-injured patients. There were 19.9% (95% confidence interval [CI]: 15.9-23.9%) and 25.6% (95% CI: 21.2-29.9%) patients receiving the pain and agitation-sedation scale assessment, respectively. The rates of these two types of assessments were significantly lower in brain-injured patients than non-brain-injured patients (p = 0.003 and < 0.001). Delirium assessment was only performed in three patients (0.8, 95% CI: 0.1-1.7%). In questionnaires collected from 91 physicians, 70.3% (95% CI: 60.8-79.9%) and 82.4% (95% CI: 74.4-90.4%) reported routine use of pain and agitation-sedation scale assessments, respectively. More than half of the physicians (52.7, 95% CI: 42.3-63.2%) reported daily screening for delirium using an assessment scale. CONCLUSIONS The actual prevalence of pain, agitation-sedation and delirium assessment, especially delirium screening, was suboptimal in Chinese ICUs. There is a gap between physicians' perceptions and actual clinical practice in pain, agitation-sedation and delirium assessments. Our results will prompt further quality improvement projects to optimize the practice of pain, agitation-sedation and delirium management in China. TRIAL REGISTRATION ClinicalTrials.gov, identifier NCT03975751 . Retrospectively registered on 2 June 2019.
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Affiliation(s)
- Kai Chen
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Yan-Lin Yang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Hong-Liang Li
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Dan Xiao
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Yang Wang
- Medical Research & Biometrics Center, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Linlin Zhang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Jian-Xin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, China.
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Brain Tissue Oxygen Response as Indicator for Cerebral Lactate Levels in Aneurysmal Subarachnoid Hemorrhage Patients. J Neurosurg Anesthesiol 2020; 34:193-200. [PMID: 32701532 DOI: 10.1097/ana.0000000000000713] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 06/05/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Early detection of cerebral ischemia and metabolic crisis is crucial in critically ill subarachnoid hemorrhage (SAH) patients. Variable increases in brain tissue oxygen tension (PbtO2) are observed when the fraction of inspired oxygen (FiO2) is increased to 1.0. The aim of this prospective study was to evaluate whether a 3-minute hyperoxic challenge can identify patients at risk for cerebral ischemia detected by cerebral microdialysis. METHODS Twenty consecutive severe SAH patients undergoing continuous cerebral PbtO2 and microdialysis monitoring were included. FiO2 was increased to 1.0 for 3 minutes (the FiO2 challenge) twice a day and PbtO2 responses during the FiO2 challenges were related to cerebral microdialysis-measures, ie, lactate, the lactate-pyruvate ratio, and glycerol. Multivariable linear and logistic regression models were created for each outcome parameter. RESULTS After predefined exclusions, 274 of 400 FiO2 challenges were included in the analysis. Lower absolute increases in PbtO2 ([INCREMENT]PbtO2) during FiO2 challenges were significantly associated with higher cerebral lactate concentration (P<0.001), and patients were at higher risk for ischemic lactate levels >4 mmol/L (odds ratio 0.947; P=0.04). Median (interquartile range) [INCREMENT]PbtO2 was 7.1 (4.6 to 12.17) mm Hg when cerebral lactate was >4 mmol/L and 10.2 (15.76 to 14.24) mm Hg at normal lactate values (≤4 mmol/L). Median [INCREMENT]PbtO2 was significantly lower during hypoxic than during hyperglycolytic lactate elevations (4.6 vs. 10.6 mm Hg, respectively; P<0.001). Lactate-pyruvate ratio and glycerol levels were mainly determined by baseline characteristics. CONCLUSIONS A 3-minute FiO2 challenge is an easy to perform and feasible bedside diagnostic tool in SAH patients. The absolute increase in PbtO2 during the FiO2 challenge might be a useful surrogate marker to estimate cerebral lactate concentrations and might be used to identify patients at risk for impending ischemia.
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Abstract
Background Currently, continuous electroencephalographic monitoring (cEEG) is the only available diagnostic tool for continuous monitoring of brain function in intensive care unit (ICU) patients. Yet, the exact relevance of routinely applied ICU cEEG remains unclear, and information on the implementation of cEEG, especially in Europe, is scarce. This study explores current practices of cEEG in adult Dutch ICU departments focusing on organizational and operational factors, development over time and factors perceived relevant for abstaining its use. Methods A national survey on cEEG in adults among the neurology and adult intensive care departments of all Dutch hospitals (n = 82) was performed. Results The overall institutional response rate was 78%. ICU cEEG is increasingly used in the Netherlands (in 37% of all hospitals in 2016 versus in 21% in 2008). Currently in 88% of university, 55% of teaching and 14% of general hospitals use ICU cEEG. Reasons for not performing cEEG are diverse, including perceived non-feasibility and lack of data on the effect of cEEG use on patient outcome. Mostly, ICU cEEG is used for non-convulsive seizures or status epilepticus and prognostication. However, cEEG is never or rarely used for monitoring cerebral ischemia and raised intracranial pressure in traumatic brain injury. Review and reporting practices differ considerably between hospitals. Nearly all hospitals perform non-continuous review of cEEG traces. Methods for moving toward continuous review of cEEG traces are available but infrequently used in practice. Conclusions cEEG is increasingly used in Dutch ICUs. However, cEEG practices vastly differ between hospitals. Future research should focus on uniform cEEG practices including unambiguous EEG interpretation to facilitate collaborative research on cEEG, aiming to provide improved standard patient care and robust data on the impact of cEEG use on patient outcome.
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Abstract
Neurological diseases frequently demanding admittance to a dedicated neurological intensive care unit (neurocritical care) comprise space-occupying ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, traumatic brain injury, status epilepticus, bacterial meningitis, myasthenic crisis and Guillain-Barré syndrome. Due to often necessary analgesia, sedation and mechanical ventilation, neuromonitoring should ideally be employed. This consists of bedside invasive and non-invasive methods for monitoring cerebral perfusion, oxygenation, metabolism and neurophysiology. Modern treatment principles in neurocritical care mainly aim at avoiding or attenuating secondary neurological brain damage, in particular directed at sufficient perfusion and oxygenation. These include measures such as neuroprotective ventilation, stabilization of the circulation, decreasing intracranial pressure in brain edema and space-occupying processes, anticonvulsive treatment, temperature management and targeted disease-specific treatment.
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Affiliation(s)
- Julian Bösel
- Klinik für Neurologie, Klinikum Kassel, Mönchebergstr. 41-43, 34125, Kassel, Deutschland.
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Herzer G, Mirth C, Illievich UM, Voelckel WG, Trimmel H. Analgosedation of adult patients with elevated intracranial pressure : Survey of current clinical practice in Austria. Wien Klin Wochenschr 2017; 130:45-53. [PMID: 28733841 DOI: 10.1007/s00508-017-1228-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 06/22/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Analgesia and sedation are key items in intensive care. Recently published S3 guidelines specifically address treatment of patients with elevated intracranial pressure. METHODS The Austrian Society of Anesthesiology, Resuscitation and Intensive Care Medicine carried out an online survey of neurointensive care units in Austria in order to evaluate the current state of practice in the areas of analgosedation and delirium management in this high-risk patient group. RESULTS The response rate was 88%. Induction of anesthesia in patients with elevated intracranial pressure is carried out with propofol/fentanyl/rocuronium in >80% of the intensive care units (ICU), 60% use midazolam, 33.3% use esketamine, 13.3% use barbiturates and 6.7% use etomidate. For maintenance of analgosedation up to 72 h, propofol is used by 80% of the ICUs, followed by remifentanil (46.7%), sufentanil (40%) and fentanyl (6.7%). For long-term sedation, 86.7% of ICUs use midazolam, 73.3% sufentanil and 73.3% esketamine. For sedation periods longer than 7 days, 21.4% of ICUs use propofol. Reasons for discontinuing propofol are signs of rhabdomyolysis (92.9%), green urine, elevated liver enzymes (71.4% each) and elevated triglycerides (57.1%). Muscle relaxants are only used during invasive procedures. Inducing a barbiturate coma is rated as a last resort by 53.3% of respondents. The monitoring methods used are bispectral index (BIS™, 61.5% of ICUs), somatosensory-evoked potentials (SSEP, 53.8%), processed electroencephalography (EEG, 38.5%), intraparenchymal partial pressure of oxygen (pO2, 38.5%) and microdialysis (23.1%). Sedation and analgesia are scored using the Richmond agitation and sedation score (RASS, 86.7%), sedation agitation scale (SAS, 6.7%) or numeric rating scale (NRS, 50%) and behavioral pain scale (BPS, 42.9%), visual analogue scale (VAS), critical care pain observation tool (CCPOT, each 14.3%) and verbal rating scale (VRS, 7.1%). Delirium monitoring is done using the confusion assessment method for intensive care units (CAM-ICU, 46.2%) and intensive care delirium screening checklist (ICDSC, 7.7%). Of the ICUs 46.2% do not carry out delirium monitoring. CONCLUSION We found good general compliance with the recommendations of the current S3 guidelines. Room for improvement exists in monitoring and the use of scores to detect delirium.
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Affiliation(s)
- Guenther Herzer
- Department of Anesthesia, Emergency Medicine and Intensive Care; Karl Landsteiner Institute for Emergency Medicine, Medical Simulation and Patient Safety, General Hospital Wiener Neustadt, Corvinusring 3-5, 2700, Wiener Neustadt, Austria
| | - Claudia Mirth
- Clinical Department of Anesthesia and Intensive Care, University Hospital, St. Pölten, Austria
| | - Udo M Illievich
- Department of Neuroanesthesia and Intensive Care, Kepler University Hospital, Linz, Austria
| | - Wolfgang G Voelckel
- Department of Anesthesia and Intensive Care, AUVA Trauma Hospital, Salzburg, Austria
| | - Helmut Trimmel
- Department of Anesthesia, Emergency Medicine and Intensive Care; Karl Landsteiner Institute for Emergency Medicine, Medical Simulation and Patient Safety, General Hospital Wiener Neustadt, Corvinusring 3-5, 2700, Wiener Neustadt, Austria.
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11
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Abstract
In Germany dedicated neurological-neurosurgical critical care (NCC) is the fastest growing specialty and one of the five big disciplines integrated within the German critical care society (Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin; DIVI). High-quality investigations based on resilient evidence have underlined the need for technical advances, timely optimization of therapeutic procedures, and multidisciplinary team-work to treat those critically ill patients. This evolution has repeatedly raised questions, whether NCC-units should be run independently or better be incorporated within multidisciplinary critical care units, whether treatment variations exist that impact clinical outcome, and whether nowadays NCC-units can operate cost-efficiently? Stroke is the most frequent disease entity treated on NCC-units, one of the most common causes of death in Germany leading to a great socio-economic burden due to long-term disabled patients. The main aim of NCC employs surveillance of structural and functional integrity of the central nervous system as well as the avoidance of secondary brain damage. However, clinical evaluation of these severely injured commonly sedated and mechanically ventilated patients is challenging and highlights the importance of neuromonitoring to detect secondary damaging mechanisms. This multimodal strategy not only requires medical expertise but also enforces the need for specialized teams consisting of qualified nurses, technical assistants and medical therapists. The present article reviews most recent data and tries to answer the aforementioned questions.
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12
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The Monitoring and Management of Severe Traumatic Brain Injury in the United Kingdom: Is there a Consensus?: A National Survey. J Neurosurg Anesthesiol 2016; 27:241-5. [PMID: 25493928 DOI: 10.1097/ana.0000000000000143] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND To survey the current practice of monitoring and management of severe traumatic brain injury (TBI) patients in the critical care units across the United Kingdom. METHODS A structured telephone interview was conducted with senior medical or nursing staff of all the adult neurocritical care units. Thirty-one neurocritical care units that managed adult patients with severe TBI were identified from the Risk Adjustment in Neurocritical Care (RAIN) study and the Society of British Neurological Surgeons. RESULTS Intracranial pressure (ICP) monitoring was used in all the 31 institutions. Cerebral perfusion pressure was used in 30 of the 31 units and a Cerebral perfusion pressure target of 60 to 70 mm Hg was the most widely used target (25 of 31 units). Transcranial Doppler was used in 12 units (39%); brain tissue oxygen (PbtO(2)) was used in 8 (26%); cerebral microdialysis was used in 4 (13%); jugular bulb oximetry in 1 unit; and near-infrared spectrometry was not used in any unit. Continuous capnometry was used in 28 (91%) units for mechanically ventilated patients. Mannitol was the most commonly used agent for osmotherapy to treat intracranial hypertension. CONCLUSIONS We identified that there was no clear consensus and considerable variation in practice in the management of TBI patients in UK neurocritical care units. A protocol-based management has been shown to improve outcome in sepsis patients. Given the magnitude of the problem, we conclude that there is an urgent need for international consensus guidelines for management of TBI patients in critical care units.
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Neugebauer H, Wiedmann S, Jüttler E. [Survey regarding the treatment of malignant middle cerebral artery infarction in German hospitals]. DER NERVENARZT 2016; 87:426-32. [PMID: 26818024 DOI: 10.1007/s00115-016-0073-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND There are a variety of intensive care therapies in the treatment of malignant middle cerebral artery infarction (MMI) besides hemicraniectomy (HC), the only treatment with proven efficacy. It is, however, not known how HC and conservative treatments are utilized in German hospitals, Furthermore, data on the care-situation of patients with MMI in Germany is scarce. METHODS An anonymous questionnaire was sent to 297 neurological and 133 neurosurgical hospitals in Germany. RESULTS The Response rate was 24,7%. Most respondents indicated personal experience in the treatment of MMI (83,3%). HC is usually performed early on site (83,3%). Indication to HC is confirmed on a high level of hierarchy and profession using clinical and radiological criteria in 78,2% of hospitals. Inherent standardized treatment protocols are established in 70,8% of hospitals. Patients are treated on an intensive care unit in 74,5% of hospitals after DHC and in 42,5% of hospitals under non-surgical treatment. Intracranial pressure monitoring is not performed on a regular basis. Differing opinions were observed concerning diagnosis and treatment of MMI without recognizable consensus. CONCLUSION Basically, structural requirements for the treatment of MMI exist in the participating hospitals. Heterogeneity in the treatment of MMI is striking. The implementation of treatment protocols and adherence to guidelines are desirable steps to optimize treatment.
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Affiliation(s)
- H Neugebauer
- Klinik für Neurologie, Universitätsklinikum Ulm, Oberer Eselsberg 45, 89081, Ulm, Deutschland.
| | - S Wiedmann
- Institut für klinische Epidemiologie und Biometrie, Universitätsklinik Würzburg, Deutsches Zentrum für Herzinsuffizienz, Josef-Schneider-Str. 2/Haus D7, 97080, Würzburg, Deutschland
| | - E Jüttler
- Neurologische Klinik, Ostalb-Klinikum Aalen, Im Kälblesrain 1, 73043, Aalen, Deutschland
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14
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Abstract
Purpose. To characterize indications, treatment, and length of stay in a stand-alone neurological intensive care unit with focus on comparison between ventilated and nonventilated patient. Methods. We performed a single-center retrospective cohort study of all treated patients in our neurological intensive care unit between October 2006 and December 2008. Results. Overall, 512 patients were treated in the surveyed period, of which 493 could be included in the analysis. Of these, 40.8% had invasive mechanical ventilation and 59.2% had not. Indications in both groups were predominantly cerebrovascular diseases. Length of stay was 16.5 days in mean for ventilated and 3.6 days for nonventilated patient. Conclusion. Most patients, ventilated or not, suffer from vascular diseases with further impairment of other organ systems or systemic complications. Data reflects close relationship and overlap of treatment on nICU with a standardized stroke unit treatment and suggests, regarding increasing therapeutic options, the high impact of acute high-level treatment to reduce consequential complications.
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15
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Abstract
PURPOSE OF REVIEW In recent years, we have begun to better understand how to monitor the injured brain, look for less common complications and importantly, reduce unnecessary and potentially harmful intervention. However, the lack of consensus regarding triggers for intervention, best neuromonitoring techniques and standardization of therapeutic approach is in need of more careful study. This review covers the most recent evidence within this exciting and dynamic field. RECENT FINDINGS The role of intracranial pressure monitoring has been challenged; however, it still remains a cornerstone in the management of the severely brain-injured patient and should be used to compliment other techniques, such as clinical examination and serial imaging.The use of multimodal monitoring continues to be refined and it may be possible to use them to guide novel brain resuscitation techniques, such as the use of exogenous lactate supplementation in the future. SUMMARY Neurocritical care management of traumatic brain injury continues to evolve. However, it is important not to use a 'one-treatment-fits-all' approach, and perhaps look to use targeted therapies to individualize treatment.
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Bösel J, Möhlenbruch M, Sakowitz OW. [News and perspectives in neurocritical care]. DER NERVENARZT 2015; 85:928-38. [PMID: 25096787 DOI: 10.1007/s00115-014-4040-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Neurocritical care is an ever-evolving discipline and its implementation in intensive care leads to reduction in mortality and to improvement of functional outcome in patients with devastating injuries to the nervous system. However, the decisive elements of the complete field of neurocritical care remain relatively unclear, as well as the exact ways to optimize them. During recent years new insights have been gained and new exciting studies have been initiated from which results are soon to be expected. This review focuses on the following management aspects: neuromonitoring, airway and ventilation, endovascular therapy, cerebrospinal fluid drainage, decompressive craniectomy, hematoma evacuation, blood pressure, and targeted temperature management. The application of these measures to brain diseases and injuries frequently treated in neurointensive care units will be addressed in the context of current studies.
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Affiliation(s)
- J Bösel
- Neurologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland,
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Huttner HB, Schwab S. Neurocritical care in Germany: need for guidance. Neurocrit Care 2014; 20:173-5. [PMID: 24566981 DOI: 10.1007/s12028-014-9963-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Hagen B Huttner
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany,
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