Background Autonomic shift (AS), characterized by increased sympathetic nervous system activation, has been implicated in neurologically mediated cardiopulmonary dysfunction and immunodepression ...after stroke. We investigated the prevalence of AS defined by readily available clinical parameters and determined the association of AS with subsequent infection in a cohort of patients with aneurysmal subarachnoid hemorrhage (aSAH). Methods Data were obtained from a single-center cohort study of aSAH patients admitted from January 1, 2007, through April 1, 2012. AS was defined as at least 1 early (<72 hours) routine clinical marker of neurologically mediated cardiopulmonary dysfunction based on electrocardiogram, echocardiogram, cardiac enzymes, or neurogenic pulmonary edema. Multivariable logistic regression models were developed to evaluate the association between AS and subsequent infection after adjusting for other covariates. Results A total of 167 patients were included in the analysis (mean age 56, 27% men). AS was seen in 66 of 167 patients (40%; 95% confidence interval CI, 32%-47%), and infection was seen in 80 of 167 patients (48%; 95% CI, 40%-55%). AS was associated with subsequent infection on unadjusted analysis (odds ratio OR 2.11; 95% CI, 1.12-3.97); however, this association was no longer significant when adjusting for other predictors of infection (OR 1.36; 95% CI, .67-2.76). Age, clinical grade, and aneurysm location were all independent predictors of infection after aSAH. Conclusions We identified AS based on readily available clinical markers in 40% of patients with aSAH, though AS defined by these clinical criteria was not an independent predictor of infection. Additional studies may be warranted to determine the optimal definition of AS and the clinical significance of this finding.
Background
Many COVID-19 patients with neurological manifestations and respiratory failure remain dependent on mechanical ventilation and require tracheostomy, which is an aerosol generating ...procedure (AGP). The risk of SARS-CoV-2 transmission to healthcare staff during AGPs is well documented, and negative-pressure rooms are often unavailable. Innovative techniques to decrease risk to healthcare providers during AGPs are necessary. Our objective was to demonstrate the feasibility of percutaneous dilatational tracheostomy (PDT) performed using a novel prefabricated low-cost negative-pressure tent (AerosolVE).
Methods
Retrospective review of consecutive PDT procedures performed by neurointensivists on intubated adult patients with COVID-19 using the AerosolVE tent during the pandemic under an innovative clinical care protocol. The AerosolVE negative-pressure tent consists of a clear plastic canopy with slits for hand access attached to a U-shaped base with air vents. Air within the tent is drawn through a high-efficiency particulate air filter and released outside. Preliminary testing during simulated AGPs demonstrated negligible escape of particulate matter beyond the tent. The main outcome measure was successful completion of PDT and bronchoscopy within the AerosolVE tent, without complications.
Results
The patients were a 53-year-old man with multifocal ischemic stroke and acute respiratory distress syndrome (ARDS), 53-year-old woman with cerebellar hemorrhage and ARDS, and a 69-year-old man with ARDS. Pre-procedure FiO
2
requirement was 40–50% and positive end-expiratory pressure (PEEP) 8–12 cm H
2
O. The tent was successfully positioned around the patient and PDT completed with real-time ultrasound guidance in all 3 patients. Bronchoscopy was performed to confirm tube position and perform pulmonary toilet. No complications occurred.
Conclusions
It is feasible to perform PDT on intubated COVID-19 patients using the AerosolVE negative-pressure tent. This is a promising low-cost device to decrease risk to healthcare providers during AGPs.
AbstractObjectivesTo summarise and compare the accuracy of physical examination, computed tomography (CT), sonography of the optic nerve sheath diameter (ONSD), and transcranial Doppler pulsatility ...index (TCD-PI) for the diagnosis of elevated intracranial pressure (ICP) in critically ill patients.DesignSystematic review and meta-analysis.Data sourcesSix databases, including Medline, EMBASE, and PubMed, from inception to 1 September 2018.Study selection criteriaEnglish language studies investigating accuracy of physical examination, imaging, or non-invasive tests among critically ill patients. The reference standard was ICP of 20 mm Hg or more using invasive ICP monitoring, or intraoperative diagnosis of raised ICP.Data extractionTwo reviewers independently extracted data and assessed study quality using the quality assessment of diagnostic accuracy studies tool. Summary estimates were generated using a hierarchical summary receiver operating characteristic (ROC) model.Results40 studies (n=5123) were included. Of physical examination signs, pooled sensitivity and specificity for increased ICP were 28.2% (95% confidence interval 16.0% to 44.8%) and 85.9% (74.9% to 92.5%) for pupillary dilation, respectively; 54.3% (36.6% to 71.0%) and 63.6% (46.5% to 77.8%) for posturing; and 75.8% (62.4% to 85.5%) and 39.9% (26.9% to 54.5%) for Glasgow coma scale of 8 or less. Among CT findings, sensitivity and specificity were 85.9% (58.0% to 96.4%) and 61.0% (29.1% to 85.6%) for compression of basal cisterns, respectively; 80.9% (64.3% to 90.9%) and 42.7% (24.0% to 63.7%) for any midline shift; and 20.7% (13.0% to 31.3%) and 89.2% (77.5% to 95.2%) for midline shift of at least 10 mm. The pooled area under the ROC (AUROC) curve for ONSD sonography was 0.94 (0.91 to 0.96). Patient level data from studies using TCD-PI showed poor performance for detecting raised ICP (AUROC for individual studies ranging from 0.55 to 0.72).ConclusionsAbsence of any one physical examination feature is not sufficient to rule out elevated ICP. Substantial midline shift could suggest elevated ICP, but the absence of shift cannot rule it out. ONSD sonography might have use, but further studies are needed. Suspicion of elevated ICP could necessitate treatment and transfer, regardless of individual non-invasive tests.RegistrationPROSPERO CRD42018105642.
INTRODUCTION:
Hydrocephalus and seizures greatly impact outcomes of patients with aneurysmal subarachnoid hemorrhage (aSAH); however, reliable tools to predict these outcomes are lacking.
METHODS:
...Total hemorrhage volume following aneurysm rupture was retrospectively analyzed on presentation CT imaging using a custom semi-automated computer program developed in MATLAB that employs intensity-based k-means clustering to automatically separate blood voxels from other tissues. Volume data was added to a prospectively maintained SAH database. Through logistic regression analysis, we evaluated the association of hemorrhage volume with shunted-hydrocephalus and seizures and evaluated the diagnostic accuracy by evaluation of the area under the receiver operating characteristic curve (AUC).
RESULTS:
288 consecutive patients with aSAH comprised the study population. Mean total hemorrhage volume was 74.9 ml. Thirty-eight patients developed seizures (13.2%). Mean hemorrhage volume in patients who developed seizures was significantly higher than patients with no seizures (mean difference 17.3 ml, P=0.01). In multivariate analysis, larger hemorrhage volume on initial CT scan and hemorrhage volume >50 ml (OR 2.81, P=0.047 CI 1.03-7.80) were predictive of seizures. 48 patients developed shunt-dependent hydrocephalus (17%). The mean hemorrhage volume in patients who developed shunt-dependent hydrocephalus was significantly higher than patients who did not (mean difference 17.2 ml, P=0.006). Larger hemorrhage volume and hemorrhage volume >50 ml (OR 2.45, P=0.03, CI 1.08-5.54) were predictive of shunt-dependent hydrocephalus. Hemorrhage volume had adequate discrimination for the development of seizures (AUC = 0.635) and shunted hydrocephalus (AUC = 0.629).
CONCLUSION:
Hemorrhage volume is an independent predictor of seizures and hydrocephalus in aSAH. Further evaluation of quantitative volumetric analysis may complement existing scales used in clinical practice and assist in prognostication and management.
Background
Sodium chloride (NaCl) 23.4% solution has been shown to reduce intracranial pressure (ICP) and reverse transtentorial herniation. A limitation of 23.4% NaCl is its high osmolarity ...(8008 mOsm/l) and the concern for tissue injury or necrosis following extravasation when administered via peripheral venous access. The use of this agent is therefore often limited to central venous or intraosseous routes of administration. Our objective was to evaluate the safety and efficacy of administration of 23.4% NaCl via peripheral venous access compared with administration via central venous access.
Methods
We reviewed pharmacy records to identify all administrations of 23.4% NaCl at our institution between December 2017 and February 2020. Medical records were then reviewed to identify complications, such as extravasation, soft tissue injury or necrosis, hypotension (mean arterial pressure less than 65 mm Hg), pulmonary edema, hemolysis, and osmotic demyelination. We also compared the change in physiological variables, such as ICP, mean arterial pressure, cerebral perfusion pressure, and heart rate, as well as laboratory values, such as sodium, chloride, bicarbonate, creatinine, and hemoglobin, following administration of 23.4% NaCl via the peripheral and central venous routes.
Results
We identified 299 administrations of 23.4% NaCl (242 central and 57 peripheral) in 141 patients during the study period. There was no documented occurrence of soft tissue injury or necrosis in any patient. One patient developed hypotension following central administration. Among the 38 patients with ICP monitoring at the time of drug administration, there was no significant difference in median ICP reduction (− 13 mm Hg central vs. − 24 mm Hg peripheral,
p
= 0.21) or cerebral perfusion pressure augmentation (16 mm Hg central vs. 15 mm Hg peripheral,
p
= 0.87) based on route of administration.
Conclusions
Peripheral venous administration of 23.4% NaCl is safe and achieves a reduction in ICP equivalent to that achieved by administration via central venous access.
Abstract only Introduction: Delayed Cerebral Ischemia (DCI) occurs during a risk period of 3-21 days following aneurysmal subarachnoid hemorrhage (aSAH) and is associated with worse outcomes. The ...identification of patients at low risk for DCI might permit triage to less intense monitoring and management. While large-vessel vasospasm (LVV) is a distinct clinical entity from DCI, the presence of moderate-severe LVV is associated with a higher risk of DCI. Hypothesis: The absence of moderate-severe LVV on screening CT angiography (CTA) performed within the first few days of the DCI risk period will accurately identify patients at low risk for subsequent DCI. Methods: Our institutional SAH outcomes registry was queried for all aSAH patients admitted 2016 - 2019 who underwent CTA brain between days 4-8 following ictus. We excluded patients who suffered DCI prior to this CTA study. All variables are prospectively entered into the registry, and outcomes including DCI and LVV are prospectively adjudicated. We evaluated the accuracy of moderate-severe LVV on CTA performed 4-8 days from ictus for the prediction of subsequent DCI, with a focus on the Negative Predictive Value (NPV). Results: A total of 243 aSAH patients were admitted during the study timeframe and 76 (31%) underwent CTA during the 4-8 day window following ictus. Of these, 22 were excluded for occurrence of DCI prior to the CTA study. Of 54 patients meeting eligibility criteria, 11 (20%) had moderate-severe LVV on the screening CTA study performed during the risk period. Seven of 11 (64%) patients with moderate-severe LVV on the day 4-8 screening CTA, vs 6 of 43 (14%) patients without, subsequently developed DCI. The NPV of CTA performed during days 4-8 for the subsequent development of DCI was 86% (95%CI 77-92%). Sensitivity was 54% (25-81%), Specificity 90% (77-97%) and Positive Predictive Value 64% (38-83%). Conclusions: The NPV of screening CTA performed between days 4-8 following SAH for the subsequent development of DCI was moderate, at 86%. The population studied likely represents a high-risk cohort, however, prospective studies of alternate risk-stratification strategies are necessary.
IMPORTANCE: Many patients with severe stroke have impaired airway protective reflexes, resulting in prolonged invasive mechanical ventilation. OBJECTIVE: To test whether early vs standard ...tracheostomy improved functional outcome among patients with stroke receiving mechanical ventilation. DESIGN, SETTING, AND PARTICIPANTS: In this randomized clinical trial, 382 patients with severe acute ischemic or hemorrhagic stroke receiving invasive ventilation were randomly assigned (1:1) to early tracheostomy (≤5 days of intubation) or ongoing ventilator weaning with standard tracheostomy if needed from day 10. Patients were randomized between July 28, 2015, and January 24, 2020, at 26 US and German neurocritical care centers. The final date of follow-up was August 9, 2020. INTERVENTIONS: Patients were assigned to an early tracheostomy strategy (n = 188) or to a standard tracheostomy (control group) strategy (n = 194). MAIN OUTCOMES AND MEASURES: The primary outcome was functional outcome at 6 months, based on the modified Rankin Scale score (range, 0 best to 6 worst) dichotomized to a score of 0 (no disability) to 4 (moderately severe disability) vs 5 (severe disability) or 6 (death). RESULTS: Among 382 patients randomized (median age, 59 years; 49.8% women), 366 (95.8%) completed the trial with available follow-up data on the primary outcome (177 patients 94.1% in the early group; 189 patients 97.4% in the standard group). A tracheostomy (predominantly percutaneously) was performed in 95.2% of the early tracheostomy group in a median of 4 days after intubation (IQR, 3-4 days) and in 67% of the control group in a median of 11 days after intubation (IQR, 10-12 days). The proportion without severe disability (modified Rankin Scale score, 0-4) at 6 months was not significantly different in the early tracheostomy vs the control group (43.5% vs 47.1%; difference, −3.6% 95% CI, −14.3% to 7.2%; adjusted odds ratio, 0.93 95% CI, 0.60-1.42; P = .73). Of the serious adverse events, 5.0% (6 of 121 reported events) in the early tracheostomy group vs 3.4% (4 of 118 reported events) were related to tracheostomy. CONCLUSIONS AND RELEVANCE: Among patients with severe stroke receiving mechanical ventilation, a strategy of early tracheostomy, compared with a standard approach to tracheostomy, did not significantly improve the rate of survival without severe disability at 6 months. However, the wide confidence intervals around the effect estimate may include a clinically important difference, so a clinically relevant benefit or harm from a strategy of early tracheostomy cannot be excluded. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02377167
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