Risk factors for ventilator-associated pneumonia in patients with severe traumatic brain injury in a Serbian trauma centre

Risk factors and outcomes of ventilator-associated pneumonia in patients with traumatic brain injury: A systematic review and meta-analysis

BACKGROUND

Ventilator-associated pneumonia (VAP) is a common complication in traumatic brain injury (TBI) patients, which increases morbidity and negatively affects outcomes. Risk factors and outcomes in these patients remain controversial. The aim of the present study is to explore the risk factors and clinical outcomes of patients with VAP and TBI.

METHODS

Two researchers conducted independent systematic literature searches of Pubmed, Cochrane Database, Scopus, Medline Ovid, Science Direct databases, published from inception to January 2024. The Newcastle-Ottawa scale was used to assess study quality. A meta-analysis was performed using a random-effects model when heterogeneity I2 > 50 % and a fixed-effects model when I2 < 50 %; in addition, a subgroup analysis was performed to explore VAP risk factors, and publication bias was assessed with the funnel plot and Begg's and Egger's tests. All results were considered statistically significant when p < 0.05. The certainty of the evidence was evaluated using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) methodology.

RESULTS

Twelve studies were included in the meta-analysis with a total of 2883 patients. Male gender [OR 1.58 (95 % CI 1.23, 2.02) p < 0.05 I2 0 %] and abbreviated injury scale (head: H-AIS) [≥ 3 OR 2.79 (95 % CI 1.58, 4.93) p < 0.05 I2 0 %] increased the risk of VAP. After subgroup analysis, blood transfusion on admission [OR 1.97 (95 % CI 1.16-3.35) p ≤0.05 I2 5 %] and barbiturate infusion [OR 3.55 (95 % CI 2.01-6.30) p ≤0.05 I2 0 %] became risk factors. Prophylactic antibiotic use [OR 0.67 (95 % CI 0.51-0.88) p ≤0.05 I2 0 %] and younger age MD -3.29 (95 % CI -5.18, -1.40) p ≤0.05 I2 41 %] emerged as significant protective factors. In VAP patients ICU stay [MD 7.02 (95 % CI 6.05-7.99) p ≤0.05 I2 37 %], duration of mechanical ventilation [MD 5.79 (95 % CI 4.40, 7.18) p ≤0.05 I2 79 %] and hospital stay [MD 11.88 (95 % CI 8.71-15.05) p ≤0.05 I2 0 %] were significantly increased. The certainty of the evidence was moderate-high for the outcomes studied.

CONCLUSIONS

Male gender, H-AIS ≥ 3, blood transfusion on admission, and barbiturate infusion were risk factors for VAP. In patients with VAP, ICU stay, duration of mechanical ventilation, hospital stay were significantly increased.

Hospital-acquired infections as a risk factor for post-traumatic epilepsy: A registry-based cohort study

OBJECTIVE

Hospital-acquired infections are a common complication for patients with moderate or severe traumatic brain injury (TBI), contributing to morbidity and mortality. As infection-mediated immune responses can predispose towards epilepsy, we hypothesized that post-injury hospital-acquired infections increase the risk of post-traumatic epilepsy (PTE).

METHODS

A retrospective cohort study of adults with moderate to severe TBI was conducted using data from the Victorian State Trauma Registry in Australia. Infections were identified from the International Statistical Classification of Diseases and Related Health Problems 10th Revision-Australian Modification (ICD-10-AM) codes, and diagnosis of PTE was determined by the Glasgow Outcome Scale - Extended questionnaire regarding epileptic fits at 24 months follow-up.

RESULTS

Of all TBI patients (n = 15 152), 24% had evidence of having had any type of infection, with the most common being pneumonia, urinary tract, and respiratory infections. Of those who responded to the PTE question at 24 months (n = 1361), 11% had developed PTE. Univariable analysis found that the incidence of PTE was higher in patients who had any type of infection compared to patients without an infection (p < 0.001). After adjustment for covariates associated with both development of PTE and risk of infection, multivariable analysis found a solid association between infection and PTE (adjusted RR = 1.59; 95% CI: 1.11-2.28; p = 0.011). Having any type of complicating infection acquired during admission was also associated with poor GOSE outcomes at subsequent follow-ups (adjusted OR = 0.20; 95% CI: 0.11-0.35, p < 0.001).

SIGNIFICANCE

These findings suggest that hospital-acquired infections contribute to PTE development after TBI. Future investigation into infections as a modifiable target to reduce poor outcomes after TBI is warranted.

PLAIN LANGUAGE SUMMARY

Hospital-acquired infections are common in patients with traumatic brain injuries. A database study of adults with moderate or severe brain injuries in Australia examined whether these infections are associated with the development of epilepsy after a brain injury. 24% of patients had infections, with pneumonia and urinary tract infections being the most common. Of those surveyed 2 years after the injury, 11% developed post-traumatic epilepsy. Patients with infections had a significantly higher risk of epilepsy, even when accounting for other known risk factors, and infections were also linked to poor outcomes more broadly. The study suggests that preventing hospital-acquired infections could be a crucial target for improving outcomes after traumatic brain injuries.

Nomogram to predict ventilator-associated pneumonia in large vessel occlusion stroke after endovascular treatment: a retrospective study

Background

Ventilator-Associated Pneumonia (VAP) severely impacts stroke patients' prognosis after endovascular treatment. Hence, this study created a nomogram to predict the occurrence of VAP after endovascular treatment.

Methods

The individuals with acute ischemic stroke and large vessel occlusion (AIS-LVO) who received mechanical ventilation and endovascular therapy between July 2020 and August 2023 were included in this retrospective study. The predictive model and nomogram were generated by performing feature selection optimization using the LASSO regression model and multifactor logistic regression analysis and assessed the evaluation, verification and clinical application.

Results

A total of 184 individuals (average age 61.85 ± 13.25 years, 73.37% male) were enrolled, and the rate of VAP occurrence was found to be 57.07%. Factors such as the Glasgow Coma Scale (GCS) score, duration of stay in the Intensive Care Unit (ICU), dysphagia, Fazekas scale 2 and admission diastolic blood pressure were found to be associated with the occurrence of VAP in the nomogram that demonstrating a strong discriminatory power with AUC of 0.862 (95% CI, 0.810-0.914), and a favorable clinical net benefit.

Conclusion

This nomogram, comprising GCS score, ICU duration, dysphagia, Fazekas scale 2 and admission diastolic blood pressure, can aid clinicians in predicting the identification of high-risk patients for VAP following endovascular treatment in large vessel occlusion stroke.

A Modern Approach to the Treatment of Traumatic Brain Injury

Background: Traumatic brain injury manifests itself in various forms, ranging from mild impairment of consciousness to severe coma and death. Traumatic brain injury remains one of the leading causes of morbidity and mortality. Currently, there is no therapy to reverse the effects associated with traumatic brain injury. New neuroprotective treatments for severe traumatic brain injury have not achieved significant clinical success. Methods: A literature review was performed to summarize the recent interdisciplinary findings on management of traumatic brain injury from both clinical and experimental perspective. Results: In the present review, we discuss the concepts of traditional and new approaches to treatment of traumatic brain injury. The recent development of different drug delivery approaches to the central nervous system is also discussed. Conclusions: The management of traumatic brain injury could be aimed either at the pathological mechanisms initiating the secondary brain injury or alleviating the symptoms accompanying the injury. In many cases, however, the treatment should be complex and include a variety of medical interventions and combination therapy.

Neuroprotection and Beyond: The Central Role of CB1 and CB2 Receptors in Stroke Recovery

The endocannabinoid system, with its intricate presence in numerous cells, tissues, and organs, offers a compelling avenue for therapeutic interventions. Central to this system are the cannabinoid receptors 1 and 2 (CB1R and CB2R), whose ubiquity can introduce complexities in targeted treatments due to their wide-ranging physiological influence. Injuries to the central nervous system (CNS), including strokes and traumatic brain injuries, induce localized pro-inflammatory immune responses, termed neuroinflammation. Research has shown that compensatory immunodepression usually follows, and these mechanisms might influence immunity, potentially affecting infection risks in patients. As traditional preventive treatments like antibiotics face challenges, the exploration of immunomodulatory therapies offers a promising alternative. This review delves into the potential neuroprotective roles of the cannabinoid receptors: CB1R's involvement in mitigating excitotoxicity and CB2R's dual role in promoting cell survival and anti-inflammatory responses. However, the potential of cannabinoids to reduce neuroinflammation must be weighed against the risk of exacerbating immunodepression. Though the endocannabinoid system promises numerous therapeutic benefits, understanding its multifaceted signaling mechanisms and outcomes remains a challenge.

Construction and validation of a predictive model of pneumonia for ICU patients with traumatic brain injury (TBI)

The incidence of pneumonia in ICU patients with TBI is very high, seriously affecting the prognosis. This study aims to construct a predictive model for pneumonia in ICU patients with TBI and provide help for the prevention of TBI-related pneumonia.Clinical data of ICU patients with TBI were collected from the Medical Information Mart for Intensive Care (MIMIC)-IV database and hospital data. Variables were screened by lasso and multivariate logistic regression to construct a predictive nomogram model, verified in internal validation cohort and external validation cohort by receiver operator characteristic (ROC) curve, calibration curve and decision curve analysis (DCA).A total of 1850 ICU patients with TBI were enrolled in the study from the MIMIC-IV database, including 1298 in the training cohort and 552 in internal validation cohort. The external validation cohort included 240 ICU patients with TBI from hospital data. Nine variables were selected from the training cohort by lasso regression and multivariate logistic regression, and a pneumonia prediction nomogram was constructed. This nomogram has a high discrimination in training, internal validation and external validation cohorts (AUC = 0.857, 0.877, 0.836). The calibration curve and DCA showed that this nomogram had a high calibration and better clinical decision-making efficiency.The nomogram showed excellent discrimination and clinical utility to predict pneumonia, and could identify pneumonia high-risk patients early, thus providing personalised treatment strategies for ICU patients with TBI.

Evaluation of the Risk Factors of Nosocomial Pneumonia and the Prevalence of Antibiotic Resistance in Trauma Patients in Need of Immediate Intervention

Background: Pneumonia is the most common nosocomial infection reported worldwide in intensive care units. This study aimed to evaluate the risk factors of nosocomial pneumonia and the frequency of antibiotic resistance in trauma patients who need immediate intervention. Patients and Methods: This prospective cohort study was conducted in Shahid Rajaei Trauma Hospital in Shiraz between 2020 and 2021. All the trauma patients who needed immediate intervention (levels 1 and 2 based on the Canadian Emergency Department Triage and Acuity Scale) and had no symptoms of infection were included. Patients who were discharged or died before 48 hours were excluded. Results: The results demonstrated that major trauma (Injury Severity Score [ISS] ≥16), intubation, and use of invasive mechanical ventilation increase nosocomial pneumonia and death rate. The most common causes of nosocomial infections were Acinetobacter baumannii (23%) and coagulase-negative staphylococcus (18.5%). The highest levels of antibiotic resistance were related to cefoxitin, erythromycin, ciprofloxacin, and trimethoprim-sulfamethoxazole. Conclusions: Major trauma, intubation, and invasive mechanical ventilation were the effective factors in the development of nosocomial pneumonia. Continuous monitoring for mentioned risk factors and strict surveillance of antibiotic prescription can decrease the prevalence of nosocomial infections and subsequent deaths.

Translocation and Dissemination of Gut Bacteria after Severe Traumatic Brain Injury

Enterobacteriaceae are often found in the lungs of patients with severe Traumatic Brain Injury (sTBI). However, it is unknown whether these bacteria come from the gut microbiota. To investigate this hypothesis, the mice model of sTBI was used in this study. After sTBI, Chao1 and Simpson index peaking at 7 d in the lungs (p < 0.05). The relative abundance of Acinetobacter in the lungs increased to 16.26% at 7 d after sTBI. The chao1 index of gut microbiota increased after sTBI and peaked at 7 d (p < 0.05). Three hours after sTBI, the conditional pathogens such as Lachnoclostridium, Acinetobacter, Bacteroides and Streptococcus grew significantly. At 7 d and 14 d, the histology scores in the sTBI group were significantly higher than the control group (p < 0.05). The myeloperoxidase (MPO) activity increased at all-time points after sTBI and peaked at 7 d (p < 0.05). The LBP and sCD14 peaking 7 d after sTBI (p < 0.05). The Zonulin increased significantly at 3 d after sTBI and maintained the high level (p < 0.05). SourceTracker identified that the lung tissue microbiota reflects 49.69% gut source at 7 d after sTBI. In the small intestine, sTBI induced gastrointestinal dysfunction with increased apoptosis and decreasing antimicrobial peptides. There was a negative correlation between gut conditional pathogens and the expression level of antimicrobial peptides in Paneth cells. Our data indicate that gut bacteria translocated to the lungs after sTBI, and Paneth cells may regulate gut microbiota stability and translocation.

Ventilator Associated Pneumonia and Intubation Location in Adults with Traumatic Injuries: Systematic Review and Meta-analysis

BACKGROUND

Ventilator associated pneumonia (VAP) is an important cause of morbidity and mortality among critically ill patients, particularly those who present with traumatic injuries. This review aims to determine whether patients with traumatic injuries who are intubated in the prehospital setting are at higher risk of developing VAP compared to those intubated in the hospital.

METHODS

A systematic review of Medline, Scopus and Cochrane electronic databases was conducted from inception through January 2021. Inclusion criteria were patients with traumatic injuries who were intubated in the prehospital or hospital settings with VAP as an outcome. Using a random effects model, the risk of VAP across study arms was compared by calculating a summary relative risk (RR) with 95% confidence intervals (CI). The results of individual studies were also summarized qualitatively.

RESULTS

The search identified 754 articles of which 6 studies (N = 2990) met inclusion criteria. All studies were good quality based on assessment with the Newcastle Ottawa scale. Prehospital intubation demonstrated an increased risk of VAP development in 2 of the 6 studies. Among the 6 studies, the overall quality weighted risk ratio was 1.09 (95% CI 0.90-1.31).

CONCLUSIONS

Traumatically injured patients who are intubated in the prehospital setting have a similar risk of developing VAP compared to those that are intubated in the hospital setting.

LEVEL OF EVIDENCE

Level IV systematic review and meta-analysis.

Effect of modified care bundle for prevention of ventilator-associated pneumonia in critically-ill neurosurgical patients

Background:

Care bundles for ventilator-associated pneumonia (VAP) have been shown to minimize the rate of VAP in critically ill patients. Standard care bundles may need to be modified in resource-constrained situations. The goal of this study was to see if our modified VAP-care bundles lowered the risk of VAP in neurosurgical patients.

Methods:

A prospective cohort study was conducted in mechanically ventilated neurosurgical patients. The VAP bundle was adjusted in the cohort group by increasing the frequency of intermittent endotracheal tube cuff pressure monitoring to six times a day while reducing oral care with 0.12% chlorhexidine to three times a day. The rate of VAP was compared to the historical control group.

Results:

A total of 146 and 145 patients were enrolled in control and cohort groups, respectively. The mean age of patients was 52±16 years in both groups (P=0.803). The admission Glasgow coma scores were 7.79±2.67 and 7.80±2.77 in control and cohort group, respectively (P=0.969). VAP was found in nine patients in control group but only one patient in cohort group. The occurrence rate of VAP was significantly reduced in cohort group compared to control group (0.88/1,000 vs. 6.84/1,000 ventilator days, P=0.036).

Conclusions:

The modified VAP bundle is effective in lowering the VAP rate in critically ill neurosurgical patients. It requires low budget and manpower and can be employed in resource-constrained settings.

Brain-lung interaction: a vicious cycle in traumatic brain injury

The brain-lung interaction can seriously affect patients with traumatic brain injury, triggering a vicious cycle that worsens patient prognosis. Although the mechanisms of the interaction are not fully elucidated, several hypotheses, notably the "blast injury" theory or "double hit" model, have been proposed and constitute the basis of its development and progression. The brain and lungs strongly interact via complex pathways from the brain to the lungs but also from the lungs to the brain. The main pulmonary disorders that occur after brain injuries are neurogenic pulmonary edema, acute respiratory distress syndrome, and ventilator-associated pneumonia, and the principal brain disorders after lung injuries include brain hypoxia and intracranial hypertension. All of these conditions are key considerations for management therapies after traumatic brain injury and need exceptional case-by-case monitoring to avoid neurological or pulmonary complications. This review aims to describe the history, pathophysiology, risk factors, characteristics, and complications of brain-lung and lung-brain interactions and the impact of different old and recent modalities of treatment in the context of traumatic brain injury.

The incidence and outcomes of healthcare-associated respiratory tract infections in non-ventilated neurocritical care patients: Results of a 10-year cohort study

The incidence of healthcare-associated respiratory tract infections in non-ventilated patients (NVA-HARTI) in neurosurgical intensive care units (ICUs) is unknown. The impact of NVA-HARTI on patient outcomes and differences between NVA-HARTI and ventilator-associated healthcare-associated respiratory tract infections (VA-HARTI) are poorly understood. Our objectives were to report the incidence, hospital length of stay (LOS), ICU LOS, and mortality in NVA-HARTI patients and compare these characteristics to VA-HARTI in neurocritical care patients. This cohort study was conducted in a neurosurgical ICU in Moscow. From 2011 to 2020, all patients with an ICU LOS > 48 h were included. A competing risk model was used for survival and risk analysis. A total of 3,937 ICU admissions were analyzed. NVA-HARTI vs VA-HARTI results were as follows: cumulative incidence 7.2 (95%CI: 6.4-8.0) vs 15.4 (95%CI: 14.2-16.5) per 100 ICU admissions; incidence rate 4.2 ± 2.0 vs 9.5 ± 3.0 per 1000 patient-days in the ICU; median LOS 32 [Q1Q3: 21, 48.5] vs 46 [Q1Q3: 28, 76.5] days; median ICU LOS 15 [Q1Q3: 10, 28.75] vs 26 [Q1Q3: 17, 43] days; mortality 12.3% (95%CI: 7.9-16.8) vs 16.7% (95%CI: 13.6-19.7). The incidence of VA-HARTI decreased over ten years while NVA-HARTI incidence did not change. VA-HARTI was an independent risk factor of death, OR 1.54 (1.11-2.14), while NVA-HARTI was not. Our findings suggest that NVA-HARTI in neurocritical care patients represents a significant healthcare burden with relatively high incidence and associated poor outcomes. Unlike VA-HARTI, the incidence of NVA-HARTI remained constant despite preventive measures. This suggests that extrapolating VA-HARTI research findings to NVA-HARTI should be avoided.

Nutritional Status Disorders and Selected Risk Factors of Ventilator-Associated Pneumonia (VAP) in Patients Treated in the Intensive Care Ward-A Retrospective Study

Introduction: The development of pneumonia in patients treated in intensive care wards is influenced by numerous factors resulting from the primary health condition and co-morbidities. The aim of this study is the determination of the correlation between nutritional status disorders and selected risk factors (type of injury, epidemiological factors, mortality risk, inflammation parameters, age, and gender) and the time of pneumonia occurrence in patients mechanically ventilated in intensive care wards. Material and method: The study included 121 patients with injuries treated in the intensive care ward who had been diagnosed with pneumonia related to mechanical ventilation. The data were collected using the method of retrospective analysis of patients’ medical records available in the electronic system. Results: Ventilator-associated pneumonia (VAP) occurred more frequently in patients over 61 years of age (40.4%), men (67.8%), after multiple-organ injury (45.5%), and those with a lower albumin level (86%), higher CRP values (83.5%), and leukocytes (68.6%). The risk of under-nutrition assessed with the NRS-2002 system was confirmed in the whole study group. The statistical analysis demonstrated a correlation between the leukocytes level (p = 0.012) and epidemiological factors (p = 0.035) and the VAP contraction time. Patients infected with Staphylococcus aureus had 4% of odds for the development of late VAP in comparison to Acinetobacter baumannii (p < 0.001), whereas patients infected by any other bacteria or fungi had about four times lower odds of the development of late VAP in comparison to Acinetobacter baumannii (p = 0.02). Patients with results in APACHE from 20 to 24 and from 25 to 29 had 13% and 21%, respectively, odds of the development of late VAP in comparison to patients with APACHE II scores ranging from 10 to 19 (respectively, p = 0.006; p = 0.028). Conclusions: The development of VAP is impacted by many factors, the monitoring of which has to be included in prophylactics and treatment.

Early Antibiotic Administration is Independently Associated with Improved Survival in Traumatic Brain Injury

BACKGROUND

Central and systemic immune dysfunction after traumatic brain injury (TBI) can lead to infectious-related complications, which may result in delayed mortality. The role of early empiric antibiotics after TBI has not been characterized to date, but is recommended in select cases to decrease complications. We aimed to determine the relationship between early antibiotic use and in-hospital mortality in TBI patients.

METHODS

A retrospective review was conducted of TBI patients requiring ICU admission at an urban, academic, Level I trauma center from 01/2014 to 08/2016. Data collection included demographics, injury characteristics, details regarding antibiotic use, and outcomes. Early antibiotic administration was defined as any antibiotic given within 48 hs from admission. Patients given early antibiotics (EARLY) were compared to those who received their first dose later or did not receive any antibiotics (non-EARLY).

RESULTS

Of the 488 TBI patients meeting inclusion criteria, 189 (38.7%) received early antibiotics. EARLY patients were younger (EARLY 54.2 versus non-EARLY 61.5 ys, P <0.01) and more likely to be male (71.4% versus 60.9%, P = 0.02). Injury severity scores (23.6 versus 17.2, P <0.01) and regional head abbreviated injury scale scores (3.9 versus 3.7, P <0.01) were significantly higher in patients who received early antibiotics. Unadjusted in-hospital mortality rates were similar, however EARLY was associated with a lower mortality rate (AOR 0.17, 95% CI: 0.07 - 0.43, adjusted P <0.01) after adjusting for confounders.

CONCLUSIONS

Despite presenting with a higher injury burden, TBI patients who received early antibiotics had a lower associated mortality rate compared to their counterparts. Future investigations are necessary to understand the underlying mechanisms that result in this potential survival benefit.

Brain-lung interactions and mechanical ventilation in patients with isolated brain injury

During the last decade, experimental and clinical studies have demonstrated that isolated acute brain injury (ABI) may cause severe dysfunction of peripheral extracranial organs and systems. Of all potential target organs and systems, the lung appears to be the most vulnerable to damage after brain injury (BI). The pathophysiology of these brain–lung interactions are complex and involve neurogenic pulmonary oedema, inflammation, neurodegeneration, neurotransmitters, immune suppression and dysfunction of the autonomic system. The systemic effects of inflammatory mediators in patients with BI create a systemic inflammatory environment that makes extracranial organs vulnerable to secondary procedures that enhance inflammation, such as mechanical ventilation (MV), surgery and infections. Indeed, previous studies have shown that in the presence of a systemic inflammatory environment, specific neurointensive care interventions—such as MV—may significantly contribute to the development of lung injury, regardless of the underlying mechanisms. Although current knowledge supports protective ventilation in patients with BI, it must be born in mind that ABI-related lung injury has distinct mechanisms that involve complex interactions between the brain and lungs. In this context, the role of extracerebral pathophysiology, especially in the lungs, has often been overlooked, as most physicians focus on intracranial injury and cerebral dysfunction. The present review aims to fill this gap by describing the pathophysiology of complications due to lung injuries in patients with a single ABI, and discusses the possible impact of MV in neurocritical care patients with normal lungs.

Machine Learning Model to Predict Ventilator Associated Pneumonia in patients with Traumatic Brain Injury: The C.5 Decision Tree Approach

BACKGROUND

There is paucity in the literature to predict the occurrence of Ventilator Associated Pneumonia (VAP) in patients with Traumatic Brain Injury (TBI). We aimed to build a C.5. Decision Tree (C.5 DT) machine learning model to predict VAP in patients with moderate to severe TBI.

METHODS

This was a retrospective study including all adult patients who were hospitalized with TBI plus head abbreviated injury scale (AIS) ≥ 3 and were mechanically ventilated in a level 1 trauma center between 2014 and 2019.

RESULTS

A total of 772 eligible patients were enrolled, of them 169 had VAP (22%). The C.5 DT model achieved moderate performance with 83.5% accuracy, 80.5% area under the curve, 71% precision, 86% negative predictive value, 43% sensitivity, 95% specificity and 54% F-score. Out of 24 predictors, C.5 DT identified 5 variables predicting occurrence of VAP post-moderate to severe TBI (Time from injury to emergency department arrival, blood transfusion during resuscitation, comorbidities, Injury Severity Score and pneumothorax).

CONCLUSIONS

This study could serve as baseline for the quest of predicting VAP in patients with TBI through the utilization of C.5. DT machine learning approach. This model helps provide timely decision support to caregivers to improve patient's outcomes.

Post-craniotomy fever and its associated factors in patients with traumatic brain injury

BACKGROUND

Fever frequently occurs in patients with traumatic brain injury and can cause secondary damage to the brain. Critical care nurses play essential roles in assessing and managing fever in these patients.

AIM

The study aimed to (a) examine the fever causes in and condition of neurosurgical patients with traumatic brain injury in intensive care, (b) identify the factors associated with fever, and (c) determine the effects of fever on hospital stay and prognosis.

STUDY DESIGN

This study is a retrospective observational design.

METHODS

Data were collected through chart reviews of 93 traumatic brain injury patients admitted to a teaching hospital's intensive care unit for postoperative care. Fever was defined as at least one episode of body temperature >38°C.

RESULTS

Of the 93 patients, 76 developed a fever within 1-week post-craniotomy. Of these, 49 were infection-related and 27 were unexplained. Results of logistic regression showed that the preoperative Glasgow coma scale score (ß = -.323; P = .013) and length of intubation (ß = .480; P = .005) were the key predictors of unexplained post-craniotomy fever, and these two variables (ß = -.494; P < .001 and ß = .479; P = .006, respectively) were also the key predictors of infection-related fever.

CONCLUSION

A significant portion of patients developed a fever during the first post-craniotomy week. Patients with a lower pre-craniotomy Glasgow coma scale score and a longer intubation length were at a greater risk for both infection-related fever and unexplained fever. Patients with fever had a bad outcome score.

RELEVANCE TO CLINICAL PRACTICE

Critical care nurses should closely monitor traumatic brain injury patients' body temperatures and employ evidence-based infection prevention and control measures to minimize their infection risks. Respiratory care and intensive care unit Liberation Bundle should be reinforced to liberate these patients from mechanical ventilation and its associated complications.

Effects of CNS Injury-Induced Immunosuppression on Pulmonary Immunity

Patients suffering from stroke, traumatic brain injury, or other forms of central nervous system (CNS) injury have an increased risk of nosocomial infections due to CNS injury-induced immunosuppression (CIDS). Immediately after CNS-injury, the response in the brain is pro-inflammatory; however, subsequently, local and systemic immunity is suppressed due to the compensatory release of immunomodulatory neurotransmitters. CIDS makes patients susceptible to contracting infections, among which pneumonia is very common and often lethal. Ventilator-acquired pneumonia has a mortality of 20–50% and poses a significant risk to vulnerable patients such as stroke survivors. The mechanisms involved in CIDS are not well understood. In this review, we consolidate the evidence for cellular processes underlying the pathogenesis of CIDS, the emerging treatments, and speculate further on the immune elements at play.

Advanced Modeling to Predict Pneumonia in Combat Trauma Patients

BACKGROUND

Tools to assist clinicians in predicting pneumonia could lead to a significant decline in morbidity. Therefore, we sought to develop a model in combat trauma patients for identifying those at highest risk of pneumonia.

METHODS

This was a retrospective study of 73 primarily blast-injured casualties with combat extremity wounds. Binary classification models for pneumonia prediction were developed with measurements of injury severity from the Abbreviated Injury Scale (AIS), transfusion blood products received before arrival at Walter Reed National Military Medical Center (WRNMMC), and serum protein levels. Predictive models were generated with leave-one-out-cross-validation using the variable selection method of backward elimination (BE) and the machine learning algorithms of random forests (RF) and logistic regression (LR). BE was attempted with two predictor sets: (1) all variables and (2) serum proteins alone.

RESULTS

Incidence of pneumonia was 12% (n = 9). Different variable sets were produced by BE when considering all variables and just serum proteins alone. BE selected the variables ISS, AIS chest, and cryoprecipitate within the first 24 h following injury for the first predictor set 1 and FGF-basic, IL-2R, and IL-6 for predictor set 2. Using both variable sets, a RF was generated with AUCs of 0.95 and 0.87-both higher than LR algorithms.

CONCLUSION

Advanced modeling allowed for the identification of clinical and biomarker data predictive of pneumonia in a cohort of predominantly blast-injured combat trauma patients. The generalizability of the models developed here will require an external validation dataset.

Trauma and Antimicrobial Resistance Are Independent Predictors of Inadequate Empirical Antimicrobial Treatment of Ventilator-Associated Pneumonia in Critically Ill Patients

Background: We aimed to assess independent risk factors for inadequate initial antimicrobial treatment (IAT) in critically ill patients with ventilator-associated pneumonia (VAP) treated in intensive care units (ICU) and to determine whether IAT is associated with adverse outcomes in patients with VAP. Patients and Methods: A prospective cohort study was performed and included 152 patients with VAP treated in an ICU for more than 48 hours. The main outcomes of interest were all-cause ICU mortality and VAP-related mortality. Other outcomes considered were: intra-hospital mortality, VAP-related sepsis, relapse, re-infection, length of stay in ICU (ICU LOS), and number of days on mechanical ventilation (MV). Results: One-third of patients (35.5%) received inadequate antimicrobial therapy. Trauma (odds ratio [OR], 3.55; 95% confidence interval [CI], 1.25-10.06) and extensively drug-resistant (XDR) causative agent (OR, 3.09; 95% CI, 1.23-7.74) were independently associated with inadequate IAT. Inadequate IAT was associated with a higher mortality rate (OR, 3.08; 95% CI, 1.30-7.26), VAP-related sepsis (OR, 2.39; 95% CI, 1.07-5.32), relapse (OR, 3.25; 95% CI, 1.34-7.89), re-infection (OR, 6.06; 95% CI, 2.48-14.77), and ICU LOS (β 4.65; 95% CI, 0.93-8.36). Acinetobacter spp., Pseudomonas aeruginosa and Klebsiella/Enterobacter spp. were the most common bacteria in patients with IAT and those with adequate antimicrobial therapy. Conclusions: This study demonstrated that inadequate IAT is associated with a higher risk of the majority of adverse outcomes in patients with VAP treated in ICUs. Trauma and XDR strains of bacteria are independent predictors of inadequate IAT of VAP in critically ill patients.

Hospital-acquired infections in the adult intensive care unit-Epidemiology, antimicrobial resistance patterns, and risk factors for acquisition and mortality

BACKGROUND

Acquisition of Hospital-acquired infections (HAIs) in intensive care units (ICUs) predispose patients to higher mortality rates and additional adverse events. Serbian adult ICUs are rarely investigated for HAIs. The aim of this study was to look into HAIs in an adult ICU and identify risk factors for acquisition of HAIs and mortality.

METHODS

This retrospective study included 355 patients hospitalized over a 2-year period. Patient characteristics, antimicrobial resistance patterns, and risk factors of acquisition and predictors of mortality in patients who had a HAI were examined.

RESULTS

HAIs were diagnosed in 32.7% of patients. Resistance rates > 50% were observed in all antimicrobials except for tigecycline (14%), colistin (9%), and linezolid (0%). Predictors of HAI acquisition were underlying viral CNS infections and invasive devices-urinary and central venous catheters, and nasogastric tubes. Diabetes mellitus and intubation (odds ratio 2.5 and 6.7, P = .042 and <.001) were identified as predictors for increased mortality in patients who had a HAI.

CONCLUSIONS

Prevalence of HAIs and resistance rates are high compared to ICUs in other European countries. Risk factors for both acquisition of HAI and mortality were identified. Large-scale studies are necessary to look at HAIs in adult ICUs in Serbia.

Using trauma registry data to predict prolonged mechanical ventilation in patients with traumatic brain injury: Machine learning approach

OBJECTIVES

We aimed to build a machine learning predictive model to predict the risk of prolonged mechanical ventilation (PMV) for patients with Traumatic Brain Injury (TBI).

METHODS

This study included TBI patients who were hospitalized in a level 1 trauma center between January 2014 and February 2019. Data were analyzed for all adult patients who received mechanical ventilation following TBI with abbreviated injury severity (AIS) score for the head region of ≥ 3. This study designed three sets of machine learning models: set A defined PMV to be greater than 7 days, set B (PMV > 10 days) and set C (PMV >14 days) to determine the optimal model for deployment. Patients' demographics, injury characteristics and CT findings were used as predictors. Logistic regression (LR), Artificial neural networks (ANN) Support vector machines (SVM), Random Forest (RF) and C.5 Decision Tree (C.5 DT) were used to predict the PMV.

RESULTS

The number of eligible patients that were included in the study were 674, 643 and 622 patients in sets A, B and C respectively. In set A, LR achieved the optimal performance with accuracy 0.75 and Area under the curve (AUC) 0.83. SVM achieved the optimal performance among other models in sets B with accuracy/AUC of 0.79/0.84 respectively. ANNs achieved the optimal performance in set C with accuracy/AUC of 0.76/0.72 respectively. Machine learning models in set B demonstrated more stable performance with higher prediction success and discrimination power.

CONCLUSION

This study not only provides evidence that machine learning methods outperform the traditional multivariate analytical methods, but also provides a perspective to reach a consensual definition of PMV.

Prediction of in-hospital mortality in patients with post traumatic brain injury using National Trauma Registry and Machine Learning Approach

BACKGROUND

The use of machine learning techniques to predict diseases outcomes has grown significantly in the last decade. Several studies prove that the machine learning predictive techniques outperform the classical multivariate techniques. We aimed to build a machine learning predictive model to predict the in-hospital mortality for patients who sustained Traumatic Brain Injury (TBI).

METHODS

Adult patients with TBI who were hospitalized in the level 1 trauma center in the period from January 2014 to February 2019 were included in this study. Patients' demographics, injury characteristics and CT findings were used as predictors. The predictive performance of Artificial Neural Networks (ANN) and Support Vector Machines (SVM) was evaluated in terms of accuracy, Area Under the Curve (AUC), sensitivity, precision, Negative Predictive Value (NPV), specificity and F-score.

RESULTS

A total of 1620 eligible patients were included in the study (1417 survival and 203 non-survivals). Both models achieved accuracy over 91% and AUC over 93%. SVM achieved the optimal performance with accuracy 95.6% and AUC 96%.

CONCLUSIONS

for prediction of mortality in patients with TBI, SVM outperformed the well-known classical models that utilized the conventional multivariate analytical techniques.

Incidence and Prognostic Value of Acute Coagulopathy After Extensive Severe Burns

Acute burn-induced coagulopathy (ABIC) occurs after severe burns. However, the incidence, prognostic value, and clinical significance of ABIC after an extensive severe burn remain inconclusive due to wide variances in burn severity and coagulation profile evaluation timings in previous studies. This retrospective study explored the incidence and clinical and prognostic significance of early phase ABIC in 129 adult patients with extensive burns (&gt;50% total body surface area [TBSA]) admitted to the burn centers of two hospitals within 10 hours postburn injury during 2009–2017. Demographics (age and sex) and clinical data (burn severity, vital signs, prehospital fluid replacement volume, hemodynamic parameters, coagulation profile, blood gas, and blood biochemical indicators) were collected upon admission. The incidence of ABIC in patients with severe burns and its relationship with their survival and clinical significance were analyzed. The average postburn interval was 5.7 ± 2.7 hours, and the incidence of ABIC was 31% (40/129). A logistic regression analysis identified ABIC as an independent predictor of 4-week severe mortality due to severe burn. The incidence of ABIC was significantly associated with the total burn area, lactic acid levels upon admission, and postburn admission interval, but not with the prehospital fluid replacement volume. In conclusion, approximately 30% of patients with severe burns developed ABIC within 10 hours postburn, and this condition strongly predicts 4-week mortality. Although burn severity and tissue ischemia/hypoxia are main risk factors for ABIC, the pathogenesis is not fully understood and should be explored in future studies.

Incidence, Risk Factors, and Outcomes of Ventilator-Associated Pneumonia in Traumatic Brain Injury: A Meta-analysis

Ventilator-associated pneumonia (VAP) is one of the most severe complications in patients with traumatic brain injury (TBI) and is considered a risk factor for poor outcomes. However, the incidence of VAP among patients with TBI reported in studies varies widely. What is more, the risk factors and outcomes of VAP are controversial. This study estimates the incidence, risk factors, and outcomes of VAP in patients with TBI and provides evidence for prevention and treatment. PubMed, EMBASE, Cochrane Library, and Web of Science databases were searched from the earliest records to May 2018. Data involving the incidence, risk factors, and outcomes were extracted for meta-analysis. The results showed that the incidence of VAP was 36% (95% confidence interval (CI) 31-41%); risk factors analyses showed that smoking [odds ratio (OR) 2.13; 95% CI 1.16-3.92], tracheostomy (OR 9.55; 95% CI 3.24-28.17), blood transfusion on admission (OR 2.54; 95% CI 1.24-5.18), barbiturate infusion (OR 3.52; 95% CI 1.68-7.40), injury severity score (OR 4.65; 95% CI 1.96-7.34), and head abbreviated injury scale (OR 2.99; 95% CI 1.66-5.37) were related to the occurrence of VAP. When patients developed VAP, mechanical ventilation time (OR 5.45; 95% CI 3.78-7.12), ICU length of stay (OR 6.85; 95% CI 4.90-8.79), and hospital length of stay (OR 10.92; 95% CI 9.12-12.72) were significantly increased. However, VAP was not associated with an increased risk of mortality (OR 1.28; 95% CI 0.74-2.21). VAP is common in patients with TBI. It is affected by a series of factors and has a poor prognosis.

Splenectomy does not affect the development of pneumonia following severe traumatic brain injury

The cholinergic anti-inflammatory pathway offers a proposed mechanism to describe the increased risk of pneumonia following severe traumatic brain injury (sTBI). Vagal activity transmitted to the spleen results in decreased inflammatory cytokine production and immunosuppression. However, no clinical evidence exists. We sought to compare pneumonia rates among patients with TBI and splenectomy using a retrospective analysis of all trauma patients with splenic injury requiring splenectomy or TBI admitted to an ACS verified level one trauma center from 2011 to 2016. Admission Glasgow Coma Score (GCS) ≤ 8 was used to identify sTBI. Pneumonia was defined by respiratory culture obtained by bronchoalveolar lavage. Analysis included χ2 and one-way analysis of variance followed by multivariate logistic regression to determine the association of sTBI and splenectomy of development of pneumonia. Four hundred and twenty-seven patients were included for primary analysis, 247 with sTBI, 180 with splenectomy, and 14 with both sTBI and splenectomy. Rates of pneumonia were increased, although not significant among patients with sTBI and splenectomy and both sTBI alone (71.4 vs. 49.4%, p = 0.11). On multivariate regression, the risk of pneumonia was increased with both splenectomy and sTBI (OR 3.18; 95% CI, 0.75-13.45) and sTBI alone, although significant in the latter only (OR 3.56; 95% CI, 2.12-5.97). Based on these results, splenectomy does not appear to influence the development of pulmonary immunosuppression and pneumonia following sTBI.

Healthcare-Associated Infections in the Neurocritical Care Unit

PURPOSE OF REVIEW

This article summarizes updated data and knowledge on healthcare-associated infections in the neurocritical care unit, with a focus on central nervous system infections and systemic infectious complications in patients with acute brain disease. It also reviews the concept of brain injury-induced immune modulation, an underlying mechanism to explain why the neuro-ICU population is particularly susceptible to infections.

RECENT FINDINGS

Healthcare-associated infections in the neuro-ICU are common: up to 40 % of meningitides in the developed world are now healthcare-associated. The number of gram-negative infections is rising. New diagnostic approaches attempt to aid in the diagnosis of healthcare-associated meningitis and ventriculitis. Healthcare-associated infections in the neurocritical care unit remain a challenge for diagnosis, treatment, and prevention. Gaining a better understanding of at-risk patients and development of preventative strategies will be the goal for future investigation.

Management of tracheostomized patients after poor grade subarachnoid hemorrhage: Disease related and pulmonary risk factors for failed and delayed decannulation

OBJECTIVE

Tracheostomy is often indicated in patients with spontaneous subarachnoid hemorrhage (sSAH). Decannulation is a major goal of neurorehabilitation, but cannot be achieved in all patients. The aim of this study was to describe the course of decannulation and to identify associated risk factors in a single-center collective.

PATIENTS AND METHODS

We retrospectively reviewed 87 sSAH patients with WFNS (World Federation of Neurosurgical Societies) grade III-IV, who received tracheostomy. Decannulation events and the time from tracheostomy to decannulation were recorded in a 200-days follow-up. Variables analyzed were: age, sex, WFNS grade, Fisher grade, the presence of intracerebral or intraventricular hematoma, acute hydrocephalus, aneurysm location, aneurysm obliteration (surgical vs. endovascular), treatment related complications, decompressive craniectomy, symptomatic cerebral vasospasm, vasospasm-related infarction and timing of tracheostomy. Further risk factors analyzed were preexisting chronic lung disease and pneumonia. Functional outcome was assessed by the modified Rankin Scale (mRS).

RESULTS

The rate of successful decannulation was 84% after a median of 47 days. A higher WFNS grade and pneumonia were associated with both a prolonged time to decannulation (TTD) and decannulation failure (DF). Older age (> 60 years) and necessity for decompressive craniectomy were only associated with prolonged TTD. Outcome analysis revealed that patients with DF show a significantly (p < 0.01) higher rate of unfavorable outcome (mRS 3-6).

CONCLUSION

Successful decannulation is possible in the majority of sSAH patients and particularly, in all patients with WFNS grade III. WFNS grading, age, the necessity for decompressive craniectomy and pneumonia are significantly associated with the TTD. WFNS grade and pneumonia are significantly associated with DF. The mean cannulation time of sSAH patients is shorter in relation to stroke patients.

Prehospital Airway Management in Severe Traumatic Brain Injury

OBJECTIVE

Traumatic brain injury (TBI) is a leading cause of death and disability among trauma patients. The final outcome of TBI results from a complex interaction between primary and secondary mechanisms of injury that begin immediately after the traumatic event. The aim of this review was to evaluate the latest evidence regarding the impact of prehospital airway management and the outcome after traumatic brain injury.

METHODS

PubMed, Embase, and Cochrane searches were conducted using the MeSH database. Airway management, traumatic brain injury, pneumonia, and the subheadings of these Medical Subject Headings were combined.

RESULTS

The review is structured into 4 major topics: airway management devices, prehospital pharmacologic management, mortality and neurologic outcomes, and early respiratory infections. The available literature shows a shift toward a more comprehensive view of prehospital airway management, taking into account not only the location where airway management is attempted but also the drugs administered, the airway management devices used, and the skills of the main professional figures attending the scene.

CONCLUSIONS

Literature about this topic is still inconclusive; however, new evidence taking into consideration more complex aspects of airway management rather than orotracheal intubation per se shows improved outcomes with aggressive prehospital airway management.

Risk factors of ventilator-associated pneumonia in elderly patients receiving mechanical ventilation

Purpose: The aim of this study was to verify the potential risk factors of ventilator-associated pneumonia (VAP) in elderly Chinese patients receiving mechanical ventilation (MV). The secondary aim of this study was to present logistical regression prediction models of VAP occurrence in elderly Chinese patients receiving MV. Methods: Patients (aged 80 years or above) receiving MV for ≥48 h were enrolled from the Chinese People's Liberation Army (PLA) General Hospital from January 2011 to December 2015. A chi-squared test and Mann-Whitney U-test were used to compare the data between participants with VAP and without VAP. Univariate logistic regression models were performed to explore the relationship between risk factors and VAP. Results: A total of 901 patients were included in the study, of which 156 were diagnosed as VAP (17.3%). The incidence density of VAP was 4.25/1,000 ventilator days. Logistic regression analysis showed that the independent risk factors for elderly patients with VAP were COPD (OR =1.526, P < 0.05), intensive care unit (ICU) admission (OR=1.947, P < 0.01), the MV methods (P < 0.023), the number of antibiotics administered (OR=4.947, P < 0.01), the number of central venous catheters (OR=1.809, P < 0.05), the duration of indwelling urinary catheter (OR=1.805, P < 0.01) and the use of corticosteroids prior to MV (OR=1.618, P < 0.05). Logistic regression prediction model of VAP occurrence in the Chinese elderly patients with mechanical ventilation:L o g i t   P = - 6 . 468 + 0 . 423 X 1 + 0 . 666 X 2 + 0 . 871 X 3 + - 0 . 501 X 5 + 0 . 122 X 6 + 0 . 593 X 7 + 0 . 590 X 8 + 1 . 599 X 9 . Conclusion: VAP occurrence is associated with a variety of controllable factors including the MV methods and the number of antibiotics administered. A model was established to predict VAP occurrence so that high-risk patients could be identified as early as possible.

Risk Factors of Ventilator-Associated Pneumonia in Critically III Patients

Ventilator-associated pneumonia (VAP), a hospital acquired pneumonia that occurs more than 48 h after mechanical ventilation, is a common complication of mechanical ventilation with a high mortality rate. VAP can cause patients to have difficulty weaning off the ventilator and to stay in the hospital longer, which results in a huge financial burden to patients and a huge demand for medical resources. Several strategies, such as drugs including chlorhexidine, β-lactam antibiotics and probiotics, have been used to prevent VAP in clinic. The incidence and the mortality rate of VAP have been decreased with the development of preventative strategies in the past decades, but VAP remains one of the most common causes of nosocomial infections and death in the intensive care unit. Current challenges in the management of VAP involved the lack of a gold standard for diagnosis, the absence of effective preventative strategies, and the rise in antibiotic resistance. Therefore, in order to reduce the incidence of VAP and improve the outcome of patients with mechanical ventilation, it is necessary to clarify the risk factors of VAP for clinical prevention and control of VAP. This paper reviews the international risk factors of VAP occurrence reported in recent years, including patient characteristics, increased mechanical ventilation time and prolonged length of hospital stay, disorders of consciousness, burns, comorbidities, prior antibiotic therapy, invasive operations, gene polymorphisms, and mentions the corresponding preventive measures. Each factor is not only an independent risk factor of VAP, but also has an influence on each other. A better understanding of risk factors for VAP is helpful for predicting the occurrence of VAP, improving the prevention and control of VAP, and reducing the morbidity and mortality rates of patients with VAP.

Early-Onset Ventilator-Associated Pneumonia in Severe Traumatic Brain Injury: is There a Relationship with Prehospital Airway Management?

BACKGROUND

Prehospital airway management in severe traumatic brain injury (TBI) is widely recommended by international guidelines for the management of trauma. Early-onset ventilator-associated pneumonia (EOVAP) is a common occurrence in this population and can worsen mortality and functional outcome.

OBJECTIVES

In this retrospective observational study, we aimed to evaluate the association between different prehospital airway management variables and the occurrence of EOVAP. Secondarily we evaluated the correlation between EOVAP and mortality and neurological outcome.

METHODS

The study retrospectively evaluated 223 patients admitted from 2010 to 2017 in our trauma intensive care unit for severe TBI. The population was divided into three groups on the basis of the airway management technique adopted (bag mask ventilation, laryngeal tube, orotracheal intubation). Uni- and multivariate logistic regression analyses were performed using the occurrence of EOVAP as the dependent variable, to investigate potential associations with prehospital airway management.

RESULTS

A total of 131 episodes (58.7%) of EOVAP were registered in the study population (223 patients). Laryngeal tube and orotracheal intubation were used in patients with significantly lower Glasgow Coma Scale score on scene and a higher Face Abbreviated Injury Scale; advanced airway management significantly increased the total rescue time. The prehospital airway management technique adopted, prehospital type of sedation or use of muscle relaxants, type of transport, and rescue times were not associated with the occurrence of EOVAP.

CONCLUSIONS

Prehospital airway management does not have a significant impact on the occurrence of EOVAP in severe TBI patients. Similarly, it does not have a significant impact on mortality or long-term neurological outcome despite increasing duration of mechanical ventilation, intensive care unit, and hospital stay.

Molecular Epidemiology and Risk Factors of Ventilator-Associated Pneumonia Infection Caused by Carbapenem-Resistant Enterobacteriaceae

Ventilator-associated pneumonia (VAP) infection caused by carbapenem-resistant Enterobacteriaceae (CRE) is becoming more prevalent, thus seriously affecting patient outcomes. In this paper, we studied the drug resistance mechanism and epidemiological characteristics of CRE, and analyzed the infection and prognosis factors of VAP caused by CRE, to provide evidence for effective control of nosocomial infection in patients with VAP. A total of 58 non-repetitive CRE strains of VAP were collected from January 2016 to June 2018. To explore the risk factors of CRE infection, 1:2 group case control method was used to select non CRE infection patients at the same period as the control group. Among the 58 CRE strains, the most common isolates included Klebsiella pneumoniae and Escherichia coli. All strains were sensitive to polymyxin B, which features better sensitivity to other antibiotics such as minocycline, trimethoprim/sulfamethoxazole, and amikacin. Multiple drug resistance genes were detected at the same time in most strains. KPC-2 was the most common carbapenemase-resistant gene in Klebsiella pneumoniae, whereas NDM-1 was more common in Escherichia coli. The risk factors correlated with CRE infection included intensive care unit (ICU) occupancy time >7 days (OR = 2.793; 95% CI 1.439~5.421), antibiotic exposure during hospital stay including those to enzyme inhibitors (OR = 1.977; 95% CI 1.025~3.812), carbapenems (OR = 3.268; 95% CI 1.671~6.392), antibiotic combination therapy(OR = 1.951; 95% CI 1.020~3.732), and nerve damage (OR = 3.013; 95% CI 1.278~7.101). Multivariable analysis showed that ICU stay >7 days (OR = 1.867; 95% CI 1.609~20.026), beta-lactamase inhibitor antibiotics (OR = 7.750; 95% CI 2.219~27.071), and carbapenem (OR = 9.143; 95% CI 2.259~37.01) are independent risk factors for VAP carbapenem caused by Carbapenem-resistant Enterobacteriaceae. A high resistance rate of CRE isolated from VAP indicated that the infected patients featured higher mortality and longer hospital stay time than the control group. Multiple risk factors for CRE infection and their control can effectively prevent the spread of VAP.

Impact of grouping complications on mortality in traumatic brain injury: A nationwide population-based study

Traumatic brain injury (TBI) is an important health issue with high mortality. Various complications of physiological and cognitive impairment may result in disability or death after TBI. Grouping of these complications could be treated as integrated post-TBI syndromes. To improve risk estimation, grouping TBI complications should be investigated, to better predict TBI mortality. This study aimed to estimate mortality risk based on grouping of complications among TBI patients. Taiwan's National Health Insurance Research Database was used in this study. TBI was defined according to the International Classification of Diseases, Ninth Revision, Clinical Modification codes: 801-804 and 850-854. The association rule data mining method was used to analyze coexisting complications after TBI. The mortality risk of post-TBI complication sets with the potential risk factors was estimated using Cox regression. A total 139,254 TBI patients were enrolled in this study. Intracerebral hemorrhage was the most common complication among TBI patients. After frequent item set mining, the most common post-TBI grouping of complications comprised pneumonia caused by acute respiratory failure (ARF) and urinary tract infection, with mortality risk 1.55 (95% C.I.: 1.51-1.60), compared with those without the selected combinations. TBI patients with the combined combinations have high mortality risk, especially those aged <20 years with septicemia, pneumonia, and ARF (HR: 4.95, 95% C.I.: 3.55-6.88). We used post-TBI complication sets to estimate mortality risk among TBI patients. According to the combinations determined by mining, especially the combination of septicemia with pneumonia and ARF, TBI patients have a 1.73-fold increased mortality risk, after controlling for potential demographic and clinical confounders. TBI patients aged<20 years with each combination of complications also have increased mortality risk. These results could provide physicians and caregivers with important information to increase their awareness about sequences of clinical syndromes among TBI patients, to prevent possible deaths among these patients.

Risk factors for ventilator-associated pneumonia in trauma patients: A descriptive analysis

BACKGROUND

We sought to evaluate the risk factors for developing ventilator-associated pneumonia (VAP) and whether the location of intubation posed a risk in trauma patients.

METHODS

Data were retrospectively reviewed for adult trauma patients requiring intubation for > 48 hours, admitted between 2010 and 2013. Patients' demographics, clinical presentations and outcomes were compared according to intubation location (prehospital intubation [PHI] vs. trauma room [TRI]) and presence vs. absence of VAP. Multivariate regression analysis was performed to identify predictors of VAP.

RESULTS

Of 471 intubated patients, 332 patients met the inclusion criteria (124 had PHI and 208 had TRI) with a mean age of 30.7±14.8 years. PHI group had lower GCS (P=0.001), respiratory rate (P=0.001), and higher frequency of head (P=0.02) and chest injuries (P=0.04). The rate of VAP in PHI group was comparable to the TRI group (P=0.60). Patients who developed VAP were 6 years older, had significantly lower GCS and higher ISS, head AIS, and higher rates of polytrauma. The overall mortality was 7.5%, and was not associated with intubation location or pneumonia rates. In the early-VAP group, gram-positive pathogens were more common, while gram-negative microorganisms were more frequently encountered in the late VAP group. Logistic regression analysis and modeling showed that the impact of the location of intubation in predicting the risk of VAP appeared only when chest injury was included in the models.

CONCLUSION

In trauma, the risk of developing VAP is multifactorial. However, the location of intubation and presence of chest injury could play an important role.

Acute brain trauma, lung injury, and pneumonia: more than just altered mental status and decreased airway protection

Traumatic brain injury (TBI) is a major cause of mortality and morbidity worldwide. Even when patients survive the initial insult, there is significant morbidity and mortality secondary to subsequent pulmonary edema, acute lung injury (ALI), and nosocomial pneumonia. Whereas the relationship between TBI and secondary pulmonary complications is recognized, little is known about the mechanistic interplay of the two phenomena. Changes in mental status secondary to acute brain injury certainly impair airway- and lung-protective mechanisms. However, clinical and translational evidence suggests that more specific neuronal and cellular mechanisms contribute to impaired systemic and lung immunity that increases the risk of TBI-mediated lung injury and infection. To better understand the cellular mechanisms of that immune impairment, we review here the current clinical data that support TBI-induced impairment of systemic and lung immunity. Furthermore, we also review the animal models that attempt to reproduce human TBI. Additionally, we examine the possible role of damage-associated molecular patterns, the chlolinergic anti-inflammatory pathway, and sex dimorphism in post-TBI ALI. In the last part of the review, we discuss current treatments and future pharmacological therapies, including fever control, tracheostomy, and corticosteroids, aimed to prevent and treat pulmonary edema, ALI, and nosocomial pneumonia after TBI.

Neuropulmonology

Neuropulmonology refers to the complex interconnection between the central nervous system and the respiratory system. Neurologic injury includes traumatic brain injury, hemorrhage, stroke, and seizures, and in each there are far-reaching effects that can result in pulmonary dysfunction. Systemic changes can induce impairment of pulmonary function due to changes in the core structure and function of the lung. The conditions and disorders that often occur in these patients include aspiration pneumonia, neurogenic pulmonary edema, and acute respiratory distress syndrome, but also several abnormal respiratory patterns and sleep-disordered breathing. Lung infections, pulmonary edema - neurogenic or cardiogenic - and pulmonary embolus all are a serious barrier to recovery and can have significant effects on outcomes such as hospital course, prognosis, and mortality. This review presents the spectrum of pulmonary abnormalities seen in neurocritical care.

THE GLYCOCALYX AND TRAUMA: A REVIEW

In the United States trauma is the leading cause of mortality among those under the age of 45, claiming approximately 192,000 lives each year. Significant personal disability, lost productivity, and long-term healthcare needs are common and contribute 580 billion dollars in economic impact each year. Improving resuscitation strategies and the early acute care of trauma patients has the potential to reduce the pathological sequelae of combined exuberant inflammation and immune suppression that can co-exist, or occur temporally, and adversely affect outcomes. The endothelial and epithelial glycocalyx has emerged as an important participant in both inflammation and immunomodulation. Constituents of the glycocalyx have been used as biomarkers of injury severity and have the potential to be target(s) for therapeutic interventions aimed at immune modulation. In this review, we provide a contemporary understanding of the physiologic structure and function of the glycocalyx and its role in traumatic injury with a particular emphasis on lung injury.

Clinical factors and incidence of prolonged fever in neurosurgical patients

AIMS AND OBJECTIVES

To describe the incidence of prolonged fever in patients admitted to the neurosurgery department, and the corresponding risk indicators.

BACKGROUND

Prolonged fever was defined as a temperature higher than 38·3°C lasting more than five days. Prolonged fever is a common phenomenon and could lead to worsened outcomes in specific patient groups, especially for those with brain injury. However, the studies on prolonged fever in neurosurgical patients are limited and insufficient.

DESIGN

A retrospective observational study.

METHODS

Retrospective data were collected from 1 January 2014 to 31 December 2014, at the neurosurgical department of a large teaching hospital. We performed univariate and multivariate analyses to identify independent indicators for prolonged fever vs. short-term fever.

RESULTS

Among 2845 patients, prolonged fever occurred in 466 (16%). The older patients were associated with longer duration of mechanical ventilation and hospital stay. It predominantly occurred in patients with subarachnoid haemorrhage (SAH) and traumatic brain injury. Patients receiving antibiotic treatment tended to manifest prolonged fever more frequently. Multivariate analysis revealed that the use of antibiotics, central venous catheter and prolonged mechanical ventilation were independent risk predictors for prolonged fever. Patients diagnosed with brain tumour seemed to be not associated with prolonged fever.

CONCLUSIONS

Prolonged fever is the common complication in neurosurgical patients. The risks of prolonged fever in patients are attributed to antibiotic therapy, use of central venous catheter and prolonged mechanical ventilation. Indicators of prolonged fever are helpful for better identification of high-risk patients and fever control.

RELEVANCE TO CLINICAL PRACTICE

A better reveal on the epidemiology and predictable factors of prolonged fever in neurosurgical patients will provide a better understanding on those patients who are most at risk, and therefore contribute to fever control and better outcome.

Clinical predictors and microbiology of ventilator-associated pneumonia in the intensive care unit: a retrospective analysis in six Italian hospitals

The purpose of this study was to assess the main clinical predictors and microbiological features of ventilator-associated pneumonia (VAP) in the Intensive Care Unit (ICU) environment. This work is a retrospective analysis over one year from September 2010 to September 2011. Patients' risk factors, causes of admission, comorbidities and respiratory specimens collected in six Italian ICUs were reviewed. Incidence and case fatality rate of VAP were evaluated. After stratification for VAP development, univariate and multivariate analyses were performed to assess the impact of patients' conditions on the onset of this infection. A total of 1,647 ICU patients (pts) were considered. Overall, 115 patients (6.9 %) experienced at least one episode of VAP. The incidence rate for VAP was 5.82/1,000 pts-days, with a case fatality rate of 44.3 %. Multivariate analysis showed that admission for neurological disorders (aIRR 4.12, CI 1.24-13.68, p = 0.02) and emergency referral to ICU from other hospitals (aIRR 2.11, CI 1.03-4.31, p = 0.04) were associated with higher risk of VAP, whereas a tendency to a higher risk of infection was detected for admission due to respiratory disease, cardiac disease, trauma and for having obesity or renal failure. A total of 372 microbiological isolates from respiratory specimens were collected in VAP patients. The most common species were Klebsiella pneumoniae, Acinetobacter baumannii and Pseudomonas aeruginosa, showing high resistance rates to carbapenems. Neurological disorders and emergency referral at the admission into the ICU are significantly associated with the onset of VAP. A high incidence of multi-drug resistant Gram- species was detected in the respiratory specimens.