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Gordillo-Resina M, Aranda-Martinez C, Arias-Verdú MD, Guerrero-López F, Castillo-Lorente E, Rodríguez-Rubio D, Rivera-López R, Rosa-Garrido C, Gómez-Jiménez FJ, Lafuente-Baraza J, Aguilar-Alonso E, Arráez-Sánchez MA, Rivera-Fernández R. Mortality, Functional Status, and Quality of Life after 5 Years of Patients Admitted to Critical Care for Spontaneous Intracerebral Hemorrhage. Neurocrit Care 2024; 41:583-597. [PMID: 38589693 DOI: 10.1007/s12028-024-01960-0] [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: 09/13/2023] [Accepted: 02/13/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND The objective of this study was to assess long-term outcome in patients with spontaneous intracerebral hemorrhage admitted to the intensive care unit. METHODS Mortality and Glasgow Outcome Scale, Barthel Index, and 5-level EQ-5D version (EQ-5D-5L) scores were analyzed in a multicenter cohort study of three Spanish hospitals (336 patients). Mortality was also analyzed in the Medical Information Mart for Intensive Care III (MIMIC-III) database. RESULTS The median (25th percentile-75th percentile) age was 62 (50-70) years, the median Glasgow Coma Score was 7 (4-11) points, and the median Acute Physiology and Chronic Health disease Classification System II (APACHE-II) score was 21 (15-26) points. Hospital mortality was 54.17%, mortality at 90 days was 56%, mortality at 1 year was 59.2%, and mortality at 5 years was 66.4%. In the Glasgow Outcome Scale, a normal or disabled self-sufficient situation was recorded in 21.5% of patients at 6 months, in 25.5% of patients after 1 year, and in 22.1% of patients after 5 years of follow-up (4.5% missing). The Barthel Index score of survivors improved over time: 50 (25-80) points at 6 months, 70 (35-95) points at 1 year, and 90 (40-100) points at 5 years (p < 0.001). Quality of life evaluated with the EQ-5D-5L at 1 year and 5 years indicated that greater than 50% of patients had no problems or slight problems in all items (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression). In the MIMIC-III study (N = 1354), hospital mortality was 31.83% and was 40.5% at 90 days and 56.2% after 5 years. CONCLUSIONS In patients admitted to the intensive care unit with a diagnosis of nontraumatic intracerebral hemorrhage, hospital mortality up to 90 days after admission is very high. Between 90 days and 5 years after admission, mortality is not high. A large percentage of survivors presented a significant deficit in quality of life and functional status, although with progressive improvement over time. Five years after the hemorrhagic stroke, a survival of 30% was observed, with a good functional status seen in 20% of patients who had been admitted to the hospital.
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Affiliation(s)
| | | | | | | | | | | | - Ricardo Rivera-López
- Cardiology Department, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Carmen Rosa-Garrido
- Biosanitary Research Foundation in Eastern Andalusia, Alejandro Otero, Hospital Universitario de Jaén, Jaén, Spain
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Le Gall A, Eustache G, Coquet A, Seguin P, Launey Y. End-tidal carbon dioxide and arterial to end-tidal carbon dioxide gradient are associated with mortality in patients with neurological injuries. Sci Rep 2024; 14:19172. [PMID: 39160225 PMCID: PMC11333476 DOI: 10.1038/s41598-024-69143-7] [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: 03/12/2024] [Accepted: 08/01/2024] [Indexed: 08/21/2024] Open
Abstract
Pre-hospital end-tidal carbon dioxide (EtCO2) monitoring and arterial to end-tidal carbon dioxide gradient (Pa-EtCO2) have been associated with mortality in patients with traumatic brain injury. Our study aimed to analyze the association between alveolar EtCO2 or Pa-EtCO2 and mortality in patients admitted in intensive care unit (ICU) with neurological injuries. In our retrospective analysis from using large de-identified ICU databases (MIMIC-III and -IV and eICU databases), we included 2872 ICU patients with neurological injuries, identified according to the International Classification of Diseases (ICD-9 and -10), who underwent EtCO2 monitoring. We performed logistic regression and extended Cox regression to assess the association between mortality and candidate covariates, including EtCO2 and Pa-EtCO2. In-hospital mortality was 26% (n = 747). In univariate analysis, both the Pa-EtCO2 gradient and EtCO2 levels during the first 24 h were significantly associated with mortality (for a 1 mmHg increase: OR = 1.03 [CI95 1.016-1.035] and OR = 0.94 [CI95 0.923-0.953]; p < 0.001). The association remained significant in multivariate analysis. The time-varying evolution of EtCO2 was independently associated with mortality (for a 1 mmHg increase: HR = 0.976 [CI95 0.966-0.985]; p < 0.001). The time-varying Pa-EtCO2 gradient was associated with mortality only in univariate analysis. In neurocritical patients, lower EtCO2 levels at admission and throughout the ICU stay were independently associated with mortality and should be avoided.
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Affiliation(s)
- Arthur Le Gall
- Rennes University Hospital, Rennes, France.
- DOMASIA Team, LTSI-INSERM UMR 1099, Rennes, France.
- Service d'anesthésie-réanimation, Hôpital Pontchaillou, 2 Rue Henri Le Guillou, 35000, Rennes, France.
| | - Gabriel Eustache
- Rennes University Hospital, Rennes, France
- Service d'anesthésie-réanimation, Hôpital Pontchaillou, 2 Rue Henri Le Guillou, 35000, Rennes, France
| | - Alice Coquet
- Rennes University Hospital, Rennes, France
- Service d'anesthésie-réanimation, Hôpital Pontchaillou, 2 Rue Henri Le Guillou, 35000, Rennes, France
| | - Philippe Seguin
- Rennes University Hospital, Rennes, France
- Service d'anesthésie-réanimation, Hôpital Pontchaillou, 2 Rue Henri Le Guillou, 35000, Rennes, France
| | - Yoann Launey
- Rennes University Hospital, Rennes, France
- Service d'anesthésie-réanimation, Hôpital Pontchaillou, 2 Rue Henri Le Guillou, 35000, Rennes, France
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van Valburg MK, Termorshuizen F, Geerts BF, Abdo WF, van den Bergh WM, Brinkman S, Horn J, van Mook WNKA, Slooter AJC, Wermer MJH, Siegerink B, Arbous MS. Predicting 30-day mortality in intensive care unit patients with ischaemic stroke or intracerebral haemorrhage. Eur J Anaesthesiol 2024; 41:136-145. [PMID: 37962175 PMCID: PMC10763719 DOI: 10.1097/eja.0000000000001920] [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: 11/15/2023]
Abstract
BACKGROUND Stroke patients admitted to an intensive care unit (ICU) follow a particular survival pattern with a high short-term mortality, but if they survive the first 30 days, a relatively favourable subsequent survival is observed. OBJECTIVES The development and validation of two prognostic models predicting 30-day mortality for ICU patients with ischaemic stroke and for ICU patients with intracerebral haemorrhage (ICH), analysed separately, based on parameters readily available within 24 h after ICU admission, and with comparison with the existing Acute Physiology and Chronic Health Evaluation IV (APACHE-IV) model. DESIGN Observational cohort study. SETTING All 85 ICUs participating in the Dutch National Intensive Care Evaluation database. PATIENTS All adult patients with ischaemic stroke or ICH admitted to these ICUs between 2010 and 2019. MAIN OUTCOME MEASURES Models were developed using logistic regressions and compared with the existing APACHE-IV model. Predictive performance was assessed using ROC curves, calibration plots and Brier scores. RESULTS We enrolled 14 303 patients with stroke admitted to ICU: 8422 with ischaemic stroke and 5881 with ICH. Thirty-day mortality was 27% in patients with ischaemic stroke and 41% in patients with ICH. Important factors predicting 30-day mortality in both ischaemic stroke and ICH were age, lowest Glasgow Coma Scale (GCS) score in the first 24 h, acute physiological disturbance (measured using the Acute Physiology Score) and the application of mechanical ventilation. Both prognostic models showed high discrimination with an AUC 0.85 [95% confidence interval (CI), 0.84 to 0.87] for patients with ischaemic stroke and 0.85 (0.83 to 0.86) in ICH. Calibration plots and Brier scores indicated an overall good fit and good predictive performance. The APACHE-IV model predicting 30-day mortality showed similar performance with an AUC of 0.86 (95% CI, 0.85 to 0.87) in ischaemic stroke and 0.87 (0.86 to 0.89) in ICH. CONCLUSION We developed and validated two prognostic models for patients with ischaemic stroke and ICH separately with a high discrimination and good calibration to predict 30-day mortality within 24 h after ICU admission. TRIAL REGISTRATION Trial registration: Dutch Trial Registry ( https://www.trialregister.nl/ ); identifier: NTR7438.
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Affiliation(s)
- Mariëlle K van Valburg
- From the Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht (MKvV, AJCS), Department of Anaesthesiology, Intensive Care and Pain Medicine, Amphia Hospital, Breda (MKvV), National Intensive Care Evaluation Foundation, Amsterdam University Medical Center (FT, SB, MSA), Department of Medical Informatics, Amsterdam University Medical Center, Amsterdam (FT, SB), Healthplus.ai BV, Amsterdam (BFG), Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen (WFA), Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen (WMvdB), Department of Intensive Care, Amsterdam University Medical Center, Amsterdam (JH), Department of Intensive Care Medicine, and Academy for Postgraduate Training, Maastricht University Medical Center (WNKAvM), School of Health Professions Education, Maastricht University, Maastricht (WNKAvM), the UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, the Netherlands (AJCS), Department of Neurology, UZ Brussel and Vrije Universiteit Brussel, Brussels, Belgium (AJCS), Department of Neurology, Leiden University Medical Center, Leiden (MJHW), Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen (MJHW), Department of Clinical Epidemiology, Leiden University Medical Center (BS, MSA), Department of Intensive Care, Leiden University Medical Center, Leiden, the Netherlands (MSA)
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Tejerina EE, Gonçalves G, Gómez-Mediavilla K, Jaramillo C, Jiménez J, Frutos-Vivar F, Lorente JÁ, Thuissard IJ, Andreu-Vázquez C. The effect of age on clinical outcomes in critically ill brain-injured patients. Acta Neurol Belg 2023; 123:1709-1715. [PMID: 35737277 DOI: 10.1007/s13760-022-01987-0] [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: 02/26/2022] [Accepted: 05/23/2022] [Indexed: 11/01/2022]
Abstract
PURPOSE We studied the impact of age on survival and functional recovery in brain-injured patients. METHODS We performed an observational cohort study of all consecutive adult patients with brain injury admitted to ICU in 8 years. To estimate the optimal cut-off point of the age associated with unfavorable outcomes (mRS 3-6), receiver operating characteristic (ROC) curve analyses were used. Multivariate logistic regression analyses were performed to identify prognostic factors for unfavorable outcomes. RESULTS We included 619 brain-injured patients. We identified 60 years as the cut-off point at which the probability of unfavorable outcomes increases. Patients ≥ 60 years had higher severity scores at ICU admission, longer duration of mechanical ventilation, longer ICU and hospital stays, and higher mortality. Factors identified as associated with unfavorable outcomes (mRS 3-6) were an advanced age (≥ 60 years) [Odds ratio (OR) 4.59, 95% confidence interval (CI) 2.73-7.74, p < 0.001], a low GCS score (≤ 8 points) [OR 3.72, 95% CI 1.95-7.08, p < 0.001], the development of intracranial hypertension [OR 5.52, 95% CI 2.70-11.28, p < 0.001], and intracerebral hemorrhage as the cause of neurologic disease [OR 3.87, 95% CI 2.34-6.42, p < 0.001]. CONCLUSION Mortality and unfavorable functional outcomes in critically ill brain-injured patients were associated with older age (≥ 60 years), higher clinical severity (determined by a lower GCS score at admission and the development of intracranial hypertension), and an intracerebral hemorrhage as the cause of neurologic disease.
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Affiliation(s)
- Eva E Tejerina
- Hospital Universitario de Getafe and Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Intensive Care Unit, Carretera de Toledo, km 12.5, 28905, Getafe, Spain.
| | | | | | | | | | - Fernando Frutos-Vivar
- Hospital Universitario de Getafe and Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Intensive Care Unit, Carretera de Toledo, km 12.5, 28905, Getafe, Spain
| | - José Ángel Lorente
- Hospital Universitario de Getafe and Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Intensive Care Unit, Carretera de Toledo, km 12.5, 28905, Getafe, Spain
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5
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Bögli SY, Schmidt T, Imbach LL, Nellessen F, Brandi G. Nonconvulsive status epilepticus in neurocritical care: A critical reappraisal of outcome prediction scores. Epilepsia 2023; 64:2409-2420. [PMID: 37392404 DOI: 10.1111/epi.17708] [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: 04/19/2023] [Revised: 06/29/2023] [Accepted: 06/29/2023] [Indexed: 07/03/2023]
Abstract
OBJECTIVE Nonconvulsive status epilepticus (NCSE) is a frequent condition in the neurocritical care unit (NCCU) patient population, with high morbidity and mortality. We aimed to assess the validity of available outcome prediction scores for prognostication in an NCCU patient population in relation to their admission reason (NCSE vs. non-NCSE related). METHODS All 196 consecutive patients diagnosed with NCSE during the NCCU stay between January 2010 and December 2020 were included. Demographics, Simplified Acute Physiology Score II (SAPS II), NCSE characteristics, and in-hospital and 3-month outcome were extracted from the electronic charts. Status Epilepticus Severity Score (STESS), Epidemiology-Based Mortality Score in Status Epilepticus (EMSE), and encephalitis, NCSE, diazepam resistance, imaging features, and tracheal intubation score (END-IT) were evaluated as previously described. Univariable and multivariable analysis and comparison of sensitivity/specificity/positive and negative predictive values/accuracy were performed. RESULTS A total of 30.1% died during the hospital stay, and 63.5% of survivors did not achieve favorable outcome at 3 months after onset of NCSE. Patients admitted primarily due to NCSE had longer NCSE duration and were more likely to be intubated at diagnosis. The receiver operating characteristic (ROC) for SAPS II, EMSE, and STESS when predicting mortality was between .683 and .762. The ROC for SAPS II, EMSE, STESS, and END-IT when predicting 3-month outcome was between .649 and .710. The accuracy in predicting mortality/outcome was low, when considering both proposed cutoffs and optimized cutoffs (estimated using the Youden Index) as well as when adjusting for admission reason. SIGNIFICANCE The scores EMSE, STESS, and END-IT perform poorly when predicting outcome of patients with NCSE in an NCCU environment. They should be interpreted cautiously and only in conjunction with other clinical data in this particular patient group.
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Affiliation(s)
- Stefan Y Bögli
- Neurocritical Care Unit, Institute for Intensive Care Medicine and Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Department of Neurology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Tanja Schmidt
- Neurocritical Care Unit, Institute for Intensive Care Medicine and Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Lukas L Imbach
- Swiss Epilepsy Center, Klinik Lengg, Zurich, Switzerland
| | - Friederike Nellessen
- Neurocritical Care Unit, Institute for Intensive Care Medicine and Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Giovanna Brandi
- Neurocritical Care Unit, Institute for Intensive Care Medicine and Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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6
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Göcking B, Biller-Andorno N, Brandi G, Gloeckler S, Glässel A. Aneurysmal Subarachnoid Hemorrhage and Clinical Decision-Making: A Qualitative Pilot Study Exploring Perspectives of Those Directly Affected, Their Next of Kin, and Treating Clinicians. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:3187. [PMID: 36833886 PMCID: PMC9958564 DOI: 10.3390/ijerph20043187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 02/02/2023] [Accepted: 02/07/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Exploring the experience and impact of aneurysmal subarachnoid hemorrhage (aSAH) from three perspectives, that of those directly affected (AFs), their next of kin (NoK), and treating clinicians, is a way to support and empower others to make informed medical decisions. METHODS In a Swiss neurosurgical intensive care unit (ICU), eleven semi-structured interviews were conducted as part of a Database of Individual Patient Experiences (DIPEx) pilot project and thematically analyzed. Interviews were held with two clinicians, five people experiencing aSAH, and four NoK 14-21 months after the bleeding event. RESULTS Qualitative analysis revealed five main themes from the perspective of clinicians: emergency care, diagnosis and treatment, outcomes, everyday life in the ICU, and decision-making; seven main themes were identified for AFs and NoK: the experience of the aSAH, diagnosis and treatment, outcomes, impact on loved ones, identity, faith, religion and spirituality, and decision-making. Perspectives on decision-making were compared, and, whereas clinicians tended to focus their attention on determining treatment, AFs and NoK valued participation in shared decision-making processes. CONCLUSIONS Overall, aSAH was perceived as a life-threatening event with various challenges depending on severity. The results suggest the need for tools that aid decision-making and better prepare AFs and NoK using accessible means and at an early stage.
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Affiliation(s)
- Beatrix Göcking
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Winterthurerstrasse 30, CH-8006 Zurich, Switzerland
| | - Nikola Biller-Andorno
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Winterthurerstrasse 30, CH-8006 Zurich, Switzerland
| | - Giovanna Brandi
- Institute of Intensive Care Medicine, University Hospital Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland
| | - Sophie Gloeckler
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Winterthurerstrasse 30, CH-8006 Zurich, Switzerland
| | - Andrea Glässel
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Winterthurerstrasse 30, CH-8006 Zurich, Switzerland
- Department of Health Sciences, Institute of Public Health, Zurich University of Applied Sciences, Katharina-Sulzer-Platz 9, CH-8401 Winterthur, Switzerland
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7
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Gu S, Wang Y, Ke K, Tong X, Gu J, Zhang Y. Development and validation of a RASS-related nomogram to predict the in-hospital mortality of neurocritical patients: a retrospective analysis based on the MIMIC-IV clinical database. Curr Med Res Opin 2022; 38:1923-1933. [PMID: 35972210 DOI: 10.1080/03007995.2022.2113690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Richmond agitation-sedation scale (RASS) is a simple and widely used tool for evaluating sedation and agitation in adult ICU patients. Early deep sedation has been shown to be an important independent predictor of death, however, studies on the role of RASS in the prognostic assessment of neurocritical patients are lacking. The purpose of this study was to investigate the relationship between RASS and in-hospital mortality in neurocritical patients, and to develop and validate an effective predictive model based on this. METHODS This was a retrospective study of neurocritical patients from a large clinical database. A total of 2651 patients were collected, including general demographic characteristics, past medical history, biochemical test data and physical examination within 24 h of admission, and related medical records. Univariate and multivariate logistic regression analyses were used to screen out significant variables. Finally, 11 significant predictors were included into the logistic regression to establish the nomogram. RESULTS The area under the curve (AUC) of the nomogram was 0.9087(0.8950-0.9224) and the corrected c index was 0.9043, which gave the model better discriminatory ability compared with critical care related scales, such as SOFA and SAPSII scores. Besides, tools including calibration curve, decision curve analysis (DCA), and clinical impact curve (CIC) were used to verify that the model had good discrimination, calibration, and clinical applicability. CONCLUSIONS RASS score was an independent prognostic predictor of in-hospital death in neurocritical patients, and patients who are deeply sedated have a worse prognosis. RASS-related nomogram could be applied to predict the prognosis of neurocritical patients and to take effective intervention measures in early stage.
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Affiliation(s)
- Shenyan Gu
- Department of Neurology, Affiliated Hospital of Nantong University, Medical School of Nantong University, Nantong, China
| | - Yuqin Wang
- Department of Neurology, Affiliated Hospital of Nantong University, Nantong, China
| | - Kaifu Ke
- Department of Neurology, Affiliated Hospital of Nantong University, Nantong, China
| | - Xin Tong
- Department of Neurology, Affiliated Hospital of Nantong University, Medical School of Nantong University, Nantong, China
| | - Jiahui Gu
- Department of Neurology, Affiliated Hospital of Nantong University, Medical School of Nantong University, Nantong, China
| | - Yuanyuan Zhang
- Department of Neurology, Affiliated Hospital of Nantong University, Nantong, China
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8
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Owen B, Vangala A, Fritch C, Alsarah AA, Jones T, Davis H, Shuttleworth CW, Carlson AP. Cerebral Autoregulation Correlation With Outcomes and Spreading Depolarization in Aneurysmal Subarachnoid Hemorrhage. Stroke 2022; 53:1975-1983. [PMID: 35196873 PMCID: PMC9133018 DOI: 10.1161/strokeaha.121.037184] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Delayed cerebral ischemia remains one of the principal therapeutic targets after aneurysmal subarachnoid hemorrhage. While large vessel vasospasm may contribute to ischemia, increasing evidence suggests that physiological impairment through disrupted impaired cerebral autoregulation (CA) and spreading depolarizations (SDs) also contribute to delayed cerebral ischemia and poor neurological outcome. This study seeks to explore the intermeasure correlation of different measures of CA, as well as correlation with SD and neurological outcome. METHODS Simultaneous measurement of 7 continuous indices of CA was calculated in 19 subjects entered in a prospective study of SD in aneurysmal subarachnoid hemorrhage undergoing surgical aneurysm clipping. Intermeasure agreement was assessed, and the association of each index with modified Rankin Scale score at 90 days and occurrence of SD was assessed. RESULTS There were 4102 hours of total monitoring time across the 19 subjects. In time-resolved assessment, no CA measures demonstrated significant correlation; however, most demonstrate significant correlation averaged over 1 hour. Pressure reactivity (PRx), oxygen reactivity, and oxygen saturation reactivity were significantly correlated with modified Rankin Scale score at 90 days. PRx and oxygen reactivity also were correlated with the occurrence of SD events. Across multiple CA measure reactivity indices, a threshold between 0.3 and 0.5 was most associated with intervals containing SD. CONCLUSIONS Different continuous CA indices do not correlate well with each other on a highly time-resolved basis, so should not be viewed as interchangeable. PRx and oxygen reactivity are the most reliable indices in identifying risk of worse outcome in patients with aneurysmal subarachnoid hemorrhage undergoing surgical treatment. SD occurrence is correlated with impaired CA across multiple CA measurement techniques and may represent the pathological mechanism of delayed cerebral ischemia in patients with impaired CA. Optimization of CA in patients with aneurysmal subarachnoid hemorrhage may lead to decreased incidence of SD and improved neurological outcomes. Future studies are needed to evaluate these hypotheses and approaches.
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Affiliation(s)
- Bryce Owen
- University of New Mexico, School of Medicine
| | - Adarsh Vangala
- University of Arizona College of Medicine, Department of Internal Medicine
| | - Chanju Fritch
- Penn State School of Medicine, Department of Neurosurgery
| | - Ali A. Alsarah
- University of New Mexico School of Medicine, Department of Neurology
| | - Tom Jones
- University of New Mexico School of Medicine, Department of Psychiatry
| | - Herbert Davis
- University of New Mexico School of Medicine, Department of Internal Medicine, Division of Epidemiology, Biostatistics, and Preventive Medicine
| | | | - Andrew P. Carlson
- University of New Mexico School of Medicine, Department of Neurosurgery
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Kortelainen S, Curtze S, Martinez‐Majander N, Raj R, Skrifvars MB. Acute ischemic stroke in a university hospital intensive care unit: 1-year costs and outcome. Acta Anaesthesiol Scand 2022; 66:516-525. [PMID: 35118640 PMCID: PMC9304289 DOI: 10.1111/aas.14037] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 11/05/2021] [Accepted: 01/08/2022] [Indexed: 11/29/2022]
Abstract
Background and purpose Little is currently known about the cost‐effectiveness of intensive care of acute ischemic stroke (AIS). We evaluated 1‐year costs and outcome for patients with AIS treated in the intensive care unit (ICU). Materials and methods A single‐center retrospective study of patients admitted to an academic ICU with AIS between 2003 and 2013. True healthcare expenditure was obtained up to 1 year after admission and adjusted to consumer price index of 2019. Patient outcome was 12‐month functional outcome and mortality. We used multivariate logistic regression analysis to identify independent predictors of favorable outcomes and linear regression analysis to assess factors associated with costs. We calculated the effective cost per survivor (ECPS) and effective cost per favorable outcome (ECPFO). Results The study population comprised 154 patients. Reasons for ICU admission were: decreased consciousness level (47%) and need for respiratory support (40%). There were 68 (44%) 1 year survivors, of which 27 (18%) had a favorable outcome. High age (odds ratio [OR] 0.95, 95% confidence interval [CI] 0.91–0.98) and high hospital admission National Institutes of Health Stroke Scale score (OR 0.92, 95% CI 0.87–0.97) were independent predictors of poor outcomes. Increased age had a cost ratio of 0.98 (95% CI 0.97–0.99) per added year. The ECPS and ECPFO were 115,628€ and 291,210€, respectively. Conclusions Treatment of AIS in the ICU is resource‐intense, and in an era predating mechanical thrombectomy the outcome is often poor, suggesting a need for further research into cost‐efficacy of ICU care for AIS patients.
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Affiliation(s)
- Simon Kortelainen
- Department of Emergency Care and Services University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Sami Curtze
- Department of Neurology University of Helsinki and Helsinki University Hospital Helsinki Finland
| | | | - Rahul Raj
- Department of Neurosurgery University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Markus B. Skrifvars
- Department of Emergency Care and Services University of Helsinki and Helsinki University Hospital Helsinki Finland
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10
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Robba C, van Dijk EJ, van der Jagt M. Acute ischaemic stroke and its challenges for the intensivist. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:258-268. [PMID: 35134852 DOI: 10.1093/ehjacc/zuac004] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 01/12/2022] [Accepted: 01/13/2022] [Indexed: 06/14/2023]
Abstract
Acute ischaemic stroke (AIS) is responsible for almost 90% of all strokes and is one of the leading causes of death and disability. Acute ischaemic stroke is caused by a critical alteration in focal cerebral blood flow (ischaemia) from a variety of causes, resulting in infarction. The primary cerebral injury due to AIS occurs in the first hours, therefore early reperfusion importantly impacts on patient outcome ('Time is brain' concept). Secondary cerebral damage progressively evolves over the following hours and days due to cerebral oedema, haemorrhagic transformation, and cerebral inflammation. Systemic complications, such as pneumonia, sepsis, and deep venous thrombosis, could also affect outcome. The risk of a recurrent ischaemic stroke is in particular high in the first days, which necessitate particular attention. The role of intensive care unit physicians is therefore to avoid or reduce the risk of secondary damage, especially in the areas where the brain is functionally impaired and 'at risk' of further injury. Therapeutic strategies therefore consist of restoration of blood flow and a bundle of medical, endovascular, and surgical strategies, which-when applied in a timely and consistent manner-can prevent secondary deterioration due to cerebral and systemic complications and recurrent stroke and improve short- and long-term outcomes. A multidisciplinary collaboration between neurosurgeons, interventional radiologists, neurologists, and intensivists is necessary to elaborate the best strategy for the treatment of these patients.
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Affiliation(s)
- Chiara Robba
- Department of Anaesthesia and Intensive Care, Policlinico San Martino, IRCCS for Oncology and Neuroscience, Genova, Italy
- Dipartimento di Scienze Chirurgiche Diagnostiche Integrate, University of Genova, Genova, Italy
| | - Ewoud J van Dijk
- Department of Neurology, Donders Institute for Brain Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Mathieu van der Jagt
- Department of Intensive Care Adults, Erasmus MC-University Medical Center, Rotterdam, The Netherlands
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11
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Ali KM, Salih MH, AbuGabal HH, Omer MEA, Yagoub FEAM, Ahmed AE. The pattern of neurocritical disorders in multicenter in Khartoum State November 2020 to January 2021. Brain Behav 2022; 12:e2495. [PMID: 35134280 PMCID: PMC8933781 DOI: 10.1002/brb3.2495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 11/28/2021] [Accepted: 01/02/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Neurocritical care is a growing subspecialty. It concerns with the management of life-threatening neurological disorders. There is limited information regarding epidemiological data, disease characteristics, variability of clinical care, and in-hospital mortality of neurocritical patients worldwide. OBJECTIVES To study the pattern of neurocritical disorders in intensive care units. METHODOLOGY This prospective observational study was conducted on neurocritical patients who were admitted to four intensive care units of major hospitals in Khartoum state during the period from November 2020 to January 2021. RESULTS Seventy-two neurocritical patients were included in this study, 40 (55.6%) were males and 32(44.4%) were females. Twenty-three (31.9%) patients were with stroke, 12 (16.7%) with encephalitis, 9 (12.5%) with status epilepticus, 6 (8.3%) with Guillain Barre syndrome, and 4(5.6%) with Myasthenia Gravis (MG). Twenty-three patients (39.9%) needed mechanical ventilation (MV), which was the major indication for intensive care unit admission. CONCLUSION Stroke was the dominant diagnostic pattern requiring intensive care unit admission. Mechanical ventilation was the major indication for admission. Establishing specialized neurocritical intensive care units is highly recommended.
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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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12
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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] [MESH Headings] [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)
| | | | - Hiba Hassan AbuGabal
- Department of Internal MedicineFajr College for Science and TechnologyKhartoumSudan
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13
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Schlichter E, Lopez O, Scott R, Ngwenya L, Kreitzer N, Dangayach NS, Ferioli S, Foreman B. Feasibility of Nurse-Led Multidimensional Outcome Assessments in the Neuroscience Intensive Care Unit. Crit Care Nurse 2021; 40:e1-e8. [PMID: 32476030 DOI: 10.4037/ccn2020681] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND The outcome focus for survivors of critical care has shifted from mortality to patient-centered outcomes. Multidimensional outcome assessments performed in critically ill patients typically exclude those with primary neurological injuries. OBJECTIVE To determine the feasibility of measurements of physical function, cognition, and quality of life in patients requiring neurocritical care. METHODS This evaluation of a quality improvement initiative involved all patients admitted to the neuroscience intensive care unit at the University of Cincinnati Medical Center. INTERVENTIONS Telephone assessments of physical function (Glasgow Outcome Scale-Extended and modified Rankin Scale scores), cognition (modified Telephone Interview for Cognitive Status), and quality of life (5-level EQ-5D) were conducted between 3 and 6 months after admission. RESULTS During the 2-week pilot phase, the authors contacted and completed data entry for all patients admitted to the neuroscience intensive care unit over a 2-week period in approximately 11 hours. During the 18-month implementation phase, the authors followed 1324 patients at a mean (SD) time of 4.4 (0.8) months after admission. Mortality at follow-up was 38.9%; 74.8% of these patients underwent withdrawal of care. The overall loss to follow-up rate was 23.6%. Among all patients contacted, 94% were available by the second attempt to interview them by telephone. CONCLUSIONS Obtaining multidimensional outcome assessments by telephone across a diverse population of neurocritically ill patients was feasible and efficient. The sample was similar to those in other cohort studies in the neurocritical care population, and the loss to follow-up rate was comparable with that of the general critical care population.
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Affiliation(s)
- Erika Schlichter
- Erika Schlichter is a bedside critical care nurse, UCHealth, University of Cincinnati Medical Center, and a member of the Collaborative for Research on Acute Neurological Injuries (CRANI), University of Cincinnati, Cincinnati, Ohio
| | - Omar Lopez
- Omar Lopez is a research coordinator with the Division of Neuro-critical Care, Department of Neurology and Rehabilitation Medicine, University of Cincinnati Medical Center, and a member of CRANI
| | - Raymond Scott
- Raymond Scott is a medical student, College of Medicine, University of Cincinnati Medical Center
| | - Laura Ngwenya
- Laura Ngwenya is an assistant professor, Department of Neurology and Rehabilitation Medicine and Department of Neurosurgery, University of Cincinnati Medical Center, and Director, Neurotrauma Center, University of Cincinnati Gardner Neuroscience Institute, Cincinnati, Ohio. She is a cofounder of CRANI
| | - Natalie Kreitzer
- Natalie Kreitzer is an assistant professor, Department of Emergency Medicine, University of Cincinnati Medical Center, and a member of CRANI
| | - Neha S Dangayach
- Neha S. Dangayach is an assistant professor, Department of Neurology, Icahn School of Medicine and Mount Sinai Health System, New York, New York
| | - Simona Ferioli
- Simona Ferioli is an assistant professor, Department of Neurology and Rehabilitation Medicine, University of Cincinnati Medical Center, and a member of CRANI
| | - Brandon Foreman
- Brandon Foreman is an associate professor, Department of Neurology and Rehabilitation Medicine, University and Department of Neurosurgery, University of Cincinnati Medical Center. He is a cofounder of CRANI
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14
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Roberts M, Jin P, Shin S, Dhamoon M. Readmissions After Guillain-Barre Syndrome: Nationally Representative Data. J Clin Neuromuscul Dis 2021; 22:183-191. [PMID: 34019002 DOI: 10.1097/cnd.0000000000000319] [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: 06/12/2023]
Abstract
OBJECTIVES We aimed to obtain nationally representative data on hospital readmission rates after Guillain-Barre syndrome (GBS). METHODS International Classification of Disease, Ninth Revision codes from the 2013 National Readmissions Database identified adult GBS admissions, comorbidities, and readmission diagnoses. Logistic regression estimated odds ratios (ORs) for readmission. RESULTS Of 2109 GBS admissions identified, 20.8% were readmitted within 1 year and 12.2% within 30 days. Age did not predict readmission. Plasmapheresis use showed a nonsignificant trend toward readmission versus intravenous immunoglobulin use [OR 1.43, 95% confidence interval (CI) 1.00-2.051, P = 0.050]. Respiratory failure (OR 1.70, 95% CI 1.23-2.35, P = 0.0014), heart failure (OR 2.14, 95% CI 1.25-3.66, P = 0.0057), and renal failure (OR 2.00, 95% CI 1.20-3.32, P = 0.0078) predicted readmission. Top readmission diagnoses included GBS or chronic inflammatory demyelinating polyneuropathy (42.0%) and sepsis (3.5%). CONCLUSIONS One-fifth of GBS patients were readmitted within 1 year. Comorbid illnesses and respiratory complications increased a readmission risk but age did not.
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Affiliation(s)
- Mallory Roberts
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; and
| | - Peter Jin
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD
| | - Susan Shin
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; and
| | - Mandip Dhamoon
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; and
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15
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Long-Term Mortality Among ICU Patients With Stroke Compared With Other Critically Ill Patients. Crit Care Med 2021; 48:e876-e883. [PMID: 32931193 DOI: 10.1097/ccm.0000000000004492] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Assessment of all-cause mortality of intracerebral hemorrhage and ischemic stroke patients admitted to the ICU and comparison to the mortality of other critically ill ICU patients classified into six other diagnostic subgroups and the general Dutch population. DESIGN Observational cohort study. SETTING All ICUs participating in the Dutch National Intensive Care Evaluation database. PATIENTS All adult patients admitted to these ICUs between 2010 and 2015; patients were followed until February 2017. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of all 370,386 included ICU patients, 7,046 (1.9%) were stroke patients, 4,072 with ischemic stroke, and 2,974 with intracerebral hemorrhage. Short-term mortality in ICU-admitted stroke patients was high with 30 days mortality of 31% in ischemic stroke and 42% in intracerebral hemorrhage. In the longer term, the survival curve gradient among ischemic stroke and intracerebral hemorrhage patients stabilized. The gradual alteration of mortality risk after ICU admission was assessed using left-truncation with increasing minimum survival period. ICU-admitted stroke patients who survive the first 30 days after suffering from a stroke had a favorable subsequent survival compared with other diseases necessitating ICU admission such as patients admitted due to sepsis or severe community-acquired pneumonia. After having survived the first 3 months after ICU admission, multivariable Cox regression analyses showed that case-mix adjusted hazard ratios during the follow-up period of up to 3 years were lower in ischemic stroke compared with sepsis (adjusted hazard ratio, 1.21; 95% CI, 1.06-1.36) and severe community-acquired pneumonia (adjusted hazard ratio, 1.57; 95% CI, 1.39-1.77) and in intracerebral hemorrhage patients compared with these groups (adjusted hazard ratio, 1.14; 95% CI, 0.98-1.33 and adjusted hazard ratio, 1.49; 95% CI, 1.28-1.73). CONCLUSIONS Stroke patients who need intensive care treatment have a high short-term mortality risk, but this alters favorably with increasing duration of survival time after ICU admission in patients with both ischemic stroke and intracerebral hemorrhage, especially compared with other populations of critically ill patients such as sepsis or severe community-acquired pneumonia patients.
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16
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Intensive Care Admission and Management of Patients With Acute Ischemic Stroke: A Cross-sectional Survey of the European Society of Intensive Care Medicine. J Neurosurg Anesthesiol 2021; 34:313-320. [PMID: 33587531 DOI: 10.1097/ana.0000000000000761] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 12/31/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND No specific recommendations are available regarding the intensive care management of critically ill acute ischemic stroke (AIS) patients, and questions remain regarding optimal ventilatory, hemodynamic, and general intensive care unit (ICU) therapeutic targets in this population. We performed an international survey to investigate ICU admission criteria and management of AIS patients. METHODS An electronic questionnaire including 25 items divided into 3 sections was available on the European Society of Intensive Care Medicine Web site between November 1, 2019 and March 30, 2020 and advertised through the neurointensive care (NIC) section newsletter. This survey was emailed directly to the NIC members and was endorsed by the European Society of Intensive Care Medicine. RESULTS There were 214 respondents from 198 centers, with response rate of 16.5% of total membership (214/1296). In most centers (67%), the number of AIS patients admitted to respondents' hospitals in 2019 was between 100 and 300, and, among them, fewer than 50 required ICU admission per hospital. The most widely accepted indication for ICU admission criteria was a requirement for intubation and mechanical ventilation. A standard protocol for arterial blood pressure (ABP) management was utilized by 88 (58%) of the respondents. For patients eligible for intravenous thrombolysis, the most common ABP target was <185/110 mm Hg (n=77 [51%]), whereas for patients undergoing mechanical thrombectomy it was ≤160/90 mm Hg (n=79 [54%]). The preferred drug for reducing ABP was labetalol (n=84 [55.6%]). Other frequently used therapeutic targets included: blood glucose 140 to 180 mg/dL (n=65 [43%]) maintained with intravenous insulin infusion in most institutions (n=110 [72.4%]); enteral feeding initiated within 2 to 3 days from stroke onset (n=142 [93.4%]); oxygen saturation (SpO2) >95% (n=80 [53%]), and tidal volume 6 to 8 mL/kg of predicted body weight (n=135 [89%]). CONCLUSIONS The ICU management of AIS, including therapeutic targets and clinical practice strategies, importantly varies between centers. Our findings may be helpful to define future studies and create a research agenda regarding the ICU therapeutic targets for AIS patients.
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17
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Hajeb M, Singh TD, Sakusic A, Graff-Radford J, Gajic O, Rabinstein AA. Functional outcome after critical illness in older patients: a population-based study. Neurol Res 2020; 43:103-109. [PMID: 33012281 DOI: 10.1080/01616412.2020.1831302] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE To determine the prevalence of disability among ICU survivors one year after admission, and which factors influence functional outcome. METHODS We examined consecutive patients enrolled in the population-based Mayo Clinic Olmsted Study of Aging and then admitted to medical or surgical adult ICUs at Mayo Clinic, Rochester between January 1, 2006, and December 31, 2014 to determine one-year functional outcomes. RESULTS 831cases were included. Mean age was 84 years (IQR 79-88). 569 (68.5%) patients were alive one year after ICU admission. Of them, 546 patients had functional assessment at one year and 367 (67.2%) had good functional outcome. On multivariable analysis, poor one-year functional outcome (death or disability) was more common among women, older patients, and patients with baseline cognitive impairment (mild cognitive impairment or dementia), higher Carlson scores, and longer ICU stay (all P <.01). After excluding deceased patients, these associations remained unchanged. In addition, 120 (32.3%) of 372 patients who had post-ICU cognitive evaluation experienced cognitive decline after the ICU admission. CONCLUSIONS On a population-based cohort of older, predominantly elderly patients, approximately two-thirds of survivors maintained or regained good functional status 1 year after ICU hospitalization. However, older age, female sex, greater comorbidities, abnormal baseline cognition, and longer ICU stay were associated with poor functional recovery and cognitive decline was common.
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Affiliation(s)
- Mania Hajeb
- Departments of Neurology, Mayo Clinic , Rochester, MN, USA
| | - Tarun D Singh
- Departments of Neurology, Mayo Clinic , Rochester, MN, USA
| | - Amra Sakusic
- University Clinical Center Tuzla, Bosnia and Herzegovina; and Multidisciplinary Epidemiology and Translational Research in Intensive Care, Emergency and Perioperative Medicine (METRIC), Mayo Clinic , Rochester, MN, USA
| | | | - Ognjen Gajic
- Pulmonary Medicine and Multidisciplinary Epidemiology and Translational Research in Intensive Care, Emergency and Perioperative Medicine (METRIC), Mayo Clinic , Rochester, MN, USA
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18
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Mc Lernon S, Schwarz G, Wilson D, Ambler G, Goodwin R, Shakeshaft C, Cohen H, Yousry T, Al-Shahi Salman R, Lip GYH, Houlden H, Brown MM, Muir KW, Jäger HR, Terry L, Werring DJ. Association between critical care admission and 6-month functional outcome after spontaneous intracerebral haemorrhage. J Neurol Sci 2020; 418:117141. [PMID: 32977232 DOI: 10.1016/j.jns.2020.117141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 09/11/2020] [Accepted: 09/12/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND There is uncertainty about the clinical benefit of admission to critical care after spontaneous intracerebral haemorrhage (ICH). PURPOSE We investigated factors associated with critical care admission after spontaneous ICH and evaluated associations between critical care and 6-month functional outcome. METHODS We included 825 patients with acute spontaneous non-traumatic ICH, recruited to a prospective multicenter observational study. We evaluated the characteristics associated with critical care admission and poor 6-month functional outcome (modified Rankin Scale, mRS > 3) using univariable (chi-square test and Wilcoxon rank-sum test, as appropriate) and multivariable analysis. RESULTS 286 patients (38.2%) had poor 6-month functional outcome. Seventy-seven (9.3%) patients were admitted to critical care. Patients admitted to critical care were younger (p < 0.001), had lower GCS score (p < 0.001), larger ICH volume (p < 0.001), more often had intraventricular extension (p = 0.008) and underwent neurosurgery (p < 0.001). Critical care admission was associated with poor functional outcome at 6 months (39/77 [50.7%] vs 286/748 [38.2%]; p = 0.034); adjusted OR 2.43 [95%CI 1.36-4.35], p = 0.003), but not with death (OR 1.29 [95%CI 0.71-2.35; p = 0.4). In ordinal logistic regression, patients admitted to critical care showed an OR 1.47 (95% CI 0.98-2.20; p = 0.07) for a shift in the 6-month modified Rankin Scale. CONCLUSIONS Admission to critical care is associated with poor 6-month functional outcome after spontaneous ICH but not with death. Patients admitted to critical care were a priori more severely affected. Although adjusted for main known predictors of poor outcome, our findings could still be confounded by unmeasured factors. Establishing the true effectiveness of critical care after ICH requires a randomised trial with clinical outcomes and quality of life assessments.
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Affiliation(s)
- Siobhan Mc Lernon
- Stroke Research Centre, University College London, Institute of Neurology, London, UK; London South Bank University, School of Health and Social Care, London, UK.
| | - Ghil Schwarz
- Stroke Research Centre, University College London, Institute of Neurology, London, UK; Department of Neurology, Stroke Unit San Raffaele Hospital, Milan, Italy
| | - Duncan Wilson
- Stroke Research Centre, University College London, Institute of Neurology, London, UK
| | - Gareth Ambler
- Department of Statistical Science, University College London, Gower Street, London, UK
| | - Russell Goodwin
- London South Bank University, School of Health and Social Care, London, UK
| | - Clare Shakeshaft
- Stroke Research Centre, University College London, Institute of Neurology, London, UK
| | - Hannah Cohen
- Haemostasis Research Unit, Department of Haematology, University College London, 51 Chenies Mews, London, UK
| | - Tarek Yousry
- Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London, UK
| | - Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh, Edinburgh, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK; and Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Henry Houlden
- Department of Molecular Neuroscience, UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Martin M Brown
- Stroke Research Centre, University College London, Institute of Neurology, London, UK
| | - Keith W Muir
- Institute of Neuroscience & Psychology, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, UK
| | - Hans Rolf Jäger
- Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London, UK
| | - Louise Terry
- London South Bank University, School of Health and Social Care, London, UK
| | - David J Werring
- Stroke Research Centre, University College London, Institute of Neurology, London, UK
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Rath K, Kreitzer N, Schlichter E, Lopez O, Ferioli S, Ngwenya LB, Foreman B. The Experience of a Neurocritical Care Admission and Discharge for Patients and Their Families: A Qualitative Analysis. J Neurosci Nurs 2020; 52:179-185. [PMID: 32371682 PMCID: PMC7335345 DOI: 10.1097/jnn.0000000000000515] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION A qualitative assessment of discharge resource needs is important for developing evidence-based care improvements in neurocritically ill patients. METHODS We conducted a quality improvement initiative at an academic hospital and included all patients admitted to the neuroscience intensive care unit (ICU) during an 18-month period. Telephone assessments were made at 3 to 6 months after admission. Patients or caregivers were asked whether they had adequate resources upon discharge and whether they had any unanswered questions. The content of responses was reviewed by a neurointensivist and a neurocritical care nurse practitioner. A structured codebook was developed, organized into themes, and applied to the responses. RESULTS Sixty-one patients or caregivers responded regarding access to resources at discharge with 114 individual codable responses. Responses centered around 5 themes with 23 unique codes: satisfied, needs improvement, dissatisfied, poor post-ICU care, and poor health. The most frequently coded responses were that caregivers believed their loved one had experienced an unclear discharge (n = 11) or premature discharge (n = 12). Two hundred four patients or caregivers responded regarding unanswered questions or additional comments at follow-up, with 516 codable responses. These centered around 6 themes with 26 unique codes: positive experience, negative experience, neutral experience, medical questions, ongoing medical care or concern, or remembrance of time spent in the ICU. The most frequent response was that caregivers or patients stated that they received good care (n = 115). Multiple concerns were brought up, including lack of follow-up after hospitalization (n = 15) and dissatisfaction with post-ICU care (n = 15). CONCLUSIONS Obtaining qualitative responses after discharge provided insight into the transition from critical care. This could form the basis for an intervention to provide a smoother transition from the ICU to the outpatient setting.
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Affiliation(s)
- Kelly Rath
- University of Cincinnati Division of Neurocritical Care
- University of Cincinnati Department of Neurology
- University of Cincinnati College of Nursing
| | - Natalie Kreitzer
- University of Cincinnati Division of Neurocritical Care
- University of Cincinnati Department of Emergency Medicine
| | - Erika Schlichter
- University of Cincinnati Division of Neurocritical Care
- University of Cincinnati Department of Neurology
- University of Cincinnati College of Nursing
| | - Omar Lopez
- University of Cincinnati Division of Neurocritical Care
- University of Cincinnati Department of Neurology
- University of Cincinnati Collaborative for Research on Acute Neurological Injury
| | - Simona Ferioli
- University of Cincinnati Division of Neurocritical Care
- University of Cincinnati Department of Neurology
| | - Laura B. Ngwenya
- University of Cincinnati Department of Neurology
- University of Cincinnati Collaborative for Research on Acute Neurological Injury
- University of Cincinnati Department of Neurosurgery
| | - Brandon Foreman
- University of Cincinnati Division of Neurocritical Care
- University of Cincinnati Department of Neurology
- University of Cincinnati Collaborative for Research on Acute Neurological Injury
- University of Cincinnati Department of Neurosurgery
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20
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Fitzgerald E, Hammond N, Tian DH, Bradford C, Flower O, Harbor K, Johnson P, Lee R, Parkinson J, Tracey A, Delaney A. Functional outcomes at 12 months for patients with traumatic brain injury, intracerebral haemorrhage and subarachnoid haemorrhage treated in an Australian neurocritical care unit: A prospective cohort study. Aust Crit Care 2020; 33:497-503. [PMID: 32739245 DOI: 10.1016/j.aucc.2020.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 03/17/2020] [Accepted: 03/25/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Acute severe brain injury is associated with significant morbidity and mortality. Patients and their families need accurate information regarding expected outcomes. Few studies have reported the long-term functional outcome of patients with acute severe brain injury treated in an Australian neurocritical care unit. OBJECTIVE The objective of this study was to describe 12-month functional outcomes (using the extended Glasgow Outcome Scale) of patients with acute severe brain injury treated in an Australian neurocritical care unit. METHODS This was a single-centre prospective cohort study. Patients with a diagnosis of traumatic brain injury, subarachnoid haemorrhage or intracranial haemorrhage admitted between 2015 and 2019 were enrolled. RESULTS In total, 915 participants were enrolled during the 51-month study period. Of the cohort, 403 (44%) were admitted after traumatic brain injury, 274 (30%) after subarachnoid haemorrhage and 238 (26%) after intracranial haemorrhage. The median duration of intensive care admission was 5 days (interquartile range: 2-13), 458 (50%) received invasive ventilation, 417 (46%) received vasopressor support and 286 (31%) received an external ventricular drain. At discharge from intensive care, 150 of 915 (16.4%) had died, and the in-hospital mortality was seen in 191 of 915 patients (20.9%). Favourable functional outcome, as defined by an extended Glasgow Outcome Scale score of 5-8, was reported in 358 of available 795 patients (45.0%) at six months and in 311 of 672 available patients (46.3%) at 12 months. Those with intracranial haemorrhage reported the highest rates of unfavourable outcomes with 112 of 166 patients (67.4%) at 12 months. CONCLUSIONS In this selected population, admission to a neurocritical care unit was associated with significant resource use. At 12 months after admission, almost half of those admitted to an Australian neurocritical unit with traumatic brain injury, subarachnoid haemorrhage and intracerebral haemorrhage report a good functional outcome.
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Affiliation(s)
- Emily Fitzgerald
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, Australia.
| | - Naomi Hammond
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, Australia; Division of Critical Care, The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - David H Tian
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, Australia
| | - Celia Bradford
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, Australia
| | - Oliver Flower
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, Australia; Northern Clinical School, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Kelly Harbor
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, Australia
| | - Phil Johnson
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, Australia
| | - Richard Lee
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, Australia; Northern Clinical School, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Jonathon Parkinson
- Northern Clinical School, Sydney Medical School, University of Sydney, Sydney, Australia; Department of Neurosurgery, Royal North Shore Hospital, Sydney, Australia
| | - Ashleigh Tracey
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, Australia
| | - Anthony Delaney
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, Australia; Northern Clinical School, Sydney Medical School, University of Sydney, Sydney, Australia; Division of Critical Care, The George Institute for Global Health, University of New South Wales, Sydney, Australia
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Clinical Predictors of Survival and Functional Outcome of Stroke Patients Admitted to Critical Care. Crit Care Med 2019; 46:1085-1092. [PMID: 29608513 DOI: 10.1097/ccm.0000000000003127] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To determine the predictive value of commonly used clinical variables upon ICU admission for long-term all-cause mortality and functional outcome of adult stroke patients admitted to the ICU. DESIGN Retrospective observational cohort study. SETTING General and neurosurgical ICUs of the University College London Hospitals in North Central London. PATIENTS All adult ICU patients with a clinical diagnosis of acute stroke admitted between February 2010 and May 2012. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Demographic and clinical data concerning the first 24 hours after ICU admission were obtained. Patients were followed until February 2016 to assess long-term survival. Functional outcome was determined using the modified Rankin Scale. We evaluated 131 critically ill stroke patients, with a median (interquartile range) age of 70 years (55-78 yr). One-year mortality rate was 52.7%. Surviving patients were followed up over a median (interquartile range) period of 4.3 years (4.0-4.8 yr). The multivariable model that best predicted long-term all-cause mortality indicated that mortality of critically ill stroke patients was predicted by high Acute Physiology and Chronic Health Evaluation II score, impaired consciousness (Glasgow Coma Scale score ≤ 8) as reason for ICU admission, low Glasgow Coma Scale sum score after 24 hours, and absence of brainstem reflexes. Long-term independent functional status occurred in 30.9% of surviving patients and was predicted by low Acute Physiology and Chronic Health Evaluation II score, high Glasgow Coma Scale sum score at ICU admission, and absence of mass effect on CT scan. CONCLUSIONS Mortality in critically ill stroke patients is high and occurs most often shortly after the event. Less than one in three surviving patients is able to function independently after 1 year. This study has identified several clinical variables that predict long-term all-cause mortality and functional outcome among critically ill stroke patients and found that mainly acute physiologic disturbance and absolute values of neurologic clinical assessment are predictive.
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Smith M, Reddy U, Robba C, Sharma D, Citerio G. Acute ischaemic stroke: challenges for the intensivist. Intensive Care Med 2019; 45:1177-1189. [PMID: 31346678 DOI: 10.1007/s00134-019-05705-y] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 07/17/2019] [Indexed: 12/25/2022]
Abstract
PURPOSE To provide an update about the rapidly developing changes in the critical care management of acute ischaemic stroke patients. METHODS A narrative review was conducted in five general areas of acute ischaemic stroke management: reperfusion strategies, anesthesia for endovascular thrombectomy, intensive care unit management, intracranial complications, and ethical considerations. RESULTS The introduction of effective reperfusion strategies, including IV thrombolysis and endovascular thrombectomy, has revolutionized the management of acute ischaemic stroke and transformed outcomes for patients. Acute therapeutic efforts are targeted to restoring blood flow to the ischaemic penumbra before irreversible tissue injury has occurred. To optimize patient outcomes, secondary insults, such as hypotension, hyperthermia, or hyperglycaemia, that can extend the penumbral area must also be prevented or corrected. The ICU management of acute ischaemic stroke patients, therefore, focuses on the optimization of systemic physiological homeostasis, management of intracranial complications, and neurological and haemodynamic monitoring after reperfusion therapies. Meticulous blood pressure management is of central importance in improving outcomes, particularly in patients that have undergone reperfusion therapies. CONCLUSIONS While consensus guidelines are available to guide clinical decision making after acute ischaemic stroke, there is limited high-quality evidence for many of the recommended interventions. However, a bundle of medical, endovascular, and surgical strategies, when applied in a timely and consistent manner, can improve long-term stroke outcomes.
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Affiliation(s)
- M Smith
- Neurocritical Care Unit, The National Hospital for Neurology and Neurosurgery, University College London Hospitals, Queen Square, London, UK. .,Department of Medical Physics and Biomedical Engineering, University College London, London, UK.
| | - U Reddy
- Neurocritical Care Unit, The National Hospital for Neurology and Neurosurgery, University College London Hospitals, Queen Square, London, UK
| | - C Robba
- Department of Anaesthesia and Intensive Care, Policlinico San Martino IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - D Sharma
- Division of Neuroanesthesiology and Perioperative Neurosciences, Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, USA
| | - G Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.,Neurointensive Care Unit, San Gerardo Hospital, ASST-Monza, Monza, MB, Italy
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23
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Liu F, Wang Q, Chen X. Myasthenic crisis treated in a Chinese neurological intensive care unit: clinical features, mortality, outcomes, and predictors of survival. BMC Neurol 2019; 19:172. [PMID: 31324153 PMCID: PMC6642475 DOI: 10.1186/s12883-019-1384-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 06/27/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Myasthenic crisis (MC) often requires admission to an intensive care unit (ICU). METHODS We retrospectively investigated 113 consecutive patients with first MC admitted to the neurological ICU. Patients' demographic, clinical and other characteristics were examined, as well as therapeutic interventions, mortality and functional outcome. RESULTS MC patients at first onset admitted to neurological ICU had a mortality rate of 18.6%. PCO2 level before intubation and score on Myasthenia Gravis-Activities of Daily Living (MG-ADL) scale at MC onset correlated with duration of ventilation and length of ICU stay. Compared with patients with good functional outcome, patients with intermediate or poor functional outcome were older at first MC onset, had lower pH and PO2, and had higher PCO2 before intubation. Multivariate logistic analysis identified pre-intubation PCO2 level as an independent predictor of survival. Cox regression showed that age at first MC onset requiring ICU management was the factor which significantly influenced the mortality. CONCLUSIONS Our results suggest that PCO2 before intubation and MG-ADL score at MC onset may be useful indicators of more severe disease likely to require extensive respiratory support and ICU management. Higher pre-intubation PCO2 indicates chronic respiratory acidosis that can increase risk of severe disability and death, especially in patients with older age at first MC onset.
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Affiliation(s)
- Fan Liu
- Department of Nursing, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China
| | - Qiong Wang
- Neurological Intensive Care Unit, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xueping Chen
- Department of Neurology, West China Hospital, Sichuan University, 610041, Guoxuexiang #37, Chengdu, Sichuan, China.
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24
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Tanwar G, Singh U, Kundra S, Chaudhary AK, Kaytal S, Grewal A. Evaluation of airway care score as a criterion for extubation in patients admitted in neurosurgery intensive care unit. J Anaesthesiol Clin Pharmacol 2019; 35:85-91. [PMID: 31057247 PMCID: PMC6495608 DOI: 10.4103/joacp.joacp_362_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background and Aims: Early extubation in neurocritical patients has several potential benefits. Glasgow Coma Scale (GCS) is a crude measure of neurologic function in these patients and a low GCS score does not necessarily mean contraindication for extubation. Data on patients with neurosurgical or neurological pathology undergoing early extubation utilizing the airway score criteria is limited. Hence, this study was conceived to assess the usefulness of modified airway care score (ACS) as a criterion for successful extubation of neurocritical patients whilst comparing various outcomes. Material and Methods: One hundred and twenty four patient who underwent endotracheal intubation in the neurocritical care unit were enrolled in this prospective observational study over a period of 12 months. Patients were randomly enrolled into either the study group patients (S), who were extubated immediately after a successful spontaneous breathing trial (SBT) and an ACS ≤7 or into the control group (N), wherein patients were extubated/tracheostomized at discretion of the attending neurointensivist. Both groups were observed for comparison of preset outcomes and analyzed statistically. Results: Patients of study group experienced a statistically significant shorter extubation delay (3.28 h vs 25.41 h) compared to the control group. Successful extubation rate was significantly higher and reintubation rate was significantly lower in study group (6.6% vs 29.3%). Incidence of nosocomial pneumonia, duration of ICU stay and overall duration of mechanical ventilation were significantly lower in the study group. ACS and GCS had a negative correlation at the time of extubation. Conclusion: ACS can be used as a criterion for successful early extubation of neurocritical patients.
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Affiliation(s)
- Gayatri Tanwar
- Department of Anaesthesiology, Dr. S.N. Medical College, Jodhpur, Rajasthan, India
| | - Udeyana Singh
- Department of Anaesthesiology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Sandeep Kundra
- Department of Anaesthesiology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Ashwani K Chaudhary
- Department of Neurosurgery, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Sunil Kaytal
- Department of Anaesthesiology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Anju Grewal
- Department of Anaesthesiology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
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25
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Gao Q, Yuan F, Yang XA, Zhu JW, Song L, Bi LJ, Jiao ZY, Kang XG, Yang F, Jiang W. Development and validation of a new score for predicting functional outcome of neurocritically ill patients: The INCNS score. CNS Neurosci Ther 2019; 26:21-29. [PMID: 30968580 PMCID: PMC6930816 DOI: 10.1111/cns.13134] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 03/16/2019] [Accepted: 03/20/2019] [Indexed: 11/29/2022] Open
Abstract
Aims To develop and validate a novel score for prediction of 3‐month functional outcome in neurocritically ill patients. Methods The development of the novel score was based on two widely used scores for general critical illnesses (Acute Physiology and Chronic Health Evaluation II, APACHE II; Simplified Acute Physiology Score II, SAPS II) and consideration of the characteristics of neurocritical illness. Data from consecutive patients admitted to neurological ICU (N‐ICU) between January 2013 and June 2016 were used for the validation. The modified Rankin Scale (mRS) was used to evaluate 3‐month functional outcomes. APACHE II scores, SAPS II scores, and our novel scores at 24 hours and 72 hours in N‐ICU were obtained. We compared the prognostic performance of our score with APACHE II and SAPS II. Results We developed a 44‐point scoring system named the INCNS score, and it includes 19 items which were categorized into five parts: inflammation (I), nutrition (N), consciousness (C), neurological function (N), and systemic function (S). We validated the INCNS score with a cohort of 941 N‐ICU patients. The 72‐hours INCNS score achieved an area under the receiver operating characteristic curve (AUC) of 0.828 (95% CI: 0.802‐0.854), and the 24‐hours INCNS score achieved an AUC of 0.788 (95% CI: 0.759‐0.817). The INCNS score exhibited significantly better discriminative and prognostic performance than APACHE II and SAPS II at both 24 hours and 72 hours in N‐ICU. Conclusion We developed an INCNS score with superior predictive power for functional outcome of neurocritically ill patients.
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Affiliation(s)
- Qiong Gao
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Fang Yuan
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Xi-Ai Yang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Ji-Wen Zhu
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Lu Song
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Li-Jie Bi
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Ze-Yu Jiao
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Xiao-Gang Kang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Fang Yang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Wen Jiang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
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Akavipat P, Thinkhamrop J, Thinkhamrop B, Sriraj W. ACUTE PHYSIOLOGY AND CHRONIC HEALTH EVALUATION (APACHE) II SCORE - THE CLINICAL PREDICTOR IN NEUROSURGICAL INTENSIVE CARE UNIT. Acta Clin Croat 2019; 58:50-56. [PMID: 31363325 PMCID: PMC6629196 DOI: 10.20471/acc.2019.58.01.07] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The APACHE II scoring system is approved for its benchmarking and mortality predictions, but there are only a few articles published to demonstrate it in neurosurgical patients. Therefore, this study was performed to acknowledge this score and its predictive performance to hospital mortality in a tertiary referral neurosurgical intensive care unit (ICU). All patients admitted to the Neurosurgical ICU from February 1 to July 31, 2011 were recruited. The parameters indicated in APACHE II score were collected. The adjusted predicted risk of death was calculated and compared with the death rate observed. Descriptive statistics including the receiver operating characteristic curve (ROC) was performed. The results showed that 276 patients were admitted during the mentioned period. The APACHE II score was 16.56 (95% CI, 15.84-17.29) and 19.08 (95% CI, 15.40-22.76) in survivors and non-survivors, while the adjusted predicted death rates were 13.39% (95% CI, 11.83-14.95) and 17.49% (95% CI, 9.81-25.17), respectively. The observed mortality was only 4.35%. The area under the ROC of APACHE II score to the hospital mortality was 0.62 (95% CI, 0.44-0.79). In conclusion, not only the APACHE II score in neurosurgical patients indicated low severity, but its performance to predict hospital mortality was also inferior. Additional studies of predicting mortality among these critical patients should be undertaken.
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Affiliation(s)
| | - Jadsada Thinkhamrop
- 1Anesthesiology Department, Prasat Neurological Institute, Bangkok, Thailand; 2Department of Obstetrics and Gynecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand; 3Department of Biostatistics and Demography, Faculty of Public Health, Khon Kaen University, Khon Kaen, Thailand; 4Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Bandit Thinkhamrop
- 1Anesthesiology Department, Prasat Neurological Institute, Bangkok, Thailand; 2Department of Obstetrics and Gynecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand; 3Department of Biostatistics and Demography, Faculty of Public Health, Khon Kaen University, Khon Kaen, Thailand; 4Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Wimonrat Sriraj
- 1Anesthesiology Department, Prasat Neurological Institute, Bangkok, Thailand; 2Department of Obstetrics and Gynecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand; 3Department of Biostatistics and Demography, Faculty of Public Health, Khon Kaen University, Khon Kaen, Thailand; 4Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
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Improved Outcomes following the Establishment of a Neurocritical Care Unit in Saudi Arabia. Crit Care Res Pract 2018; 2018:2764907. [PMID: 30123585 PMCID: PMC6079555 DOI: 10.1155/2018/2764907] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 04/27/2018] [Accepted: 06/20/2018] [Indexed: 12/15/2022] Open
Abstract
Background Dedicated neurocritical care units have dramatically improved the management and outcome following brain injury worldwide. Aim This is the first study in the Middle East to evaluate the clinical impact of a neurocritical care unit (NCCU) launched within the diverse clinical setting of a polyvalent intensive care unit (ICU). Design and Methods A retrospective before and after cohort study comparing the outcomes of neurologically injured patients. Group one met criteria for NCCU admission but were admitted to the general ICU as the NCCU was not yet operational (group 1). Group two were subsequently admitted thereafter to the NCCU once it had opened (group 2). The primary outcome was all-cause ICU and hospital mortality. Secondary outcomes were ICU length of stay (LOS), predictors of ICU and hospital discharge, ICU discharge Glasgow Coma Scale (GCS), frequency of tracheostomies, ICP monitoring, and operative interventions. Results Admission to NCCU was a significant predictor of increased hospital discharge with an odds ratio of 2.3 (95% CI: 1.3–4.1; p=0.005). Group 2 (n = 208 patients) compared to Group 1 (n = 364 patients) had a significantly lower ICU LOS (15 versus 21.4 days). Group 2 also had lower ICU and hospital mortality rates (5.3% versus 10.2% and 9.1% versus 19.5%, respectively; all p < 0.05). Group 2 patients had higher discharge GCS and underwent fewer tracheostomies but more interventional procedures (all p < 0.05). Conclusion Admission to NCCU, within a polyvalent Middle Eastern ICU, was associated with significantly decreased mortality and increased hospital discharge.
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28
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Gerges PRA, Moore L, Léger C, Lauzier F, Shemilt M, Zarychanski R, Scales DC, Burns KEA, Bernard F, Zygun D, Neveu X, Turgeon AF. Intensity of care and withdrawal of life-sustaining therapies in severe traumatic brain injury patients: a post-hoc analysis of a multicentre retrospective cohort study. Can J Anaesth 2018; 65:996-1003. [PMID: 29949093 DOI: 10.1007/s12630-018-1171-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 03/20/2018] [Accepted: 04/25/2018] [Indexed: 11/24/2022] Open
Abstract
PURPOSE The intensity of care provided to critically ill patients has been shown to be associated with mortality. In patients with traumatic brain injury (TBI), specialized neurocritical care is often required, but whether it affects clinically significant outcomes is unknown. We aimed to determine the association of the intensity of care on mortality and the incidence of withdrawal of life-sustaining therapies in critically ill patients with severe TBI. METHODS We conducted a post hoc analysis of a multicentre retrospective cohort study of critically ill adult patients with severe TBI. We defined the intensity of care as a daily cumulative sum of interventions during the intensive care unit stay. Our outcome measures were all-cause hospital mortality and the incidence of withdrawal of life-sustaining therapies. RESULTS Seven hundred sixteen severe TBI patients were included in our study. Most were male (77%) with a mean (standard deviation) age of 42 (20.5) yr and a median [interquartile range] Glasgow Coma Scale score of 3 [3-6]. Our results showed an association between the intensity of care and mortality (hazard ratio [HR], 0.69; 95% confidence interval [CI], 0.63 to 0.74) and the incidence of withdrawal of life-sustaining therapy (HR, 0.73; 95% CI, 0.67 to 0.79). CONCLUSION In general, more intense care was associated with fewer deaths and a lower incidence of withdrawal of life-sustaining therapies in critically ill patients with severe TBI.
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Affiliation(s)
- Peter R A Gerges
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Université Laval, 1401, 18e rue, local Z-204, Québec City, QC, G1J 1Z4, Canada
| | - Lynne Moore
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Université Laval, 1401, 18e rue, local Z-204, Québec City, QC, G1J 1Z4, Canada.,Department of Social and Preventive Medicine, Université Laval, Québec City, QC, Canada
| | - Caroline Léger
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Université Laval, 1401, 18e rue, local Z-204, Québec City, QC, G1J 1Z4, Canada
| | - François Lauzier
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Université Laval, 1401, 18e rue, local Z-204, Québec City, QC, G1J 1Z4, Canada.,Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec City, QC, Canada.,Department of Medicine, Université Laval, Québec City, QC, Canada
| | - Michèle Shemilt
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Université Laval, 1401, 18e rue, local Z-204, Québec City, QC, G1J 1Z4, Canada
| | - Ryan Zarychanski
- Department of Internal Medicine, Sections of Critical Care Medicine, Haematology and of Medical Oncology, University of Manitoba, Winnipeg, MB, Canada
| | - Damon C Scales
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Li Ka Shing Knowledge Institute, St-Michaels Hospital, Toronto, ON, Canada
| | - Francis Bernard
- Department of Internal Medicine, Université de Montréal, Montréal, QC, Canada
| | - David Zygun
- Department of Critical Care Medicine, University of Alberta, Edmonton, AB, Canada
| | - Xavier Neveu
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Université Laval, 1401, 18e rue, local Z-204, Québec City, QC, G1J 1Z4, Canada
| | - Alexis F Turgeon
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Université Laval, 1401, 18e rue, local Z-204, Québec City, QC, G1J 1Z4, Canada. .,Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec City, QC, Canada.
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Decavèle M, Weiss N, Rivals I, Prodanovic H, Idbaih A, Mayaux J, Similowski T, Demoule A. Prognosis of patients with primary malignant brain tumors admitted to the intensive care unit: a two-decade experience. J Neurol 2017; 264:2303-2312. [PMID: 28993874 DOI: 10.1007/s00415-017-8624-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Revised: 09/03/2017] [Accepted: 09/19/2017] [Indexed: 12/11/2022]
Abstract
The purpose of this study is to describe the reasons for ICU admission and to evaluate the outcome and prognostic factors of patients with primary malignant brain tumors (PMBT) admitted to the intensive care unit (ICU). This is a retrospective observational cohort study of 196 PMBT patients admitted to two ICUs over a 19-year period. Acute respiratory failure was the main reason for ICU admission (45%) followed by seizures (25%) and non-epileptic coma (14%). Seizures were more common in patients with glial lesions (84 vs. 67%), whereas patients with primary brain lymphoma were more frequently admitted for shock (42 vs. 18%). Overall ICU and 90-day mortality rates were 23 and 50%, respectively. Admission for seizures was independently associated with lower ICU mortality [odds ratio (OR) 0.06], whereas the need for mechanical ventilation (OR 6.85), cancer progression (OR 7.84), respiratory rate (OR 1.11) and Glasgow coma scale (OR 0.85) were associated with higher ICU mortality. Among the 95 patients who received invasive mechanical ventilation, ICU mortality was 37% (n = 35). For these patients, admission for seizures was associated with lower ICU mortality (OR 0.050) whereas cancer progression (OR 7.49) and respiratory rate (OR 1.08) were associated with higher ICU mortality. The prognosis of PMBT patients admitted to the ICU appears relatively favorable compared to that of hematologic malignancies or solid tumors, especially when the patient is admitted for seizures. The presence of a PMBT, therefore, does not appear to be sufficient for refusal of ICU admission. Predictive factors of mortality may help clinicians make optimal triage decisions.
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Affiliation(s)
- Maxens Decavèle
- Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMRS_1158, Paris, France.,Department of Respiratory and Critical Care Medicine, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département "R3S"), AP-HP, 47-83 Boulevard de l'Hôpital, 75013, Paris, France
| | - Nicolas Weiss
- Unité de Réanimation Neurologique, Département de Neurologie, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Pôle des Maladies du Système Nerveux et Institut de Neurosciences Translationnelles, IHU-A-ICM, Paris, France
| | - Isabelle Rivals
- Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMRS_1158, Paris, France.,Equipe de Statistique Appliquée, ESPCI ParisTech, PSL Research University, Paris, France
| | - Hélène Prodanovic
- Department of Respiratory and Critical Care Medicine, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département "R3S"), AP-HP, 47-83 Boulevard de l'Hôpital, 75013, Paris, France
| | - Ahmed Idbaih
- Institut du Cerveau et de la Moelle Épinière, ICM, Inserm U 1127, CNRS, UMR 7225, Sorbonne Universités, UPMC Univ Paris 06, UMRS_1127, 75013, Paris, France.,Hôpitaux Universitaires La Pitié Salpêtrière, Charles Foix, Service de Neurologie 2-Mazarin, AP-HP, 75013, Paris, France
| | - Julien Mayaux
- Department of Respiratory and Critical Care Medicine, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département "R3S"), AP-HP, 47-83 Boulevard de l'Hôpital, 75013, Paris, France
| | - Thomas Similowski
- Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMRS_1158, Paris, France.,Department of Respiratory and Critical Care Medicine, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département "R3S"), AP-HP, 47-83 Boulevard de l'Hôpital, 75013, Paris, France
| | - Alexandre Demoule
- Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMRS_1158, Paris, France. .,Department of Respiratory and Critical Care Medicine, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département "R3S"), AP-HP, 47-83 Boulevard de l'Hôpital, 75013, Paris, France.
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Steidl C, Bösel J, Suntrup-Krueger S, Schönenberger S, Al-Suwaidan F, Warnecke T, Minnerup J, Dziewas R. Tracheostomy, Extubation, Reintubation: Airway Management Decisions in Intubated Stroke Patients. Cerebrovasc Dis 2017; 44:1-9. [PMID: 28395275 DOI: 10.1159/000471892] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 03/20/2017] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Both delayed and premature extubation increase complication rate, the need for tracheostomy (TT), the duration of intensive care unit stay, and mortality. In this study, we therefore investigated factors associated with primary TT and predictors for extubation failure (EF) in a sample of severely affected ventilated stroke patients. METHODS One hundred eighty five intubated stroke patients were prospectively analyzed in this observational study. Patients not meeting predefined clinical and respiratory extubation criteria received a TT. All other patients were extubated and followed up for the need of reintubation. Characteristics of patients with and without extubation attempt were examined. Additionally, within the group of extubated patients, subgroups of successfully vs. unsuccessfully extubated patients were compared. Clinical factors associated with reintubation, including a previously established semi-quantitative airway score, were determined and predictors of EF were assessed. RESULTS Ninety-eight of 185 patients (53%) were primarily extubated; EF rate was 37% (36 patients). Eighty-seven (47%) were tracheostomized without a prior extubation attempt. Primarily tracheostomized patients had more severe strokes, which were more often hemorrhagic, presented with a lower level of consciousness, needed neurosurgical intervention more often, had a higher rate of obesity, and were more frequently intubated because of suspicion of compromised protective reflexes. EF was independently predicted by prior neurosurgical treatment and low airway management scores. No differences were found for the ability to follow simple commands and classical weaning criteria. CONCLUSION Airway management decisions in intubated stroke patients represent a clinical challenge. Classical weaning criteria and parameters reflecting the patient's state of consciousness are not reliably predictive of extubation success. Criteria more closely related to airway safety and secretion handling may provide the most relevant information and should therefore be assessed by specific clinical scoring systems.
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Fiehler J, Cognard C, Gallitelli M, Jansen O, Kobayashi A, Mattle HP, Muir KW, Mazighi M, Schaller K, Schellinger PD. European recommendations on organisation of interventional care in acute stroke (EROICAS). Eur Stroke J 2016; 1:155-170. [PMID: 31008277 DOI: 10.1177/2396987316659033] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Affiliation(s)
- Jens Fiehler
- Department of Neuroradiology, University Medical Center, Hamburg, Germany
| | - Christophe Cognard
- Department of Neuroradiology, University Hospital of Toulouse, Toulouse, France
| | - Mauro Gallitelli
- Emergency Department, Ospedale "Santi Giovanni e Paolo", Venice, Italy
| | - Olav Jansen
- Department of Radiology and Neuroradiology, University Medical Center of Schleswig-Holstein, Campus Kiel, Germany
| | - Adam Kobayashi
- 2nd Department of Neurology and Interventional Stroke and Cerebrovascular Treatment Centre, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Heinrich P Mattle
- Department of Neurology, Inselspital, University of Bern, Bern, Switzerland
| | - Keith W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, Scotland, United Kingdom
| | - Mikael Mazighi
- Department of Neurology and Stroke Center, AP-HP, Lariboisière Hospital, Paris, France
| | - Karl Schaller
- Department of Neurosurgery, University of Geneva, Medical Center, Geneva, Switzerland
| | - Peter D Schellinger
- Departments of Neurology and Neurogeriatrics, Johannes Wesling Klinikum Minden, Minden, Germany
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Fiehler J, Cognard C, Gallitelli M, Jansen O, Kobayashi A, Mattle HP, Muir KW, Mazighi M, Schaller K, Schellinger PD. European Recommendations on Organisation of Interventional Care in Acute Stroke (EROICAS). Int J Stroke 2016; 11:701-16. [DOI: 10.1177/1747493016647735] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Jens Fiehler
- Department of Neuroradiology, University Medical Center, Hamburg, Germany
| | - Christophe Cognard
- Department of Neuroradiology, University Hospital of Toulouse, Toulouse, France
| | - Mauro Gallitelli
- Emergency Department, Ospedale “Santi Giovanni e Paolo”, Venice, Italy
| | - Olav Jansen
- Department of Radiology and Neuroradiology, University Medical Center of Schleswig-Holstein, Campus Kiel, Germany
| | - Adam Kobayashi
- 2nd Department of Neurology and Interventional Stroke and Cerebrovascular Treatment Centre, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Heinrich P Mattle
- Department of Neurology, Inselspital, University of Bern, Bern, Switzerland
| | - Keith W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, Scotland, United Kingdom
| | - Mikael Mazighi
- Department of Neurology and Stroke Center, AP-HP, Lariboisière Hospital, Paris, France
| | - Karl Schaller
- Department of Neurosurgery, University of Geneva, Medical Center, Geneva, Switzerland
| | - Peter D Schellinger
- Departments of Neurology and Neurogeriatrics, Johannes Wesling Klinikum Minden, Minden, Germany
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Ho WM, Lin JR, Wang HH, Liou CW, Chang KC, Lee JD, Peng TY, Yang JT, Chang YJ, Chang CH, Lee TH. Prediction of in-hospital stroke mortality in critical care unit. SPRINGERPLUS 2016; 5:1051. [PMID: 27462499 PMCID: PMC4940351 DOI: 10.1186/s40064-016-2687-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 06/23/2016] [Indexed: 01/12/2023]
Abstract
BACKGROUND Critical stroke causes high morbidity and mortality. We examined if variables in the early stage of critical stroke could predict in-hospital mortality. METHODS We recruited 611 ischemic and 805 hemorrhagic stroke patients who were admitted within 24 h after the symptom onset. Data were analyzed with independent t test and Chi square test, and then with multivariate logistic regression analysis. RESULTS In ischemic stroke, National Institutes of Health Stroke Scale (NIHSS) score (OR 1.08; 95 % CI 1.06-1.11; P < 0.01), white blood cell count (OR 1.11; 95 % CI 1.05-1.18; P < 0.01), systolic blood pressure (BP) (OR 0.49; 95 % CI 0.26-0.90; P = 0.02) and age (OR 1.03; 95 % CI 1.00-1.05; P = 0.03) were associated with in-hospital mortality. In hemorrhagic stroke, NIHSS score (OR 1.12; 95 % CI 1.09-1.14; P < 0.01), systolic BP (OR 0.25; 95 % CI 0.15-0.41; P < 0.01), heart disease (OR 1.94; 95 % CI 1.11-3.39; P = 0.02) and creatinine (OR 1.16; 95 % CI 1.01-1.34; P = 0.04) were related to in-hospital mortality. Nomograms using these significant predictors were constructed for easy and quick evaluation of in-hospital mortality. CONCLUSION Variables in acute stroke can predict in-hospital mortality and help decision-making in clinical practice using nomogram.
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Affiliation(s)
- Wei-Min Ho
- />Dementia Center and Department of Neurology, Linkou Medical Center, Chang Gung Memorial Hospital, No.5, Fuxing St., Guishan Dist., Taoyuan City, 333 Taiwan, ROC
| | - Jr-Rung Lin
- />Clinical Informatics and Medical Statistics Research Center, Chang Gung University, No.261, Wenhua 1st Rd., Guishan Dist., Taoyuan City, 333 Taiwan, ROC
| | - Hui-Hsuan Wang
- />Department of Healthcare Management, College of Management, Chang Gung University, No.261, Wenhua 1st Rd., Guishan Dist., Taoyuan City, 333 Taiwan, ROC
| | - Chia-Wei Liou
- />Stroke Center and Department of Neurology, Kaohsiung Medical Center, Chang Gung Memorial Hospital, No.123, Dapi Rd., Niaosong Dist., Kaohsiung City, 833 Taiwan, ROC
| | - Ku-Chou Chang
- />Stroke Center and Department of Neurology, Kaohsiung Medical Center, Chang Gung Memorial Hospital, No.123, Dapi Rd., Niaosong Dist., Kaohsiung City, 833 Taiwan, ROC
| | - Jiann-Der Lee
- />Stroke Center and Department of Neurology, Chiayi Medical Center, Chang Gung Memorial Hospital, No.6, Sec. W., Jiapu Rd., Puzi City, 613 Chiayi County Taiwan, ROC
| | - Tsung-Yi Peng
- />Department of Neurology, Chang Gung Memorial Hospital, No.222, Maijin Rd., Anle Dist., Keelung City, 204 Taiwan, ROC
| | - Jen-Tsung Yang
- />Department of Neurosurgery, Chiayi Medical Center, Chang Gung Memorial Hospital, No.6, Sec. W., Jiapu Rd., Puzi City, 613 Chiayi County Taiwan, ROC
| | - Yeu-Jhy Chang
- />Stroke Center and Department of Neurology, Linkou Medical Center, Chang Gung Memorial Hospital, No.5, Fuxing St., Guishan Dist., Taoyuan City, 333 Taiwan, ROC
| | - Chien-Hung Chang
- />Stroke Center and Department of Neurology, Linkou Medical Center, Chang Gung Memorial Hospital, No.5, Fuxing St., Guishan Dist., Taoyuan City, 333 Taiwan, ROC
| | - Tsong-Hai Lee
- />Stroke Center and Department of Neurology, Linkou Medical Center, Chang Gung Memorial Hospital, No.5, Fuxing St., Guishan Dist., Taoyuan City, 333 Taiwan, ROC
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Scheinfeld MH, Erdfarb AJ, Krieger DA, Bhupali D, Zampolin RL. A radiologist's guide to the clinical scales used in the 2015 Endovascular Stroke Trials and the Revised American Heart Association/American Stroke Association Guidelines for Endovascular Stroke Treatment. Emerg Radiol 2016; 23:497-501. [PMID: 27389543 DOI: 10.1007/s10140-016-1420-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 06/29/2016] [Indexed: 10/21/2022]
Abstract
In 2015, five trials demonstrated the efficacy of endovascular treatment for acute stroke, culminating in the revised American Heart Association/American Stroke Association (AHA/ASA) recommendations for stroke management. The different clinical scales used in these trials may be unfamiliar to emergency and on-call radiologists. The modified Rankin Scale was used to describe patient disability for prestroke assessment in three of the trials and for the 90-day follow up in all five trials. The Barthel index was used in one trial to score prestroke ability to perform activities of daily living. The NIH Stroke Scale was used as part of eligibility criteria in four of the stroke trials to assess pre-existing neurological deficits. Also, the modified Rankin Scale and the NIH Stroke Scale are used in the revised AHA/ASA recommendations. By understanding these scales, emergency and on-call radiologists will better appreciate the stroke patient's condition and will be able to more actively collaborate in the care of acute stroke patients.
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Affiliation(s)
- Meir H Scheinfeld
- Department of Radiology, Division of Emergency Radiology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, 10467, USA.
| | - Amichai J Erdfarb
- Department of Radiology, Division of Neuroradiology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, 10467, USA
| | - Daniel A Krieger
- Department of Radiology and Imaging Sciences, Division of Neuroradiology, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | - Deepa Bhupali
- Department of Neurology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, 10467, USA
| | - Richard L Zampolin
- Department of Radiology, Division of Neuroradiology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, 10467, USA
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Abstract
Purpose. To characterize indications, treatment, and length of stay in a stand-alone neurological intensive care unit with focus on comparison between ventilated and nonventilated patient. Methods. We performed a single-center retrospective cohort study of all treated patients in our neurological intensive care unit between October 2006 and December 2008. Results. Overall, 512 patients were treated in the surveyed period, of which 493 could be included in the analysis. Of these, 40.8% had invasive mechanical ventilation and 59.2% had not. Indications in both groups were predominantly cerebrovascular diseases. Length of stay was 16.5 days in mean for ventilated and 3.6 days for nonventilated patient. Conclusion. Most patients, ventilated or not, suffer from vascular diseases with further impairment of other organ systems or systemic complications. Data reflects close relationship and overlap of treatment on nICU with a standardized stroke unit treatment and suggests, regarding increasing therapeutic options, the high impact of acute high-level treatment to reduce consequential complications.
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36
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Sadek AR, Damian M, Eynon CA. The role of neurosciences intensive care in neurological conditions. Br J Hosp Med (Lond) 2014; 74:558-63. [PMID: 24105308 DOI: 10.12968/hmed.2013.74.10.558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The neurosciences intensive care unit provides specialized medical and nursing care to both the neurosurgical and neurological patient. This second of two articles describes the role it plays in the management of patients with neurological conditions.
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Affiliation(s)
- Ahmed-Ramadan Sadek
- Walport Academic Clinical Fellow in Neurosurgery and Jason Brice Fellow in Neurosurgical Research, University Hospital Southampton NHS Foundation Trust, Southampton
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[Survey study: update on neurological intensive care in Germany 2012: structure, standards and scores in neurological intensive care units]. DER NERVENARZT 2013; 83:1609-18. [PMID: 23247999 DOI: 10.1007/s00115-012-3541-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Neurological critical care lacks high-quality evidence to guide optimal treatment. Furthermore, it is presently rather unclear as to what extent German neurological intensivists adhere to guidelines, employ standard operating procedures or use scoring tools. METHODS An e-mail-based questionnaire was distributed to physicians directing German neurological, neurosurgical and neurological/neurosurgical interdisciplinary intensive care units (ICUs). RESULTS Of the 326 departments 78 answered the questionnaire and of these 53% were university units. The ICUs were either led by neurologists (37%), neurosurgeons (22%), anesthetists (28%) or a combination of these (13%). The mean number of ICU beds was 11.2 and the mean number of intensivists 7.7. Guideline adherence was stated to amount to 75 % by 41 % of the ICUs. Applications of standard procedures was achieved by more than 80 % for several ICU management aspects, while only 5 out of 19 of the respondents routinely used scoring tools in > 60% of the ICUs. The extent of protocol and score applications differed significantly according to hospital status or leading speciality. CONCLUSION This survey suggests an obvious interest in but also an unfulfilled need of guidance in a standardized approach to neurological critical care in Germany. More activity in multicentre clinical research with a neurocritical focus to provide optimization of protocols, scores and guidelines appears to be warranted.
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Damian MS, Ben-Shlomo Y, Howard R, Bellotti T, Harrison D, Griggs K, Rowan K. The effect of secular trends and specialist neurocritical care on mortality for patients with intracerebral haemorrhage, myasthenia gravis and Guillain–Barré syndrome admitted to critical care. Intensive Care Med 2013; 39:1405-12. [DOI: 10.1007/s00134-013-2960-6] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Accepted: 05/07/2013] [Indexed: 11/28/2022]
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39
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Should age be considered when proposing decompressive hemicraniectomy in malignant stroke, and if so where is the limit? Neurocrit Care 2013; 17:159-60. [PMID: 22669790 DOI: 10.1007/s12028-012-9722-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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40
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Long-term outcome in patients with Guillain–Barré syndrome requiring mechanical ventilation. J Neurol 2013; 260:1367-74. [DOI: 10.1007/s00415-012-6806-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Revised: 12/11/2012] [Accepted: 12/12/2012] [Indexed: 10/27/2022]
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41
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Indikationen und Outcome beatmeter Patienten einer neurologischen Intensivstation. DER NERVENARZT 2012; 83:741-50. [DOI: 10.1007/s00115-011-3411-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Abstract
In 2010 Critical Care published a large number of articles on critical care aspects of neurologic and neurosurgical conditions. These aspects included investigation of diagnostic criteria for bacterial meningitis, critical illness myopathy and their relationship to systemic inflammation. A number of studies investigated the biology of sepsis-related delirium, its biomarkers, its relationship to inflammation and its impact on outcome. Other teams reported on the use of magnetic resonance imaging, biomarkers and electroencephalogram to predict outcome in patients who were comatose following cardiac arrest. Our understanding of the pathophysiology as well as management of subarachnoid hemorrhage was addressed in several papers. Topics included the effect of hemodynamic treatment of delayed cerebral ischemia, pulmonary edema and the impact of subarachnoid hemorrhage on endocrine function. Finally, outcome from neurocritical care and patients' retrospective willingness to consent to the treatment they received were reported.
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Affiliation(s)
- Michael T Scalfani
- Neurology/Neurosurgery Intensive Care Unit, Department of Neurology, Washington University School of Medicine, Campus Box 8111, 660 S, Euclid Avenue, St Louis, MO 63110, USA
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