Hemodynamic response during endotracheal suctioning predicts awakening and functional outcome in subarachnoid hemorrhage patients

Follow-Up Imaging in Angiography-Negative Spontaneous Subarachnoid Hemorrhage

BACKGROUND

The aim of this study was to assess the diagnostic yield of follow-up investigations in aneurysm-negative subarachnoid hemorrhage (SAH) patients.

METHODS

In 109 (25%) of 435 patients with SAH and initial negative digital subtraction angiography (DSA), the diagnostic yield of repeat DSA and magnetic resonance imaging (MRI) of the brain and craniocervical junction was reviewed.

RESULTS

Of the 109 patients with an initial negative DSA, 51 (47%) had perimesencephalic (PM), 54 (50%) had nonperimesencephalic (NPM) blood distribution, and 4 (3.7%) had computed tomography-negative SAH. A delayed bleeding source was determined in 3 of 82 (3.7%) patients who underwent repeat DSA and in 1 of 5 patients who underwent a third DSA. The bleeding patterns of these patients were all NPM (n = 4). Repeat DSA did not identify a bleeding source in patients with PM-SAH. MRI of the brain and craniocervical junction after 2 days revealed a bleeding source in 1 of 105 patients (1%) in a computed tomography-negative SAH. When all diagnostic modalities, including exploratory craniotomy and MRI of the spinal axis, were considered, the rate of delayed diagnosis of the bleeding source was 6.4% (7/109). In addition to the bleeding pattern, patients with delayed diagnosis of the bleeding source were characterized by worse disease severity parameters, worse radiological grading scales, and more in-hospital complications than patients without delayed diagnosis of a bleeding source.

CONCLUSIONS

The results of this study support the use of repeat DSA in patients with NPM-SAH; however, routine repeat DSA may not be indicated in PM-SAH patients. The routine use of MRI remains controversial.

Effects of an Early Intensive Blood Pressure-lowering Strategy Using Remifentanil and Dexmedetomidine in Patients with Spontaneous Intracerebral Hemorrhage: A Multicenter, Prospective, Superiority, Randomized Controlled Trial

BACKGROUND

Although it has been established that elevated blood pressure and its variability worsen outcomes in spontaneous intracerebral hemorrhage, antihypertensives use during the acute phase still lacks robust evidence. A blood pressure-lowering regimen using remifentanil and dexmedetomidine might be a reasonable therapeutic option given their analgesic and antisympathetic effects. The objective of this superiority trial was to validate the efficacy and safety of this blood pressure-lowering strategy that uses remifentanil and dexmedetomidine in patients with acute intracerebral hemorrhage.

METHODS

In this multicenter, prospective, single-blinded, superiority randomized controlled trial, patients with intracerebral hemorrhage and systolic blood pressure (SBP) 150 mmHg or greater were randomly allocated to the intervention group (a preset protocol with a standard guideline management using remifentanil and dexmedetomidine) or the control group (standard guideline-based management) to receive blood pressure-lowering treatment. The primary outcome was the SBP control rate (less than 140 mmHg) at 1 h posttreatment initiation. Secondary outcomes included blood pressure variability, neurologic function, and clinical outcomes.

RESULTS

A total of 338 patients were allocated to the intervention (n = 167) or control group (n = 171). The SBP control rate at 1 h posttreatment initiation in the intervention group was higher than that in controls (101 of 161, 62.7% vs. 66 of 166, 39.8%; difference, 23.2%; 95% CI, 12.4 to 34.1%; P < 0.001). Analysis of secondary outcomes indicated that patients in the intervention group could effectively reduce agitation while achieving lighter sedation, but no improvement in clinical outcomes was observed. Regarding safety, the incidence of bradycardia and respiratory depression was higher in the intervention group.

CONCLUSIONS

Among intracerebral hemorrhage patients with a SBP 150 mmHg or greater, a preset protocol using a remifentanil and dexmedetomidine-based standard guideline management significantly increased the SBP control rate at 1 h posttreatment compared with the standard guideline-based management.

EDITOR’S PERSPECTIVE

Benefits and harms of normal saline instillation before endotracheal suctioning in mechanically ventilated adult patients in intensive care units: A systematic literature review and meta-analysis

OBJECTIVES

This systematic review aimed to identify the effects of normal saline instillation before endotracheal suctioning on clinical outcomes in critically ill patients on a mechanical ventilator.

RESEARCH METHODOLOGY

This review was based on the guidelines of the National Evidence-based Healthcare Collaborating Agency in Korea and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Six electronic databases were searched for relevant literature. Other sources were also searched, including the reference lists of identified reports and previous systematic reviews. After the initial literature search, a two-step retrieval process was performed to select eligible studies. Then, data were collected using a newly developed form, and the risk of bias was assessed using the checklists of the Joanna Briggs Institute. Data were analyzed using both narrative syntheses and meta-analyses.

RESULTS

In total, 16 studies: 13 randomized controlled trials and three quasi-experimental studies, were included. From the narrative syntheses, instilling normal saline before endotracheal suctioning was associated with a decrease in oxygen saturation, prolonged time for oxygen saturation to recover to baseline, decreased arterial pH, increased secretion amount, reduced incidence of ventilator-associated pneumonia, increased heart rate, and increased systolic blood pressure. Meta-analyses showed a significant difference in heart rate at five minutes after suctioning but no significant differences in oxygen saturation at two and five minutes after suctioning and heart rate at two minutes after suctioning.

CONCLUSION

This systematic review indicated that instilling normal saline before performing endotracheal suctioning has more harmful effects than benefits.

IMPLICATIONS FOR CLINICAL PRACTICE

As recommended in the current guidelines, it is necessary to refrain from routine normal saline instillation before endotracheal suctioning.

Prognosis of consciousness disorders in the intensive care unit

Assessments of consciousness are a critical part of prognostic algorithms for critically ill patients suffering from severe brain injuries. There have been significant advances in the field of coma science over the past two decades, providing clinicians with more advanced and precise tools for diagnosing and prognosticating disorders of consciousness (DoC). Advanced neuroimaging and electrophysiological techniques have vastly expanded our understanding of the biological mechanisms underlying consciousness, and have helped identify new states of consciousness. One of these, termed cognitive motor dissociation, can predict functional recovery at 1 year post brain injury, and is present in up to 15-20% of patients with DoC. In this chapter, we review several tools that are used to predict DoC, describing their strengths and limitations, from the neurological examination to advanced imaging and electrophysiologic techniques. We also describe multimodal assessment paradigms that can be used to identify covert consciousness and thus help recognize patients with the potential for future recovery and improve our prognostication practices.

Effects of endotracheal tube fixation methods on haemodynamic parameters during endotracheal suction: A single-blind non-randomized clinical trial study

AIM

This study aimed to determine the effect of the methods used in endotracheal tube fixation on haemodynamic parameters (systolic and diastolic blood pressure, heart rate and oxygen saturation) during endotracheal suction.

METHODS

The sample of this prospective, parallel two-armed, single-blind non-randomized clinical trial study included 86 intubated patients treated in the cardiovascular surgery intensive care unit between September 2016 and December 2017. The endotracheal tube was fixed with tube holders in the intervention group (n = 43), whereas the endotracheal tube was fixed with plasters in the control group (n = 43). The patients' haemodynamic parameters were measured before, during, at the end of suction, and 5 and 15 min after suction.

RESULTS

In comparison with the patients with plasters, patients with tube holders had significantly lower systolic blood pressure 15 min after endotracheal suction and significantly lower diastolic blood pressure during and at the end of endotracheal suction. Oxygen saturation of the patients with tube holder during, at the end, and following 5 min after endotracheal suction were higher than patients with plaster. Heart rate was not affected during endotracheal suction in both groups.

CONCLUSION

The study showed the tube holder affected the haemodynamic parameters during endotracheal suction less than the plaster.

A Precision Medicine Framework for Classifying Patients with Disorders of Consciousness: Advanced Classification of Consciousness Endotypes (ACCESS)

BACKGROUND

Consciousness in patients with brain injury is traditionally assessed based on semiological evaluation at the bedside. This classification is limited because of low granularity, ill-defined and rigid nomenclatures incompatible with the highly fluctuating nature of consciousness, failure to identify specific brain states like cognitive motor dissociation, and neglect for underlying biological mechanisms. Here, the authors present a pragmatic framework based on consciousness endotypes that combines clinical phenomenology with all essential physiological and biological data, emphasizing recovery trajectories, therapeutic potentials and clinical feasibility.

METHODS

The Neurocritical Care Society's Curing Coma Campaign identified an international group of experts who convened in a series of online meetings between May and November 2020 to discuss and propose a novel framework for classifying consciousness.

RESULTS

The expert group proposes Advanced Classification of Consciousness Endotypes (ACCESS), a tiered multidimensional framework reflecting increasing complexity and an aspiration to consider emerging and future approaches. Tier 1 is based on clinical phenotypes and structural imaging. Tier 2 adds functional measures including EEG, PET and functional MRI, that can be summarized using the Arousal, Volition, Cognition and Mechanisms (AVCM) score (where "Volition" signifies volitional motor responses). Finally, Tier 3 reflects dynamic changes over time with a (theoretically infinite) number of physiologically distinct states to outline consciousness recovery and identify opportunities for therapeutic interventions.

CONCLUSIONS

Whereas Tiers 1 and 2 propose an approach for low-resource settings and state-of-the-art expertise at leading academic centers, respectively, Tier 3 is a visionary multidimensional consciousness paradigm driven by continuous incorporation of new knowledge while addressing the Curing Coma Campaign's aspirational goals.