Abstract
Brain hypoxia can occur after non-traumatic subarachnoid hemorrhage (SAH), even when levels of intracranial pressure (ICP) remain normal. Brain tissue oxygenation (PbtO
2
) can be measured ...as a part of a neurological multimodal neuromonitoring. Low PbtO
2
has been associated with poor neurologic recovery. There is scarce data on the impact of PbtO
2
guided-therapy on patients’ outcome. This single-center cohort study (June 2014–March 2020) included all patients admitted to the ICU after SAH who required multimodal monitoring. Patients with imminent brain death were excluded. Our primary goal was to assess the impact of PbtO
2
-guided therapy on neurological outcome. Secondary outcome included the association of brain hypoxia with outcome. Of the 163 patients that underwent ICP monitoring, 62 were monitored with PbtO
2
and 54 (87%) had at least one episode of brain hypoxia. In patients that required treatment based on neuromonitoring strategies, PbtO
2
-guided therapy (OR 0.33 CI 95% 0.12–0.89) compared to ICP-guided therapy had a protective effect on neurological outcome at 6 months. In this cohort of SAH patients, PbtO
2
-guided therapy might be associated with improved long-term neurological outcome, only when compared to ICP-guided therapy.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
Background
Intracranial multimodality monitoring (iMMM) is increasingly used in acute brain-injured patients; however, safety and reliability remain major concerns to its routine implementation.
...Methods
We performed a retrospective study including all patients undergoing iMMM at a single European center between July 2016 and January 2020. Brain tissue oxygenation probe (PbtO
2
), alone or in combination with a microdialysis catheter and/or an 8-contact depth EEG electrode, was inserted using a triple-lumen bolt system and targeting normal-appearing at-risk brain area on the injured side, whenever possible. Surgical complications, adverse events, and technical malfunctions, directly associated with iMMM, were collected. A blinded imaging review was performed by an independent radiologist.
Results
One hundred thirteen patients with 123 iMMM insertions were included for a median monitoring time of 9 3–14 days. Of those, 93 (76%) patients had only PbtO
2
probe insertion and 30 (24%) had also microdialysis and/or iEEG monitoring. SAH was the most frequent indication for iMMM (
n
= 60, 53%). At least one complication was observed in 67/123 (54%) iMMM placement, corresponding to 58/113 (51%) patients. Misplacement was observed in 16/123 (13%), resulting in a total of 6/16 (38%) malfunctioning PbtO
2
catheters. Intracranial hemorrhage was observed in 14 iMMM placements (11%), of which one required surgical drainage. Five placements were complicated by pneumocephalus and 4 with bone fragments; none of these requires additional surgery. No CNS infection related to iMMM was observed. Seven (6%) probes were accidentally dislodged and 2 probes (2%) were accidentally broken. Ten PbtO
2
probes (8%) presented a technical malfunction after a median of 9 ranges: 2–24 days after initiation of monitoring and 4 of them were replaced.
Conclusions
In this study, a high occurrence of complications related to iMMM was observed, although most of them did not require specific interventions and did not result in malfunctioning monitoring.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Brain tissue oxygenation (PbtO2)-guided therapy can improve the neurological outcome of traumatic brain injury (TBI) patients. With several Phase-III ongoing studies, most of the existing evidence is ...based on before-after cohort studies and a phase-II randomized trial. The aim of this study was to assess the effectiveness of PbtO2-guided therapy in a single-center cohort. We performed a retrospective analysis of consecutive severe TBI patients admitted to our center who received either intracranial pressure (ICP) guided therapy (from January 2012 to February 2016) or ICP/PbtO2-guided therapy (February 2017 to December 2019). A genetic matching was performed based on covariates including demographics, comorbidities, and severity scores on admission. Intracranial hypertension (IH) was defined as ICP > 20 mmHg for at least 5 min. Brain hypoxia (BH) was defined as PbtO2 < 20 mmHg for at least 10 min. IH and BH were targeted by specific interventions. Mann−Whitney U and Fisher’s exact tests were used to assess differences between groups. A total of 35 patients were matched in both groups: significant differences in the occurrence of IH (ICP 85.7% vs. ICP/PbtO2 45.7%, p < 0.01), ICU length of stay 6 (3−13) vs. 16 (9−25) days, p < 0.01 and Glasgow Coma Scale at ICU discharge 10 (5−14) vs. 13 (11−15), p = 0.036 were found. No significant differences in ICU mortality and Glasgow Outcome Scales at 3 months were observed. This study suggests that the role of ICP/PbtO2-guided therapy should await further confirmation in well-conducted large phase III studies.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
Traumatic brain injury (TBI) is a major public health burden, causing death and disability worldwide. Intracranial hypertension and brain hypoxia are the main mechanisms of secondary brain injury. As ...such, management strategies guided by intracranial pressure (ICP) and brain oxygen (PbtO
2
) monitoring could improve the prognosis of these patients. Our objective was to summarize the current evidence regarding the impact of PbtO
2
-guided therapy on the outcome of patients with TBI. We performed a systematic search of PubMed, Scopus, and the Cochrane library databases, following the protocol registered in PROSPERO. Only studies comparing PbtO
2
/ICP–guided therapy with ICP-guided therapy were selected. Primary outcome was neurological outcome at 3 and 6 months assessed by using the Glasgow Outcome Scale; secondary outcomes included hospital and long-term mortality, burden of intracranial hypertension, and brain tissue hypoxia. Out of 6254 retrieved studies, 15 studies (
n
= 37,245 patients, of who 2184 received PbtO
2
-guided therapy) were included in the final analysis. When compared with ICP-guided therapy, the use of combined PbO
2
/ICP–guided therapy was associated with a higher probability of favorable neurological outcome (odds ratio 2.21 95% confidence interval 1.72–2.84) and of hospital survival (odds ratio 1.15 95% confidence interval 1.04–1.28). The heterogeneity (
I
2
) of the studies in each analysis was below 40%. However, the quality of evidence was overall low to moderate. In this meta-analysis, PbtO
2
-guided therapy was associated with reduced mortality and more favorable neurological outcome in patients with TBI. The low-quality evidence underlines the need for the results from ongoing phase III randomized trials.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
5.
Laryngopharyngeal reflux in otitis media with effusion Lechien, Jerome R.; Maniaci, Antonino; Gengler, Isabelle M. ...
American journal of otolaryngology,
March-April 2024, 2024 Mar-Apr, 2024-03-00, 20240301, Volume:
45, Issue:
2
Journal Article
Peer reviewed
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Intracranial multimodal monitoring (iMMM) is increasingly used for neurocritical care. However, concerns arise regarding iMMM invasiveness considering limited evidence in its clinical significance ...and safety profile. We conducted a synthesis of evidence regarding complications associated with iMMM to delineate its safety profile. We performed a systematic review and meta-analysis (PROSPERO Registration Number: CRD42021225951) according to the Preferred Reporting Items for Systematic Review and Meta-Analysis and Peer Review of Electronic Search Strategies guidelines to retrieve evidence from studies reporting iMMM use in humans that mention related complications. We assessed risk of bias using the Newcastle–Ottawa Scale and funnel plots. The primary outcomes were iMMM complications. The secondary outcomes were putative risk factors. Of the 366 screened articles, 60 met the initial criteria and were further assessed by full-text reading. We included 22 studies involving 1206 patients and 1434 iMMM placements. Most investigators used a bolt system (85.9%) and a three-lumen device (68.8%), mainly inserting iMMM into the most injured hemisphere (77.9%). A total of 54 postoperative intracranial hemorrhages (pooled rate of 4%; 95% confidence interval CI 0–10%;
I
2
86%,
p
< 0.01 random-effects model) was reported, along with 46 misplacements (pooled rate of 6%; 95% CI 1–12%;
I
2
78%,
p
< 0.01) and 16 central nervous system infections (pooled rate of 0.43%; 95% CI 0–2%;
I
2
64%,
p
< 0.01). We found 6 system breakings, 18 intracranial bone fragments, and 5 cases of pneumocephalus. Currently, iMMM systems present a similar safety profile as intracranial devices commonly used in neurocritical care. Long-term outcomes of prospective studies will complete the benefit-risk assessment of iMMM in neurocritical care. Consensus-based reporting guidelines on iMMM use are needed to bolster future collaborative efforts.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
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