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Bastos LSL, Hamacher S, Kurtz P, Ranzani OT, Zampieri FG, Soares M, Bozza FA, Salluh JIF. The Association Between Prepandemic ICU Performance and Mortality Variation in COVID-19: A Multicenter Cohort Study of 35,619 Critically Ill Patients. Chest 2024; 165:870-880. [PMID: 37838338 DOI: 10.1016/j.chest.2023.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 09/20/2023] [Accepted: 10/05/2023] [Indexed: 10/16/2023] Open
Abstract
BACKGROUND During the COVID-19 pandemic, ICUs remained under stress and observed elevated mortality rates and high variations of outcomes. A knowledge gap exists regarding whether an ICU performing best during nonpandemic times would still perform better when under high pressure compared with the least performing ICUs. RESEARCH QUESTION Does prepandemic ICU performance explain the risk-adjusted mortality variability for critically ill patients with COVID-19? STUDY DESIGN AND METHODS This study examined a cohort of adults with real-time polymerase chain reaction-confirmed COVID-19 admitted to 156 ICUs in 35 hospitals from February 16, 2020, through December 31, 2021, in Brazil. We evaluated crude and adjusted in-hospital mortality variability of patients with COVID-19 in the ICU during the pandemic. Association of baseline (prepandemic) ICU performance and in-hospital mortality was examined using a variable life-adjusted display (VLAD) during the pandemic and a multivariable mixed regression model adjusted by clinical characteristics, interaction of performance with the year of admission, and mechanical ventilation at admission. RESULTS Thirty-five thousand six hundred nineteen patients with confirmed COVID-19 were evaluated. The median age was 52 years, median Simplified Acute Physiology Score 3 was 42, and 18% underwent invasive mechanical ventilation. In-hospital mortality was 13% and 54% for those receiving invasive mechanical ventilation. Adjusted in-hospital mortality ranged from 3.6% to 63.2%. VLAD in the most efficient ICUs was higher than the overall median in 18% of weeks, whereas VLAD was 62% and 84% in the underachieving and least efficient groups, respectively. The least efficient baseline ICU performance group was associated independently with increased mortality (OR, 2.30; 95% CI, 1.45-3.62) after adjusting for patient characteristics, disease severity, and pandemic surge. INTERPRETATION ICUs caring for patients with COVID-19 presented substantial variation in risk-adjusted mortality. ICUs with better baseline (prepandemic) performance showed reduced mortality and less variability. Our findings suggest that achieving ICU efficiency by targeting improvement in organizational aspects of ICUs may impact outcomes, and therefore should be a part of the preparedness for future pandemics.
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Affiliation(s)
- Leonardo S L Bastos
- Department of Industrial Engineering, Pontifical Catholic University of Rio de Janeiro, Rio de Janeiro, Brazil.
| | - Silvio Hamacher
- Department of Industrial Engineering, Pontifical Catholic University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Pedro Kurtz
- Hospital Copa Star, Rio de Janeiro, Brazil; Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil; D'Or Institute for Research and Education, Rio de Janeiro, Brazil
| | - Otavio T Ranzani
- Pulmonary Division, Heart Institute, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil; Barcelona Institute for Global Health, ISGlobal, Universitat Pompeu Fabra, CIBER Epidemiología y Salud Pública, Barcelona, Spain
| | - Fernando G Zampieri
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil; Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Marcio Soares
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil
| | - Fernando A Bozza
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil; National Institute of Infectious Disease Evandro Chagas, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Jorge I F Salluh
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil; Postgraduate Program of Internal Medicine, Federal University of Rio de Janeiro, (UFRJ), Rio de Janeiro, Brazil
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França ARM, Rocha E, Bastos LSL, Bozza FA, Kurtz P, Maccariello E, Lapa E Silva JR, Salluh JIF. Development and validation of a machine learning model to predict the use of renal replacement therapy in 14,374 patients with COVID-19. J Crit Care 2024; 80:154480. [PMID: 38016226 DOI: 10.1016/j.jcrc.2023.154480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 11/11/2023] [Accepted: 11/15/2023] [Indexed: 11/30/2023]
Abstract
PURPOSE To develop a model to predict the use of renal replacement therapy (RRT) in COVID-19 patients. MATERIALS AND METHODS Retrospective analysis of multicenter cohort of intensive care unit (ICU) admissions of Brazil involving COVID-19 critically adult patients, requiring ventilatory support, admitted to 126 Brazilian ICUs, from February 2020 to December 2021 (development) and January to May 2022 (validation). No interventions were performed. RESULTS Eight machine learning models' classifications were evaluated. Models were developed using an 80/20 testing/train split ratio and cross-validation. Thirteen candidate predictors were selected using the Recursive Feature Elimination (RFE) algorithm. Discrimination and calibration were assessed. Temporal validation was performed using data from 2022. Of 14,374 COVID-19 patients with initial respiratory support, 1924 (13%) required RRT. RRT patients were older (65 [53-75] vs. 55 [42-68]), had more comorbidities (Charlson's Comorbidity Index 1.0 [0.00-2.00] vs 0.0 [0.00-1.00]), had higher severity (SAPS-3 median: 61 [51-74] vs 48 [41-58]), and had higher in-hospital mortality (71% vs 22%) compared to non-RRT. Risk factors for RRT, such as Creatinine, Glasgow Coma Scale, Urea, Invasive Mechanical Ventilation, Age, Chronic Kidney Disease, Platelets count, Vasopressors, Noninvasive Ventilation, Hypertension, Diabetes, modified frailty index (mFI) and Gender, were identified. The best discrimination and calibration were found in the Random Forest (AUC [95%CI]: 0.78 [0.75-0.81] and Brier's Score: 0.09 [95%CI: 0.08-0.10]). The final model (Random Forest) showed comparable performance in the temporal validation (AUC [95%CI]: 0.79 [0.75-0.84] and Brier's Score, 0.08 [95%CI: 0.08-0.1]). CONCLUSIONS An early ML model using easily available clinical and laboratory data accurately predicted the use of RRT in critically ill patients with COVID-19. Our study demonstrates that using ML techniques is feasible to provide early prediction of use of RRT in COVID-19 patients.
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Affiliation(s)
- Allan R M França
- Postgraduate Program of Internal Medicine, Federal University of Rio de Janeiro, (UFRJ), Rio de Janeiro, Brazil.
| | - Eduardo Rocha
- Postgraduate Program of Internal Medicine, Federal University of Rio de Janeiro, (UFRJ), Rio de Janeiro, Brazil; Postgraduate Program, D'Or Institute for Research and Education (IDOR), Rio de Janeiro, RJ, Brazil
| | - Leonardo S L Bastos
- Department of Industrial Engineering (DEI), Pontifical Catholic University of Rio de Janeiro (PUC-Rio), Rio de Janeiro, RJ, Brazil
| | - Fernando A Bozza
- Postgraduate Program, D'Or Institute for Research and Education (IDOR), Rio de Janeiro, RJ, Brazil; National Institute of Infectious Disease Evandro Chagas (INI), Oswaldo Cruz Foundation (FIOCRUZ), Rio de Janeiro, RJ, Brazil
| | - Pedro Kurtz
- Postgraduate Program, D'Or Institute for Research and Education (IDOR), Rio de Janeiro, RJ, Brazil; Hospital Copa Star, Rio de Janeiro, RJ, Brazil
| | - Elizabeth Maccariello
- Postgraduate Program, D'Or Institute for Research and Education (IDOR), Rio de Janeiro, RJ, Brazil
| | - José Roberto Lapa E Silva
- Postgraduate Program of Internal Medicine, Federal University of Rio de Janeiro, (UFRJ), Rio de Janeiro, Brazil
| | - Jorge I F Salluh
- Postgraduate Program of Internal Medicine, Federal University of Rio de Janeiro, (UFRJ), Rio de Janeiro, Brazil; Postgraduate Program, D'Or Institute for Research and Education (IDOR), Rio de Janeiro, RJ, Brazil
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Kurtz P, van den Boogaard M, Girard TD, Hermann B. Acute encephalopathy in the ICU: a practical approach. Curr Opin Crit Care 2024; 30:106-120. [PMID: 38441156 DOI: 10.1097/mcc.0000000000001144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
PURPOSE OF REVIEW Acute encephalopathy (AE) - which frequently develops in critically ill patients with and without primary brain injury - is defined as an acute process that evolves rapidly and leads to changes in baseline cognitive status, ranging from delirium to coma. The diagnosis, monitoring, and management of AE is challenging. Here, we discuss advances in definitions, diagnostic approaches, therapeutic options, and implications to outcomes of the clinical spectrum of AE in ICU patients without primary brain injury. RECENT FINDINGS Understanding and definitions of delirium and coma have evolved. Delirium is a neurocognitive disorder involving impairment of attention and cognition, usually fluctuating, and developing over hours to days. Coma is a state of unresponsiveness, with absence of command following, intelligible speech, or visual pursuit, with no imaging or neurophysiological evidence of cognitive motor dissociation. The CAM-ICU(-7) and the ICDSC are validated, guideline-recommended tools for clinical delirium assessment, with identification of clinical subtypes and stratification of severity. In comatose patients, the roles of continuous EEG monitoring and neuroimaging have grown for the early detection of secondary brain injury and treatment of reversible causes. SUMMARY Evidence-based pharmacologic treatments for delirium are limited. Dexmedetomidine is effective for mechanically ventilated patients with delirium, while haloperidol has minimal effect of delirium but may have other benefits. Specific treatments for coma in nonprimary brain injury are still lacking.
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Affiliation(s)
- Pedro Kurtz
- D'Or Institute of Research and Education
- Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Mark van den Boogaard
- Radboud University Medical Center, Department of Intensive Care, Nijmegen, The Netherlands
| | - Timothy D Girard
- Center for Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) in the Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Bertrand Hermann
- Medical Intensive Care Unit, Hôpital Européen Georges Pompidou, Assistance Publique des Hôpitaux de Paris - Centre (APHP-Centre)
- INSERM UMR 1266, Institut de Psychiatrie et Neurosciences de Paris (IPNP), Université Paris Cité, Paris, France
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Rynkowski CB, Hegele V, Soares PHR, Tonello ML, Petterson L, Gomes FK, Rabinstein AA, Bastos LSL, Turon R, Gonçalves B, Righy C, Bozza FA, Kurtz P. Correction: Effects of Tranexamic Acid in Patients with Subarachnoid Hemorrhage in Brazil: A Prospective Observational Study with Propensity Score Analysis. Neurocrit Care 2023; 39:754. [PMID: 37821722 DOI: 10.1007/s12028-023-01866-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Affiliation(s)
- Carla B Rynkowski
- Intensive Care Unit, Cristo Redentor Hospital, Porto Alegre, Brazil
- Intensive Care Unit, Ernesto Dornelles Hospital, Porto Alegre, Brazil
| | - Vanessa Hegele
- Pharmacy Department, Cristo Redentor Hospital, Porto Alegre, Brazil
| | | | | | | | | | | | - Leonardo S L Bastos
- Department of Industrial Engineering (DEI), Pontifical Catholic University of Rio de Janeiro (PUC-Rio), Rio de Janeiro, RJ, Brazil
| | - Ricardo Turon
- Department of Neurointensive Care, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Bruno Gonçalves
- Department of Neurointensive Care, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Cassia Righy
- Department of Neurointensive Care, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
- National Institute of Infectious Diseases, Fundação Osvaldo Cruz, Rio de Janeiro, Brazil
| | - Fernando A Bozza
- National Institute of Infectious Diseases, Fundação Osvaldo Cruz, Rio de Janeiro, Brazil
- D ́Or Institute for Research and Education, Rua Diniz Cordeiro 30, Rio de Janeiro, RJ, 22281-100, Brazil
| | - Pedro Kurtz
- Department of Neurointensive Care, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil.
- D ́Or Institute for Research and Education, Rua Diniz Cordeiro 30, Rio de Janeiro, RJ, 22281-100, Brazil.
- Department of Neurointensive Care, Hospital Copa Star, Rio de Janeiro, Brazil.
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Gouvêa Bogossian E, Blandino Ortiz A, Esposito V, Caricato A, Righy Shinotsuka C, Monléon Lopez B, Giannì G, Macchini E, de Pablo Sanchez R, Pisapia L, Turon R, Gonçalves B, Badenes R, Kurtz P, Taccone FS. Neurological Pupil Index and Delayed Cerebral Ischemia after Subarachnoid Hemorrhage: A Retrospective Multicentric Study. Neurocrit Care 2023; 39:116-124. [PMID: 37225941 DOI: 10.1007/s12028-023-01744-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 04/24/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Delayed cerebral ischemia (DCI) occurs in around 30% of patients suffering from nontraumatic subarachnoid hemorrhage (SAH) and is associated with poor neurological outcome. Whether the Neurological Pupil index (NPi) derived from the automated pupillometry could help to diagnose the occurrence of DCI remains unknown. The aim of this study was to investigate the association of NPi with the occurrence of DCI in patients with SAH. METHODS This was a multicenter, retrospective cohort study of consecutive patients with SAH admitted to the intensive care units of five hospitals between January 2018 and December 2020 who underwent daily NPi recordings (every 8 h) during the first 10 days of admission. DCI was diagnosed according to standard definitions (in awake patients) or based on neuroimaging and neuromonitoring (in sedated or unconscious patients). An NPi < 3 was defined as abnormal. The primary outcome of the study was to assess the time course of daily NPi between patients with DCI and patients without DCI. Secondary outcome included the number of patients who had an NPi < 3 before DCI. RESULTS A total of 210 patients were eligible for the final analysis; DCI occurred in 85 (41%) patients. Patients who developed DCI had similar values of mean and worst daily NPi over time when compared with patients without DCI. Patients with DCI had a higher proportion of at least one NPi < 3 at any moment before DCI when compared with others (39/85, 46% vs. 35/125, 38%, p = 0.009). Similarly, the worst NPi before DCI diagnosis was lower in the DCI group when compared with others (3.1 [2.5-3.8] vs. 3.7 [2.7-4.1], p = 0.05). In the multivariable logistic regression analysis, the presence of NPi < 3 was not independently associated with the development of DCI (odds ratio 1.52 [95% confidence interval 0.80-2.88]). CONCLUSIONS In this study, NPi measured three times a day and derived from the automated pupillometry had a limited value for the diagnosis of DCI in patients with SAH.
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Affiliation(s)
- Elisa Gouvêa Bogossian
- Department of Intensive Care, Hopital Universitaire de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium.
| | - Aaron Blandino Ortiz
- Intensive Care Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Departament of Medicine and Medical Specialties, University of Alcalá, Madrid, Spain
| | - Valentina Esposito
- Department of Intensive Care, Hopital Universitaire de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Anselmo Caricato
- Department of Anesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Cassia Righy Shinotsuka
- Department of Neurointensive Care, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil
- Laboratório de Medicina Intensiva, Fundação Oswaldo Cruz, Instituto Nacional de Infectologia, Rio de Janeiro, Brazil
| | - Berta Monléon Lopez
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Giuseppina Giannì
- Department of Intensive Care, Hopital Universitaire de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Elisabetta Macchini
- Department of Intensive Care, Hopital Universitaire de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Raúl de Pablo Sanchez
- Intensive Care Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Departament of Medicine and Medical Specialties, University of Alcalá, Madrid, Spain
| | - Luca Pisapia
- Department of Anesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Ricardo Turon
- Department of Neurointensive Care, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil
| | - Bruno Gonçalves
- Department of Neurointensive Care, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil
| | - Rafael Badenes
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clínico Universitario de Valencia, Valencia, Spain
- Department of Surgery, University of Valencia, Valencia, Spain
- INCLIVA Health Research Institute, Valencia, Spain
| | - Pedro Kurtz
- Department of Neurointensive Care, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil
- D'Or Institute of Research and Education, Rio de Janeiro, Brazil
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hopital Universitaire de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
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Rynkowski CB, Hegele V, Soares PHR, Tonello ML, Petterson L, Gomes FK, Rabinstein AA, Bastos LSL, Turon R, Gonçalves B, Righy C, Bozza FA, Kurtz P. Effects of Tranexamic Acid in Patients with Subarachnoid Hemorrhage in Brazil: A Prospective Observational Study with Propensity Score Analysis. Neurocrit Care 2023; 39:191-197. [PMID: 37131089 DOI: 10.1007/s12028-023-01732-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 04/06/2023] [Indexed: 05/04/2023]
Abstract
BACKGROUND Rebleeding from a ruptured aneurysm increases the risk of unfavorable outcomes after subarachnoid hemorrhage (SAH) and is prevented by early aneurysm occlusion. The role of antifibrinolytics before aneurysm obliteration remains controversial. We investigated the effects of tranexamic acid on long-term functional outcomes of patients with aneurysmal SAH (aSAH). METHODS This was a single-center, prospective, observational study conducted in a high-volume tertiary hospital in a middle-income country from December 2016 to February 2020. We included all consecutive patients with aSAH who either received or did not receive tranexamic acid (TXA) treatment. Multivariate logistic regression analysis using propensity score was used to evaluate the association of TXA use with long-term functional outcomes, measured by the modified Rankin Scale (mRS) at 6 months. RESULTS A total of 230 patients with aSAH were analyzed. The median (interquartile range) age was 55 (46-63) years, 72% were women, 75% presented with good clinical grade (World Federation of Neurological Surgeons grade 1-3), and 83% had a Fisher scale of 3 or 4. Around 80% of patients were admitted up to 72 h from ictus. The aneurysm occlusion method was surgical clipping in 80% of the patients. A total of 129 patients (56%) received TXA. In multivariable logistic regression using inverse probability treatment weighting, the long-term rate of unfavorable outcomes (modified Rankin scale 4-6) was the same in the TXA and non-TXA groups (61 [48%] in TXA group vs. 33 [33%] in non-TXA group; odds ratio [OR] 1.39, 95% confidence interval [CI] 0.67-2.92; p = 0.377). The TXA group had higher in-hospital mortality (33 vs. 11% in non-TXA group; OR 4.13, 95% CI 1.55-12.53, p = 0.007). There were no differences between the groups concerning intensive care unit length of stay (16 ± 11.22 days in TXA group vs. 14 ± 9.24 days in non-TXA group; p = 0.2) or hospital (23 ± 13.35 days in TXA group vs. 22 ± 13.36 days in non-TXA group; p = 0.9). There was no difference in the rates of rebleeding (7.8% in TXA group vs. 8.9% in non-TXA group; p = 0.31) or delayed cerebral ischemia (27% in TXA group vs. 19% in non-TXA group; p = 0.14). For the propensity-matched analysis, 128 individuals were selected (64 in TXA group and 64 in non-TXA group), and the rates of unfavorable outcomes at 6 months were also similar between groups (45% in TXA group and 36% in non-TXA group; OR 1.22, 95% CI 0.51-2.89; p = 0.655). CONCLUSIONS Our findings in a cohort with delayed aneurysm treatment reinforce previous data that TXA use before aneurysm occlusion does not improve functional outcomes in aSAH.
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Affiliation(s)
- Carla B Rynkowski
- Intensive Care Unit, Cristo Redentor Hospital, Porto Alegre, Brazil
- Intensive Care Unit, Ernesto Dornelles Hospital, Porto Alegre, Brazil
| | - Vanessa Hegele
- Pharmacy Department, Cristo Redentor Hospital, Porto Alegre, Brazil
| | | | | | | | | | | | - Leonardo S L Bastos
- Department of Industrial Engineering (DEI), Pontifical Catholic University of Rio de Janeiro (PUC-Rio), Rio de Janeiro, RJ, Brazil
| | - Ricardo Turon
- Department of Neurointensive Care, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Bruno Gonçalves
- Department of Neurointensive Care, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Cassia Righy
- Department of Neurointensive Care, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
- National Institute of Infectious Diseases, Fundação Osvaldo Cruz, Rio de Janeiro, Brazil
| | - Fernando A Bozza
- National Institute of Infectious Diseases, Fundação Osvaldo Cruz, Rio de Janeiro, Brazil
- D ́Or Institute for Research and Education, Rua Diniz Cordeiro 30, Rio de Janeiro, RJ, 22281-100, Brazil
| | - Pedro Kurtz
- Department of Neurointensive Care, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil.
- D ́Or Institute for Research and Education, Rua Diniz Cordeiro 30, Rio de Janeiro, RJ, 22281-100, Brazil.
- Department of Neurointensive Care, Hospital Copa Star, Rio de Janeiro, Brazil.
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Kurtz P, Bastos LSL, Ranzani OT, Soares M, Zampieri F, Hamacher S, Salluh J, Bozza FA. Variants of concern and clinical outcomes in critically ill COVID-19 patients. Intensive Care Med 2023; 49:697-699. [PMID: 37067557 PMCID: PMC10108805 DOI: 10.1007/s00134-023-07039-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2023] [Indexed: 04/18/2023]
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Mendes-de-Almeida DP, Kehdy FSG, Martins-Gonçalves R, Bokel J, Grinsztejn E, Mouta Nunes de Oliveira P, Maia MDLDS, Hoagland B, Wagner Cardoso S, Grinsztejn B, Siqueira MM, Kurtz P, Bozza PT, Garcia CC. A case report of vaccine-induced immune thrombotic thrombocytopenia (VITT) with genetic analysis. Front Cardiovasc Med 2023; 10:1189320. [PMID: 37351283 PMCID: PMC10284151 DOI: 10.3389/fcvm.2023.1189320] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 04/24/2023] [Indexed: 06/24/2023] Open
Abstract
The emergence of the rare syndrome called vaccine-induced immune thrombocytopenia and thrombosis (VITT) after adenoviral vector vaccines, including ChAdOx1 nCov-19, raises concern about one's predisposing risk factors. Here we report the case of a 56-year-old white man who developed VITT leading to death within 9 days of symptom onset. He presented with superior sagittal sinus thrombosis, right frontal intraparenchymal hematoma, frontoparietal subarachnoid and massive ventricular hemorrhage, and right lower extremity arterial and venous thrombosis. His laboratory results showed elevated D-dimer, C-reactive protein, tissue factor, P-selectin (CD62p), and positive anti-platelet factor 4. The patient's plasma promoted higher CD62p expression in healthy donors' platelets than the controls. Genetic investigation on coagulation, thrombophilia, inflammation, and type I interferon-related genes was performed. From rare variants in European or African genomic databases, 68 single-nucleotide polymorphisms (SNPs) in one allele and 11 in two alleles from common SNPs were found in the patient genome. This report highlights the possible relationship between VITT and genetic variants. Additional investigations regarding the genetic predisposition of VITT are needed.
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Affiliation(s)
- Daniela P. Mendes-de-Almeida
- Department of Hematology, Evandro Chagas National Institute of Infectious Diseases, Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brazil
- Department of Medical Affairs, Clinical Studies, and Post-Registration Surveillance (DEAME), Institute of Technology in Immunobiologicals/Bio-Manguinhos, Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brazil
- Research Center, Instituto Nacional de Câncer (INCA), Rio de Janeiro, Brazil
| | - Fernanda S. G. Kehdy
- Laboratório de Hanseníase, Instituto Oswaldo Cruz, Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brazil
| | - Remy Martins-Gonçalves
- Laboratory of Immunopharmacology, Instituto Oswaldo Cruz, Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brazil
| | - Joanna Bokel
- Department of Hematology, Evandro Chagas National Institute of Infectious Diseases, Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brazil
- Onco-Hematology Unit, Clínica São Vicente, Rio de Janeiro, Brazil
| | - Eduarda Grinsztejn
- Department of Medicine, Hematology and Oncology Division, University Hospitals, Case Western University, Cleveland, OH, United States
| | - Patrícia Mouta Nunes de Oliveira
- Department of Medical Affairs, Clinical Studies, and Post-Registration Surveillance (DEAME), Institute of Technology in Immunobiologicals/Bio-Manguinhos, Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brazil
| | - Maria de Lourdes de Sousa Maia
- Department of Medical Affairs, Clinical Studies, and Post-Registration Surveillance (DEAME), Institute of Technology in Immunobiologicals/Bio-Manguinhos, Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brazil
| | - Brenda Hoagland
- Laboratory of Clinical Research on STD/AIDS, Evandro Chagas National Institute of Infectious Diseases Oswaldo Cruz Foundation (FIOCRUZ), Rio de Janeiro, Brazil
| | - Sandra Wagner Cardoso
- Laboratory of Clinical Research on STD/AIDS, Evandro Chagas National Institute of Infectious Diseases Oswaldo Cruz Foundation (FIOCRUZ), Rio de Janeiro, Brazil
| | - Beatriz Grinsztejn
- Laboratory of Clinical Research on STD/AIDS, Evandro Chagas National Institute of Infectious Diseases Oswaldo Cruz Foundation (FIOCRUZ), Rio de Janeiro, Brazil
| | - Marilda M. Siqueira
- Laboratório de Vírus Respiratórios, Exantemáticos, Enterovírus e Emergências Virais, Instituto Oswaldo Cruz, Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brazil
| | - Pedro Kurtz
- Intensive Care Department, Instituto D’Or de Pesquisa e Ensino, Rio de Janeiro, Brazil
| | - Patricia T. Bozza
- Laboratory of Immunopharmacology, Instituto Oswaldo Cruz, Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brazil
| | - Cristiana C. Garcia
- Laboratório de Vírus Respiratórios, Exantemáticos, Enterovírus e Emergências Virais, Instituto Oswaldo Cruz, Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brazil
- Grupo Integrado de Pesquisas em Biomarcadores, Instituto René Rachou, Fundação Oswaldo Cruz (FIOCRUZ-Minas), Belo Horizonte, Brazil
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Gonçalves B, Rynkowski C, Turon R, Charris N, Miranda F, de Caro V, Prazeres M, Santos T, Greer DM, Sharshar T, Guillaume T, Bozza FA, Righy C, Kurtz P. Clinical Characteristics and Outcomes of Patients with Aneurysmal Subarachnoid Hemorrhage: A Prospective Multicenter Study in a Middle-Income Country. Neurocrit Care 2023; 38:378-387. [PMID: 36324005 DOI: 10.1007/s12028-022-01629-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 10/03/2022] [Indexed: 04/13/2023]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (SAH) is associated with high mortality and long-term functional impairment. Data on clinical management and functional outcomes from developing countries are scarce. We aimed to define patient profiles and clinical practices and evaluate long-term outcomes after SAH in a middle-income country. METHODS This was a prospective study including consecutive adult patients admitted with SAH to two reference centers in Brazil from January 2016 to February 2020. The primary outcome was functional status at 6 months using the modified Rankin Scale. Mixed multivariable analysis was performed to determine the relationship between clinical variables and functional outcomes. RESULTS From 471patients analyzed, the median time from symptom onset to arrival at a study center was 4 days (interquartile range 0-9). Median age was 55 years (interquartile range 46-62) and 353 (75%) patients were women. A total of 426 patients (90%) were transferred from nonspecialized general hospitals, initial computed tomography revealed thick hemorrhage in 73% of patients (modified Fisher score of 3 or 4), and 136 (29%) had poor clinical grade (World Federation of Neurological Surgeons score of 4 or 5). A total of 312 (66%) patients underwent surgical clipping, and 119 (25%) underwent endovascular coiling. Only 34 patients (7%) underwent withdrawal or withholding of life-sustaining therapy during their hospital stay, and in-hospital mortality was 24%. A total of 187 (40%) patients had an unfavorable long-term functional outcome (modified Rankin Scale score of 4 to 6). Factors associated with unfavorable outcome were age (adjusted odds ratio [OR] 1.05, 95% confidence interval [CI] 1.03-1.08), hypertension (adjusted OR 1.81, 95% CI 1.04-3.16), poor clinical grade (adjusted OR 4.92, 95% CI 2.85-8.48), external ventricular drain (adjusted OR 3.8, 95% CI 2.31-6.24), postoperative deterioration (adjusted OR 2.33, 95% CI 1.32-4.13), cerebral infarction (adjusted OR 3.16, 95% CI 1.81-5.52), rebleeding (adjusted OR 2.95, 95% CI 1.13-7.69), and sepsis (adjusted OR 2.68, 95% CI 1.42-5.05). CONCLUSIONS Our study demonstrated that SAH management in a middle-income country diverges significantly from published cohorts and current guidelines, despite comparable clinical profiles on presentation and admission to high-volume referral centers. Earlier aneurysm occlusion and increased use of endovascular therapy could potentially reduce modifiable in-hospital complications and improve functional outcomes in Brazil.
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Affiliation(s)
- Bruno Gonçalves
- Department of Neurointensive Care, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil
| | - Carla Rynkowski
- Department of Intensive Care Medicine, Hospital Cristo Redentor, Porto Alegre, Brazil
| | - Ricardo Turon
- Department of Neurointensive Care, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil
| | - Nestor Charris
- Department of Neurointensive Care, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil
| | - Fabio Miranda
- Department of Neurointensive Care, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil
- Department of Neurointensive Care, Hospital Copa Star, Rio de Janeiro, Brazil
| | - Vanessa de Caro
- Department of Neurointensive Care, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil
| | - Marco Prazeres
- Department of Neurointensive Care, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil
| | - Thayana Santos
- Department of Neurointensive Care, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil
- Department of Neurointensive Care, Hospital Copa Star, Rio de Janeiro, Brazil
| | - David M Greer
- Department of Neurology, Boston University School of Medicine, Boston Medical Center, Boston, MA, USA
| | - Tarek Sharshar
- Department of Neuro-Intensive Care Medicine, Sainte-Anne Hospital, Paris-Descartes University, Paris, France
| | - Turc Guillaume
- GHU Paris Psychiatrie et Neurosciences, Paris, France
- Université Paris Cité, Paris, France
- INSERM, Paris, France
- FHU NeuroVasc, Paris, France
| | - Fernando A Bozza
- D'Or Institute for Research and Education, Rua Diniz Cordeiro, 30 - 3º andar, Rio de Janeiro, RJ, CEP 22281-100, Brazil
- National Institute of Infectious Diseases, Fundação Osvaldo Cruz, Rio de Janeiro, Brazil
| | - Cassia Righy
- Department of Neurointensive Care, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil
- Department of Neurointensive Care, Hospital Copa Star, Rio de Janeiro, Brazil
- National Institute of Infectious Diseases, Fundação Osvaldo Cruz, Rio de Janeiro, Brazil
| | - Pedro Kurtz
- Department of Neurointensive Care, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil.
- Department of Neurointensive Care, Hospital Copa Star, Rio de Janeiro, Brazil.
- D'Or Institute for Research and Education, Rua Diniz Cordeiro, 30 - 3º andar, Rio de Janeiro, RJ, CEP 22281-100, Brazil.
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10
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Antunes BBP, Silva AAB, Nunes PHC, Martin-Loeches I, Kurtz P, Hamacher S, Bozza FA. Antimicrobial consumption and drug utilization patterns among COVID-19 and non-COVID-19 patients. J Antimicrob Chemother 2023; 78:840-849. [PMID: 36740939 DOI: 10.1093/jac/dkad025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 01/04/2023] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES To understand differences in antimicrobial use between COVID-19 and non-COVID-19 patients. To compare two metrics commonly used for antimicrobial use: Defined Daily Dose (DDD) and Days of Therapy (DOT). To analyse the order in which antimicrobials were prescribed to COVID-19 patients using process mining techniques. METHODS We analysed data regarding all ICU admissions from 1 January 2018 to 14 September 2020, in 17 Brazilian hospitals. Our main outcome was the antimicrobial use estimated by the DDD and DOT (Days of Therapy). We compared clinical characteristics and antimicrobial consumption between COVID-19 and non-COVID-19 patients. We used process mining to evaluate the order in which the antimicrobial schemes were prescribed to each COVID-19 patient. RESULTS We analysed 68 405 patients admitted before the pandemic, 12 319 non-COVID-19 patients and 3240 COVID-19 patients. Comparing those admitted during the pandemic, the COVID-19 patients required advanced respiratory support more often (42% versus 12%). They also had longer ICU length of stay (6 versus 3 days), higher ICU mortality (18% versus 5.4%) and greater use of antimicrobials (70% versus 39%). Most of the COVID-19 treatments started with penicillins with ß-lactamase inhibitors (30%), third-generation cephalosporins (22%), or macrolides in combination with penicillins (19%). CONCLUSIONS Antimicrobial prescription increased in Brazilian ICUs during the COVID-19 pandemic, especially during the first months of the epidemic. We identified greater use of broad-spectrum antimicrobials by COVID-19 patients. Overall, the DDD metric overestimated antimicrobial use compared with the DOT metric.
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Affiliation(s)
- Bianca B P Antunes
- Department of Industrial Engineering, Pontifical Catholic University of Rio de Janeiro (PUC-Rio), Rio de Janeiro, RJ, Brazil
| | - Amanda A B Silva
- Department of Industrial Engineering, Pontifical Catholic University of Rio de Janeiro (PUC-Rio), Rio de Janeiro, RJ, Brazil
| | - Patricia H C Nunes
- Laboratory of Clinical Research in Intensive Care Medicine, National Institute of Infectious Disease Evandro Chagas (INI), Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil.,Intensive Care Department, D'Or Institute for Research and Education (IDOR), Rio de Janeiro, RJ, Brazil
| | - Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St James' Hospital, Dublin, Ireland.,Hospital Clinic, Universitat de Barcelona, IDIBAPS, CIBERES, Barcelona, Spain
| | - Pedro Kurtz
- Intensive Care Department, D'Or Institute for Research and Education (IDOR), Rio de Janeiro, RJ, Brazil.,Intensive Care Department, Copa Star Hospital, Rio de Janeiro, RJ, Brazil.,Intensive Care Department, Paulo Niemeyer State Brain Institute (IECPN), Rio de Janeiro, RJ, Brazil
| | - Silvio Hamacher
- Department of Industrial Engineering, Pontifical Catholic University of Rio de Janeiro (PUC-Rio), Rio de Janeiro, RJ, Brazil
| | - Fernando A Bozza
- Laboratory of Clinical Research in Intensive Care Medicine, National Institute of Infectious Disease Evandro Chagas (INI), Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil.,Intensive Care Department, D'Or Institute for Research and Education (IDOR), Rio de Janeiro, RJ, Brazil
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11
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Kurtz P, Bastos LSL, Zampieri FG, de Freitas GR, Bozza FA, Soares M, Salluh JIF. Trends in Intensive Care Admissions and Outcomes of Stroke Patients Over 10 Years in Brazil: Impact of the COVID-19 Pandemic. Chest 2023; 163:543-553. [PMID: 36347322 PMCID: PMC9636603 DOI: 10.1016/j.chest.2022.10.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 10/10/2022] [Accepted: 10/23/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The coronavirus 2019 (COVID-19) pandemic affected stroke care worldwide. Data from low- and middle-income countries are limited. RESEARCH QUESTION What was the impact of the pandemic in ICU admissions and outcomes of patients with stroke, in comparison with trends over the last 10 years? STUDY DESIGN AND METHODS Retrospective cohort study including prospectively collected data from 165 ICUs in Brazil between 2011 and 2020. We analyzed clinical characteristics and mortality over a period of 10 years and evaluated the impact of the pandemic on stroke outcomes, using the following approach: analyses of admissions for ischemic and hemorrhagic strokes and trends in in-hospital mortality over 10 years; analysis of variable life-adjusted display (VLAD) during 2020; and a mixed-effects multivariable logistic regression model. RESULTS A total of 17,115 stroke admissions were analyzed, from which 13,634 were ischemic and 3,481 were hemorrhagic. In-hospital mortality was lower after ischemic stroke as compared with hemorrhagic (9% vs 24%, respectively). Changes in VLAD across epidemiological weeks of 2020 showed that the rise in COVID-19 cases was accompanied by increased mortality, mainly after ischemic stroke. In logistic regression mixed models, mortality was higher in 2020 compared with 2019, 2018, and 2017 in patients with ischemic stroke, namely, in those without altered mental status. In hemorrhagic stroke, the increased mortality in 2020 was observed in patients 50 years of age or younger, as compared with 2019. INTERPRETATION Hospital outcomes of stroke admissions worsened during the COVID-19 pandemic, interrupting a trend of improvements in survival rates over 10 years. This effect was more pronounced during the surge of COVID-19 ICU admissions affecting predominantly patients with ischemic stroke without coma, and young patients with hemorrhagic stroke.
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Affiliation(s)
- Pedro Kurtz
- D'Or Institute for Research and Education (IDOR), Rio de Janeiro, RJ, Brazil; Hospital Copa Star, Rio de Janeiro, RJ, Brazil; Paulo Niemeyer State Brain Institute (IECPN), Rio de Janeiro, RJ, Brazil.
| | - Leonardo S L Bastos
- Department of Industrial Engineering (DEI), Pontifical Catholic University of Rio de Janeiro (PUC-Rio), Rio de Janeiro, RJ, Brazil
| | - Fernando G Zampieri
- Intensive Care Unit, Hospital Vila Nova Star, São Paulo, Brazil; Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Gabriel R de Freitas
- D'Or Institute for Research and Education (IDOR), Rio de Janeiro, RJ, Brazil; Department of Neurology, Universidade Federal Fluminense, Rio de Janeiro, Brazil
| | - Fernando A Bozza
- D'Or Institute for Research and Education (IDOR), Rio de Janeiro, RJ, Brazil; National Institute of Infectious Disease Evandro Chagas (INI), Oswaldo Cruz Foundation (FIOCRUZ), Rio de Janeiro, RJ, Brazil
| | - Marcio Soares
- D'Or Institute for Research and Education (IDOR), Rio de Janeiro, RJ, Brazil
| | - Jorge I F Salluh
- D'Or Institute for Research and Education (IDOR), Rio de Janeiro, RJ, Brazil; Postgraduate Program of Internal Medicine, Federal University of Rio de Janeiro, (UFRJ), Rio de Janeiro, Brazil
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12
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Taccone FS, Badenes R, Rynkowski CB, Bouzat P, Caricato A, Kurtz P, Moller K, Diaz MQ, Van Der Jagt M, Videtta W, Vincent JL. TRansfusion strategies in Acute brain INjured patients (TRAIN): a prospective multicenter randomized interventional trial protocol. Trials 2023; 24:20. [PMID: 36611210 PMCID: PMC9825124 DOI: 10.1186/s13063-022-07061-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 12/30/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Although blood transfusions can be lifesaving in severe hemorrhage, they can also have potential complications. As anemia has also been associated with poor outcomes in critically ill patients, determining an optimal transfusion trigger is a real challenge for clinicians. This is even more important in patients with acute brain injury who were not specifically evaluated in previous large randomized clinical trials. Neurological patients may be particularly sensitive to anemic brain hypoxia because of the exhausted cerebrovascular reserve, which adjusts cerebral blood flow to tissue oxygen demand. METHODS We described herein the methodology of a prospective, multicenter, randomized, pragmatic trial comparing two different strategies for red blood cell transfusion in patients with acute brain injury: a "liberal" strategy in which the aim is to maintain hemoglobin (Hb) concentrations greater than 9 g/dL and a "restrictive" approach in which the aim is to maintain Hb concentrations greater than 7 g/dL. The target population is patients suffering from traumatic brain injury (TBI), subarachnoid hemorrhage (SAH), or intracerebral hemorrhage (ICH). The primary outcome is the unfavorable neurological outcome, evaluated using the extended Glasgow Outcome Scale (eGOS) of 1-5 at 180 days after the initial injury. Secondary outcomes include, among others, 28-day survival, intensive care unit (ICU) and hospital lengths of stay, the occurrence of extra-cerebral organ dysfunction/failure, and the development of any infection or thromboembolic events. The estimated sample size is 794 patients to demonstrate a reduction in the primary outcome from 50 to 39% between groups (397 patients in each arm). The study was initiated in 2016 in several ICUs and will be completed in December 2022. DISCUSSION This trial will assess the impact of a liberal versus conservative strategy of blood transfusion in a large cohort of critically ill patients with a primary acute brain injury. The results of this trial will help to improve blood product and transfusion use in this specific patient population and will provide additional data in some subgroups of patients at high risk of brain ischemia, such as those with intracranial hypertension or cerebral vasospasm. TRIAL REGISTRATION ClinicalTrials.gov NCT02968654.
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Affiliation(s)
- Fabio Silvio Taccone
- grid.412157.40000 0000 8571 829XDepartment of Intensive Care, Route de Lennik, Erasme Hospital, Université Libre de Bruxelles, 808, 1070 Brussels, Belgium ,Hospital Nacional Professor Alejandro Posadas, Buenos Aires, Argentina
| | - Rafael Badenes
- grid.5338.d0000 0001 2173 938XDepartment of Anesthesiology and Surgical-Trauma ICU, Hospital Clínic Universitari de Valencia, University of Valencia, Valencia, Spain
| | - Carla Bittencourt Rynkowski
- Intensive Care Unit of Cristo Redentor Hospital, Porto Alegre, Brazil ,Intensive Care Unit, Hospital Ernesto Dornelles, Porto Alegre, Brazil
| | - Pierre Bouzat
- grid.462307.40000 0004 0429 3736Université Grenoble AlpesInserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences, Grenoble, France
| | - Anselmo Caricato
- grid.8142.f0000 0001 0941 3192Institute of Anesthesiology and Intensive Care, Catholic University School of Medicine, Rome, Italy
| | - Pedro Kurtz
- grid.472984.4Department of Intensive Care Medicine, DOr Institute of Research and Education, Rio de Janeiro, Brazil ,grid.511762.60000 0004 7693 2242Department of Neurointensive Care, Instituto Estadual Do Cerebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Kirsten Moller
- grid.475435.4Department of Neuroanaesthesiology, Neuroscience Centre, Copenhagen University, Hospital Rigshospitalet, Copenhagen, Denmark ,grid.5254.60000 0001 0674 042XDepartment of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Manuel Quintana Diaz
- grid.81821.320000 0000 8970 9163Department of Intensive Care Medicine, Hospital Universitario de La Paz, Madrid, Spain
| | - Mathieu Van Der Jagt
- grid.5645.2000000040459992XDepartment of Intensive Care Adults, Erasmus MC – University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Walter Videtta
- grid.5645.2000000040459992XDepartment of Intensive Care Adults, Erasmus MC – University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jean-Louis Vincent
- grid.412157.40000 0000 8571 829XDepartment of Intensive Care, Route de Lennik, Erasme Hospital, Université Libre de Bruxelles, 808, 1070 Brussels, Belgium
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13
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Santos DPDAD, Thirumala PD, Reddy G, Barros DFD, Faria VNR, Shandal V, Kurtz P. Risk of perioperative stroke and cerebral autoregulation monitoring: a systematic review. Arq Neuropsiquiatr 2022; 80:1196-1203. [PMID: 36580956 PMCID: PMC9800166 DOI: 10.1055/s-0042-1758648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Perioperative stroke, delirium, and cognitive impairment could be related to management and to variations in blood pressure control, cerebral hypoperfusion and raised blood volume. Cerebral autoregulation (CAR) is a mechanism to maintain cerebral perfusion through the control of the vascular tone and hemodynamic reactions in the circulation. OBJECTIVE The present systematic review addresses the relationship between impaired CAR and perioperative stroke by evaluating the rate of neurological complications after surgery in studies in which perioperative CAR was tested or monitored. METHODS We included randomized clinical trials and prospective observational studies. All studies had adjusted the relative risk, hazard ratio or 95% confidence interval (95%CI) values. These estimation effects were tested using random-effects models. Heterogeneity among the selected studies was assessed using the Higgins and Thompson I2 statistics. RESULTS The Web of Science, PubMed and EMBASE electronic databases were searched to retrieve articles. A total of 4,476 studies published between 1983 and 2019 were analyzed, but only 5 qualified for the data extraction and were included in the final analysis. The combined study cohort comprised 941 patients who underwent CAR monitoring during surgical procedures. All studies provided information about perioperative stroke, which equated to 16% (158 of 941) of the overall patient population. CONCLUSION The present meta-analysis showed evidence of the impact of CAR impairment in the risk of perioperative stroke. On the pooled analysis, blood fluctuations or other brain insults large enough to compromise CAR were associated with the outcome of stroke (odds ratio [OR]: 2.26; 95%CI: 1.54-2.98; p < 0.0001).
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Affiliation(s)
- Daniel Paes de Almeida dos Santos
- Hospital Copa Star, Centro de Terapia Intensiva, Rio de Janeiro RJ, Brazil.,Sinapse Clínica, Rio de Janeiro RJ, Brazil.,Address for correspondence Daniel P. A. Santos
| | | | - Gautama Reddy
- Sinapse Clínica, Rio de Janeiro RJ, Brazil.,Intraneuro, Rio de Janeiro RJ, Brazil.
| | | | - Vinicius Naves Rezende Faria
- Sinapse Clínica, Rio de Janeiro RJ, Brazil.,Universidade Federal de Uberlândia, Faculdade de Engenharia Elétrica, Uberlândia MG, Brazil.
| | - Varun Shandal
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States.
| | - Pedro Kurtz
- Instituto D'Or de Pesquisa e Ensino, Departamento de Cuidado Intensivo, São Paulo SP, Brazil.
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14
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Tomazini BM, Nassar AP, Lisboa TC, Azevedo LCPD, Veiga VC, Catarino DGM, Fogazzi DV, Arns B, Piastrelli FT, Dietrich C, Negrelli KL, Jesuíno IDA, Reis LFL, Mattos RRD, Pinheiro CCG, Luz MN, Spadoni CCDS, Moro EE, Bueno FR, Sampaio CSJC, Silva DP, Baldassare FP, Silva ACA, Veiga T, Barbante L, Lambauer M, Campos VB, Santos E, Santos RHN, Laranjeiras LN, Valeis N, Santucci E, Miranda TA, Patrocínio ACLD, Carvalho AD, Sousa EMCD, Sousa AHFD, Malheiro DT, Bezerra IL, Rodrigues MB, Malicia JC, Silva SSD, Gimenes BDP, Sesin GP, Zavascki AP, Sganzerla D, Medeiros GS, Santos RDRMD, Silva FKR, Cheno MY, Abrahão CF, Oliveira Junior HAD, Rocha LL, Nunes Neto PA, Pereira VC, Paciência LEM, Bueno ES, Caser EB, Ribeiro LZ, Fernandes CCF, Garcia JM, Silva VDFF, Santos AJD, Machado FR, Souza MAD, Ferronato BR, Urbano HCDA, Moreira DCA, Souza-Dantas VCD, Duarte DM, Coelho J, Figueiredo RC, Foreque F, Romano TG, Cubos D, Spirale VM, Nogueira RS, Maia IS, Zandonai CL, Lovato WJ, Cerantola RB, Toledo TGP, Tomba PO, Almeida JRD, Sanches LC, Pierini L, Cunha M, Sousa MT, Azevedo B, Dal-Pizzol F, Damasio DDC, Bainy MP, Beduhn DAV, Jatobá JDVN, Moura MTFD, Rego LRDM, Silva AVD, Oliveira LP, Sodré Filho ES, Santos SSD, Neves IDL, Leão VCDA, Paes JLL, Silva MCM, Oliveira CDD, Santiago RCB, Paranhos JLDR, Wiermann IGDS, Pedroso DFF, Sawada PY, Prestes RM, Nascimento GC, Grion CMC, Carrilho CMDDM, Dantas RLADM, Silva EP, Silva ACD, Oliveira SMBD, Golin NA, Tregnago R, Lima VP, Silva KGND, Boschi E, Buffon V, Machado AS, Capeletti L, Foernges RB, Carvalho ASD, Oliveira Junior LCD, Oliveira DCD, Silva EM, Ribeiro J, Pereira FC, Salgado FB, Deutschendorf C, Silva CFD, Gobatto ALN, Oliveira CBD, Dracoulakis MDA, Alvaia NOS, Souza RMD, Araújo LLCD, Melo RMVD, Passos LCS, Vidal CFDL, Rodrigues FLDA, Kurtz P, Shinotsuka CR, Tavares MB, Santana IDV, Gavinho LMDS, Nascimento AB, Pereira AJ, Cavalcanti AB. IMPACTO-MR: a Brazilian nationwide platform study to assess infections and multidrug resistance in intensive care units. Rev Bras Ter Intensiva 2022; 34:418-425. [PMID: 36888821 PMCID: PMC9987010 DOI: 10.5935/0103-507x.20220209-pt] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 10/19/2022] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE To describe the IMPACTO-MR, a Brazilian nationwide intensive care unit platform study focused on the impact of health care-associated infections due to multidrug-resistant bacteria. METHODS We described the IMPACTO-MR platform, its development, criteria for intensive care unit selection, characterization of core data collection, objectives, and future research projects to be held within the platform. RESULTS The core data were collected using the Epimed Monitor System® and consisted of demographic data, comorbidity data, functional status, clinical scores, admission diagnosis and secondary diagnoses, laboratory, clinical, and microbiological data, and organ support during intensive care unit stay, among others. From October 2019 to December 2020, 33,983 patients from 51 intensive care units were included in the core database. CONCLUSION The IMPACTO-MR platform is a nationwide Brazilian intensive care unit clinical database focused on researching the impact of health care-associated infections due to multidrug-resistant bacteria. This platform provides data for individual intensive care unit development and research and multicenter observational and prospective trials.
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Affiliation(s)
- Bruno M Tomazini
- Hospital Sírio-Libanês - São Paulo (SP), Brasil.,Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil
| | - Antonio Paulo Nassar
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil.,Hospital Israelita Albert Einstein - São Paulo (SP), Brasil.,Hospital A. C. Camargo Cancer Center - São Paulo (SP), Brasil
| | - Thiago Costa Lisboa
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil.,Instituto de Pesquisa, HCor-Hospital do Coração - São Paulo (SP), Brasil
| | - Luciano César Pontes de Azevedo
- Hospital Sírio-Libanês - São Paulo (SP), Brasil.,Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil
| | - Viviane Cordeiro Veiga
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil.,BP - A Beneficência Portuguesa de São Paulo - São Paulo (SP), Brasil
| | | | | | - Beatriz Arns
- Hospital Moinhos de Vento - Porto Alegre (RS), Brasil
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Thabata Veiga
- Instituto de Pesquisa, HCor-Hospital do Coração - São Paulo (SP), Brasil
| | - Leticia Barbante
- Instituto de Pesquisa, HCor-Hospital do Coração - São Paulo (SP), Brasil
| | - Marianne Lambauer
- Instituto de Pesquisa, HCor-Hospital do Coração - São Paulo (SP), Brasil
| | | | - Elton Santos
- Instituto de Pesquisa, HCor-Hospital do Coração - São Paulo (SP), Brasil
| | | | | | - Nanci Valeis
- Instituto de Pesquisa, HCor-Hospital do Coração - São Paulo (SP), Brasil
| | - Eliana Santucci
- Instituto de Pesquisa, HCor-Hospital do Coração - São Paulo (SP), Brasil
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Flávia Ribeiro Machado
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil.,Hospital São Paulo, Escola Paulista de Medicina, Universidade Federal de São Paulo - São Paulo (SP), Brasil
| | - Maria Aparecida de Souza
- Hospital São Paulo, Escola Paulista de Medicina, Universidade Federal de São Paulo - São Paulo (SP), Brasil
| | | | | | | | - Vicente Cés de Souza-Dantas
- Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro - Rio de Janeiro (RJ), Brasil
| | - Diego Meireles Duarte
- Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro - Rio de Janeiro (RJ), Brasil
| | - Juliana Coelho
- BP - A Beneficência Portuguesa de São Paulo - São Paulo (SP), Brasil
| | | | | | | | - Daniel Cubos
- Hospital e Maternidade São Luiz Itaim - São Paulo (SP), Brasil
| | | | | | - Israel Silva Maia
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil.,Hospital Nereu Ramos - Florianópolis (SC), Brasil
| | | | - Wilson José Lovato
- Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo - Ribeirão Preto (SP), Brasil
| | - Rodrigo Barbosa Cerantola
- Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo - Ribeirão Preto (SP), Brasil
| | | | | | | | | | | | | | | | - Bruna Azevedo
- Fundação Hospitalar São Francisco de Assis - Belo Horizonte (MG), Brasil
| | - Felipe Dal-Pizzol
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil.,Hospital São José - Criciúma (SC), Brasil
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Cintia Magalhães Carvalho Grion
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil.,Hospital Universitário, Universidade Estadual de Londrina - Londrina (PR), Brasil
| | | | | | - Eliane Pereira Silva
- Hospital Universitário Onofre Lopes, Universidade Federal do Rio Grande do Norte - Natal (RN), Brasil
| | | | | | | | | | - Valéria Paes Lima
- Hospital Universitário de Brasília, Universidade de Brasília - Brasília (DF), Brasil
| | | | - Emerson Boschi
- Hospital Geral de Caxias do Sul - Caxias do Sul (RS), Brasil
| | - Viviane Buffon
- Hospital Geral de Caxias do Sul - Caxias do Sul (RS), Brasil
| | | | | | | | | | | | | | | | | | | | | | - Caroline Deutschendorf
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Cristofer Farias da Silva
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | | | | | | | | | | | | | | | | | | | | | - Pedro Kurtz
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil.,Instituto Estadual do Cérebro Paulo Niemeyer - Rio de Janeiro (RJ), Brasil
| | - Cássia Righy Shinotsuka
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil.,Instituto Estadual do Cérebro Paulo Niemeyer - Rio de Janeiro (RJ), Brasil
| | | | | | | | | | - Adriano J Pereira
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil.,Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
| | - Alexandre Biasi Cavalcanti
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brasil.,Instituto de Pesquisa, HCor-Hospital do Coração - São Paulo (SP), Brasil
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15
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Tomazini BM, Nassar Jr AP, Lisboa TC, de Azevedo LCP, Veiga VC, Catarino DGM, Fogazzi DV, Arns B, Piastrelli FT, Dietrich C, Negrelli KL, Jesuíno IDA, Reis LFL, de Mattos RR, Pinheiro CCG, Luz MN, Spadoni CCDS, Moro EE, Bueno FR, Sampaio CSJC, Silva DP, Baldassare FP, Silva ACA, Veiga T, Barbante L, Lambauer M, Campos VB, Santos E, Santos RHN, Laranjeiras LN, Valeis N, Santucci E, Miranda TA, do Patrocínio ACL, de Carvalho A, de Sousa EMC, de Sousa AHF, Malheiro DT, Bezerra IL, Rodrigues MB, Malicia JC, da Silva SS, Gimenes BDP, Sesin GP, Zavascki AP, Sganzerla D, Medeiros GS, dos Santos RDRM, Silva FKR, Cheno MY, Abrahão CF, de Oliveira Junior HA, Rocha LL, Nunes Neto PA, Pereira VC, Paciência LEM, Bueno ES, Caser EB, Ribeiro LZ, Fernandes CCF, Garcia JM, Silva VDFF, dos Santos AJ, Machado FR, de Souza MA, Ferronato BR, Urbano HCDA, Moreira DCA, de Souza-Dantas VC, Duarte DM, Coelho J, Figueiredo RC, Foreque F, Romano TG, Cubos D, Spirale VM, Nogueira RS, Maia IS, Zandonai CL, Lovato WJ, Cerantola RB, Toledo TGP, Tomba PO, de Almeida JR, Sanches LC, Pierini L, Cunha M, Sousa MT, Azevedo B, Dal-Pizzol F, Damasio DDC, Bainy MP, Beduhn DAV, Jatobá JDVN, de Moura MTF, Rego LRDM, da Silva AV, Oliveira LP, Sodré Filho ES, dos Santos SS, Neves IDL, Leão VCDA, Paes JLL, Silva MCM, de Oliveira CD, Santiago RCB, Paranhos JLDR, Wiermann IGDS, Pedroso DFF, Sawada PY, Prestes RM, Nascimento GC, Grion CMC, Carrilho CMDDM, Dantas RLADM, Silva EP, da Silva AC, de Oliveira SMB, Golin NA, Tregnago R, Lima VP, da Silva KGN, Boschi E, Buffon V, Machado AS, Capeletti L, Foernges RB, de Carvalho AS, de Oliveira Junior LC, de Oliveira DC, Silva EM, Ribeiro J, Pereira FC, Salgado FB, Deutschendorf C, da Silva CF, Gobatto ALN, de Oliveira CB, Dracoulakis MDA, Alvaia NOS, de Souza RM, de Araújo LLC, de Melo RMV, Passos LCS, Vidal CFDL, Rodrigues FLDA, Kurtz P, Shinotsuka CR, Tavares MB, Santana IDV, Gavinho LMDS, Nascimento AB, Pereira AJ, Cavalcanti AB. IMPACTO-MR: a Brazilian nationwide platform study to assess infections and multidrug resistance in intensive care units. Rev Bras Ter Intensiva 2022; 34:418-425. [PMID: 36888821 PMCID: PMC9987010 DOI: 10.5935/0103-507x.20220209-en] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 10/19/2022] [Indexed: 12/20/2023] Open
Abstract
OBJECTIVE To describe the IMPACTO-MR, a Brazilian nationwide intensive care unit platform study focused on the impact of health care-associated infections due to multidrug-resistant bacteria. METHODS We described the IMPACTO-MR platform, its development, criteria for intensive care unit selection, characterization of core data collection, objectives, and future research projects to be held within the platform. RESULTS The core data were collected using the Epimed Monitor System® and consisted of demographic data, comorbidity data, functional status, clinical scores, admission diagnosis and secondary diagnoses, laboratory, clinical, and microbiological data, and organ support during intensive care unit stay, among others. From October 2019 to December 2020, 33,983 patients from 51 intensive care units were included in the core database. CONCLUSION The IMPACTO-MR platform is a nationwide Brazilian intensive care unit clinical database focused on researching the impact of health care-associated infections due to multidrug-resistant bacteria. This platform provides data for individual intensive care unit development and research and multicenter observational and prospective trials.
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Affiliation(s)
- Bruno M Tomazini
- Hospital Sírio-Libanês - São Paulo (SP),
Brazil
- Brazilian Research in Intensive Care Network (BRICNet) - São
Paulo (SP), Brazil
| | - Antonio Paulo Nassar Jr
- Brazilian Research in Intensive Care Network (BRICNet) - São
Paulo (SP), Brazil
- Hospital Israelita Albert Einstein - São Paulo (SP),
Brazil
- Hospital A. C. Camargo Cancer Center - São Paulo (SP),
Brazil
| | - Thiago Costa Lisboa
- Brazilian Research in Intensive Care Network (BRICNet) - São
Paulo (SP), Brazil
- Research Institute, HCor-Hospital do Coração - São Paulo (SP),
Brazil
| | - Luciano César Pontes de Azevedo
- Hospital Sírio-Libanês - São Paulo (SP),
Brazil
- Brazilian Research in Intensive Care Network (BRICNet) - São
Paulo (SP), Brazil
| | - Viviane Cordeiro Veiga
- Brazilian Research in Intensive Care Network (BRICNet) - São
Paulo (SP), Brazil
- BP - A Beneficência Portuguesa de São Paulo -
São Paulo (SP), Brazil
| | | | | | - Beatriz Arns
- Hospital Moinhos de Vento - Porto Alegre (RS), Brazil
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Thabata Veiga
- Research Institute, HCor-Hospital do Coração - São Paulo (SP),
Brazil
| | - Leticia Barbante
- Research Institute, HCor-Hospital do Coração - São Paulo (SP),
Brazil
| | - Marianne Lambauer
- Research Institute, HCor-Hospital do Coração - São Paulo (SP),
Brazil
| | | | - Elton Santos
- Research Institute, HCor-Hospital do Coração - São Paulo (SP),
Brazil
| | | | | | - Nanci Valeis
- Research Institute, HCor-Hospital do Coração - São Paulo (SP),
Brazil
| | - Eliana Santucci
- Research Institute, HCor-Hospital do Coração - São Paulo (SP),
Brazil
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Flávia Ribeiro Machado
- Brazilian Research in Intensive Care Network (BRICNet) - São
Paulo (SP), Brazil
- Hospital São Paulo, Escola Paulista de Medicina,
Universidade Federal de São Paulo - São Paulo (SP), Brazil
| | - Maria Aparecida de Souza
- Hospital São Paulo, Escola Paulista de Medicina,
Universidade Federal de São Paulo - São Paulo (SP), Brazil
| | | | | | | | - Vicente Cés de Souza-Dantas
- Hospital Universitário Clementino Fraga Filho, Universidade
Federal do Rio de Janeiro - Rio de Janeiro (RJ), Brazil
| | - Diego Meireles Duarte
- Hospital Universitário Clementino Fraga Filho, Universidade
Federal do Rio de Janeiro - Rio de Janeiro (RJ), Brazil
| | - Juliana Coelho
- BP - A Beneficência Portuguesa de São Paulo -
São Paulo (SP), Brazil
| | | | | | | | - Daniel Cubos
- Hospital e Maternidade São Luiz Itaim - São Paulo
(SP), Brazil
| | | | | | - Israel Silva Maia
- Brazilian Research in Intensive Care Network (BRICNet) - São
Paulo (SP), Brazil
- Hospital Nereu Ramos - Florianópolis (SC), Brazil
| | | | - Wilson José Lovato
- Hospital das Clínicas, Faculdade de Medicina de
Ribeirão Preto, Universidade de São Paulo - Ribeirão Preto
(SP), Brazil
| | - Rodrigo Barbosa Cerantola
- Hospital das Clínicas, Faculdade de Medicina de
Ribeirão Preto, Universidade de São Paulo - Ribeirão Preto
(SP), Brazil
| | | | | | | | | | | | | | | | - Bruna Azevedo
- Fundação Hospitalar São Francisco de Assis -
Belo Horizonte (MG), Brazil
| | - Felipe Dal-Pizzol
- Brazilian Research in Intensive Care Network (BRICNet) - São
Paulo (SP), Brazil
- Hospital São José - Criciúma (SC),
Brazil
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Cintia Magalhães Carvalho Grion
- Brazilian Research in Intensive Care Network (BRICNet) - São
Paulo (SP), Brazil
- Hospital Universitário, Universidade Estadual de Londrina -
Londrina (PR), Brazil
| | | | | | - Eliane Pereira Silva
- Hospital Universitário Onofre Lopes, Universidade Federal
do Rio Grande do Norte - Natal (RN), Brazil
| | | | | | | | | | - Valéria Paes Lima
- Hospital Universitário de Brasília, Universidade de
Brasília - Brasília (DF), Brazil
| | | | - Emerson Boschi
- Hospital Geral de Caxias do Sul - Caxias do Sul (RS),
Brazil
| | - Viviane Buffon
- Hospital Geral de Caxias do Sul - Caxias do Sul (RS),
Brazil
| | | | | | | | | | | | | | | | | | | | | | - Caroline Deutschendorf
- Hospital de Clínicas de Porto Alegre, Universidade Federal
do Rio Grande do Sul - Porto Alegre (RS), Brazil
| | - Cristofer Farias da Silva
- Hospital de Clínicas de Porto Alegre, Universidade Federal
do Rio Grande do Sul - Porto Alegre (RS), Brazil
| | | | | | | | | | | | | | | | | | | | | | - Pedro Kurtz
- Brazilian Research in Intensive Care Network (BRICNet) - São
Paulo (SP), Brazil
- Instituto Estadual do Cérebro Paulo Niemeyer - Rio de
Janeiro (RJ), Brazil
| | - Cássia Righy Shinotsuka
- Brazilian Research in Intensive Care Network (BRICNet) - São
Paulo (SP), Brazil
- Instituto Estadual do Cérebro Paulo Niemeyer - Rio de
Janeiro (RJ), Brazil
| | | | | | | | | | - Adriano J Pereira
- Brazilian Research in Intensive Care Network (BRICNet) - São
Paulo (SP), Brazil
- Hospital Israelita Albert Einstein - São Paulo (SP),
Brazil
| | - Alexandre Biasi Cavalcanti
- Brazilian Research in Intensive Care Network (BRICNet) - São
Paulo (SP), Brazil
- Research Institute, HCor-Hospital do Coração - São Paulo (SP),
Brazil
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16
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Alkhachroum A, Appavu B, Egawa S, Foreman B, Gaspard N, Gilmore EJ, Hirsch LJ, Kurtz P, Lambrecq V, Kromm J, Vespa P, Zafar SF, Rohaut B, Claassen J. Electroencephalogram in the intensive care unit: a focused look at acute brain injury. Intensive Care Med 2022; 48:1443-1462. [PMID: 35997792 PMCID: PMC10008537 DOI: 10.1007/s00134-022-06854-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 07/31/2022] [Indexed: 02/04/2023]
Abstract
Over the past decades, electroencephalography (EEG) has become a widely applied and highly sophisticated brain monitoring tool in a variety of intensive care unit (ICU) settings. The most common indication for EEG monitoring currently is the management of refractory status epilepticus. In addition, a number of studies have associated frequent seizures, including nonconvulsive status epilepticus (NCSE), with worsening secondary brain injury and with worse outcomes. With the widespread utilization of EEG (spot and continuous EEG), rhythmic and periodic patterns that do not fulfill strict seizure criteria have been identified, epidemiologically quantified, and linked to pathophysiological events across a wide spectrum of critical and acute illnesses, including acute brain injury. Increasingly, EEG is not just qualitatively described, but also quantitatively analyzed together with other modalities to generate innovative measurements with possible clinical relevance. In this review, we discuss the current knowledge and emerging applications of EEG in the ICU, including seizure detection, ischemia monitoring, detection of cortical spreading depolarizations, assessment of consciousness and prognostication. We also review some technical aspects and challenges of using EEG in the ICU including the logistics of setting up ICU EEG monitoring in resource-limited settings.
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Affiliation(s)
- Ayham Alkhachroum
- Department of Neurology, University of Miami, Miami, FL, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, FL, USA
| | - Brian Appavu
- Department of Child Health and Neurology, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
- Department of Neurosciences, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Satoshi Egawa
- Neurointensive Care Unit, Department of Neurosurgery, and Stroke and Epilepsy Center, TMG Asaka Medical Center, Saitama, Japan
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH, USA
| | - Nicolas Gaspard
- Department of Neurology, Erasme Hospital, Free University of Brussels, Brussels, Belgium
| | - Emily J Gilmore
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
- Neurocritical Care and Emergency Neurology, Department of Neurology, Ale University School of Medicine, New Haven, CT, USA
| | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Pedro Kurtz
- Department of Intensive Care Medicine, D'or Institute for Research and Education, Rio de Janeiro, Brazil
- Neurointensive Care, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil
| | - Virginie Lambrecq
- Department of Clinical Neurophysiology and Epilepsy Unit, AP-HP, Pitié Salpêtrière Hospital, Reference Center for Rare Epilepsies, 75013, Paris, France
| | - Julie Kromm
- Departments of Critical Care Medicine and Clinical Neurosciences, Cumming School of Medicine, Calgary, AB, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, Calgary, AB, Canada
| | - Paul Vespa
- Brain Injury Research Center, Department of Neurosurgery, University of California, Los Angeles, USA
| | - Sahar F Zafar
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Benjamin Rohaut
- Department of Neurology, Sorbonne Université, Pitié-Salpêtrière-AP-HP and Paris Brain Institute, ICM, Inserm, CNRS, Paris, France
| | - Jan Claassen
- Department of Neurology, Neurological Institute, Columbia University, New York Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA.
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17
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Chiu WT, Campozano V, Schiefecker A, Rodriguez DR, Ferreira D, Headlee A, Zeidan S, Grinea A, Huang YH, Doyle K, Shen Q, Gómez D, Hocker SE, Rohaut B, Sonneville R, Hong CT, Demeret S, Kurtz P, Maldonado N, Helbok R, Fernandez T, Claassen J. Management of Refractory Status Epilepticus: An International Cohort Study (MORSE CODe) Analysis of Patients Managed in the ICU. Neurology 2022; 99:e1191-e1201. [PMID: 35918156 PMCID: PMC9536742 DOI: 10.1212/wnl.0000000000200818] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 04/19/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Status epilepticus that continues after the initial benzodiazepine and a second anticonvulsant medication is known as refractory status epilepticus (RSE). Management is highly variable because adequately powered clinical trials are missing. We aimed to determine whether propofol and midazolam were equally effective in controlling RSE in the intensive care unit, focusing on management in resource-limited settings. METHODS Patients with RSE treated with midazolam or propofol between January 2015 and December 2018 were retrospectively identified among 9 centers across 4 continents from upper-middle-income economies in Latin America and high-income economies in North America, Europe, and Asia. Demographics, Status Epilepticus Severity Score, etiology, treatment details, and discharge modified Rankin Scale (mRS) were collected. The primary outcome measure was good functional outcome defined as a mRS score of 0-2 at hospital discharge. RESULTS Three hundred eighty-seven episodes of RSE (386 patients) were included, with 162 (42%) from upper-middle-income and 225 (58%) from high-income economies. Three hundred six (79%) had acute and 79 (21%) remote etiologies. Initial RSE management included midazolam in 266 (69%) and propofol in 121 episodes (31%). Seventy episodes (26%) that were initially treated with midazolam and 42 (35%) with propofol required the addition of a second anesthetic to treat RSE. Baseline characteristics and outcomes of patients treated with midazolam or propofol were similar. Breakthrough (odds ratio [OR] 1.6, 95% CI 1.3-2.0) and withdrawal seizures (OR 2.0, 95% CI 1.7-2.5) were associated with an increased number of days requiring continuous intravenous anticonvulsant medications (cIV-ACMs). Prolonged EEG monitoring was associated with fewer days of cIV-ACMs (1-24 hours OR 0.5, 95% CI 0.2-0.9, and >24 hours OR 0.7, 95% CI 0.5-1.0; reference EEG <1 hour). This association was seen in both, high-income and upper-middle-income economies, but was particularly prominent in high-income countries. One hundred ten patients (28%) were dead, and 80 (21%) had good functional outcomes at hospital discharge. DISCUSSION Outcomes of patients with RSE managed in the intensive care unit with propofol or midazolam infusions are comparable. Prolonged EEG monitoring may allow physicians to decrease the duration of anesthetic infusions safely, but this will depend on the implementation of RSE management protocols. Goal-directed management approaches including EEG targets may hold promise for patients with RSE. CLASSIFICATION OF EVIDENCE This study provides Class III data that propofol and midazolam are equivalently efficacious for RSE.
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Affiliation(s)
- Wei-Ting Chiu
- From the Neurological Institute (W.-T.C., K.D., Q.S., J.C.), Columbia University, NY Presbyterian Hospital; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), Taipei Medical University; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), School of Medicine, College of Medicine, Taipei Medical University; Taiwan; Universidad de Especialidades Espíritu Santo/Hospital Luis Vernaza (V.C., D.G., T.F.), Guayaquil, Ecuador; Department of Neurology (A.S., R.H.), Neurocritical Care, Medical University of Innsbruck, Austria; Department of Neurology (D.R.R., N.M.), Universidad San Francisco de Quito USFQ, Hospital Eugenio Espejo, Ecuador; Instituto Estadual do Cérebro Paulo Niemeyer (D.F., P.K.), Rio de Jairo; Hospital Copa Star (D.F., P.K.), Rio de Janeiro, Brazil; Division of Critical Care Neurology (A.H., S.E.H.), Department of Neurology, Mayo Clinic, Rochester, MN; Neurointensive Care Unit (S.Z., B.R., S.D.), DMU Neurosciences, AP-HP Hôpital de La Pitié Salpêtrière, Paris; Université de Paris (A.G., R.S.), INSERM UMR1148 and Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital; and Sorbonne Université (B.R.), Institut du Cerveau (ICM)-Paris Brain Institute, Inserm, CNRS, France
| | - Vanessa Campozano
- From the Neurological Institute (W.-T.C., K.D., Q.S., J.C.), Columbia University, NY Presbyterian Hospital; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), Taipei Medical University; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), School of Medicine, College of Medicine, Taipei Medical University; Taiwan; Universidad de Especialidades Espíritu Santo/Hospital Luis Vernaza (V.C., D.G., T.F.), Guayaquil, Ecuador; Department of Neurology (A.S., R.H.), Neurocritical Care, Medical University of Innsbruck, Austria; Department of Neurology (D.R.R., N.M.), Universidad San Francisco de Quito USFQ, Hospital Eugenio Espejo, Ecuador; Instituto Estadual do Cérebro Paulo Niemeyer (D.F., P.K.), Rio de Jairo; Hospital Copa Star (D.F., P.K.), Rio de Janeiro, Brazil; Division of Critical Care Neurology (A.H., S.E.H.), Department of Neurology, Mayo Clinic, Rochester, MN; Neurointensive Care Unit (S.Z., B.R., S.D.), DMU Neurosciences, AP-HP Hôpital de La Pitié Salpêtrière, Paris; Université de Paris (A.G., R.S.), INSERM UMR1148 and Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital; and Sorbonne Université (B.R.), Institut du Cerveau (ICM)-Paris Brain Institute, Inserm, CNRS, France
| | - Alois Schiefecker
- From the Neurological Institute (W.-T.C., K.D., Q.S., J.C.), Columbia University, NY Presbyterian Hospital; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), Taipei Medical University; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), School of Medicine, College of Medicine, Taipei Medical University; Taiwan; Universidad de Especialidades Espíritu Santo/Hospital Luis Vernaza (V.C., D.G., T.F.), Guayaquil, Ecuador; Department of Neurology (A.S., R.H.), Neurocritical Care, Medical University of Innsbruck, Austria; Department of Neurology (D.R.R., N.M.), Universidad San Francisco de Quito USFQ, Hospital Eugenio Espejo, Ecuador; Instituto Estadual do Cérebro Paulo Niemeyer (D.F., P.K.), Rio de Jairo; Hospital Copa Star (D.F., P.K.), Rio de Janeiro, Brazil; Division of Critical Care Neurology (A.H., S.E.H.), Department of Neurology, Mayo Clinic, Rochester, MN; Neurointensive Care Unit (S.Z., B.R., S.D.), DMU Neurosciences, AP-HP Hôpital de La Pitié Salpêtrière, Paris; Université de Paris (A.G., R.S.), INSERM UMR1148 and Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital; and Sorbonne Université (B.R.), Institut du Cerveau (ICM)-Paris Brain Institute, Inserm, CNRS, France
| | - Dannys Rivero Rodriguez
- From the Neurological Institute (W.-T.C., K.D., Q.S., J.C.), Columbia University, NY Presbyterian Hospital; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), Taipei Medical University; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), School of Medicine, College of Medicine, Taipei Medical University; Taiwan; Universidad de Especialidades Espíritu Santo/Hospital Luis Vernaza (V.C., D.G., T.F.), Guayaquil, Ecuador; Department of Neurology (A.S., R.H.), Neurocritical Care, Medical University of Innsbruck, Austria; Department of Neurology (D.R.R., N.M.), Universidad San Francisco de Quito USFQ, Hospital Eugenio Espejo, Ecuador; Instituto Estadual do Cérebro Paulo Niemeyer (D.F., P.K.), Rio de Jairo; Hospital Copa Star (D.F., P.K.), Rio de Janeiro, Brazil; Division of Critical Care Neurology (A.H., S.E.H.), Department of Neurology, Mayo Clinic, Rochester, MN; Neurointensive Care Unit (S.Z., B.R., S.D.), DMU Neurosciences, AP-HP Hôpital de La Pitié Salpêtrière, Paris; Université de Paris (A.G., R.S.), INSERM UMR1148 and Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital; and Sorbonne Université (B.R.), Institut du Cerveau (ICM)-Paris Brain Institute, Inserm, CNRS, France
| | - Daniel Ferreira
- From the Neurological Institute (W.-T.C., K.D., Q.S., J.C.), Columbia University, NY Presbyterian Hospital; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), Taipei Medical University; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), School of Medicine, College of Medicine, Taipei Medical University; Taiwan; Universidad de Especialidades Espíritu Santo/Hospital Luis Vernaza (V.C., D.G., T.F.), Guayaquil, Ecuador; Department of Neurology (A.S., R.H.), Neurocritical Care, Medical University of Innsbruck, Austria; Department of Neurology (D.R.R., N.M.), Universidad San Francisco de Quito USFQ, Hospital Eugenio Espejo, Ecuador; Instituto Estadual do Cérebro Paulo Niemeyer (D.F., P.K.), Rio de Jairo; Hospital Copa Star (D.F., P.K.), Rio de Janeiro, Brazil; Division of Critical Care Neurology (A.H., S.E.H.), Department of Neurology, Mayo Clinic, Rochester, MN; Neurointensive Care Unit (S.Z., B.R., S.D.), DMU Neurosciences, AP-HP Hôpital de La Pitié Salpêtrière, Paris; Université de Paris (A.G., R.S.), INSERM UMR1148 and Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital; and Sorbonne Université (B.R.), Institut du Cerveau (ICM)-Paris Brain Institute, Inserm, CNRS, France
| | - Amy Headlee
- From the Neurological Institute (W.-T.C., K.D., Q.S., J.C.), Columbia University, NY Presbyterian Hospital; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), Taipei Medical University; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), School of Medicine, College of Medicine, Taipei Medical University; Taiwan; Universidad de Especialidades Espíritu Santo/Hospital Luis Vernaza (V.C., D.G., T.F.), Guayaquil, Ecuador; Department of Neurology (A.S., R.H.), Neurocritical Care, Medical University of Innsbruck, Austria; Department of Neurology (D.R.R., N.M.), Universidad San Francisco de Quito USFQ, Hospital Eugenio Espejo, Ecuador; Instituto Estadual do Cérebro Paulo Niemeyer (D.F., P.K.), Rio de Jairo; Hospital Copa Star (D.F., P.K.), Rio de Janeiro, Brazil; Division of Critical Care Neurology (A.H., S.E.H.), Department of Neurology, Mayo Clinic, Rochester, MN; Neurointensive Care Unit (S.Z., B.R., S.D.), DMU Neurosciences, AP-HP Hôpital de La Pitié Salpêtrière, Paris; Université de Paris (A.G., R.S.), INSERM UMR1148 and Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital; and Sorbonne Université (B.R.), Institut du Cerveau (ICM)-Paris Brain Institute, Inserm, CNRS, France
| | - Sinead Zeidan
- From the Neurological Institute (W.-T.C., K.D., Q.S., J.C.), Columbia University, NY Presbyterian Hospital; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), Taipei Medical University; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), School of Medicine, College of Medicine, Taipei Medical University; Taiwan; Universidad de Especialidades Espíritu Santo/Hospital Luis Vernaza (V.C., D.G., T.F.), Guayaquil, Ecuador; Department of Neurology (A.S., R.H.), Neurocritical Care, Medical University of Innsbruck, Austria; Department of Neurology (D.R.R., N.M.), Universidad San Francisco de Quito USFQ, Hospital Eugenio Espejo, Ecuador; Instituto Estadual do Cérebro Paulo Niemeyer (D.F., P.K.), Rio de Jairo; Hospital Copa Star (D.F., P.K.), Rio de Janeiro, Brazil; Division of Critical Care Neurology (A.H., S.E.H.), Department of Neurology, Mayo Clinic, Rochester, MN; Neurointensive Care Unit (S.Z., B.R., S.D.), DMU Neurosciences, AP-HP Hôpital de La Pitié Salpêtrière, Paris; Université de Paris (A.G., R.S.), INSERM UMR1148 and Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital; and Sorbonne Université (B.R.), Institut du Cerveau (ICM)-Paris Brain Institute, Inserm, CNRS, France
| | - Alexandra Grinea
- From the Neurological Institute (W.-T.C., K.D., Q.S., J.C.), Columbia University, NY Presbyterian Hospital; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), Taipei Medical University; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), School of Medicine, College of Medicine, Taipei Medical University; Taiwan; Universidad de Especialidades Espíritu Santo/Hospital Luis Vernaza (V.C., D.G., T.F.), Guayaquil, Ecuador; Department of Neurology (A.S., R.H.), Neurocritical Care, Medical University of Innsbruck, Austria; Department of Neurology (D.R.R., N.M.), Universidad San Francisco de Quito USFQ, Hospital Eugenio Espejo, Ecuador; Instituto Estadual do Cérebro Paulo Niemeyer (D.F., P.K.), Rio de Jairo; Hospital Copa Star (D.F., P.K.), Rio de Janeiro, Brazil; Division of Critical Care Neurology (A.H., S.E.H.), Department of Neurology, Mayo Clinic, Rochester, MN; Neurointensive Care Unit (S.Z., B.R., S.D.), DMU Neurosciences, AP-HP Hôpital de La Pitié Salpêtrière, Paris; Université de Paris (A.G., R.S.), INSERM UMR1148 and Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital; and Sorbonne Université (B.R.), Institut du Cerveau (ICM)-Paris Brain Institute, Inserm, CNRS, France
| | - Yao-Hsien Huang
- From the Neurological Institute (W.-T.C., K.D., Q.S., J.C.), Columbia University, NY Presbyterian Hospital; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), Taipei Medical University; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), School of Medicine, College of Medicine, Taipei Medical University; Taiwan; Universidad de Especialidades Espíritu Santo/Hospital Luis Vernaza (V.C., D.G., T.F.), Guayaquil, Ecuador; Department of Neurology (A.S., R.H.), Neurocritical Care, Medical University of Innsbruck, Austria; Department of Neurology (D.R.R., N.M.), Universidad San Francisco de Quito USFQ, Hospital Eugenio Espejo, Ecuador; Instituto Estadual do Cérebro Paulo Niemeyer (D.F., P.K.), Rio de Jairo; Hospital Copa Star (D.F., P.K.), Rio de Janeiro, Brazil; Division of Critical Care Neurology (A.H., S.E.H.), Department of Neurology, Mayo Clinic, Rochester, MN; Neurointensive Care Unit (S.Z., B.R., S.D.), DMU Neurosciences, AP-HP Hôpital de La Pitié Salpêtrière, Paris; Université de Paris (A.G., R.S.), INSERM UMR1148 and Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital; and Sorbonne Université (B.R.), Institut du Cerveau (ICM)-Paris Brain Institute, Inserm, CNRS, France
| | - Kevin Doyle
- From the Neurological Institute (W.-T.C., K.D., Q.S., J.C.), Columbia University, NY Presbyterian Hospital; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), Taipei Medical University; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), School of Medicine, College of Medicine, Taipei Medical University; Taiwan; Universidad de Especialidades Espíritu Santo/Hospital Luis Vernaza (V.C., D.G., T.F.), Guayaquil, Ecuador; Department of Neurology (A.S., R.H.), Neurocritical Care, Medical University of Innsbruck, Austria; Department of Neurology (D.R.R., N.M.), Universidad San Francisco de Quito USFQ, Hospital Eugenio Espejo, Ecuador; Instituto Estadual do Cérebro Paulo Niemeyer (D.F., P.K.), Rio de Jairo; Hospital Copa Star (D.F., P.K.), Rio de Janeiro, Brazil; Division of Critical Care Neurology (A.H., S.E.H.), Department of Neurology, Mayo Clinic, Rochester, MN; Neurointensive Care Unit (S.Z., B.R., S.D.), DMU Neurosciences, AP-HP Hôpital de La Pitié Salpêtrière, Paris; Université de Paris (A.G., R.S.), INSERM UMR1148 and Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital; and Sorbonne Université (B.R.), Institut du Cerveau (ICM)-Paris Brain Institute, Inserm, CNRS, France
| | - Qi Shen
- From the Neurological Institute (W.-T.C., K.D., Q.S., J.C.), Columbia University, NY Presbyterian Hospital; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), Taipei Medical University; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), School of Medicine, College of Medicine, Taipei Medical University; Taiwan; Universidad de Especialidades Espíritu Santo/Hospital Luis Vernaza (V.C., D.G., T.F.), Guayaquil, Ecuador; Department of Neurology (A.S., R.H.), Neurocritical Care, Medical University of Innsbruck, Austria; Department of Neurology (D.R.R., N.M.), Universidad San Francisco de Quito USFQ, Hospital Eugenio Espejo, Ecuador; Instituto Estadual do Cérebro Paulo Niemeyer (D.F., P.K.), Rio de Jairo; Hospital Copa Star (D.F., P.K.), Rio de Janeiro, Brazil; Division of Critical Care Neurology (A.H., S.E.H.), Department of Neurology, Mayo Clinic, Rochester, MN; Neurointensive Care Unit (S.Z., B.R., S.D.), DMU Neurosciences, AP-HP Hôpital de La Pitié Salpêtrière, Paris; Université de Paris (A.G., R.S.), INSERM UMR1148 and Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital; and Sorbonne Université (B.R.), Institut du Cerveau (ICM)-Paris Brain Institute, Inserm, CNRS, France
| | - Diana Gómez
- From the Neurological Institute (W.-T.C., K.D., Q.S., J.C.), Columbia University, NY Presbyterian Hospital; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), Taipei Medical University; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), School of Medicine, College of Medicine, Taipei Medical University; Taiwan; Universidad de Especialidades Espíritu Santo/Hospital Luis Vernaza (V.C., D.G., T.F.), Guayaquil, Ecuador; Department of Neurology (A.S., R.H.), Neurocritical Care, Medical University of Innsbruck, Austria; Department of Neurology (D.R.R., N.M.), Universidad San Francisco de Quito USFQ, Hospital Eugenio Espejo, Ecuador; Instituto Estadual do Cérebro Paulo Niemeyer (D.F., P.K.), Rio de Jairo; Hospital Copa Star (D.F., P.K.), Rio de Janeiro, Brazil; Division of Critical Care Neurology (A.H., S.E.H.), Department of Neurology, Mayo Clinic, Rochester, MN; Neurointensive Care Unit (S.Z., B.R., S.D.), DMU Neurosciences, AP-HP Hôpital de La Pitié Salpêtrière, Paris; Université de Paris (A.G., R.S.), INSERM UMR1148 and Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital; and Sorbonne Université (B.R.), Institut du Cerveau (ICM)-Paris Brain Institute, Inserm, CNRS, France
| | - Sara E Hocker
- From the Neurological Institute (W.-T.C., K.D., Q.S., J.C.), Columbia University, NY Presbyterian Hospital; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), Taipei Medical University; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), School of Medicine, College of Medicine, Taipei Medical University; Taiwan; Universidad de Especialidades Espíritu Santo/Hospital Luis Vernaza (V.C., D.G., T.F.), Guayaquil, Ecuador; Department of Neurology (A.S., R.H.), Neurocritical Care, Medical University of Innsbruck, Austria; Department of Neurology (D.R.R., N.M.), Universidad San Francisco de Quito USFQ, Hospital Eugenio Espejo, Ecuador; Instituto Estadual do Cérebro Paulo Niemeyer (D.F., P.K.), Rio de Jairo; Hospital Copa Star (D.F., P.K.), Rio de Janeiro, Brazil; Division of Critical Care Neurology (A.H., S.E.H.), Department of Neurology, Mayo Clinic, Rochester, MN; Neurointensive Care Unit (S.Z., B.R., S.D.), DMU Neurosciences, AP-HP Hôpital de La Pitié Salpêtrière, Paris; Université de Paris (A.G., R.S.), INSERM UMR1148 and Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital; and Sorbonne Université (B.R.), Institut du Cerveau (ICM)-Paris Brain Institute, Inserm, CNRS, France
| | - Benjamin Rohaut
- From the Neurological Institute (W.-T.C., K.D., Q.S., J.C.), Columbia University, NY Presbyterian Hospital; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), Taipei Medical University; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), School of Medicine, College of Medicine, Taipei Medical University; Taiwan; Universidad de Especialidades Espíritu Santo/Hospital Luis Vernaza (V.C., D.G., T.F.), Guayaquil, Ecuador; Department of Neurology (A.S., R.H.), Neurocritical Care, Medical University of Innsbruck, Austria; Department of Neurology (D.R.R., N.M.), Universidad San Francisco de Quito USFQ, Hospital Eugenio Espejo, Ecuador; Instituto Estadual do Cérebro Paulo Niemeyer (D.F., P.K.), Rio de Jairo; Hospital Copa Star (D.F., P.K.), Rio de Janeiro, Brazil; Division of Critical Care Neurology (A.H., S.E.H.), Department of Neurology, Mayo Clinic, Rochester, MN; Neurointensive Care Unit (S.Z., B.R., S.D.), DMU Neurosciences, AP-HP Hôpital de La Pitié Salpêtrière, Paris; Université de Paris (A.G., R.S.), INSERM UMR1148 and Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital; and Sorbonne Université (B.R.), Institut du Cerveau (ICM)-Paris Brain Institute, Inserm, CNRS, France
| | - Romain Sonneville
- From the Neurological Institute (W.-T.C., K.D., Q.S., J.C.), Columbia University, NY Presbyterian Hospital; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), Taipei Medical University; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), School of Medicine, College of Medicine, Taipei Medical University; Taiwan; Universidad de Especialidades Espíritu Santo/Hospital Luis Vernaza (V.C., D.G., T.F.), Guayaquil, Ecuador; Department of Neurology (A.S., R.H.), Neurocritical Care, Medical University of Innsbruck, Austria; Department of Neurology (D.R.R., N.M.), Universidad San Francisco de Quito USFQ, Hospital Eugenio Espejo, Ecuador; Instituto Estadual do Cérebro Paulo Niemeyer (D.F., P.K.), Rio de Jairo; Hospital Copa Star (D.F., P.K.), Rio de Janeiro, Brazil; Division of Critical Care Neurology (A.H., S.E.H.), Department of Neurology, Mayo Clinic, Rochester, MN; Neurointensive Care Unit (S.Z., B.R., S.D.), DMU Neurosciences, AP-HP Hôpital de La Pitié Salpêtrière, Paris; Université de Paris (A.G., R.S.), INSERM UMR1148 and Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital; and Sorbonne Université (B.R.), Institut du Cerveau (ICM)-Paris Brain Institute, Inserm, CNRS, France
| | - Chien-Tai Hong
- From the Neurological Institute (W.-T.C., K.D., Q.S., J.C.), Columbia University, NY Presbyterian Hospital; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), Taipei Medical University; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), School of Medicine, College of Medicine, Taipei Medical University; Taiwan; Universidad de Especialidades Espíritu Santo/Hospital Luis Vernaza (V.C., D.G., T.F.), Guayaquil, Ecuador; Department of Neurology (A.S., R.H.), Neurocritical Care, Medical University of Innsbruck, Austria; Department of Neurology (D.R.R., N.M.), Universidad San Francisco de Quito USFQ, Hospital Eugenio Espejo, Ecuador; Instituto Estadual do Cérebro Paulo Niemeyer (D.F., P.K.), Rio de Jairo; Hospital Copa Star (D.F., P.K.), Rio de Janeiro, Brazil; Division of Critical Care Neurology (A.H., S.E.H.), Department of Neurology, Mayo Clinic, Rochester, MN; Neurointensive Care Unit (S.Z., B.R., S.D.), DMU Neurosciences, AP-HP Hôpital de La Pitié Salpêtrière, Paris; Université de Paris (A.G., R.S.), INSERM UMR1148 and Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital; and Sorbonne Université (B.R.), Institut du Cerveau (ICM)-Paris Brain Institute, Inserm, CNRS, France
| | - Sophie Demeret
- From the Neurological Institute (W.-T.C., K.D., Q.S., J.C.), Columbia University, NY Presbyterian Hospital; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), Taipei Medical University; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), School of Medicine, College of Medicine, Taipei Medical University; Taiwan; Universidad de Especialidades Espíritu Santo/Hospital Luis Vernaza (V.C., D.G., T.F.), Guayaquil, Ecuador; Department of Neurology (A.S., R.H.), Neurocritical Care, Medical University of Innsbruck, Austria; Department of Neurology (D.R.R., N.M.), Universidad San Francisco de Quito USFQ, Hospital Eugenio Espejo, Ecuador; Instituto Estadual do Cérebro Paulo Niemeyer (D.F., P.K.), Rio de Jairo; Hospital Copa Star (D.F., P.K.), Rio de Janeiro, Brazil; Division of Critical Care Neurology (A.H., S.E.H.), Department of Neurology, Mayo Clinic, Rochester, MN; Neurointensive Care Unit (S.Z., B.R., S.D.), DMU Neurosciences, AP-HP Hôpital de La Pitié Salpêtrière, Paris; Université de Paris (A.G., R.S.), INSERM UMR1148 and Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital; and Sorbonne Université (B.R.), Institut du Cerveau (ICM)-Paris Brain Institute, Inserm, CNRS, France
| | - Pedro Kurtz
- From the Neurological Institute (W.-T.C., K.D., Q.S., J.C.), Columbia University, NY Presbyterian Hospital; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), Taipei Medical University; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), School of Medicine, College of Medicine, Taipei Medical University; Taiwan; Universidad de Especialidades Espíritu Santo/Hospital Luis Vernaza (V.C., D.G., T.F.), Guayaquil, Ecuador; Department of Neurology (A.S., R.H.), Neurocritical Care, Medical University of Innsbruck, Austria; Department of Neurology (D.R.R., N.M.), Universidad San Francisco de Quito USFQ, Hospital Eugenio Espejo, Ecuador; Instituto Estadual do Cérebro Paulo Niemeyer (D.F., P.K.), Rio de Jairo; Hospital Copa Star (D.F., P.K.), Rio de Janeiro, Brazil; Division of Critical Care Neurology (A.H., S.E.H.), Department of Neurology, Mayo Clinic, Rochester, MN; Neurointensive Care Unit (S.Z., B.R., S.D.), DMU Neurosciences, AP-HP Hôpital de La Pitié Salpêtrière, Paris; Université de Paris (A.G., R.S.), INSERM UMR1148 and Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital; and Sorbonne Université (B.R.), Institut du Cerveau (ICM)-Paris Brain Institute, Inserm, CNRS, France
| | - Nelson Maldonado
- From the Neurological Institute (W.-T.C., K.D., Q.S., J.C.), Columbia University, NY Presbyterian Hospital; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), Taipei Medical University; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), School of Medicine, College of Medicine, Taipei Medical University; Taiwan; Universidad de Especialidades Espíritu Santo/Hospital Luis Vernaza (V.C., D.G., T.F.), Guayaquil, Ecuador; Department of Neurology (A.S., R.H.), Neurocritical Care, Medical University of Innsbruck, Austria; Department of Neurology (D.R.R., N.M.), Universidad San Francisco de Quito USFQ, Hospital Eugenio Espejo, Ecuador; Instituto Estadual do Cérebro Paulo Niemeyer (D.F., P.K.), Rio de Jairo; Hospital Copa Star (D.F., P.K.), Rio de Janeiro, Brazil; Division of Critical Care Neurology (A.H., S.E.H.), Department of Neurology, Mayo Clinic, Rochester, MN; Neurointensive Care Unit (S.Z., B.R., S.D.), DMU Neurosciences, AP-HP Hôpital de La Pitié Salpêtrière, Paris; Université de Paris (A.G., R.S.), INSERM UMR1148 and Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital; and Sorbonne Université (B.R.), Institut du Cerveau (ICM)-Paris Brain Institute, Inserm, CNRS, France
| | - Raimund Helbok
- From the Neurological Institute (W.-T.C., K.D., Q.S., J.C.), Columbia University, NY Presbyterian Hospital; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), Taipei Medical University; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), School of Medicine, College of Medicine, Taipei Medical University; Taiwan; Universidad de Especialidades Espíritu Santo/Hospital Luis Vernaza (V.C., D.G., T.F.), Guayaquil, Ecuador; Department of Neurology (A.S., R.H.), Neurocritical Care, Medical University of Innsbruck, Austria; Department of Neurology (D.R.R., N.M.), Universidad San Francisco de Quito USFQ, Hospital Eugenio Espejo, Ecuador; Instituto Estadual do Cérebro Paulo Niemeyer (D.F., P.K.), Rio de Jairo; Hospital Copa Star (D.F., P.K.), Rio de Janeiro, Brazil; Division of Critical Care Neurology (A.H., S.E.H.), Department of Neurology, Mayo Clinic, Rochester, MN; Neurointensive Care Unit (S.Z., B.R., S.D.), DMU Neurosciences, AP-HP Hôpital de La Pitié Salpêtrière, Paris; Université de Paris (A.G., R.S.), INSERM UMR1148 and Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital; and Sorbonne Université (B.R.), Institut du Cerveau (ICM)-Paris Brain Institute, Inserm, CNRS, France
| | - Telmo Fernandez
- From the Neurological Institute (W.-T.C., K.D., Q.S., J.C.), Columbia University, NY Presbyterian Hospital; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), Taipei Medical University; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), School of Medicine, College of Medicine, Taipei Medical University; Taiwan; Universidad de Especialidades Espíritu Santo/Hospital Luis Vernaza (V.C., D.G., T.F.), Guayaquil, Ecuador; Department of Neurology (A.S., R.H.), Neurocritical Care, Medical University of Innsbruck, Austria; Department of Neurology (D.R.R., N.M.), Universidad San Francisco de Quito USFQ, Hospital Eugenio Espejo, Ecuador; Instituto Estadual do Cérebro Paulo Niemeyer (D.F., P.K.), Rio de Jairo; Hospital Copa Star (D.F., P.K.), Rio de Janeiro, Brazil; Division of Critical Care Neurology (A.H., S.E.H.), Department of Neurology, Mayo Clinic, Rochester, MN; Neurointensive Care Unit (S.Z., B.R., S.D.), DMU Neurosciences, AP-HP Hôpital de La Pitié Salpêtrière, Paris; Université de Paris (A.G., R.S.), INSERM UMR1148 and Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital; and Sorbonne Université (B.R.), Institut du Cerveau (ICM)-Paris Brain Institute, Inserm, CNRS, France
| | - Jan Claassen
- From the Neurological Institute (W.-T.C., K.D., Q.S., J.C.), Columbia University, NY Presbyterian Hospital; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), Taipei Medical University; Department of Neurology (W.-T.C., Y.-H.H., C.-T.H.), School of Medicine, College of Medicine, Taipei Medical University; Taiwan; Universidad de Especialidades Espíritu Santo/Hospital Luis Vernaza (V.C., D.G., T.F.), Guayaquil, Ecuador; Department of Neurology (A.S., R.H.), Neurocritical Care, Medical University of Innsbruck, Austria; Department of Neurology (D.R.R., N.M.), Universidad San Francisco de Quito USFQ, Hospital Eugenio Espejo, Ecuador; Instituto Estadual do Cérebro Paulo Niemeyer (D.F., P.K.), Rio de Jairo; Hospital Copa Star (D.F., P.K.), Rio de Janeiro, Brazil; Division of Critical Care Neurology (A.H., S.E.H.), Department of Neurology, Mayo Clinic, Rochester, MN; Neurointensive Care Unit (S.Z., B.R., S.D.), DMU Neurosciences, AP-HP Hôpital de La Pitié Salpêtrière, Paris; Université de Paris (A.G., R.S.), INSERM UMR1148 and Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital; and Sorbonne Université (B.R.), Institut du Cerveau (ICM)-Paris Brain Institute, Inserm, CNRS, France.
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Salluh JIF, Kurtz P, Bastos LSL, Quintairos A, Zampieri FG, Bozza FA. The resilient intensive care unit. Ann Intensive Care 2022; 12:37. [PMID: 35471746 PMCID: PMC9038989 DOI: 10.1186/s13613-022-01011-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 04/15/2022] [Indexed: 11/18/2022] Open
Abstract
Background The COVID-19 pandemic tested the capacity of intensive care units (ICU) to respond to a crisis and demonstrated their fragility. Unsurprisingly, higher than usual mortality rates, lengths of stay (LOS), and ICU-acquired complications occurred during the pandemic. However, worse outcomes were not universal nor constant across ICUs and significant variation in outcomes was reported, demonstrating that some ICUs could adequately manage the surge of COVID-19. Methods In the present editorial, we discuss the concept of a resilient Intensive Care Unit, including which metrics can be used to address the capacity to respond, sustain results and incorporate new practices that lead to improvement. Results We believe that a resiliency analysis adds a component of preparedness to the usual ICU performance evaluation and outcomes metrics to be used during the crisis and in regular times. Conclusions The COVID-19 pandemic demonstrated the need for a resilient health system. Although this concept has been discussed for health systems, it was not tested in intensive care. Future studies should evaluate this concept to improve ICU organization for standard and pandemic times.
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Affiliation(s)
- Jorge I F Salluh
- D'Or Institute for Research and Education (IDOR), Rua Diniz Cordeiro, 30 - 3º andar, Rio de Janeiro, RJ, Brazil.,Postgraduate Program of Internal Medicine, Federal University of Rio de Janeiro, (UFRJ), Rio de Janeiro, RJ, Brazil
| | - Pedro Kurtz
- D'Or Institute for Research and Education (IDOR), Rua Diniz Cordeiro, 30 - 3º andar, Rio de Janeiro, RJ, Brazil.,Hospital Copa Star, Rio de Janeiro, RJ, Brazil.,Paulo Niemeyer State Brain Institute (IECPN), Rio de Janeiro, RJ, Brazil
| | - Leonardo S L Bastos
- Department of Industrial Engineering (DEI), Pontifical Catholic University of Rio de Janeiro (PUC-Rio), Rio de Janeiro, RJ, Brazil
| | - Amanda Quintairos
- D'Or Institute for Research and Education (IDOR), Rua Diniz Cordeiro, 30 - 3º andar, Rio de Janeiro, RJ, Brazil. .,Department of Critical and Intensive Care Medicine, Academic Hospital Fundación Santa Fe de Bogota, Bogota, Colombia.
| | - Fernando G Zampieri
- D'Or Institute for Research and Education (IDOR), Rua Diniz Cordeiro, 30 - 3º andar, Rio de Janeiro, RJ, Brazil.,HCor Research Institute, Sao Paulo, Brazil
| | - Fernando A Bozza
- D'Or Institute for Research and Education (IDOR), Rua Diniz Cordeiro, 30 - 3º andar, Rio de Janeiro, RJ, Brazil.,National Institute of Infectious Disease Evandro Chagas (INI), Oswaldo Cruz Foundation (FIOCRUZ), Rio de Janeiro, RJ, Brazil
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Temerozo JR, Fintelman-Rodrigues N, Dos Santos MC, Hottz ED, Sacramento CQ, de Paula Dias da Silva A, Mandacaru SC, Dos Santos Moraes EC, Trugilho MRO, Gesto JSM, Ferreira MA, Saraiva FB, Palhinha L, Martins-Gonçalves R, Azevedo-Quintanilha IG, Abrantes JL, Righy C, Kurtz P, Jiang H, Tan H, Morel C, Bou-Habib DC, Bozza FA, Bozza PT, Souza TML. Human endogenous retrovirus K in the respiratory tract is associated with COVID-19 physiopathology. Microbiome 2022; 10:65. [PMID: 35459226 PMCID: PMC9024070 DOI: 10.1186/s40168-022-01260-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 03/15/2022] [Indexed: 05/04/2023]
Abstract
BACKGROUND Critically ill 2019 coronavirus disease (COVID-19) patients under invasive mechanical ventilation (IMV) are 10 to 40 times more likely to die than the general population. Although progression from mild to severe COVID-19 has been associated with hypoxia, uncontrolled inflammation, and coagulopathy, the mechanisms involved in the progression to severity are poorly understood. METHODS The virome of tracheal aspirates (TA) from 25 COVID-19 patients under IMV was assessed through unbiased RNA sequencing (RNA-seq), and correlation analyses were conducted using available clinical data. Unbiased sequences from nasopharyngeal swabs (NS) from mild cases and TA from non-COVID patients were included in our study for further comparisons. RESULTS We found higher levels and differential expression of human endogenous retrovirus K (HERV-K) genes in TA from critically ill and deceased patients when comparing nasopharyngeal swabs from mild cases to TA from non-COVID patients. In critically ill patients, higher HERV-K levels were associated with early mortality (within 14 days of diagnosis) in the intensive care unit. Increased HERV-K expression in deceased patients was associated with IL-17-related inflammation, monocyte activation, and an increased consumption of clotting/fibrinolysis factors. Moreover, increased HERV-K expression was detected in human primary monocytes from healthy donors after experimental SARS-CoV-2 infection in vitro. CONCLUSION Our data implicate the levels of HERV-K transcripts in the physiopathology of COVID-19 in the respiratory tract of patients under invasive mechanical ventilation. Video abstract.
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Affiliation(s)
- Jairo R Temerozo
- Laboratory on Thymus Research, Oswaldo Cruz Institute (IOC), Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil
- National Institute for Science and Technology on Neuroimmunomodulation (INCT/NIM), Oswaldo Cruz Institute (IOC), Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil
- Laboratory of Immunopharmacology, Oswaldo Cruz Institute (IOC), Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil
- Center for Technological Development in Health (CDTS), National Institute for Science and Technology on Innovation on Disease Of Neglected Poppulations (INCT/IDPN), Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Natalia Fintelman-Rodrigues
- Laboratory of Immunopharmacology, Oswaldo Cruz Institute (IOC), Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil
- Center for Technological Development in Health (CDTS), National Institute for Science and Technology on Innovation on Disease Of Neglected Poppulations (INCT/IDPN), Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Monique Cristina Dos Santos
- Laboratory of Immunopharmacology, Oswaldo Cruz Institute (IOC), Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Eugenio D Hottz
- Laboratory of Immunopharmacology, Oswaldo Cruz Institute (IOC), Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil
- Laboratory of Immunothrombosis, Department of Biochemistry, Federal University of Juiz de Fora (UFJF), Juiz de Fora, Minas Gerais, Brazil
| | - Carolina Q Sacramento
- Laboratory of Immunopharmacology, Oswaldo Cruz Institute (IOC), Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil
- Center for Technological Development in Health (CDTS), National Institute for Science and Technology on Innovation on Disease Of Neglected Poppulations (INCT/IDPN), Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Aline de Paula Dias da Silva
- Laboratory of Immunopharmacology, Oswaldo Cruz Institute (IOC), Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil
- Center for Technological Development in Health (CDTS), National Institute for Science and Technology on Innovation on Disease Of Neglected Poppulations (INCT/IDPN), Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Samuel Coelho Mandacaru
- Center for Technological Development in Health (CDTS), National Institute for Science and Technology on Innovation on Disease Of Neglected Poppulations (INCT/IDPN), Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil
- Laboratory of Toxinology, Oswaldo Cruz Institute (IOC), Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Emilly Caroline Dos Santos Moraes
- Laboratory of Immunopharmacology, Oswaldo Cruz Institute (IOC), Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil
- Laboratory of Toxinology, Oswaldo Cruz Institute (IOC), Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Monique R O Trugilho
- Center for Technological Development in Health (CDTS), National Institute for Science and Technology on Innovation on Disease Of Neglected Poppulations (INCT/IDPN), Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil
- Laboratory of Toxinology, Oswaldo Cruz Institute (IOC), Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil
| | - João S M Gesto
- Center for Technological Development in Health (CDTS), National Institute for Science and Technology on Innovation on Disease Of Neglected Poppulations (INCT/IDPN), Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Marcelo Alves Ferreira
- Center for Technological Development in Health (CDTS), National Institute for Science and Technology on Innovation on Disease Of Neglected Poppulations (INCT/IDPN), Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Felipe Betoni Saraiva
- Instituto de Tecnologia em Imunobiológicos (Bio-Manguinhos), Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Lohanna Palhinha
- Laboratory of Immunopharmacology, Oswaldo Cruz Institute (IOC), Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Remy Martins-Gonçalves
- Laboratory of Immunopharmacology, Oswaldo Cruz Institute (IOC), Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil
| | | | - Juliana L Abrantes
- Instituto de Ciências Biomédicas, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil
| | - Cássia Righy
- Paulo Niemeyer State Brain Institute (IECPN), Rio de Janeiro, RJ, Brazil
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Pedro Kurtz
- Paulo Niemeyer State Brain Institute (IECPN), Rio de Janeiro, RJ, Brazil
- D'Or Institute for Research and Education, Rio de Janeiro, RJ, Brazil
| | - Hui Jiang
- MGI Tech Co. Ltd, Building No.11, Beishan Industrial Zone, Yantian District, Shenzhen, 518083, China
| | - Hongdong Tan
- MGI Tech Co. Ltd, Building No.11, Beishan Industrial Zone, Yantian District, Shenzhen, 518083, China
| | - Carlos Morel
- Center for Technological Development in Health (CDTS), National Institute for Science and Technology on Innovation on Disease Of Neglected Poppulations (INCT/IDPN), Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Dumith Chequer Bou-Habib
- Laboratory on Thymus Research, Oswaldo Cruz Institute (IOC), Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil
- National Institute for Science and Technology on Neuroimmunomodulation (INCT/NIM), Oswaldo Cruz Institute (IOC), Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Fernando A Bozza
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil
- D'Or Institute for Research and Education, Rio de Janeiro, RJ, Brazil
| | - Patrícia T Bozza
- Laboratory of Immunopharmacology, Oswaldo Cruz Institute (IOC), Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Thiago Moreno L Souza
- Laboratory of Immunopharmacology, Oswaldo Cruz Institute (IOC), Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil.
- Center for Technological Development in Health (CDTS), National Institute for Science and Technology on Innovation on Disease Of Neglected Poppulations (INCT/IDPN), Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil.
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20
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Kurtz P, Peres IT, Soares M, Salluh JIF, Bozza FA. Hospital Length of Stay and 30-Day Mortality Prediction in Stroke: A Machine Learning Analysis of 17,000 ICU Admissions in Brazil. Neurocrit Care 2022; 37:313-321. [PMID: 35381967 DOI: 10.1007/s12028-022-01486-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 03/07/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Hospital length of stay and mortality are associated with resource use and clinical severity, respectively, in patients admitted to the intensive care unit (ICU) with acute stroke. We proposed a structured data-driven methodology to develop length of stay and 30-day mortality prediction models in a large multicenter Brazilian ICU cohort. METHODS We analyzed data from 130 ICUs from 43 Brazilian hospitals. All consecutive adult patients admitted with stroke (ischemic or nontraumatic hemorrhagic) to the ICU from January 2011 to December 2020 were included. Demographic data, comorbidities, acute disease characteristics, organ support, and laboratory data were retrospectively analyzed by a data-driven methodology, which included seven different types of machine learning models applied to training and test sets of data. The best performing models, based on discrimination and calibration measures, are reported as the main results. Outcomes were hospital length of stay and 30-day in-hospital mortality. RESULTS Of 17,115 ICU admissions for stroke, 16,592 adult patients (13,258 ischemic and 3334 hemorrhagic) were analyzed; 4298 (26%) patients had a prolonged hospital length of stay (> 14 days), and 30-day mortality was 8% (n = 1392). Prolonged hospital length of stay was best predicted by the random forests model (Brier score = 0.17, area under the curve = 0.73, positive predictive value = 0.61, negative predictive value = 0.78). Mortality prediction also yielded the best discrimination and calibration through random forests (Brier score = 0.05, area under the curve = 0.90, positive predictive value = 0.66, negative predictive value = 0.94). Among the 20 strongest contributor variables in both models were (1) premorbid conditions (e.g., functional impairment), (2) multiple organ dysfunction parameters (e.g., hypotension, mechanical ventilation), and (3) acute neurological aspects of stroke (e.g., Glasgow coma scale score on admission, stroke type). CONCLUSIONS Hospital length of stay and 30-day mortality of patients admitted to the ICU with stroke were accurately predicted through machine learning methods, even in the absence of stroke-specific data, such as the National Institutes of Health Stroke Scale score or neuroimaging findings. The proposed methods using general intensive care databases may be used for resource use allocation planning and performance assessment of ICUs treating stroke. More detailed acute neurological and management data, as well as long-term functional outcomes, may improve the accuracy and applicability of future machine-learning-based prediction algorithms.
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Affiliation(s)
- Pedro Kurtz
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil.,Hospital Copa Star, Rio de Janeiro, Brazil.,Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil
| | - Igor Tona Peres
- Department of Industrial Engineering, Pontifical Catholic University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marcio Soares
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil
| | - Jorge I F Salluh
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil.,Postgraduate Program of Internal Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Fernando A Bozza
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil. .,National Institute of Infectious Disease Evandro Chagas, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil.
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21
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Temerozo JR, Sacramento CQ, Fintelman-Rodrigues N, Pão CRR, de Freitas CS, Dias SSG, Ferreira AC, Mattos M, Soares VC, Teixeira L, Azevedo-Quintanilha IG, Hottz ED, Kurtz P, Bozza FA, Bozza PT, Souza TML, Bou-Habib DC. VIP plasma levels associate with survival in severe COVID-19 patients, correlating with protective effects in SARS-CoV-2-infected cells. J Leukoc Biol 2022; 111:1107-1121. [PMID: 35322471 PMCID: PMC9088587 DOI: 10.1002/jlb.5cova1121-626r] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 02/11/2022] [Accepted: 02/25/2022] [Indexed: 12/11/2022] Open
Abstract
Infection by SARS‐CoV‐2 may elicit uncontrolled and damaging inflammatory responses. Thus, it is critical to identify compounds able to inhibit virus replication and thwart the inflammatory reaction. Here, we show that the plasma levels of the immunoregulatory neuropeptide VIP are elevated in patients with severe COVID‐19, correlating with reduced inflammatory mediators and with survival on those patients. In vitro, vasoactive intestinal peptide (VIP) and pituitary adenylate cyclase‐activating polypeptide (PACAP), highly similar neuropeptides, decreased the SARS‐CoV‐2 RNA content in human monocytes and viral production in lung epithelial cells, also reducing cell death. Both neuropeptides inhibited the production of proinflammatory mediators in lung epithelial cells and in monocytes. VIP and PACAP prevented in monocytes the SARS‐CoV‐2‐induced activation of NF‐kB and SREBP1 and SREBP2, transcriptions factors involved in proinflammatory reactions and lipid metabolism, respectively. They also promoted CREB activation, a transcription factor with antiapoptotic activity and negative regulator of NF‐kB. Specific inhibition of NF‐kB and SREBP1/2 reproduced the anti‐inflammatory, antiviral, and cell death protection effects of VIP and PACAP. Our results support further clinical investigations of these neuropeptides against COVID‐19.
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Affiliation(s)
- Jairo R Temerozo
- Laboratory on Thymus Research, Oswaldo Cruz Institute, Fiocruz, Rio de Janeiro, RJ, Brazil.,National Institute for Science and Technology on Neuroimmunomodulation, Oswaldo Cruz Institute, Fiocruz, Rio de Janeiro, RJ, Brazil
| | - Carolina Q Sacramento
- Laboratory of Immunopharmacology, Oswaldo Cruz Institute, Fiocruz, Rio de Janeiro, RJ, Brazil.,National Institute for Science and Technology on Innovation in Diseases of Neglected Populations (INCT/IDPN), Center for Technological Development in Health (CDTS), Fiocruz, Rio de Janeiro, RJ, Brazil
| | - Natalia Fintelman-Rodrigues
- Laboratory of Immunopharmacology, Oswaldo Cruz Institute, Fiocruz, Rio de Janeiro, RJ, Brazil.,National Institute for Science and Technology on Innovation in Diseases of Neglected Populations (INCT/IDPN), Center for Technological Development in Health (CDTS), Fiocruz, Rio de Janeiro, RJ, Brazil
| | - Camila R R Pão
- Laboratory of Immunopharmacology, Oswaldo Cruz Institute, Fiocruz, Rio de Janeiro, RJ, Brazil
| | - Caroline S de Freitas
- Laboratory of Immunopharmacology, Oswaldo Cruz Institute, Fiocruz, Rio de Janeiro, RJ, Brazil.,National Institute for Science and Technology on Innovation in Diseases of Neglected Populations (INCT/IDPN), Center for Technological Development in Health (CDTS), Fiocruz, Rio de Janeiro, RJ, Brazil
| | - Suelen Silva Gomes Dias
- Laboratory of Immunopharmacology, Oswaldo Cruz Institute, Fiocruz, Rio de Janeiro, RJ, Brazil
| | - André C Ferreira
- Laboratory of Immunopharmacology, Oswaldo Cruz Institute, Fiocruz, Rio de Janeiro, RJ, Brazil.,National Institute for Science and Technology on Innovation in Diseases of Neglected Populations (INCT/IDPN), Center for Technological Development in Health (CDTS), Fiocruz, Rio de Janeiro, RJ, Brazil.,Iguaçu University, Nova Iguaçu, RJ, Brazil
| | - Mayara Mattos
- Laboratory of Immunopharmacology, Oswaldo Cruz Institute, Fiocruz, Rio de Janeiro, RJ, Brazil.,National Institute for Science and Technology on Innovation in Diseases of Neglected Populations (INCT/IDPN), Center for Technological Development in Health (CDTS), Fiocruz, Rio de Janeiro, RJ, Brazil
| | - Vinicius Cardoso Soares
- Laboratory of Immunopharmacology, Oswaldo Cruz Institute, Fiocruz, Rio de Janeiro, RJ, Brazil.,Program of Immunology and Inflammation, Federal University of Rio de Janeiro, UFRJ, Rio de Janeiro, RJ, Brazil
| | - Lívia Teixeira
- Laboratory of Immunopharmacology, Oswaldo Cruz Institute, Fiocruz, Rio de Janeiro, RJ, Brazil
| | | | - Eugenio D Hottz
- Laboratory of Immunothrombosis, Department of Biochemistry, Federal University of Juiz de Fora (UFJF), Juiz de Fora, Minas Gerais, Brazil
| | - Pedro Kurtz
- Paulo Niemeyer State Brain Institute, Rio de Janeiro, RJ, Brazil.,D'Or Institute for Research and Education, Rio de Janeiro, RJ, Brazil
| | - Fernando A Bozza
- D'Or Institute for Research and Education, Rio de Janeiro, RJ, Brazil.,Evandro Chagas National Institute of Infectious Diseases, Fiocruz, Rio de Janeiro, RJ, Brazil
| | - Patrícia T Bozza
- Laboratory of Immunopharmacology, Oswaldo Cruz Institute, Fiocruz, Rio de Janeiro, RJ, Brazil
| | - Thiago Moreno L Souza
- Laboratory of Immunopharmacology, Oswaldo Cruz Institute, Fiocruz, Rio de Janeiro, RJ, Brazil.,National Institute for Science and Technology on Innovation in Diseases of Neglected Populations (INCT/IDPN), Center for Technological Development in Health (CDTS), Fiocruz, Rio de Janeiro, RJ, Brazil
| | - Dumith Chequer Bou-Habib
- Laboratory on Thymus Research, Oswaldo Cruz Institute, Fiocruz, Rio de Janeiro, RJ, Brazil.,National Institute for Science and Technology on Neuroimmunomodulation, Oswaldo Cruz Institute, Fiocruz, Rio de Janeiro, RJ, Brazil
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22
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Mendes-de-Almeida DP, Martins-Gonçalves R, Morato-Santos R, De Carvalho GAC, Martins SA, Palhinha L, Sandim V, Avvad-Portari E, Bozza FA, Monteiro RQ, Bozza PT, Kurtz P. Intracerebral hemorrhage associated with vaccine-induced thrombotic thrombocytopenia following ChAdOx1 nCOVID-19 vaccine in a pregnant woman. Haematologica 2021; 106:3025-3028. [PMID: 34261297 PMCID: PMC8561298 DOI: 10.3324/haematol.2021.279407] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Indexed: 11/09/2022] Open
Abstract
Not available.
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Affiliation(s)
- Daniela P Mendes-de-Almeida
- Department of Hematology, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brazil; Division of Molecular Carcinogenesis, Research Center, Instituto Nacional de Câncer (INCA), Rio de Janeiro, Brazil; Division of Epidemiology, Department of Pediatrics, University of Minnesota, Minneapolis
| | - Remy Martins-Gonçalves
- Laboratory of Immunopharmacology, Instituto Oswaldo Cruz, Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro
| | - Renata Morato-Santos
- Department of Obstetrics, Universidade Federal do Estado do Rio de Janeiro (UNIRIO), Rio de Janeiro
| | - Gustavo Adolpho C De Carvalho
- Neurosurgical Deptartment, Hospital Sao Lucas, Rio de Janeiro, Brazil; Neurosurgical Deptartment, Hospital Adventista Silvestre, Rio de Janeiro
| | - Silas A Martins
- Neurosurgical Deptartment, Hospital Sao Lucas, Rio de Janeiro, Brazil; Neurosurgical Deptartment, Hospital Adventista Silvestre, Rio de Janeiro
| | - Lohanna Palhinha
- Laboratory of Immunopharmacology, Instituto Oswaldo Cruz, Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro
| | - Vanessa Sandim
- Institute of Medical Biochemistry Leopoldo de Meis, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro
| | - Elyzabeth Avvad-Portari
- Department of Pathologic Anatomy, Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira, Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brazil; Department of Pathologic Anatomy, Histology, and Embryology, Medical Sciences Faculty, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro
| | - Fernando A Bozza
- Laboratory of Intensive Care, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brazil; D'Or Institute for Research and Education, Rio de Janeiro
| | - Robson Q Monteiro
- Institute of Medical Biochemistry Leopoldo de Meis, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro
| | - Patrícia T Bozza
- Laboratory of Immunopharmacology, Instituto Oswaldo Cruz, Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro
| | - Pedro Kurtz
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil; Department of Neurointensive Care, Instituto Estadual do Cérebro Paulo Niemeyer (IECPN), Rio de Janeiro, Brazil; Department of Intensive Care Medicine, Hospital Copa Star, Rio de Janeiro.
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Kurtz P, Bastos LSL, Salluh JIF, Bozza FA, Soares M. SAPS-3 performance for hospital mortality prediction in 30,571 patients with COVID-19 admitted to ICUs in Brazil. Intensive Care Med 2021; 47:1047-1049. [PMID: 34244829 PMCID: PMC8270768 DOI: 10.1007/s00134-021-06474-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 07/02/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Pedro Kurtz
- D'Or Institute for Research and Education (IDOR), Rio de Janeiro, RJ, Brazil.,Hospital Copa Star, Rio de Janeiro, RJ, Brazil.,Paulo Niemeyer State Brain Institute (IECPN), Rio de Janeiro, RJ, Brazil
| | - Leonardo S L Bastos
- Department of Industrial Engineering (DEI), Pontifical Catholic University of Rio de Janeiro (PUC-Rio), Rio de Janeiro, RJ, Brazil
| | - Jorge I F Salluh
- D'Or Institute for Research and Education (IDOR), Rio de Janeiro, RJ, Brazil.,Postgraduate Program of Internal Medicine, Federal University of Rio de Janeiro, (UFRJ), Rio de Janeiro, Brazil
| | - Fernando A Bozza
- D'Or Institute for Research and Education (IDOR), Rio de Janeiro, RJ, Brazil.,National Institute of Infectious Disease Evandro Chagas (INI), Oswaldo Cruz Foundation (FIOCRUZ), Rio de Janeiro, RJ, Brazil
| | - Marcio Soares
- D'Or Institute for Research and Education (IDOR), Rio de Janeiro, RJ, Brazil.
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24
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Kurtz P, Bastos LSL, Dantas LF, Zampieri FG, Soares M, Hamacher S, Salluh JIF, Bozza FA. Evolving changes in mortality of 13,301 critically ill adult patients with COVID-19 over 8 months. Intensive Care Med 2021; 47:538-548. [PMID: 33852032 PMCID: PMC8044656 DOI: 10.1007/s00134-021-06388-0] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 03/18/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE Clinical characteristics and management of COVID-19 patients have evolved during the pandemic, potentially changing their outcomes. We analyzed the associations of changes in mortality rates with clinical profiles and respiratory support strategies in COVID-19 critically ill patients. METHODS A multicenter cohort of RT-PCR-confirmed COVID-19 patients admitted at 126 Brazilian intensive care units between February 27th and October 28th, 2020. Assessing temporal changes in deaths, we identified distinct time periods. We evaluated the association of characteristics and respiratory support strategies with 60-day in-hospital mortality using random-effects multivariable Cox regression with inverse probability weighting. RESULTS Among the 13,301 confirmed-COVID-19 patients, 60-day in-hospital mortality was 13%. Across four time periods identified, younger patients were progressively more common, non-invasive respiratory support was increasingly used, and the 60-day in-hospital mortality decreased in the last two periods. 4188 patients received advanced respiratory support (non-invasive or invasive), from which 42% underwent only invasive mechanical ventilation, 37% only non-invasive respiratory support and 21% failed non-invasive support and were intubated. After adjusting for organ dysfunction scores and premorbid conditions, we found that younger age, absence of frailty and the use of non-invasive respiratory support (NIRS) as first support strategy were independently associated with improved survival (hazard ratio for NIRS first [95% confidence interval], 0.59 [0.54-0.65], p < 0.001). CONCLUSION Age and mortality rates have declined over the first 8 months of the pandemic. The use of NIRS as the first respiratory support measure was associated with survival, but causal inference is limited by the observational nature of our data.
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Affiliation(s)
- Pedro Kurtz
- D'Or Institute for Research and Education (IDOR), Rio de Janeiro, RJ, Brazil.,Hospital Copa Star, Rio de Janeiro, RJ, Brazil.,Paulo Niemeyer State Brain Institute (IECPN), Rio de Janeiro, RJ, Brazil
| | - Leonardo S L Bastos
- Department of Industrial Engineering (DEI), Pontifical Catholic University of Rio de Janeiro (PUC-Rio), Rio de Janeiro, RJ, Brazil
| | - Leila F Dantas
- Department of Industrial Engineering (DEI), Pontifical Catholic University of Rio de Janeiro (PUC-Rio), Rio de Janeiro, RJ, Brazil
| | - Fernando G Zampieri
- D'Or Institute for Research and Education (IDOR), Rio de Janeiro, RJ, Brazil.,Research Institute, Hospital Do Coração (HCor), São Paulo, Brazil.,Center for Epidemiological Research, Southern Denmark University, Odense, Denmark
| | - Marcio Soares
- D'Or Institute for Research and Education (IDOR), Rio de Janeiro, RJ, Brazil
| | - Silvio Hamacher
- Department of Industrial Engineering (DEI), Pontifical Catholic University of Rio de Janeiro (PUC-Rio), Rio de Janeiro, RJ, Brazil
| | - Jorge I F Salluh
- D'Or Institute for Research and Education (IDOR), Rio de Janeiro, RJ, Brazil.,Postgraduate Program of Internal Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, UFRJ, Brazil
| | - Fernando A Bozza
- D'Or Institute for Research and Education (IDOR), Rio de Janeiro, RJ, Brazil. .,National Institute of Infectious Disease Evandro Chagas (INI), Oswaldo Cruz Foundation (FIOCRUZ), Rio de Janeiro, RJ, Brazil.
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25
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Kirschen MP, Lewis A, Rubin M, Kurtz P, Greer DM. New perspectives on brain death. J Neurol Neurosurg Psychiatry 2021; 92:255-262. [PMID: 33219040 DOI: 10.1136/jnnp-2020-323952] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/06/2020] [Accepted: 10/14/2020] [Indexed: 11/04/2022]
Abstract
Brain death, or death by neurological criteria (BD/DNC), has been accepted conceptually, medically and legally for decades. Nevertheless, some areas remain controversial or understudied, pointing to a need for focused research to advance the field. Multiple recent contributions have increased our understanding of BD/DNC, solidified our practice and provided guidance where previously lacking. There have also been important developments on a global scale, including in low-to-middle income countries such as in South America. Although variability in protocols and practice still exists, new efforts are underway to reduce inconsistencies and better train practitioners in accurate and sound BD/DNC determination. Various legal challenges have required formal responses from national societies, and the American Academy of Neurology has filled this void with much needed guidance. Questions remain regarding concepts such as 'whole brain' versus 'brainstem' death, and the intersection of BD/DNC and rubrics of medical futility. These concepts are the subject of this review.
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Affiliation(s)
- Matthew P Kirschen
- Anesthesia and Critical Care Medicine, Neurology and Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Ariane Lewis
- Neurology and Neurosurgery, NYU Langone Medical Center, New York, New York, USA
| | - Michael Rubin
- Neurology, University of Texas Southwestern Medical School, Dallas, Texas, USA
| | - Pedro Kurtz
- Hospital Copa Star, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - David M Greer
- Neurology, Boston University, Boston, Massachusetts, USA
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Kurtz P, Righy C, Gadelha M, Bozza FA, Bozza PT, Gonçalves B, Bastos LSL, Vale AM, Higa LM, Castilho L, Monteiro FL, Charris N, Fialho F, Turon R, Guterres A, Lyra Miranda R, de Azeredo Lima CH, de Caro V, Prazeres MA, Ventura N, Gaspari C, Miranda F, Jose da Mata P, Pêcego M, Mateos S, Lopes ME, Castilho S, Oliveira Á, Boquimpani C, Rabello A, Lopes J, Neto OC, Ferreira ODC, Tanuri A, Filho PN, Amorim L. Effect of Convalescent Plasma in Critically Ill Patients With COVID-19: An Observational Study. Front Med (Lausanne) 2021; 8:630982. [PMID: 33585529 PMCID: PMC7876445 DOI: 10.3389/fmed.2021.630982] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 01/04/2021] [Indexed: 12/15/2022] Open
Abstract
Background: Convalescent plasma is a potential therapeutic option for critically ill patients with coronavirus disease 19 (COVID-19), yet its efficacy remains to be determined. The aim was to investigate the effects of convalescent plasma (CP) in critically ill patients with COVID-19. Methods: This was a single-center prospective observational study conducted in Rio de Janeiro, Brazil, from March 17th to May 30th, with final follow-up on June 30th. We included 113 laboratory-confirmed COVID-19 patients with respiratory failure. Primary outcomes were time to clinical improvement and survival within 28 days. Secondary outcomes included behavior of biomarkers and viral loads. Kaplan–Meier analyses and Cox proportional-hazards regression using propensity score with inverse-probability weighing were performed. Results: 41 patients received CP and 72 received standard of care (SOC). Median age was 61 years (IQR 48–68), disease duration was 10 days (IQR 6–13), and 86% were mechanically ventilated. At least 29 out of 41CP-recipients had baseline IgG titers ≥ 1:1,080. Clinical improvement within 28 days occurred in 19 (46%) CP-treated patients, as compared to 23 (32%) in the SOC group [adjusted hazard ratio (aHR) 0.91 (0.49–1.69)]. There was no significant change in 28-day mortality (CP 49% vs. SOC 56%; aHR 0.90 [0.52–1.57]). Biomarker assessment revealed reduced inflammatory activity and increased lymphocyte count after CP. Conclusions: In this study, CP was not associated with clinical improvement or increase in 28-day survival. However, our study may have been underpowered and included patients with high IgG titers and life-threatening disease. Clinical Trial Registration: The study protocol was retrospectively registered at the Brazilian Registry of Clinical Trials (ReBEC) with the identification RBR-4vm3yy (http://www.ensaiosclinicos.gov.br).
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Affiliation(s)
- Pedro Kurtz
- Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Cassia Righy
- Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Monica Gadelha
- Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Fernando A Bozza
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil.,National Institute of Infectious Disease Evandro Chagas, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Patricia T Bozza
- Laboratory of Immunopharmacology, Oswaldo Cruz Institute, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Bruno Gonçalves
- Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Leonardo S L Bastos
- Industrial Engineering Department, Pontifical Catholic University of Rio de Janeiro (PUC-Rio), Rio de Janeiro, Brazil
| | - Andre M Vale
- Laboratory of Lymphocyte Biology, Program in Immunobiology, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - Luiza M Higa
- Laboratory of Molecular Virology, Department of Genetics, Institute of Biology, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Leda Castilho
- Laboratory of Cell Culture Engineering, COPPE, Chemical Engineering Program, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - Fabio L Monteiro
- Laboratory of Molecular Virology, Department of Genetics, Institute of Biology, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Nestor Charris
- Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Fernanda Fialho
- Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Ricardo Turon
- Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | | | | | | | - Vanessa de Caro
- Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | | | - Nina Ventura
- Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Clara Gaspari
- Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Fabio Miranda
- Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | | | - Margarida Pêcego
- Instituto Estadual de Hematologia Arthur de Siqueira Cavalcanti (HEMORIO), Rio de Janeiro, Brazil
| | - Sheila Mateos
- Instituto Estadual de Hematologia Arthur de Siqueira Cavalcanti (HEMORIO), Rio de Janeiro, Brazil
| | - Maria Esther Lopes
- Instituto Estadual de Hematologia Arthur de Siqueira Cavalcanti (HEMORIO), Rio de Janeiro, Brazil
| | - Shirley Castilho
- Instituto Estadual de Hematologia Arthur de Siqueira Cavalcanti (HEMORIO), Rio de Janeiro, Brazil
| | - Álvaro Oliveira
- Instituto Estadual de Hematologia Arthur de Siqueira Cavalcanti (HEMORIO), Rio de Janeiro, Brazil
| | - Carla Boquimpani
- Instituto Estadual de Hematologia Arthur de Siqueira Cavalcanti (HEMORIO), Rio de Janeiro, Brazil
| | - Andréa Rabello
- Instituto Estadual de Hematologia Arthur de Siqueira Cavalcanti (HEMORIO), Rio de Janeiro, Brazil
| | - Josiane Lopes
- Instituto Estadual de Hematologia Arthur de Siqueira Cavalcanti (HEMORIO), Rio de Janeiro, Brazil
| | - Orlando Conceição Neto
- Instituto Estadual de Hematologia Arthur de Siqueira Cavalcanti (HEMORIO), Rio de Janeiro, Brazil
| | - Orlando da C Ferreira
- Laboratory of Molecular Virology, Department of Genetics, Institute of Biology, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Amilcar Tanuri
- Laboratory of Molecular Virology, Department of Genetics, Institute of Biology, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Luiz Amorim
- Instituto Estadual de Hematologia Arthur de Siqueira Cavalcanti (HEMORIO), Rio de Janeiro, Brazil
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McNett M, Fink EL, Schober M, Mainali S, Helbok R, Robertson CL, Mejia-Mantilla J, Kurtz P, Righy C, Roa JD, Villamizar-Rosales C, Altamirano V, Frontera JA, Maldonado N, Menon D, Suarez J, Chou SHY. The Global Consortium Study of Neurological Dysfunction in COVID-19 (GCS-NeuroCOVID): Development of Case Report Forms for Global Use. Neurocrit Care 2020; 33:793-828. [PMID: 32948987 PMCID: PMC7500499 DOI: 10.1007/s12028-020-01100-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 09/01/2020] [Indexed: 12/17/2022]
Abstract
Since its original report in January 2020, the coronavirus disease 2019 (COVID-19) due to Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) infection has rapidly become one of the deadliest global pandemics. Early reports indicate possible neurological manifestations associated with COVID-19, with symptoms ranging from mild to severe, highly variable prevalence rates, and uncertainty regarding causal or coincidental occurrence of symptoms. As neurological involvement of any systemic disease is frequently associated with adverse effects on morbidity and mortality, obtaining accurate and consistent global data on the extent to which COVID-19 may impact the nervous system is urgently needed. To address this need, investigators from the Neurocritical Care Society launched the Global Consortium Study of Neurological Dysfunction in COVID-19 (GCS-NeuroCOVID). The GCS-NeuroCOVID consortium rapidly implemented a Tier 1, pragmatic study to establish phenotypes and prevalence of neurological manifestations of COVID-19. A key component of this global collaboration is development and application of common data elements (CDEs) and definitions to facilitate rigorous and systematic data collection across resource settings. Integration of these elements is critical to reduce heterogeneity of data and allow for future high-quality meta-analyses. The GCS-NeuroCOVID consortium specifically designed these elements to be feasible for clinician investigators during a global pandemic when healthcare systems are likely overwhelmed and resources for research may be limited. Elements include pediatric components and translated versions to facilitate collaboration and data capture in Latin America, one of the epicenters of this global outbreak. In this manuscript, we share the specific data elements, definitions, and rationale for the adult and pediatric CDEs for Tier 1 of the GCS-NeuroCOVID consortium, as well as the translated versions adapted for use in Latin America. Global efforts are underway to further harmonize CDEs with other large consortia studying neurological and general aspects of COVID-19 infections. Ultimately, the GCS-NeuroCOVID consortium network provides a critical infrastructure to systematically capture data in current and future unanticipated disasters and disease outbreaks.
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Affiliation(s)
- Molly McNett
- College of Nursing, The Ohio State University, Columbus, OH, USA.
| | - Ericka L Fink
- Division of Pediatric Critical Care Medicine and Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Michelle Schober
- Primary Children's Hospital, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Shraddha Mainali
- Division of Stroke and Neurocritical Care, Department of Neurology, The Ohio State University, Columbus, OH, USA
| | - Raimund Helbok
- Neurocritical Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Courtney L Robertson
- Departments of Anesthesiology and Critical Care Medicine, and Pediatrics, The Johns Hopkins University SOM, Johns Hopkins Children's Center, Baltimore, MD, USA
| | - Jorge Mejia-Mantilla
- Department of Neuro-Intensive Care and Anesthesiology, Fundacio Valle del Lili, University Hospital, Cali, Colombia
| | - Pedro Kurtz
- Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil
| | - Cássia Righy
- National Institute of Infectious Diseases Evandro Chagas, Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brazil
| | - Juan D Roa
- Department of Pediatric Neurology and Critical Care, Universidad Nacional de Colombia and Fundación Universitaria de Ciencias de la Salud, Bogotá, Colombia
| | | | | | | | - Nelson Maldonado
- Department of Neurology, Universidad San Francisco de Quito (USFQ), de los Valles Quito, Ecuador
| | - David Menon
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital Cambridge, Cambridge, UK
| | - Jose Suarez
- Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sherry H Y Chou
- Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, Safar Center for Resuscitation Research, Pittsburgh, PA, USA
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Robba C, Poole D, McNett M, Asehnoune K, Bösel J, Bruder N, Chieregato A, Cinotti R, Duranteau J, Einav S, Ercole A, Ferguson N, Guerin C, Siempos II, Kurtz P, Juffermans NP, Mancebo J, Mascia L, McCredie V, Nin N, Oddo M, Pelosi P, Rabinstein AA, Neto AS, Seder DB, Skrifvars MB, Suarez JI, Taccone FS, van der Jagt M, Citerio G, Stevens RD. Mechanical ventilation in patients with acute brain injury: recommendations of the European Society of Intensive Care Medicine consensus. Intensive Care Med 2020; 46:2397-2410. [PMID: 33175276 PMCID: PMC7655906 DOI: 10.1007/s00134-020-06283-0] [Citation(s) in RCA: 110] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 10/05/2020] [Indexed: 12/29/2022]
Abstract
Purpose To provide clinical practice recommendations and generate a research agenda on mechanical ventilation and respiratory support in patients with acute brain injury (ABI). Methods An international consensus panel was convened including 29 clinician-scientists in intensive care medicine with expertise in acute respiratory failure, neurointensive care, or both, and two non-voting methodologists. The panel was divided into seven subgroups, each addressing a predefined clinical practice domain relevant to patients admitted to the intensive care unit (ICU) with ABI, defined as acute traumatic brain or cerebrovascular injury. The panel conducted systematic searches and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method was used to evaluate evidence and formulate questions. A modified Delphi process was implemented with four rounds of voting in which panellists were asked to respond to questions (rounds 1–3) and then recommendation statements (final round). Strong recommendation, weak recommendation, or no recommendation were defined when > 85%, 75–85%, and < 75% of panellists, respectively, agreed with a statement. Results The GRADE rating was low, very low, or absent across domains. The consensus produced 36 statements (19 strong recommendations, 6 weak recommendations, 11 no recommendation) regarding airway management, non-invasive respiratory support, strategies for mechanical ventilation, rescue interventions for respiratory failure, ventilator liberation, and tracheostomy in brain-injured patients. Several knowledge gaps were identified to inform future research efforts. Conclusions This consensus provides guidance for the care of patients admitted to the ICU with ABI. Evidence was generally insufficient or lacking, and research is needed to demonstrate the feasibility, safety, and efficacy of different management approaches. Electronic supplementary material The online version of this article (10.1007/s00134-020-06283-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Chiara Robba
- San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Daniele Poole
- Anesthesia and Intensive Care Operative Unit, S. Martino Hospital, Belluno, Italy
| | - Molly McNett
- Implementation Science, The Helene Fuld Health Trust National Institute for EBP, College of Nursing, The Ohio State University, Columbus, OH, USA
| | - Karim Asehnoune
- Department of Anaesthesia and Critical Care, Hôtel Dieu, University Hospital of Nantes, Nantes, France
| | - Julian Bösel
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
- Department of Neurology, Klinikum Kassel, Kassel, Germany
| | - Nicolas Bruder
- Anesthesiology-Intensive Care Department, Aix-Marseille University, APHM, CHU Timone, Marseille, France
| | - Arturo Chieregato
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Raphael Cinotti
- Department of Anaesthesia and Critical Care, Hôpital Guillaume et René Laennec, University Hospital of Nantes, Saint-Herblain, France
| | - Jacques Duranteau
- Department of Anesthesiology and Perioperative Intensive Care Medicine, Bicêtre Hospital, Assistance Publique Hôpitaux de Paris, Paris-Saclay University, Paris, France
| | - Sharon Einav
- Faculty of Medicine, Intensive Care Unit of the Shaare Zedek Medical Centre and Hebrew University, Jerusalem, Israel
| | - Ari Ercole
- University of Cambridge Division of Anaesthesia, Addenbrooke's Hospital, Cambridge, UK
| | - Niall Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Physiology, University of Toronto, Toronto, ON, Canada
| | - Claude Guerin
- Medecine Intensive-Réanimation, Hopital Edouard Herriot, University of Lyon, Lyon, France
- INSERM 955, Créteil, France
| | - Ilias I Siempos
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, New York-Presbyterian Hospital-Weill Cornell Medical Center, Weill Cornell Medicine, New York, NY, USA
| | - Pedro Kurtz
- Department of Neurointensive Care, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Nicole P Juffermans
- Department of Intensive Care Medicine, Olvg Hospital, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Jordi Mancebo
- Servei Medicina Intensiva, Hospital Sant Pau, Barcelona, Spain
| | - Luciana Mascia
- Alma Mater Studiorum, Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy
| | - Victoria McCredie
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Nicolas Nin
- Department of Intensive Care Medicine, Hospital Español, Montevideo, Uruguay
| | - Mauro Oddo
- Department of Intensive Care Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), University of Lausanne, Lausanne, Switzerland
| | - Paolo Pelosi
- San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | | | - Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Critical Care Medicine, Hospital Israelita Alberto Einstein, São Paulo, Brazil
| | - David B Seder
- Department of Critical Care Services, Neuroscience Institute, Maine Medical Center, 22 Bramhall Street, Portland, ME, 04102, USA
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Meilahden sairaala, Haartmaninkatu 4, 00029 HUS, Helsinki, Finland
| | - Jose I Suarez
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Phipps 455, Baltimore, MD, 21287, USA
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fabio Silvio Taccone
- Department of Intensive Care Medicine, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Mathieu van der Jagt
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano - Bicocca, Milan, Italy
| | - Robert D Stevens
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Phipps 455, Baltimore, MD, 21287, USA.
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Kurtz P, Taccone FS, Bozza FA, Bastos LSL, Righy C, Gonçalves B, Turon R, Machado MM, Maia M, Ferez MA, Nassif C, Soares M, Salluh JIF. Systemic Severity and Organ Dysfunction in Subarachnoid Hemorrhage: A Large Retrospective Multicenter Cohort Study. Neurocrit Care 2020; 35:56-61. [PMID: 33150574 DOI: 10.1007/s12028-020-01139-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 10/20/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND AND PURPOSE Acute physiologic derangements and multiple organ dysfunction are common after subarachnoid hemorrhage. We aimed to evaluate the simplified acute physiology score 3 (SAPS-3) and the sequential organ failure assessment (SOFA) scores for the prediction of in-hospital mortality in a large multicenter cohort of SAH patients. METHODS This was a retrospective analysis of prospectively collected data from 45 ICUs in Brazil, during 2014 and 2015. Patients admitted with non-traumatic subarachnoid hemorrhage (SAH) were included. Clinical and outcome data were retrieved from an electronic ICU quality registry. SAPS-3 and SOFA scores, without the neurological components (i.e., nSAPS-3 and nSOFA, respectively) were recorded, as well as the World Federation of Neurological Surgeons (WFNS) scale. We used multilevel logistic regression analysis to identify factors associated with in-hospital mortality. We evaluated performance using the area under the receiver operating characteristic curve (AUROC), as well as calibration belts and precision-recall plots. RESULTS The study included 997 patients, from which 426 (43%) had poor clinical grade (WFNS 4 or 5) and in-hospital mortality was 34%. Median nSAPS-3 and nSOFA score at admission were 46 (IQR: 38-55) and 2 (0-5), respectively. Non-survivors were older, had higher nSAPS-3 and nSOFA, and more often poor grade. After adjustment for age, poor grade and withdrawal of life sustaining therapies, multivariable analysis identified nSAPS-3 and nSOFA score as independent clinical predictors of in-hospital mortality. The AUROC curve that included nSAPS-3 and nSOFA scores significantly improved the already good discrimination and calibration of age and WFNS to predict in-hospital mortality (AUROC: 0.89 for the full final model vs. 0.85 for age and WFNS; P < 0.0001). CONCLUSIONS nSAPS-3 and nSOFA scores were independently associated with in-hospital mortality after SAH. The addition of these scores improved early prediction of hospital mortality in our cohort and should be integrated to other specific prognostic indices in the early assessment of SAH.
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Affiliation(s)
- Pedro Kurtz
- Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil. .,D ́Or Institute for Research and Education, Rio de Janeiro, Brazil. .,Hospital Copa Star, Rio de Janeiro, Brazil.
| | - Fabio Silvio Taccone
- Dpt of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Fernando A Bozza
- D ́Or Institute for Research and Education, Rio de Janeiro, Brazil.,National Institute of Infection, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Leonardo S L Bastos
- Pontifical Catholic University of Rio de Janeiro (PUC-Rio), Rio de Janeiro, Brazil
| | - Cassia Righy
- Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Bruno Gonçalves
- Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Ricardo Turon
- Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | | | | | | | | | - Marcio Soares
- D ́Or Institute for Research and Education, Rio de Janeiro, Brazil
| | - Jorge I F Salluh
- D ́Or Institute for Research and Education, Rio de Janeiro, Brazil.,Postgraduate Program, Internal Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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Kurtz P, Bastos LS, Aguilar S, Hamacher S, Bozza FA. Effect of seasonal and temperature variation on hospitalizations for stroke over a 10-year period in Brazil. Int J Stroke 2020; 16:406-410. [PMID: 32752950 DOI: 10.1177/1747493020947333] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Seasonal variation in stroke incidence remains controversial. AIMS We aimed to describe the pattern of seasonality in hospitalizations for stroke in Brazil. METHODS We evaluated age-adjusted hospitalization rates for stroke per month using data from the Brazilian Unified Healthcare System and median monthly temperature data obtained from the National Institute of Meteorology. To detect a seasonality pattern in time series, we used seasonal-trend decomposition using LOESS. We calculated a seasonal strength statistic and used Kruskal-Wallis test to evaluate the presence of seasonality in Brazil and its five regions. We also assessed the association of temperature and stroke hospitalization rates using Spearman's rho correlation. RESULTS We identified 1,422,496 stroke-related hospitalizations between 2009 and 2018. Mean age was 67 years, 51% were male and 77.5% of stroke diagnoses were not specified as ischemic or hemorrhagic. Median temperature was 23.8℃ (IQR 22.3-24.4). Age-adjusted hospitalizations demonstrated significant seasonal variation during all the years analyzed, with increased rates during the winter. When regional differences were analyzed, seasonal behavior was present in the south, southeast and northeast regions of the country. These were also the regions with lower median temperatures during the winter months and greater amplitude of average temperatures between warmer and colder months. CONCLUSIONS In this large national cohort of stroke patients in Brazil, we demonstrated the presence of seasonal variation in the age-adjusted hospitalization rate, with peak rates during the winter months. The regional gradient of incidence of stroke was directly associated with colder winters and greater amplitude of temperature.
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Affiliation(s)
- Pedro Kurtz
- Department of Neurointensive Care, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil.,Department of Neurointensive Care, Hospital Copa Star, Rio de Janeiro, Brazil
| | - Leonardo Sl Bastos
- Industrial Engineering Department, Pontifical Catholic University of Rio de Janeiro (PUC-Rio), Rio de Janeiro, Brazil
| | - Soraida Aguilar
- Industrial Engineering Department, Pontifical Catholic University of Rio de Janeiro (PUC-Rio), Rio de Janeiro, Brazil
| | - Silvio Hamacher
- Industrial Engineering Department, Pontifical Catholic University of Rio de Janeiro (PUC-Rio), Rio de Janeiro, Brazil
| | - Fernando A Bozza
- National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil.,D'Or Institute for Research and Education (IDOR), Rio de Janeiro, Brazil
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31
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Kurtz P, Rocha EEM. Nutrition Therapy, Glucose Control, and Brain Metabolism in Traumatic Brain Injury: A Multimodal Monitoring Approach. Front Neurosci 2020; 14:190. [PMID: 32265626 PMCID: PMC7105880 DOI: 10.3389/fnins.2020.00190] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 02/21/2020] [Indexed: 12/19/2022] Open
Abstract
The goal of neurocritical care in patients with traumatic brain injury (TBI) is to prevent secondary brain damage. Pathophysiological mechanisms lead to loss of body mass, negative nitrogen balance, dysglycemia, and cerebral metabolic dysfunction. All of these complications have been shown to impact outcomes. Therapeutic options are available that prevent or mitigate their negative impact. Nutrition therapy, glucose control, and multimodality monitoring with cerebral microdialysis (CMD) can be applied as an integrated approach to optimize systemic immune and organ function as well as adequate substrate delivery to the brain. CMD allows real-time bedside monitoring of aspects of brain energy metabolism, by measuring specific metabolites in the extracellular fluid of brain tissue. Sequential monitoring of brain glucose and lactate/pyruvate ratio may reveal pathologic processes that lead to imbalances in supply and demand. Early recognition of these patterns may help individualize cerebral perfusion targets and systemic glucose control following TBI. In this direction, recent consensus statements have provided guidelines and recommendations for CMD applications in neurocritical care. In this review, we summarize data from clinical research on patients with severe TBI focused on a multimodal approach to evaluate aspects of nutrition therapy, such as timing and route; aspects of systemic glucose management, such as intensive vs. moderate control; and finally, aspects of cerebral metabolism. Research and clinical applications of CMD to better understand the interplay between substrate supply, glycemic variations, insulin therapy, and their effects on the brain metabolic profile were also reviewed. Novel mechanistic hypotheses in the interpretation of brain biomarkers were also discussed. Finally, we offer an integrated approach that includes nutritional and brain metabolic monitoring to manage severe TBI patients.
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Affiliation(s)
- Pedro Kurtz
- Department of Neurointensive Care, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil.,Department of Intensive Care Medicine, Hospital Copa Star, Rio de Janeiro, Brazil
| | - Eduardo E M Rocha
- Department of Intensive Care Medicine, Hospital Copa Star, Rio de Janeiro, Brazil
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32
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Meyfroidt G, Kurtz P, Sonneville R. Critical care management of infectious meningitis and encephalitis. Intensive Care Med 2020; 46:192-201. [PMID: 31938828 DOI: 10.1007/s00134-019-05901-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Accepted: 12/14/2019] [Indexed: 01/14/2023]
Affiliation(s)
- Geert Meyfroidt
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium. .,Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium.
| | - Pedro Kurtz
- Neuro-Critical Care Unit, Instituto Estadual Do Cérebro Paulo Niemeyer and Hospital Copa Star, Rio de Janeiro, Brasil
| | - Romain Sonneville
- Université de Paris, INSERM UMR1148, team 6, 75018, Paris, France.,APHP, Intensive Care Medicine, Hôpital Bichat-Claude Bernard, 75018, Paris, France
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Gonçalves B, Kurtz P, Bozza FA, Righy C. In Reply to the Letter to the Editor Regarding “Effect of Early Brain Infarction After Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis”. World Neurosurg 2019; 124:473. [PMID: 30684696 DOI: 10.1016/j.wneu.2019.01.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Accepted: 01/02/2019] [Indexed: 11/15/2022]
Affiliation(s)
- Bruno Gonçalves
- Intensive Care Unit, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil.
| | - Pedro Kurtz
- Intensive Care Unit, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil
| | | | - Cassia Righy
- Intensive Care Unit, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil; Oswaldo Cruz Foundation, National Institute of Infectology, Rio de Janeiro, Brazil
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Gonçalves B, Turon R, Mendes A, Melo N, Lacerda P, Brasil P, Bozza FA, Kurtz P, Righy C. Effect of Early Brain Infarction After Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis. World Neurosurg 2018; 115:e292-e298. [PMID: 29660554 DOI: 10.1016/j.wneu.2018.04.037] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 04/04/2018] [Accepted: 04/05/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Aneurysmal subarachnoid hemorrhage (aSAH) is an acute cerebrovascular event that leads to devastating consequences. Early brain infarction (EBI) develops very early, within the first 72 hours after bleeding, and may have a significant impact on long-term outcomes. The incidence and impact of EBI in the prognosis of aSAH remain uncertain. We performed a systematic review and meta-analysis to evaluate the incidence of EBI in patients with aSAH and determine its effect on mortality and functional outcomes. METHODS We performed a systematic review and meta-analysis. Inclusion criteria were 1) studies that evaluated aSAH within 72 hours after bleeding; 2) performed a brain imaging study up to 72 hours of hemorrhage; 3) used computed tomography or magnetic resonance imaging; and 4) included a description of the findings of the brain imaging study (whether or not an infarct was present). RESULTS Ten studies that met the criteria were included. The incidence of EBI was 17%. The risk ratio for 3-month mortality was 2.18 (95% confidence interval 1.48-3.30). The overall risk ratio for poor outcome was 2.26 (95% confidence interval 1.75-2.93). CONCLUSIONS EBI plays an important role in the outcome of patients with aSAH. Its significant impact could represent a new therapeutic frontier for improving outcomes of these patients.
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Affiliation(s)
- Bruno Gonçalves
- Paulo Niemeyer State Brain Institute, Intensive Care Unit, Rio de Janeiro, Brazil; Oswaldo Cruz Foundation, National Institute of Infectology, Rio de Janeiro, Brazil; Copa Star Hospital, Intensive Care Unit, Rio de Janeiro, Brazil.
| | - Ricardo Turon
- Paulo Niemeyer State Brain Institute, Intensive Care Unit, Rio de Janeiro, Brazil; Niterói Hospital Complex, Neurocritical Care Unit, Niterói, Brazil
| | - Antenor Mendes
- Paulo Niemeyer State Brain Institute, Intensive Care Unit, Rio de Janeiro, Brazil; Copa Star Hospital, Intensive Care Unit, Rio de Janeiro, Brazil
| | - Nivea Melo
- Paulo Niemeyer State Brain Institute, Intensive Care Unit, Rio de Janeiro, Brazil; Copa Star Hospital, Intensive Care Unit, Rio de Janeiro, Brazil
| | - Paula Lacerda
- Paulo Niemeyer State Brain Institute, Intensive Care Unit, Rio de Janeiro, Brazil
| | - Pedro Brasil
- Oswaldo Cruz Foundation, National Institute of Infectology, Rio de Janeiro, Brazil
| | - Fernando Augusto Bozza
- Oswaldo Cruz Foundation, National Institute of Infectology, Rio de Janeiro, Brazil; D'Or Institute for Research and Eduaction, Rio de Janeiro, Brazil
| | - Pedro Kurtz
- Paulo Niemeyer State Brain Institute, Intensive Care Unit, Rio de Janeiro, Brazil; Copa Star Hospital, Intensive Care Unit, Rio de Janeiro, Brazil
| | - Cassia Righy
- Paulo Niemeyer State Brain Institute, Intensive Care Unit, Rio de Janeiro, Brazil; Oswaldo Cruz Foundation, National Institute of Infectology, Rio de Janeiro, Brazil
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D'Brot A, Kurtz P, Regan E, Jakubowski B, Abrams JM. A platform for interrogating cancer-associated p53 alleles. Oncogene 2017; 36:292. [PMID: 27991923 DOI: 10.1038/onc.2016.190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Kurtz P, Helbok R, Claassen J, Schmidt JM, Fernandez L, Stuart RM, Connolly ES, Lee K, Mayer SA, Badjatia N. The Effect of Packed Red Blood Cell Transfusion on Cerebral Oxygenation and Metabolism After Subarachnoid Hemorrhage. Neurocrit Care 2016. [PMID: 26195087 DOI: 10.1007/s12028-015-0180-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Anemia adversely affects cerebral oxygenation and metabolism after subarachnoid hemorrhage (SAH) and is also associated with poor outcome. There is limited evidence to support the use of packed red blood cell (PRBC) transfusion to optimize brain homeostasis after SAH. The aim of this study was to investigate the effect of transfusion on cerebral oxygenation and metabolism in patients with SAH. METHODS This was a prospective observational study in a neurological intensive care unit of a university hospital. Nineteen transfusions were studied in 15 consecutive patients with SAH that underwent multimodality monitoring (intracranial pressure, brain tissue oxygen, and cerebral microdialysis). Data were collected at baseline and for 12 h after transfusion. The relationship between hemoglobin (Hb) change and lactate/pyruvate ratio (LPR) orbrain tissue oxygen (PbtO2) was tested using univariate and multivariable analyses. RESULTS PRBC transfusion was administered on the median post-bleed day 8. The average Hb concentration at baseline was 8.1 g/dL and increased by 2.2 g/dL after transfusion. PbtO2 increased between hours 2 and 4 post-transfusion and this increase was maintained until hour 10. LPR did not change significantly during the 12-h monitoring period. After adjusting for SpO2, cerebral perfusion pressure, and LPR, the change in Hb concentration was independently and positively associated with a change in PbtO2 (adjusted b estimate = 1.39 [95% confidence interval 0.09-2.69]; P = 0.04). No relationship between the change in Hb concentration and LPR was found. CONCLUSIONS PRBC transfusion resulted in PbtO2 improvement without a clear effect on cerebral metabolism prior to SAH.
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Affiliation(s)
- Pedro Kurtz
- Neurological Intensive Care Unit, Brain Institute Paulo Niemeyer, Rio de Janeiro, Brazil.
| | - Raimund Helbok
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria.
| | - Jan Claassen
- Division of Critical Care Neurology and Comprehensive Epilepsy Center, College of Physicians and Surgeons, Neurological Institute, Columbia University, New York, NY, USA.
| | - J Michael Schmidt
- Division of Critical Care Neurology, Neurological Institute, Columbia University College of Physicians and Surgeons, New York, NY, USA.
| | - Luis Fernandez
- Division of Critical Care Neurology, Neurological Institute, Columbia University College of Physicians and Surgeons, New York, NY, USA.
| | - R Morgan Stuart
- Department of Neurological Surgery, Columbia University College of Physicians and Surgeons, New York, NY, USA.
| | - E Sander Connolly
- Department of Neurological Surgery, Columbia University College of Physicians and Surgeons, New York, NY, USA.
| | - Kiwon Lee
- Departments of Neurology and Neurosurgery, The University of Texas Medical School at Houston, Houston, TX, USA.
| | - Stephan A Mayer
- Institute of Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Neeraj Badjatia
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MA, USA.
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Velasquez T, Mackey G, Lusk J, Kyle UG, Fontenot T, Marshall P, Shekerdemian LS, Coss-Bu JA, Nishigaki A, Yatabe T, Tamura T, Yamashita K, Yokoyama M, Ruiz-Rodriguez JC, Encina B, Belmonte R, Troncoso I, Tormos P, Riveiro M, Baena J, Sanchez A, Bañeras J, Cordón J, Duran N, Ruiz A, Caballero J, Nuvials X, Riera J, Serra J, Rutten AMF, van Ieperen SNM, Der Kinderen EPHM, Van Logten T, Kovacikova L, Skrak P, Zahorec M, Kyle UG, Akcan-Arikan A, Silva JC, Mackey G, Lusk J, Goldsworthy M, Shekerdemian LS, Coss-Bu JA, Wood D, Harrison D, Parslow R, Davis P, Pappachan J, Goodwin S, Ramnarayan P, Chernyshuk S, Yemets H, Zhovnir V, Pulitano’ SM, De Rosa S, Mancino A, Villa G, Tosi F, Franchi P, Conti G, Patel B, Khine H, Shah A, Sung D, Singer L, Haghbin S, Inaloo S, Serati Z, Idei M, Nomura T, Yamamoto N, Sakai Y, Yoshida T, Matsuda Y, Yamaguchi Y, Takaki S, Yamaguchi O, Goto T, Longani N, Medar S, Abdel-Aal IR, El Adawy AS, Mohammed HMEH, Mohamed AN, Parry SM, Knight LD, Denehy L, De Morton N, Baldwin CE, Sani D, Kayambu G, da Silva VZM, Phongpagdi P, Puthucheary ZA, Granger CL, Rydingsward JE, Horkan CM, Christopher KB, Muscedere J, Scott SH, Saha T, Hamilton A, Petsikas D, Payne D, Boyd JG, Puthucheary ZA, McNelly AS, Rawal J, McWilliams D, Connolly B, McPhail MJ, Sidhu P, Rowlerson A, Moxham J, Harridge SD, Hart N, Montgomery HE, Jovaisa T, Thomas B, Jones C, Gupta D, Wijayatilake DS, Shum HP, King HS, Chan KC, Tang KB, Yan WW, Arias CC, Latorre J, De La Rica AS, Reeves E, Garrido EM, Feijoo AM, Gancedo CH, Tofiño AL, Rodríguez FG, Gemmell LK, Campbell R, Doherty P, MacKay A, Singh N, Atkins G, Vitaller S, Nagib H, Prieto J, Del Arco A, Zayas B, Gomez C, Tirumala S, Pasha SA, Kumari BK, Martinez-Lopez P, Snelson C, Puerto-Morlán A, Nuevo-Ortega P, Pujol LM, Dolset RA, González BS, Riera SQ, Álvarez JT, Quintana S, Martínez L, Algarte R, Aitken LM, Sánchez B, Trenado J, Tomas E, Brock N, Viegas E, Filipe E, Cottle D, Traynor T, Martínez MVT, Márquez MP, Rattray J, Gómez LC, Martínez NA, Muñoz JMM, Bellver BQ, Varea MM, Llorente MÁA, Calvo CP, Hillier SD, Faulds MC, Hendra H, Kenardy J, Lawrence N, Maekawa K, Hayakawa M, Ono Y, Kodate A, Sadamoto Y, Tominaga N, Mizugaki A, Murakami H, Yoshida T, Hull AM, Katabami K, Wada T, Sawamura A, Gando S, Silva S, Kerhuel L, Malagurski B, Citerio G, Chabanne R, Laureys S, Ullman A, Puybasset L, Nobile L, Pognuz ER, Rossetti AO, Verginella F, Gaspard N, Creteur J, Ben-Hamouda N, Oddo M, Taccone FS, Le Brocque R, Ono Y, Hayakawa M, Iijima H, Maekawa K, Kodate A, Sadamoto Y, Mizugaki A, Murakami H, Katabami K, Wada T, Mitchell M, Sawamura A, Gando S, Kodate A, Katabami K, Wada T, Ono Y, Maekawa K, Hayakawa M, Sawamura A, Gando S, Davis C, Andersen LW, Raymond T, Berg R, Nadkarni V, Grossestreuer A, Kurth T, Donnino M, Krüger A, Ostadal P, Janotka M, Macfarlane B, Vondrakova D, Kongpolprom N, Cholkraisuwat J, Pekkarinen PT, Ristagno G, Masson S, Latini R, Bendel S, Ala-Kokko T, Varpula T, Azevedo JC, Vaahersalo J, Hoppu S, Tiainen M, Mion MM, Plebani M, Pettilä V, Skrifvars M, Son Y, Kim KS, Suh GJ, Rocha LL, Kwon WY, Ko JI, Park MJ, Cavicchi FZ, Iesu E, Nobile L, Vincent JL, Creteur J, Taccone FS, Tanaka H, De Freitas FFM, Otani N, Ode S, Ishimatsu S, Martínez L, Algarte R, Sánchez B, Romero I, Martínez F, Quintana S, Trenado J, Cavalheiro AM, Vondrakova D, Ostadal P, Kruger A, Janotka M, Malek F, Neuzil P, Yeh YC, Chen YS, Wang CH, Huang CH, Lucinio NM, Chao A, Lee CT, Lai CH, Chan WS, Cheng YJ, Sun WZ, Kaese S, Horstmann C, Lebiedz P, Mourad M, Lobato MS, Gaudard P, Eliet J, Zeroual N, Colson P, Ostadal P, Mlcek M, Hrachovina M, Kruger A, Vondrakova D, Janotka M, Ebeling G, Mates M, Hala P, Kittnar O, Neuzil P, Jacky A, Rudiger A, Spahn DR, Bettex DA, Kara A, Akin S, Kraegpoeth A, Dos reis Miranda D, Struijs A, Caliskan K, van Thiel RJ, Dubois EA, de Wilde W, Zijlstra F, Gommers D, Ince C, Marca L, Laerkner E, Xini A, Mongkolpun W, Cordeiro CPR, Leite RT, Lheureux O, Bader A, Rincon L, Santacruz C, Preiser JC, Chao A, De Brito-Ashurst I, Chao AS, Chen YS, Kim W, Ahn C, Cho Y, Lim TH, Oh J, Choi KS, Jang BH, Ha JK, White C, Mecklenburg A, Stamm J, Soeffker G, Kubik M, Sydow K, Reichenspurner H, Kluge S, Braune S, Bergantino B, Ruberto F, Gregory S, Magnanimi E, Privato E, Zullino V, Bruno K, Pugliese F, Sales G, Girotto V, Vittone F, Brazzi L, Fritz C, Forni LG, Kimmoun A, Vanhuyse F, Trifan B, Orlowski S, Albuisson E, Tran N, Levy B, Chhor V, Joachim J, Follin A, Flowers E, Champigneulle B, Chatelon J, Fave G, Mantz J, Pirracchio R, Diaz DD, Villanova M, Aguirregabyria M, Andrade G, López L, Curtis A, Palencia E, John G, Cowan R, Hart R, Lake K, Litchfield K, Song JW, Lee YJ, Cho YJ, Choi S, Wood CA, Vermeir P, Vandijck D, Blot S, Mariman A, Verhaeghe R, Deveugele M, Vogelaers D, Chok L, Bachli EB, Bettex D, Siu K, Cottini SR, Keller E, Maggiorini M, Schuepbach R, Fiks T, Stiphout C, Grevelink M, Vaneker I, Ruijter A, Buise M, Venkatesan K, Spronk PE, Tena SA, Barrachina LG, Portillo JHR, Aznar GP, Campos LM, Sellés MDF, Tomás MA, Muncharaz AB, Skinner L, Muhammad JBH, Monsalvo S, Olavarria E, Stümpfle R, Na SJ, Park J, Chung CR, Park CM, Suh GY, Yang JH, Witter T, Ng L, Brousseau C, Butler MB, Erdogan M, Dougall PCM, Green RS, Abbott TEF, Torrance HDT, Cron N, Vaid N, Emmanuel J, Seet E, Siddiqui SS, Prabu N, Chaudhari HK, Patil VP, Divatia JV, Solanki S, Kulkarni AP, Gutierrez LAR, Bader A, Brasseur A, Baptista N, Lheureux O, Vincent JL, Creteur J, Taccone FS, Hempel D, Stauffert N, Recker F, Schröder T, Reusch S, Schleifer J, Escoval A, Breitkreutz R, Sjövall F, Perner A, Møller MH, Moraes RB, Borges FK, Guillen JAV, Zabaletta WJC, Ruiz-Ramos J, Ramirez P, Tomas E, Marqués-Miñana MR, Villarreal E, Gordon M, Sosa M, Concha P, Castellanos A, Menendez R, Ramírez CS, Santana MC, Balcázar LC, Agrawal R, Escalada SH, Viera MAH, Vázquez CFL, Díaz JJD, Campelo FA, Monroy NS, Santana PS, Santana SR, Gutiérrez-Pizarraya A, Garnacho-Montero J, 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Hodgson LE, Lortat-Jacob B, Stubbs C, Forni LG, Venn R, Londoño JG, Cardenas CL, Ginés AS, Gubianas CM, Sánchez EC, Sirvent JM, Panafidina V, Augustin P, Shlyk I, Ilyina V, Judickas S, Kezyte G, Urbanaviciute I, Serpytis M, Gaizauskas E, Sipylaite J, Sprung CL, Munteanu G, Desmard M, Morales RC, Kasdan H, Volker T, Reiter A, Cohen Y, Himmel Y, Meissonnier J, Banderas-Bravo ME, Gómez-Jiménez C, García-Martínez MV, Montravers P, Martínez-Carmona JF, Fernández-Ortega JF, O‘Dwyer MJ, Starczewska M, Wilks M, Vincent JL, Torsvik M, Gustad LT, Bangstad IL, Vinje LJ, de Molina FJG, Damås JK, Solligård E, Mehl A, Tsunoda M, Kang M, Saito M, Saito N, Akizuki N, Namiki M, Takeda M, Barbadillo S, Yuzawa J, Yaguchi A, Frantzeskaki F, Tsirigotis P, Chondropoulos S, Paramythiotou E, Theodorakopoulou M, Stamouli M, Gkirkas K, Dimopoulou IK, Alejandro R, Makiko S, Tsunoda M, Kang M, Yuzawa J, Akiduki N, Namiki M, Takeda M, Yaguchi A, Preau S, Ambler M, Álvarez-Lerma F, Sigurta A, Saeed S, Singer M, Jochmans S, Chelly J, Vong LVP, Sy O, Serbource-Goguel J, Rolin N, Weyer CM, Vallés J, Abdallah RI, Adrie C, Vinsonneau C, Monchi M, Mayr U, Huber W, Karsten E, Lahmer T, Thies P, Henschel B, Catalán RM, Fischer G, Schmid RM, Ediboglu O, Ataman S, Naz I, Yaman G, Kirakli C, Su PL, Kou PS, Lin WC, Palencia E, Chen CW, Lozano JAB, Sánchez PC, Francioni JEB, Ferrón FR, Simón JMS, Riad Z, Mezidi M, Aublanc M, Perinel S, Jareño A, Lissonde F, Louf-Durier A, Yonis H, Tapponnier R, Richard JC, Louis B, Guérin C, Mezidi M, Yonis H, Aublanc M, Granada RM, Lissonde F, Louf-Durier A, Perinel S, Tapponnier R, Richard JC, Guérin C, Marmanidou K, Oikonomou M, Nouris C, Loizou C, Ignacio ML, Soilemezi E, Matamis D, Somhorst P, Gommers D, Hayashi K, Hirayama T, Yumoto T, Tsukahara K, Iida A, Nosaka N, Cui N, Sato K, Ugawa T, Nakao A, Ujike Y, Hirohata S, Mojoli F, Torriglia F, Giannantonio M, Orlando A, Bianzina S, Liu D, Tavazzi G, Mongodi S, Pozzi M, Iotti GA, Braschi A, Jansen D, Gadgil S, Doorduin 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E, Juliarena A, Bisso MC, Grando M, Tapia A, Camargo M, Ulla DV, Corzo L, dos Santos HP, Ramos A, Doglia JA, Estenssoro E, Carbonara M, Magnoni S, Donald CLM, Shimony JS, Conte V, Triulzi F, Stretti F, Macrì M, Snyder AZ, Stocchetti N, Brody DL, Podlepich V, Shimanskiy V, Savin I, Lapteva K, Chumaev A, Tjepkema-Cloostermans MC, Hofmeijer J, Beishuizen A, Hom H, Blans MJ, van Putten MJAM, Longhi L, Frigeni B, Curinga M, Mingone D, Beretta S, Patruno A, Gandini L, Vargiolu A, Ferri F, Ceriani R, Rottoli MR, Lorini L, Citerio G, Pifferi S, Battistini M, Cordolcini V, Agarossi A, Di Rosso R, Ortolano F, Stocchetti N, Lourido CM, Cabrera JLS, Santana JDM, Alzola LM, del Rosario CG, Pérez HR, Torrent RL, Eslami S, Dalhuisen A, Fiks T, Schultz MJ, Hanna AA, Spronk PE, Wood M, Maslove D. ESICM LIVES 2016: part three. Intensive Care Med Exp 2016. [PMCID: PMC5042925 DOI: 10.1186/s40635-016-0100-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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D'Brot A, Kurtz P, Regan E, Jakubowski B, Abrams JM. A platform for interrogating cancer-associated p53 alleles. Oncogene 2016; 36:286-291. [PMID: 26996664 PMCID: PMC5031501 DOI: 10.1038/onc.2016.48] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Revised: 01/06/2016] [Accepted: 01/19/2016] [Indexed: 12/13/2022]
Abstract
p53 is the most frequently mutated gene in human cancer. Compelling evidence argues that full transformation involves loss of growth suppression encoded by wild-type p53 together with poorly understood oncogenic activity encoded by missense mutations. Furthermore, distinguishing disease alleles from natural polymorphisms is an important clinical challenge. To interrogate the genetic activity of human p53 variants, we leveraged the Drosophila model as an in vivo platform. We engineered strains that replace the fly p53 gene with human alleles, producing a collection of stocks that are, in effect, ‘humanized’ for p53 variants. Like the fly counterpart, human p53 transcriptionally activated a biosensor and induced apoptosis after DNA damage. However, all humanized strains representing common alleles found in cancer patients failed to complement in these assays. Surprisingly, stimulus-dependent activation of hp53 occurred without stabilization, demonstrating that these two processes can be uncoupled. Like its fly counterpart, hp53 formed prominent nuclear foci in germline cells but cancer-associated p53 variants did not. Moreover, these same mutant alleles disrupted hp53 foci and inhibited biosensor activity, suggesting that these properties are functionally linked. Together these findings establish a functional platform for interrogating human p53 alleles and suggest that simple phenotypes could be used to stratify disease variants.
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Affiliation(s)
- A D'Brot
- Department of Cell Biology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - P Kurtz
- Department of Cell Biology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - E Regan
- Department of Physical Therapy, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - B Jakubowski
- Southwestern Medical School, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, USA
| | - J M Abrams
- Department of Cell Biology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Ko SB, Choi HA, Helbok R, Kurtz P, Schmidt JM, Badjatia N, Claassen J, Connolly ES, Mayer SA, Lee K. Acute effects of intraventricular nicardipine on cerebral hemodynamics: A preliminary finding. Clin Neurol Neurosurg 2016; 144:48-52. [PMID: 26971295 DOI: 10.1016/j.clineuro.2016.02.037] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Revised: 02/26/2016] [Accepted: 02/27/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Intraventricular nicardipine (IVTN) is a treatment option for severe vasospasm in patients with subarachnoid hemorrhage (SAH). However, its acute effects on cerebral hemodynamics have not been studied in detail. METHODS Between June 2008 and December 2010, IVTN was administered (mainly 4mg every 8h) to 11 SAH patients (54 doses) with multimodality monitoring for refractory vasospasm. Retrospective analyses on physiological parameters were made from baseline and up to 6h after IVTN injection. Statistical analysis was performed with a mixed-effects model. RESULTS Mean intracranial pressure (ICP) increased slightly, reaching its peak at 20min after IVTN injection (2.5±0.9mmHg (mean±standard error), P<0.01), and decreased gradually thereafter over the next hour. Mean cerebral perfusion pressure transiently decreased 20-30min after injection (3.7±1.8mmHg, P<0.05). Mean arterial pressure, partial pressure of brain oxygen tension (PbtO2), cerebral blood flow (CBF), autoregulation indices did not change significantly. Lactate/pyruvate ratio and glucose remained stable. One patient underwent transcranial Doppler ultrasonography monitoring while on IVTN, which showed a transient increase in mean flow velocity with concomitant decrease in Pulsatility index, suggesting vasodilation in the distal resistance vessels. CONCLUSIONS The vasodilatory effect of IVTN transiently increased ICP, but did not significantly affect PbtO2, CBF or oxidative glucose metabolism in the immediate phase after injection.
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Affiliation(s)
- Sang-Bae Ko
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of Korea
| | - H Alex Choi
- Department of Neurology and Neurosurgery, The Mischer Neuroscience Institute, Memorial Hermann of Texas Medical Center, Houston, TX, USA
| | - Raimund Helbok
- Clinical Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
| | - Pedro Kurtz
- Neuro Intensive Care Unit, Brain Institute Paulo Niemeyer, Rio de Janeiro, RJ, Brazil
| | - J Michael Schmidt
- Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Neeraj Badjatia
- Section of Neurocritical Care, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD, USA
| | - Jan Claassen
- Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY, USA; Department of Neurosurgery, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - E Sander Connolly
- Department of Neurosurgery, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Stephan A Mayer
- Departments of Neurology and Neurosurgery, Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kiwon Lee
- Department of Neurology and Neurosurgery, The Mischer Neuroscience Institute, Memorial Hermann of Texas Medical Center, Houston, TX, USA.
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Kurtz P, Claassen J, Helbok R, Schmidt J, Fernandez L, Presciutti M, Stuart RM, Connolly ES, Lee K, Badjatia N, Mayer SA. Systemic glucose variability predicts cerebral metabolic distress and mortality after subarachnoid hemorrhage: a retrospective observational study. Crit Care 2014; 18:R89. [PMID: 24887049 PMCID: PMC4056693 DOI: 10.1186/cc13857] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Accepted: 04/24/2014] [Indexed: 01/04/2023]
Abstract
Introduction Cerebral glucose metabolism and energy production are affected by serum glucose levels. Systemic glucose variability has been shown to be associated with poor outcome in critically ill patients. The objective of this study was to assess whether glucose variability is associated with cerebral metabolic distress and outcome after subarachnoid hemorrhage. Methods A total of 28 consecutive comatose patients with subarachnoid hemorrhage, who underwent cerebral microdialysis and intracranial pressure monitoring, were studied. Metabolic distress was defined as lactate/pyruvate ratio (LPR) >40. The relationship between daily glucose variability, the development of cerebral metabolic distress and hospital outcome was analyzed using a multivariable general linear model with a logistic link function for dichotomized outcomes. Results Daily serum glucose variability was expressed as the standard deviation (SD) of all serum glucose measurements. General linear models were used to relate this predictor variable to cerebral metabolic distress and mortality at hospital discharge. A total of 3,139 neuromonitoring hours and 181 days were analyzed. After adjustment for Glasgow Coma Scale (GCS) scores and brain glucose, SD was independently associated with higher risk of cerebral metabolic distress (adjusted odds ratio = 1.5 (1.1 to 2.1), P = 0.02). Increased variability was also independently associated with in hospital mortality after adjusting for age, Hunt Hess, daily GCS and symptomatic vasospasm (P = 0.03). Conclusions Increased systemic glucose variability is associated with cerebral metabolic distress and increased hospital mortality. Therapeutic approaches that reduce glucose variability may impact on brain metabolism and outcome after subarachnoid hemorrhage.
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Kurtz P, Vargas-Lopes C, Madeira C, Mello I, Panizzutti R, Azevedo LC, Bozza FA. Pathophysiology of sepsis-associated brain dysfunction: an experimental study of cerebral microdialysis and mitochondrial function. Crit Care 2013. [PMCID: PMC3642671 DOI: 10.1186/cc11961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Turon R, Ferreira FR, Prado D, Kurtz P, Damasceno M. One-year extended Glasgow Outcome Scale and hospital mortality predictors in patients with severe traumatic brain injury in Brazil. Crit Care 2013. [PMCID: PMC3642589 DOI: 10.1186/cc12275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Helbok R, Kurtz P, Vibbert M, Schmidt MJ, Fernandez L, Lantigua H, Ostapkovich ND, Connolly SE, Lee K, Claassen J, Mayer SA, Badjatia N. Early neurological deterioration after subarachnoid haemorrhage: risk factors and impact on outcome. J Neurol Neurosurg Psychiatry 2013; 84:266-70. [PMID: 23012446 PMCID: PMC3582083 DOI: 10.1136/jnnp-2012-302804] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Early neurological deterioration occurs frequently after subarachnoid haemorrhage (SAH). The impact on hospital course and outcome remains poorly defined. METHODS We identified risk factors for worsening on the Hunt-Hess grading scale within the first 24 h after admission in 609 consecutively admitted aneurysmal SAH patients. Admission risk factors and the impact of early worsening on outcome was evaluated using multivariable analysis adjusting for age, gender, admission clinical grade, admission year and procedure type. Outcome was evaluated at 12 months using the modified Rankin Scale (mRS). RESULTS 211 patients worsened within the first 24 h of admission (35%). In a multivariate adjusted model, early worsening was associated with older age (OR 1.02, 95% CI 1.001 to 1.03; p=0.04), the presence of intracerebral haematoma on initial CT scan (OR 2.0, 95% CI 1.2 to 3.5; p=0.01) and higher SAH and intraventricular haemorrhage sum scores (OR 1.05, 95% CI 1.03 to 1.08 and 1.1, 95% CI 1.01 to 1.2; p<0.001 and 0.03, respectively). Early worsening was associated with more hospital complications and prolonged length of hospital stay and was an independent predictor of death (OR 12.1, 95% CI 5.7 to 26.1; p<0.001) and death or moderate to severe disability (mRS 4-6, OR 8.4, 95% CI 4.9 to 14.5; p=0.01) at 1 year. CONCLUSIONS Early worsening after SAH occurs in 35% of patients, is predicted by clot burden and is associated with mortality and poor functional outcome at 1 year.
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Affiliation(s)
- Raimund Helbok
- Department of Neurology, Division of Neurocritical Care, Columbia University College of Physicians and Surgeons, New York, NY, USA
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Helbok R, Kurtz P, Schmidt MJ, Stuart MR, Fernandez L, Connolly SE, Lee K, Schmutzhard E, Mayer SA, Claassen J, Badjatia N. Effects of the neurological wake-up test on clinical examination, intracranial pressure, brain metabolism and brain tissue oxygenation in severely brain-injured patients. Crit Care 2012. [PMID: 23186037 PMCID: PMC3672610 DOI: 10.1186/cc11880] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction Daily interruption of sedation (IS) has been implemented in 30 to 40% of intensive care units worldwide and may improve outcome in medical intensive care patients. Little is known about the benefit of IS in acutely brain-injured patients. Methods This prospective observational study was performed in a neuroscience intensive care unit in a tertiary-care academic center. Twenty consecutive severely brain-injured patients with multimodal neuromonitoring were analyzed for levels of brain lactate, pyruvate and glucose, intracranial pressure (ICP), cerebral perfusion pressure (CPP) and brain tissue oxygen tension (PbtO2) during IS trials. Results Of the 82 trial days, 54 IS-trials were performed as interruption of sedation and analgesics were not considered safe on 28 days (34%). An increase in the FOUR Score (Full Outline of UnResponsiveness score) was observed in 50% of IS-trials by a median of three (two to four) points. Detection of a new neurologic deficit occurred in one trial (2%), and in one-third of IS-trials the trial had to be stopped due to an ICP-crisis (> 20 mmHg), agitation or systemic desaturation. In IS-trials that had to be aborted, a significant increase in ICP and decrease in PbtO2 (P < 0.05), including 67% with critical values of PbtO2 < 20 mmHg, a tendency to brain metabolic distress (P < 0.07) was observed. Conclusions Interruption of sedation revealed new relevant clinical information in only one trial and a large number of trials could not be performed or had to be stopped due to safety issues. Weighing pros and cons of IS-trials in patients with acute brain injury seems important as related side effects may overcome the clinical benefit.
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Kurtz P, Fitts V, Sumer Z, Jalon H, Cooke J, Kvetan V, Mayer SA. How does care differ for neurological patients admitted to a neurocritical care unit versus a general ICU? Neurocrit Care 2012; 15:477-80. [PMID: 21519958 DOI: 10.1007/s12028-011-9539-2] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Neurological patients have lower mortality and better outcomes when cared for in specialized neurointensive care units than in general ICUs. However, little is known about how the process of care differs between these types of units. METHODS The Greater New York Hospital Association conducted a city-wide 24-h ICU prevalence survey on March 15th, 2007. Data was collected on all patients admitted to 143 ICUs in 69 different hospitals. RESULTS Of 1,906 ICU patients surveyed, 231 had a primary neurological diagnosis. Of these, 52 (22%) were admitted to one of 9 neuro-ICU's in NY and 179 (78%) to a medical or surgical ICU. Neurological patients in neuro-ICUs were more likely to have been transferred from an outside hospital (37% vs. 11%, P < 0.0001). Hemorrhagic stroke was more frequent in neuro-ICUs (46% vs. 16%, P < 0.0001), whereas traumatic brain injury (2% vs. 24%, P < 0.0001) and ischemic stroke (0% vs. 19%, P = 0.001) were less common. Despite a lower rate of mechanical ventilation (39% vs. 50%, P = 0.15), ICU length of stay was longer in neuro-ICU patients (≥10 days, 40% vs. 17%, P < 0.0001). More neuro-ICU patients had undergone tracheostomy (35% vs. 15%, P = 0.04), invasive hemodynamic monitoring (40% vs. 20%, P = 0.002), and invasive intracranial pressure monitoring (29% vs. 9%, P < 0.001) than patients cared for in general ICUs. Intravenous sedation was less prevalent in neuro-ICUs (12% vs. 30%, P = 0.009) and more patients were receiving nutritional support compared to general ICUs (67% vs. 39%, P < 0.001). CONCLUSIONS Neurological patients cared for in specialty neuro-ICUs underwent more invasive intracranial and hemodynamic monitoring, tracheostomy, and nutritional support, and received less IV sedation than patients in general ICUs. These differences in care may explain previously observed disparities in outcome between neurocritical care and general ICUs.
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Affiliation(s)
- Pedro Kurtz
- The Department of Neurology, Columbia University, New York, NY, USA
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Penna G, Fialho F, Japiassu A, Salgado D, Kurtz P, Nobre G, Kalichsztein M, Villela N, Bouskela E. Effect of propofol and midazolan on microcirculation of septic shock patients. Crit Care 2012. [PMCID: PMC3363749 DOI: 10.1186/cc10938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Almeida GF, Vegni R, Japiassú AM, Kurtz P, Drumond LE, Freitas M, Penna G, Nobre G, Kalichzstein M. Postoperative complications of surgically treated ascending aortic dissection. Rev Bras Ter Intensiva 2011; 23:304-311. [PMID: 23949402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Accepted: 08/06/2011] [Indexed: 06/02/2023] Open
Abstract
OBJECTIVES Ascending aortic dissection has a poor prognosis if it is not promptly corrected surgically. Even with surgical correction, postoperative management is feared because of its complicated course. Our aim was to describe the incidence of postoperative complications and identify the 1 and 6-month mortality rate of our ascending aortic dissection surgical cohort. Secondarily, a comparison was made between ascending aortic dissection patients and paired-matched patients who received urgent coronary artery bypass graft surgery. METHODS A retrospective analysis of a prospectively-collected database from February 2005 through June 2008 revealed 12 ascending aortic dissection and 10 elective ascending aortic aneurysm repair patients. These patients were analyzed for demographic and perioperative characteristics. Ascending aortic dissection patients were compared to paired-matched coronary artery bypass graft surgery patients according to age (± 3 years), gender, elective/urgent procedure and surgical team. The main outcome was in-hospital morbidity, defined by postoperative complications, intensive care unit admission and hospital length of stay. RESULTS Twenty-two patients received operations to correct ascending aortic dissections and ascending aortic aneurysms, while 246 patients received coronary artery bypass graft surgeries. Ascending aortic dissection patients were notably similar to ascending aortic aneurysm brackets, except for longer mechanical ventilation times and lengths of stay in the hospital. After matching coronary artery bypass graft surgery patients to an ascending aortic dissection group, the following significantly worse results were found for the Aorta group: higher incidence of postoperative complications (91% vs. 45%, p=0.03), and longer hospital length of stay (19 [11-41] vs. 12.5 [8.5-13] days, p=0.05). No difference in mortality was found at the 1-month (8.3%) or 6-month (16.6%) postoperative care date. CONCLUSION Ascending aortic dissection correction is associated with an increased incidence of postoperative complications and an increased hospital length of stay, but 1 and 6-month mortality is similar to that of paired-matched coronary artery bypass graft surgery patients.
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Almeida GF, Vegni R, Japiassú AM, Kurtz P, Drumond LE, Freitas M, Penna G, Nobre G, Kalichzstein M. Complicações pós-operatórias de pacientes com dissecção de aorta ascendente tratados cirurgicamente. Rev Bras Ter Intensiva 2011. [DOI: 10.1590/s0103-507x2011000300008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Aiub A, Fajardo RV, Lourenço PM, Presto B, Kurtz P, Almeida GF, Nobre GF, Kalichsztein M, Japiassú AM. AGE AND ACUTE-SEVERITY ILLNESS PORTEND DAILY ACTIVITY DYSFUNCTION 6 MONTHS AFTER HOSPITAL DISCHARGE. J Am Geriatr Soc 2011; 59:1155-7. [DOI: 10.1111/j.1532-5415.2011.03443.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Helbok R, Ko SB, Schmidt JM, Kurtz P, Fernandez L, Choi HA, Connolly ES, Lee K, Badjatia N, Mayer SA, Claassen J. Global cerebral edema and brain metabolism after subarachnoid hemorrhage. Stroke 2011; 42:1534-9. [PMID: 21493918 DOI: 10.1161/strokeaha.110.604488] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Global cerebral edema is common among patients with poor-grade subarachnoid hemorrhage and is associated with poor outcome. Currently no targeted therapy exists largely due to an incomplete understanding of the underlying mechanisms. METHODS This is a prospective observational study including 39 consecutive patients with poor-grade subarachnoid hemorrhage with multimodal neuromonitoring. Levels of microdialysate lactate-pyruvate ratio, episodes of cerebral metabolic crisis (lactate-pyruvate ratio >40 and brain glucose <0.7 mmol/L), brain tissue oxygen tension, cerebral perfusion pressure, and transcranial Doppler sonography flow velocities were analyzed. RESULTS Median age was 54 years (range, 45 to 61 years) and 62% were female. Patients with global cerebral edema on admission (n=24 [62%]) had a higher incidence of metabolic crisis in the first 12 hours of monitoring (n=15 [15% versus 2%], P<0.05) and during the total time of neuromonitoring (20% versus 3%, P<0.001) when compared to those without global cerebral edema. There was no difference in brain tissue oxygen tension or cerebral perfusion pressure between the groups; however, in patients with global cerebral edema, a higher cerebral perfusion pressure was associated with lower lactate-pyruvate ratio (P<0.05). Episodes of metabolic crisis were associated with poor outcome (modified Rankin Scale score 5 or 6, P<0.05). CONCLUSIONS In patients with poor-grade subarachnoid hemorrhage, global cerebral edema is associated with early brain metabolic distress.
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Affiliation(s)
- Raimund Helbok
- Division of Critical Care Neurology, Department of Neurology, Columbia University Medical Center, New York, NY 10032, USA
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