To prospectively describe 1-year outcomes, with a focus on functional outcome, cognitive outcome, and the burden of anxiety, depression, and post-traumatic stress disorder, in coronavirus disease ...2019 patients managed with extracorporeal membrane oxygenation.
Prospective case series.
Tertiary extracorporeal membrane oxygenation center in the United States.
Adult coronavirus disease 2019 acute respiratory distress syndrome patients managed with extracorporeal membrane oxygenation March 1, 2020, to July 31, 2020.
Baseline variables, treatment measures, and short-term outcomes were obtained from the medical record. Survivors were interviewed by telephone, a year following the index intensive care admission. Functional outcome was assessed using the modified Rankin Scale and the World Health Organization Disability Assessment Scale 2.0. Cognitive status was assessed with the 5-minute Montreal Cognitive Assessment. The Hospital Anxiety and Depression Scale was used to screen for anxiety and depression. Screening for post-traumatic stress disorder was performed with the Posttraumatic Stress Disorder Checklist 5 instrument.
Twenty-three patients were managed with extracorporeal membrane oxygenation, 14 (61%) survived to hospital discharge. Thirteen (57%) were alive at 1 year. One patient was dependent on mechanical ventilation, another intermittently required supplemental oxygen at 1 year. The median modified Rankin Scale score was 2 (interquartile range, 1-2), median World Health Organization Disability Assessment Scale 2.0 impairment score was 21% (interquartile range, 6-42%). Six of 12 previously employed individuals (50%) had returned to work, and 10 of 12 (83%) were entirely independent in activities of daily living. The median Montreal Cognitive Assessment score was 14 (interquartile range, 13-14). Of 10 patients assessed with Hospital Anxiety and Depression Scale, 4 (40%) screened positive for depression and 6 (60%) for anxiety. Four of 10 (40%) screened positive for post-traumatic stress disorder.
Functional impairment was common a year following the use of extracorporeal membrane oxygenation in coronavirus disease 2019, although the majority achieved independence in daily living and about half returned to work. Long-term anxiety, depression, and post-traumatic stress disorder were common, but cognitive impairment was not.
Neurocritical care as a recognized and distinct subspecialty of critical care has grown remarkably since its inception in the 1980s. As of 2016, there were 61 fellowship training programs accredited ...by the United Council for Neurologic Subspecialties (UCNS) in the United States and more than 1,000 UCNS-certified neurointensivists from diverse medical backgrounds. In late 2015, the Program Accreditation, Physician Certification, and Fellowship Training (PACT) Committee of the Neurocritical Care Society (NCS) was convened to promote and support excellence in the training and certification of neurointensivists. One of the first tasks of the committee was to survey neurocritical care fellowship training program directors to ascertain the current state of fellowship training and attitudes regarding transition to Accreditation Council for Graduate Medical Education (ACGME) accreditation of training programs and American Board of Medical Specialties (ABMS) certification of physicians. First, the survey revealed significant heterogeneities in the manner of neurocritical care training and a lack of consistency in requirements for fellow procedural competency. Second, although a majority of the 33 respondents indicated that a move toward ACGME accreditation/ABMS certification would facilitate further growth and mainstreaming of training in neurocritical care, many programs do not currently meet administrative requirements and do not receive the level of institutional support that would be needed for such a transition. In summary, the results revealed that there is an opportunity for future harmonization of training standards and that a transition to ACGME accreditation/ABMS certification is preferred. While the results reflect the opinions of more than half of the survey respondents, they represent only a small sample of neurointensivists.
Abstract
BACKGROUND:
Elevated mean cerebral blood flow velocity (mCBFV) on transcranial Doppler predicts vasospasm of the large intracranial arteries after aneurysmal subarachnoid hemorrhage (aSAH). ...The pulsatility index (PI) is a measure of distal vascular resistance, which may be low when there is compensatory distal vasodilatation following hypoperfusion caused by large-vessel vasospasm.
OBJECTIVE:
To study the predictive value of low PI for symptomatic large-vessel vasospasm (SLVVS) after aSAH.
METHODS:
Medical records of patients admitted with aSAH between January 2007 and April 2009 were reviewed. Transcranial color-coded duplex (TCCD) sonography was performed daily between days 2 and 14. Patients with unexplained acute neurological decline underwent catheter- or computed tomography-angiography. The lowest recorded PI and the highest mCBFV on TCCD were correlated to the occurrence of SLVVS, angiographic vasospasm, and delayed cerebral infraction in multivariate analysis by use of logistic regression. Functional outcome was assessed at first follow-up.
RESULTS:
Eighty-one patients met inclusion criteria. Mean lowest PI was 0.71 + 0.19. Median highest mCBFV was 135 cm/s (interquartile range 99-194 cm/s). SLVVS was seen in 21 of 81 (26%) patients, whereas 27 of 55 (49%) patients with repeat angiography had moderate or severe angiographic vasospasm. Following multivariate analysis, only the lowest PI was an independent predictor of SLVVS (P = .03, odds ratio 0.04, 95% confidence interval 0.001-0.54), whereas only the highest mCBFV was an independent predictor of angiographic vasospasm (P = .02, odds ratio 1.01, 95% confidence interval 1.002-1.02). SLVVS was independently associated with functional outcome at follow-up.
CONCLUSION:
Low PI on TCCD is an independent predictor of SLVVS after aSAH, whereas mCBFV is a better predictor of angiographic vasospasm.
Background
Optic nerve ultrasonography (ONUS) may help identify raised intracranial pressure (ICP). The optimal optic nerve sheath diameter (ONSD) cut-off for the identification of intracranial ...hypertension has not been established, with some clinical studies suggesting a higher cut-off than may be expected on the basis of prior laboratory investigation.
Objective
To validate ONUS performed by neurointensivists as a technique for the detection of intracranial hypertension and identify the optimal ONSD criterion for the detection of ICP > 20 mmHg.
Methods
Prospective blinded observational study. Patients in the ICU with either external ventricular drains or intraparenchymal ICP monitors at risk for intracranial hypertension were enrolled. The ONSD was measured by neurointensivists at the bedside with simultaneous invasive ICP measurement. An ROC curve was constructed to determine the optimal ONSD for the detection of ICP > 20 mmHg.
Measurements and Results
A total of 536 ONSD measurements were performed on 65 patients. Diagnoses included subarachnoid hemorrhage, traumatic brain injury, intracerebral hemorrhage, ischemic stroke and brain tumor. ROC curve analysis revealed area under the curve (AUC) = 0.98 (95% CI 0.96–0.99;
P
< 0.0001 for AUC = 0.5). Optimal ONSD for detection of ICP > 20 mmHg was ≥0.48 cm sensitivity 96% (95% CI 91–99%); specificity 94% (92–96%). Sensitivity of the higher cutoff of ≥0.52 cm proposed by some authors was only 67% (58–75%), with specificity 98% (97–99%).
Conclusions
Bedside ONSD measurement, performed by neurointensivists, is an accurate, non-invasive method to identify ICP > 20 mmHg in a heterogeneous group of patients with acute brain injury. ONSD ≥0.48 cm has the greatest accuracy, however, internal validation of ONSD criteria may be required.
OBJECTIVES:Intracranial pressure monitoring plays a critical role in the management of severe traumatic brain injury. Our objective was to evaluate the accuracy of optic nerve sheath diameter as a ...noninvasive screening test for the detection of elevated intracranial pressure and prediction of intracranial pressure treatment intensity.
DESIGN:Prospective, blinded study of diagnostic accuracy.
SETTING:Neurotrauma ICU.
SUBJECTS:Consecutive patients with severe traumatic brain injury.
INTERVENTIONS:Optic nerve ultrasound was performed daily and optic nerve ultrasound measured at the point-of-care as well as remotely by an expert blinded to all patient details. Optic disc elevation was also measured. The index test was the highest remote-expert optic nerve ultrasound for the admission. The reference standard was the concurrent invasive intracranial pressure, with test-positivity set at intracranial pressure greater than 22 mm Hg. A priori the minimally acceptable sensitivity threshold was 90% with corresponding specificity 60%. We also evaluated the ability of optic nerve ultrasound to predict a therapeutic intensity level greater than 10.
MEASUREMENTS AND MAIN RESULTS:One hundred twenty patients were enrolled. The intraclass correlation coefficient between point of care and expert optic nerve sheath diameter after enrollment of 50 subjects was poor at 0.16 (–0.08 to 0.41) but improved to 0.87 (0.81–0.92) for the remaining subjects after remedial training. The area under the curve of the receiver operating characteristic curve of the highest expert-measured optic nerve sheath diameter to detect intracranial pressure greater than 22 mm Hg was 0.81 (0.73–0.87); area under the curve for prediction of therapeutic intensity level greater than 10 was 0.51 (0.42–0.60). Optic nerve sheath diameter greater than 0.72 demonstrated sensitivity 82% (48–98%) and specificity 79% (70–86%) for intracranial pressure greater than 22 mm Hg. The area under the curve of highest measured optic disc elevation to detect intracranial pressure greater than 22 mm Hg was 0.84 (0.76–0.90). Optic disc elevation greater than 0.04 cm attained sensitivity 90% (56–100%) and specificity 71% (61–79%).
CONCLUSIONS:While optic nerve sheath diameter demonstrated a modest, statistically significant correlation with intracranial pressure, a predetermined level of diagnostic accuracy to justify routine clinical use as a screening test was not achieved. Measurement of optic disc elevation appears promising for the detection of elevated intracranial pressure, however, verification from larger studies is necessary.
The Safety and Efficacy of Thrombolysis for Strokes After Cardiac Catheterization Pooja Khatri, Robert A. Taylor, Vanessa Palumbo, Venkatakrishna Rajajee, Jeffrey M. Katz, Julio A. Chalela, Ann ...Geers, Joseph Haymore, Daniel M. Kolansky, Scott E. Kasner, for the Treatment of Acute Stroke after Cardiac Catheterization (TASCC) Study Group Ischemic strokes after cardiac catheterization procedures lead to the morbidity and mortality of thousands of patients each year. We compared clinical outcomes of those treated with thrombolysis with those without treatment. Sixty-six consecutive cases of ischemic stroke after cardiac catheterization were abstracted retrospectively at 7 major academic centers. Twelve (18%) were treated with thrombolysis. Improvement in stroke symptoms, the primary efficacy measure, was greater in treated versus nontreated cases (p < 0.001). There were no significant differences in safety events. Thrombolysis might improve early outcomes after post-catheterization strokes and seems safe in this context. Emergent cerebral revascularization should be a routine consideration.
Abstract only Introduction: Hyperfibrinolysis is associated with intracerebral hemorrhage (ICH) after the use of tPA for acute ischemic stroke (AIS). Point-of-care Rotational ThromboElastoMetry ...(ROTEM) testing may rapidly detect hyperfibrinolysis and identify AIS patients at high risk for hemorrhage. Hypothesis: Evidence of fibrinogen depletion on ROTEM will accurately predict bleeding following revascularization therapy for AIS. Methods: We reviewed medical records of AIS patients who underwent revascularization therapy between 2019-2020. All patients underwent ROTEM testing post-procedure to facilitate targeted blood product transfusion should hemorrhage occur. However, transfusion was not performed prophylactically. Repeat imaging with dual-energy CT was performed within 24 hours. A quality control registry of all AIS patients who undergo revascularization is maintained for purposes of Joint Commission certification. All variables, including ROTEM values and occurrence of intra- and extracranial hemorrhage, were entered prospectively. We examined the predictive value of a FIBTEM-A10 <10mm for post-procedural hemorrhage. Results: A total of 52 patients were included. Median age was 68 years (Interquartile Range, IQR 60-83), and median admission NIHSS was 16 (IQR 10-20). Thirty-four patients (65%) received tPA, 46 (88%) received mechanical thrombectomy, and 28 (54%) received both. Median post-procedure FIBTEM-A10 was 16mm (IQR 14-22); 5 patients had values <10mm. Overall, 19 (37%) suffered radiographic ICH, 5 (10%) symptomatic ICH, and 3 (6%) extracranial hemorrhage. FIBTEM-A10 <10mm had sensitivity 17% and specificity 97% for any post-procedural hemorrhage. For symptomatic ICH, sensitivity was 0% and specificity 89%. Conclusions: The use of ROTEM to identify hyperfibrinolysis following AIS revascularization therapy achieved poor sensitivity and high specificity for prediction of any post-procedural hemorrhage, but was inaccurate for the prediction of symptomatic ICH.
Airway management and ventilation are central to the resuscitation of the neurologically ill. These patients often have evolving processes that threaten the airway and adequate ventilation. ...Furthermore, intubation, ventilation, and sedative choices directly affect brain perfusion. Therefore, Airway, Ventilation, and Sedation was chosen as an Emergency Neurological Life Support protocol. Topics include airway management, when and how to intubate with special attention to hemodynamics and preservation of cerebral blood flow, mechanical ventilation settings and the use of sedative agents based on the patient’s neurological status.
Data on long-term functional recovery (LFR) following severe brain injury are essential for counseling of surrogates and for appropriate timing of outcome assessment in clinical trials. Delayed ...functional recovery (DFR) beyond 3-6 months is well documented following severe traumatic brain injury (sTBI), but there are limited data on DFR following severe cerebrovascular brain injury. The objective of this study was to assess LFR and DFR in patients with sTBI and severe stroke dependent on tracheostomy and tube feeding at the time of discharge from the intensive care unit (ICU).
The authors identified patients entered into their tracheostomy database 2008-2013 with sTBI and severe stroke, encompassing SAH, intracerebral hemorrhage (ICH), and acute ischemic stroke (AIS). Eligibility criteria included disease-specific indicators of severity, Glasgow Coma Scale score < 9 at time of tracheostomy, and need for tracheostomy and tube feeding at ICU discharge. Assessment was at 1-3 months, 6-12 months, 12-24 months, and 24-36 months after initial injury for presence of tracheostomy, ability to walk, and ability to perform basic activities of daily living (B-ADLs). Long-term functional recovery (LFR) was defined as recovery of the ability to walk or perform B-ADLs by the 24- to 36-month follow-up. Delayed functional recovery (DFR) was defined as progression in functional milestones between any 2 time points beyond the 1- to 3-month follow-up.
A total of 129 patients met the eligibility criteria. Functional outcomes were available for 129 (100%), 97 (75%), 83 (64%), and 80 (62%) patients, respectively, from assessments at 1-3, 6-12, 12-24 and 24-36 months; 33 (26%) died by 24-36 months. Fifty-nine (46%) regained the ability to walk and 48 (37%) performed B-ADLs at some point during their recovery. Among survivors who had not achieved the respective milestone at 1-3 months, 29/58 (50%) were able to walk and 28/74 (38%) performed B-ADLs at 6-12 months. Among survivors who had not achieved the respective milestone at 6-12 months, 5/16 (31%) were able to walk and 13/30 (43%) performed B-ADLs at 12-24 months. There was no significant difference in rates of LFR or DFR between patients with sTBI and those with severe stroke.
Among patients with severe brain injury requiring tracheostomy and tube feeding at ICU discharge, 46% regained the ability to walk and 37% performed B-ADLs 2-3 years after injury. DFR beyond 1-3 and 6-12 months was seen in over 30% of survivors, with no significant difference between sTBI and severe stroke.
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