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Niveditha M, Kasana R, Barua AR, Barthakur M, Undela K. Assessment of disease pattern and drug utilization among neurology intensive care unit patients in a developing country: an observational analysis. Hosp Pract (1995) 2024:1-7. [PMID: 38781014 DOI: 10.1080/21548331.2024.2358747] [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: 01/07/2024] [Accepted: 05/20/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVE This study aimed to assess the disease pattern and drug utilization among admitted patients in a tertiary-care hospital's neurology intensive care unit (neuro ICU). METHODS A prospective observational cohort study was conducted between August 2022 and January 2023. Patients of any age and gender admitted to the neuro ICU were included, but those who declined to participate were excluded. Demographics, clinical, and medication details were consistently gathered and maintained until discharge. The World Health Organization (WHO)/International Network of Rational Use of Drugs (INRUD) prescribing indicators and the Anatomical Therapeutic Chemical (ATC) classification/Defined Daily Dose (DDD) system were used to evaluate drug use. RESULTS A total of 516 patients were included, predominantly male (65.1%), with an average age of 54.62 ± 15.02 years. The most common diagnosis was stroke [72.3%, comprised of hemorrhagic (46.7%) and ischemic (25.6%)], followed by seizure disorders (6.6%), and central nervous system infections (5.4%). Patients received an average of 7.8 medications, 32.3% prescribed by generic name, 16.0% antibiotics, 74.1% injections, and 100% essential drugs. A (28.5%), C (19.2%), N (17.3%), J (19.2%), B (13.5%), and R (2.3%) were commonly prescribed ATC classes of medications. Number of DDDs was maximum for pantoprazole and furosemide. Based on discharged status, 41.0% were discharged on request, 24.8% against medical advice, 23.8% routine, and 10.2% mortality during hospitalization. CONCLUSION Our study reveals a high prevalence of hemorrhagic stroke, especially among men, diverging from global ischemic stroke trends. Irregular hypertension treatment is the primary cause, exacerbated by low healthcare knowledge in rural areas, where patients often discharge on request, probably due to poor socio-economic conditions. Urgent public awareness campaigns and further research are needed to address this elevated hemorrhagic stroke incidence.
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Affiliation(s)
- Mamidi Niveditha
- Department of Pharmacy Practice, National Institute of Pharmaceutical Education and Research (NIPER) Guwahati, Kamrup, Assam, India
| | - Ruby Kasana
- Department of Pharmacy Practice, National Institute of Pharmaceutical Education and Research (NIPER) Guwahati, Kamrup, Assam, India
| | - Amit Ranjan Barua
- Department of Neurology and Critical Care, Guwahati Neurological Research Centre (GNRC) Institute of Medical Science, North Guwahati, Assam, India
| | - Mausumi Barthakur
- Department of Neurophysiology, Guwahati Neurological Research Centre (GNRC) Institute of Medical Science, North Guwahati, Assam, India
| | - Krishna Undela
- Department of Pharmacy Practice, National Institute of Pharmaceutical Education and Research (NIPER) Guwahati, Kamrup, Assam, India
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2
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Dumas G, Arabi YM, Bartz R, Ranzani O, Scheibe F, Darmon M, Helms J. Diagnosis and management of autoimmune diseases in the ICU. Intensive Care Med 2024; 50:17-35. [PMID: 38112769 DOI: 10.1007/s00134-023-07266-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 11/01/2023] [Indexed: 12/21/2023]
Abstract
Autoimmune diseases encompass a broad spectrum of disorders characterized by disturbed immunoregulation leading to the development of specific autoantibodies, resulting in inflammation and multiple organ involvement. A distinction should be made between connective tissue diseases (mainly systemic lupus erythematosus, systemic scleroderma, inflammatory muscle diseases, and rheumatoid arthritis) and vasculitides (mainly small-vessel vasculitis such as antineutrophil cytoplasmic antibody-associated vasculitis and immune-complex mediated vasculitis). Admission of patients with autoimmune diseases to the intensive care unit (ICU) is often triggered by disease flare-ups, infections, and organ failure and is associated with high mortality rates. Management of these patients is complex, including prompt disease identification, immunosuppressive treatment initiation, and life-sustaining therapies, and requires multi-disciplinary involvement. Data about autoimmune diseases in the ICU are limited and there is a need for multicenter, international collaboration to improve patients' diagnosis, management, and outcomes. The objective of this narrative review is to summarize the epidemiology, clinical features, and selected management of severe systemic autoimmune diseases.
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Affiliation(s)
- Guillaume Dumas
- Medical Intensive Care Unit, Service de Médecine Intensive-Réanimation, CHU Grenoble-Alpes, Université Grenoble-Alpes, INSERM, U1042-HP2, Grenoble, France.
| | - Yaseen M Arabi
- Intensive Care Department, Ministry of the National Guard-Health Affairs, Riyadh, Kingdom of Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
- King Saud Bin Abdulaziz University for Health Sciences Riyadh, Riyadh, Kingdom of Saudi Arabia
| | - Raquel Bartz
- Department of Anesthesia, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Otavio Ranzani
- Barcelona Institute for Global Health, ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Pulmonary Division, Faculdade de Medicina, Heart Institute, InCor, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Franziska Scheibe
- Department of Neurology and Experimental Neurology, Charité- Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Michaël Darmon
- Medical Intensive Care Unit, APHP, Hôpital Saint-Louis, Famirea Study Group, ECSTRA Team, and Clinical EpidemiologyUMR 1153, Center of Epidemiology and Biostatistics, Sorbonne Paris Cité, CRESS, INSERM, Université Paris Cité, Paris, France
| | - Julie Helms
- Faculté de Médecine, Service de Médecine Intensive-Réanimation, Université de Strasbourg (UNISTRA), Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, 1 Place de L'Hôpital, Strasbourg, France
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Khedr A, Rokser D, Borge J, Rushing H, Zoesch G, Johnson W, Wang HY, Lanz A, Bartlett BN, Poehler J, Surani S, Khan SA. Intensive care unit adaptations in the COVID-19 pandemic: Lessons learned. World J Virol 2022; 11:394-398. [PMID: 36483101 PMCID: PMC9724203 DOI: 10.5501/wjv.v11.i6.394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 09/17/2022] [Accepted: 10/19/2022] [Indexed: 11/23/2022] Open
Abstract
The coronavirus disease 2019 pandemic had deleterious effects on the healthcare systems around the world. To increase intensive care units (ICUs) bed capacities, multiple adaptations had to be made to increase surge capacity. In this editorial, we demonstrate the changes made by an ICU of a midwest community hospital in the United States. These changes included moving patients that used to be managed in the ICU to progressive care units, such as patients requiring non-invasive ventilation and high flow nasal cannula, ST-elevation myocardial infarction patients, and post-neurosurgery patients. Additionally, newer tactics were applied to the processes of assessing oxygen supply and demand, patient care rounds, and post-ICU monitoring.
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Affiliation(s)
- Anwar Khedr
- Department of Medicine, BronxCare Health System, Bronx, NY 10457, United States
| | - David Rokser
- Department of Critical Care Medicine, Mayo Health System, Mankato, MN 56001, United States
| | - Jeanine Borge
- Department of Critical Care Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
| | - Hannah Rushing
- Department of Critical Care Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
| | - Greta Zoesch
- Department of Critical Care Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
| | - Wade Johnson
- Department of Administration, Mayo Clinic Health System, Mankato, MN 56001, United States
| | - Han-Yin Wang
- Hospital Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
| | - April Lanz
- Department of Administration, Mayo Clinic Health System, Mankato, MN 56001, United States
| | - Brian N Bartlett
- Department of Emergency Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
| | - Jessica Poehler
- Department of Critical Care Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
| | - Salim Surani
- Department of Medicine, Texas A&M University, Health Science Center, College Station, TX 77843, United States
| | - Syed A Khan
- Department of Critical Care Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
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Predictive Values for Time from Transducer Stopcock Closure to Accurate Intracranial Pressure Reading. Neurocrit Care 2022; 38:422-428. [PMID: 35999410 DOI: 10.1007/s12028-022-01581-5] [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: 05/25/2022] [Accepted: 07/29/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND When using an external ventricular drain (EVD) to monitor intracranial pressure (ICP), nurses need to know how long to wait after each manipulation of the transducer before the displayed ICP value represents an accurate signal. This study explores ICP signal equilibration time (EqT) under clinical conditions. METHODS This was a prospective ex vivo study using a simulated skull, standard EVD tubing, and a strain gauge transducer. All 270 trials simulating 90 combinations of different pressures and common clinical conditions were completed in August 2021. Each trial was recorded on video. Videos were scored using video editing software to obtain the exact start and stop time for each trial. RESULTS The mean EqT was 44.90 (18.77) seconds. One hundred fifty (55.56%) observations did not reach their expected value within 60 s. The longest mean EqTs were noted when blood was present in the EVD tubing (57.67 [8.91] seconds), when air bubbles were in the tubing (57.41 [8.73] seconds), and when EVD tubing was not flat (level) (50.77 [15.43] seconds). An omnibus test comparing mean EqT for conditions with no variables manipulated (30.08 [16.07] seconds) against mean EqT for all others (47.18 [18.13] seconds) found that mean EqTs were significantly different (P < 0.001). CONCLUSIONS Even when no additional variables were introduced, the mean EqTs were ~ 30 s. Common clinical variables increase the length of time before a transducer connected to an EVD will provide an accurate reading. Nurses should wait at least 30 s after turning the EVD stopcock before assuming ICP value reflects accurate ICP.
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Ali KM, Salih MH, AbuGabal HH, Omer MEA, Ahmed AE, Abbasher Hussien Mohamed Ahmed K. Outcome of neurocritical disorders, a multicenter prospective cross-sectional study. Brain Behav 2022; 12:e2540. [PMID: 35196419 PMCID: PMC8933777 DOI: 10.1002/brb3.2540] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 02/10/2022] [Accepted: 02/10/2022] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Patients with neurocritical disorders who require admission to intensive care units (ICUs) constitute about 10-15% of critical care cases. OBJECTIVES To study the outcome of neurocritical disorders in intensive care units. METHODOLOGY This is a prospective cross-sectional study that was conducted among neurocritical patients who were admitted in four intensive care units of four major hospitals in Khartoum state during the period from November 2020 to March 2021. RESULTS Seventy-two neurocritical patients were included in this study; 40(55.6%) were males and 32(44.4%) were females. Twenty-one (29.2%) patients fully recovered, 35 (48.6%) partially recovered and 16 (22.2%) died. The mortality of the common neurocritical diseases were as follows: stroke 30.4%, encephalitis (8.3%), status epilepticus (11.1%), Guillain-Barre syndrome (GBS) (16.7%), and myasthenia gravis (MG) (25%). CONCLUSION This study identified that near two-thirds of the patients required mechanical ventilation. Delayed admission was observed due to causes distributed between the medical side and patient side. The majority of patients were discharged from ICU with partial recovery.
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Affiliation(s)
| | - Mahmoud Hussien Salih
- Faculty of Medicine, Department of Medicine, University of Gezira, Wad Madani, Sudan
| | - Hiba Hassan AbuGabal
- Department of Internal Medicine, Fajr College for Science and Technology, Khartoum, Sudan
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6
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Dawson B, McConvey K, Gofton TE. When to initiate palliative care in neurology. HANDBOOK OF CLINICAL NEUROLOGY 2022; 190:105-125. [PMID: 36055710 DOI: 10.1016/b978-0-323-85029-2.00011-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Life-limiting and life-threatening neurologic conditions often progress slowly. Patients live with a substantial symptom burden over a long period of time, and there is often a high degree of functional and cognitive impairment. Because of this, the most appropriate time to initiate neuropalliative care is often difficult to identify. Further challenges to the incorporation of neuropalliative care include communication barriers, such as profound dysarthria or language impairments, and loss of cognitive function and decision-making capacity that prevent shared decision making and threaten patient autonomy. As a result, earlier initiation of at least some components of palliative care is paramount to ensuring patient-centered care while the patient is still able to communicate effectively and participate as fully as possible in their medical care. For these reasons, neuropalliative care is also distinct from palliative care in oncology, and there is a growing evidence base to guide timely initiation and integration of neuropalliative care. In this chapter, we will focus on when to initiate palliative care in patients with life-limiting, life-threatening, and advanced neurologic conditions. We will address three main questions, which patients with neurologic conditions will benefit from initiation of palliative care, what aspects of neurologic illness are most amenable to neuropalliative care, and when to initiate neuropalliative care?
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Affiliation(s)
- Benjamin Dawson
- Department of Clinical Neurologic Sciences, Western University, London, ON, Canada
| | - Kayla McConvey
- Department of Clinical Neurologic Sciences, Western University, London, ON, Canada
| | - Teneille E Gofton
- Department of Clinical Neurologic Sciences, Western University, London, ON, Canada.
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7
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Rohaut B, Demeret S. Shaping the future of neurocritical care in France. Rev Neurol (Paris) 2022; 178:7-8. [DOI: 10.1016/j.neurol.2022.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 01/18/2022] [Indexed: 11/16/2022]
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8
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Hernandez S, Kittelty K, Hodgson CL. Rehabilitating the neurological patient in the ICU: what is important? Curr Opin Crit Care 2021; 27:120-130. [PMID: 33395083 DOI: 10.1097/mcc.0000000000000804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To describe recent literature evaluating the effectiveness of early rehabilitation in neurocritical care patients. RECENT FINDINGS There is a drive for early rehabilitation within the ICU; however, there are unique considerations for the neurocritically ill patient that include hemiplegia, cognitive impairments and impaired conscious state that can complicate rehabilitation. Additionally, neurological complications, such as hemorrhage expansion and cerebral edema can lead to the risk of further neurological damage. It is, therefore, important to consider the effect of exercise and position changes on cerebral hemodynamics in patients with impaired cerebral autoregulation. There is a paucity of evidence to provide recommendations on timing of early rehabilitation postneurological insult. There are also mixed findings on the effectiveness of early mobilization with one large, multicenter RCT demonstrating the potential harm of early and intensive mobilization in stroke patients. Conversely, observational trials have found early rehabilitation to be well tolerated and feasible, reduce hospital length of stay and improve functional outcomes in neurological patients admitted to ICU. SUMMARY Further research is warranted to determine the benefits and harm of early rehabilitation in neurological patients. As current evidence is limited, and given recent findings in stroke studies, careful consideration should be taken when prescribing exercises in neurocritically ill patients.
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Affiliation(s)
- Sabrina Hernandez
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne
- Discipline of Physiotherapy, Department of Allied Health, The Royal Melbourne Hospital
| | - Katherine Kittelty
- Department of Physiotherapy, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Carol L Hodgson
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne
- Department of Physiotherapy, The Alfred Hospital, Melbourne, Victoria, Australia
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9
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Sun Y, Kaur R, Gupta S, Paul R, Das R, Cho SJ, Anand S, Boutilier JJ, Saria S, Palma J, Saluja S, McAdams RM, Kaur A, Yadav G, Singh H. Development and validation of high definition phenotype-based mortality prediction in critical care units. JAMIA Open 2021; 4:ooab004. [PMID: 33796821 PMCID: PMC7991779 DOI: 10.1093/jamiaopen/ooab004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 01/12/2021] [Accepted: 01/24/2021] [Indexed: 12/02/2022] Open
Abstract
Objectives The objectives of this study are to construct the high definition phenotype (HDP), a novel time-series data structure composed of both primary and derived parameters, using heterogeneous clinical sources and to determine whether different predictive models can utilize the HDP in the neonatal intensive care unit (NICU) to improve neonatal mortality prediction in clinical settings. Materials and Methods A total of 49 primary data parameters were collected from July 2018 to May 2020 from eight level-III NICUs. From a total of 1546 patients, 757 patients were found to contain sufficient fixed, intermittent, and continuous data to create HDPs. Two different predictive models utilizing the HDP, one a logistic regression model (LRM) and the other a deep learning long–short-term memory (LSTM) model, were constructed to predict neonatal mortality at multiple time points during the patient hospitalization. The results were compared with previous illness severity scores, including SNAPPE, SNAPPE-II, CRIB, and CRIB-II. Results A HDP matrix, including 12 221 536 minutes of patient stay in NICU, was constructed. The LRM model and the LSTM model performed better than existing neonatal illness severity scores in predicting mortality using the area under the receiver operating characteristic curve (AUC) metric. An ablation study showed that utilizing continuous parameters alone results in an AUC score of >80% for both LRM and LSTM, but combining fixed, intermittent, and continuous parameters in the HDP results in scores >85%. The probability of mortality predictive score has recall and precision of 0.88 and 0.77 for the LRM and 0.97 and 0.85 for the LSTM. Conclusions and Relevance The HDP data structure supports multiple analytic techniques, including the statistical LRM approach and the machine learning LSTM approach used in this study. LRM and LSTM predictive models of neonatal mortality utilizing the HDP performed better than existing neonatal illness severity scores. Further research is necessary to create HDP–based clinical decision tools to detect the early onset of neonatal morbidities.
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Affiliation(s)
- Yao Sun
- Division of Neonatology, Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Ravneet Kaur
- Research and Development, Child Health Imprints (CHIL) Pte. Ltd., Singapore
| | - Shubham Gupta
- Research and Development, Child Health Imprints (CHIL) Pte. Ltd., Singapore
| | - Rahul Paul
- Research and Development, Child Health Imprints (CHIL) Pte. Ltd., Singapore
| | - Ritu Das
- Research and Development, Child Health Imprints (CHIL) Pte. Ltd., Singapore
| | - Su Jin Cho
- Department of Pediatrics, College of Medicine, Ewha Womans University Seoul, Seoul, Korea
| | - Saket Anand
- Department of Computer Science, Indraprastha Institute of Information Technology, New Delhi, India
| | - Justin J Boutilier
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Wisconsin, USA
| | - Suchi Saria
- Machine Learning and Healthcare Lab, Johns Hopkins University, Baltimore, Maryland, USA.,Department of Applied Math & Statistics, Johns Hopkins University, Baltimore, Maryland, USA.,Department of Health Policy & Management, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jonathan Palma
- Department of Pediatrics, Stanford University, Stanford, California, USA
| | - Satish Saluja
- Department of Neonatology, Sir Ganga Ram Hospital, New Delhi, India
| | - Ryan M McAdams
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Avneet Kaur
- Department of Neonatology, Apollo Cradle Hospitals, New Delhi, India
| | - Gautam Yadav
- Department of Pediatrics, Kalawati Hospital, Rewari, India
| | - Harpreet Singh
- Research and Development, Child Health Imprints (CHIL) Pte. Ltd., Singapore
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Meyer M, Fuest S, Krain D, Juenemann M, Braun T, Thal SC, Schramm P. Evaluation of a new wireless technique for continuous electroencephalography monitoring in neurological intensive care patients. J Clin Monit Comput 2020; 35:765-770. [PMID: 32488677 DOI: 10.1007/s10877-020-00533-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 05/19/2020] [Indexed: 10/24/2022]
Abstract
A novel wireless eight-channel electroencephalography (EEG) headset specially developed for ICUs was tested in regard of comparability with standard 10/20 EEG systems. The continuous EEG (cEEG) derivations via CerebAir EEG headset (Nihon Kohden Europe, Rosbach, Germany) and internationally standardized 10/20 reference EEGs as the diagnostic standard were performed in a mixed collective on a neurointensive care unit (neuro-ICU). The derivations were verified for comparability in detection of EEG background activity, epileptiform discharges, and seizure patterns. Fifty-two patients with vigilance reduction following serious neurological or metabolic diseases were included, and both methods were applied and further analyzed in 47. EEG background activity matched in 24 of 45 patients (53%; p = 0.126), epileptiform discharges matched in 32 (68%) patients (p = 0.162), and seizure activity matched in 98%. Overall, in 89% of the patients, cEEG detected the same or additional ICU-relevant EEG patterns. The tested wireless cEEG headset is a useful monitoring tool in patients with consciousness disorders. The present study indicates that long-term measurements with the wireless eight-channel cEEG lead to a higher seizure and epileptiform discharge detection compared to intermittent 10/20 EEG derivations in the ICU setting.
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Affiliation(s)
- Marco Meyer
- Department of Geriatrics, Jung-Stilling Hospital Siegen, Wichernstrasse 40, 57074, Siegen, Germany.
| | - Sven Fuest
- Department of Neurology, Universitaetsklinikum Giessen & Marburg Standort Marburg, Baldingerstrasse, 35033, Marburg, Germany
| | - Dominique Krain
- Department of Neurology, Universitaetsklinikum Giessen & Marburg Standort Giessen, Klinikstrasse 33, 35385, Giessen, Germany
| | - Martin Juenemann
- Department of Neurology, Universitaetsklinikum Giessen & Marburg Standort Giessen, Klinikstrasse 33, 35385, Giessen, Germany
| | - Tobias Braun
- Department of Neurology, Universitaetsklinikum Giessen & Marburg Standort Giessen, Klinikstrasse 33, 35385, Giessen, Germany
| | - Serge C Thal
- Department of Anesthesiology, Helios Universitaetsklinikum Wuppertal University Witten/Herdecke, Heusnerstraße 40, 42283, Wuppertal, Germany
| | - Patrick Schramm
- Department of Anesthesiology, Johannes Gutenberg Universitaet, Universitaetsmedizin Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
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11
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Saviluoto A, Harve-Rytsälä H, Lääperi M, Kirves H, Jäntti H, Nurmi J. A potential method of identifying stroke and other intracranial lesions in a prehospital setting. Scand J Trauma Resusc Emerg Med 2020; 28:39. [PMID: 32404134 PMCID: PMC7222442 DOI: 10.1186/s13049-020-00728-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 04/24/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Identifying stroke and other intracranial lesions in patients with a decreased level of consciousness may be challenging in prehospital settings. Our objective was to investigate whether the combination of systolic blood pressure, heart rate and age could be used to identify intracranial lesions. METHODS We conducted a retrospective case-control study including patients with a decreased level of consciousness who had their airway secured during prehospital care. Patients with intracranial lesions were identified based on the final diagnoses at the end of hospitalization. We investigated the ability of systolic blood pressure, heart rate and age to identify intracranial lesions and derived a decision instrument. RESULTS Of 425 patients, 127 had an intracranial lesion. Patients with a lesion were characterized by higher systolic blood pressure, lower heart rate and higher age (P < 0.0001 for all). A systolic blood pressure ≥ 140 mmHg had an odds ratio (OR) of 3.5 (95% confidence interval [CI] 1.7 to 7.0), and > 170 mmHg had an OR of 8.2 (95% CI 4.5-15.32) for an intracranial lesion (reference: < 140 mmHg). A heart rate < 100 beats/min had an OR of 3.4 (95% CI 2.0 to 6.0, reference: ≥100). Age 50-70 had an OR of 4.1 (95% CI 2.0 to 9.0), and > 70 years had an OR of 10.2 (95% CI 4.8 to 23.2), reference: < 50. Logarithms of ORs were rounded to the nearest integer to create a score with 0-2 points for age and blood pressure and 0-1 for heart rate, with an increasing risk for an intracranial lesion with higher scores. The area under the receiver operating characteristics curve for the instrument was 0.810 (95% CI 0.850-0.890). CONCLUSIONS An instrument combining systolic blood pressure, heart rate and age may help identify stroke and other intracranial lesions in patients with a decreased level of consciousness in prehospital settings. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Anssi Saviluoto
- Research and Development Unit, FinnHEMS, WTC Helsinki Airport, Lentäjäntie 3, FI-01530, Vantaa, Finland.
- University of Eastern Finland, PO Box 1627, FI-70211, Kuopio, Finland.
| | - Heini Harve-Rytsälä
- Department of Emergency Medicine and Services, University of Helsinki and Helsinki University Hospital, PO Box 340, FI-00029, HUS, Finland
| | - Mitja Lääperi
- Research and Development Unit, FinnHEMS, WTC Helsinki Airport, Lentäjäntie 3, FI-01530, Vantaa, Finland
| | - Hetti Kirves
- Prehospital Emergency Care, Hyvinkää hospital area, Hospital District of Helsinki and Uusimaa, PO Box 585, FI-05850, Hyvinkää, Finland
| | - Helena Jäntti
- University of Eastern Finland, PO Box 1627, FI-70211, Kuopio, Finland
- Center for Prehospital Emergency Care, Kuopio University Hospital, PO Box 100, FI-70029, Kuopio, Finland
| | - Jouni Nurmi
- Research and Development Unit, FinnHEMS, WTC Helsinki Airport, Lentäjäntie 3, FI-01530, Vantaa, Finland
- Department of Emergency Medicine and Services, University of Helsinki and Helsinki University Hospital, PO Box 340, FI-00029, HUS, Finland
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12
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Stoeter DJ, Michael BD, Solomon T, Poole L. Managing acute central nervous system infections in the UK adult intensive care unit in the wake of UK encephalitis guidelines. J Intensive Care Soc 2015; 16:330-338. [PMID: 28979440 DOI: 10.1177/1751143715587927] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
The acute central nervous system infections meningitis and encephalitis commonly require management on intensive care units. The clinical features often overlap and in the acute phase-altered consciousness and seizures may also need to be managed. In April 2012, the first UK national guideline for the management of suspected viral encephalitis was published by the British Infection Association and Association of British Neurologists, and other key stakeholders, and included a simple management algorithm. The new guideline results from evidence demonstrating a number of common oversights in the standard management of suspected viral encephalitis in many settings. In combination with British Infection Association meningitis guidelines, evidence-based approaches now exist to facilitate the non-expert managing patients with suspected central nervous system infections. Here we bring together these guidelines and the supporting evidence applicable for intensivists into a single resource.
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Affiliation(s)
- D J Stoeter
- Department of Intensive Care, Royal Liverpool University Hospital, Liverpool, UK
| | - B D Michael
- Institute of Infection and Global Health, and NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool, UK.,Walton Centre NHS Foundation Trust, Liverpool, UK
| | - T Solomon
- Institute of Infection and Global Health, and NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool, UK.,Walton Centre NHS Foundation Trust, Liverpool, UK
| | - L Poole
- Department of Intensive Care, Royal Liverpool University Hospital, Liverpool, UK
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Bhat A, Chakravarthy K, Rao BK. Chest physiotherapy techniques in neurological intensive care units of India: A survey. Indian J Crit Care Med 2014; 18:363-8. [PMID: 24987235 PMCID: PMC4071680 DOI: 10.4103/0972-5229.133890] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
CONTEXT Neurological intensive care units (ICUs) are a rapidly developing sub-specialty of neurosciences. Chest physiotherapy techniques are of great value in neurological ICUs in preventing, halting, or reversing the impairments caused due to neurological disorder and ICU stay. However, chest physiotherapy techniques should be modified to a greater extent in the neurological ICU as compared with general ICUs. AIM The aim of this study is to obtain data on current chest physiotherapy practices in neurological ICUs of India. SETTINGS AND DESIGN A tertiary care hospital in Karnataka, India, and cross-sectional survey. SUBJECTS AND METHODS A questionnaire was formulated and content validated to assess the current chest physiotherapy practices in neurological ICUs of India. The questionnaire was constructed online and a link was distributed via E-mail to 185 physiotherapists working in neurological ICUs across India. STATISTICAL ANALYSIS USED Descriptive statistics. RESULTS The response rate was 44.3% (n = 82); 31% of the physiotherapists were specialized in cardiorespiratory physiotherapy and 30% were specialized in neurological physiotherapy. Clapping, vibration, postural drainage, aerosol therapy, humidification, and suctioning were used commonly used airway clearance (AC) techniques by the majority of physiotherapists. However, devices for AC techniques such as Flutter, Acapella, and standard positive expiratory pressure devices were used less frequently for AC. Techniques such as autogenic drainage and active cycle of breathing technique are also frequently used when appropriate for the patients. Lung expansion therapy techniques such as breathing exercises, incentive spirometry exercises, and positioning, proprioceptive neuromuscular facilitation of breathing are used by majority of physiotherapists. CONCLUSIONS Physiotherapists in this study were using conventional chest physiotherapy techniques more frequently in comparison to the devices available for AC.
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Affiliation(s)
- Anup Bhat
- Department of Physiotherapy, M. S. Ramaiah Medical College, Bengaluru, India
| | | | - Bhamini K Rao
- School of Allied Health Sciences, Manipal University, Manipal, Karnataka, India
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Abstract
Paralytic poliomyelitis, Reye syndrome, Hemophilus Influenzae type B epiglottitis, bacterial meningitis, and meningococcal septic shock are catastrophic illnesses that in the last 60 years have shaped the development of pediatric intensive care. Neurocritical care has been at the forefront of our thinking and, more latterly, as a specialty we have had the technology and means to develop this focus, educate the next generation and show that outcomes can be improved-first in adult critical care and now the task is to translate these benefits to critically ill children. In our future we will need to advance interventions in patient care with clinical trials. MeSH terms: Neurocritical care; child; traumatic brain injury; status epilepticus; cerebrovascular.
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Affiliation(s)
- Robert C Tasker
- Departments of Neurology and Anesthesiology, Perioperative and Pain Medicine, Division of Critical Care Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
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Faigle R, Sharrief A, Marsh EB, Llinas RH, Urrutia VC. Predictors of critical care needs after IV thrombolysis for acute ischemic stroke. PLoS One 2014; 9:e88652. [PMID: 24533130 PMCID: PMC3922971 DOI: 10.1371/journal.pone.0088652] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 01/09/2014] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND AND PURPOSE Intravenous (IV) tissue plasminogen activator (tPA) is the only Food and Drug Administration (FDA)-approved treatment for acute ischemic stroke. Post tPA patients are typically monitored in an intensive care unit (ICU) for at least 24 hours. However, rigorous evidence to support this practice is lacking. This study evaluates factors that predict ICU needs after IV thrombolysis. METHODS A retrospective chart review was performed for 153 patients who received intravenous tPA for acute ischemic stroke. Data on stroke risk factors, physiologic parameters on presentation, and stroke severity were collected. The timing and nature of an intensive care intervention, if needed, was recorded. Using multivariable logistic regression, we determined factors associated with requiring ICU care. RESULTS African American race (Odds Ratio [OR] 8.05, 95% Confidence Interval [CI] 2.65-24.48), systolic blood pressure, and National Institutes of Health Stroke Scale (NIHSS) (OR 1.20 per point increase, 95% CI 1.09-1.31) were predictors of utilization of ICU resources. Patients with an NIHSS≥10 had a 7.7 times higher risk of requiring ICU resources compared to patients who presented with an NIHSS<10 (p<0.001). Most patients with ICU needs developed them prior to the end of tPA infusion (81.0%, 95% CI 68.8-93.1). Only 7% of patients without ICU needs by the end of the tPA infusion went on to require ICU care later on. These patients were more likely to have diabetes mellitus and had significantly higher NIHSS compared to patients without further ICU needs (mean NIHSS 17.3, 95% CI 11.5-22.9 vs. 9.2, 95% CI 7.7-9.6). CONCLUSION Race, NIHSS, and systolic blood pressure predict ICU needs following tPA for acute ischemic stroke. We propose that patients without ICU needs by the end of the tPA infusion might be safely monitored in a non-ICU setting if NIHSS at presentation is low.
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Affiliation(s)
- Roland Faigle
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Anjail Sharrief
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Department of Neurology, University of Texas Health Science Center, Houston, Texas, United States of America
| | - Elisabeth B. Marsh
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Rafael H. Llinas
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Victor C. Urrutia
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
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Diccini S. The challenge of neuro intensive care units. ACTA PAUL ENFERM 2012. [DOI: 10.1590/s0103-21002012000800001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Abstract
PURPOSE OF REVIEW Neurocritical care in adults with life-threatening neurological disease is a distinct discipline that has developed out of critical care medicine and neurology. This review considers whether it is time for such a specialized service to be developed in pediatrics. RECENT FINDINGS Recent reports describe how some institutions and pediatric professional bodies have set about transferring the specialist neurocritical care experience in adults to pediatric practice. The issue, now, is whether such a development would improve pediatric healthcare, medical education and training in the newly defined field. Adult neurocritical care did not develop in a void. The historical influences were the polio epidemics and the investment in experimental neuroprotection. These traditions provided a foundation for success in recent clinical trials, patient outcomes and healthcare research. Pediatric neurocritical care does not have the equivalent parallels and track record in healthcare research. Size of practice and casemix is also significantly different, with one-third of potential beneficiaries of the new field having a primary medical, rather than neurological, disorder. Three types of development for pediatric neurocritical services are, therefore, suggested by the literature and the implications of these on cross-discipline staffing and education are discussed. SUMMARY Pediatric neurocritical care is the new frontier for pediatric critical care medicine and pediatric neurology. There is sufficient specialist interest and momentum for the development of a multidisciplinary collaboration that has the aim of improving patient care.
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An alternative perspective on the management of status epilepticus. Epilepsy Behav 2008; 12:349-53. [PMID: 18262847 DOI: 10.1016/j.yebeh.2007.12.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2007] [Accepted: 12/25/2007] [Indexed: 02/08/2023]
Abstract
The definition of status epilepticus (SE) has been reduced from 30 minutes to 5 minutes and this article questions if treatment should not be offered before reaching that window. After provision of first aid, benzodiazepines (BDZ) are the initial form of intervention, with either nasal or buccal midazolam being favored for nonprofessionals. Proper patient supervision, including admission to an intensive care unit for more difficult patients, is endorsed, and the need to warn nonprofessionals of the potential risk of respiratory depression is imperative. The article criticizes the use of phenytoin as the antiepileptic medication (AEM) with which to load patients, as it is no longer a first-line AEM, and argues in favor of using a first-line AEM such as valproate or carbamazepine, or preferably the AEM that previously proved efficacious in a patient with known epilepsy who was noncompliant. Alternative routes of administration of AEMs are discussed, and the use of blood level monitoring, as an adjunct to management, to protect against further episodes of SE, is supported. Touched on in this article are the use of some of the newer AEMs in the management of SE and exploration of treatment strategies that acknowledge that treatment must also include patient education that incorporates techniques to enhance compliance.
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