actor associated with outcomes and mortality in COVID-19 patients includes cardiovascular and cerebrovascular comorbidities but the underlying mechanisms are still hypothetical 1. We report the case ...of a 73-year-old patient who developed within a week after the onset of respiratory symptoms related to SARS-CoV2 infection, an acute ischemic stroke (AIS) complicating a large floating thrombus within the common carotid artery. The patient has no specific past medical history, no treatment and no vascular risk factors. He presented at the emergency department on March 25th for the onset of fever and dry cough. Clinical evaluation was reassuring and the patient was discharged home. He was readmitted 7 days later for the acute onset of aphasia and right hemiparesis evolving for 9 hours. On admission, the patient was in respiratory distress, and neurological examination revealed a left middle cerebral artery (MCA) syndrome with a NIH stroke scale (NIHSS) of 10. Chest CT showed ground glass opacities typically reported in SARS-CoV2 infection, which was subsequently confirmed by real-time reverse transcriptase–polymerase chain reaction assay on a nasopharyngeal swab sample. Brain Computer Tomography (CT), CT angiography (CTA) and CT perfusion, performed on a 64-channel scanner (Optima, General Electric, USA), showed subtle cortical left frontal hypoattenuation with more extended surrounding hypoperfusion and distal occlusion of branch. CT perfusion was acquired before CTA, and both were performed using, for each, a 40 cc-bolus of iodine contrast injected at a 5 cc/sec rate (iobitridol 350, Guerbet, France), pushed by 40 cc of physiological serum. Cervical CTA also revealed a large intraluminal floating thrombus appended to a hypoattenuated non-stenosing plaque of the left common carotid artery wall. Dedicated wall imaging with 3 T MRI (Skyra, Siemens, Germany) and Doppler ultrasoonography confirmed the diagnosis of a large thrombus adherent to a thin atheromatous plaque. Of note, those examination disclosed no ulceration, plaque hemorrhage or circumferential gadolinium enhancement of the wall potentially suggestive of arteritis. Diffusion-Weighted Imaging performed 2 days later confirmed the diagnosis of multiple AIS with foci of hyperintensity scattered within left carotid territory.
Background
The literature is unresolved on whether female receive advanced cardiac life support less than do male and on whether female have a survival advantage over male after cardiopulmonary ...resuscitation.
Methods
We systematically searched PubMed, Embase and Web of Science databases (from inception to 23-April-2022) for papers reporting outcomes in adult male and female after out-of-hospital cardiac arrest. The main study outcome was the rate of adjusted survival to hospital discharge or 30 days. Secondary outcomes included unadjusted survival to hospital discharge and favourable neurological outcome.
Results
A total of 28 studies were included, involving 1,931,123 patients. Female were older than male, their cardiac arrests were less likely to be witnessed and less likely to present with a shockable rhythm. Unadjusted analysis showed that females had a lower likelihood of survival than males (OR 0.68 0.62–0.74,
I
2
= 97%). After adjustment, no significant difference was identified between male and female in survival at hospital discharge/30 days (OR 1.01 0.93–1.11,
I
2
= 87%). Data showed that male had a significantly higher likelihood of favorable neurological outcome in unadjusted analysis but this trend disappeared after adjustment. Both the primary outcome (adjusted for several variables) and the secondary outcomes were associated with substantial heterogeneity. The variables examined using meta-regression, subgroup and sensitivity analyses (i.e., study type, location, years, population, quality of adjustment, risk of bias) did not reduce heterogeneity.
Conclusions
The adjusted rate of survival to hospital discharge/30 days was similar for male and female despite an initial seeming survival advantage for male. The validity of this finding is limited by substantial heterogeneity despite in-depth investigation of its causes, which raises concerns regarding latent inequalities in some reports nonetheless. Further study on this topic may require inclusion of factors not reported in the Utstein template and in-depth analysis of decision-making processes.
To assess incidence and predicting factors of awake craniotomy complications.
Retrospective cohort study.
Operating room and Post Anesthesia Care unit.
162 patients who underwent 188 awake craniotomy ...procedures for brain tumor, ASA I to III, with monitored anesthesia care.
We classified procedures in 3 groups: major event group, minor event group, and no event group. Major events were defined as respiratory failure requiring face mask or invasive ventilation; hemodynamic instability treated by vasoactive drugs, or bradycardia treated by atropine, bleeding >500 ml, transfusion, gaseous embolism, cardiac arrest; seizure, cerebral edema, or any events leading to stopping of the cerebral mapping. Minor event was defined as any complication not classified as major. Multivariate logistic regression was used to determine predicting factors of major complication, adjusted for age and ASA score.
45 procedures (24%) were classified in major event group, 126 (67%) in minor event group, and 17 (9%) in no event group. Seizure was the main complication (n = 13). Asthma (odds ratio: 10.85 1.34; 235.6), Remifentanil infusion (odds ratio: 2.97 1.08; 9.85) and length of the operation after the brain mapping (odds ratio per supplementary minute: 1.01 1.01; 1.03) were associated with major events.
Previous medical history of asthma, remifentanil infusion and a long duration of neurosurgery after cortical mapping appear to be risk factors for major complications during AC.
•Seizure is the main per operative complication of awake craniotomy•History of asthma, remifentanil use and time after cerebral mapping were associated with major event•Awake craniotomy was associated with less hypotension, nausea/vomiting, and reduced length of stay than general anesthesia
Despite extensive evidence of benefit of thrombectomy in adult ischemic stroke due to large-vessel occlusion in the 6-h window, its role remains uncertain in very young children. We describe ...hereafter the case of a 2-year-old female child who had a successful thrombectomy 9 h after stroke onset. The patient presented with right hemiplegia, central facial palsy, a normal level of consciousness, and speech difficulties. The PedNIHS score was 11. CT scan without contrast injection displayed spontaneous hyperdensity of the middle cerebral artery (MCA), with only limited early signs of ischemia (ASPECTS 8). CT angiography demonstrated occlusion of the proximal MCA with good collaterals. Thrombectomy was realized. Complete recanalization (TICI 3) was obtained under general anesthesia after two passes of a stent retriever. Time from symptoms onset to full recanalization was 9 h. The acute ischemic stroke was caused by embolic thrombus from a congenital heart disease. Clinical recovery was complete. Three months after the thrombectomy, the young patient was doing well without any neurological sequelae (PedNIHSS 0; modified Rankin Scale: 0). This case report is an example of a decision-making process to perform thrombectomy in a very young child, which included cardio-embolic etiology as a parameter that potentially might have participated to the successful outcome of the therapeutic procedure.
(1) Background: The effects of lockdown repetition on work-related stress, expressed through Effort-Reward Imbalance (ERI), during the COVID-19 pandemic are poorly documented. We investigated the ...effect of repetitive lockdowns on the ERI in French workers, its difference across occupations, and the change in its influencing factors across time. (2) Methods: Participants were included in a prospective cross-sectional observational study from 30 March 2020 to 28 May 2021. The primary outcome was the ERI score (visual analog scale). The ERI score of the population was examined via Generalized Estimating Equations. For each period, the factors influencing ERI were studied by multivariate linear regression. (3) Results: In 8121 participants, the ERI score decreased in the first 2 lockdowns (53.2 ± 0.3, p < 0.001; 50.5 ± 0.7, p < 0.001) and after lockdown 2 (54.8 ± 0.8, p = 0.004) compared with the pre-pandemic period (59 ± 0.4). ERI was higher in medical than in paramedical professionals in the pre-pandemic and the first 2 lockdowns. Higher workloads were associated with better ERI scores. (4) Conclusions: In a large French sample, Effort-Reward Imbalance worsened during the COVID-19 pandemic until the end of the 2nd lockdown. Paramedical professionals experienced a higher burden of stress compared with medical professionals.
Glial fibrillary acidic protein (GFAP), ubiquitin carboxy-terminal hydrolase-L1 (UCH-L1), and matrix metalloproteinase 9 (MMP-9) are potential biomarkers of traumatic brain injury (TBI) but also of ...secondary insults to the brain. The aim of this study was to describe the cerebral distribution of GFAP, UCH-L1, and MMP-9 in a rat model of diffuse TBI associated with standardized hypoxia-hypotension (HH). Adult male Sprague-Dawley rats were allocated to Sham (n = 10), TBI (n = 10), HH (n = 10), and TBI+HH (n = 10) groups. After 4 hours, brains were rapidly removed and immunostaining of GFAP, UCH-L1, and MMP-9 was performed. Areas of interest that have been described as particularly sensitive to hypoxic insults were analyzed. For GFAP, in the neocortex, immunostaining revealed a significant decrease in strong staining for HH and TBI+HH groups compared with TBI group (P < .0001). For UCH-L1, the total immunostaining (6 regions of interest) reported a significant increase in strong staining (P < .0001) and decrease in weak staining (P < .0001) for the HH and TBI+HH groups compared with the Sham and TBI groups. For MMP-9, for the HH and TBI+HH groups, a significant increase in moderate (P < .0001) and weak staining (P < .0001) and a decrease in negative staining (P < .0001) compared with the Sham and TBI groups were observed. UCH-L1 and MMP-9 immunostainings increased after HH alone or HH combined with TBI compared with TBI alone. GFAP immunostaining decreased particularly in the neocortex after HH alone or HH combined with TBI compared with TBI alone. These three biomarkers could therefore be considered as potential biomarkers of HH insults independently of TBI.
Procalcitonin (PCT) protocols to guide antibiotic treatment for ventilator-associated pneumonia (VAP) in the intensive care unit aim at reducing antibiotic exposure. Our study goal was to measure ...compliance with a PCT protocol for VAP and to determine the associated variables.
From 2017 to 2021, we conducted a retrospective, monocentric study including patients treated for VAP. In our PCT protocol, PCT was measured at the initiation of antibiotic treatment and every 48 h until treatment completion; antibiotics were stopped if PCT decreased by more than 80% from its highest value or fell below 0.5 ng/mL. We assessed the compliance with the PCT protocol and compared the compliant and noncompliant groups.
Among the 177 included patients, compliance with the PCT protocol was assessed at 58%. Noncompliance was due to lack of PCT measurements in 76% of cases. Compliance was higher in the medical patients (
= 0.04) and in those admitted for SARS-CoV-2 (
= 0.02). Compliance regarding the interruption of antibiotic therapy based on PCT was lower on weekends and holidays (
= 0.01). Outcomes did not differ according to compliance.
This study assessed real-life compliance with the PCT protocol to monitor antibiotic treatment for VAP. Improving the measurement of PCT at the bedside would increase the rate.
The demographics and outcomes of ICU patients admitted for a COVID-19 infection have been characterized in extensive reports, but little is known about antimicrobial stewardship for these patients. ...We designed this retrospective, observational study to investigate our hypothesis that the COVID-19 pandemic has disrupted antimicrobial stewardship practices and likely affected the rate of antibiotic de-escalation (ADE), patient outcomes, infection recurrence, and multidrug-resistant bacteria acquisition. We reviewed the prescription of antibiotics in three ICUs during the pandemic from March 2020 to December 2021. All COVID-19 patients with suspected or proven bacterial superinfections who received antibiotic treatment were included. The primary outcome was the rate of ADE, and secondary outcomes included the rate of appropriate empirical treatment, mortality rates and a comparison with a control group of infected patients before the COVID-19 pandemic. We included 170 COVID-19 patients who received antibiotic treatment for a suspected or proven superinfection, of whom 141 received an empirical treatment. For the latter, antibiotic treatment was de-escalated in 47 (33.3%) patients, escalated in 5 (3.5%) patients, and continued in 89 (63.1%) patients. The empirical antibiotic treatment was appropriate for 87.2% of cases. ICU, hospital, and day 28 and day 90 mortality rates were not associated with the antibiotic treatment strategy. The ADE rate was 52.2% in the control group and 27.6% in the COVID-19 group (p < 0.001). Our data suggest that empirical antibiotic treatment was appropriate in most cases. The ADE rates were lower in the COVID-19 group than in the control group, suggesting that the stress associated with COVID-19 affected our practices.
Background: LUS is a validated tool for the management of COVID-19 pneumonia. Chair positioning (CP) may have beneficial effects on oxygenation and lung aeration, and may be an easier alternative to ...PP. This study assessed the effects of a CP session on oxygenation and lung aeration (LA) changes in non-intubated COVID-19 patients. Methods: A retrospective multicenter study was conducted in an ICU. We analyzed data from LUS exams and SpO2:FiO2 performed before/after a CP session in non-intubated COVID-19 patients. Patients were divided into groups of responders or non-responders in terms of oxygenation or LA. Results: Thirty-three patients were included in the study; fourteen (44%) were oxygenation non-responders and eighteen (56%) were oxygenation responders, while thirteen (40.6%) and nineteen (59.4%) patients were classified as LA non-responders and responders, respectively. Changes in oxygenation and LA before/after a CP session were not correlated (r = −0.19, p = 0.3, 95% CI: −0.5–0.17). The reaeration scores did not differ between oxygenation responders and non-responders (1 (−0.75–3.75) vs. 4 (−1–6), p = 0.41). The LUS score was significantly correlated with SpO2:FiO2 before a CP session (r = 0.37, p = 0.04, 95% CI: 0.03–0.64) but not after (r = 0.17, p = 0.35, 95% CI: −0.19–0.50). Conclusion: A CP session was associated with improved oxygenation and LA in more than half of the non-intubated COVID-19 patients.
Purpose of review The incidence of infective endocarditis (IE) is increasing worldwide, resulting in a higher number of patients with IE being admitted to intensive care units (ICU). Nearly half of ...patients with IE develop a complication during their clinical course. However, few well conducted studies or reviews are devoted to critically ill IE patients. This review discusses the contemporary perioperative and intensive care literature. Recent findings IE epidemiology is changing towards elderly and frail patients. ICU patients are at risk of risk of developing IE because they are often in a pro-inflammatory state and many also have several indwelling catheters, which favors infection. Increased performance and recent advances in cardiac imaging allow for easier diagnosis of EI, but the applicability of these techniques to ICU patients is still relatively limited. New developments in antibiotic treatment and adjunctive therapies are explored further in this review. Summary The lack of evidence on ICU patients with IE highlights the critical importance of multidisciplinary decision-making and the need for further research.
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