Background
Elevated intracranial pressure (ICP) is an important cause of death following acute liver failure (ALF). While invasive ICP monitoring (IICPM) is most accurate, the presence of ...coagulopathy increases bleeding risk in ALF. Our objective was to evaluate the accuracy of three noninvasive ultrasound-based measures for the detection of concurrent ICP elevation in ALF—optic nerve sheath diameter (ONSD) using optic nerve ultrasound (ONUS); middle cerebral artery pulsatility index (PI) on transcranial Doppler (TCD); and ICP calculated from TCD flow velocities (ICPtcd) using the estimated cerebral perfusion pressure (CPPe) technique.
Methods
In this retrospective study, consecutive ALF patients admitted over a 6-year period who underwent IICPM as well as measurement of ONSD, TCD-PI or ICPtcd were included. ONSD was measured offline by a blinded investigator from deidentified videos. The ability of highest ONSD, TCD-PI, and ICPtcd to detect concurrent invasive ICP > 20 mmHg was assessed using receiver operating characteristic (ROC) curves. The ROC area under the curve (AUC) was calculated with 95% confidence interval (95% CI) and evaluated against the null hypothesis of AUC = 0.5. Noninvasive measures were also evaluated as predictors of in-hospital death.
Results
Forty-one ALF patients were admitted during the study period. In total, 27 (66%) underwent IICPM, of these, 23 underwent ONUS and 21 underwent TCD. Eleven out of 23 (48%) patients died (two from intracranial hypertension). Results of ROC analysis for detection of concurrent ICP > 20 mmHg were as follows: ONSD AUC = 0.59 (95% CI 0.37–0.79,
p
= 0.54); TCD-PI AUC = 0.55 (95% CI 0.34–0.75,
p
= 0.70); and ICPtcd AUC = 0.90 (0.72–0.98,
p
< 0.0001). None of the noninvasive measures were significant predictors of death.
Conclusions
In patients with ALF, neither ONSD nor TCD-PI reliably detected concurrent ICP elevation on invasive monitoring. Estimation of ICP (ICPtcd) using the TCD CPPe technique was associated with concurrent ICP elevation. Additional studies of TCD CPPe in larger numbers of ALF patients may prove worthwhile.
Ultrasound (US) performed prior to percutaneous tracheostomy (PT) may be useful in avoiding injury to pretracheal vascular structures and in avoiding high placement of the tube. Bedside real-time US ...guidance with visualization of needle path is routinely utilized for other procedures such as central venous catheterization, and may enhance the safety and accuracy of PT without causing airway occlusion or hypercarbia. Our objective was to demonstrate that PT performed under real-time US guidance with visualization of needle path during tracheal puncture is feasible, including in patients with features that increase the technical difficulty of PT.
Mechanically ventilated patients with acute brain injury requiring tracheostomy underwent US guided PT. The orotracheal tube was withdrawn using direct laryngoscopy. The trachea was punctured under real-time US guidance (with visualization of the needle path) while using the acoustic shadows of the cricoid and the tracheal rings to identify the level of puncture. After guidewire passage the site and level of entry was verified using the bronchoscope, which was then withdrawn. Following dilatation and tube placement, placement in the airway was confirmed using auscultation and the "lung sliding" sign on US. Bronchoscopy and chest X-ray were then performed to identify any complications.
Thirteen patients successfully underwent US guided PT. Three patients were morbidly obese, two were in cervical spine precautions and one had a previous tracheostomy. In all 13 patients bronchoscopy confirmed that guidewire entry was through the anterior wall and between the first and fifth tracheal rings. There was no case of tube misplacement, pneumothorax, posterior wall injury, significant bleeding or other complication during the procedure.
Percutaneous tracheostomy performed under real-time ultrasound guidance is feasible and appears accurate and safe, including in patients with morbid obesity and cervical spine precautions. Larger studies are required to further define the safety and relative benefits of this technique.
UMIN Clinical Trials Registry, UMIN000005023.
OBJECTIVE Recent observational data suggest that ultra-early treatment of ruptured aneurysms prevents rebleeding, thus improving clinical outcomes. However, advances in critical care management of ...patients with ruptured aneurysms may reduce the rate of rebleeding in comparison with earlier trials, such as the International Cooperative Study on the Timing of Aneurysm Surgery. The objective of the present study was to determine if an ultra-early aneurysm repair protocol will or will not significantly reduce the number of incidents of rebleeding following aneurysmal subarachnoid hemorrhage (SAH). METHODS A retrospective analysis of data from a prospectively collected cohort of patients with SAH was performed. Rebleeding was diagnosed as new or expanded hemorrhage on CT, which was determined by independent review conducted by multiple physicians. Preventability of rebleeding by ultra-early aneurysm clipping or coiling was also independently reviewed. Standard statistics were used to determine statistically significant differences between the demographic characteristics of those with rebleeding compared with those without. RESULTS Of 317 patients with aneurysmal SAH, 24 (7.6%, 95% CI 4.7-10.5) experienced rebleeding at any time point following initial aneurysm rupture. Only 1/24 (4.2%, 95% CI -3.8 to 12.2) incidents of rebleeding could have been prevented by a 24-hour ultra-early aneurysm repair protocol. The other 23 incidents could not have been prevented for the following reasons: rebleeding prior to admission to the authors' institution (14/23, 60.9%); initial diagnostic angiography negative for aneurysm (4/23, 17.4%); postoperative rebleeding (2/23, 8.7%); patient unable to undergo operation due to medical instability (2/23, 8.7%); intraoperative rebleeding (1/23, 4.3%). CONCLUSIONS At a single tertiary academic center, the overall rebleeding rate was 7.6% (95% CI 4.7-10.5) for those presenting with ruptured aneurysms. Implementation of a 24-hour ultra-early aneurysm repair protocol would only result in, at most, a 0.3% (95% CI -0.3 to 0.9) reduction in the incidence of rebleeding.
The use of continuous positive airway pressure has been shown to improve the tolerance of the apnea test, a critical component of brain death evaluation. The ability to deactivate the apnea backup ...setting has made apnea testing possible using several conventional mechanical ventilators. Our goal was to evaluate the safety and efficacy of apnea testing performed on mechanical ventilation, compared with the oxygen insufflation technique, for the determination of brain death.
This was a retrospective study. In 2016, our institution approved a change in policy to permit apnea testing on conventional mechanical ventilation. We examined the records of consecutive adults who underwent apnea testing as part of the brain death evaluation process between 2016 and 2022. Using an apnea test technique was decided at the discretion of the attending physician. Outcomes were successful apnea test and the occurrence of patient instability during the test. This included oxygen desaturation (SpO2) < 90%, hypotension (mean arterial pressure < 65 mm Hg despite titration of vasopressor), cardiac arrhythmia, pneumothorax, and cardiac arrest.
Ninety-two adult patients underwent apnea testing during the study period: 58 (63%) with mechanical ventilation, 32 (35%) with oxygen insufflation, and 2 (2%) lacked documentation of technique. Apnea tests could not be completed successfully in 3 of 92 (3%) patients-two patients undergoing the oxygen insufflation technique (one patient with hypoxemia and one patient with hypotension) and one patient on mechanical ventilation (aborted for hemodynamic instability). Hypoxemia occurred in 4 of 32 (12.5%) patients with oxygen insufflation and in zero patients on mechanical ventilation (p = 0.01). Hypotension occurred during 3 of 58 (5%) tests with mechanical ventilation and 4 of 32 (12.5%) tests with oxygen insufflation (p = 0.24). In multivariate analysis, the use of oxygen insufflation was an independent predictor of patient instability during the apnea test (odds ratio 37.74, 95% confidence interval 2.74-520.14).
Apnea testing on conventional mechanical ventilation is feasible and offers several potential advantages over other techniques.
Although a recent clinical trial (BEST TRIP) demonstrated no improvement in outcomes with invasive intracranial pressure (ICP) monitoring (ICPM) following severe traumatic brain injury (TBI), its ...generalizability has been called into question. In several global settings ICPM is not the standard of care and is used at the discretion of the attending neurosurgeon. Our objective was to determine the impact of ICPM on mortality and 6-month functional outcomes following severe TBI. The setting was a referral trauma center with 36 intensive care unit (ICU) beds and 300-600 TBI admissions per year. During a 2-year period data were prospectively entered into a severe TBI registry. Patients with severe TBI aged >12 years meeting Brain Trauma Foundation (BTF) criteria for ICPM were included in the study. Outcomes of interest were in-hospital mortality and poor 6-month functional outcome defined as Glasgow Outcome Scale (GOS) score of 3 or lower. A propensity score based analysis incorporating known predictors of outcome in TBI was utilized to examine the impact of ICPM on outcomes. Of 1345 patients meeting study criteria 497 (37%) underwent ICPM. In-hospital mortality was 35% (471/1345). Of 454 patients for whom 6-month outcome was available, 161 (35%) suffered a poor functional outcome. Following propensity score analysis ICPM use was associated with an 8% (p = 0.002) decrease in mortality but no significant effect (p = 0.2) on functional outcome. The use of ICPM following severe TBI was associated with decreased in-hospital mortality. Further clinical trials of ICPM in TBI may be warranted.
Recent studies have demonstrated the feasibility of real-time ultrasound guidance during percutaneous dilatational tracheostomy, including in patients with risk factors such as coagulopathy, cervical ...spine immobilization and morbid obesity. Use of real-time ultrasound guidance has been shown to improve the technical accuracy of percutaneous dilatational tracheostomy; however, it is unclear if there is an associated reduction in complications. Our objective was to determine whether the peri-procedural use of real-time ultrasound guidance is associated with a reduction in complications of percutaneous dilatational tracheostomy using a propensity score analysis.
This study reviewed all percutaneous dilatational tracheostomies performed in an 8-year period in a neurocritical care unit. Percutaneous dilatational tracheostomies were typically performed by trainees under guidance of the attending intensivist. Bronchoscopic guidance was used for all procedures with addition of real-time ultrasound guidance at the discretion of the attending physician. Real-time ultrasound guidance was used to guide endotracheal tube withdrawal, guide tracheal puncture, identify guidewire entry level and confirm bilateral lung sliding. The primary outcome was a composite of previously defined complications including (among others) bleeding, infection, loss of airway, inability to complete procedure, need for revision, granuloma and early dislodgement. Propensity score analysis was used to ensure that the relationship of not using real-time ultrasound guidance with the probability of an adverse outcome was examined within groups of patients having similar covariate profiles. Covariates included were age, gender, body mass index, diagnosis, Acute Physiology and Chronic Health Evaluation II score, timing of tracheostomy, positive end-expiratory pressure and presence of risk factors including coagulopathy, cervical spine immobilization and prior tracheostomy.
A total of 200 patients underwent percutaneous dilatational tracheostomy during the specified period, and 107 received real-time ultrasound guidance. Risk factors for percutaneous dilatational tracheostomy were present in 63 (32%). There were nine complications in the group without real-time ultrasound guidance: bleeding (n = 4), need for revision related to inability to ventilate or dislodgement (n = 3) and symptomatic granuloma (n = 2). There was one complication in the real-time ultrasound guidance group (early dislodgement). The odds of having an adverse outcome for patients receiving real-time ultrasound guidance were significantly lower (odds ratio = 0.08; 95% confidence interval, 0.009 to 0.811; P = 0.032) than for those receiving a standard technique while holding the propensity score quartile fixed.
The use of real-time ultrasound guidance during percutaneous dilatational tracheostomy was associated with a significant reduction in procedure-related complications.
Background and Purpose:
A variety of neurological manifestations have been attributed to COVID-19, but there is currently limited evidence regarding risk factors and outcomes for delirium in ...critically ill patients with COVID-19. The purpose of this study was to identify delirium in a large cohort of ICU patients with COVID-19, and to identify associated features and clinical outcomes at the time of hospital discharge.
Methods:
This is an observational cohort study of 213 consecutive patients admitted to an ICU for COVID-19 respiratory illness. Delirium was diagnosed by trained abstractors using the CHART-DEL instrument. The associations between key clinical features, sedation and delirium were examined, as were the impacts of delirium on clinical outcomes.
Results:
Delirium was identified in 57.3% of subjects. Delirious patients were more likely to receive mechanical ventilation, had lower P: F ratios, higher rates of renal replacement therapy and ECMO, and were more likely to receive enteral benzodiazepines. Only mechanical ventilation remained a significant predictor of delirium in a logistic regression model. Mortality was not significantly different, but delirious patients experienced greater mechanical ventilation duration, ICU/hospital lengths of stay, worse functional outcomes at discharge, and were less likely to be discharged home.
Conclusions:
Delirium is common in critically ill patients with COVID-19 and appears to be associated with greater disease severity. When present, delirium is associated with worse functional status at discharge, but not increased mortality. Additional studies are necessary to determine the generalizability of these results and the impact of delirium on longer-term cognitive and functional outcomes.
Length of Stay Beyond Medical Readiness Linzey, Joseph R; Foshee, Rachel; Moriguchi, Francine ...
Neurosurgery,
12/2020, Letnik:
67, Številka:
Supplement_1
Journal Article
Recenzirano
INTRODUCTION There is significant pressure on neurosurgeons to provide cost-effective healthcare and discharge patients once they are medically fit. Given a number of factors, it is not uncommon for ...patients to stay in the hospital beyond medical readiness (BMR). METHODS We performed a prospective, cohort analysis of all admitted neurosurgical patients to our institution. The length of stay (LOS) BMR was assessed daily by the attending neurosurgeon and neuro-intensivist with a standardized criterion. Univariate and multivariate logistic regressions were performed. RESULTS Of the 884 patients, 229 (25.9%) had a LOS-BMR. Patients with a LOS-BMR were significantly more likely to be older (61.5 ± 14.0 vs 57.3 ± 15.1, P = .0002), have hemiplegia (5.7% vs. 1.2%, P = .001), have dementia (2.2% vs. 0.2%, P = .005), have liver disease (6.6% vs. 3.4%, P = .04), have renal disease (14.4% vs. 9.5%, P = .04), and have diabetes mellitus (23.1% vs. 16.6%, P = .03). Patients with a LOS-BMR were significantly more likely to be discharged to subacute rehabilitation/skilled nursing facility (40.2% vs 4.1%) or an acute/inpatient rehabilitation facility (22.7% vs. 1.7%, P < .0001). After multivariate logistic regression, patients with a LOS-BMR were almost 4 times more likely to have a consult to PT placed during their hospital admission (OR 3.82, 95% CI 1.94-7.55, P = .0001). Patients who were discharged to subacute rehabilitation/skilled nursing facilities (OR 12.11, 95% CI 6.18-23.72, P < .0001) or acute/inpatient rehabilitation facilities (OR 11.09, 95% CI 4.90-25.08, P < .0001) were significantly more likely to have a LOS-BMR. The average LOS-BMR was 2.7 ± 3.1 days. During those days beyond medical readiness, the average cost was $9,148.28 ± $12,983.10 per day. In the 884 patients, the total cost incurred during the “beyond medical readiness” period was $2,076,659.32. CONCLUSION A quarter of admitted neurosurgical patients remained in the hospital after they were medically ready for discharge, costing over $2,000,000.
Abstract
BACKGROUND
The LACE index (Length of stay, Acuity of admission, Comorbidities, Emergency department use) quantifies the risk of mortality or unplanned readmission within 30 d after hospital ...discharge. The index was validated originally in a large, general population and, subsequently, in several specialties, not including neurosurgery.
OBJECTIVE
To determine if the LACE index accurately predicts mortality and unplanned readmission of neurosurgery patients within 30 d of discharge.
METHODS
We performed a retrospective, cohort study of consecutive neurosurgical procedures between January 1 and September 29, 2017 at our institution. The LACE index and other clinical data were abstracted. Data analysis included univariate and multivariate logistic regressions.
RESULTS
Of the 1,054 procedures on 974 patients, 52.7% were performed on females. Mean age was 54.2 ± 15.4 yr. At time of discharge, the LACE index was low (1-4) in 58.3% of patients, moderate (5-9) in 32.4%, and high (10-19) in 9.3%. Rates of readmission and mortality within 30 d were 7.0, 11.4, and 14.3% in the low-, moderate-, and high-risk groups, respectively. Moderate-risk (odds ratio OR 1.62, 95% CI 1.02-2.56, P = .04) and high-risk LACE indexes (OR 2.20, 95% CI 1.15-4.19, P = .02) were associated with greater odds of readmission or mortality, adjusting for all variables. Additionally, longer operations (OR 1.11, 95% CI 1.02-1.21, P = .02) had greater odds of readmission. Specificity of the high-risk score to predict 30-d readmission or mortality was 91.2%.
CONCLUSION
A moderate- or high-risk LACE index can be applied to neurosurgical populations to predict 30-d readmission and mortality. Longer operations are potential predictors of readmission or mortality.
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