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Halpern NA, Tan KS, Bothwell LA, Boyce L, Dulu AO. Defining Intensivists: A Retrospective Analysis of the Published Studies in the United States, 2010-2020. Crit Care Med 2024; 52:223-236. [PMID: 38240506 DOI: 10.1097/ccm.0000000000005984] [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: 01/23/2024]
Abstract
OBJECTIVES The Society of Critical Care Medicine last published an intensivist definition in 1992. Subsequently, there have been many publications relating to intensivists. Our purpose is to assess how contemporary studies define intensivist physicians. DESIGN Systematic search of PubMed, Embase, and Web of Science (2010-2020) for publication titles with the terms intensivist, and critical care or intensive care physician, specialist, or consultant. We included studies focusing on adult U.S. intensivists and excluded non-data-driven reports, non-U.S. publications, and pediatric or neonatal ICU reports. We aggregated the study title intensivist nomenclatures and parsed Introduction and Method sections to discern the text used to define intensivists. Fourteen parameters were found and grouped into five definitional categories: A) No definition, B) Background training and certification, C) Works in ICU, D) Staffing, and E) Database related. Each study was re-evaluated against these parameters and grouped into three definitional classes (single, multiple, or no definition). The prevalence of each parameter is compared between groups using Fisher exact test. SETTING U.S. adult ICUs and databases. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 657 studies, 105 (16%) met inclusion criteria. Within the study titles, 17 phrases were used to describe an intensivist; these were categorized as intensivist in 61 titles (58%), specialty intensivist in 30 titles (29%), and ICU/critical care physician in 14 titles (13%). Thirty-one studies (30%) used a single parameter (B-E) as their definition, 63 studies (60%) used more than one parameter (B-E) as their definition, and 11 studies (10%) had no definition (A). The most common parameter "Works in ICU" (C) in 52 studies (50%) was more likely to be used in conjunction with other parameters rather than as a standalone parameter (multiple parameters vs single-parameter studies; 73% vs 17%; p < 0.0001). CONCLUSIONS There was no consistency of intensivist nomenclature or definitions in contemporary adult intensivist studies in the United States.
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Affiliation(s)
- Neil A Halpern
- Department of Anesthesiology and Critical Care Medicine, Critical Care Center, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kay See Tan
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Lilly A Bothwell
- Department of Strategy and Innovation, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Lindsay Boyce
- MSK Library, Technology Division, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Alina O Dulu
- Department of Anesthesiology and Critical Care Medicine, Critical Care Center, Memorial Sloan Kettering Cancer Center, New York, NY
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Calixte A, Lartigue S, McGaugh S, Mathelier M, Patel A, Siyanaki MRH, Pierre K, Lucke-Wold B. Neurointerventional Radiology: History, Present and Future. JOURNAL OF RADIOLOGY AND ONCOLOGY 2023; 7:26-32. [PMID: 37795208 PMCID: PMC10550195 DOI: 10.29328/journal.jro.1001049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
Neurointerventional Radiology (NIR), encompassing neuroendovascular surgery, endovascular neurosurgery, and interventional neurology, is an innovative and rapidly evolving multidisciplinary specialty focused on minimally invasive therapies for a wide range of neurological disorders. This review provides a comprehensive overview of NIR, discussing the three routes into the field, highlighting their distinct training paradigms, and emphasizing the importance of unified approaches through organizations like the Society of Neurointerventional Surgery (SNIS). The paper explores the benefits of co-managed care and its potential to improve patient outcomes, as well as the role of interdisciplinary collaboration and cross-disciplinary integration in advancing the field. We discuss the various contributions of neurosurgery, radiology, and neurology to cerebrovascular surgery, aiming to inform and educate those interested in pursuing a career in neurointervention. Additionally, the review examines the adoption of innovative technologies such as robotic-assisted techniques and artificial intelligence in NIR, and their implications for patient care and the future of the specialty. By presenting a comprehensive analysis of the field of neurointervention, we hope to inspire those considering a career in this exciting and rapidly advancing specialty, and underscore the importance of interdisciplinary collaboration in shaping its future.
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Affiliation(s)
- Andre Calixte
- New York Medical College, Valhalla, New York, 10595, USA
| | - Schan Lartigue
- New York Medical College, Valhalla, New York, 10595, USA
| | - Scott McGaugh
- University of Florida College of Medicine, Gainesville, Florida, 32608, USA
| | - Michael Mathelier
- University of Florida College of Medicine, Gainesville, Florida, 32608, USA
| | - Anjali Patel
- University of Florida College of Medicine, Gainesville, Florida, 32608, USA
| | | | - Kevin Pierre
- University of Florida Department of Radiology, Gainesville, Florida, 32608, USA
| | - Brandon Lucke-Wold
- University of Florida Department of Neurosurgery, Gainesville, Florida, 32608, USA
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Pham X, Ray J, Neto AS, Laing J, Perucca P, Kwan P, O’Brien TJ, Udy AA. Association of Neurocritical Care Services With Mortality and Functional Outcomes for Adults With Brain Injury: A Systematic Review and Meta-analysis. JAMA Neurol 2022; 79:1049-1058. [PMID: 36036899 PMCID: PMC9425286 DOI: 10.1001/jamaneurol.2022.2456] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 07/01/2022] [Indexed: 11/14/2022]
Abstract
Importance Neurocritical care (NCC) aims to improve the outcomes of critically ill patients with brain injury, although the benefits of such subspecialized care are yet to be determined. Objective To evaluate the association of NCC with patient-centered outcomes in adults with acute brain injury who were admitted to intensive care units (ICUs). The protocol was preregistered on PROSPERO (CRD42020177190). Data Sources Three electronic databases were searched (Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials) from inception through December 15, 2021, and by citation chaining. Study Selection Studies were included for interventions of neurocritical care units (NCCUs), neurointensivists, or NCC consulting services compared with general care in populations of neurologically ill adults or adults with acute brain injury in ICUs. Data Extraction and Synthesis Data extraction was performed in keeping with PRISMA guidelines and risk of bias assessed through the ROBINS-I Cochrane tool by 2 independent reviewers. Data were pooled using a random-effects model. Main Outcomes and Measures The primary outcome was all-cause mortality at longest follow-up until 6 months. Secondary outcomes were ICU length of stay (LOS), hospital LOS, and functional outcomes. Data were measured as risk ratio (RR) if dichotomous or standardized mean difference if continuous. Subgroup analyses were performed for disease and models of NCC delivery. Results After 5659 nonduplicated published records were screened, 26 nonrandomized observational studies fulfilled eligibility criteria. A meta-analysis of mortality outcomes for 55 792 patients demonstrated a 17% relative risk reduction (RR, 0.83; 95% CI, 0.75-0.92; P = .001) in those receiving subspecialized care (n = 27 061) compared with general care (n = 27 694). Subgroup analyses did not identify subgroup differences. Eight studies including 4667 patients demonstrated a 17% relative risk reduction (RR, 0.83; 95% CI, 0.70-0.97; P = .03) for an unfavorable functional outcome with subspecialized care compared with general care. There were no differences in LOS outcomes. Heterogeneity was substantial in all analyses. Conclusions and Relevance Subspecialized NCC is associated with improved survival and functional outcomes for critically ill adults with brain injury. However, confidence in the evidence is limited by substantial heterogeneity. Further investigations are necessary to determine the specific aspects of NCC that contribute to these improved outcomes and its cost-effectiveness.
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Affiliation(s)
- Xiuxian Pham
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Jason Ray
- Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Neurology, Austin Health, Melbourne, Victoria, Australia
| | - Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care, Austin Health, Melbourne, Victoria, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Australia
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Joshua Laing
- Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Piero Perucca
- Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Bladin-Berkovic Comprehensive Epilepsy Program, Department of Neurology, Austin Health, Melbourne, Victoria, Australia
- Epilepsy Research Centre, Department of Medicine (Austin Health), University of Melbourne, Melbourne, Victoria, Australia
| | - Patrick Kwan
- Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Medicine and Neurology, University of Melbourne, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Terence J. O’Brien
- Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Andrew A. Udy
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care and Hyperbaric Medicine, Alfred Health, Melbourne, Victoria, Australia
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Quality Improvement in Neurocritical Care: a Review of the Current Landscape and Best Practices. Curr Treat Options Neurol 2022. [DOI: 10.1007/s11940-022-00734-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Abstract
Purpose of Review
The field of neurocritical care (NCC) has grown such that there is now a substantial body of literature on quality improvement specific to NCC. This review will discuss the development of this literature over time and highlight current best practices with practical tips for providers.
Recent Findings
There is tremendous variability in patient care models for NCC patients, despite evidence showing that certain structural elements are associated with better outcomes. There now also exist evidence-based recommendations for neurocritical care unit (NCCU) structure and processes, as well as NCC-specific performance measure (PM) sets; however, awareness of these is variable among care providers. The evidence-based literature on NCC structure, staffing, training, standardized order sets and bundles, transitions of care including handoff, prevention of bounce backs, bed flow optimization, and inter-hospital transfers is growing and offers many examples of successful performance improvement initiatives in NCCUs.
Summary
NCC providers care for patients with life-threatening conditions like intracerebral and subarachnoid hemorrhages, ischemic stroke, and traumatic brain injury, which are associated with high morbidity, complexity of treatment, and cost. Quality improvement initiatives have been successful in improving many aspects of NCC patient care, and NCC providers should continue to update and standardize their practices with consideration of this data. More research is needed to continue to identify high-risk and high-cost NCCU structures and processes and strategies to optimize them, validate current NCC PMs, and encourage clinical adoption of those that prove to be associated with improved outcomes.
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Picetti E, Berardino M, Bertuccio A, Bertuetti R, Boccardi EP, Caricato A, Castioni CA, Cenzato M, Chieregato A, Citerio G, Gritti P, Longhi L, Martino C, Munari M, Rossi S, Stocchetti N, Zoerle T, Rasulo F, Robba C. Early management of patients with aneurysmal subarachnoid hemorrhage in a hospital without neurosurgical/neuroendovascular facilities: a consensus and clinical recommendations of the Italian Society of Anesthesia and Intensive Care (SIAARTI). JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2021; 1:10. [PMCID: PMC10245649 DOI: 10.1186/s44158-021-00012-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 10/11/2021] [Indexed: 06/16/2023]
Abstract
Abstract
Background
The immediate management of subarachnoid hemorrhage (SAH) patients in hospitals without neurosurgical/neurointerventional facilities and their transfer to a specialized center is challenging and not well covered in existing guidelines. To address these issues, we created a consensus of experts endorsed by the Italian Society of Anesthesia and Intensive Care (SIAARTI) to provide clinical guidance.
Methods
A multidisciplinary consensus panel composed by 19 physicians selected for their established clinical and scientific expertise in the acute management of SAH patients with different specializations (anesthesia/intensive care, neurosurgery and interventional neuroradiology) was created. A modified Delphi approach was adopted.
Results
A total of 14 statements have been discussed. Consensus was reached on 11 strong recommendations and 2 weak recommendations. In one case, where consensus could not be agreed upon, no recommendation could be provided.
Conclusions
Management of SAH in a non-specialized setting and early transfer are difficult and may have a critical impact on outcome. Clinical advice, based on multidisciplinary consensus, might be helpful. Our recommendations cover most, but not all, topics of clinical relevance.
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Bach AM, Fang AY, Bonifacio S, Rogers EE, Scheffler A, Partridge JC, Xu D, Barkovich AJ, Ferriero DM, Glass HC, Gano D. Early Magnetic Resonance Imaging Predicts 30-Month Outcomes after Therapeutic Hypothermia for Neonatal Encephalopathy. J Pediatr 2021; 238:94-101.e1. [PMID: 34237346 DOI: 10.1016/j.jpeds.2021.07.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 06/02/2021] [Accepted: 07/01/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate the association of therapeutic hypothermia with magnetic resonance imaging (MRI) findings and 30-month neurodevelopment in term neonatal encephalopathy. STUDY DESIGN Cross-sectional analysis of 30-month neurodevelopment (IQR 19.0-31.4) in a prospective cohort of mild-to-severe neonatal encephalopathy imaged on day 4 (1993-2017 with institutional implementation of therapeutic hypothermia in 2007). MRI injury was classified as normal, watershed, or basal ganglia/thalamus. Abnormal motor outcome was defined as Bayley-II psychomotor developmental index <70, Bayley-III motor score <85 or functional motor deficit. Abnormal cognitive outcome was defined as Bayley-II mental developmental index <70 or Bayley-III cognitive score <85. Abnormal composite outcome was defined as abnormal motor and/or cognitive outcome, or death. The association of therapeutic hypothermia with MRI and outcomes was evaluated with multivariable logistic regression adjusted for propensity to receive therapeutic hypothermia. RESULTS Follow-up was available in 317 (78%) surviving children, of whom 155 (49%) received therapeutic hypothermia. Adjusting for propensity, therapeutic hypothermia was independently associated with decreased odds of abnormal motor (OR 0.15, 95% CI 0.06-0.40, P < .001) and cognitive (OR 0.11, 95% CI 0.04-0.33, P < .001) outcomes. This association remained statistically significant after adjustment for injury pattern. The predictive accuracy of MRI pattern for abnormal composite outcome was unchanged between therapeutic hypothermia-treated (area under the receiver operating curve 0.76; 95% CI 0.61-0.91) and untreated (area under the receiver operating curve 0.74; 95% CI 0.67-0.81) infants. The negative predictive value of normal MRI was high in therapeutic hypothermia-treated and untreated infants (motor 96% vs 90%; cognitive 99% vs 95%). CONCLUSIONS Therapeutic hypothermia is associated with lower rates of brain injury and adverse 30-month outcomes after neonatal encephalopathy. The predictive accuracy of MRI in the first week of life is unchanged by therapeutic hypothermia. Normal MRI remains reassuring for normal 30-month outcome after therapeutic hypothermia.
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Affiliation(s)
- Ashley M Bach
- Departments of Neurology and Pediatrics, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Department of Pediatrics, University of California-San Francisco, San Francisco, CA; Department of Neurology, University of California-San Francisco, San Francisco, CA
| | - Annie Y Fang
- Department of Pediatric Hospital Medicine, Kaiser Permanente, Oakland, CA
| | - Sonia Bonifacio
- Department of Pediatrics, Stanford University, Palo Alto, CA
| | - Elizabeth E Rogers
- Department of Pediatrics, University of California-San Francisco, San Francisco, CA
| | - Aaron Scheffler
- Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, CA
| | - J Colin Partridge
- Department of Pediatrics, University of California-San Francisco, San Francisco, CA
| | - Duan Xu
- Department of Radiology, University of California-San Francisco, San Francisco, CA
| | - A James Barkovich
- Department of Radiology, University of California-San Francisco, San Francisco, CA
| | - Donna M Ferriero
- Department of Pediatrics, University of California-San Francisco, San Francisco, CA; Department of Neurology, University of California-San Francisco, San Francisco, CA
| | - Hannah C Glass
- Department of Pediatrics, University of California-San Francisco, San Francisco, CA; Department of Neurology, University of California-San Francisco, San Francisco, CA; Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, CA
| | - Dawn Gano
- Department of Pediatrics, University of California-San Francisco, San Francisco, CA; Department of Neurology, University of California-San Francisco, San Francisco, CA
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Neurocritical Care Resource Utilization in Pandemics: A Statement by the Neurocritical Care Society. Neurocrit Care 2021; 33:13-19. [PMID: 32468327 PMCID: PMC7255702 DOI: 10.1007/s12028-020-01001-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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8
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Neurological Critical Care: The Evolution of Cerebrovascular Critical Care. Crit Care Med 2021; 49:881-900. [PMID: 33653976 DOI: 10.1097/ccm.0000000000004933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kaplan L, Moheet AM, Livesay SL, Provencio JJ, Suarez JI, Bader MK, Bailey H, Chang CWJ. A Perspective from the Neurocritical Care Society and the Society of Critical Care Medicine: Team-Based Care for Neurological Critical Illness. Neurocrit Care 2021; 32:369-372. [PMID: 32043264 DOI: 10.1007/s12028-020-00927-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The Neurocritical Care Society and the Society of Critical Care Medicine have worked together to create a perspective regarding the Standards of Neurologic Critical Care Units (Moheet et al. in Neurocrit Care 29:145-160, 2018). The most neurologically ill or injured patients warrant the highest standard of care available; this supports the need for defining and establishing specialized neurological critical care units. Rather than interpreting the Standards as being exclusionary, it is most appropriate to embrace them in the setting of team-based care. Since there are many more patients than there are highly specialized beds, collaborative care and appropriate transfer agreements are essential in promoting excellent patient outcomes. This viewpoint addresses areas of clarification and emphasizes the need for collegiality and partnership in delivering the best specialty critical care to our patients.
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Affiliation(s)
- Lewis Kaplan
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Corporal Michael J Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Asma M Moheet
- OhioHealth Riverside Methodist Hospital, Columbus, OH, USA
| | | | | | | | | | | | - Cherylee W J Chang
- Neuroscience Institute/Neurocritical Care, The Queen's Medical Center Neuroscience Institute, Honolulu, HI, 96813, USA.
- John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA.
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10
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Perfil clínico y evolución de pacientes con hemorragia subaracnoidea durante 11 años. Neurocirugia (Astur) 2021; 32:10-20. [DOI: 10.1016/j.neucir.2020.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 12/06/2019] [Accepted: 03/23/2020] [Indexed: 11/20/2022]
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Mourelo-Fariña M, Pértega S, Galeiras R. A Model for Prediction of In-Hospital Mortality in Patients with Subarachnoid Hemorrhage. Neurocrit Care 2020; 34:508-518. [PMID: 32671649 DOI: 10.1007/s12028-020-01041-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Despite being a rare cause of stroke, spontaneous subarachnoid hemorrhage (SAH) is associated with high mortality rates. The prediction models that are currently being used on SAH patients are heterogeneous, and few address premature mortality. The aim of this study was to develop a mortality risk stratification score for SAH. METHODS A retrospective study was carried out with 536 patients diagnosed with SAH who had been admitted to the intensive care unit (ICU) at the University Hospital Complex of A Coruña (Spain) between 2003 and 2013. A multivariate logistic regression model was developed to predict the likelihood of in-hospital mortality, adjusting it exclusively for variables present on admission. A predictive equation of in-hospital mortality was then computed based on the model's coefficients, along with a points-based risk-scoring system. Its discrimination ability was also tested based on the area under the receiver operating characteristics curve and compared with previously developed scores. RESULTS The mean age of the patients included in this study was 56.9 ± 14.1 years. Most of these patients (73.9%) had been diagnosed with aneurysmal SAH. Their median length of stay was 7 days in the ICU and 20 days in the general hospital ward, with an overall in-hospital mortality rate of 28.5%. The developed scales included the following admission variables independently associated with in-hospital mortality: coma at onset [odds ratio (OR) = 1.87; p = 0.028], Fisher scale score of 3-4 (OR = 2.27; p = 0.032), Acute Physiology and Chronic Health Evaluation II (APACHE II) score within the first 24 h (OR = 1.10; p < 0.001), and total Sequential Organ Failure Assessment (SOFA) score on day 0 (OR = 1.19; p = 0.004). Our predictive equation demonstrated better discrimination [area under the curve (AUC) = 0.835] (bootstrap-corrected AUC = 0.831) and calibration properties than those of the HAIR scale (AUC = 0.771; p ≤ 0.001) and the Functional Recovery Expected after Subarachnoid Hemorrhage scale (AUC = 0.814; p = 0.154). CONCLUSIONS In addition to the conventional risk factors for in-hospital mortality, in our study, mortality was associated with the presence of coma at onset of the condition, the physiological variables assessed by means of the APACHE II scale within the first 24 h, and the total SOFA score on day 0. A simple prediction model of mortality was developed with novel parameters assessed on admission, which also assessed organ failure and did not require a previous etiological diagnosis.
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Affiliation(s)
- Mónica Mourelo-Fariña
- Critical Care Unit, Complejo Hospitalario Universitario de A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC), SERGAS, Universidade de A Coruña (UDC), As Xubias, 15006, A Coruña, Spain.
| | - Sonia Pértega
- Clinical Epidemiology and Biostatistics Unit, Complejo Hospitalario Universitario de A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC), SERGAS, Universidade de A Coruña (UDC), As Xubias, 15006, A Coruña, Spain
| | - Rita Galeiras
- Critical Care Unit, Complejo Hospitalario Universitario de A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC), SERGAS, Universidade de A Coruña (UDC), As Xubias, 15006, A Coruña, Spain
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12
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Kim TJ, Lee JS, Yoon JS, Oh MS, Kim JW, Jung KH, Yu KH, Lee BC, Ko SB, Yoon BW. Impact of the Dedicated Neurointensivists on the Outcome in Patients with Ischemic Stroke Based on the Linked Big Data for Stroke in Korea. J Korean Med Sci 2020; 35:e135. [PMID: 32476299 PMCID: PMC7261699 DOI: 10.3346/jkms.2020.35.e135] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 03/22/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Neurocritical care by dedicated neurointensivists may improve outcomes of critically ill patients with severe brain injury. In this study, we aimed to validate whether neurointensive care could improve the outcome in patients with critically ill acute ischemic stroke using the linked big dataset on stroke in Korea. METHODS We included 1,405 acute ischemic stroke patients with mechanical ventilator support in the intensive care unit after an index stroke. Patients were retrieved from linking the Clinical Research Center for Stroke Registry and the Health Insurance Review and Assessment Service data from the period between January 2007 and December 2014. The outcomes were mortality at discharge and at 3 months after an index stroke. The main outcomes were compared between the centers with and without dedicated neurointensivists. RESULTS Among the included patients, 303 (21.6%) were admitted to the centers with dedicated neurointensivists. The patients treated by dedicated neurointensivists had significantly lower in-hospital mortality (18.3% vs. 26.8%, P = 0.002) as well as lower mortality at 3-month (38.0% vs. 49.1%, P < 0.001) than those who were treated without neurointensivists. After adjusting for confounders, a treatment without neurointensivists was independently associated with higher in-hospital mortality (odds ratio [OR], 1.59; 95% confidence intervals [CIs], 1.13-2.25; P = 0.008) and 3-month mortality (OR, 1.48; 95% CIs, 1.12-1.95; P = 0.005). CONCLUSION Treatment by dedicated neurointensivists is associated with lower in-hospital and 3-month mortality using the linked big datasets for stroke in Korea. This finding stresses the importance of neurointensivists in treating patients with severe ischemic stroke.
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Affiliation(s)
- Tae Jung Kim
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea
| | - Ji Sung Lee
- Department of Clinical Research Center, Asan Institute for Life Sciences, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Sun Yoon
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Mi Sun Oh
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Ji Woo Kim
- Health Insurance Review and Assessment Service, Wonju, Korea
| | - Keun Hwa Jung
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Kyung Ho Yu
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Byung Chul Lee
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Sang Bae Ko
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea.
| | - Byung Woo Yoon
- Department of Neurology, Seoul National University Hospital, Seoul, Korea.
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Busl KM, Bleck TP, Varelas PN. Neurocritical Care Outcomes, Research, and Technology: A Review. JAMA Neurol 2020; 76:612-618. [PMID: 30667464 DOI: 10.1001/jamaneurol.2018.4407] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Importance Neurocritical care has grown into an organized specialty that may have consequences for patient care, outcomes, research, and neurointensive care (neuroICU) technology. Observations Neurocritical care improves care and outcomes of the patients who are neurocritically ill, and neuroICUs positively affect the financial state of health care systems. The development of neurocritical care as a recognized subspecialty has fostered multidisciplinary research, neuromonitoring, and neurocritical care information technology, with advances and innovations in practice and progress. Conclusions and Relevance Neurocritical care has become an important part of health systems and an established subspecialty of neurology. Understanding its structure, scope of practice, consequences for care, and research are important.
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Affiliation(s)
- Katharina Maria Busl
- NeuroIntensive Care Unit, University of Florida Health Shands Hospital, Gainesville.,Department of Neurology, Division of Neurocritical Care, College of Medicine, University of Florida, Gainesville
| | - Thomas P Bleck
- Rush University Medical Center, Rush Medical College, Chicago, Illinois
| | - Panayiotis N Varelas
- Neurosciences Critical Care Services, Neuro-Intensive Care Unit, Henry Ford Hospital, Wayne State University, Detroit, Michigan
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Kim SH, Yum KS, Jeong JH, Choi JH, Park HS, Song YJ, Kim DH, Cha JK, Han MK. Impact of Neurointensivist Co-Management in a Semiclosed Neurocritical-Care Unit. J Clin Neurol 2020; 16:681-687. [PMID: 33029976 PMCID: PMC7541986 DOI: 10.3988/jcn.2020.16.4.681] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 08/19/2020] [Accepted: 08/19/2020] [Indexed: 11/19/2022] Open
Abstract
Background and Purpose The importance of the specialized management of neurocritical patients is being increasingly recognized. We evaluated the impact of neurointensivist comanagement on the clinical outcomes (particularly the mortality rate) of neurocritical patients admitted to a semiclosed neurocritical-care unit (NCU). Methods We retrospectively included neurocritical patients admitted to the NCU between March 2015 and February 2018. We analyzed the clinical data and compared the outcomes between patients admitted before and after the initiation of neurointensivist co-management in March 2016. Results There were 1,785 patients admitted to the NCU during the study period. Patients younger than 18 years (n=28) or discharged within 48 hours (n=200) were excluded. The 1,557 remaining patients comprised 590 and 967 who were admitted to the NCU before and after the initiation of co-management, respectively. Patients admitted under neurointensivist co-management were older and had higher Acute Physiologic Assessment and Chronic Health Evaluation II scores. The 30-day mortality rate was significantly lower after neurointensivist co-management (p=0.042). A multivariate logistic regression analysis demonstrated that neurointensivist co-management significantly reduced mortality rates in the NCU and in the hospital overall [odds ratio=0.590 (p=0.002) and 0.585 (p=0.001), respectively]. Conclusions Despite the higher severity of the condition during neurointensivist co-management, co-management significantly improved clinical outcomes (including the mortality rate) in neurocritical patients.
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Affiliation(s)
- Sang Hwa Kim
- Department of Neurosurgery, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea
| | - Kyu Sun Yum
- Department of Neurology, Chungbuk National University Hospital, Cheongju, Korea
| | - Jin Heon Jeong
- Department of Intensive Care Medicine, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea.,Department of Neurology, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea.,Stroke Center, Dong-A University Hospital, Busan, Korea.
| | - Jae Hyung Choi
- Department of Neurosurgery, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea.,Stroke Center, Dong-A University Hospital, Busan, Korea
| | - Hyun Seok Park
- Department of Neurosurgery, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea.,Stroke Center, Dong-A University Hospital, Busan, Korea
| | - Young Jin Song
- Department of Neurosurgery, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea
| | - Dae Hyun Kim
- Department of Neurology, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea.,Stroke Center, Dong-A University Hospital, Busan, Korea
| | - Jae Kwan Cha
- Department of Neurology, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea.,Stroke Center, Dong-A University Hospital, Busan, Korea
| | - Moon Ku Han
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Korea
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15
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Building a Case for a Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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16
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Abstract
PURPOSE OF REVIEW With the advent of therapeutic hypothermia for treatment of hypoxic ischemic encephalopathy, and improvements in neuroimaging and bedside neuromonitoring, a new era of neonatal brain-focused care has emerged in recent years. We describe the development of the first neurointensive care nursery (NICN) as a model for comanagement of neonates with identified neurologic risk factors by a multidisciplinary team constituted of neurologists, neonatologists, specialized nurses, and others with the goal of optimizing management, preventing secondary injury and maximizing long-term outcomes. RECENT FINDINGS Optimizing brain metabolic environment and perfusion and preventing secondary brain injury are key to neurocritical care. This includes close management of temperature, blood pressure, oxygenation, carbon dioxide, and glucose levels. Early developmental interventions and involvement of physical and occupational therapy provide additional assessment information. Finally, long-term follow-up is essential for any neurocritical care program. SUMMARY The NICN model aims to optimize evidence-based care of infants at risk for neurologic injury. Results from ongoing hypothermia and neuroprotective trials are likely to yield additional treatments. New technologies, such as functional MRI, continuous neurophysiological assessment, and whole genomic approaches to rapid diagnosis may further enhance clinical protocols and neonatal precision medicine. Importantly, advances in neurocritical care improve our ability to provide comprehensive information when counseling families. Long-term follow-up data will determine if the NICN/Neuro-NICU provides enduring benefit to infants at risk for neurologic injury.
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17
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Roberts DJ, Leonard SD, Stein DM, Williams GW, Wade CE, Cotton BA. Can trauma surgeons keep up? A prospective cohort study comparing outcomes between patients with traumatic brain injury cared for in a trauma versus neuroscience intensive care unit. Trauma Surg Acute Care Open 2019; 4:e000229. [PMID: 30899790 PMCID: PMC6407533 DOI: 10.1136/tsaco-2018-000229] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 01/09/2019] [Accepted: 01/27/2019] [Indexed: 12/27/2022] Open
Abstract
Background Although many patients with traumatic brain injury (TBI) are admitted to trauma intensive care units (ICUs), some question whether outcomes would improve if their care was provided in neurocritical care units. We sought to compare characteristics and outcomes of patients with TBI admitted to and cared for in a trauma versus neuroscience ICU. Methods We conducted a prospective cohort study of adult (≥18 years of age) blunt trauma patients with TBI admitted to a trauma versus neuroscience ICU between May 2015 and December 2016. We used multivariable logistic regression to estimate an adjusted odds ratio (OR) comparing 30-day mortality between cohorts. Results In total, 548 patients were included in the study, including 207 (38%) who were admitted to the trauma ICU and 341 (62%) to the neuroscience ICU. When compared with neuroscience ICU admissions, patients admitted to the trauma ICU were more likely to have sustained their injuries from a high-speed mechanism (71% vs. 34%) and had a higher Injury Severity Score (ISS) (median 25 vs. 16) despite a similar head Abbreviated Injury Scale score (3 vs. 3, p=0.47) (all p<0.05). Trauma ICU patients also had a lower initial Glasgow Coma Scale score (5 vs. 15) and systolic blood pressure (128 mm Hg vs. 136 mm Hg) and were more likely to have fixed or unequal pupils at admission (13% vs. 8%) (all p<0.05). After adjusting for age, ISS, a high-speed mechanism of injury, fixed or unequal pupils at admission, and field intubation, the odds of 30-day mortality was 70% lower among patients admitted to the trauma versus neuroscience ICU (adjusted OR=0.30, 95% CI 0.11 to 0.82). Conclusions Despite a higher injury burden and worse neurological examination and hemodynamics at presentation, patients admitted to the trauma ICU had a lower adjusted 30-day mortality. This finding may relate to improved care of associated injuries in trauma versus neuroscience ICUs. Level of evidence Prospective comparative study, level II.
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Affiliation(s)
- Derek J Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada.,Center for Translational Injury Research, The University of Texas Health Science Center, Houston, Texas, USA
| | - Samuel D Leonard
- Center for Translational Injury Research, The University of Texas Health Science Center, Houston, Texas, USA.,Department of Surgery, The McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Deborah M Stein
- Department of Surgery, The University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - George W Williams
- Department of Anesthesiology, The McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA.,Department of Neurosurgery, The McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Charles E Wade
- Center for Translational Injury Research, The University of Texas Health Science Center, Houston, Texas, USA.,Department of Surgery, The McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Bryan A Cotton
- Center for Translational Injury Research, The University of Texas Health Science Center, Houston, Texas, USA.,Department of Surgery, The McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
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18
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Ko MA, Lee JH, Kim JG, Jeong S, Kang DW, Lim CM, Lee SA, Kim KK, Jeon SB. Effects of Appointing a Full-Time Neurointensivist to Run a Closed-Type Neurological Intensive Care Unit. J Clin Neurol 2019; 15:360-368. [PMID: 31286709 PMCID: PMC6620450 DOI: 10.3988/jcn.2019.15.3.360] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 02/25/2019] [Accepted: 02/25/2019] [Indexed: 01/08/2023] Open
Abstract
Background and Purpose To investigate whether appointing a full-time neurointensivist to manage a closed-type neurological intensive care unit (NRICU) improves the quality of critical care and patient outcomes. Methods This study included patients admitted to the NRICU at a university hospital in Seoul, Korea. Two time periods were defined according to the presence of a neurointensivist in the preexisting open-type NRICU: the before and after periods. Hospital medical records were queried and compared between these two time periods, as were the biannual satisfaction survey results for the families of patients. Results Of the 15,210 patients in the neurology department, 2,199 were admitted to the NRICU (n=995 and 1,204 during the before and after periods, respectively; p<0.001). The length of stay was shorter during the after than during the before period in both the NRICU (3 vs. 4 days; p<0.001) and the hospital overall (12.5 vs. 14.0 days; p<0.001). Neurological consultations (2,070 vs. 3,097; p<0.001) and intrahospital transfers from general intensive care units to the NRICU (21 vs. 40; p=0.111) increased from the before to after the period. The mean satisfaction scores of the families of the patients also increased, from 78.3 to 89.7. In a Cox proportional hazards model, appointing a neurointensivist did not result in a statistically significant change in 6-month mortality (hazard ratio, 0.82; 95% confidence interval, 0.652–1.031; p=0.089). Conclusions Appointing a full-time neurointensivist to manage a closed-type NRICU had beneficial effects on quality indicators and patient outcomes.
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Affiliation(s)
- Myung Ah Ko
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung Hwa Lee
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Joong Goo Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.,Department of Neurology, Jeju National University Hospital, Jeju, Korea
| | - Suyeon Jeong
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Wha Kang
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chae Man Lim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Ahm Lee
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kwang Kuk Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Beom Jeon
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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19
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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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20
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Does the subspecialty of an intensive care unit (ICU) has an impact on outcome in patients suffering from aneurysmal subarachnoid hemorrhage? Neurosurg Rev 2018; 42:147-153. [PMID: 29603031 DOI: 10.1007/s10143-018-0973-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 03/08/2018] [Accepted: 03/22/2018] [Indexed: 10/17/2022]
Abstract
We retrospectively compared the outcome of aneurysmal subarachnoid hemorrhage (aSAH) patients treated in a neurosurgical ICU (nICU) between 1990 and 2005 with that of patients treated in a general ICU (gICU) between 2005 and 2013 with almost identical treatment strategies. Among other parameters, we registered the initial Hunt and Hess grade, Fisher score, the incidence of vasospasm, and outcome. A multivariate analysis (logistic regression model) was performed to adjust for different variables. In total, 755 patients were included in this study with 456 patients assigned to the nICU and 299 patients to the gICU. Multivariate logistic regression analysis revealed no significant difference between the patient outcome treated in a nICU versus gICU after adjusting for different variables. The outcome of patients after aSAH is not influenced by the type of ICU (gICU versus nICU). The data do not allow claiming that aSAH patients need to be treated in a specialized ICU for obtaining better results. Parameters which might differ from hospital to hospital, especially warranty of neurosurgical expertise on gICU, have the potential to influence the results.
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21
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Yu W, Kavi T, Majic T, Alva K, Moheet A, Lyden P, Schievink W, Lekovic G, Alexander M. Treatment Modality and Quality Benchmarks of Aneurysmal Subarachnoid Hemorrhage at a Comprehensive Stroke Center. Front Neurol 2018; 9:152. [PMID: 29599745 PMCID: PMC5862861 DOI: 10.3389/fneur.2018.00152] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Accepted: 03/01/2018] [Indexed: 01/23/2023] Open
Abstract
Background Aneurysmal subarachnoid hemorrhage (aSAH) is the most severe type of stroke. In 2012, the Joint Commission, in collaboration with the American Heart Association/American Stroke Association (AHA/ASA), launched the Advanced Certification for Comprehensive Stroke Centers (CSCs). This new level of certification was designed to promote higher standard of care for patients with complex stroke. Objective The goal of this study was to examine the treatment modality and quality benchmarks of aSAH at one of the first five certified CSCs in the United States. Methods Consecutive patients with aSAH at Cedars-Sinai Medical Center between April 1, 2012 and May 30, 2014 were included for this retrospective study. The ruptured aneurysm was treated with coiling or clipping within 24 h. All patients were managed per AHA guidelines. Discharge outcomes were assessed using modified Rankin Scale (mRS). The rate of aneurysm treatment, door-to-treatment time, rate of posttreatment rebleed, hospital length of stay (LOS), discharge outcome, and mortality rates were evaluated as quality indicators. Results The median age (interquartile range) of the 118 patients with aSAH was 55 (19). Among them, 84 (71.2%) were females, 94 (79.7%) were transfers from outside hospitals, and 74 (62.7%) had Hunt and Hess grades 1-3. Sixty patients (50.8%) were treated with coiling, 52 (44.1%) with clipping, and 6 (5.1%) untreated due to ictal cardiac arrest or severe comorbidities. The rate of aneurysm treatment was 95% (112/118) with median door-to-treatment time at 12.5 (8.5) h and 0.9% (1/112) posttreatment rebleed. The median ICU and hospital LOS were 12.5 (7) and 17.0 (14.5) days, respectively. Coiling was associated with significantly shorter LOS than clipping. There were 59 patients (50%) with favorable outcome and 19 deaths (16.1%) at hospital discharge. There was no significant difference in discharge outcome between coiling and clipping. Conclusion Care of aSAH at one of the early CSCs in the United States was associated with high rate of aneurysm treatment, fast door-to-treatment time, low posttreatment rebleed, excellent outcome, and low mortality rate. Coiling was associated with significant shorter LOS than clipping. There was no significant difference in discharge outcomes between treatment modalities.
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Affiliation(s)
- Wengui Yu
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, United States.,Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, United States.,Department of Neurology, University of California Irvine Medical Center, Orange, CA, United States
| | - Tapan Kavi
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, United States.,Department of Neurology and Neurosurgery, Cooper University Hospital, Camden, NJ, United States
| | - Tamara Majic
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Kimberly Alva
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Asma Moheet
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, United States.,Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Patrick Lyden
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Wouter Schievink
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Gregory Lekovic
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, United States.,Division of Neurosurgery, House Clinic, Los Angeles, CA, United States
| | - Michael Alexander
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, United States
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22
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Tendencies in cerebral aneurism treatment: Analysis of a hospital series. NEUROLOGÍA (ENGLISH EDITION) 2017. [DOI: 10.1016/j.nrleng.2015.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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23
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Ryu JA, Yang JH, Chung CR, Suh GY, Hong SC. Impact of Neurointensivist Co-management on the Clinical Outcomes of Patients Admitted to a Neurosurgical Intensive Care Unit. J Korean Med Sci 2017; 32:1024-1030. [PMID: 28480662 PMCID: PMC5426243 DOI: 10.3346/jkms.2017.32.6.1024] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 03/10/2017] [Indexed: 12/03/2022] Open
Abstract
Limited data are available on improved outcomes after initiation of neurointensivist co-management in neurosurgical intensive care units (NSICUs) in Korea. We evaluated the impact of a newly appointed neurointensivist on the outcomes of neurosurgical patients admitted to an intensive care unit (ICU). This retrospective observational study involved neurosurgical patients admitted to the NSICU at Samsung Medical Center between March 2013 and May 2016. Neurointensivist co-management was initiated in October 1 2014. We compared the outcomes of neurosurgical patients before and after neurointensivist co-management. The primary outcome was ICU mortality. A total of 571 patients were admitted to the NSICU during the study period, 291 prior to the initiation of neurointensivist co-management and 280 thereafter. Intracranial hemorrhage (29.6%) and traumatic brain injury (TBI) (26.6%) were the most frequent reasons for ICU admission. TBI was the most common cause of death (39.0%). There were no significant differences in mortality rates and length of ICU stay before and after co-management. However, the rates of ICU and 30-day mortality among the TBI patients were significantly lower after compared to before initiation of neurointensivist co-management (8.5% vs. 22.9%; P = 0.014 and 11.0% vs. 27.1%; P = 0.010, respectively). Although overall outcomes were not different after neurointensivist co-management, initiation of a strategy of routine involvement of a neurointensivist significantly reduced the ICU and 30-day mortality rates of TBI patients.
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Affiliation(s)
- Jeong Am Ryu
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Hoon Yang
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Chi Ryang Chung
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Gee Young Suh
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Chyul Hong
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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24
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Okazaki T, Hifumi T, Kawakita K, Shishido H, Ogawa D, Okauchi M, Shindo A, Kawanishi M, Inoue S, Tamiya T, Kuroda Y. Serial blood lactate measurements and its prognostic significance in intensive care unit management of aneurysmal subarachnoid hemorrhage patients. J Crit Care 2017; 41:229-233. [PMID: 28591679 DOI: 10.1016/j.jcrc.2017.06.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 05/20/2017] [Accepted: 06/01/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE This study assesses the behavior of serial blood lactate measurements during intensive care unit (ICU) stay to identify prognostic factors of unfavorable neurological outcomes (UO) in patients with aneurysmal subarachnoid hemorrhage (SAH). METHODS We retrospectively reviewed all patients who were consecutively hospitalized with SAH between 2009 and 2016. Arterial blood lactate levels were routinely obtained on admission and every 6h in the ICU. Univariate/multivariate analyses were performed to identify independent predictors of UO (modified Rankin scale of 3-6 upon hospital discharge). RESULTS There were 145 patients with 46% of UO. Initially, increased lactate levels reached maximum levels during the first 24h and then decreased to within the normal range. Then, the levels slightly increased again to within the normal range for the next 24h, especially in UO. On multiple regression analysis, lactate levels measured at 24h, and 48h after admission were strong predictors of UO. Lactate level measured at 48h after admission demonstrated the greatest accuracy and the highest specificity (area under the curve, 0.716; sensitivity, 40%; specificity, 92.1%). CONCLUSIONS The lactate level at 48h after admission was the most accurate predictor of UO with a high specificity in SAH patients.
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Affiliation(s)
- Tomoya Okazaki
- Emergency Medical Center, Kagawa University Hospital, 1750-1 Ikenobe, Miki, Kita, Kagawa 761-0793, Japan
| | - Toru Hifumi
- Emergency Medical Center, Kagawa University Hospital, 1750-1 Ikenobe, Miki, Kita, Kagawa 761-0793, Japan.
| | - Kenya Kawakita
- Emergency Medical Center, Kagawa University Hospital, 1750-1 Ikenobe, Miki, Kita, Kagawa 761-0793, Japan.
| | - Hajime Shishido
- Emergency Medical Center, Kagawa University Hospital, 1750-1 Ikenobe, Miki, Kita, Kagawa 761-0793, Japan.
| | - Daisuke Ogawa
- Department of Neurosurgery, Kagawa University Hospital, 1750-1 Ikenobe, Miki, Kita, Kagawa 761-0793, Japan.
| | - Masanobu Okauchi
- Department of Neurosurgery, Kagawa University Hospital, 1750-1 Ikenobe, Miki, Kita, Kagawa 761-0793, Japan.
| | - Atsushi Shindo
- Department of Neurosurgery, Kagawa University Hospital, 1750-1 Ikenobe, Miki, Kita, Kagawa 761-0793, Japan.
| | - Masahiko Kawanishi
- Department of Neurosurgery, Kagawa University Hospital, 1750-1 Ikenobe, Miki, Kita, Kagawa 761-0793, Japan.
| | - Shigeaki Inoue
- Department of Emergency and Critical Care Medicine, Tokai University Hachioji Hospital, Ishikawa-cho 1838, Hachioji City, Tokyo 192-0032, Japan.
| | - Takashi Tamiya
- Department of Neurosurgery, Kagawa University Hospital, 1750-1 Ikenobe, Miki, Kita, Kagawa 761-0793, Japan.
| | - Yasuhiro Kuroda
- Emergency Medical Center, Kagawa University Hospital, 1750-1 Ikenobe, Miki, Kita, Kagawa 761-0793, Japan.
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25
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Jeong JH, Bang J, Jeong W, Yum K, Chang J, Hong JH, Lee K, Han MK. A Dedicated Neurological Intensive Care Unit Offers Improved Outcomes for Patients With Brain and Spine Injuries. J Intensive Care Med 2017; 34:104-108. [PMID: 28460590 DOI: 10.1177/0885066617706675] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Admission to an intensive care unit (ICU) specialized for brain and spine injury patients is associated with improved outcome. We investigated the effects of the first dedicated, combined neurological and neurosurgical ICU (NeuroICU) in Korea on patient outcomes. METHODS The first dedicated NeuroICU in Korea was established in March 2013. We retrospectively analyzed the clinical data and compared the outcomes between patients admitted to the ICU before and after NeuroICU establishment. The predicted mortality of NeuroICU patients was calculated using their Acute Physiology and Chronic Health Evaluation II scores. Patients' functional outcomes were evaluated using their modified Rankin scale (mRS) scores at 6 months after ICU admission, which were obtained from medical records or telephone interviews. RESULTS We included 2487 patients, 1572 and 915 of whom were admitted prior to and after NeuroICU establishment, respectively. The demographic characteristics, Glasgow Coma Scale scores, and disease proportions did not differ significantly between the groups. The length of ICU stay and the number of days on ventilation were significantly lower in NeuroICU patients than they were in general ICU patients ( P = .024, P = .001). Intensive care unit mortality was significantly lower in NeuroICU patients (7.3% vs 4.7%, P = .012). The predicted mortality was obtained from 473 NeuroICU patients. The mortality ratio (observed mortality/predicted mortality) was 0.34 (8.9%/26.1%), and 228 (48.1%) patients showed good functional recovery (mRS, 0-2). CONCLUSION Our findings suggest that admission to a dedicated NeuroICU significantly improves the neurological outcomes of patients with brain and spine injuries, including their postoperative care, in Korea.
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Affiliation(s)
- Jin-Heon Jeong
- 1 Department of Intensive Care Medicine and Neurology, Stroke Center, Dong-A University Hospital, Busan, South Korea.,These authors contributed equally to this work
| | - JaeSeung Bang
- 2 Department of Neurosurgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea.,These authors contributed equally to this work
| | - WonJoo Jeong
- 2 Department of Neurosurgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - KyuSun Yum
- 3 Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - JunYoung Chang
- 4 Department of Neurology, Gyeongsang National University Changwon Hospital, Changwon, South Korea
| | - Jeong-Ho Hong
- 5 Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, South Korea
| | - Kiwon Lee
- 6 Department of Neurology and Neurosurgery, The University of Texas Houston Medical School and Memorial Hermann Texas Medical Center, Houston, TX, United States
| | - Moon-Ku Han
- 3 Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
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Malekpour M, Kulwin C, Bohnstedt BN, Radmand G, Sethia R, Mendenhall SK, Weyhenmeyer J, Hendricks BK, Leipzig T, Payner TD, Shah MV, Scott J, DeNardo A, Sahlein D, Cohen-Gadol AA. Effect of short-term ε-aminocaproic acid treatment on patients undergoing endovascular coil embolization following aneurysmal subarachnoid hemorrhage. J Neurosurg 2017; 126:1606-1613. [DOI: 10.3171/2016.4.jns152951] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEAneurysmal rebleeding before definitive obliteration of the aneurysm is a cause of mortality and morbidity. There are limited data on the role of short-term antifibrinolytic therapy among patients undergoing endovascular intervention.METHODSAll consecutive patients receiving endovascular therapy for their ruptured saccular aneurysm at the authors' institution between 2000 and 2011 were included in this study. These patients underwent endovascular coiling of their aneurysm within 72 hours of admission. In patients receiving ε-aminocaproic acid (EACA), the EACA administration was continued until the time of the endovascular procedure. Complications and clinical outcomes of endovascular treatment after aneurysmal subarachnoid hemorrhage (aSAH) were compared between EACA-treated and untreated patients.RESULTSDuring the 12-year study period, 341 patients underwent endovascular coiling. Short-term EACA treatment was administered in 146 patients and was withheld in the other 195 patients. EACA treatment did not change the risk of preinterventional rebleeding in this study (OR 0.782, 95% CI 0.176–3.480; p = 0.747). Moreover, EACA treatment did not increase the rate of thromboembolic events. On the other hand, patients who received EACA treatment had a significantly longer duration of hospital stay compared with their counterparts who were not treated with EACA (median 19 days, interquartile range [IQR] 12.5–30 days vs median 14 days, IQR 10–23 days; p < 0.001). EACA treatment was associated with increased odds of shunt requirement (OR 2.047, 95% CI 1.043–4.018; p = 0.037) and decreased odds of developing cardiac complications (OR 0.138, 95% CI 0.031–0.604; p = 0.009) and respiratory insufficiency (OR 0.471, 95% CI 0.239–0.926; p = 0.029). Short-term EACA treatment did not affect the Glasgow Outcome Scale score at discharge, 6 months, or 1 year following discharge.CONCLUSIONSIn this study, short-term EACA treatment in patients who suffered from aSAH and received endovascular aneurysm repair did not decrease the risk of preinterventional rebleeding or increase the risk of thrombotic events. EACA did not affect outcome. Randomized clinical trials are required to provide robust clinical recommendation on short-term use of EACA.
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Affiliation(s)
- Mahdi Malekpour
- 1Goodman Campbell Brain and Spine, Indiana University, Department of Neurological Surgery
| | - Charles Kulwin
- 1Goodman Campbell Brain and Spine, Indiana University, Department of Neurological Surgery
| | - Bradley N. Bohnstedt
- 1Goodman Campbell Brain and Spine, Indiana University, Department of Neurological Surgery
| | - Golnar Radmand
- 2Department of Biostatistics, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Rishabh Sethia
- 1Goodman Campbell Brain and Spine, Indiana University, Department of Neurological Surgery
| | - Stephen K. Mendenhall
- 1Goodman Campbell Brain and Spine, Indiana University, Department of Neurological Surgery
| | - Jonathan Weyhenmeyer
- 1Goodman Campbell Brain and Spine, Indiana University, Department of Neurological Surgery
| | - Benjamin K. Hendricks
- 1Goodman Campbell Brain and Spine, Indiana University, Department of Neurological Surgery
| | - Thomas Leipzig
- 1Goodman Campbell Brain and Spine, Indiana University, Department of Neurological Surgery
| | - Troy D. Payner
- 1Goodman Campbell Brain and Spine, Indiana University, Department of Neurological Surgery
| | - Mitesh V. Shah
- 1Goodman Campbell Brain and Spine, Indiana University, Department of Neurological Surgery
| | - John Scott
- 1Goodman Campbell Brain and Spine, Indiana University, Department of Neurological Surgery
| | - Andrew DeNardo
- 1Goodman Campbell Brain and Spine, Indiana University, Department of Neurological Surgery
| | - Daniel Sahlein
- 1Goodman Campbell Brain and Spine, Indiana University, Department of Neurological Surgery
| | - Aaron A. Cohen-Gadol
- 1Goodman Campbell Brain and Spine, Indiana University, Department of Neurological Surgery
- 3Indiana University Simon Cancer Center, Indianapolis, Indiana; and
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Implementation of Neurocritical Care Is Associated With Improved Outcomes in Traumatic Brain Injury. Can J Neurol Sci 2017; 44:350-357. [PMID: 28343456 DOI: 10.1017/cjn.2017.25] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Traditionally, the delivery of dedicated neurocritical care (NCC) occurs in distinct NCC units and is associated with improved outcomes. Institution-specific logistical challenges pose barriers to the development of distinct NCC units; therefore, we developed a consultancy NCC service coupled with the implementation of invasive multimodal neuromonitoring, within a medical-surgical intensive care unit. Our objective was to evaluate the effect of a consultancy NCC program on neurologic outcomes in severe traumatic brain injury patients. METHODS We conducted a single-center quasi-experimental uncontrolled pre- and post-NCC study in severe traumatic brain injury patients (Glasgow Coma Scale ≤8). The NCC program includes consultation with a neurointensivist and neurosurgeon and multimodal neuromonitoring. Demographic, injury severity metrics, neurophysiologic data, and therapeutic interventions were collected. Glasgow Outcome Scale (GOS) at 6 months was the primary outcome. Multivariable ordinal logistic regression was used to model the association between NCC implementation and GOS at 6 months. RESULTS A total of 113 patients were identified: 76 pre-NCC and 37 post-NCC. Mean age was 39 years (standard deviation [SD], 2) and 87 of 113 (77%) patients were male. Median admission motor score was 3 (interquartile ratio, 1-4). Daily mean arterial pressure was higher (95 mmHg [SD, 10]) versus (88 mmHg [SD, 10], p<0.001) and daily mean core body temperature was lower (36.6°C [SD, 0.90]) versus (37.2°C [SD, 1.0], p=0.001) post-NCC compared with pre-NCC, respectively. Multivariable regression modelling revealed the NCC program was associated with a 2.5 increased odds (odds ratios, 2.5; 95% confidence interval, 1.1-5.3; p=0.022) of improved 6-month GOS. CONCLUSIONS Implementation of a NCC program is associated with improved 6 month GOS in severe TBI patients.
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Detection of Impaired Cerebral Autoregulation Using Selected Correlation Analysis: A Validation Study. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2017; 2017:8454527. [PMID: 28255331 PMCID: PMC5307252 DOI: 10.1155/2017/8454527] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 01/02/2017] [Accepted: 01/09/2017] [Indexed: 01/08/2023]
Abstract
Multimodal brain monitoring has been utilized to optimize treatment of patients with critical neurological diseases. However, the amount of data requires an integrative tool set to unmask pathological events in a timely fashion. Recently we have introduced a mathematical model allowing the simulation of pathophysiological conditions such as reduced intracranial compliance and impaired autoregulation. Utilizing a mathematical tool set called selected correlation analysis (sca), correlation patterns, which indicate impaired autoregulation, can be detected in patient data sets (scp). In this study we compared the results of the sca with the pressure reactivity index (PRx), an established marker for impaired autoregulation. Mean PRx values were significantly higher in time segments identified as scp compared to segments showing no selected correlations (nsc). The sca based approach predicted cerebral autoregulation failure with a sensitivity of 78.8% and a specificity of 62.6%. Autoregulation failure, as detected by the results of both analysis methods, was significantly correlated with poor outcome. Sca of brain monitoring data detects impaired autoregulation with high sensitivity and sufficient specificity. Since the sca approach allows the simultaneous detection of both major pathological conditions, disturbed autoregulation and reduced compliance, it may become a useful analysis tool for brain multimodal monitoring data.
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Quimby AE, Shamy MCF, Rothwell DM, Liu EY, Dowlatshahi D, Stotts G. A Novel Neuroscience Intermediate-Level Care Unit Model: Retrospective Analysis of Impact on Patient Flow and Safety. Neurohospitalist 2016; 7:83-90. [PMID: 28400902 DOI: 10.1177/1941874416672558] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND AND PURPOSE Neurointensive care units have been shown to improve patient outcomes across a variety of neurological and neurosurgical conditions. However, the efficacy of less resource-intensive intermediate-level care units to deliver similar care has not been well studied. The purpose of this study is to evaluate the impact of neurocritical specialist comanagement on patient flow and safety in a neuroscience intermediate-level care unit. METHODS Our intervention consisted of the addition of a physician with critical care experience as well as training in neurology, anesthesiology, or intensive care to a neuroscience intermediate-level care unit to comanage patients alongside neurology and neurosurgery staff during weekday daytime hours. A retrospective analysis was performed on prospectively collected data pertaining to all patients admitted to the unit over a 3-year period, 1 year before our intervention and 2 years after. Patient statistics including wait times to admission, length of stay (LOS), and mortality were reviewed. RESULTS Following the intervention, there were significant reductions in wait times to unit admission from both the emergency department and postanesthetic care unit, as well as reductions in the average LOS. No significant safety concerns were identified. CONCLUSION This study has demonstrated that the optimization of a neuroscience intermediate-level care unit involving comanagement of patients by a neurocritical specialist can reduce wait times to admission and lengths of stay, with preserved safety outcomes.
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Affiliation(s)
- Alexandra E Quimby
- Department of Otolaryngology-Head & Neck Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Michel C F Shamy
- Division of Neurology, University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Deanna M Rothwell
- The Ottawa Hospital, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Erin Y Liu
- The Ottawa Hospital, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Dar Dowlatshahi
- Division of Neurology, University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Grant Stotts
- Division of Neurology, University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital, Ottawa, Ontario, Canada
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Rodricks MB, Hawkins SE, Anderson GA, Basignani C, Tuppeny M. Mandatory Intensivist Management Decreases Length of Stay, Facilitates an Increase in Admissions and Minimizes Closure of a Neurocritical Care Unit. Neurocrit Care 2016. [PMID: 26209280 DOI: 10.1007/s12028-015-0148-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The primary objectives of this study were to identify patient and community benefits of mandatory intensivist management in a neurocritical care (NCC) unit. Our hospital recently mandated intensivist management for patients admitted to the NCC unit. As one of the only comprehensive stroke centers in Orlando, an unacceptably high number of patients were being denied admission because of overcapacity. We compared length of stay (LOS), complications, outcomes, total admissions, and emergency transfer center closure rates before and after implementation of mandatory intensivist management. METHODS A retrospective review comparing 1551 patients admitted to a 20 bed NCC unit from November 1, 2009 to October 31, 2010 (prior to mandatory intensivist management) with 1702 patients admitted from January 1, 2011 to December 31, 2011 (after the requirement) was performed. This included examining LOS, Acute Physiology and Chronic Health Evaluation III (APACHE) scores, service line closure rates, and mortality during both time periods. RESULTS Analysis revealed that despite comparable APACHE scores, implementation of mandatory intensivist management reduced overall NCC LOS, 4.6 versus 3.7 days, (p < 0.01) and increased the number of monthly admissions, 129 versus 142, (p = 0.02). The percentage of patients declined admission because of a closed service line was reduced from 12.36 to 5.66 %, (p = 0.02). Mortality and infection rates remained unchanged. CONCLUSIONS Implementation of mandatory intensivist management in the NCC unit decreased LOS, increased admissions, and decreased service line closure rates, while maintaining patient care.
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Affiliation(s)
- M B Rodricks
- Neurocritical Care, Florida Hospital Orlando, Orlando, FL, USA. .,College of Medicine, Florida State University, Orlando, FL, USA.
| | - S E Hawkins
- Neuroscience Research Institute, Florida Hospital Orlando, Orlando, FL, USA
| | - G A Anderson
- Neuroscience Research Institute, Florida Hospital Orlando, Orlando, FL, USA
| | - C Basignani
- Neuroscience Research Institute, Florida Hospital Orlando, Orlando, FL, USA.,College of Medicine, University of Central Florida, Orlando, FL, USA
| | - M Tuppeny
- Neurocritical Care, Florida Hospital Orlando, Orlando, FL, USA
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Glass HC, Rowitch DH. The Role of the Neurointensive Care Nursery for Neonatal Encephalopathy. Clin Perinatol 2016; 43:547-57. [PMID: 27524453 PMCID: PMC4988330 DOI: 10.1016/j.clp.2016.04.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Neonatal encephalopathy due to intrapartum events is estimated at 1 to 2 per 1000 live births in high-income countries. Outcomes have improved over the past decade due to implementation of therapeutic hypothermia, the only clinically available neuroprotective strategy for hypoxic-ischemic encephalopathy. Neonatal encephalopathy is the most common condition treated within a neonatal neurocritical care unit. Neonates with encephalopathy benefit from a neurocritical care approach due to prevention of secondary brain injury through attention to basic physiology, earlier recognition and treatment of neurologic complications, consistent management using guidelines and protocols, and use of optimized teams at dedicated referral centers.
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Affiliation(s)
- Hannah C Glass
- Department of Neurology, Benioff Children's Hospital, University of California San Francisco, 675 Nelson Rising Lane, Room 494, Box 0663, San Francisco, CA 94158, USA; Department of Pediatrics, Benioff Children's Hospital, University of California San Francisco, San Francisco, CA, USA; Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA, USA.
| | - David H. Rowitch
- Department of Pediatrics; Benioff Children’s Hospital, University of California San Francisco, San Francisco, CA, USA
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Herzer G, Illievich U, Voelckel WG, Trimmel H. Current practice in neurocritical care of patients with subarachnoid haemorrhage and severe traumatic brain injury : Results of the Austrian Neurosurvey Study. Wien Klin Wochenschr 2016; 128:649-57. [PMID: 27405601 DOI: 10.1007/s00508-016-1027-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 05/27/2016] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The task force Neuroanaesthesia of the Austrian Society of Anaesthesiology, Resuscitation and Intensive Care Medicine (ÖGARI) is aiming to develop and provide recommendations in order to improve neurocritical care in Austria. Thus, a survey on neurocritical care concepts in Austria regarding intensive care of subarachnoid haemorrhage (SAH) and severe traumatic brain injury (TBI) was performed to assess the current status. METHODS An online internet questionnaire comprising 59 items on current concepts of SAH and TBI critical care was sent to 117 anaesthesiology departments. RESULTS The survey was answered by 30 (25.6 %) of the hospitals, 24 (80 %) of them treating patients with SAH and/or TBI. Data from ten SAH centres reveal that definitive care was achieved within 24 h in all hospitals; a case load >50 per year is noted in 70 % of intensive care units (ICU). In all, 50 % of departments employ written protocols for treatment. Regarding the treatment of TBI patients, 14 answers were received, indicating that 42.9 % of departments provide care for >50 patients per year. Time between arrival and CT scan is <30 min in all hospitals, and 28.6 % of departments rely on written protocols. Only 14.3 % of hospitals report about routine morbidity and mortality rounds. While the neurologic status is assessed at discharge from the ICU, there is no evaluation of 1‑year outcome. CONCLUSIONS Definitive care of SAH and TBI patients is achieved timely in Austria. When compared with SAH, more hospitals with lower case loads take care of TBI patients. Written guidelines and protocols at institutional level are often missing. Since routine morbidity and mortality conferences are sparse, and long-term outcome is not assessed, there is room for improvement.
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Affiliation(s)
- Günther Herzer
- Department of Anaesthesiology, Emergency and Critical Care Medicine, Karl Landsteiner Institute of Emergency Medicine, General Hospital Wiener Neustadt, Corvinusring 3-5, 2700, Wiener Neustadt, Austria
| | - Udo Illievich
- Department of Anaesthesiology and Critical Care Medicine, Landes-Nervenklinik Wagner-Jauregg, Linz, Austria
| | - Wolfgang G Voelckel
- Department of Anaesthesiology and Critical Care Medicine, AUVA Trauma Centre Salzburg, Salzburg, Austria
| | - Helmut Trimmel
- Department of Anaesthesiology, Emergency and Critical Care Medicine, Karl Landsteiner Institute of Emergency Medicine, General Hospital Wiener Neustadt, Corvinusring 3-5, 2700, Wiener Neustadt, Austria.
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Abstract
This update comprises six important topics under neurocritical care that require reevaluation. For post-cardiac arrest brain injury, the evaluation of the injury and its corresponding therapy, including temperature modulation, is required. Analgosedation for target temperature management is an essential strategy to prevent shivering and minimizes endogenous stress induced by catecholamine surges. For severe traumatic brain injury, the diverse effects of therapeutic hypothermia depend on the complicated pathophysiology of the condition. Continuous electroencephalogram monitoring is an essential tool for detecting nonconvulsive status epilepticus in the intensive care unit (ICU). Neurocritical care, including advanced hemodynamic monitoring, is a fundamental approach for delayed cerebral ischemia following subarachnoid hemorrhage. We must be mindful of the high percentage of ICU patients who may develop sepsis-associated brain dysfunction.
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Affiliation(s)
- Yasuhiro Kuroda
- Department of Emergency, Disaster, and Critical Care Medicine, Faculty of Medicine, Kagawa University, 1750-1, Ikenobe, Miki, Kita, Kagawa Japan 761-0793
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Lago A, López-Cuevas R, Tembl JI, Fortea G, Górriz D, Aparici F, Parkhutik V. Tendencies in cerebral aneurism treatment: Analysis of a hospital series. Neurologia 2016; 32:371-376. [PMID: 26971811 DOI: 10.1016/j.nrl.2015.12.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 11/28/2015] [Accepted: 12/21/2015] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION AND OBJECTIVE To discover if there have been changes in the treatment time for SAH in our hospital environment. MATERIAL AND METHODS Comparative analysis of 571 patients treated at Hospital Universitari la Fe during 2 different time periods. The SAH-OLD group consisted of 462 patients attended consecutively between April 1997 and March 2005, while SAH-NEW comprised 109 patients attended consecutively between March 2007 and April 2010. We analysed demographic factors, risk factors, severity at time of admission, time to arteriography, diagnosis of aneurysm, use of surgical or endovascular treatment and time to treatment, frequency of neurological complications, in-hospital deaths, and modified Rankin Scale (mRS) at discharge. RESULTS Mean time to arteriography was 2.18 ± 2.5 days for the SAH-OLD group and 2.37 ± 2.23 days, for the SAH-NEW group (P=.49). Mortality rates for SAH-OLD patients were calculated at 30%, compared to 18.3% in SAH-NEW patients (P=.01). Among patients surviving the hospital stay in the SAH-OLD group, 13.3% had an mRS > 3, compared to 21.3% of survivors in the SAH-NEW group (P=.06). Two hundred forty-five patients in the SAH-OLD group had cerebral aneurysms and 208 were treated (45% of the patient total). Sixty-five of the SAH-NEW patients received treatment (60% of the patient total, P=.007). In the SAH-OLD group, 62.9% of the patients underwent embolisation vs 74.6% in the SAH-NEW group (P=.08). Time to embolisation was 4.7 ± 8.2 days for SAH-OLD patients and 2.12 ± 2.2 days for SAH-NEW patients (P=.01). Twenty-two percent of SAH-OLD patients underwent surgery, compared to 25.4% in the SAH-NEW group (P=.62). CONCLUSIONS Care for SAH patients has improved in this hospital: results include fewer mortalities, a higher number of treatments with a smaller proportion of endovascular treatments, and shorter times to treatment. Elapsed time to arteriography remains stable.
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Affiliation(s)
- A Lago
- Servicio de Neurología, Hospital Universitario La Fe, Valencia, España.
| | - R López-Cuevas
- Servicio de Neurología, Hospital Universitario La Fe, Valencia, España
| | - J I Tembl
- Servicio de Neurología, Hospital Universitario La Fe, Valencia, España
| | - G Fortea
- Servicio de Neurología, Hospital Universitario La Fe, Valencia, España
| | - D Górriz
- Servicio de Neurología, Hospital Universitario La Fe, Valencia, España
| | - F Aparici
- Sevicio de Radiología, Hospital Universitario La Fe, Valencia, España
| | - V Parkhutik
- Servicio de Neurología, Hospital Universitario La Fe, Valencia, España
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English JD, Yavagal DR, Gupta R, Janardhan V, Zaidat OO, Xavier AR, Nogueira RG, Kirmani JF, Jovin TG. Mechanical Thrombectomy-Ready Comprehensive Stroke Center Requirements and Endovascular Stroke Systems of Care: Recommendations from the Endovascular Stroke Standards Committee of the Society of Vascular and Interventional Neurology (SVIN). INTERVENTIONAL NEUROLOGY 2016; 4:138-50. [PMID: 27051410 DOI: 10.1159/000442715] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Five landmark multicenter, prospective, randomized, open-label, blinded end point clinical trials have recently demonstrated significant clinical benefit of endovascular therapy with mechanical thrombectomy in acute ischemic stroke (AIS) patients presenting with proximal intracranial large vessel occlusions. The Society of Vascular and Interventional Neurology (SVIN) appointed an expert writing committee to summarize this new evidence and make recommendations on how these data should guide emergency endovascular therapy for AIS patients.
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Affiliation(s)
- Joey D English
- Neurointerventional Surgery, California Pacific Medical Center, San Francisco, Calif., USA
| | - Dileep R Yavagal
- Neurology and Neurosurgery, University of Miami School of Medicine, Miami, Fla., USA
| | - Rishi Gupta
- Neurosurgery, WellStar Medical Group, Marietta, Ga., USA
| | | | | | | | | | - Jawad F Kirmani
- Stroke and Neurovascular Center, JFK Medical Center, Edison, N.J., USA
| | - Tudor G Jovin
- Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pa., USA
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Schaller SJ, Stäuble CG, Suemasa M, Heim M, Duarte IM, Mensch O, Bogdanski R, Lewald H, Eikermann M, Blobner M. The German Validation Study of the Surgical Intensive Care Unit Optimal Mobility Score. J Crit Care 2015; 32:201-6. [PMID: 26857328 DOI: 10.1016/j.jcrc.2015.12.020] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Revised: 12/03/2015] [Accepted: 12/24/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE Immobilization of critically ill patients leads to muscle weakness, which translates to increased costs of care and long-term functional disability. We tested the validity of a German Surgical Intensive Care Unit (ICU) Optimal Mobilization Score (SOMS) in 2 different cohorts (neurocritical and nonneurocritical care patients). MATERIALS AND METHODS Physical therapists estimated the patients' mobilization capacity by using the German version of the SOMS the morning after admission. We tested the prognostic value of the prediction for ICU and hospital length of stay (LOS) as well as for mortality, and built a model to account for other known predictors of these outcomes in the 2 cohorts. RESULTS A total of 128 patients were included in the analysis, 48 of these were neurocritical care patients. The SOMS predicted mortality and ICU and hospital LOS. Neurocritical care patients stayed significantly longer in the ICU (median 12 vs 4 days, P < .001) and in the hospital (25 vs 17 days, P = .02). The SOMS predicted ICU and hospital LOS. It predicted mortality only in nonneurocritical patients. CONCLUSIONS The German SOMS assessed by physical therapists on the day after ICU admission predicts ICU and hospital LOS, and mortality. Our data suggest that the association between early mobilization and mortality is more complex in neurocritical care patients.
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Affiliation(s)
- Stefan J Schaller
- Klinik für Anaesthesiologie, Klinikum rechts der Isar, Technische Universität München, Munich, Germany.
| | - Christiane G Stäuble
- Klinik für Anaesthesiologie, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Mika Suemasa
- Klinik für Anaesthesiologie, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Markus Heim
- Klinik für Anaesthesiologie, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Ingrid Moreno Duarte
- Department of Anesthesia, Critical Care, Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Oliver Mensch
- Klinik für Anaesthesiologie, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Ralph Bogdanski
- Klinik für Anaesthesiologie, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Heidrun Lewald
- Klinik für Anaesthesiologie, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Matthias Eikermann
- Department of Anesthesia, Critical Care, Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Manfred Blobner
- Klinik für Anaesthesiologie, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
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Egawa S, Hifumi T, Kawakita K, Okauchi M, Shindo A, Kawanishi M, Tamiya T, Kuroda Y. Impact of neurointensivist-managed intensive care unit implementation on patient outcomes after aneurysmal subarachnoid hemorrhage. J Crit Care 2015; 32:52-5. [PMID: 26703419 DOI: 10.1016/j.jcrc.2015.11.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 11/06/2015] [Accepted: 11/14/2015] [Indexed: 11/30/2022]
Abstract
PURPOSE The purpose of the study is to evaluate the impact of neurointensivist-managed intensive care unit (NIM-ICU) implementation for patients admitted with aneurysmal subarachnoid hemorrhage (SAH). METHODS This study retrospectively evaluated 234 patients (mean age, 61.7 years; male, 67) admitted with SAH between January 1, 2001, and March 31, 2014. Neurologic outcomes between patients admitted from January 2001 to December 2006 (intensivist-managed intensive care unit group) and January 2007 to March 2014 (NIM-ICU group) were compared. The primary outcome was the incidence of a good neurologic outcome at discharge (GO; the modified Ranking Scale score: GO, 0-2; poor neurological outcome, 3-6) at discharge. RESULTS Neurointensivist-managed intensive care unit was initiated for 151 (64.5%) of 234 patients. Univariate analysis demonstrated significantly better outcomes for NIM-ICU group vs intensivist-managed intensive care unit group (GOs, 58.3% vs 41.0%, respectively, P = .01). Multivariate logistic regression was used to evaluate NIM-ICU efficacy for SAH patients, but NIM-ICU was not significantly associated with GOs (P = .054). Subgroup analysis of patient grading by Hunt and Kosnik grades I to II showed that NIM-ICU implementation was an independent predictor of GOs (odds ratio, 4.54; 95% confidence interval, 1.08-22.17; P = .04). CONCLUSION Neurointensivist-managed intensive care unit may improve neurologic outcomes in SAH patients with Hunt and Kosnik grades I to II.
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Affiliation(s)
- Satoshi Egawa
- Emergency Medical Center, Kagawa University Hospital, Kagawa 761-0793, Japan.
| | - Toru Hifumi
- Emergency Medical Center, Kagawa University Hospital, Kagawa 761-0793, Japan.
| | - Kenya Kawakita
- Emergency Medical Center, Kagawa University Hospital, Kagawa 761-0793, Japan.
| | - Masanobu Okauchi
- Department of Neurosurgery, Kagawa University Hospital, Kagawa 761-0793, Japan.
| | - Atsushi Shindo
- Department of Neurosurgery, Kagawa University Hospital, Kagawa 761-0793, Japan.
| | - Masahiko Kawanishi
- Department of Neurosurgery, Kagawa University Hospital, Kagawa 761-0793, Japan.
| | - Takashi Tamiya
- Department of Neurosurgery, Kagawa University Hospital, Kagawa 761-0793, Japan.
| | - Yasuhiro Kuroda
- Emergency Medical Center, Kagawa University Hospital, Kagawa 761-0793, Japan.
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International multidisciplinary consensus conference on multimodality monitoring: ICU processes of care. Neurocrit Care 2015; 21 Suppl 2:S215-28. [PMID: 25208666 DOI: 10.1007/s12028-014-0020-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
There is an increased focus on evaluating processes of care, particularly in the high acuity and cost environment of intensive care. Evaluation of neurocritical-specific care and evidence-based protocol implementation are needed to effectively determine optimal processes of care and effect on patient outcomes. General quality measures to evaluate intensive care unit (ICU) processes of care have been proposed; however, applicability of these measures in neurocritical care populations has not been established. A comprehensive literature search was conducted for English language articles from 1990 to August 2013. A total of 1,061 articles were reviewed, with 145 meeting criteria for inclusion in this review. Care in specialized neurocritical care units or by neurocritical teams can have a positive impact on mortality, length of stay, and in some cases, functional outcome. Similarly, implementation of evidence-based protocol-directed care can enhance outcome in the neurocritical care population. There is significant evidence to support suggested quality indicators for the general ICU population, but limited research regarding specific use in neurocritical care. Quality indices for neurocritical care have been proposed; however, additional research is needed to further validate measures.
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Mapa B, Taylor BES, Appelboom G, Bruce EM, Claassen J, Connolly ES. Impact of Hyponatremia on Morbidity, Mortality, and Complications After Aneurysmal Subarachnoid Hemorrhage: A Systematic Review. World Neurosurg 2015; 85:305-14. [PMID: 26361321 DOI: 10.1016/j.wneu.2015.08.054] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 08/14/2015] [Accepted: 08/18/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND Hyponatremia is a common metabolic disturbance after aneurysmal subarachnoid hemorrhage (SAH), and it may worsen outcomes. This review aims to characterize the effect of hyponatremia on morbidity and mortality after SAH. OBJECTIVES We sought to determine the prevalence of hyponatremia after SAH, including in subgroups, as well as its effect on mortality and certain outcome measures, including degree of disability and duration of hospitalization. METHODS A search of terms "hyponatremia" and "subarachnoid hemorrhage" was performed on PubMed, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and EMBASE. Studies were included if they reported prevalence of hyponatremia and if they discussed outcomes such as mortality, duration of stay, functional outcomes (e.g., Glasgow Outcomes Scale), or incidence of complications in patients with aneurysmal SAH. Two independent researchers assessed the titles and abstracts and reviewed articles for inclusion. RESULTS Thirteen studies met inclusion criteria. The prevalence of at least mild hyponatremia was 859 of 2387 (36%) of patients. Hyponatremia was associated with vasospasm and duration of hospitalization, but it did not influence mortality. CONCLUSION Hyponatremia is common after SAH, and there is evidence that it is associated with certain poorer outcomes. Larger, prospective studies are needed to assess these findings and provide further evidence.
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Affiliation(s)
- Ben Mapa
- Cerebrovascular Lab, Columbia University Medical Center, New York, New York, USA
| | - Blake E S Taylor
- Cerebrovascular Lab, Columbia University Medical Center, New York, New York, USA; Department of Neurosurgery, Columbia University, New York, New York, USA.
| | - Geoffrey Appelboom
- Cerebrovascular Lab, Columbia University Medical Center, New York, New York, USA; Department of Neurosurgery, Columbia University, New York, New York, USA
| | - Eliza M Bruce
- Cerebrovascular Lab, Columbia University Medical Center, New York, New York, USA; Department of Neurosurgery, Columbia University, New York, New York, USA
| | - Jan Claassen
- Department of Neurology, Columbia University, New York, New York, USA; Neuro-intensive Care Unit, Columbia University, New York, New York, USA
| | - E Sander Connolly
- Cerebrovascular Lab, Columbia University Medical Center, New York, New York, USA; Department of Neurosurgery, Columbia University, New York, New York, USA; Department of Neurology, Columbia University, New York, New York, USA
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Rabinstein AA. Critical care of aneurysmal subarachnoid hemorrhage: state of the art. ACTA NEUROCHIRURGICA. SUPPLEMENT 2015; 120:239-42. [PMID: 25366630 DOI: 10.1007/978-3-319-04981-6_40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Subarachnoid hemorrhage (SAH) from a ruptured aneurysm is a very complex disease. The brain can be injured from the immediate effects of the acute bleeding, but can also be threatened by secondary insults hours and days later. Early and delayed systemic complications are common and can be very serious. This brief paper summarizes key practical concepts regarding the neurocritical care of patients with aneurysmal SAH (aSAH). It proposes as a framework the division of the time course of the disease into a first phase (from aneurysm rupture to aneurysm treatment) of resuscitation and stabilization and a second phase (from aneurysm treatment to the end of the acute hospitalization) of prevention and treatment of secondary insults. The main mechanisms of cerebral injury and the principal systemic complications are discussed and diagnostic and therapeutic advice is provided based on a combination of available evidence and clinical experience.
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Affiliation(s)
- Alejandro A Rabinstein
- Department of Neurology, Mayo Clinic, 200 First Street SW, Mayo W8B, Rochester, MN, 55905, USA,
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Impact of specialist neurovascular care in subarachnoid haemorrhage. Clin Neurol Neurosurg 2015; 133:55-60. [PMID: 25839916 DOI: 10.1016/j.clineuro.2015.03.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Revised: 02/18/2015] [Accepted: 03/07/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND The management of neurosurgical disorders has become increasingly specialised. The care of patients with subarachnoid haemorrhage (SAH) has generally been part of core neurosurgical practice, provided by general neurosurgeons whatever their specialist interest. The aim of this present study therefore is to ascertain if, and to what extent care provided by a dedicated neurovascular team (compared to care provided by a general neurosurgical team) change patient disposition in SAH. METHODS This is a retrospective analysis of SAH patients, identified from a departmental database of a single neurosurgical centre. In 2008, the service was reorganised such that a neurovascular team cared for all SAH patients. We compared clinical outcome in people admitted prior to this service reorganisation (Period A, 2004-2007) with patients admitted afterwards (Period B, 2009-2011). Survival and recovery were assessed according to the Glasgow Outcome Scale (GOS). Multi-factorial logistic regression analysis was performed to determine the injury and age adjusted incidence of complications, odds of survival at discharge, discharge home, mortality, good recovery (GOS 5) and favourable outcome, by dichotomising GOS (GOS 4-5 vs. GOS 1-3) at 3 months. RESULTS 1114 patients were included in the study. The mean age of patients presenting in Period A (n = 543) was younger [50 years (SD 13.5)] than those in Period B (n = 571) [53 years (SD 13)]. Patients admitted in Period B were more likely to present as poor grade (World Federation of Neurological surgeons (WFNS) grades 4 and 5) compared to Period A (26.5% vs. 21.3%). No statistical differences between the groups in the incidence of pre-operative re-bleeding (3% vs. 5%) or rates of delayed cerebral ischaemia (16.1% vs. 16.1%) were observed. After adjustment for age, sex and injury severity, the odds of patient time to discharge, discharge home and good recovery (GOS 5) were 27% (p < 0.001), 45% (p = 0.001) and 93% (p < 0.001) higher respectively in Period B than Period A. CONCLUSIONS The data presented here demonstrates that management of SAH by a dedicated neurovascular team improves the potential for patient recovery.
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Stapleton CJ, Walcott BP, Butler WE, Ogilvy CS. Neurological outcomes following intraprocedural rerupture during coil embolization of ruptured intracranial aneurysms. J Neurosurg 2015; 122:128-35. [PMID: 25361491 DOI: 10.3171/2014.9.jns14616] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Intraprocedural rerupture (IPR) of intracranial aneurysms during coil embolization is associated with significant periprocedural disability and death. However, whether this morbidity and mortality are secondary to an increased risk of vasospasm and hydrocephalus is unknown. The authors undertook this study to determine the in-hospital and long-term neurological outcomes for patients with aneurysmal subarachnoid hemorrhage (SAH) treated with coil embolization who suffer aneurysm rerupture during treatment. METHODS The records of 156 patients admitted with SAH from previously untreated, ruptured, intracranial aneurysms and treated with endovascular coiling between January 2007 and January 2014 were retrospectively reviewed. Twelve patients (7.7%) experienced IPR during coil embolization. RESULTS Compared with the cohort of patients with uncomplicated coil embolization procedures, patients with aneurysm rerupture were more likely to require external ventricular drain (EVD) placement (91.7% vs 58.3%, p = 0.02) and postprocedural EVD placement (36.4% vs 7.1%, p = 0.01), to undergo permanent ventriculoperitoneal shunt placement (50.0% vs 18.8%, p = 0.02), to develop symptomatic vasospasm (50.0% vs 18.1%, p = 0.02), and to have longer lengths of hospital stay (median 21.5 days vs 15.0 days, p = 0.04). Admission Hunt and Hess, modified Fisher, and Barrow Neurological Institute grades did not differ between the 2 cohorts, nor did long-term functional neurological outcomes as assessed by the modified Rankin Scale. CONCLUSIONS Intraprocedural rerupture during coil embolization for ruptured intracranial aneurysms is associated with an increased risk of symptomatic vasospasm and need for temporary and permanent cerebrospinal fluid diversion for hydrocephalus.
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Botting MJ, Phan N, Rubenfeld GD, Speke AK, Chapman MG. Using barriers analysis to refine a novel model of neurocritical care. Neurocrit Care 2015; 20:5-14. [PMID: 24101105 DOI: 10.1007/s12028-013-9905-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND In order to deliver specialized neurocritical care (NCC) without a dedicated neurological intensive care unit (ICU), we established a virtual NCC unit within an existing mixed level III ICU. This initiative required changes to patient allocation, physician staffing, and care protocols. In advance of its implementation, we gaged readiness, assessed barriers, and solicited feedback from staff. METHODS Clinicians at our academic hospital and trauma centre in Toronto, Ontario were the subjects of this concurrent mixed methods study. Eighteen stakeholders were individually interviewed. 116 of 217 eligible ICU staff participated in the survey and 36 staff attended the focus group sessions. RESULTS From the survey, the most significant barriers to this reorganization were staff anxiety about coping (28 %) and a concern that patients would not receive better care (24 %). Noteworthy obstacles about the use of protocols were their lack of flexibility (19 %) and that implementation was seen as impractical (16 %). Seventeen barriers were proposed through an open-ended survey question. Content analysis revealed general resistance, educational challenges, workflow adjustment to a diagnosis-based rounding pattern and coordination conflicts to be the central barriers. These findings were confirmed in focus group discussions, with a lack of resources as an additional important challenge. CONCLUSIONS A new workable model for NCC has been developed, facilitated by this analysis. Steps to overcome barriers demonstrated in this study include additional educational measures, changes to the rounding protocols, and patient allocation algorithms.
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Affiliation(s)
- Marianne J Botting
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Room D108, 2075 Bayview Avenue, Toronto, ON, M4N3M5, Canada
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Park JH, Kim YI, Lim YC. Clinical outcomes of treatment for intracranial aneurysm in elderly patients. J Cerebrovasc Endovasc Neurosurg 2014; 16:193-9. [PMID: 25340020 PMCID: PMC4205244 DOI: 10.7461/jcen.2014.16.3.193] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Revised: 07/28/2014] [Accepted: 08/11/2014] [Indexed: 11/24/2022] Open
Abstract
Objective The aim of this study is to evaluate the clinical course of intracranial aneurysm in patients aged 65 years and older and the immediate outcome after its aggressive management. Materials and Methods We performed a retrospective analysis using the medical records of 159 elderly patients managed at our institute from September 2008 to December 2013. Obtained clinical information included age, sex, Hunt and Hess grade (HHG), aneurysm location, Fisher grade (FG) and the treatment modality. Concomitant clinical data aside from cerebrovascular condition (hypertension, diabetes, previous medication) were evaluated to determine risk factors that might affect the functional outcomes. Results A total of 108 patients (67.9%) presented with subarachnoid hemorrhage (SAH), and 51 (32.1%) with unruptured intracranial aneurysms (UIAs). Coiling was performed in 101 patients and 58 patients underwent clipping. In the SAH population, 62 patients (57.4%) showed favorable outcomes, with a mortality rate of 11.3% (n = 18). In the UIAs population, 50 (98%) patients achieved 'excellent' and one (2%) achieved 'good' outcome. Factors including high-grade HHG (p < 0.001), advanced age (p = 0.014), and the presence of intraventricular hematoma (IVH) (p = 0.017) were significant predictors of poor outcome. Conclusion SAH patients with high grade HHG and IVH are associated with poor outcome with statistical significance, all the more prominent the older the patient is. Therefore, the indication for aggressive therapy should be considered more carefully in these patients. However, as the outcomes for elderly patients with UIAs were excellent regardless of the treatment modality, aggressive treatment could always be considered in UIAs cases.
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Affiliation(s)
- Jun Hee Park
- Department of Neurosurgery, Ajou University School of Medicine, Suwon, Korea
| | - Young Im Kim
- Department of Neurosurgery, Ajou University School of Medicine, Suwon, Korea
| | - Yong Cheol Lim
- Department of Neurosurgery, Ajou University School of Medicine, Suwon, Korea
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Ghaly RF. Do neurosurgeons need Neuroanesthesiologists? Should every neurosurgical case be done by a Neuroanesthesiologist? Surg Neurol Int 2014; 5:76. [PMID: 24949219 PMCID: PMC4061581 DOI: 10.4103/2152-7806.133106] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Accepted: 03/19/2014] [Indexed: 11/30/2022] Open
Abstract
Neuroscience is exponentially growing and accompanied with everyday innovations and intriguing developments. There are new branches of science that are being developed within neuroscience. For instance, the fields of computer interface nanotechnology, molecular biology, ultra cellular, and gene therapy. The neuroscience programs have been established nationwide and worldwide. There is strong belief that better patient care is obtained through high volume and specialty physicians and hospitals. In fact, there are new subspecialties that already developed from within the specialty itself. Neuroanesthesia is one of the specialties that has contributed tremendously over the years to neuroscience yet it remained non-accredited and supported. In fact, there is a discouraging trend to pursue advocating the necessity of neurosurgery cases to be done by neuroanesthesiologists. It is one of the specialties that is lagging behind compared with other specialties and subspecialties in neuroscience. There is an ongoing debate within the neuroanesthesia society about the role of neuroanesthesiologists in neurosurgery. The author, being a neurosurgeon, neuroanesthesiologist, and neurointensivist, is presenting the topic, the views and expressing his opinion.
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Affiliation(s)
- Ramsis F. Ghaly
- Professor of Neurological Surgery and Anesthesiology University of Illinois at Chicago, Ghaly Neurosurgical Associates, Aurora, Illinois, Advocate Illinois Masonic medical center and JSH of Cook County hospital, Chicago, Illinois, USA
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Management of status epilepticus in neurological versus medical intensive care unit: does it matter? Neurocrit Care 2014; 19:4-9. [PMID: 23589183 DOI: 10.1007/s12028-013-9840-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Admission of patients with status epilepticus (SE) to the neurosciences intensive care unit (NICU) may improve management and outcomes compared to general ICUs. METHODS We reviewed all patients with SE admitted to the NICU versus the Medical ICU in our institution between 2005 and 2008. We included only patients with definite or probable SE based on pre-defined criteria. We collected demographic and clinical data, including severity of admission scores and adjusted short-term outcomes for admission and management in the two ICUs. RESULTS There were 168 visits in 151 patients for definite or probable SE, 46 (27 %) of which were in the NICU and 122 (73 %) in the MICU. APACHE II scores were significant higher in the MICU group (17.5 vs 13.4, p = 0.003) and age in the NICU (58.3 vs 51.5 years, p = 0.041). More continuous EEGs were ordered in the NICU (85 vs 30 %, p < 0.001), where fewer patients were intubated, but more eventually tracheostomized. The NICU had a higher rate of complex partial SE and more alert or somnolent patients, whereas the MICU had a higher rate of generalized SE and more stuporous or comatose patients. Admission diagnoses also differed, with the NICU having higher rate of strokes and the MICU higher rate of toxometabolic etiologies (39 vs 12 % and 11 vs 21 %, p = 0.002). After adjustment, no difference was found in mortality, the ICU or hospital length of stay and modified Rankin score at discharge. CONCLUSION SE treatment revealed increased use of continuous EEG in NICU-admitted patients, but without concomitant reduction in LOS or discharge outcomes compared to the MICU.
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Burns JD, Green DM, Lau H, Winter M, Koyfman F, DeFusco CM, Holsapple JW, Kase CS. The effect of a neurocritical care service without a dedicated neuro-ICU on quality of care in intracerebral hemorrhage. Neurocrit Care 2014; 18:305-12. [PMID: 23479068 DOI: 10.1007/s12028-013-9818-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Introduction of neurocritical care services to dedicated neuro-ICUs is associated with improved quality of care. The impact of a neurocritical care service without a dedicated neuro-ICU has not been studied. METHODS We retrospectively identified all patients admitted to our institution with intracerebral hemorrhage (ICH) in two 12-month periods: immediately before the arrival of the first neurointensivist ("before") and after the neurocritical care service was established ("after"). There was no nursing team, ICU housestaff/physician extender team, or physical unit dedicated to the care of patients with critical neurologic illness during either period. Using an uncontrolled before-after design, we compared clinical outcomes and performance on quality metrics between groups. RESULTS We included 74 patients with primary supratentorial ICH. Mortality, length of stay (LOS), proportion of patients with modified Rankin Score 0-3, and destination on discharge did not differ between groups when adjusted for confounders. Time to first two consecutive systolic blood pressure (SBP) measurements <180 mmHg was shorter in the "after" cohort (mean 4.5 vs. 3.2 h, p = 0.001). Area under the curve measurement for change in SBP from baseline over the first 24 h after ED arrival demonstrated greater, sustained SBP reduction in the "after" cohort (mean -187.9 vs. -720.9, p = 0.04). A higher proportion of patients were fed without passing a dysphagia screen in the "before" group (45 vs. 0%, p < 0.001). CONCLUSIONS Introduction of a neurocritical service without a neuro-ICU at our institution was associated with a trend toward longer ICU LOS and improvement in some key metrics of quality of care for patients with ICH.
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Affiliation(s)
- Joseph D Burns
- Department of Neurology, Boston University School of Medicine, Boston, MA 02118, USA.
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Sheth SA, Hausrath D, Numis AL, Lawton MT, Josephson SA. Intraoperative rerupture during surgical treatment of aneurysmal subarachnoid hemorrhage is not associated with an increased risk of vasospasm. J Neurosurg 2013; 120:409-14. [PMID: 24313615 DOI: 10.3171/2013.10.jns13934] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Intraoperative rerupture during open surgical clipping of cerebral aneurysms in subarachnoid hemorrhage (SAH) is a relatively frequent and potentially catastrophic occurrence. Patients who suffer rerupture have been shown to have worse outcomes at discharge compared with those who do not have rerupture. Perioperative injury likely plays a large part in the clinical worsening of these patients. However, due to the increased vessel manipulation and repeat exposure to acute hemorrhage, it is possible that secondary injury from increased incidence of vasospasm also contributes. Identifying an increased rate of vasospasm in these patients would justify early aggressive treatment with measures to prevent delayed cerebral ischemia. The authors investigated whether patients who suffer intraoperative rerupture during surgical treatment of ruptured cerebral aneurysms are at increased risk of developing vasospasm. METHODS Five hundred consecutive patients treated with open surgical clipping for SAH were reviewed, and clinical and imaging data were collected. Angiographic vasospasm was defined as vessel narrowing believed to be consistent with vasospasm on angiography. Symptomatic vasospasm was defined as angiographic vasospasm in the setting of a clinical change attributable to vasospasm. Rates of angiographic and symptomatic vasospasm among patients with and without intraoperative rerupture were compared. RESULTS There were no significant differences between the groups with and without rupture with respect to age, sex, modified Fisher grade, history of hypertension, or smoking. The group with intraoperative rupture had more patients with Hunt and Hess Grade I. Angiographic vasospasm was noted in 279 (66%) of the 425 patients without rerupture compared with 49 (65%) of the 75 patients with rerupture (p = 1.0, Fisher's exact test). Symptomatic vasospasm was noted in 154 (36%) of the 425 patients without rerupture, compared with 31 (41%) of the 75 patients with rerupture (p = 0.44, Fisher's exact test). In multivariate analysis, higher modified Fisher grade was significantly predictive of vasospasm, whereas older age and male sex were protective. CONCLUSIONS This study found no significant influence of intraoperative rerupture during open surgical clipping on the rate of angiographic or symptomatic vasospasm. Brief exposure to acute hemorrhage and vessel manipulation associated with rerupture events did not affect the rate of vasospasm. Risk of vasospasm was related to increased modified Fisher grade, and inversely related to age and male sex. These results do not justify early, targeted vasospasm therapy in patients with intraoperative rerupture.
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Naval NS, Kowalski RG, Chang TR, Caserta F, Carhuapoma JR, Tamargo RJ. The SAH Score: a comprehensive communication tool. J Stroke Cerebrovasc Dis 2013; 23:902-9. [PMID: 24103667 DOI: 10.1016/j.jstrokecerebrovasdis.2013.07.035] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Revised: 06/28/2013] [Accepted: 07/25/2013] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND The Hunt and Hess grade and World Federation of Neurological Surgeons (WFNS) scale are commonly used to predict mortality after aneurysmal subarachnoid hemorrhage (aSAH). Our objective was to improve the accuracy of mortality prediction compared with the aforementioned scales by creating the "SAH score." METHODS The aSAH database at our institution was analyzed for factors affecting in-hospital mortality using multiple logistic regression analysis. Scores were weighted based on relative risk of mortality after stratification of each of these variables. Glasgow Coma Scale (GCS) was subdivided into groups of 3-4 (score = 1), 5-8 (score = 2), 9-13 (score = 3), and 14-15 (score = 4). Age was categorized into 4 subgroups: 18-49 (score = 1), 50-69 (score = 2), 70-79 (score = 3), and 80 years or more (score = 4). Medical comorbidities were subdivided into none (score = 1), 1 (score = 2), or 2 or more (score = 3). RESULTS In total, 1134 patients were included; all-cause SAH hospital mortality was 18.3%. Admission GCS, age, and medical comorbidities significantly affected mortality after multivariate analysis (P < .05). Summated scores ranged from 0 to 8 with escalating mortality at higher scores (0 = 2%, 1 = 6%, 2 = 8%, 3 = 15%, 4 = 30%, 5 = 58%, 6 = 79%, 7 = 87%, and 8 = 100%). Positive predictive value (PPV) for scores in the range 7-8 was 88.5%, whereas 6-8 was 83%. Negative predictive value (NPV) was 94% for range 0-2 and 92% for 0-3. The area under the curve (AUC) for the SAH score was .821 (good accuracy), compared with the WFNS scale (AUC .777, fair accuracy) and the Hunt and Hess grade (AUC .771, fair accuracy). CONCLUSIONS The SAH score was found to be more accurate in predicting aSAH mortality compared with the Hunt and Hess grade and WFNS scale.
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Affiliation(s)
- Neeraj S Naval
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Anesthesia Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Robert G Kowalski
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Tiffany R Chang
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Filissa Caserta
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - J Ricardo Carhuapoma
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Anesthesia Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rafael J Tamargo
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Blood transfusion is an important predictor of hospital mortality among patients with aneurysmal subarachnoid hemorrhage. Neurocrit Care 2013; 18:209-15. [PMID: 22965325 DOI: 10.1007/s12028-012-9777-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Red blood cell (RBC) transfusion after aneurysmal subarachnoid hemorrhage (aSAH) has been associated with increased mortality but prior studies have not adequately adjusted for transfusion-indication bias. METHODS This is a retrospective study of consecutive aSAH patients admitted to the intensive care units of two academic medical centers over a 7-year period. Data collection included demographics, World Federation of Neurosurgical Surgeons score (WFNS), modified Fisher score (mFisher), admission and nadir hemoglobin (Hb) level, vasospasm, cerebral infarction, acute lung injury, and hospital mortality. The association between RBC transfusion and mortality was evaluated using a multivariate logistic regression analysis using the propensity for RBC transfusion as a covariate. RESULTS We identified 318 patients. The median age was 54 years (46, 65), and 204 (64 %) were females. Hospital mortality was 13 % (42/318). Seventy-two (23 %) patients were transfused. Predictors of transfusion were admit and nadir Hb levels (p < 0.001), age (p = 0.02), gender (0.008), WFNS score (p < 0.001), mFisher score (p = 0.009), surgical versus endovascular treatment (p < 0.001) and moderate to severe vasospasm (p = 0.025) were predictors of transfusion. After adjustment for probability of receiving RBC transfusion, APACHE IV and nadir Hb, transfusion remained independently associated with hospital mortality (OR 3.16, 95 % CI = 1.02-9.69, p = 0.047). CONCLUSIONS Among patients with aSAH, RBC transfusion was independently associated with an increased mortality after adjustment for the most common clinical indications for transfusion.
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