1
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Taran S, Perrot B, Angriman F, Cinotti R. Evaluating the Sum of Eye and Motor Components of the Glasgow Coma Score As a Predictor of Extubation Failure in Patients With Acute Brain Injury. Crit Care Med 2024; 52:1258-1263. [PMID: 38557684 DOI: 10.1097/ccm.0000000000006283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
OBJECTIVES To evaluate the association between the pre-extubation sum of eye and motor components of the Glasgow Coma Score (GCS-EM) and odds of extubation failure in patients with acute brain injury being liberated from mechanical ventilation. DESIGN Secondary analysis of a prospective, multicenter observational study ( ClinicalTrials.gov identifier NCT03400904). SETTING Sixty-three hospital sites worldwide, with patient recruitment from January 2018 to November 2020. PATIENTS One thousand one hundred fifty-two critically ill patients with acute brain injury, with a median age of 54 years, of whom 783 (68.0%) were male, 559 (48.5%) had traumatic brain injury, and 905 (78.6%) had a GCS-EM greater than 8 before extubation (scores range from 2 to 10). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS GCS-EM was computed in intubated patients on the day of extubation. The main outcome was extubation failure, defined as unplanned reintubation within 5 days of extubation. Analyses used multilevel logistic regression with adjustment for patient characteristics and a random intercept for hospital site. In the primary analysis, GCS-EM was not associated with extubation failure (odds ratio, 1.07 per additional point; 95% CI, 0.87-1.31). Findings were consistent in sensitivity analyses that: 1) used different adjustment covariates, 2) included a verbal estimate to derive an overall GCS, 3) accounted for missing data, 4) considered a 2-day time interval to define extubation failure, 5) accounted for competing risks, and 6) used a propensity score-based model. There was no association between GCS-EM and extubation outcome in subgroups defined by brain injury diagnosis or age. CONCLUSIONS In this large, contemporary, multicenter cohort of patients with acute brain injury, we found no association between the GCS-EM and odds of extubation failure. However, few patients had a pre-extubation GCS-EM less than or equal to 8, and the possibility of a true prognostic association in patients with low scores is not excluded.
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Affiliation(s)
- Shaurya Taran
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Bastien Perrot
- Nantes Université, Tours Université, INSERM, UMR 1246 MethodS in Patient-centered outcomes and HEalth REsearch, SPHERE, Nantes, France
| | - Federico Angriman
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Raphael Cinotti
- Nantes Université, Tours Université, INSERM, UMR 1246 MethodS in Patient-centered outcomes and HEalth REsearch, SPHERE, Nantes, France
- Department of Anaesthesia and Critical Care, CHU Nantes, Nantes Université, Hôtel Dieu, 44000, Nantes, France
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2
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I Cardi A, Drohan CM, Elmer J, Callaway CW, X Guyette F, Doshi AA, Rittenberger JC. The association of brainstem and motor recovery with awakening after out-of-hospital cardiac arrest. Resusc Plus 2022; 12:100332. [DOI: 10.1016/j.resplu.2022.100332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 10/29/2022] [Accepted: 10/30/2022] [Indexed: 12/13/2022] Open
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Bicciato G, Narula G, Brandi G, Eisele A, Schulthess S, Friedl S, Willms JF, Westphal L, Keller E. Functional NIRS to detect covert consciousness in neurocritical patients. Clin Neurophysiol 2022; 144:72-82. [PMID: 36306692 DOI: 10.1016/j.clinph.2022.10.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 10/01/2022] [Accepted: 10/03/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE This pilot study assesses the feasibility to detect covert consciousness in clinically unresponsive patients by means of functional near infrared spectroscopy (fNIRS) in a real intensive care unit setting. We aimed to verify if the hemodynamic response to familiar music measured with fNIRS varies according to the level consciousness of the patients. METHODS 22 neurocritical patients and 6 healthy controls were included. The experiment consisted in 3 subsequent blocks including a first resting state recording, a period of music playback and a second resting state recording. fNIRS measurement were performed on each subject with two optodes on the forehead. Main oscillatory frequencies of oxyhemoglobin signal were analyzed. Spectral changes of low frequency oscillations (LFO) between subsequent experimental blocks were used as a marker of cortical response. Cortical response was compared to the level of consciousness of the patients and their functional outcome, through validated clinical scores. RESULTS Cortical hemodynamic response to music on the left prefrontal brain was associated with the level of consciousness of the patients and with their clinical outcome after three months. CONCLUSIONS Variations in LFO spectral power measured with fNIRS may be a new marker of cortical responsiveness to detect covert consciousness in neurocritical patients. Left prefrontal cortex may play an important role in the perception of familiar music. SIGNIFICANCE We showed the feasibility of a simple fNIRS approach to detect cortical response in the real setting of an intensive care unit.
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Affiliation(s)
- Giulio Bicciato
- Neurocritical Care Unit, Department of Neurosurgery, Institute of Intensive Care Medicine, University Hospital, University of Zurich, 8091 Zurich, Switzerland; Department of Neurology, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland.
| | - Gagan Narula
- Neurocritical Care Unit, Department of Neurosurgery, Institute of Intensive Care Medicine, University Hospital, University of Zurich, 8091 Zurich, Switzerland
| | - Giovanna Brandi
- Neurocritical Care Unit, Department of Neurosurgery, Institute of Intensive Care Medicine, University Hospital, University of Zurich, 8091 Zurich, Switzerland
| | - Amanda Eisele
- Neurocritical Care Unit, Department of Neurosurgery, Institute of Intensive Care Medicine, University Hospital, University of Zurich, 8091 Zurich, Switzerland; Department of Neurology, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland
| | - Sven Schulthess
- Neurocritical Care Unit, Department of Neurosurgery, Institute of Intensive Care Medicine, University Hospital, University of Zurich, 8091 Zurich, Switzerland
| | - Susanne Friedl
- Neurocritical Care Unit, Department of Neurosurgery, Institute of Intensive Care Medicine, University Hospital, University of Zurich, 8091 Zurich, Switzerland
| | - Jan Folkard Willms
- Neurocritical Care Unit, Department of Neurosurgery, Institute of Intensive Care Medicine, University Hospital, University of Zurich, 8091 Zurich, Switzerland
| | - Laura Westphal
- Neurocritical Care Unit, Department of Neurosurgery, Institute of Intensive Care Medicine, University Hospital, University of Zurich, 8091 Zurich, Switzerland; Department of Neurology, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland
| | - Emanuela Keller
- Neurocritical Care Unit, Department of Neurosurgery, Institute of Intensive Care Medicine, University Hospital, University of Zurich, 8091 Zurich, Switzerland
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4
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Tamoto M, Imai T, Aida R, Harada Y, Wakabayashi Y, Satone G, Ichoda S, Unoki T, Shintani A. Survey of Glasgow Coma Scale and
PaO
2
/
FIO
2
ratio assessment methods for the Sequential Organ Failure Assessment score in Japanese intensive care units. Acute Med Surg 2022; 9:e785. [PMID: 36176324 PMCID: PMC9480922 DOI: 10.1002/ams2.785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 08/09/2022] [Accepted: 08/22/2022] [Indexed: 11/30/2022] Open
Abstract
Aim Accurately calculating the Sequential Organ Failure Assessment (SOFA) score is essential for medical resource allocation and decision‐making. This study surveyed Japanese intensive care units regarding their assessment of the Glasgow Coma Scale (GCS) and PaO2/FIO2 ratio, components of the SOFA score. Methods A cross‐sectional, web‐based survey was conducted among healthcare workers. The survey consisted of questions about the intensive care units where they work and questions for respondents. It was distributed to healthcare workers by e‐mail through the Japanese Society of Intensive Care Medicine mailing list and social networking service. Results Among 414 responses, we obtained 211 valid responses and 175 survey results from unique intensive care units. When assessing GCS in patients under the influence of sedatives, 45.1% (95% confidence interval, 37.6–52.8) of intensive care units assessed GCS assuming that the sedatives had no influence. For the PaO2/FIO2 ratio in the SOFA score, calculation based on the Japanese Intensive Care Patient Database definition document and mechanical ventilator settings were the most common methods in patients with oxygen masks and on extracorporeal membrane oxygenation, respectively. Approximately 60% of respondents indicated that it was difficult to assess GCS assuming that sedatives had no influence. Conclusion In patients under the influence of sedatives, approximately half of the intensive care units assessed assumed GCS. There was variation in the methods used to assess the PaO2/FIO2 ratio. Standardized assessment methods for GCS and the PaO2/FIO2 ratio are needed to obtain valid SOFA score.
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Affiliation(s)
- Mitsuhiro Tamoto
- Department of Medical Statistics, Graduate School of Medicine Osaka City University Osaka Japan
| | - Takumi Imai
- Department of Medical Statistics, Graduate School of Medicine Osaka City University Osaka Japan
| | - Rei Aida
- Department of Medical Statistics, Graduate School of Medicine Osaka City University Osaka Japan
| | - Yusuke Harada
- Department of Nursing Osaka City University Hospital Osaka Japan
| | - Yuki Wakabayashi
- Department of Nursing Kobe City Medical Center General Hospital Kobe Japan
| | - Gaku Satone
- Department of Nursing Teine Keijinkai Hospital Hokkaido Japan
| | | | - Takeshi Unoki
- Department of Acute and Critical Care Nursing, School of Nursing Sapporo City University Sapporo Hokkaido Japan
| | - Ayumi Shintani
- Department of Medical Statistics, Graduate School of Medicine Osaka City University Osaka Japan
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5
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Bodien Y, Barra A, Temkin N, Barber J, Foreman B, Vassar M, Robertson CS, Taylor SR, Markowitz AJ, Manley GT, Giacino J, Edlow BL. Diagnosing Level of Consciousness: The Limits of the Glasgow Coma Scale Total Score. J Neurotrauma 2021; 38:3295-3305. [PMID: 34605668 DOI: 10.1089/neu.2021.0199] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
In nearly all clinical and research contexts, the initial severity of a traumatic brain injury (TBI) is measured using the Glasgow Coma Scale (GCS) total score. However, the GCS total score may not accurately reflect level of consciousness, a critical indicator of injury severity. We investigated the relationship between GCS total scores and level of consciousness in a consecutive sample of 2,455 adult subjects assessed with the GCS 69,487 times as part of the multi-center Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study. We assigned each GCS subscale score combination a level of consciousness rating based upon published criteria for the following disorders of consciousness (DoC) diagnoses: coma, vegetative state/unresponsive wakefulness syndrome, minimally conscious state, and post-traumatic confusional state, and present our findings using summary statistics and four illustrative cases. Participants had the following characteristics: mean (standard deviation) age 41.9 (17.6) years, 69% male, initial GCS 3-8=13%; 9-12=5%; 13-15=82%. All GCS total scores between 4-14 were associated with more than one DoC diagnosis; the greatest variability was observed for scores of 7-11. Furthermore, a wide range of total scores were associated with identical DoC diagnoses. Importantly, a diagnosis of coma was only possible with GCS total scores of 3-6. The GCS total score does not accurately reflect level of consciousness based on published DoC diagnostic criteria. To improve the classification of patients with TBI and to inform the design of future clinical trials, clinicians and investigators should consider individual subscale behaviors and more comprehensive assessments when evaluating TBI severity.
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Affiliation(s)
- Yelena Bodien
- Massachusetts General Hospital, 2348, Neurology, Boston, Massachusetts, United States.,Spaulding Rehabilitation Hospital, 24498, Physical Medicine and Rehabilitation, Charlestown, Massachusetts, United States;
| | | | - Nancy Temkin
- University of Washington, 7284, Departments of Neurological Surgery and Biostatistics, Seattle, Washington, United States;
| | - Jason Barber
- University of Washington, 7284, Seattle, Washington, United States;
| | - Brandon Foreman
- University of Cincinnati, Neurology, Cincinnati, Ohio, United States;
| | - Mary Vassar
- University of California San Francisco, 8785, San Francisco, California, United States;
| | - Claudia S Robertson
- Baylor College of Medicine, Neurosurgery, One Baylor Plaza, Houston, Texas, United States, 77030;
| | - Sabrina R Taylor
- University of California San Francisco Department of Neurological Surgery, 189227, San Francisco, California, United States;
| | - Amy J Markowitz
- University of California, San Francisco, Brain and Spinal Injury Center (BASIC), 1001 Potrero Ave, Bldg 1 Rm 101, San Francisco, California, United States, 94110;
| | - Geoffrey T Manley
- University of California San Francisco, Neurosurgery, San Francisco, California, United States.,UCSF Weill Institute for Neurosciences, San Francisco, California, United States;
| | - Joseph Giacino
- Spaulding Rehabilitation Hospital, 24498, PM&R, 300 1st Ave, Charlestown, Massachusetts, United States, 02129-3109;
| | - Brian L Edlow
- Harvard Medical School, 1811, 175 Cambridge Street - Suite 300, Boston, Massachusetts, United States, 02115.,Massachusetts General Hospital, 2348, Athinoula A. Martinos Center for Biomedical Imaging, Boston, Massachusetts, United States;
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6
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Marzano LAS, de Castro FLM, Machado CA, de Barros JLVM, Macedo E Cordeiro T, Simões E Silva AC, Teixeira AL, Silva de Miranda A. Potential Role of Adult Hippocampal Neurogenesis in Traumatic Brain Injury. Curr Med Chem 2021; 29:3392-3419. [PMID: 34561977 DOI: 10.2174/0929867328666210923143713] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 07/28/2021] [Accepted: 08/18/2021] [Indexed: 11/22/2022]
Abstract
Traumatic brain injury (TBI) is a serious cause of disability and death among young and adult individuals, displaying complex pathophysiology including cellular and molecular mechanisms that are not fully elucidated. Many experimental and clinical studies investigated the potential relationship between TBI and the process by which neurons are formed in the brain, known as neurogenesis. Currently, there are no available treatments for TBI's long-term consequences being the search for novel therapeutic targets, a goal of highest scientific and clinical priority. Some studies evaluated the benefits of treatments aimed at improving neurogenesis in TBI. In this scenario, herein, we reviewed current pre-clinical studies that evaluated different approaches to improving neurogenesis after TBI while achieving better cognitive outcomes, which may consist in interesting approaches for future treatments.
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Affiliation(s)
- Lucas Alexandre Santos Marzano
- Laboratório Interdisciplinar de Investigação Médica (LIIM), Faculdade de Medicina, Universidade Federal de Minas Gerais (UFMG), Brazil
| | | | - Caroline Amaral Machado
- Laboratório de Neurobiologia, Departamento de Morfologia, Instituto de Ciências Biológicas, UFMG, Brazil
| | | | - Thiago Macedo E Cordeiro
- Laboratório Interdisciplinar de Investigação Médica (LIIM), Faculdade de Medicina, Universidade Federal de Minas Gerais (UFMG), Brazil
| | - Ana Cristina Simões E Silva
- Laboratório Interdisciplinar de Investigação Médica (LIIM), Faculdade de Medicina, Universidade Federal de Minas Gerais (UFMG), Brazil
| | - Antônio Lúcio Teixeira
- Neuropsychiatry Program, Department of Psychiatry and Behavioral Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, United States
| | - Aline Silva de Miranda
- Laboratório Interdisciplinar de Investigação Médica (LIIM), Faculdade de Medicina, Universidade Federal de Minas Gerais (UFMG), Brazil
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7
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Ercole A, Dixit A, Nelson DW, Bhattacharyay S, Zeiler FA, Nieboer D, Bouamra O, Menon DK, Maas AIR, Dijkland SA, Lingsma HF, Wilson L, Lecky F, Steyerberg EW. Imputation strategies for missing baseline neurological assessment covariates after traumatic brain injury: A CENTER-TBI study. PLoS One 2021; 16:e0253425. [PMID: 34358231 PMCID: PMC8345855 DOI: 10.1371/journal.pone.0253425] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 06/03/2021] [Indexed: 12/02/2022] Open
Abstract
Statistical models for outcome prediction are central to traumatic brain injury research and critical to baseline risk adjustment. Glasgow coma score (GCS) and pupil reactivity are crucial covariates in all such models but may be measured at multiple time points between the time of injury and hospital and are subject to a variable degree of unreliability and/or missingness. Imputation of missing data may be undertaken using full multiple imputation or by simple substitution of measurements from other time points. However, it is unknown which strategy is best or which time points are more predictive. We evaluated the pseudo-R2 of logistic regression models (dichotomous survival) and proportional odds models (Glasgow Outcome Score—extended) using different imputation strategies on the The Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study dataset. Substitution strategies were easy to implement, achieved low levels of missingness (<< 10%) and could outperform multiple imputation without the need for computationally costly calculations and pooling multiple final models. While model performance was sensitive to imputation strategy, this effect was small in absolute terms and clinical relevance. A strategy of using the emergency department discharge assessments and working back in time when these were missing generally performed well. Full multiple imputation had the advantage of preserving time-dependence in the models: the pre-hospital assessments were found to be relatively unreliable predictors of survival or outcome. The predictive performance of later assessments was model-dependent. In conclusion, simple substitution strategies for imputing baseline GCS and pupil response can perform well and may be a simple alternative to full multiple imputation in many cases.
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Affiliation(s)
- Ari Ercole
- Division of Anaesthesia, University of Cambridge, Cambridge, United Kingdom
- Centre for Artificial Intelligence in Medicine, University of Cambridge, Cambridge, United Kingdom
- * E-mail:
| | - Abhishek Dixit
- Division of Anaesthesia, University of Cambridge, Cambridge, United Kingdom
| | - David W. Nelson
- Section for Anesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | | | - Frederick A. Zeiler
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Daan Nieboer
- Department of Public Health, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Omar Bouamra
- Trauma Audit Research Network, University of Manchester, Salford, United Kingdom
| | - David K. Menon
- Division of Anaesthesia, University of Cambridge, Cambridge, United Kingdom
| | - Andrew I. R. Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Simone A. Dijkland
- Department of Public Health, Erasmus University Medical Center, Rotterdam, Netherlands
- Center for Medical Decision Making, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Hester F. Lingsma
- Department of Public Health, Erasmus University Medical Center, Rotterdam, Netherlands
- Center for Medical Decision Making, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Lindsay Wilson
- Division of Psychology, University of Stirling, Stirling, United Kingdom
| | - Fiona Lecky
- Centre for Urgent and Emergency Care Research (CURE), School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, United Kingdom
| | - Ewout W. Steyerberg
- Department of Public Health, Erasmus University Medical Center, Rotterdam, Netherlands
- Center for Medical Decision Making, Erasmus University Medical Center, Rotterdam, Netherlands
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, Netherlands
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8
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Kebapçı A, Dikeç G, Topçu S. Interobserver Reliability of Glasgow Coma Scale Scores for Intensive Care Unit Patients. Crit Care Nurse 2021; 40:e18-e26. [PMID: 32737493 DOI: 10.4037/ccn2020200] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Intensive care units frequently use the Glasgow Coma Scale to objectively assess patients' levels of consciousness. Interobserver reliability of Glasgow Coma Scale scores is critical in determining the degree of impairment. OBJECTIVE To evaluate interobserver reliability of intensive care unit patients' Glasgow Coma Scale scores. Methods This prospective observational study evaluated Glasgow Coma Scale scoring agreement among 21 intensive care unit nurses and 2 independent researchers who assessed 202 patients with neurosurgical or neurological diseases. Each assessment was completed independently and within 1 minute. Participants had no knowledge of the others' assessments. RESULTS Agreement between Glasgow Coma Scale component and sum scores recorded by the 2 researchers ranged from 89.5% to 95.9% (P = .001). Significant agreement among nurses and the 2 researchers was found for eye response (73.8%), motor response (75.0%), verbal response (68.1%), and sum scores (62.4%) (all P = .001). Significant agreement among nurses and the 2 researchers (55.2%) was also found for sum scores of patients with sum scores of 10 or less (P = .03). CONCLUSIONS Although the study showed near-perfect agreement between the 2 researchers' Glasgow Coma Scale scores, agreement among nurses and the 2 researchers was moderate (not near perfect) for subcomponent and sum scores. Accurate Glasgow Coma Scale evaluation requires that intensive care unit nurses have adequate knowledge and skills. Educational strategies such as simulations or orientation practice with a preceptor nurse can help develop such skills.
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Affiliation(s)
- Ayda Kebapçı
- Ayda Kebapçı is an assistant professor and Serpil Topçu is a lecturer in the Faculty of Nursing, Koç University, Istanbul, Turkey
| | - Gül Dikeç
- Gül Dikeç is an assistant professor in the Department of Psychiatric Nursing, Faculty of Nursing, University of Health Sciences, Istanbul
| | - Serpil Topçu
- Ayda Kebapçı is an assistant professor and Serpil Topçu is a lecturer in the Faculty of Nursing, Koç University, Istanbul, Turkey
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9
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Gélinas C, Bérubé M, Puntillo KA, Boitor M, Richard-Lalonde M, Bernard F, Williams V, Joffe AM, Steiner C, Marsh R, Rose L, Dale CM, Tsoller DM, Choinière M, Streiner DL. Validation of the Critical-Care Pain Observation Tool-Neuro in brain-injured adults in the intensive care unit: a prospective cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:142. [PMID: 33849619 PMCID: PMC8042624 DOI: 10.1186/s13054-021-03561-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 03/31/2021] [Indexed: 11/10/2022]
Abstract
Background Pain assessment in brain-injured patients in the intensive care unit (ICU) is challenging and existing scales may not be representative of behavioral reactions expressed by this specific group. This study aimed to validate the French-Canadian and English revised versions of the Critical-Care Pain Observation Tool (CPOT-Neuro) for brain-injured ICU patients. Methods A prospective cohort study was conducted in three Canadian and one American sites. Patients with a traumatic or a non-traumatic brain injury were assessed with the CPOT-Neuro by trained raters (i.e., research staff and ICU nurses) before, during, and after nociceptive procedures (i.e., turning and other) and non-nociceptive procedures (i.e., non-invasive blood pressure, soft touch). Patients who were conscious and delirium-free were asked to provide their self-report of pain intensity (0–10). A first data set was completed for all participants (n = 226), and a second data set (n = 87) was obtained when a change in the level of consciousness (LOC) was observed after study enrollment. Three LOC groups were included: (a) unconscious (Glasgow Coma Scale or GCS 4–8); (b) altered LOC (GCS 9–12); and (c) conscious (GCS 13–15). Results Higher CPOT-Neuro scores were found during nociceptive procedures compared to rest and non-nociceptive procedures in both data sets (p < 0.001). CPOT-Neuro scores were not different across LOC groups. Moderate correlations between CPOT-Neuro and self-reported pain intensity scores were found at rest and during nociceptive procedures (Spearman rho > 0.40 and > 0.60, respectively). CPOT-Neuro cut-off scores ≥ 2 and ≥ 3 were found to adequately classify mild to severe self-reported pain ≥ 1 and moderate to severe self-reported pain ≥ 5, respectively. Interrater reliability of raters’ CPOT-Neuro scores was supported with intraclass correlation coefficients > 0.69. Conclusions The CPOT-Neuro was found to be valid in this multi-site sample of brain-injured ICU patients at various LOC. Implementation studies are necessary to evaluate the tool’s performance in clinical practice. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03561-1.
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Affiliation(s)
- Céline Gélinas
- Ingram School of Nursing, McGill University, 680 Sherbrooke West St., Suite 1800, Montreal, QC, H3A 2M7, Canada. .,Centre for Nursing Research and Lady Davis Institute, Jewish General Hospital, CIUSSS West-Central Montreal, 3755 Côte-Sainte-Catherine Road, Montreal, QC, H3T 1E2, Canada.
| | - Mélanie Bérubé
- Faculty of Nursing, Université Laval, 1050 Avenue de la Médecine, Room 3486, Quebec City, QC, G1V 0A6, Canada.,Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec - Université Laval, 1401, 18e rue, Room Z-243, Quebec City, QC, G1J 1Z4, Canada
| | - Kathleen A Puntillo
- Physiological Nursing, University of California San Francisco, 2 Koret Way, San Francisco, CA, 94143, USA
| | - Madalina Boitor
- Faculty of Dentistry, McGill University, 3640 University St., Montreal, QC, H3A 0C7, Canada
| | - Melissa Richard-Lalonde
- Ingram School of Nursing, McGill University, 680 Sherbrooke West St., Suite 1800, Montreal, QC, H3A 2M7, Canada.,Centre for Nursing Research and Lady Davis Institute, Jewish General Hospital, CIUSSS West-Central Montreal, 3755 Côte-Sainte-Catherine Road, Montreal, QC, H3T 1E2, Canada
| | - Francis Bernard
- Équipe de Recherche en Soins Intensifs (ERESI), Research centre, Centre Intégré Universitaire de Santé et de Services Sociaux du Nord-de-l'île-de-Montréal, Hôpital du Sacré-Coeur-de-Montréal, 5400 boulevard Gouin Ouest, K-3000, Montreal, QC, H4J 1C4, Canada.,Department of Medicine, Université de Montréal, Succursale Centre-Ville, C.P. 6128, Montreal, QC, H3C 3J7, Canada
| | - Virginie Williams
- Équipe de Recherche en Soins Intensifs (ERESI), Research centre, Centre Intégré Universitaire de Santé et de Services Sociaux du Nord-de-l'île-de-Montréal, Hôpital du Sacré-Coeur-de-Montréal, 5400 boulevard Gouin Ouest, K-3000, Montreal, QC, H4J 1C4, Canada
| | - Aaron M Joffe
- School of Medicine, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA.,Harborview Medical Center, University of Washington Medicine, 325 9th Avenue, Seattle, WA, 98104, USA
| | - Craig Steiner
- School of Medicine, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Rebekah Marsh
- Harborview Medical Center, University of Washington Medicine, 325 9th Avenue, Seattle, WA, 98104, USA
| | - Louise Rose
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, 57 Waterloo Rd, London, SE1 8WA, UK.,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Suite 130, Toronto, ON, M5T 1P8, Canada
| | - Craig M Dale
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Suite 130, Toronto, ON, M5T 1P8, Canada.,Tory Trauma Program, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, M4N 3M5, Canada
| | - Darina M Tsoller
- Centre for Nursing Research and Lady Davis Institute, Jewish General Hospital, CIUSSS West-Central Montreal, 3755 Côte-Sainte-Catherine Road, Montreal, QC, H3T 1E2, Canada
| | - Manon Choinière
- Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Université de Montréal, Succursale Centre-Ville, C.P. 6128, Montreal, QC, H3C 3J7, Canada.,Research Center, Centre Hospitalier de l'Université de Montréal, Saint Antoine Building, Room S01-126, 850 Saint Denis St, Montreal, QC, H2X 0A9, Canada
| | - David L Streiner
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, St. Joseph's Healthcare, 100 West 5th Street, Box 585, Hamilton, ON, L8N 3K7, Canada
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Brennan PM, Murray GD, Teasdale GM. A practical method for dealing with missing Glasgow Coma Scale verbal component scores. J Neurosurg 2020; 135:214-219. [PMID: 32898843 DOI: 10.3171/2020.6.jns20992] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 06/11/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The Glasgow Coma Scale (GCS) is used for the assessment of impaired consciousness; however, it is not always possible to test each component, most commonly the verbal component. This affects the derivation of the GCS sum score, which has a role in systems for predicting patient outcome. Imputation of missing scores does not add extra information, but it does allow use of tools for predicting outcome that require complete data. The authors devised a simple and practical tool to employ when verbal component data are missing. They then assessed the tool's utility by application to the GCS-Pupils plus age plus CT findings (GCS-PA CT) prognostic model. METHODS The authors inspected data from the International Mission for Prognosis and Analysis of Clinical Trials in Traumatic Brain Injury (IMPACT) cohort to characterize the frequency of missing verbal scores. The authors identified a single verbal score to impute for each eye and motor combined sum (EM) score from distributions of verbal scores in a published database of 54,069 patients. The effectiveness of the imputed verbal score was assessed using a dataset containing information from the IMPACT and Corticosteroid Randomisation After Significant Head Injury (CRASH) databases. The authors compared the performance of the prognostic model using actual verbal scores with the performance using imputed verbal scores and assessed the information yield using Nagelkerke's R2 statistic. RESULTS Verbal data were most commonly missing in patients with no eye opening and with a motor score of 4 or less. The "simple" imputation model that was developed performed as well as a more complex model involving distinct combinations of eye and motor scores. The imputation model consisted of the following: EM scores 2-6, add 1; EM score 7, add 2; EM score 8 or 9, add 4; and EM score 10, add 5 to provide the GCS sum score. Modeling without information about the verbal score reduced the R2 from 32.1% to 31.4% and from 34.9% to 34.0% for predictions of death and favorable outcome at 6 months, respectively, compared with using full verbal score information. CONCLUSIONS This strategy is particularly valuable for imputation in clinical practice, enabling clinicians to make a rapid and reliable determination of the GCS sum score when the verbal component is not testable. This will support clinical communication and decisions based on estimates of injury severity as well as enable estimation of prognosis. The authors suggest that external validation of their imputation strategy and the performance of the GCS-PA charts should be undertaken in other clinical populations.
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Affiliation(s)
- Paul M Brennan
- 1Translational Neurosurgery, Centre for Clinical Brain Sciences, University of Edinburgh
| | | | - Graham M Teasdale
- 3Institute of Health and Wellbeing, University of Glasgow, United Kingdom
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Teparrukkul P, Hantrakun V, Imwong M, Teerawattanasook N, Wongsuvan G, Day NPJ, Dondorp AM, West TE, Limmathurotsakul D. Utility of qSOFA and modified SOFA in severe malaria presenting as sepsis. PLoS One 2019; 14:e0223457. [PMID: 31596907 PMCID: PMC6785116 DOI: 10.1371/journal.pone.0223457] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 09/20/2019] [Indexed: 12/22/2022] Open
Abstract
Sepsis can be caused by malaria infection, but little is known about the utility of the quick Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA) and SOFA score in malaria. We conducted a prospective observational study from March 2013 to February 2017 to examine adults admitted with community-acquired infection in a tertiary-care hospital in Ubon Ratchathani, Northeast Thailand (Ubon-sepsis). Subjects were classified as having sepsis if they had a modified SOFA score ≥2 within 24 hours of admission. Serum was stored and later tested for malaria parasites using a nested PCR assay. Presence of severe malaria was defined using modified World Health Organization criteria. Of 4,989 patients enrolled, 153 patients (3%) were PCR positive for either Plasmodium falciparum (74 [48%]), P. vivax (69 [45%]), or both organisms (10 [7%]). Of 153 malaria patients, 80 were severe malaria patients presenting with sepsis, 70 were non-severe malaria patients presenting with sepsis, and three were non-severe malaria patients presenting without sepsis. The modified SOFA score (median 5; IQR 4–6; range 1–18) was strongly correlated with malaria severity determined by the number of World Health Organization severity criteria satisfied by the patient (Spearman’s rho = 0.61, p<0.001). Of 80 severe malaria patients, 2 (2.5%), 11 (14%), 62 (77.5%) and 5 (6%), presented with qSOFA scores of 0, 1, 2 and 3, respectively. Twenty eight-day mortality was 1.3% (2/153). In conclusion, qSOFA and SOFA can serve as markers of disease severity in adults with malarial sepsis. Patients presenting with a qSOFA score of 1 may also require careful evaluation for sepsis; including diagnosis of cause of infection, initiation of medical intervention, and consideration for referral as appropriate.
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Affiliation(s)
- Prapit Teparrukkul
- Medical Department, Sunpasitthiprasong Hospital, Ubon Ratchthani, Thailand
| | - Viriya Hantrakun
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Mallika Imwong
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Molecular Tropical Medicine and Genetics, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | - Gumphol Wongsuvan
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Nicholas PJ. Day
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Arjen M. Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - T. Eoin West
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Direk Limmathurotsakul
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
- Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- * E-mail:
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Sirko A, Kyrpa I, Yovenko I, Miziakina K, Romanukha D. Successful Surgical Treatment of Severe Perforating Diametric Craniocerebral Gunshot Wound Sustained during Combat: A Case Report. Mil Med 2019; 184:e575-e580. [PMID: 30877796 DOI: 10.1093/milmed/usz041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 02/18/2019] [Accepted: 02/23/2019] [Indexed: 11/14/2022] Open
Abstract
Many researchers classify perforating diametric craniocerebral gunshot wounds as fatal because mortality exceeds 96% and the majority of patients with such injuries die before hospitalization. A 23-year-old Ukrainian male soldier was admitted to a regional hospital with a severe perforating craniocerebral wound in a comatose state (Glasgow Coma Scale score, 5). Following brain helical computed tomography, the patient underwent primary treatment of the cerebral wound with primary duraplasty and inflow/outflow drainage. After 18 days of treatment in the intensive care unit, he was transferred to a military hospital for further rehabilitation. This report details our unusual case of successful treatment of a perforating diametric craniocerebral gunshot wound.
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Affiliation(s)
- Andrii Sirko
- Neurosurgery Department, Mechnikov Dnipropetrovsk Regional Clinical Hospital, Dnipro, Ukraine
| | - Igor Kyrpa
- Neurosurgery Department, Mechnikov Dnipropetrovsk Regional Clinical Hospital, Dnipro, Ukraine
| | - Ihor Yovenko
- Anesthesiology and Intensive Therapy Department, Mechnikov Dnipropetrovsk Regional Clinical Hospital, Dnipro, Ukraine
| | - Kateryna Miziakina
- Nervous Diseases and Neurosurgery Department, Dnipropetrovsk State Medical Academy, The Ministry of Healthcare of Ukraine, Dnipro, Ukraine
| | - Dmytro Romanukha
- Nervous Diseases and Neurosurgery Department, Dnipropetrovsk State Medical Academy, The Ministry of Healthcare of Ukraine, Dnipro, Ukraine
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Oh TK, Song IA, Jeon YT. Impact of Glasgow Coma Scale scores on unplanned intensive care unit readmissions among surgical patients. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:520. [PMID: 31807502 DOI: 10.21037/atm.2019.10.06] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Physiological instability at discharge from intensive care units (ICU) is known to increase readmission rates among critically ill patients. However, associations between consciousness levels at discharge and readmission rates remain unclear. This study aimed to investigate the association between the Glasgow Coma Scale (GCS) score at discharge and unplanned ICU readmissions in surgical patients. Methods This retrospective cohort study in a single tertiary academic hospital analyzed the electronic health records of adults aged 18 years or older, who were discharged from the ICU between January 2012 and December 2018. The primary endpoint was unplanned readmission within 48 hours after discharge. Multivariable logistic regression analysis was performed. Results Among 9,512 patients, unplanned readmissions occurred in 161 (1.7%). At discharge, GCS and verbal response scores of ≤13 (vs. ≥14) were associated with 2.28-fold higher unplanned readmissions within 48 hours [odds ratio (OR): 2.35, 95% confidence interval (CI): 1.51-3.65, P<0.001]. Sensitivity analysis showed that verbal response scores of ≤4 (vs. 5) at ICU discharge were associated with 2.21-fold higher unplanned readmissions within 48 hours (OR: 2.21, 95% CI: 1.49-3.29, P<0.001), whereas eye or motor responses at time of ICU discharge were not significantly associated with unplanned readmissions (P>0.05). Conclusions In this surgical ICU population cohort, GCS scores at ICU discharge were significantly associated with unplanned readmissions within 48 hours. This association was stronger with GCS scores of ≤13 and with verbal response scores of ≤4 at time of discharge. These findings suggest that surgical ICU patients with GCS scores of ≤13 or verbal response scores of ≤4 should be monitored carefully for discharge in order to avoid unplanned ICU readmissions.
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Affiliation(s)
- Tak Kyu Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - In-Ae Song
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Young-Tae Jeon
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea.,Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul, South Korea
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Abstract
PURPOSE OF REVIEW This article discusses the diagnostic and therapeutic approach to patients who are comatose and reviews the current knowledge on prognosis from various causes of coma. This article also provides an overview of the principles for determination of brain death as well as advice on how to avoid common pitfalls. RECENT FINDINGS Technologic advances have refined our understanding of the physiology of consciousness and the spectrum of disorders of consciousness; they also promise to improve our prognostic accuracy. Yet the clinical principles for the evaluation and treatment of coma remain unaltered. The clinical standards for determination of death by neurologic criteria (ie, brain death) are also well established, although variabilities in local protocols and legal requirements remain a problem to be resolved. SUMMARY Effective evaluation of coma demands a systematic approach relying on clinical information to ensure rational use of laboratory and imaging tests. When the cause of coma is deemed irreversible in the setting of a catastrophic brain injury and no clinical evidence exists for brain and brainstem function, patients should be evaluated for the possibility of brain death by following the clinical criteria specified in the American Academy of Neurology guidelines.
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Yamaguchi H, Nagase H, Nishiyama M, Tokumoto S, Ishida Y, Tomioka K, Tanaka T, Fujita K, Toyoshima D, Nishimura N, Kurosawa H, Nozu K, Maruyama A, Tanaka R, Iijima K. Nonconvulsive Seizure Detection by Reduced-Lead Electroencephalography in Children with Altered Mental Status in the Emergency Department. J Pediatr 2019; 207:213-219.e3. [PMID: 30528574 DOI: 10.1016/j.jpeds.2018.11.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 10/04/2018] [Accepted: 11/07/2018] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To evaluate the proportion of children presenting to the emergency department (ED) with altered mental status who demonstrate nonconvulsive seizures on reduced-lead electroencephalography (EEG), and to further investigate the characteristics, treatment, and outcomes in these patients compared with patients without nonconvulsive seizures. STUDY DESIGN In this retrospective cohort study, we reviewed the database and medical records of pediatric patients (aged <18 years) in a single ED between May 1, 2016, and April 30, 2018. We first determined the proportion of nonconvulsive seizures among patients with altered mental status (Glasgow Coma Scale <15). We then compared the clinical presentation, demographic data, clinical diagnosis, EEG results, treatment, and outcomes of patients with altered mental status with nonconvulsive seizures and those without nonconvulsive seizures. RESULTS In total, 16.9% of the patients with altered mental status (41 of 242; 95% CI, 12.2%-21.6%) evaluated by EEG had detectable nonconvulsive seizure, equivalent to 4.4% (41 of 932) of all patients with altered mental status presenting at our hospital. More than 80% of patients monitored for nonconvulsive seizures had a previous history of seizures, often febrile. Patients with nonconvulsive seizures were older (median, 68.5 vs 36.1 months) and had a higher Pediatric Cerebral Performance Category score at presentation (median, 2.0 vs 1.0). In addition, the proportion of patients admitted to the intensive care unit was significantly higher in the patients with nonconvulsive seizures (30.3% vs 15.0%). However, total duration of hospitalization, neurologic sequelae, and 30-day mortality rate did not differ between the 2 groups. CONCLUSIONS A relatively high percentage of pediatric patients with altered mental status in the ED experience nonconvulsive seizures. The use of reduced-lead EEG monitoring in the ED might facilitate the recognition and treatment of nonconvulsive seizures, especially among patients with a history of seizures.
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Affiliation(s)
- Hiroshi Yamaguchi
- Department of Neurology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan; Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan.
| | - Hiroaki Nagase
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Masahiro Nishiyama
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Shoichi Tokumoto
- Department of Neurology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan; Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yusuke Ishida
- Department of Neurology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan; Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kazumi Tomioka
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Tsukasa Tanaka
- Department of Neurology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan; Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kyoko Fujita
- Department of Emergency and General Pediatrics, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Daisaku Toyoshima
- Department of Neurology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Noriyuki Nishimura
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroshi Kurosawa
- Department of Pediatric Critical Care Medicine, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Kandai Nozu
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Azusa Maruyama
- Department of Neurology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Ryojiro Tanaka
- Department of Emergency and General Pediatrics, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Kazumoto Iijima
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
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Hantrakun V, Somayaji R, Teparrukkul P, Boonsri C, Rudd K, Day NPJ, West TE, Limmathurotsakul D. Clinical epidemiology and outcomes of community acquired infection and sepsis among hospitalized patients in a resource limited setting in Northeast Thailand: A prospective observational study (Ubon-sepsis). PLoS One 2018; 13:e0204509. [PMID: 30256845 PMCID: PMC6157894 DOI: 10.1371/journal.pone.0204509] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 09/10/2018] [Indexed: 12/22/2022] Open
Abstract
Infection and sepsis are leading causes of death worldwide but the epidemiology and outcomes are not well understood in resource-limited settings. We conducted a four-year prospective observational study from March 2013 to February 2017 to examine the clinical epidemiology and outcomes of adults admitted with community-acquired infection in a resource-limited tertiary-care hospital in Ubon Ratchathani province, Northeast Thailand. Hospitalized patients with infection and accompanying systemic manifestations of infection within 24 hours of admission were enrolled. Subjects were classified as having sepsis if they had a modified sequential organ failure assessment (SOFA) score ≥2 at enrollment. This study was registered with ClinicalTrials.gov, number NCT02217592. A total of 4,989 patients were analyzed. Of the cohort, 2,659 (53%) were male and the median age was 57 years (range 18-101). Of these, 1,173 (24%) patients presented primarily to the study hospital, 3,524 (71%) were transferred from 25 district hospitals or 8 smaller hospitals in the province, and 292 (6%) were transferred from one of 30 hospitals in other provinces. Three thousand seven hundred and sixteen (74%) patients were classified as having sepsis. Patients with sepsis had an older age distribution and a greater prevalence of comorbidities compared to patients without sepsis. Twenty eight-day mortality was 21% (765/3,716) in sepsis and 4% (54/1,273) in non-sepsis patients (p<0.001). After adjusting for gender, age, and comorbidities, sepsis on admission (adjusted hazard ratio [HR] 3.30; 95% confidence interval [CI] 2.48-4.41, p<0.001), blood culture positive for pathogenic organisms (adjusted HR 2.21; 95% CI 1.89-2.58, p<0.001) and transfer from other hospitals (adjusted HR 2.18; 95% CI 1.69-2.81, p<0.001) were independently associated with mortality. In conclusion, mortality of community-acquired sepsis in Northeast Thailand is considerable and transferred patients with infection are at increased risk of death. To reduce mortality of sepsis in this and other resource-limited setting, facilitating rapid detection of sepsis in all levels of healthcare facilities, establishing guidelines for transfer of sepsis patients, and initiating sepsis care prior to and during transfer may be beneficial.
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Affiliation(s)
- Viriya Hantrakun
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Ranjani Somayaji
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, United States
| | | | | | - Kristina Rudd
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, United States
| | - Nicholas P. J. Day
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Churchill Hospital, Oxford, United Kingdom
| | - T. Eoin West
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, United States
| | - Direk Limmathurotsakul
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Churchill Hospital, Oxford, United Kingdom
- Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
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Lie KC, Lau CY, Van Vinh Chau N, West TE, Limmathurotsakul D. Utility of SOFA score, management and outcomes of sepsis in Southeast Asia: a multinational multicenter prospective observational study. J Intensive Care 2018; 6:9. [PMID: 29468069 PMCID: PMC5813360 DOI: 10.1186/s40560-018-0279-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 02/05/2018] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Sepsis is a global threat but insufficiently studied in Southeast Asia. The objective was to evaluate management, outcomes, adherence to sepsis bundles, and mortality prediction of maximum Sequential Organ Failure Assessment (SOFA) scores in patients with community-acquired sepsis in Southeast Asia. METHODS We prospectively recruited hospitalized adults within 24 h of admission with community-acquired infection at nine public hospitals in Indonesia (n = 3), Thailand (n = 3), and Vietnam (n = 3). In patients with organ dysfunction (total SOFA score ≥ 2), we analyzed sepsis management and outcomes and evaluated mortality prediction of the SOFA scores. Organ failure was defined as the maximum SOFA score ≥ 3 for an individual organ system. RESULTS From December 2013 to December 2015, 454 adult patients presenting with community-acquired sepsis due to diverse etiologies were enrolled. Compliance with sepsis bundles within 24 h of admission was low: broad-spectrum antibiotics in 76% (344/454), ≥ 1500 mL fluid in 50% of patients with hypotension or lactate ≥ 4 mmol/L (115/231), and adrenergic agents in 71% of patients with hypotension (135/191). Three hundred and fifty-five patients (78%) were managed outside of ICUs. Ninety-nine patients (22%) died. Total SOFA score on admission of those who subsequently died was significantly higher than that of those who survived (6.7 vs. 4.6, p < 0.001). The number of organ failures showed a significant correlation with 28-day mortality, which ranged from 7% in patients without any organ failure to 47% in those with failure of at least four organs (p < 0.001). The area under the receiver operating characteristic curve of the total SOFA score for discrimination of mortality was 0.68 (95% CI 0.62-0.74). CONCLUSIONS Community-acquired sepsis in Southeast Asia due to a variety of pathogens is usually managed outside the ICU and with poor compliance to sepsis bundles. In this population, calculation of SOFA scores is feasible and SOFA scores are associated with mortality. TRIAL REGISTRATION ClinicalTrials.gov, NCT02157259. Registered 5 June 2014, retrospectively registered.
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Affiliation(s)
- Khie Chen Lie
- Department of Internal Medicine, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Chuen-Yen Lau
- Collaborative Clinical Research Branch, Division of Clinical Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, USA
| | - Nguyen Van Vinh Chau
- Department of Internal Medicine, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
- Department of Internal Medicine, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - T. Eoin West
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, WA USA
- Department of Global Health, University of Washington, Seattle, WA USA
| | - Direk Limmathurotsakul
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Road, Bangkok, 10400 Thailand
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Lee HC, Lee WJ, Dho YS, Cho WS, Kim YH, Park HP. Optic nerve sheath diameter based on preoperative brain computed tomography and intracranial pressure are positively correlated in adults with hydrocephalus. Clin Neurol Neurosurg 2018; 167:31-35. [PMID: 29433056 DOI: 10.1016/j.clineuro.2018.02.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 01/11/2018] [Accepted: 02/06/2018] [Indexed: 12/01/2022]
Abstract
OBJECTIVE The usefulness of optic nerve sheath diameter (ONSD) in predicting increased intracranial pressure (ICP) is not well established in adults with hydrocephalus. In this retrospective study, we evaluated the correlation between ONSD measured on brain computed tomography (CT) and ICP in adults with hydrocephalus. PATIENTS AND METHODS ONSDs were measured on preoperative brain CT images from 64 adult patients with hydrocephalus who underwent extracranial ventricular drainage or a ventriculoperitoneal shunt in 2016. ICP was defined as ventricular fluid pressure. RESULTS The ONSD measured on preoperative CT was greater in patients (n = 8) with a higher ICP (>20 mmHg, 5.8vs. 4.9 mm, P = 0.001). The ONSD was linearly correlated with ICP (r = 0.543, P < 0.001) and was predictive of increased ICP with an area under the receiver operating characteristic curve of 0.834. The optimal cut-off value of 5.3 mm ONSD yielded 88% sensitivity and 79% specificity. The inter-class coefficient of ONSD on preoperative CT was 0.882. The correlation between ONSD on preoperative CT and ICP was detected only in patients with communicating and non-communicating hydrocephalus (r = 0.437 and r = 0.585, P = 0.037 and P = 0.002, respectively). CONCLUSION ONSD measured on preoperative brain CT was linearly correlated with ICP in adult patients with communicating and non-communicating hydrocephalus, and it was a predictor of increased ICP with good discrimination and high inter-observer reliability. These results suggest that preoperative ONSD measurement on brain CT can be helpful to safely manage such patients by providing information about ICP.
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Affiliation(s)
- Hyung-Chul Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Won-Jong Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Yun-Sik Dho
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Won-Sang Cho
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Yong Hwy Kim
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hee-Pyoung Park
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea.
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Alkosha HM, Zakaria WK. Outcome of Early versus Delayed Evacuation of Spontaneous Lobar Hematomas in Unconscious Adults. J Neurosci Rural Pract 2017; 8:525-534. [PMID: 29204009 PMCID: PMC5709872 DOI: 10.4103/jnrp.jnrp_190_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objective: To explore the difference in outcomes of medium-sized lobar hematomas evacuated in early versus delayed fashion among unconscious noncomatose individuals. Methods: A retrospective analysis of demographic, clinical, and radiological data of unconscious patients admitted with lobar hematomas during 18 years was performed. Time to surgery was compared in various patient variables and characteristics. Outcome groups (favorable and poor) were also compared to find out any association with surgery timing, as well as potential indicators of outcome and mortality. Results: The mean follow-up period in this study was 7.5 months after discharge. Two-thirds of the patients carried favorable prognosis at final follow-up with mortality (7.3%) included among poor cases. Time to surgery was not associated to any of the patient characteristics, except for international normalized ratio and associated chest problems which represented the main indicators of delayed surgery. Rebleeding after evacuation was associated with shorter time to surgery in clots ≤35 cc but not in the whole group. Poor outcome was significantly associated with higher basal glucose levels, bigger hematomas, rebleeding after surgery, and delayed evacuation of clots >35 cc. The presence of mild intraventricular hemorrhage (IVH) per se was not associated with increased mortality or poor outcome; however, its volume was. Conclusion: Smaller lobar hematomas (≤35 cc) in unconscious adults (Glasgow Coma Scale 8–13) may be managed with initial conservative treatment, while larger hematomas (>35 cc) are better evacuated as early as possible. Basal glucose levels and volume of mild IVH should be considered in the future management planes.
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Affiliation(s)
- Hazem M Alkosha
- Department of Neurosurgery, Mansoura University Hospital, Mansoura, Egypt
| | - Wael K Zakaria
- Department of Neurosurgery, Mansoura University Hospital, Mansoura, Egypt
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20
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Senapathi TGA, Wiryana M, Aribawa IGNM, Ryalino C. Bispectral index value correlates with Glasgow Coma Scale in traumatic brain injury patients. Open Access Emerg Med 2017; 9:43-46. [PMID: 28435334 PMCID: PMC5391833 DOI: 10.2147/oaem.s130643] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Accuracy of consciousness level assessment is very important. It may determine and influence further clinical decisions, thus influences patients’ outcomes. The widest method in determining the level of awareness is the Glasgow Coma Scale (GCS). Despite its common use, GCS scores obtained by one clinician may differ from others depending on their interpretations and past experience. One of the tools used to assess the level of consciousness objectively is bispectral index (BIS). The aim of this study was to identify the correlation between BIS and GCS score in patients with traumatic brain injury. Patients and Methods A total of 78 patients who were admitted to emergency room for traumatic brain injury were included in this study. One observer evaluated the GCS of all patients to minimize subjectivity. Another investigator then obtained the BIS values for each patient. Spear-man’s rank correlation coefficient was used to determine whether GCS correlated with BIS value. Results In 78 patients, the BIS was found to be significantly correlated with GCS (r=0.744, p<0.01). The BIS values increased with an increasing GCS. Mean BIS values of mild, moderate, and severe head injury were 88.1±5.6, 72.1±11.1, and 60.4±11.7, respectively. Conclusion In this study, a significant correlation existed between GCS and BIS. This finding suggests that BIS may be used for assessing GCS in patients with traumatic brain injury. However, the scatters of BIS values for any GCS level may limit the BIS in predicting GCS accurately.
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Affiliation(s)
- Tjokorda Gde Agung Senapathi
- Department of Anesthesiology and Intensive Care, Udayana University, Sanglah General Hospital, Denpasar, Bali, Indonesia
| | - Made Wiryana
- Department of Anesthesiology and Intensive Care, Udayana University, Sanglah General Hospital, Denpasar, Bali, Indonesia
| | | | - Christopher Ryalino
- Department of Anesthesiology and Intensive Care, Udayana University, Sanglah General Hospital, Denpasar, Bali, Indonesia
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21
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Braine ME, Cook N. The Glasgow Coma Scale and evidence-informed practice: a critical review of where we are and where we need to be. J Clin Nurs 2017; 26:280-293. [PMID: 27218835 DOI: 10.1111/jocn.13390] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2016] [Indexed: 12/16/2022]
Abstract
AIMS AND OBJECTIVES This paper aims to critically consider the evidence since the Glasgow Coma Scale was first launched, reflecting on how that evidence has shaped practice. It illustrates the lack of clarity and consensus about the use of the tool in practice and draws upon existing evidence to determine the route to clarity for an evidence-informed approach to practice. BACKGROUND The Glasgow Coma Scale has permeated and influenced practice for over 40 years, being well-established worldwide as the key tool for assessing level of consciousness. During this time, the tool has been scrutinised, evaluated, challenged and re-launched in a plethora of publications. This has led to an insight into the challenges, and to some extent the opportunities, in using the Glasgow Coma Scale in practice but has also resulted in a lack of clarity. DESIGN This is a discursive paper that invites readers to explore and arrive at a more comprehensive understanding of the Glasgow Coma Scale in practice and is based on searches of Scopus, Web of Knowledge, PubMed, Science Direct and CINAHL databases. RESULTS While the Glasgow Coma Scale has been rivalled by other tools in an attempt to improve upon it, a shift in practice to those tools has not occurred. The tool has withstood the test of time in this respect, indicating the need for further research into its use and a clear education strategy to standardise implementation in practice. CONCLUSION Further exploration is needed into the application of painful stimuli in using the Glasgow Coma Scale to assess level of consciousness. In addition, a robust educational strategy is necessary to maximise consistency in its use in practice. RELEVANCE TO CLINICAL PRACTICE The evidence illustrates inconsistency and confusion in the use of the Glasgow Coma Scale in practice; this has the potential to compromise care and clarity around the issues is therefore necessary.
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Affiliation(s)
- Mary E Braine
- School of Nursing, Midwifery, Social Work & Social Sciences, University of Salford, Salford, UK
| | - Neal Cook
- School of Nursing, Ulster University, Londonderry, UK
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22
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Cheng K, Bassil R, Carandang R, Hall W, Muehlschlegel S. The Estimated Verbal GCS Subscore in Intubated Traumatic Brain Injury Patients: Is it Really Better? J Neurotrauma 2016; 34:1603-1609. [PMID: 27774844 DOI: 10.1089/neu.2016.4657] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The Glasgow Coma Scale (GCS) has limited utility in intubated patients due to the inability to assign verbal subscores. The verbal subscore can be derived from the eye and motor subscores using a mathematical model, but the advantage of this method and its use in outcome prognostication in traumatic brain injury (TBI) patients remains unknown. We compared the validated "Core+CT"-IMPACT-model performance in 251 intubated TBI patients prospectively enrolled in the longitudinal OPTIMISM study between November 2009 and May 2015 when substituting the original motor GCS (mGCS) with the total estimated GCS (teGCS; with estimated verbal subscore). We hypothesized that model performance would improve with teGCS. Glasgow Outcome Scale (GOS) scores were assessed at 3 and 12 months by trained interviewers. In the complete case analysis, there was no statistically or clinically significant difference in the discrimination (C-statistic) at either time-point using the mGCS versus the teGCS (3 months: 0.893 vs. 0.871;12 months: 0.926 vs. 0.92). At 3 months, IMPACT-model calibration was excellent with mGCS and teGCS (Hosmer-Lemeshow "goodness-of-fit" chi square p value 0.9293 and 0.9934, respectively); it was adequate at 12 months with teGCS (0.5893) but low with mGCS (0.0158), possibly related to diminished power at 12 months. At both time-points, motor GCS contributed more to the variability of outcome (Nagelkerke ΔR2) than teGCS (3 months: 5.8% vs. 0.4%; 12 months: 5% vs. 2.6%). The sensitivity analysis with imputed missing outcomes yielded similar results, with improved calibration for both GCS variants. In our cohort of intubated TBI patients, there was no statistically or clinically meaningful improvement in the IMPACT-model performance by substituting the original mGCS with teGCS.
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Affiliation(s)
- Katarina Cheng
- 1 Department of Neurology, University of Massachusetts Medical School , Worcester, Massachusetts
| | - Ribal Bassil
- 1 Department of Neurology, University of Massachusetts Medical School , Worcester, Massachusetts
| | - Raphael Carandang
- 1 Department of Neurology, University of Massachusetts Medical School , Worcester, Massachusetts.,2 Department of Surgery, University of Massachusetts Medical School , Worcester, Massachusetts.,3 Department of Anesthesiology/Critical Care, University of Massachusetts Medical School , Worcester, Massachusetts
| | - Wiley Hall
- 1 Department of Neurology, University of Massachusetts Medical School , Worcester, Massachusetts.,2 Department of Surgery, University of Massachusetts Medical School , Worcester, Massachusetts
| | - Susanne Muehlschlegel
- 1 Department of Neurology, University of Massachusetts Medical School , Worcester, Massachusetts.,2 Department of Surgery, University of Massachusetts Medical School , Worcester, Massachusetts.,3 Department of Anesthesiology/Critical Care, University of Massachusetts Medical School , Worcester, Massachusetts
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23
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Baskin JZ, Panagopoulos G, Parks C, Komisar A. Predicting Outcome in Aged and Severely Ill Patients with Prolonged Respiratory Failure. Ann Otol Rhinol Laryngol 2016; 114:902-6. [PMID: 16425554 DOI: 10.1177/000348940511401202] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives: Consultations for tracheotomy are often sought on aged and severely ill patients with respiratory insufficiency. This patient population has high short-term mortality rates and is difficult to stratify on the basis of expected outcome. We examined whether APACHE III (Acute Physiology and Chronic Health Evaluation III) scores or neurologic status assessment (NSA) scores in sedated individuals are predictive of outcome. Methods: We performed a retrospective study examining aged patients who underwent tracheotomy for respiratory insufficiency and prolonged intubation. The APACHE III scores (n = 30) and NSA (based on a modified Glasgow Coma Scale) scores (n = 37) were calculated before tracheotomy. All patients were mildly sedated. Using APACHE III and NSA scores as predictor variables and using death and ability to be weaned from the ventilator as outcome variables, we performed a Kaplan-Meier survival analysis and a Cox proportional hazard regression. Results: The APACHE III was not significantly predictive of either outcome. Higher NSA scores were associated with increased survival rates (log rank = 19.7, p < .0001) and longer median survival (88 days versus 16 days for lower scorers). Higher NSA scores also predicted a higher rate of ventilator independence. Conclusions: Neurologic function in sedated patients (and not APACHE III scores) can be used to stratify aged individuals with respiratory insufficiency on the basis of expected outcome.
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Affiliation(s)
- Jonathan Z Baskin
- Department of Otolaryngology-Head and Neck Surgery, New York University School of Medicine, New York, New York, USA
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24
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Dick WF, Baskett PJF, Grande C, Delooz H, Kloeck W, Lackner C, Lipp M, Mauritz W, Nerlich M, Nicholl J, Nolan J, Oakley P, Parr M, Seekamp A, Soreide E, Steen PA, van Camp L, Wolcke B, Yates D. Recommendations for uniform reporting of data following major trauma - the Utstein style. TRAUMA-ENGLAND 2016. [DOI: 10.1177/146040860000200105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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25
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Lee JJ, Han SJ, Kim HS, Hong KS, Choi HH, Park KT, Seo JY, Lee TH, Kim HC, Kim S, Lee SH, Hwang SM, Ha SO. Out-of-hospital cardiac arrest patients treated with cardiopulmonary resuscitation using extracorporeal membrane oxygenation: focus on survival rate and neurologic outcome. Scand J Trauma Resusc Emerg Med 2016; 24:74. [PMID: 27193212 PMCID: PMC4870801 DOI: 10.1186/s13049-016-0266-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2015] [Accepted: 05/10/2016] [Indexed: 01/12/2023] Open
Abstract
Background Extracorporeal membrane oxygenation (ECMO) is a useful treatment for refractory out-of-hospital cardiac arrest (OHCA). However, little is known about the predictors of survival and neurologic outcome after ECMO. We analyzed our institution’s experience with ECMO for refractory OHCA and evaluated the predictors of survival and neurologic outcome after ECMO. Methods This was a retrospective review of the medical records of 23 patients who were treated with ECMO due to OHCA that was unresponsive to conventional cardiopulmonary resuscitation, between January 2009 and January 2014. Results Our ECMO team was activated within 10 min for refractory OHCA, and the 30-day survival rate was 43.5 %. In a multivariate analysis that evaluated independent factors contributing to mortality, urine output ≤ 0.5 mL · kg−1 · h−1 (defined as oliguria) during the 24 h after ECMO was statistically significant (OR, 32.271; 95 % CI, 1.379–755.282; p = 0.031). Just after ECMO implantation, 6 of the 9 patients (66.7 %) who had normal findings on brain computed tomography (CT) survived with a cerebral performance category (CPC) of grade 1. However, only 3 of the 11 patients (27 %) who had evidence of hypoxic brain damage on initial brain CT survived (their CPC grade was 4). Conclusions Based on our findings, the survival rate can be improved by rapid implantation of ECMO, and oliguria seen during the first 24 h after ECMO may be an independent predictor of mortality. Furthermore, findings on brain CT just after ECMO and subsequent images may represent an important predictor for neurologic outcome after ECMO.
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Affiliation(s)
- Jae Jun Lee
- Department of Anesthesiology, Hallym University Medical Center, Chuncheon, South Korea
| | - Sang Jin Han
- Division of Cardiology, Department of Internal Medicine, Hallym University Medical Center, Chuncheon, South Korea
| | - Hyoung Soo Kim
- Department of Thoracic and Cardiovascular Surgery, Hallym University Medical Center Sacred Heart Hospital, 22 Gwanpyeong-ro 170 beon-gil, Dongan-gu, Anyang-si, Gyeonggi-do, 431-070, South Korea.
| | - Kyung Soon Hong
- Division of Cardiology, Department of Internal Medicine, Hallym University Medical Center, Chuncheon, South Korea
| | - Hyun Hee Choi
- Division of Cardiology, Department of Internal Medicine, Hallym University Medical Center, Chuncheon, South Korea
| | - Kyu Tae Park
- Division of Cardiology, Department of Internal Medicine, Hallym University Medical Center, Chuncheon, South Korea
| | - Jeong Yeol Seo
- Department of Emergency Medicine, Hallym University Medical Center, Chuncheon, South Korea
| | - Tae Hun Lee
- Department of Emergency Medicine, Hallym University Medical Center, Chuncheon, South Korea
| | - Heung Cheol Kim
- Department of Radiology, Hallym University Medical Center, Chuncheon, South Korea
| | - Seonju Kim
- Department of Anesthesiology, Hallym University Medical Center, Chuncheon, South Korea
| | - Sun Hee Lee
- Department of Thoracic and Cardiovascular Surgery, Hallym University Medical Center Sacred Heart Hospital, 22 Gwanpyeong-ro 170 beon-gil, Dongan-gu, Anyang-si, Gyeonggi-do, 431-070, South Korea
| | - Sung Mi Hwang
- Department of Anesthesiology, Hallym University Medical Center, Chuncheon, South Korea
| | - Sang Ook Ha
- Department of Emergency Medicine, Hallym University Medical Center, Chuncheon, South Korea
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Reith FCM, Van den Brande R, Synnot A, Gruen R, Maas AIR. The reliability of the Glasgow Coma Scale: a systematic review. Intensive Care Med 2015; 42:3-15. [PMID: 26564211 DOI: 10.1007/s00134-015-4124-3] [Citation(s) in RCA: 129] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 10/26/2015] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The Glasgow Coma Scale (GCS) provides a structured method for assessment of the level of consciousness. Its derived sum score is applied in research and adopted in intensive care unit scoring systems. Controversy exists on the reliability of the GCS. The aim of this systematic review was to summarize evidence on the reliability of the GCS. METHODS A literature search was undertaken in MEDLINE, EMBASE and CINAHL. Observational studies that assessed the reliability of the GCS, expressed by a statistical measure, were included. Methodological quality was evaluated with the consensus-based standards for the selection of health measurement instruments checklist and its influence on results considered. Reliability estimates were synthesized narratively. RESULTS We identified 52 relevant studies that showed significant heterogeneity in the type of reliability estimates used, patients studied, setting and characteristics of observers. Methodological quality was good (n = 7), fair (n = 18) or poor (n = 27). In good quality studies, kappa values were ≥0.6 in 85%, and all intraclass correlation coefficients indicated excellent reliability. Poor quality studies showed lower reliability estimates. Reliability for the GCS components was higher than for the sum score. Factors that may influence reliability include education and training, the level of consciousness and type of stimuli used. CONCLUSIONS Only 13% of studies were of good quality and inconsistency in reported reliability estimates was found. Although the reliability was adequate in good quality studies, further improvement is desirable. From a methodological perspective, the quality of reliability studies needs to be improved. From a clinical perspective, a renewed focus on training/education and standardization of assessment is required.
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Affiliation(s)
- Florence C M Reith
- Department of Neurosurgery, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Belgium. .,University of Antwerp, Edegem, Belgium.
| | - Ruben Van den Brande
- Department of Neurosurgery, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Belgium.,University of Antwerp, Edegem, Belgium
| | - Anneliese Synnot
- Australian & New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Cochrane Consumers and Communication Review Group, Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Melbourne, Australia.,ANZIC-RC, Department of Epidemiology and Preventive Medicine, Monash University, The Alfred Hospital, Level 6, 99 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Russell Gruen
- Central Clinical School, Monash University, Melbourne, Australia.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.,Central Clinical School, Level 6, The Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Belgium.,University of Antwerp, Edegem, Belgium
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Clinical monitoring scales in acute brain injury: assessment of coma, pain, agitation, and delirium. Neurocrit Care 2015; 21 Suppl 2:S27-37. [PMID: 25208671 DOI: 10.1007/s12028-014-0025-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Serial clinical examination represents the most fundamental and basic form of neurological monitoring, and is often the first and only form of such monitoring in patients. Even in patients subjected to physiological monitoring using a range of technologies, the clinical examination remains an essential tool to follow neurological progress. Key aspects of the clinical examination have now been systematized into scoring schemes, and address consciousness, pain, agitation, and delirium (PAD). The Glasgow Coma Scale has been the traditional tool to measure consciousness, but the full outline of unresponsiveness (FOUR) score has recently been validated in a variety of settings, and at present, both represent clinically useful tools. Assessment of PAD in neurologically compromised patients present special challenges. For pain, the Numeric Rating Scale is the preferred initial approach, with either the Behavioral Pain Scale or the Critical Care Pain Observation Tool in subjects who are not able to respond. The Nociception Coma Scale-Revised may be useful in patients with severe disorders of consciousness. Conventional sedation scoring tools for critical care, such as the Richmond Area Sedation Scale (RASS) and Sedation-Agitation Scale (SAS) may provide reasonable tools in some neurocritical care patients. The use of sedative drugs and neuromuscular blockers may invalidate the use of some clinical examination tools in others. The use of sedation interruption to assess neurological status can result in physiological derangement in unstable patients (such as those with uncontrolled intracranial hypertension), and is not recommended.
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28
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Kim KI, Lee HS, Kim HS, Ha SO, Lee WY, Park SJ, Lee SH, Lee TH, Seo JY, Choi HH, Park KT, Han SJ, Hong KS, Hwang SM, Lee JJ. The pre-ECMO simplified acute physiology score II as a predictor for mortality in patients with initiation ECMO support at the emergency department for acute circulatory and/or respiratory failure: a retrospective study. Scand J Trauma Resusc Emerg Med 2015; 23:59. [PMID: 26283075 PMCID: PMC4538750 DOI: 10.1186/s13049-015-0135-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 07/14/2015] [Indexed: 12/27/2022] Open
Abstract
Background In the emergency department (ED), extracorporeal membrane oxygenation (ECMO) can be used as a rescue treatment modality for patients with refractory circulatory and/or respiratory failure. Serious consideration must be given to the indication, and the PRESERVE and RESP scores for mortality have been investigated. However these scores were validated to predict survival in patients who received mainly veno-venous (VV) ECMO in the intensive care unit. The aim of the present study was to investigate the factors that predicted the outcomes for patients who received mixed mode (veno-arterial [VA] and VV) ECMO support in the ED. Methods This single center retrospective study included 65 patients who received ECMO support at the ED for circulatory or respiratory failure between January 2009 and December 2013. Pre-ECMO SAPS II and other variables were evaluated and compared for predicting mortality. Results Fifty-four percent of patients received ECMO-cardiopulmonary resuscitation (E-CPR), 31 % received VA and V-AV ECMO, and 15 % received VV ECMO. The 28-day and 60-month mortality rates were 52 % and 63 %. In the multivariate analysis, only the pre-ECMO Simplified Acute Physiology Score II (SAPS II) (odd ratio: 1.189, 95 % confidence interval: 1.032–1.370, p = 0.016) could predict the 28-day mortality. The area under the receiver operating characteristic curve and the optimal cutoff value for pre-ECMO SAPS II in predicting 28-day mortality was 0.852 (95 % CI: 0.753–0.951, p < 0.001) and 80 (sensitivity of 97.1 % and specificity of 71.0 %), respectively. Validation of the 80 cutoff value revealed a statistically significant difference for the 28-day and 60-month mortality rates in the overall, E-CPR, and VA groups (28-day: p < 0.001, p = 0.004, p = 0.005; 60-month: p < 0.001, p = 0.004, p = 0.020). In the Kaplan-Meier analysis, the 28-day and 60-month survival rates were lower among the patients with a pre-ECMO SAPS II of ≤80, compared to those with a score of >80 (both, p < 0.001). Conclusion The pre-ECMO SAPS II could be helpful for identifying patients with refractory acute circulatory and/or respiratory failure who will respond to ECMO support in the ED.
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Affiliation(s)
- Kun Il Kim
- Department of Thoracic and Cardiovascular Surgery, Hallym University Sacred Heart Hospital, Hallym University Medical Center, 22, Gwanpyeong-ro 170 beon-gil, Donan-gu, Anyang-si, Gyeonggi-do, 431-070, South Korea.
| | - Hee Sung Lee
- Department of Thoracic and Cardiovascular Surgery, Hallym University Sacred Heart Hospital, Hallym University Medical Center, 22, Gwanpyeong-ro 170 beon-gil, Donan-gu, Anyang-si, Gyeonggi-do, 431-070, South Korea.
| | - Hyoung Soo Kim
- Department of Emergency Medicine, Hallym University Medical Center, Kyoungki-do, South Korea.
| | - Sang Ook Ha
- Department of Emergency Medicine, Hallym University, Chuncheon, South Korea.
| | - Won Yong Lee
- Department of Emergency Medicine, Hallym University Medical Center, Kyoungki-do, South Korea.
| | - Sang Jun Park
- Department of Emergency Medicine, Hallym University Medical Center, Kyoungki-do, South Korea.
| | - Sun Hee Lee
- Department of Emergency Medicine, Hallym University Medical Center, Kyoungki-do, South Korea.
| | - Tae Hun Lee
- Division of Cardiology, Department of Internal Medicine, Hallym University, Chuncheon, South Korea.
| | - Jeong Yeol Seo
- Division of Cardiology, Department of Internal Medicine, Hallym University, Chuncheon, South Korea.
| | - Hyun Hee Choi
- Department of Anesthesiology, School of Medicine, Hallym University, Chuncheon, South Korea.
| | - Kyu Tae Park
- Department of Anesthesiology, School of Medicine, Hallym University, Chuncheon, South Korea.
| | - Sang Jin Han
- Department of Anesthesiology, School of Medicine, Hallym University, Chuncheon, South Korea.
| | - Kyung Soon Hong
- Department of Anesthesiology, School of Medicine, Hallym University, Chuncheon, South Korea.
| | - Sung Mi Hwang
- Department of Anesthesiology, School of Medicine, Hallym University, Chuncheon, South Korea.
| | - Jae Jun Lee
- Department of Anesthesiology, School of Medicine, Hallym University, Chuncheon, South Korea.
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Henninger N, Izzy S, Carandang R, Hall W, Muehlschlegel S. Severe leukoaraiosis portends a poor outcome after traumatic brain injury. Neurocrit Care 2015; 21:483-95. [PMID: 24752459 DOI: 10.1007/s12028-014-9980-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND PURPOSE It is now well accepted that traumatic white matter injury constitutes a critical determinant of post-traumatic functional impairment. However, the contribution of preexisting white matter rarefaction on outcome following traumatic brain injury (TBI) is unknown. Hence, we sought to determine whether the burden of preexisting leukoaraiosis of presumed ischemic origin is independently associated with outcome after TBI. METHODS We retrospectively analyzed consecutive, prospectively enrolled patients of ≥50 years (n = 136) who were admitted to a single neurological/trauma intensive care unit. Supratentorial white matter hypoattenuation on head CT was graded on a 5-point scale (range 0-4) reflecting increasing severity of leukoaraiosis. Outcome was ascertained according to the modified Rankin Scale (mRS) and Glasgow outcome scale (GOS) at 3 and 12 months, respectively. RESULTS After adjustment for other factors, leukoaraiosis severity was significantly associated with a poor outcome at 3 and 12 months defined as mRS 3-6 and GOS 1-3, respectively. The independent association between leukoaraiosis and poor outcome remained when the analysis was restricted to patients who survived up to 3 months, had moderate-to-severe TBI [enrollment Glasgow Coma Scale (GCS) ≤12; p = 0.001], or had mild TBI (GCS 13-15; p = 0.002), respectively. CONCLUSION We provide first evidence that preexisting cerebral small vessel disease independently predicts a poor functional outcome after closed head TBI. This association is independent of other established outcome predictors such as age, comorbid state as well as intensive care unit complications and interventions. This knowledge may help improve prognostic accuracy, clinical management, and resource utilization.
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Affiliation(s)
- Nils Henninger
- Department of Neurology, University of Massachusetts Medical School, 55 Lake Ave, North, Worcester, MA, 01655, USA,
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Detecting pain in traumatic brain-injured patients with different levels of consciousness during common procedures in the ICU: typical or atypical behaviors? Clin J Pain 2015; 30:960-9. [PMID: 24480910 DOI: 10.1097/ajp.0000000000000061] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Pain behaviors such as grimacing and muscle rigidity are recommended for pain assessment in nonverbal populations. However, these behaviors may not be appropriate for critically ill patients with a traumatic brain injury (TBI) depending on their level of consciousness (LOC). This study aimed to validate the use of behaviors for assessing pain of critically ill TBI adults with different LOC. METHODS Using a repeated measure within subject design, participants (N=45) were observed for 1 minute before (baseline), during, and 15 minutes after 2 procedures: (1) noninvasive blood pressure: NIBP (non-nociceptive); and (2) turning (nociceptive). A behavioral checklist combining 50 items from existing pain assessment tools and video recording were used to describe participants' behaviors. Intrarater and interrater agreements of observed behaviors were also examined. RESULTS Overall, pain behaviors were observed more frequently during turning (median=4; T=-5.336; P≤0.001) than at baseline (median=1), or during noninvasive blood pressure (median=0). TBI patients' pain behaviors were mostly "atypical" and included uncommon responses such as flushing, sudden eye opening, eye weeping, and flexion of limbs. These behaviors were observed in ≥25.0% of TBI participants during turning independent of their LOC, and in 22.2% to 66.7% of conscious participants who reported the presence of pain. Agreements were >92% among and between the 2 raters. CONCLUSIONS This study support previous findings that critically ill TBI patients could exhibit atypical behaviors when exposed to nociceptive procedures. As such, use of current recommended pain behaviors as part of standardized scales may not be optimal for assessing the analgesic needs of this vulnerable group.
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Choi KJ, Ryu JA, Park CM. Respiratory Complications of Small-Bore Feeding Tube Insertion in Critically Ill Patients. JOURNAL OF ACUTE CARE SURGERY 2015. [DOI: 10.17479/jacs.2015.5.1.28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Kyoung-Jin Choi
- Departments of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong-Am Ryu
- Departments of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Chi-Min Park
- Departments of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Departments of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Kochar GS, Gulati S, Lodha R, Pandey R. Full outline of unresponsiveness score versus Glasgow Coma Scale in children with nontraumatic impairment of consciousness. J Child Neurol 2014; 29:1299-304. [PMID: 24532807 DOI: 10.1177/0883073813514293] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The study was designed to compare the Full Outline of UnResponsiveness score with Glasgow Coma Scale as a predictor of mortality and poor functional outcome at hospital discharge in children with nontraumatic impairment of consciousness. Seventy children aged 5 to 18 years admitted with impaired consciousness were enrolled. The scores were applied by the Pediatric Neurology fellow within 2 hours of admission. The primary outcome studied was in-hospital mortality. Receiver operating characteristic curves were used to compare the 2 scores. The area under the curves for Glasgow Coma Scale and Full Outline of UnResponsiveness scores were 0.916 and 0.940, respectively. However, the difference between the areas under curve for the 2 scores was not statistically significant (0.023; 95% confidence interval: -0.0115 to 0.058). Our data indicate that both the scores are good predictors for in-hospital mortality and functional outcome. However, no significant difference was observed between the ability of the 2 scores to predict the outcomes.
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Affiliation(s)
- Gurpreet Singh Kochar
- Department of Pediatrics, Division of Pediatric Neurology, All India Institute of Medical Sciences, New Delhi, India Department of Pediatric Neurology, SPS Apollo Hospital, Ludhiana (Punjab), India
| | - Sheffali Gulati
- Department of Pediatrics, Division of Pediatric Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Rakesh Lodha
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Rm Pandey
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
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Teasdale G, Maas A, Lecky F, Manley G, Stocchetti N, Murray G. The Glasgow Coma Scale at 40 years: standing the test of time. Lancet Neurol 2014; 13:844-54. [PMID: 25030516 DOI: 10.1016/s1474-4422(14)70120-6] [Citation(s) in RCA: 514] [Impact Index Per Article: 51.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Since 1974, the Glasgow Coma Scale has provided a practical method for bedside assessment of impairment of conscious level, the clinical hallmark of acute brain injury. The scale was designed to be easy to use in clinical practice in general and specialist units and to replace previous ill-defined and inconsistent methods. 40 years later, the Glasgow Coma Scale has become an integral part of clinical practice and research worldwide. Findings using the scale have shown strong associations with those obtained by use of other early indices of severity and outcome. However, predictive statements should only be made in combination with other variables in a multivariate model. Individual patients are best described by the three components of the coma scale; whereas the derived total coma score should be used to characterise groups. Adherence to this principle and enhancement of the reliable practical use of the scale through continuing education of health professionals, standardisation across different settings, and consensus on methods to address confounders will maintain its role in clinical practice and research in the future.
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Affiliation(s)
- Graham Teasdale
- Mental Health and Wellbeing, Institute of Health and Wellbeing College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK.
| | - Andrew Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Fiona Lecky
- Emergency Medicine Research in Sheffield, Health Services Research Section, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Geoffrey Manley
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Nino Stocchetti
- Department of Pathophysiology and Transplantation, Milan University, and Neuroscience ICU, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Gordon Murray
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
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Glasgow Coma Scale score dominates the association between admission Sequential Organ Failure Assessment score and 30-day mortality in a mixed intensive care unit population. J Crit Care 2014; 29:780-5. [PMID: 25012961 DOI: 10.1016/j.jcrc.2014.05.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Revised: 04/25/2014] [Accepted: 05/22/2014] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The Sequential Organ Failure Assessment (SOFA) score, a measure of multiple-organ dysfunction syndrome, is used to predict mortality in critically ill patients by assigning equally weighted scores across 6 different organ systems. We hypothesized that specific organ systems would have a greater association with mortality than others. DESIGN We retrospectively studied patients admitted over a period of 4.2 years to a mixed-profile intensive care unit (ICU). We recorded age and comorbidities, and calculated SOFA organ scores. The primary outcome was 30-day all-cause mortality. We determined which organ subscores of the SOFA score were most associated with mortality using multiple analytic methods: random forests, conditional inference trees, distanced-based clustering techniques, and logistic regression. SETTING A 24-bed mixed-profile adult ICU that cares for medical, surgical, and trauma (level 1) patients at an academic referral center. PATIENTS All patients' first admission to the study ICU during the study period. MEASUREMENTS AND MAIN RESULTS We identified 9120 first admissions during the study period. Overall 30-day mortality was 12%. Multiple analytical methods all demonstrated that the best initial prediction variables were age and the central nervous system SOFA subscore, which is determined solely by Glasgow Coma Scale score. CONCLUSIONS In a mixed population of critically ill patients, the Glasgow Coma Scale score dominates the association between admission SOFA score and 30-day mortality. Future research into outcomes from multiple-organ dysfunction may benefit from new models for measuring organ dysfunction with special attention to neurologic dysfunction.
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Arbour C, Choinière M, Topolovec-Vranic J, Loiselle CG, Gélinas C. Can fluctuations in vital signs be used for pain assessment in critically ill patients with a traumatic brain injury? PAIN RESEARCH AND TREATMENT 2014; 2014:175794. [PMID: 24639895 PMCID: PMC3929987 DOI: 10.1155/2014/175794] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/07/2013] [Revised: 10/18/2013] [Accepted: 11/06/2013] [Indexed: 11/17/2022]
Abstract
Background. Many critically ill patients with a traumatic brain injury (TBI) are unable to communicate. While observation of behaviors is recommended for pain assessment in nonverbal populations, they are undetectable in TBI patients who are under the effects of neuroblocking agents. Aim. This study aimed to validate the use of vital signs for pain detection in critically ill TBI patients. Methods. Using a repeated measure within subject design, participants (N = 45) were observed for 1 minute before (baseline), during, and 15 minutes after two procedures: noninvasive blood pressure: NIBP (nonnociceptive) and turning (nociceptive). At each assessment, vital signs (e.g., systolic, diastolic, mean arterial pressure (MAP), heart rate (HR), respiratory rate (RR), capillary saturation (SpO2), end-tidal CO2, and intracranial pressure (ICP)) were recorded. Results. Significant fluctuations (P < 0.05) in diastolic (F = 6.087), HR (F = 3.566), SpO2 (F = 5.740), and ICP (F = 3.776) were found across assessments, but they were similar during both procedures. In contrast, RR was found to increase exclusively during turning (t = 3.933; P < 0.001) and was correlated to participants' self-report. Conclusions. Findings from this study support previous ones that vital signs are not specific for pain detection. While RR could be a potential pain indicator in critical care, further research is warranted to support its validity in TBI patients with different LOC.
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Affiliation(s)
- Caroline Arbour
- McGill University, Ingram School of Nursing, Montreal, Quebec, Canada H3A 2A7
- Centre for Nursing Research and Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada H3T 1E2
- Quebec Nursing Intervention Research Network (RRISIQ), Montreal, Quebec, Canada H3A 2A7
- The Alan Edwards Center for Research on Pain, McGill University, Montreal, Quebec, Canada H3A 0G1
| | - Manon Choinière
- Department of Anaesthesiology, Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Université de Montréal, Montreal, Quebec, Canada H2X 0A9
| | - Jane Topolovec-Vranic
- Trauma & Neurosurgery Program and Keenan Research Center of the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada M5B 1W8
| | - Carmen G. Loiselle
- McGill University, Ingram School of Nursing, Montreal, Quebec, Canada H3A 2A7
- Centre for Nursing Research and Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada H3T 1E2
- Quebec Nursing Intervention Research Network (RRISIQ), Montreal, Quebec, Canada H3A 2A7
| | - Céline Gélinas
- McGill University, Ingram School of Nursing, Montreal, Quebec, Canada H3A 2A7
- Centre for Nursing Research and Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada H3T 1E2
- Quebec Nursing Intervention Research Network (RRISIQ), Montreal, Quebec, Canada H3A 2A7
- The Alan Edwards Center for Research on Pain, McGill University, Montreal, Quebec, Canada H3A 0G1
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Muñana-Rodríguez J, Ramírez-Elías A. Escala de coma de Glasgow: origen, análisis y uso apropiado. ENFERMERÍA UNIVERSITARIA 2014. [DOI: 10.1016/s1665-7063(14)72661-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Determination of Tobramycin Pharmacokinetics in Burn Patients to Evaluate the Potential Utility of Once-Daily Dosing in this Population. J Burn Care Res 2014; 35:e240-9. [DOI: 10.1097/bcr.0b013e3182a226fb] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Recommendations for Uniform Reporting of Data following Major Trauma — The Utstein Style: An Initiative. Prehosp Disaster Med 2012. [DOI: 10.1017/s1049023x00027473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The document is published in collaboration with the following organisations: the European Society of Emergency Medicine (Leuven); the European Resuscitation Council (Antwerpen); the Air Medical Physician Association (Salt Lake City, US); the German Interdisciplinary Association of Critical Care Medicine; and the German Society of Anaesthesiology and Intensive Care. The document is to be published jointly in the following journals: 1) Trauma Care (ITACCS); 2) Resuscitation; 3) Prehospital and Disaster Medicine; 4) European Journal of Emergency Medicine; 5) Trauma and Emergency Medicine Journal (SA); 6) Emergency Medicine(Norway); 7) JEUR; and 8) Notfall und Rettungsmedizin (Germany).
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Effect of the modified Glasgow Coma Scale score criteria for mild traumatic brain injury on mortality prediction: comparing classic and modified Glasgow Coma Scale score model scores of 13. ACTA ACUST UNITED AC 2011; 71:1185-92; discussion 1193. [PMID: 22071923 DOI: 10.1097/ta.0b013e31823321f8] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND The Glasgow Coma Scale (GCS) classifies traumatic brain injuries (TBIs) as mild (14-15), moderate (9-13), or severe (3-8). The Advanced Trauma Life Support modified this classification so that a GCS score of 13 is categorized as mild TBI. We investigated the effect of this modification on mortality prediction, comparing patients with a GCS score of 13 classified as moderate TBI (classic model) to patients with GCS score of 13 classified as mild TBI (modified model). METHODS We selected adult TBI patients from the Pennsylvania Outcome Study database. Logistic regressions adjusting for age, sex, cause, severity, trauma center level, comorbidities, and isolated TBI were performed. A second evaluation included the time trend of mortality. A third evaluation also included hypothermia, hypotension, mechanical ventilation, screening for drugs, and severity of TBI. Discrimination of the models was evaluated using the area under receiver operating characteristic curve (AUC). Calibration was evaluated using the Hosmer-Lemershow goodness of fit test. RESULTS In the first evaluation, the AUCs were 0.922 (95% CI, 0.917-0.926) and 0.908 (95% CI, 0.903-0.912) for classic and modified models, respectively. Both models showed poor calibration (p < 0.001). In the third evaluation, the AUCs were 0.946 (95% CI, 0.943-0.949) and 0.938 (95% CI, 0.934-0.940) for the classic and modified models, respectively, with improvements in calibration (p = 0.30 and p = 0.02 for the classic and modified models, respectively). CONCLUSION The lack of overlap between receiver operating characteristic curves of both models reveals a statistically significant difference in their ability to predict mortality. The classic model demonstrated better goodness of fit than the modified model. A GCS score of 13 classified as moderate TBI in a multivariate logistic regression model performed better than a GCS score of 13 classified as mild.
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Vivien B, Yeguiayan JM, Le Manach Y, Bonithon-Kopp C, Mirek S, Garrigue D, Freysz M, Riou B. The motor component does not convey all the mortality prediction capacity of the Glasgow Coma Scale in trauma patients. Am J Emerg Med 2011; 30:1032-41. [PMID: 22035584 DOI: 10.1016/j.ajem.2011.06.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2011] [Accepted: 06/25/2011] [Indexed: 10/15/2022] Open
Abstract
PURPOSE We tested the hypothesis that the motor component of the Glasgow Coma Scale (GCS) conveys most of the predictive information of triage scores (Triage Revised Trauma Score [T-RTS] and the Mechanism, GCS, Age, arterial Pressure score [MGAP]) in trauma patients. METHOD We conducted a multicenter prospective observational study and evaluated 1690 trauma patients in 14 centers. We compared the GCS, T-RTS, MGAP, and Trauma Related Injury Severity Score (reference standard) using the full GCS or its motor component only using logistic regression model, area under the receiver operating characteristic curve, and reclassification technique. RESULTS Although some changes were noted for the GCS itself and the Trauma Related Injury Severity Score, no significant change was observed using the motor component only for T-RTS and MGAP when considering (1) the odds ratio of variables included in the logistic model as well as their discrimination and calibration characteristics, (2) the area under the receiver operating characteristic curve (0.827 ± 0.014 vs 0.831 ± 0.014, P = .31 and 0.863 ± 0.011 vs 0.859 ± 0.012, P = .23, respectively), and (3) the reclassification technique. Although the mortality rate remained less than the predetermined threshold of 5% in the low-risk stratum, it slightly increased for MGAP (from 1.9% to 3.9%, P = .048). CONCLUSION The use of the motor component only of the GCS did not change the global performance of triage scores in trauma patients. However, because a subtle increase in mortality rate was observed in the low-risk stratum for MGAP, replacing the GCS by its motor component may not be recommended in every situation.
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Affiliation(s)
- Benoît Vivien
- University Paris Descartes-Paris 5, Service d'Aide Médicale Urgente (SAMU) 75 and Department of Anesthesiology and Critical Care, Centre Hospitalo-Universitaire (CHU) Necker-Enfants Malades, Paris, France
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Namiki J, Yamazaki M, Funabiki T, Hori S. Inaccuracy and misjudged factors of Glasgow Coma Scale scores when assessed by inexperienced physicians. Clin Neurol Neurosurg 2011; 113:393-8. [DOI: 10.1016/j.clineuro.2011.01.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2010] [Revised: 09/17/2010] [Accepted: 01/02/2011] [Indexed: 10/18/2022]
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Abstract
Numerous scoring scales have been proposed and validated to evaluate coma for rapid pre-hospital assessment and triage, disease severity, and prognosis for morbidity and mortality. These scoring systems have been predicated on core features that serve as a basis for this review and include ease of use, inter-rater reliability, reproducibility, and predictive value. Here we review the benefits and limitations of the most popular coma scoring systems. The methods include search of Medline, databases, and manual review of article bibliographies. Few of the many available coma scales have gained widespread approval and popularity. The best known and widely accepted scale is the Glasgow Coma Scale (GCS). The Reaction Level Scale (RLS85) has utility and proven benefit, but little acceptance outside of Scandinavia. The newer Full Outline of UnResponsiveness (FOUR) score provides an attractive replacement for all patients with fluctuating levels of consciousness and is gradually gaining wide acceptance.
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Optimizing initial vancomycin dosing in burn patients. Burns 2011; 37:406-14. [DOI: 10.1016/j.burns.2010.06.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2010] [Revised: 06/30/2010] [Accepted: 06/30/2010] [Indexed: 11/30/2022]
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Kilic YA, Konan A, Yorganci K, Sayek I. A novel fuzzy-logic inference system for predicting trauma-related mortality: emphasis on the impact of response to resuscitation. Eur J Trauma Emerg Surg 2010; 36:543-50. [PMID: 26816309 DOI: 10.1007/s00068-010-0010-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2009] [Accepted: 01/02/2010] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Trauma scoring aims for quantification and uniform reporting of trauma-related outcomes. Despite significant advances in trauma scoring, the exact time period at which relevant calculations should be made is not clear. Considering the importance of response to resuscitation, calculation of trauma scores after a period of resuscitation can allow better discrimination of patients who will survive. METHODS A fuzzy-logic inference system, which is completely based on expert opinion and uses Glasgow Coma Scale (GCS) and systolic blood pressure at arrival to emergency room (ER) and their response to resuscitation as inputs, was developed. Records of the last 150 trauma patients admitted to our surgical intensive care unit (ICU) were used for calculations related to Injury Severity Score (ISS), Revised Trauma Score (RTS), Trauma and Injury Severity Score, and A Severity Characterization of Trauma (ASCOT) systems. Calculation of trauma severity and predicted mortality was performed at different time intervals during resuscitation [at arrival to emergency room (ER), after 1 h of resuscitation, and at ICU admission]. The performance of conventional systems and fuzzy-logic system was compared. RESULTS Mean ISS was 32.31 ± 14.01. All systems included showed acceptable discriminative power. Among the conventional systems calculated at emergency room admission, ISS was the best performing [receiver operating characteristics (ROC), 0.9033] and RTS was the worst (ROC, 0.8106). Their performances were improved by up to 13% by use of post-resuscitation physiologic variables. Fuzzy-logic inference system performed slightly better (ROC, 0.9247) then the conventional systems calculated at arrival to ER. CONCLUSIONS Response to resuscitation has significant impact on trauma mortality and must be considered in trauma scoring and mortality prediction. Fuzzy logic provides important opportunities for design of better predictive systems.
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Affiliation(s)
- Yusuf Alper Kilic
- Department of General Surgery, Faculty of Medicine, Hacettepe University, 06100, Ankara, Turkey.
- Bilgitay Study Group, 06600, Ankara, Turkey.
| | - Ali Konan
- Department of General Surgery, Faculty of Medicine, Hacettepe University, 06100, Ankara, Turkey
| | - Kaya Yorganci
- Department of General Surgery, Faculty of Medicine, Hacettepe University, 06100, Ankara, Turkey
| | - Iskender Sayek
- Department of General Surgery, Faculty of Medicine, Hacettepe University, 06100, Ankara, Turkey
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Akavipat P. Endorsement of the FOUR score for consciousness assessment in neurosurgical patients. Neurol Med Chir (Tokyo) 2010; 49:565-71. [PMID: 20035130 DOI: 10.2176/nmc.49.565] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The Full Outline of UnResponsiveness (FOUR) score was previously developed for neurological assessment, but has not been validated in neurosurgical patients, so was compared to the Glasgow Coma Scale (GCS) in practice. Four groups of raters, expert clinicians, novice clinicians, experienced nurses, and inexperienced nurses, assessed 64 patients in awake, drowsy, stuporous, and comatose conditions to investigate rater reliability. Then, 36 patients were evaluated by 1 expert clinician and 1 from the other groups randomly to test the difference. Spearman's correlation was used to find the correlation between both scores from 68 patients. The estimation of FOUR score cut points was validated by weighted kappa compared with the GCS to establish the risk prognosis. Score feasibility was analyzed by nonparametric test. Intraclass correlation in each group was over 0.9, with no difference between expert and inexperienced raters (p > 0.05). The correlation was 0.78. Low, intermediate, and high risk prognosis were associated with 0-7, 8-14, and 15-16 FOUR scores with kappa of 0.92. The feasibility of the FOUR score was lower than that of the GCS (p < 0.01). The FOUR score is reliable and valid for consciousness evaluation with some consequences for practicability. Extensive implementation would increase familiarity.
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Affiliation(s)
- Phuping Akavipat
- Department of Anesthesiology, Prasat Neurological Institute, Bangkok, Thailand.
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Hwang S, Lee SG, Park JI, Song GW, Ryu JH, Jung DH, Hwang GS, Jeong SM, Song JG, Hong SK, Lim YS, Kim KM. Continuous peritransplant assessment of consciousness using bispectral index monitoring for patients with fulminant hepatic failure undergoing urgent liver transplantation. Clin Transplant 2009; 24:91-7. [PMID: 19925461 DOI: 10.1111/j.1399-0012.2009.01148.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Rapid deterioration of consciousness is a critical situation for patients with fulminant hepatic failure (FHF). Bispectral (BIS) index was derived from electroencephalography parameters, primarily to monitor the depth of unconsciousness. AIM To assess the usability of peritransplant BIS monitoring in patients with FHF. METHODS A prospective study using peritransplant BIS monitoring was performed in 26 patients with FHF undergoing urgent liver transplantation (LT). RESULTS Pre-transplant Child-Pugh score was 12.2 +/- 1.0; model for end-stage liver disease score was 32.4 +/- 4.4; Glasgow coma score (GCS) was 9.9 +/- 1.3; and BIS index was 44.0 +/- 6.7. Pre-transplant sedation significantly decreased BIS index. After LT, all patients having endotracheal intubation recovered consciousness within one to three d and showed progressive increase in BIS index, which appeared slightly earlier and was more evident than the increase in derived GCS score. There was a significant correlation between BIS index and derived GCS scores (r(2) = 0.648). Timing of eye opening to voice was matched with BIS index of 66.3 +/- 10.4 and occurred 12.7 +/- 8.3 h after passing BIS index of 50. CONCLUSION These results suggest that BIS monitoring is a non-invasive, simple, easy-to-interpret method, which is useful in assessing peritransplant state of consciousness. BIS monitoring may therefore be a useful tool during peritransplant intensive care for patients with FHF showing hepatic encephalopathy.
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Affiliation(s)
- Shin Hwang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Moore L, Hanley JA, Turgeon AF, Lavoie A, Emond M. A multiple imputation model for imputing missing physiologic data in the national trauma data bank. J Am Coll Surg 2009; 209:572-9. [PMID: 19854396 DOI: 10.1016/j.jamcollsurg.2009.07.004] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2009] [Revised: 07/17/2009] [Accepted: 07/17/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Like most trauma registries, the National Trauma Data Bank (NTDB) is limited by the problem of missing physiologic data. Multiple imputation (MI) has been proposed to simulate missing Glasgow Coma Scale (GCS) scores, respiratory rate (RR), and systolic blood pressure (SBP). The aim of this study was to develop an MI model for missing physiologic data in the NTDB and to provide guidelines for its implementation. STUDY DESIGN The NTDB 7.0 was restricted to patients admitted in 2005 with at least one anatomic injury code. A series of auxiliary variables thought to offer information for the imputation process was selected from the NTDB by literature review and expert opinion. The relation of these variables to physiologic variables and to the fact that they were missing was examined using logistic regression. The MI model included all auxiliary variables that had a statistically significant association with physiologic variables or with the fact that they were missing (Bonferroni-corrected p value <0.05). RESULTS The NTDB sample included 373,243 observations. Glasgow Coma Scale, respiratory rate, and systolic blood pressure were missing for 20.3%, 3.9%, and 8.5% of data observations, respectively. The MI model included information on the following: gender, age, anatomic injury severity, transfer status, injury mechanism, intubation status, alcohol and drug test results, emergency department disposition, total length of stay, ICU length of stay, duration of mechanical ventilation, and discharge disposition. The MI model offered good discrimination for predicting the value of physiologic variables and the fact that they were missing (areas under the receiver operating characteristic curve between 0.832 and 0.999). CONCLUSIONS This article proposes an MI model for imputing missing physiologic data in the NTDB and provides guidelines to facilitate its use. Implementation of the model should improve the quality of research involving the NTDB. The methodology can also be adapted to other trauma registries.
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Affiliation(s)
- Lynne Moore
- Department of Epidemiology and Biostatistics, McGill University, Montreal, Quebec, Canada
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Zuercher M, Ummenhofer W, Baltussen A, Walder B. The use of Glasgow Coma Scale in injury assessment: A critical review. Brain Inj 2009; 23:371-84. [DOI: 10.1080/02699050902926267] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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