The determinants of decisions to limit life support (withholding or withdrawal) in ventilated stroke patients have been evaluated mainly for patients with intracranial hemorrhages. We aimed to ...evaluate the frequency of life support limitations in ventilated ischemic and hemorrhagic stroke patients compared with a nonbrain-injured population and to determine factors associated with such decisions.
Multicenter prospective French observational study.
Fourteen ICUs of the French OutcomeRea network.
From 2005 to 2016, we included stroke patients and nonbrain-injured patients requiring invasive ventilation within 24 hours of ICU admission.
None.
We identified 373 stroke patients (ischemic,
= 167 45%; hemorrhagic,
= 206 55%) and 5,683 nonbrain-injured patients. Decisions to limit life support were taken in 41% of ischemic stroke cases (vs nonbrain-injured patients, subdistribution hazard ratio, 3.59 95% CI, 2.78-4.65) and in 33% of hemorrhagic stroke cases (vs nonbrain-injured patients, subdistribution hazard ratio, 3.9 95% CI, 2.97-5.11). Time from ICU admission to the first limitation was longer in ischemic than in hemorrhagic stroke (5 3-9 vs 2 d 1-6 d;
< 0.01). Limitation of life support preceded ICU death in 70% of ischemic strokes and 45% of hemorrhagic strokes (
< 0.01). Life support limitations in ischemic stroke were increased by a vertebrobasilar location (vs anterior circulation, subdistribution hazard ratio, 1.61 95% CI, 1.01-2.59) and a prestroke modified Rankin score greater than 2 (2.38 1.27-4.55). In hemorrhagic stroke, an age greater than 70 years (2.29 1.43-3.69) and a Glasgow Coma Scale score less than 8 (2.15 1.08-4.3) were associated with an increased risk of limitation, whereas a higher nonneurologic admission Sequential Organ Failure Assessment score was associated with a reduced risk (per point, 0.89 0.82-0.97).
In ventilated stroke patients, decisions to limit life support are more than three times more frequent than in nonbrain-injured patients, with different timing and associated risk factors between ischemic and hemorrhagic strokes.
To describe 3-6-month neurologic outcomes of survivors of COVID-19-associated acute respiratory distress syndrome, invasively ventilated in the ICU.
A bicentric prospective study during the two first ...waves of the pandemic (March to May and September to December, 2020).
Two academic hospital ICUs, Paris, France.
Adult COVID-19-associated acute respiratory distress syndrome survivors, invasively ventilated in the ICU, were eligible for a neurologic consultation between 3 and 6 months post ICU discharge.
Follow-up by face-to-face neurologic consultation.
The primary endpoint was favorable functional outcome defined by a modified Rankin scale score less than 2, indicating survival with no significant disability. Secondary endpoints included mild cognitive impairment (Montreal Cognitive Assessment score < 26), ICU-acquired weakness (Medical Research Council score < 48), anxiety and depression (Hospital Anxiety and Depression score > 7), and posttraumatic stress disorder (posttraumatic stress disorder checklist for Diagnostic and Statistical Manual of Mental Disorders 5 score > 30). Of 54 eligible survivors, four non-French-speaking patients were excluded, eight patients were lost-to-follow-up, and one died during follow-up. Forty-one patients were included. Time between ICU discharge and neurologic consultation was 3.8 months (3.6-5.9 mo). A favorable functional outcome was observed in 16 patients (39%) and mild cognitive impairment in 17 of 33 patients tested (52%). ICU-acquired weakness, depression or anxiety, and posttraumatic stress disorder were reported in six of 37 cases (16%), eight of 31 cases (26%), and two of 27 cases (7%), respectively. Twenty-nine patients (74%) required rehabilitation (motor, cognitive, or psychologic). ICU and hospital lengths of stay, tracheostomy, and corticosteroids were negatively associated with favorable outcome. By contrast, use of alpha-2 agonists during ICU stay was associated with favorable outcome.
COVID-19-associated acute respiratory distress syndrome requiring intubation led to slight-to-severe functional disability in about 60% of survivors 4 months after ICU discharge. Cognitive impairment, muscle weakness, and psychologic symptoms were frequent. A large multicenter study is warranted to allow identification of modifiable factors for improving long-term outcome.
Background: The prognosis value of early clinical diagnosis of consciousness impairment is documented by an extremely limited number of studies, whereas it may convey important information to guide ...medical decisions.
Objective: We aimed at determining if patients diagnosed at an early stage (<90 days after brain injury) as being in the minimally conscious state (MCS) have a better prognosis than patients in the vegetative state/Unresponsive Wakefulness syndrome (VS/UWS), independent of care limitations or withdrawal decisions.
Methods: Patients hospitalized in ICUs of the Pitié-Salpêtrière Hospital (Paris, France) from November 2008 to January 2011 were included and evaluated behaviourally with standardized assessment and with the Coma Recovery Scale-Revised as being either in the VS/UWS or in the MCS. They were then prospectively followed until 1July 2011 to evaluate their outcome with the GOSE. We compared survival function and outcomes of these two groups.
Results: Both survival function and outcomes, including consciousness recovery, were significantly better in the MCS group. This difference of outcome still holds when considering only patients still alive at the end of the study.
Conclusions: Early accurate clinical diagnosis of VS/UWS or MCS conveys a strong prognostic value of survival and of consciousness recovery.
L’encéphalite associée aux anticorps anti GFAP est une entité récemment décrite, fréquemment associée à des atteintes méningés et médullaires. Nous présentons dans ce poster, un cas dont la ...présentation mimait celle d’une méningo-encéphalite tuberculeuse.
Nous rapportons le cas d’un patient guyanais de 68 ans, présentant des céphalées fébriles, un syndrome méningé, et une méningite lymphocytaire à plus de 1000 lymphocytes associé à une glycorachie normale et une hyperprotéinorachie à 2,34g/L. Les examens microbiologiques, et les anticorps anti-neuronaux étaient négatif. l’IRM cérébrale était initialement normale. Le patient avait ensuite présenté une confusion, des troubles de la vigilance et un syndrome cérébelleux. En l’absence d’argument pour un diagnostic différentiel, un traitement antituberculeux comprenant une corticothérapie avait été instauré et avait permis une amélioration partielle. Dans un second temps, étaient apparus des hypersignaux de la substance blanche et des noyaux gris centraux à l’IRM, et une quasi-cécité sur une névrite optique bilatérale sévère. La présence d’anticorps anti GFAP retrouvés dans le LCR avait permis de rectifier le diagnostic, d’introduire un traitement immunosuppresseurs par Bolus de methylprednisolone, échanges plasmatiques et Mycophénolate mofetil, permettant une évolution neurologique favorable. Le traitement n’a en revanche pas permis d’amélioration visuelle, avec à l’examen ophtalmologique, une atrophie optique importante.
Notre cas se distingue des encéphalites à anti GFAP précédemment décrite, par l’importance de sa réaction méningée, faisant suspecter une méningite infectieuse, et notamment tuberculeuse. La réponse aux corticoïdes associés aux antituberculeux a également contribué à égarer le diagnostic. Il s’en différentie également par la survenue d’une névrite optique particulièrement sévère, peut-être favorisée par le retard diagnostic.
Notre cas illustre l’importance de rechercher les anticorps des encéphalites dysimmunes chez les patients souffrant de méningo-encéphalite, y compris si le tableau est évocateur d’une origine infectieuse, si celle-ci n’est pas documentée.
Background
The respective benefits of high and low doses of dexamethasone (DXM) in patients with severe acute respiratory syndrome coronavirus 2 (SARS-Cov2) and acute respiratory failure (ARF) are ...controversial, with two large triple-blind RCTs reaching very important difference in the effect-size. In the COVIDICUS trial, no evidence of additional benefit of high-dose dexamethasone (DXM20) was found. We aimed to explore whether some specific patient phenotypes could benefit from DXM20 compared to the standard of care 6 mg dose of DXM (DXMSoC).
Methods
We performed a post hoc exploratory Bayesian analysis of 473 patients who received either DXMSoc or DXM20 in the COVIDICUS trial. The outcome was the 60 day mortality rate of DXM20 over DXMSoC, with treatment effect measured on the hazard ratio (HR) estimated from Cox model. Bayesian analyses allowed to compute the posterior probability of a more than trivial benefit (HR < 0.95), and that of a potential harm (HR > 1.05). Bayesian measures of interaction then quantified the probability of interaction (Pr Interact) that the HR of death differed across the subsets by 20%. Primary analyses used noninformative priors, centred on HR = 1.00. Sensitivity analyses used sceptical and enthusiastic priors, based on null (HR = 1.00) or benefit (HR = 0.95) effects.
Results
Overall, the posterior probability of a more than trivial benefit and potential harm was 29.0 and 51.1%, respectively. There was some evidence of treatment by subset interaction (i) according to age (Pr Interact, 84%), with a 86.5% probability of benefit in patients aged below 70 compared to 22% in those aged above 70; (ii) according to the time since symptoms onset (Pr Interact, 99%), with a 99.9% probability of a more than trivial benefit when lower than 7 days compared to a < 0.1% probability when delayed by 7 days or more; and (iii) according to use of remdesivir (Pr Interact, 91%), with a 90.1% probability of benefit in patients receiving remdesivir compared to 19.1% in those who did not.
Conclusions
In this exploratory post hoc Bayesian analysis, compared with standard-of-care DXM, high-dose DXM may benefit patients aged less than 70 years with severe ARF that occurred less than 7 days after symptoms onset. The use of remdesivir may also favour the benefit of DXM20. Further analysis is needed to confirm these findings.
Trial registration
: NCT04344730, date of registration April 14, 2020 (
https://clinicaltrials.gov/ct2/show/NCT04344730?term=NCT04344730&draw=2&rank=1
); EudraCT: 2020-001457-43 (
https://www.clinicaltrialsregister.eu/ctr-search/search?query=2020-001457-43
).
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