Predictors of tracheostomy in patients with spontaneous intracerebral hemorrhage

Predictors of extubation failure and prolonged mechanical ventilation among patients with intracerebral hemorrhage after surgery

BACKGROUND

Spontaneous intracerebral hemorrhage (ICH) is a condition associated with high mortality and morbidity. Survivors may require prolonged intubation with mechanical ventilation (MV). The aim of this study was to analyze the predictors of extubation failure and prolonged MV in patients who undergo surgical evacuation.

METHODS

This retrospective study was conducted on adult patients with ICH who underwent MV for at least 48 h and survived > 14 days after surgery. The demographics, clinical characteristics, laboratory tests, and Glasgow Coma Scale score were analyzed.

RESULTS

A total of 134 patients with ICH were included in the study. The average age of the patients was 60.34 ± 15.59 years, and 79.9% (n = 107) were extubated after satisfying the weaning parameters. Extubation failure occurred in 11.2% (n = 12) and prolonged MV in 48.5% (n = 65) patients. Multivariable regression analysis revealed that a white blood cell count > 10,000/mm3 at the time of extubation was an independent predictor of reintubation. Meanwhile, age and initial Glasgow Coma Scale scores were predictors of prolonged MV.

CONCLUSIONS

This study provided the first comprehensive characterization and analysis of the predictors of extubation failure and prolonged MV in patients with ICH after surgery. Knowledge of potential predictors is essential to improve the strategies for early initiation of adequate treatment and prognosis assessment in the early stages of the disease.

Associative factors for tracheostomy in patients presenting with stridor or upper airway obstruction

OBJECTIVE

This study aimed to identify associative factors for tracheostomy in patients presenting with airway obstruction.

METHODS

Data from a tertiary hospital were reviewed to identify patients who presented with airway obstruction between 2009 and 2020. Patient demographics, causative pathology and treatments were analysed.

RESULTS

The study identified 297 admitted patients. Of these, 66 underwent a tracheostomy and formed the 'tracheostomy' group and 231 formed the 'other intervention' group. The tracheostomy group had a higher mean age (p = 0.003), and higher percentages of males (p = 0.031) and smokers or ex-smokers (p = 0.020), compared to the other intervention group. The tracheostomy group also had a higher number of patients with a malignancy (p < 0.001) compared to the other intervention group.

CONCLUSION

Being older, male, a previous or current smoker, or developing airway obstruction due to a malignancy were found to be the main associative factors for requiring a tracheostomy.

Pulmonary complications and respiratory management in neurocritical care: a narrative review

ABSTRACT

Neurocritical care (NCC) is not only generally guided by principles of general intensive care, but also directed by specific goals and methods. This review summarizes the common pulmonary diseases and pathophysiology affecting NCC patients and the progress made in strategies of respiratory support in NCC. This review highlights the possible interactions and pathways that have been revealed between neurological injuries and respiratory diseases, including the catecholamine pathway, systemic inflammatory reactions, adrenergic hypersensitivity, and dopaminergic signaling. Pulmonary complications of neurocritical patients include pneumonia, neurological pulmonary edema, and respiratory distress. Specific aspects of respiratory management include prioritizing the protection of the brain, and the goal of respiratory management is to avoid inappropriate blood gas composition levels and intracranial hypertension. Compared with the traditional mode of protective mechanical ventilation with low tidal volume (Vt), high positive end-expiratory pressure (PEEP), and recruitment maneuvers, low PEEP might yield a potential benefit in closing and protecting the lung tissue. Multimodal neuromonitoring can ensure the safety of respiratory maneuvers in clinical and scientific practice. Future studies are required to develop guidelines for respiratory management in NCC.

Comparing the inter-observer reliability of the Tada formula among neurosurgeons while estimating the intracerebral haematoma volume

OBJECTIVE

To compare the inter-observer reliability among neurosurgeons while estimating the intracerebral haematoma (ICH) volume by the Tada formula and assess its influence on predicting the severity and prognosis of various ICHs.

METHODS

We obtained clinical data from 262 consecutive patients with spontaneous ICH. The haematoma volume was independently calculated and compared by 3D Slicer and eight neurosurgeons. The inter-observer reliability was obtained by calculating the intraclass correlation coefficients (ICC) and Cohen's kappa score (kappa), within different shape and volume ICH subgroups. We conducted the receiver operating characteristic analysis to assess the predictive value of the ICH volume evaluated for clinical features, including the Glasgow Coma Scale at the onset of the disease, ICH-related surgical treatments, the length of stay in the intensive care unit, the length of hospitalisation, the modified Rankin Scale score at discharge, and in-hospital deaths.

RESULTS

The median haematoma volume was 17.4 ml (range, 7.3-34.7 ml). The estimated volumes were significantly different among neurosurgeons (p < 0.001). Six out of eight neurosurgeons demonstrated obvious deviations from the 3D Slicer software (p < 0.001). Round (ICC: 0.947) and tapered (ICC: 0.954) haematomas were more consistently evaluated between the neurosurgeons. We observed a substantial strength of agreement between neurosurgeons with kappa> 0.693 and ICC: 0.938 in the entire volume range, and slight to fair strength of agreement with kappa> 0.175 and ICC: 0.689 between 20 ml and 40 ml volume interval. All estimated volumes had a positive predictive value for clinical features, with the area under the curve > 0.5 (p < 0.05). However, the 3D Slicer software performed relatively better than most neurosurgeons.

CONCLUSIONS

There exists a significant inter-observer variability among neurosurgeons when utilizing the Tada formula, thus demonstrating significant implications for ICH-related clinical practices and researches.

The risk factors for the postoperative pulmonary infection in patients with hypertensive cerebral hemorrhage: A retrospective analysis

ABSTRACT

The risk factors for the pulmonary infections after hypertensive cerebral hemorrhage remains unclear. We aimed to investigate the potential risk factors for the postoperative pulmonary infection in patients with hypertensive cerebral hemorrhage.Patients with hypertensive cerebral hemorrhage undergone surgery from January 2018 to December 2019 were included. Related personal and medical information were collected. Univariate and multivariate logistic regression analyses were performed to identify the potential risk factors for the postoperative pulmonary infection.A total of 264 patients were included, and the incidence of pulmonary infection for patients with hypertensive cerebral hemorrhage after surgery was 19.70%. Escherichia coli is the most common bacteria of pulmonary infection. Multivariate regression analysis revealed that the preoperative hypoalbuminemia (OR2.89, 1.67∼4.78), tracheotomy (OR5.31, 1.24∼11.79), diabetes (OR4.92, 1.32∼9.80), preoperative GCS (OR5.66, 2.84∼11.21), and the duration of mechanical ventilation (OR2.78, 2.32∼3.61) were the independent risk factors for the pulmonary infection in patients with hypertensive cerebral hemorrhage (all P < .05).Patients with hypertensive intracerebral hemorrhage after surgery have a higher risk of postoperative pulmonary infections, and there are many related risk factors, which should be taken seriously in clinical practice.

Timing and Outcomes of Tracheostomy in Patients with Hemorrhagic Stroke

OBJECTIVE

In the present study, we sought to evaluate the timing and outcomes in patients with hemorrhagic stroke who received tracheostomy.

METHODS

A retrospective database search was undertaken to identify patients with hemorrhagic stroke between January 2010 and December 2018. Clinical data on basic demographics, clinical features, and outcomes were extracted. The primary outcome was in-hospital mortality and secondary outcomes were hospital stays and hospital costs. Univariate and multivariate analyses were used to compare the characteristics and outcomes between patients with hemorrhagic stroke who underwent tracheostomy early (days 1-6) and late (days 7 or later).

RESULTS

A total of 425 patients were identified, 74.4% (n = 316) received an early tracheostomy during the hospitalization. Patients with hemorrhagic stroke who received early tracheostomy had a higher rate of neurosurgical operation (odds ratio, 2.77; 95% confidence interval, 1.54-4.99; P = 0.001) and different types of hemorrhagic stroke (P = 0.001) in comparison with the late tracheostomy patients. In addition, early tracheostomy was associated with shorter hospital stays (odds ratio, 1.02; 95% confidence interval, 1.01-1.03; P = 0.003) and reduced hospital costs (P < 0.001) than with late tracheostomy. However, no significant difference was observed with regard to in-hospital mortality between early and late tracheostomy groups (P = 0.744).

CONCLUSIONS

In our cohort, early tracheostomy in patients with hemorrhagic stroke may help reduce hospital stays and hospital costs, but not in-hospital mortality. Future prospective multicenter studies are warranted to validate these findings.

Earlier tracheostomy and percutaneous endoscopic gastrostomy in patients with hemorrhagic stroke: associated factors and effects on hospitalization

OBJECTIVE

Existing literature supports benefits of early tracheostomy and percutaneous endoscopic gastrostomy (PEG) in certain patient populations. The aim of this study was to review tracheostomy and PEG placement data in patients with hemorrhagic stroke in order to identify factors associated with earlier placement and to evaluate outcomes.

METHODS

The authors performed a retrospective review of consecutive patients treated for hemorrhagic stroke between June 1, 2011, and June 1, 2015. Data were analyzed by logistic and multiple linear regression.

RESULTS

Of 240 patients diagnosed with hemorrhagic stroke, 31.25% underwent tracheostomy and 35.83% underwent PEG tube placement. Factors significantly associated with tracheostomy and PEG included the presence of pneumonia on admission and subarachnoid hemorrhage. Earlier tracheostomy was significantly associated with shorter ICU length of stay; earlier tracheostomy and PEG placement were associated with shorter overall hospitalization. Timing of tracheostomy and PEG was not significantly associated with patient survival or the incidence of complications in this population.

CONCLUSIONS

This study identified patient risk factors associated with increased likelihood of tracheostomy and PEG in patients with hemorrhagic stroke who were critically ill. Additionally, we found that the timing of tracheostomy was associated with length of ICU stay and overall hospital stay, and that the timing of PEG was associated with overall length of hospitalization. Complication rates related to tracheostomy and PEG in this population were minimal. This retrospective data set supports some benefit to earlier tracheostomy and PEG placement in this population and justifies the need for further prospective study.

Update on the Treatment of Spontaneous Intraparenchymal Hemorrhage: Medical and Interventional Management

PURPOSE OF REVIEW

Spontaneous intraparenchymal hemorrhage (IPH) is a prominent challenge faced globally by neurosurgeons, neurologists, and intensivists. Over the past few decades, basic and clinical research efforts have been undertaken with the goal of delineating biologically and evidence-based practices aimed at decreasing mortality and optimizing the likelihood of meaningful functional outcome for patients afflicted with this devastating condition. Here, the authors review the medical and surgical approaches available for the treatment of spontaneous intraparenchymal hemorrhage, identifying areas of recent progress and ongoing research to delineate the scope and scale of IPH as it is currently understood and treated.

RECENT FINDINGS

The approaches to IPH have broadly focused on arresting expansion of hemorrhage using a number of approaches. Recent trials have addressed the effectiveness of rapid blood pressure lowering in hypertensive patients with IPH, with rapid lowering demonstrated to be safe and at least partially effective in preventing hematoma expansion. Hemostatic therapy with platelet transfusion in patients on anti-platelet medications has been recently demonstrated to have no benefit and may be harmful. Hemostasis with administration of clotting complexes has not been shown to be effective in reducing hematoma expansion or improving outcomes although correcting these abnormalities as soon as possible remains good practice until further data are available. Stereotactically guided drainage of IPH with intraventricular hemorrhage (IVH) has been shown to be safe and to improve outcomes. Research on new stereotactic surgical methods has begun to show promise. Patients with IPH should have rapid and accurate diagnosis with neuroimaging with computed tomography (CT) and computed tomography angiography (CTA). Early interventions should include control of hypertension to a systolic BP in the range of 140 mmHg for small hemorrhages without intracranial hypertension with beta blockers or calcium channel blockers, correction of any coagulopathy if present, and assessment of the need for surgical intervention. IPH and FUNC (Functional Outcome in Patients with Primary Intracerebral Hemorrhage) scores should be assessed. Patients should be dispositioned to a dedicated neurologic ICU if available. Patients should be monitored for seizures and intracranial pressure issues. Select patients, particularly those with intraventricular extension, may benefit from evacuation of hematoma with a ventriculostomy or stereotactically guided catheter. Once stabilized, patients should be reassessed with CT imaging and receive ongoing management of blood pressure, cerebral edema, ICP issues, and seizures as they arise. The goal of care for most patients is to regain capacity to receive multidisciplinary rehabilitation to optimize functional outcome.

Patient characteristics, incidence, technique, outcomes and early prediction of tracheostomy in the state of Victoria, Australia

BACKGROUND

Tracheostomy is a relatively common procedure in Intensive Care Unit (ICU) patients.

AIMS

To study the patient characteristics, incidence, technique, outcomes and prediction of tracheostomy in the State of Victoria, Australia.

METHODS

We used data from the Australian and New Zealand Intensive Care Society Adult Patient Database (ANZICS APD) and the Victorian Admitted Episode Dataset (VAED) to identify and match patients who had received a tracheostomy from 2004 to 2014.

RESULTS

Between 1st January 2004 and 30th June 2014, 9750 patients received a tracheostomy with 7670 available for matching and 6010 (78.4%) successfully matched. Of the matched tracheostomy patients, median age was 61years, median APACHE IIIJ score was 66 and overall hospital mortality was 21%. The incidence of tracheostomy almost halved over the decade with more than half of tracheostomies (53.5%) being percutaneous. Hospital mortality of patients receiving a tracheostomy decreased from 26.5% in 2004 to 16.5% in 2014 by an average decrease of 6%/year. No robust model could be developed to predict tracheostomy.

CONCLUSION

The incidence of tracheostomy and the adjusted mortality rate of patients who received a tracheostomy have significantly decreased over a decade. Day of admission information could not be used to predict subsequent tracheostomy.

Abnormal Breathing Patterns Predict Extubation Failure in Neurocritically Ill Patients

In neurologically injured patients, predictors for extubation success are not well defined. Abnormal breathing patterns may result from the underlying neurological injury. We present three patients with abnormal breathing patterns highlighting failure of successful extubation as a result of these neurologically driven breathing patterns. Recognizing abnormal breathing patterns may be predictive of extubation failure and thus need to be considered as part of extubation readiness.

How should this patient with repeated aspiration pneumonia be managed and treated?-a proposal of the Percutaneous ENdoscopIc Gastrostomy and Tracheostomy (PENlIGhT) procedure

Cerebrovascular accident (CVA) is commonly seen among the elderly with a substantial proportion of patients suffering from long-term dysphagia and/or an inability to protect their airway. This potentially imposes on them an increased risk of malnutrition and aspiration pneumonia. In this article, we present a patient with malnutrition and dysphagia secondary to CVA. We propose a procedure for which we will name the Percutaneous ENdoscopIc Gastrostomy and Tracheostomy (PENlIGhT) procedure for placement of percutaneous endoscopic gastrostomy (PEG) and tracheostomy tube (TT) at the same time. The medical literature was systematically reviewed for both PEG and tracheostomy, aiming to provide the state-of-the-art evidence for clinical use of the PENlIGhT procedure. In clinical practice, the PENlIGhT procedure is indicated for patients who are expected to have prolonged swallowing disturbance and mechanical ventilation. Some prediction tools and scores can be helpful to identify such groups of patients. Patients with poor neurological outcomes who require prolonged maintenance of life are also good candidates for the PENlIGhT procedure.

How Is Pneumonia Diagnosed in Clinical Stroke Research?

Background and Purpose—

Diagnosis of pneumonia complicating stroke is challenging, and there are currently no consensus diagnostic criteria. As a first step in developing such consensus-based diagnostic criteria, we undertook a systematic review to identify the existing diagnostic approaches to pneumonia in recent clinical stroke research to establish the variation in diagnosis and terminology.

Methods—

Studies of ischemic stroke, intracerebral hemorrhage, or both, which reported occurrence of pneumonia from January 2009 to March 2014, were considered and independently screened for inclusion by 2 reviewers after multiple searches using electronic databases. The primary analysis was to identify existing diagnostic approaches for pneumonia. Secondary analyses explored potential reasons for any heterogeneity where standard criteria for pneumonia had been applied.

Results—

Sixty-four studies (56% ischemic stroke, 6% intracerebral hemorrhage, 38% both) of 639 953 patients were included. Six studies (9%) reported no information on the diagnostic approach, whereas 12 (19%) used unspecified clinician-reported diagnosis or initiation of antibiotics. The majority used objective diagnostic criteria: 20 studies (31%) used respiratory or other published standard criteria; 26 studies (41%) used previously unpublished ad hoc criteria. The overall occurrence of pneumonia was 14.3% (95% confidence interval 13.2%–15.4%; I 2 =98.9%). Occurrence was highest in studies applying standard criteria (19.1%; 95% confidence interval 15.1%–23.4%; I 2 =98.5%). The substantial heterogeneity observed was not explained by stratifying for other potential confounders.

Conclusions—

We found considerable variation in terminology and the diagnostic approach to pneumonia. Our review supports the need for consensus development of operational diagnostic criteria for pneumonia complicating stroke.

Medical acute complications of intracerebral hemorrhage in young adults

Background. Frequency and impact of medical complications on short-term mortality in young patients with intracerebral hemorrhage (ICH) have gone unstudied. Methods. We reviewed data of all first-ever nontraumatic ICH patients between 16 and 49 years of age treated in our hospital between January 2000 and March 2010 to identify medical complications suffered. Logistic regression adjusted for known ICH prognosticators was used to identify medical complications associated with mortality. Results. Among the 325 eligible patients (59% males, median age 42 [interquartile range 34–47] years), infections were discovered in 90 (28%), venous thrombotic events in 13 (4%), cardiac complications in 4 (1%), renal failure in 59 (18%), hypoglycemia in 15 (5%), hyperglycemia in 165 (51%), hyponatremia in 146 (45%), hypernatremia in 91 (28%), hypopotassemia in 104 (32%), and hyperpotassemia in 27 (8%). Adjusted for known ICH prognosticators and diabetes, the only independent complication associated with 3-month mortality was hyperglycemia (plasma glucose >8.0 mmol/L) (odds ratio: 5.90, 95% confidence interval: 2.25–15.48, P < 0.001). Three or more separate complications suffered also associated with increased mortality (7.76, 1.42–42.49, P = 0.018). Conclusions. Hyperglycemia is a frequent complication of ICH in young adults and is independently associated with increased mortality. However, multiple separate complications increase mortality even further.

Critical care management of intracerebral hemorrhage

Primary, spontaneous intracerebral hemorrhage (ICH) confers significant early mortality and long-term morbidity worldwide. Advances in acute care including investigative, diagnostic, and management strategies are important to improving outcomes for patients with ICH. Physicians caring for patients with ICH should anticipate the need for emergent blood pressure reduction, coagulopathy reversal, cerebral edema management, and surgical interventions including ventriculostomy and hematoma evacuation. This article reviews the pathogenesis and diagnosis of ICH, and details the acute management of spontaneous ICH in the critical care setting according to existing evidence and published guidelines.