...it might also be possible to specifically target individuals to address their patterns of risk-taking behaviour.183 Irrespective of the target population, information campaigns should employ a ...range of measures to raise awareness of key issues in prevention and care for TBI. Since awareness of child abuse has increased and family risk factors have been elucidated, local programmes have been developed in the USA and other countries to educate parents about the dangers and long-term effects of brain injury, and to provide caregiver relief and advice on coping skills for stress. The GCS42 is the most commonly used approach to quantify the clinical severity of TBI358 (figure 2), but this is relatively crude and does not reflect different pathoanatomical subsets of TBI. ...the increasing use of prehospital sedation and tracheal intubation often confounds assessment with the GCS and has reduced its usefulness as a metric of injury severity.359 Existing International Classification of Diseases codes360 also do not adequately capture severity of TBI.361 Alternative TBI coding taxonomies-including the Abbreviated Injury Scale (AIS), which categorises severity of intracranial and extracranial injury,362 and the Marshall classification system, which is based on head CT findings363-are anatomically oriented and summarise the type, location, and severity of injuries. ...current management strategies are based on guidelines that favour a one-size-fits-all approach, and the care of patients with TBI is therefore poorly individualised (section 5). ...despite investment of many billions of dollars by pharmaceutical companies, no effective drugs exist for treatment in the acute setting-a failing due, in part, to insufficient targeting of therapies to patients in whom the relevant mechanism is active.
Background
Fluid challenges (FCs) are one of the most commonly used therapies in critically ill patients and represent the cornerstone of hemodynamic management in intensive care units. There are ...clear benefits and harms from fluid therapy. Limited data on the indication, type, amount and rate of an FC in critically ill patients exist in the literature. The primary aim was to evaluate how physicians conduct FCs in terms of type, volume, and rate of given fluid; the secondary aim was to evaluate variables used to trigger an FC and to compare the proportion of patients receiving further fluid administration based on the response to the FC.
Methods
This was an observational study conducted in ICUs around the world. Each participating unit entered a maximum of 20 patients with one FC.
Results
2213 patients were enrolled and analyzed in the study. The median interquartile range amount of fluid given during an FC was 500 ml (500–1000). The median time was 24 min (40–60 min), and the median rate of FC was 1000 500–1333 ml/h. The main indication for FC was hypotension in 1211 (59 %, CI 57–61 %). In 43 % (CI 41–45 %) of the cases no hemodynamic variable was used. Static markers of preload were used in 785 of 2213 cases (36 %, CI 34–37 %). Dynamic indices of preload responsiveness were used in 483 of 2213 cases (22 %, CI 20–24 %). No safety variable for the FC was used in 72 % (CI 70–74 %) of the cases. There was no statistically significant difference in the proportion of patients who received further fluids after the FC between those with a positive, with an uncertain or with a negatively judged response.
Conclusions
The current practice and evaluation of FC in critically ill patients are highly variable. Prediction of fluid responsiveness is not used routinely, safety limits are rarely used, and information from previous failed FCs is not always taken into account.
Introduction
While prone positioning (PP) has been shown to improve patient survival in moderate to severe acute respiratory distress syndrome (ARDS) patients, the rate of application of PP in ...clinical practice still appears low.
Aim
This study aimed to determine the prevalence of use of PP in ARDS patients (primary endpoint), the physiological effects of PP, and the reasons for not using it (secondary endpoints).
Methods
The APRONET study was a prospective international 1-day prevalence study performed four times in April, July, and October 2016 and January 2017. On each study day, investigators in each ICU had to screen every patient. For patients with ARDS, use of PP, gas exchange, ventilator settings and plateau pressure (Pplat) were recorded before and at the end of the PP session. Complications of PP and reasons for not using PP were also documented. Values are presented as median (1st–3rd quartiles).
Results
Over the study period, 6723 patients were screened in 141 ICUs from 20 countries (77% of the ICUs were European), of whom 735 had ARDS and were analyzed. Overall 101 ARDS patients had at least one session of PP (13.7%), with no differences among the 4 study days. The rate of PP use was 5.9% (11/187), 10.3% (41/399) and 32.9% (49/149) in mild, moderate and severe ARDS, respectively (
P
= 0.0001). The duration of the first PP session was 18 (16–23) hours. Measured with the patient in the supine position before and at the end of the first PP session, PaO
2
/F
I
O
2
increased from 101 (76–136) to 171 (118–220) mmHg (
P
= 0.0001) driving pressure decreased from 14 11–17 to 13 10–16 cmH
2
O (
P
= 0.001), and Pplat decreased from 26 23–29 to 25 23–28 cmH
2
O (
P
= 0.04). The most prevalent reason for not using PP (64.3%) was that hypoxemia was not considered sufficiently severe. Complications were reported in 12 patients (11.9%) in whom PP was used (pressure sores in five, hypoxemia in two, endotracheal tube-related in two ocular in two, and a transient increase in intracranial pressure in one).
Conclusions
In conclusion, this prospective international prevalence study found that PP was used in 32.9% of patients with severe ARDS, and was associated with low complication rates, significant increase in oxygenation and a significant decrease in driving pressure.
We aimed to explore the added value of common machine learning (ML) algorithms for prediction of outcome for moderate and severe traumatic brain injury.
We performed logistic regression (LR), lasso ...regression, and ridge regression with key baseline predictors in the IMPACT-II database (15 studies, n = 11,022). ML algorithms included support vector machines, random forests, gradient boosting machines, and artificial neural networks and were trained using the same predictors. To assess generalizability of predictions, we performed internal, internal-external, and external validation on the recent CENTER-TBI study (patients with Glasgow Coma Scale <13, n = 1,554). Both calibration (calibration slope/intercept) and discrimination (area under the curve) was quantified.
In the IMPACT-II database, 3,332/11,022 (30%) died and 5,233(48%) had unfavorable outcome (Glasgow Outcome Scale less than 4). In the CENTER-TBI study, 348/1,554(29%) died and 651(54%) had unfavorable outcome. Discrimination and calibration varied widely between the studies and less so between the studied algorithms. The mean area under the curve was 0.82 for mortality and 0.77 for unfavorable outcomes in the CENTER-TBI study.
ML algorithms may not outperform traditional regression approaches in a low-dimensional setting for outcome prediction after moderate or severe traumatic brain injury. Similar to regression-based prediction models, ML algorithms should be rigorously validated to ensure applicability to new populations.
Treatment and prevention of elevated intracranial pressure (ICP) is crucial in patients with severe traumatic brain injury (TBI). Elevated ICP is associated with secondary brain injury, and both ...intensity and duration of an episode of intracranial hypertension, often referred to as "ICP dose," are associated with worse outcomes. Prediction of such harmful episodes of ICP dose could allow for a more proactive and preventive management of TBI, with potential implications on patients' outcomes. The goal of this study was to develop and validate a machine-learning (ML) model to predict potentially harmful ICP doses in patients with severe TBI. The prediction target was defined based on previous studies and included a broad range of doses of elevated ICP that have been associated with poor long-term neurological outcomes. The ML models were used, with minute-by-minute ICP and mean arterial blood pressure signals as inputs. Harmful ICP episodes were predicted with a 30 min forewarning. Models were developed in a multi-center dataset of 290 adult patients with severe TBI and externally validated on 264 patients from the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) dataset. The external validation of the prediction model on the CENTER-TBI dataset demonstrated good discrimination and calibration (area under the curve: 0.94, accuracy: 0.89, precision: 0.87, sensitivity: 0.78, specificity: 0.94, calibration-in-the-large: 0.03, calibration slope: 0.93). The proposed prediction model provides accurate and timely predictions of harmful doses of ICP on the development and external validation dataset. A future interventional study is needed to assess whether early intervention on the basis of ICP dose predictions will result in improved outcomes.
Therapeutic moderate hypothermia (32-34 degrees C) is currently recommended for patients with out-of-hospital cardiac arrest (OHCA) and for newborns exhibiting neonatal hypoxic/ischemic ...encephalopathy. Hypothermia as neuroprotective strategy has been extensively studied in other scenarios, mainly for traumatic brain injury. Despite a negative result reported by a multicenter trial conducted in 2001 by Clifton et al. regarding the use of hypothermia on head injury patients, several studies in both clinical and laboratory settings have continued to report positive outcomes with hypothermia use in neurocritical care. To date, no adequate consensus has been reached. Though the topic is still under debate, emerging data suggest that there may not be a clear-cut answer as to whether hypothermia is beneficial. However, new research may indicate what target populations can benefit most from this therapy. Furthermore, issues of timing (when and for how long hypothermia is applied) seem to be the primary drivers of the most unambiguous findings in this matter. For the time being, we conclude that further studies are needed to assess how to better administer this possibly beneficial therapy, and who might benefit most from the technique.
To assess the efficacy of a centralised review of a voluntary low-budget head injury database with a retrospective analysis of data before and after a centralised review.
A computerised data ...collection (Neurolink) on traumatic brain injury cases admitted to three neuro-intensive care units in Milan (Italy): analysis of a three-year period (1999-2001). Data from 499 patients (epidemiology, type of lesion, clinical course, monitoring, treatment, complications and outcome). The audit involved a review of forms relating to patients enrolled in the three-year period, with the aim of improving the quality of data entry. Missing data in all empty fields were identified; evident errors and contradictory data were identified and corrected; missing and final data were analysed to test the efficacy of the review.
The total post-review missing data rate was significantly lower than the paired pre-review missing data rate (p = 0.001). The same was confirmed for each of the 3 years (p = 0.001 for each year). The missing data rate significantly improved over the three-year period (p = 0.001). Data for the pre-hospitalisation period had the highest missing rates; data regarding the ICU stay showed the greatest improvement after the review. A total of 407 items (0.44%) were identified as errors.
Data quality is fundamental to avoid information bias in database analysis. This study indicates that it is possible to generate a serious data collection without significant resources. Audit seems to be an important tool before the final data is used for scientific projects.
Object
In order to monitor cerebral autoregulation status, a software package was developed to calculate a cerebral autoregulation index (pressure reactivity index, PRx). The aim of this study is to ...evaluate whether the application of this methodology is feasible and useful in the clinical setting.
Design
Prospective observational study.
Setting
NeuroIntensive Care Unit (NICU) of a university-affiliated teaching hospital.
Patients and Participants
Twenty-six consecutive patients admitted to NICU requiring intracranial pressure (ICP) and invasive arterial pressure (AP) monitoring.
Measurements and Results
Patient’s data were collected for a total of 902 h. Mean PRx was calculated utilizing 2 h time window. CPP–PRx distribution graphs were calculated from CPP of 20 to 110 mmHg using 10 mmHg intervals. Autoregulation was preserved in 18% observations (83/451) and deranged in 49% observations (220/451). In 33% observations (148/451), autoregulation could not be clearly defined (0 < PRx < 0.2). Even if no clinical protocol was developed, autoregulation status information inserted in clinical decision pathway influenced clinical management. Mean CPP, calculated at maximum and minimum ICP every 2 h interval, resulted different between groups with good and poor reactivity (67 ± 17.6 and 85 ± 20.0 mmHg, respectively, for autoregulating observations and 60 ± 19.1 and 67 ± 19.4 mmHg, respectively, for nonautoregulating observations,
P
< 0.001, independent samples
t
-test). PRx values were normally distributed.
Conclusions
Our study demonstrates that a daily bedside measure of cerebral autoregulation is feasible. PRx values can support clinicians in the identification of a targeted CPP in patients suffering from different intracranial pathologies and requiring an intensive monitoring.
PDF
