[Survey study: update on neurological intensive care in Germany 2012: structure, standards and scores in neurological intensive care units]

[Postoperative management following decompressive hemicraniectomy for malignant middle cerebral artery infarction-A German nationwide survey study]

BACKGROUND

Malignant middle cerebral artery infarction is a potentially life-threatening disease. Decompressive hemicraniectomy constitutes an evidence-based treatment practice, especially in patients under 60 years of age; however, recommendations with respect to postoperative management and particularly duration of postoperative sedation lack standardization.

OBJECTIVE

This survey study aimed to analyze the current situation of patients with malignant middle cerebral artery infarction following hemicraniectomy in the neurointensive care setting.

MATERIAL AND METHODS

From 20 September 2021 to 31 October 2021, 43 members of the initiative of German neurointensive trial engagement (IGNITE) network were invited to participate in a standardized anonymous online survey. Descriptive data analysis was performed.

RESULTS

Out of 43 centers 29 (67.4%) participated in the survey, including 24 university hospitals. Of the hospitals 21 have their own neurological intensive care unit. While 23.1% favored a standardized approach regarding postoperative sedation, the majority utilized individual criteria (e.g., intracranial pressure increase, weaning parameters, complications) to assess the need and duration. The timing of targeted extubation varied widely between hospitals (≤ 24 h 19.2%, ≤ 3 days in 30.8%, ≤ 5 days in 19.2%, > 5 days in 15.4%). Early tracheotomy (≤ 7 days) is performed in 19.2% and 80.8% of the centers aim for tracheotomy within 14 days. Hyperosmolar treatment is used on a regular basis in 53.9% and 22 centers (84.6%) agreed to participate in a clinical trial addressing the duration of postoperative sedation and ventilation.

CONCLUSION

The results of this nationwide survey among neurointensive care units in Germany reflect a remarkable heterogeneity in the treatment practices of patients with malignant middle cerebral artery infarction undergoing hemicraniectomy, especially with respect to the duration of postoperative sedation and ventilation. A randomized trial in this matter seems warranted.

In-hospital outcomes of patients with spontaneous supratentorial intracerebral hemorrhage

Spontaneous intracerebral hemorrhage (ICH) in the brain parenchyma accounts for 16.1% of all stroke types in Taiwan. It is responsible for high morbidity and mortality in some underlying causes. The objective of this study is to discover the predicting factors focusing on in-hospital outcomes of patients with spontaneous supratentorial ICH. Between June 2014 and October 2018, there were a total of 159 patients with spontaneous supratentorial ICH ranging from 27 to 91 years old in our institution. Twenty-three patients died during hospitalization, whereas 59 patients had an extended length of stay of >30 days. The outcomes were measured by inpatient death, length of stay, and activity of daily living (ADL). Both univariate and multivariate binary logistic regression, as well as multivariate linear regression, were used for statistical analysis. Multivariate binary linear regression analysis showed the larger hematoma in initial computed tomography scan of >30 cm3 (odds ratio [OR] = 2.505, P = .013) and concurrent in-hospital infection (OR = 4.173, P = .037) were both statistically related to higher mortality. On the other hand, in-hospital infection (≥17.41 days, P = .000) and surgery (≥11.23 days, P = .001) were correlated with a longer length of stay. Lastly, drastically poor change of ADL (ΔADL <-30) was associated with larger initial ICH (>30 cc, OR = 2.915, P = .049), in-hospital concurrent infection (OR = 4.695, P = .01), and not receiving a rehabilitation training program (OR = 3.473, P = .04). The results of this study suggest that age, prothrombin, initial Glasgow Coma Scale, computed tomography image, location of the lesion, and surgery could predict the mortality and morbidity of the spontaneous ICH, which cannot be reversed at the time of occurrence. However, effective control of international normalized ratio level, careful prevention against infection, and the aid of rehabilitation programs might be important factors toward a decrease of inpatient mortality rate, the length of stay, and ADL recovery.

Prognostication after intracerebral hemorrhage: a review

Background

Approximately half of patients with spontaneous intracerebral hemorrhage (ICH) die within 1 year. Prognostication in this context is of great importance, to guide goals of care discussions, clinical decision-making, and risk stratification. However, available prognostic scores are hardly used in clinical practice. The purpose of this review article is to identify existing outcome prediction scores for spontaneous intracerebral hemorrhage (ICH) discuss their shortcomings, and to suggest how to create and validate more useful scores.

Main text

Through a literature review this article identifies existing ICH outcome prediction models. Using the Essen-ICH-score as an example, we demonstrate a complete score validation including discrimination, calibration and net benefit calculations. Score performance is illustrated in the Erlangen UKER-ICH-cohort (NCT03183167). We identified 19 prediction scores, half of which used mortality as endpoint, the remainder used disability, typically the dichotomized modified Rankin score assessed at variable time points after the index ICH. Complete score validation by our criteria was only available for the max-ICH score. Our validation of the Essen-ICH-score regarding prediction of unfavorable outcome showed good discrimination (area under the curve 0.87), fair calibration (calibration intercept 1.0, slope 0.84), and an overall net benefit of using the score as a decision tool. We discuss methodological pitfalls of prediction scores, e.g. the withdrawal of care (WOC) bias, physiological predictor variables that are often neglected by authors of clinical scores, and incomplete score validation. Future scores need to integrate new predictor variables, patient-reported outcome measures, and reduce the WOC bias. Validation needs to be standardized and thorough. Lastly, we discuss the integration of current ICH scoring systems in clinical practice with the awareness of their shortcomings.

Conclusion

Presently available prognostic scores for ICH do not fulfill essential quality standards. Novel prognostic scores need to be developed to inform the design of research studies and improve clinical care in patients with ICH.

Supplementary Information

The online version contains supplementary material available at 10.1186/s42466-021-00120-5.

[Modern principles of neurocritical care]

Neurological diseases frequently demanding admittance to a dedicated neurological intensive care unit (neurocritical care) comprise space-occupying ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, traumatic brain injury, status epilepticus, bacterial meningitis, myasthenic crisis and Guillain-Barré syndrome. Due to often necessary analgesia, sedation and mechanical ventilation, neuromonitoring should ideally be employed. This consists of bedside invasive and non-invasive methods for monitoring cerebral perfusion, oxygenation, metabolism and neurophysiology. Modern treatment principles in neurocritical care mainly aim at avoiding or attenuating secondary neurological brain damage, in particular directed at sufficient perfusion and oxygenation. These include measures such as neuroprotective ventilation, stabilization of the circulation, decreasing intracranial pressure in brain edema and space-occupying processes, anticonvulsive treatment, temperature management and targeted disease-specific treatment.

[Neurointensive care in Germany : Results of an inspection of intensive care units]

BACKGROUND

The situation of neurointensive care in Germany is unclear.

OBJECTIVES

An inspection of neurointensive wards should help to clarify the situation.

MATERIALS AND METHODS

On the occasion of stroke unit certification audits, 320 intensive care units (39 independent neurological and 20 neurosurgical, 6 combined neurological/neurosurgical, 253 interdisciplinary intensive wards) were inspected.

RESULTS

On the 39 neurological and the 20 neurosurgical intensive care units, a physician with intensive care specialization was available in 92% and 100% of units, respectively, and a physician with authorization for intensive care training was available in 74% and 80% of units, respectively. A whole day shiftwork existed in 59% and 55% of units, respectively. On the interdisciplinary wards a physician with intensive care specialization was available in 76% and a physician with authorization for intensive care training was available in 52% of units. A whole day shiftwork existed in 64% of units. A full-time neurological/neurosurgical presence during business hours was found only in 18% of units.

CONCLUSIONS

The neurological/neurosurgical presence and the opportunities for intensive care training on the interdisciplinary wards are not sufficient. There is an urgent need for improvement.

[News and perspectives in neurocritical care]

Neurocritical care is an ever-evolving discipline and its implementation in intensive care leads to reduction in mortality and to improvement of functional outcome in patients with devastating injuries to the nervous system. However, the decisive elements of the complete field of neurocritical care remain relatively unclear, as well as the exact ways to optimize them. During recent years new insights have been gained and new exciting studies have been initiated from which results are soon to be expected. This review focuses on the following management aspects: neuromonitoring, airway and ventilation, endovascular therapy, cerebrospinal fluid drainage, decompressive craniectomy, hematoma evacuation, blood pressure, and targeted temperature management. The application of these measures to brain diseases and injuries frequently treated in neurointensive care units will be addressed in the context of current studies.

Standards of scoring, monitoring, and parameter targeting in German neurocritical care units: a national survey

BACKGROUND

Optimal management of physiological parameters in neurological/neurosurgical intensive care units (NICUs) is largely unclear as high-quality evidence is lacking. The aim of this survey was to investigate if standards exist in the use of clinical scores, systemic and cerebral monitoring and the targeting of physiology values and in what way this affects clinical management in German NICUs.

METHODS

National survey, on-line anonymized questionnaire. German departments stating to run a neurological, neurosurgical or interdisciplinary neurological/neurosurgical intensive care unit were identified by a web-based search of all German hospitals and contacted via email.

RESULTS

Responses from 78 German NICUs were obtained. Of 19 proposed clinical/laboratory/radiological scores only 5 were used regularly by >60 %. Bedside neuromonitoring (NM) predominantly consisted of transcranial Doppler sonography (94 %), electroencephalography (92 %) and measurement of intracranial pressure (ICP) (90 %), and was installed if patients had or were threatened by elevated ICP (86 %), had specific diseases like subarachnoid hemorrhage (51 %) or were comatose (35 %). Although mean trigger values for interventions complied with guidelines or wide-spread customs, individual trigger values varied widely, e.g., for hyperglycemia (maximum blood glucose between 120 and 250 mg/dl) or for anemia (minimum hemoglobin values between 5 and 10 g/dl).

CONCLUSIONS

Although apparently aiming for standardization in neurocritical care, German NICUs show substantial differences in NM and monitoring-associated interventions. In terms of scoring and monitoring methods, German NICUs seem to be quite conservative. These survey results suggest a need of prospective and randomized interventional trials in neurocritical care to help define standards and target values.