An 'optimal' cerebral perfusion pressure (CPPopt) can be defined as the point on the CPP scale corresponding to the greatest autoregulatory capacity. This can be established by examining the pressure ...reactivity index PRx-CPP relationship, which is approximately U-shaped but suffers from noise and missing data. In this paper, we present a method for plotting the whole PRx-CPP relationship curve against time in the form of a colour-coded map depicting the 'landscape' of that relationship extending back for several hours and to display this robustly at the bedside.This is a short version of a full paper recently published in Critical Care Medicine (2016) containing some new insights and details of a novel bedside implementation based on a presentation during Intracranial Pressure 2016 Symposium in Boston.
Recordings from routine monitoring of traumatic brain injury patients were processed using ICM+. Time-averaged means for arterial blood pressure, intracranial pressure, cerebral perfusion pressure (CPP) and pressure reactivity index (PRx) were calculated and stored with time resolution of 1 min. ICM+ functions have been extended to include not just an algorithm of automatic calculation of CPPopt but also the 'CPPopt landscape' chart.
Examining the 'CPPopt landscape' allows the clinician to differentiate periods where the autoregulatory range is narrow and needs to be targeted from periods when the patient is generally haemodynamically stable, allowing for more relaxed CPP management. This information would not have been conveyed using the original visualisation approaches.
We describe here a natural extension to the concept of autoregulatory assessment, providing the retrospective 'landscape' of the PRx-CPP relationship extending over the past several hours. We have incorporated such visualisation techniques online in ICM+. The proposed visualisation may facilitate clinical evaluation and use of autoregulation-guided therapy.
Femoral access in extracorporeal life support (ECLS) has been associated with regional variations in arterial oxygen saturation, potentially predisposing the patient to ischemic tissue damage. ...Current monitoring techniques, however, are limited to intermittent bedside evaluation of capillary refill among other factors. The aim of this study was to assess whether cerebral and limb regional tissue oxygen saturation (rSO2) values reflect changes in various patient-related parameters during venoarterial ECLS (VA-ECLS). This retrospective observational study included adults assisted by femorofemoral VA-ECLS. Bifrontal cerebral and bilateral limb tissue oximetry was performed for the entire duration of support. Hemodynamic data were analyzed parallel to cerebral and limb rSO2. A total of 23 patients were included with a median ECLS duration of 5 1-20 days. Cardiac arrhythmias were observed in 12 patients, which was associated with a decreased mean rSO2 from 61%±11% to 51%±10% during atrial fibrillation and 67%±9% to 58%±10% during ventricular fibrillation (P<0.001 for both). A presumably sudden increase in cardiac output due to myocardial recovery (n=8) resulted in a significant decrease in mean cerebral rSO2 from 73%±7% to 54%±6% and from 69%±9% to 53%±8% for the left and right cerebral hemisphere, respectively (P=0.012 for both hemispheres). Also, right radial artery partial gas pressure for oxygen decreased from 15.6±2.8 to 8.3±1.9 kPa (P=0.028). No differences were found in cerebral desaturation episodes between patients with and without neurologic complications. In six patients, limb rSO2 increased from on average 29.3±2.7 to 64.0±5.1 following insertion of a distal cannula in the femoral artery (P=0.027). Likewise, restoration of flow in a clotted distal cannula inserted in the femoral artery was necessary in four cases and resulted in increased limb rSO2 from 31.3±0.8 to 79.5±9.0; P=0.068. Non-invasive tissue oximetry adequately reflects events influencing cerebral and limb perfusion and can aid in monitoring tissue perfusion in patients assisted by ECLS.
IntroductionOwing to the novelty of COVID-19, there are still large knowledge gaps concerning its effect on the brain and the resulting impact on peoples’ lives. This large-scale prospective ...follow-up study investigates COVID-19-associated brain damage, neuropsychological dysfunction and long-term impact on the well-being of patients and their close ones. It is hypothesised that structural brain damage and cognitive dysfunction primarily occur in severely ill patients, as compared with moderately ill patients. Cognitive complaints, emotional distress and impact on well-being are hypothesised to be less dependent on illness severity.Methods and analysisFor this multicentre study, 200 patients with COVID-19 (100 intensive care unit (ICU) patients and 100 non-ICU patients) formerly hospitalised in one of the six recruiting hospitals during the first European infection wave (ie, March to June 2020) and their close ones will be recruited. At minimally 6 months posthospital discharge, patients will perform a set of neuropsychological tests and are subjected to a 3T MRI scan. Patients and close ones will fill out a set of questionnaires, also at minimally 6 months posthospital discharge and again another 6 months thereafter. Data related to COVID-19 hospitalisation will be extracted from the patients’ medical records. MRI abnormalities will ultimately be related to neuropsychological test performance and questionnaire outcomes.Ethics and disseminationEthics approval was granted by the medical research ethics committee of Maastricht University Medical Centre and Maastricht University (NL75102.068.20). The project is sponsored by The Brain Foundation Netherlands. Findings will be presented at national and international conferences, as well as published in peer-reviewed scientific journals.Trial registration numberNCT04745611.
The effects of early upright positioning in the acute phase of ischemic stroke on both blood pressure and functional outcome have not been previously examined.
Prospective investigation of mean ...arterial pressure, heart rate, and peripheral oxygen saturation in the supine, sitting, and (if achievable) active standing position 1, 2, and 3 days after an acute stroke was performed. Also investigated was the presence of a significant postural blood pressure rise and fall using orthostatic definitions and the relation to functional outcome after 3 months.
One hundred sixty-seven patients were included (mean age, 68.5±15.2 years; median National Institutes of Health Stroke Scale, 7). Approximately 60% of the patients were able to stand. On average the mean arterial pressure increased when patients moved from the supine to sitting (Day 1: Δ 3.9 mm Hg; P<0.001) and from sitting to an active standing position (Day 1: Δ 4.6 mm Hg; P<0.001). Changes were most pronounced within the first 24 hours after a stroke. Blood pressure decreased significantly (fall) on standing in 13% of patients and increased significantly (rise) in 20% of the patients. The latter was independently associated with a favorable outcome (P=0.003). Moving to the standing position was accompanied by an increase of heart rate. No difference in oxygen saturation was observed in the various positions over the period of investigation.
We found that a significant blood pressure rise during early upright positioning in patients with acute stroke was independently associated with a favorable outcome. No contraindication to early mobilization was found in this study.
To clarify the significance of any form of myoclonus in comatose patients after cardiac arrest with rhythmic and periodic EEG patterns (RPPs) by analyzing associations between myoclonus and EEG ...pattern, response to anti-seizure medication and neurological outcome.
Post hoc analysis of the prospective randomized Treatment of ELectroencephalographic STatus Epilepticus After Cardiopulmonary Resuscitation (TELSTAR) trial.
Eleven ICUs in the Netherlands and Belgium.
One hundred and fifty-seven adult comatose post-cardiac arrest patients with RPPs on continuous EEG monitoring.
Anti-seizure medication vs no anti-seizure medication in addition to standard care.
Of 157 patients, 98 (63%) had myoclonus at inclusion. Myoclonus was not associated with one specific RPP type. However, myoclonus was associated with a smaller probability of a continuous EEG background pattern (48% in patients with vs 75% without myoclonus, odds ratio (OR) 0.31; 95% confidence interval (CI) 0.16–0.64) and earlier onset of RPPs (24% vs 9% within 24 hours after cardiac arrest, OR 3.86;95% CI 1.64–9.11). Myoclonus was associated with poor outcome at three months, but not invariably so (poor neurological outcome in 96% vs 82%, p = 0.004). Anti-seizure medication did not improve outcome, regardless of myoclonus presence (6% good outcome in the intervention group vs 2% in the control group, OR 0.33; 95% CI 0.03–3.32).
Myoclonus in comatose patients after cardiac arrest with RPPs is associated with poor outcome and discontinuous or suppressed EEG. However, presence of myoclonus does not interact with the effects of anti-seizure medication and cannot predict a poor outcome without false positives.
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•Advanced neuroimaging complements structural clinical imaging findings in COVID-19.•Advanced neuroimaging findings reflect hypoxic, vascular, and inflammatory damage.•In vivo ...advanced neuroimaging findings are supported by postmortem histology.•Cerebral abnormalities are likely attributed to indirect viral infection.•Understanding COVID-19 neuropathology demands multiparametric imaging protocols.
Many Coronavirus Disease 2019 (COVID-19) patients are suffering from long-term neuropsychological sequelae. These patients may benefit from a better understanding of the underlying neuropathophysiological mechanisms and identification of potential biomarkers and treatment targets. Structural clinical neuroimaging techniques have limited ability to visualize subtle cerebral abnormalities and to investigate brain function. This scoping review assesses the merits and potential of advanced neuroimaging techniques in COVID-19 using literature including advanced neuroimaging or postmortem analyses in adult COVID-19 patients published from the start of the pandemic until December 2023. Findings were summarized according to distinct categories of reported cerebral abnormalities revealed by different imaging techniques. Although no unified COVID-19-specific pattern could be subtracted, a broad range of cerebral abnormalities were revealed by advanced neuroimaging (likely attributable to hypoxic, vascular, and inflammatory pathology), even in absence of structural clinical imaging findings. These abnormalities are validated by postmortem examinations. This scoping review emphasizes the added value of advanced neuroimaging compared to structural clinical imaging and highlights implications for brain functioning and long-term consequences in COVID-19.
Summary
Objective To understand factors influencing patients’ decisions to choose either fracture treatment by a bonesetter or in the hospital and to explore patients’ experiences with bonesetter ...treatment.
Method In‐depth interviews with 46 patients with a radiological proven fracture in a district hospital in central Ghana.
Results Traditional healers, such as bonesetters, play a substantial role in the Ghanaian healthcare system. Over a period of 3 months, 14 patients with a proven fracture left hospital for treatment by a bonesetter. The hospital is considered the only institution where emergency care can be provided and reliable, extensive diagnostic and treatment facilities are available for fracture treatment. Patients opting for bonesetter treatment are guided by the severity of the fracture, availability of the service, their financial status and past experiences. The healing methods used by different bonesetters are based on mutual comparable principles.
Conclusion Fracture treatment can serve as a model for respectful and efficient co‐existence of traditional and biomedical medicine.
Objectif Comprendre les facteurs influençant la décision des patients pour le choix entre le traitement des fractures par un rebouteur ou à l'hôpital; explorer les expériences des patients dans le traitement par rebouteurs.
Methode Entretiens détaillés avec 46 patients avec une fracture radiologiquement confirmée, dans un hôpital de district du centre du Ghana.
Resultats Les guérisseurs traditionnels tels que les rebouteurs jouent un rôle important dans le système de santé ghanéen. Sur une période de trois mois, 14 patients avec une fracture confirmée sont partis de l'hôpital pour se faire soigner par un rebouteur. L'hôpital est considéré comme étant le seul établissement où les soins d'urgence peuvent être obtenus et un service (étendu). fiable pour le diagnostic et le traitement des fractures est disponible. Les patients optant pour le traitement par un rebouteur sont guidés par la sévérité de la fracture, la disponibilité du service, leur situation financière et les expériences antérieures. Les méthodes curatives employées par différents rebouteurs sont basées sur des principes similaires.
Conclusion Le traitement des fractures pourrait servir de modèle à la coexistence respectueuse et efficace entre la médecine traditionnelle et biomédicale.
Objetivo Entender los factores que influyen en los pacientes a la hora de tomar decisiones sobre quien ha de tratarles en caso de fractura: si un huesero o en un hospital, así como explorar las experiencias de los pacientes tras un tratamiento con un huesero.
Método Entrevistas en profundidad con 46 pacientes con fractura probada radiológicamente en un hospital distrital de Ghana central.
Resultados Los sanadores tradicionales, como es el caso de los hueseros, juegan un papel importante en el sistema sanitario Ghaniano. Durante un periodo de tres meses, 14 pacientes con una factura probada dejaron el hospital para buscar tratamiento con un huesero. El hospital se considera como la única institución en la que se puede ofrecer tratamiento de emergencia y en la cual se dispone de la infraestructura fiable (y extensa). para el diagnóstico y tratamiento. Los pacientes que preferían ser tratados por hueseros, iban guiados por la severidad de la fractura, la disponibilidad del servicio, su condición financiera y experiencias pasadas. Los métodos de sanación utilizados por diferentes hueseros están basados en principios comparables.
Conclusión El tratamiento de fracturas puede servir como modelo de la coexistencia eficiente y respetuosa entre las medicinas tradicional y alopática.
Background. Routine lateral turning of patients has become an accepted standard of care to prevent complications of immobility. The haemodynamic and oxygenation effects for patients in both lateral ...positions (45°) are still a matter of debate. We aimed to study the effect of these positions on blood pressure, heart rate and oxygenation in a general intensive care population.
Design. Observational study.
Method. Twenty stable intensive care unit patients had intra‐arterial blood pressure recordings in the supine and lateral positions with the correction of hydrostatic height compared with a fixed reference point (phlebostatic level). A multilevel model was used to analyse the data.
Results. Mean arterial pressure readings in the lateral positions were, on average, 5 mmHg higher than in the supine position (p < 0·001). There were no significant differences between mean arterial pressure recordings in the left and right lateral position (p = 1·0). No important differences in oxygenation and heart rate were observed. After correction for covariates, the effects persisted.
Conclusion. Our study demonstrated an increase, albeit small, in blood pressure in the lateral positions. No major differences between the left and right lateral position were found. No important differences in oxygenation and heart rate were observed.
Relevance to clinical practice. Turning haemodynamically stable patients in the intensive care unit has no important effects on blood pressure measurements when continuous hydrostatic height correction is applied.
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