Neurologic complications in non-neurological intensive care units

Impact of neurological problems on mechanical ventilation and intensive care unit outcomes in pulmonary intensive care unit patients: a retrospective analysis of a single-center cohort

Neurological problems (NPs) are frequently connected with different critical illnesses in intensive care unit (ICU) patients, and they may influence ICU outcomes. This study aims to examine the effects of NPs on ICU outcomes, especially in pulmonary ICU patients. This is a retrospective observational study comprising adult pulmonary critical care patients who were hospitalized between 2015 and 2019. The frequency of NPs at admission, their impact on mechanical ventilation (MV), ICU outcomes, the rate of NP development during the ICU stay, and risk factors for them were investigated. A total of 361 patients were included in the study, and 130 of them (36%) had NPs (group 1). The noninvasive ventilation requirement rate in patients with NPs was less than in those without NPs (group 2), and the requirement of MV was significantly more frequent in this group (37% and 19%, p<0.05). The duration of MV (19±27 and 8±6 days, p=0.003) and sepsis rate (31% and 18%, p=0.005) were also higher in group 1. NPs developing after ICU admission increased the MV requirement 3 times as an independent risk factor. Risk factors for ICU-acquired NPs were the existence of sepsis during admission [odds ratio (OR): 2.01, confidence interval (CI) 95%: 1.02-4, p=0.045] and longer MV durations before ICU admission (OR: 1.05, CI 95%: 1.004-41.103, p=0.033). NPs were not independent risk factors for mortality (OR: 0.67, CI 95%: 0.37-1.240, p=0.207). NPs did not increase mortality but more frequently caused MV requirement, more extubation failure, and a longer ICU stay in this study population. Additionally, our data suggest that having sepsis during admission and a longer length of MV prior to admission may increase the neurological complication rate.

Neurology consultations in the intensive care units

OBJECTIVE

Critical treatment and management have advanced over the recent decades, bringing many benefits but also causing increasing complication rates. Among these complications, neurological complications have an important place and may increase in mortality rates. The aim of our study was to find the causes of neurological consultations in the level 3 adult intensive care units (ICU).

METHODS

The study population consisted of patients who were requested to have neurology consultation in the level 3 Adult ICUs between April 2013 and April 2017. The records in the hospital automation system of patients required neurology consultation were evaluated retrospectively.

RESULTS

A total of 906 neurology consultations were requested in ICUs and 302 patients were included in this study. Altered consciousness and unconsciousness (32.1%), seizure (26.5%), management and treatment (15.9%) were the most common reasons for neurological consultations. Epileptic seizures (16.9%), status epilepticus (9.3%) and ischemic stroke (8.6%) were the most common final neurological diagnoses after consultation. Wernicke encephalopathy, posterior reversible encephalopathy syndrome, motor neuron disease, Creutzfeldt-Jakob disease, critical illness polyneuropathy and critical illness myopathy were less frequently diagnosed (< 1%). The diagnostic benefit was 83.1%. Treatment change following neurological consultation occurred in 56.6% of the patients.

CONCLUSIONS

In our study, spanning a period of 4 years, the most common diagnoses were epileptic seizure, status epilepticus, and ischemic stroke. More frequent complications, such as stroke and seizure, as well as less common complications such as Wernicke's encephalopathy and posterior reversible encephalopathy syndrome, should be intervened immediately. In case of consultation, neurologists should be able to manage neurological complications as a consultant physician in the early period and evaluate the ICU patient systematically and be familiar with the complexity of intubation, sedation and sometimes paralyzed intensive ICU patients who have had severely limited routine clinical evaluations.

The current significance of the FOUR score: A systematic review and critical analysis of the literature

BACKGROUND

The Full Outline of Un-Responsiveness Score (FOURs) is a scale for clinical assessment of consciousness that was introduced to overcome disadvantages of the widely accepted Glasgow Coma Scale (GCS).

OBJECTIVE

To carry out a systematic review and critical analysis of the available literature on the clinical application of FOURs and perform a comparison to GCS, in terms of reliability and predictive value.

METHODS

Initial search retrieved a total of 147 papers. After applying strict inclusion criteria and further article selection to overcome data heterogeneity, a statistical comparison of inter-rater reliability, in-hospital mortality and long-term outcome prediction between the two scales in the adult and pediatric population was done.

RESULTS

Even though FOURs is more complicated than GCS, its application remains quite simple. Its reliability, validity and predictive value have been supported by an increasing number of studies, especially in critical care. A statistically significant difference (p = .034) in predicting in-hospital mortality in adults, in favor of FOURs when compared to GCS, was found. However, whether it poses a clinically significant advantage in detecting patients' deterioration and outcome prediction, compared to other scaling systems, remains unclear.

CONCLUSIONS

Further studies are needed to discern the FOURs' clinical usefulness, especially in patients in non-critical condition, with milder disorders of consciousness.

Prognosis of neurologic complications in critical illness

Neurologic complications of critical illness require extensive clinical and neurophysiologic evaluation to establish a reliable prognosis. Many sequelae of intensive care unit (ICU) treatment, such as delirium and ICU-acquired weakness, although highly associated with adverse outcomes, are less suitable for prognostication, but should rather prompt clinicians to seek previously unnoticed persisting underlying illnesses. Prognostication can be confounded by drug administration particularly because its clearance is abnormal in critical illness. Some neurological complications are severe, and can last for months or years after discharge from ICU. The most important ethical aspects regarding neurologic complications in critically ill patients are prevention, recognition, and identification, and prevention of self-fulfilling prophecies. This chapter summarizes the tool of prognostication of major neurological complications of critical illness.