Impact of neurointensivist-managed intensive care unit implementation on patient outcomes after aneurysmal subarachnoid hemorrhage

Contemporary management of aneurysmal subarachnoid haemorrhage. An update for the intensivist

Aneurysmal subarachnoid haemorrhage (aSAH) is a rare yet profoundly debilitating condition associated with high global case fatality and morbidity rates. The key determinants of functional outcome include early brain injury, rebleeding of the ruptured aneurysm and delayed cerebral ischaemia. The only effective way to reduce the risk of rebleeding is to secure the ruptured aneurysm quickly. Prompt diagnosis, transfer to specialized centers, and meticulous management in the intensive care unit (ICU) significantly improved the prognosis of aSAH. Recently, multimodality monitoring with specific interventions to correct pathophysiological imbalances has been proposed. Vigilance extends beyond intracranial concerns to encompass systemic respiratory and haemodynamic monitoring, as derangements in these systems can precipitate secondary brain damage. Challenges persist in treating aSAH patients, exacerbated by a paucity of robust clinical evidence, with many interventions showing no benefit when tested in rigorous clinical trials. Given the growing body of literature in this field and the issuance of contemporary guidelines, our objective is to furnish an updated review of essential principles of ICU management for this patient population. Our review will discuss the epidemiology, initial stabilization, treatment strategies, long-term prognostic factors, the identification and management of post-aSAH complications. We aim to offer practical clinical guidance to intensivists, grounded in current evidence and expert clinical experience, while adhering to a concise format.

Clinical Outcome of Patients with Poor-Grade Aneurysmal Subarachnoid Hemorrhage with Bundled Treatments: A Propensity Score-Matched Analysis

BACKGROUND

Poor-grade aneurysmal subarachnoid hemorrhage (aSAH), defined as Hunt and Hess (HH) grades IV and V, is a challenging disease because of its high mortality and poor functional outcomes. The effectiveness of bundled treatments has been demonstrated in critical diseases. Therefore, poor-grade aSAH bundled treatments have been established. This study aims to evaluate whether bundled treatments can improve long-term outcomes and mortality in patients with poor-grade aSAH.

METHODS

This is a comparative study using historical control from 2008 to 2022. Bundled treatments were introduced in 2017. We compared the rate of favorable outcomes (modified Rankin Scale score 0-2) at 6 months and mortality before and after the introduction of the bundled treatments. To eliminate confounding bias, the propensity score matching method was used.

RESULTS

A total of 90 consecutive patients were evaluated. Forty-three patients received bundled treatments, and 47 patients received conventional care. The proportion of patients with HH grade V was higher in the bundle treatment group (41.9% vs. 27.7%). Conversely, the proportion of patients with fixed pupils on the initial examination was higher in the conventional group (30.2% vs. 38.3%). After 1:1 propensity score matching, 31 pairs were allocated to each group. The proportion of patients with 6-month favorable functional outcomes was significantly higher in the bundled treatments group (46.4% vs. 20.7%, p = 0.04). The 6-month mortality rate was 14.3% in the bundled treatments group and 27.3% in the conventional group (p = 0.01). Bundled treatments (odd ratio 14.6 [95% confidence interval 2.1-100.0], p < 0.01) and the presence of an initial pupil reflex (odd ratio 12.0 [95% confidence interval 1.4-104.6], p = 0.02) were significantly associated with a 6-month favorable functional outcome.

CONCLUSIONS

The bundled treatments improve 6-month functional outcome and mortality in patients with poor-grade aSAH.

Research trends within aneurysmal subarachnoid hemorrhage from 2017 to 2021: a bibliometric study

Bibliometric analyses are a well-established strategy for understanding the dynamics of publications. Aneurysmal subarachnoid hemorrhage (aSAH) is a hot topic in neurology and neurosurgery research. To perform a bibliometric analysis of recent publications within aSAH. Articles addressing aSAH published between 2017 and 2021 were included and had their information extracted from Scopus. A total of 2177 articles were included. The mean number of citations was 6.18 (95%CI = 5.77-6.59). 2021 and 2020 were the most prolific years. World Neurosurgery (N = 389/2,177 articles; 17,87%) was the leading publisher, and American Journal of Neuroradiology had the highest number of citations per article (14.82) among journals with ≥ 10 publications. Primary research (N = 1624/2177) predominated, followed by case reports (N = 434/2,177). Among secondary studies, systematic reviews (N = 78/119) surpassed narrative reviews (N = 41/119). USA led the number of publications (N = 548/2,177 articles; 25.17%), followed by China (N = 358/2,177 articles; 16.44%). High-income countries had a higher number of publications (N = 1624/2177) and more citations per article (6.84) than middle-income countries (N = 553/2177 and 4.25, respectively). There were zero articles from low-income countries. European and North American institutions had the greatest research impact. There was an increase in the number of published articles in the last few years (2020 and 2021). Many studies had a low level of evidence, whereas interventional studies were uncommon.

The Efficacy of Acute Myocardial Infarction Intensive Care Unit Management with a Collaborative Intensivists and Cardiologists in Japan: A Retrospective Observational Study

Objective Dedicated intensive care unit (ICU) physician staffing is associated with a reduction in ICU mortality rates in general medical and surgical ICUs. However, limited data are available on the role of intensivists in ICU for cardiac disease, especially in Japan. This study investigated the association of collaborative intensivists and cardiologist care with clinical outcomes in patients with acute myocardial infarction (AMI) admitted to the ICU. Methods This study analyzed 106 patients admitted to the ICU at Nara Prefecture General Medical Center in Nara, Japan, from April 2017 to April 2019. Eligible patients were divided into either the high-intensity ICU management group (n=51) or the low-intensity ICU management group (n=55). The primary outcome of in-hospital mortality was compared in the two groups. Results The high-intensity ICU group was found to be associated with a lower mortality rate in a multivariate analysis than the low-intensity group [7.8% vs. 16.4%; odds ratio (OR): 0.07; 95% confidence interval (CI): 0.01-0.54; p=0.01]. There were no significant differences in the length of either the ICU stay or hospital stay or the hospital costs between the two groups. A subgroup analysis revealed that the in-hospital mortality rate was lower in the high-intensity ICU group than in the low-intensity ICU group among patients with Killip class IV (16.7% vs. 34.6%; OR, 0.08; 95% CI, 0.01-0.67; p=0.02). Conclusion The presence of dedicated intensivists in high-intensity ICU collaborating with cardiologists might reduce in-hospital mortality in patients with Killip class IV AMI who require critical care.

Association of Neurocritical Care Services With Mortality and Functional Outcomes for Adults With Brain Injury: A Systematic Review and Meta-analysis

Importance

Neurocritical care (NCC) aims to improve the outcomes of critically ill patients with brain injury, although the benefits of such subspecialized care are yet to be determined.

Objective

To evaluate the association of NCC with patient-centered outcomes in adults with acute brain injury who were admitted to intensive care units (ICUs). The protocol was preregistered on PROSPERO (CRD42020177190).

Data Sources

Three electronic databases were searched (Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials) from inception through December 15, 2021, and by citation chaining.

Study Selection

Studies were included for interventions of neurocritical care units (NCCUs), neurointensivists, or NCC consulting services compared with general care in populations of neurologically ill adults or adults with acute brain injury in ICUs.

Data Extraction and Synthesis

Data extraction was performed in keeping with PRISMA guidelines and risk of bias assessed through the ROBINS-I Cochrane tool by 2 independent reviewers. Data were pooled using a random-effects model.

Main Outcomes and Measures

The primary outcome was all-cause mortality at longest follow-up until 6 months. Secondary outcomes were ICU length of stay (LOS), hospital LOS, and functional outcomes. Data were measured as risk ratio (RR) if dichotomous or standardized mean difference if continuous. Subgroup analyses were performed for disease and models of NCC delivery.

Results

After 5659 nonduplicated published records were screened, 26 nonrandomized observational studies fulfilled eligibility criteria. A meta-analysis of mortality outcomes for 55 792 patients demonstrated a 17% relative risk reduction (RR, 0.83; 95% CI, 0.75-0.92; P = .001) in those receiving subspecialized care (n = 27 061) compared with general care (n = 27 694). Subgroup analyses did not identify subgroup differences. Eight studies including 4667 patients demonstrated a 17% relative risk reduction (RR, 0.83; 95% CI, 0.70-0.97; P = .03) for an unfavorable functional outcome with subspecialized care compared with general care. There were no differences in LOS outcomes. Heterogeneity was substantial in all analyses.

Conclusions and Relevance

Subspecialized NCC is associated with improved survival and functional outcomes for critically ill adults with brain injury. However, confidence in the evidence is limited by substantial heterogeneity. Further investigations are necessary to determine the specific aspects of NCC that contribute to these improved outcomes and its cost-effectiveness.

Spontaneous subarachnoid haemorrhage

Subarachnoid haemorrhage (SAH) is the third most common subtype of stroke. Incidence has decreased over past decades, possibly in part related to lifestyle changes such as smoking cessation and management of hypertension. Approximately a quarter of patients with SAH die before hospital admission; overall outcomes are improved in those admitted to hospital, but with elevated risk of long-term neuropsychiatric sequelae such as depression. The disease continues to have a major public health impact as the mean age of onset is in the mid-fifties, leading to many years of reduced quality of life. The clinical presentation varies, but severe, sudden onset of headache is the most common symptom, variably associated with meningismus, transient or prolonged unconsciousness, and focal neurological deficits including cranial nerve palsies and paresis. Diagnosis is made by CT scan of the head possibly followed by lumbar puncture. Aneurysms are commonly the underlying vascular cause of spontaneous SAH and are diagnosed by angiography. Emergent therapeutic interventions are focused on decreasing the risk of rebleeding (ie, preventing hypertension and correcting coagulopathies) and, most crucially, early aneurysm treatment using coil embolisation or clipping. Management of the disease is best delivered in specialised intensive care units and high-volume centres by a multidisciplinary team. Increasingly, early brain injury presenting as global cerebral oedema is recognised as a potential treatment target but, currently, disease management is largely focused on addressing secondary complications such as hydrocephalus, delayed cerebral ischaemia related to microvascular dysfunction and large vessel vasospasm, and medical complications such as stunned myocardium and hospital acquired infections.

A Perspective from the Neurocritical Care Society and the Society of Critical Care Medicine: Team-Based Care for Neurological Critical Illness

The Neurocritical Care Society and the Society of Critical Care Medicine have worked together to create a perspective regarding the Standards of Neurologic Critical Care Units (Moheet et al. in Neurocrit Care 29:145-160, 2018). The most neurologically ill or injured patients warrant the highest standard of care available; this supports the need for defining and establishing specialized neurological critical care units. Rather than interpreting the Standards as being exclusionary, it is most appropriate to embrace them in the setting of team-based care. Since there are many more patients than there are highly specialized beds, collaborative care and appropriate transfer agreements are essential in promoting excellent patient outcomes. This viewpoint addresses areas of clarification and emphasizes the need for collegiality and partnership in delivering the best specialty critical care to our patients.

Early Hyperoxia in The Intensive Care Unit is Significantly Associated With Unfavorable Neurological Outcomes in Patients With Mild-to-Moderate Aneurysmal Subarachnoid Hemorrhage

INTRODUCTION

Although oxygen administration is fundamental in the management of aneurysmal subarachnoid hemorrhage (SAH) patients in the acute stage, hyperoxia has harmful effects. The effects of hyperoxia on neurological outcomes in SAH patients are unclear. We aimed to examine the association of hyperoxia during the first 24 h in the intensive care unit (ICU) with unfavorable neurological outcomes in SAH patients.

METHODS

We retrospectively selected consecutive adult patients admitted to ICU for SAH between January 2009 and April 2018. We defined normoxia during the first 24 h in ICU as PaO2 of 60 mm Hg to 120 mm Hg, mild hyperoxia as PaO2 of 121 mm Hg to 200 mm Hg, moderate hyperoxia as PaO2 of 201 mm Hg to 300 mm Hg, and severe hyperoxia as PaO2 of >300 mm Hg. Univariate and multivariate analyses were performed to examine the association between hyperoxia during the first 24 h in ICU and unfavorable neurological outcomes (i.e., modified Rankin scale score of 3-6 at hospital discharge).

RESULTS

Among 196 SAH patients, 90 had unfavorable neurological outcomes. Hyperoxia was observed in 93.4% of patients. No significant association was observed between unfavorable neurological outcomes and hyperoxia in overall patients. However, we found that early hyperoxia in ICU was significantly associated with unfavorable neurological outcomes in SAH patients with Hunt and Kosnik (H&K) grades I to III (Relative risk, 1.84; 95% confidence interval, 1.10-2.94; P = 0.02).

CONCLUSIONS

Early hyperoxia was not associated with unfavorable neurological outcomes in overall SAH patients, but it was associated with unfavorable neurological outcomes in those with H&K grades I to III.

Neurocritical Care Outcomes, Research, and Technology: A Review

Importance

Neurocritical care has grown into an organized specialty that may have consequences for patient care, outcomes, research, and neurointensive care (neuroICU) technology.

Observations

Neurocritical care improves care and outcomes of the patients who are neurocritically ill, and neuroICUs positively affect the financial state of health care systems. The development of neurocritical care as a recognized subspecialty has fostered multidisciplinary research, neuromonitoring, and neurocritical care information technology, with advances and innovations in practice and progress.

Conclusions and Relevance

Neurocritical care has become an important part of health systems and an established subspecialty of neurology. Understanding its structure, scope of practice, consequences for care, and research are important.

Between-center and between-country differences in outcome after aneurysmal subarachnoid hemorrhage in the Subarachnoid Hemorrhage International Trialists (SAHIT) repository

OBJECTIVE

Differences in clinical outcomes between centers and countries may reflect variation in patient characteristics, diagnostic and therapeutic policies, or quality of care. The purpose of this study was to investigate the presence and magnitude of between-center and between-country differences in outcome after aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

The authors analyzed data from 5972 aSAH patients enrolled in randomized clinical trials of 3 different treatments from the Subarachnoid Hemorrhage International Trialists (SAHIT) repository, including data from 179 centers and 20 countries. They used random effects logistic regression adjusted for patient characteristics and timing of aneurysm treatment to estimate between-center and between-country differences in unfavorable outcome, defined as a Glasgow Outcome Scale score of 1-3 (severe disability, vegetative state, or death) or modified Rankin Scale score of 4-6 (moderately severe disability, severe disability, or death) at 3 months. Between-center and between-country differences were quantified with the median odds ratio (MOR), which can be interpreted as the ratio of odds of unfavorable outcome between a typical high-risk and a typical low-risk center or country.

RESULTS

The proportion of patients with unfavorable outcome was 27% (n = 1599). The authors found substantial between-center differences (MOR 1.26, 95% CI 1.16-1.52), which could not be explained by patient characteristics and timing of aneurysm treatment (adjusted MOR 1.21, 95% CI 1.11-1.44). They observed no between-country differences (adjusted MOR 1.13, 95% CI 1.00-1.40).

CONCLUSIONS

Clinical outcomes after aSAH differ between centers. These differences could not be explained by patient characteristics or timing of aneurysm treatment. Further research is needed to confirm the presence of differences in outcome after aSAH between hospitals in more recent data and to investigate potential causes.

The neurointensive nursery: concept, development, and insights gained

PURPOSE OF REVIEW

With the advent of therapeutic hypothermia for treatment of hypoxic ischemic encephalopathy, and improvements in neuroimaging and bedside neuromonitoring, a new era of neonatal brain-focused care has emerged in recent years. We describe the development of the first neurointensive care nursery (NICN) as a model for comanagement of neonates with identified neurologic risk factors by a multidisciplinary team constituted of neurologists, neonatologists, specialized nurses, and others with the goal of optimizing management, preventing secondary injury and maximizing long-term outcomes.

RECENT FINDINGS

Optimizing brain metabolic environment and perfusion and preventing secondary brain injury are key to neurocritical care. This includes close management of temperature, blood pressure, oxygenation, carbon dioxide, and glucose levels. Early developmental interventions and involvement of physical and occupational therapy provide additional assessment information. Finally, long-term follow-up is essential for any neurocritical care program.

SUMMARY

The NICN model aims to optimize evidence-based care of infants at risk for neurologic injury. Results from ongoing hypothermia and neuroprotective trials are likely to yield additional treatments. New technologies, such as functional MRI, continuous neurophysiological assessment, and whole genomic approaches to rapid diagnosis may further enhance clinical protocols and neonatal precision medicine. Importantly, advances in neurocritical care improve our ability to provide comprehensive information when counseling families. Long-term follow-up data will determine if the NICN/Neuro-NICU provides enduring benefit to infants at risk for neurologic injury.

Association of abnormal carbon dioxide levels with poor neurological outcomes in aneurysmal subarachnoid hemorrhage: a retrospective observational study

Background

In patients with aneurysmal subarachnoid hemorrhage (SAH), an association between hypocapnia and poor clinical outcomes has been reported. However, the optimal arterial carbon dioxide tension (PaCO₂) remains unknown. The present retrospective study aimed to examine the association of abnormal PaCO₂ levels with neurological outcomes and investigate the optimal target PaCO₂ level in patients with SAH.

Methods

We retrospectively selected consecutive adult patients hospitalized in the intensive care unit (ICU) for SAH between January 2009 and April 2017. Univariate and multivariate analyses were performed to identify the independent predictors of unfavorable neurological outcomes (i.e., modified Rankin scale score of 3–6 on hospital discharge).

Results

Among 158 patients with SAH, 73 had unfavorable neurological outcomes. During the first 2 weeks in the ICU, the median number of PaCO₂ measurements per patient was 43. The factors significantly associated with unfavorable neurological outcomes were age, Hunt and Kosnik grade, maximum lactate levels during the first 24 h, and maximum (odds ratio [OR], 1.12; 95% confidence interval [CI], 1.03–1.21; p < 0.01) and minimum PaCO₂ levels (OR, 0.81; 95% CI, 0.72–0.92; p < 0.01). Receiver operating characteristic curve analysis revealed that the cutoff range of PaCO₂ was 30.2–48.3 mmHg. Unfavorable neurological outcomes were noted in 78.8% of patients with PaCO₂ levels outside this range and in 22.8% of patients with PaCO₂ levels within this range.

Conclusions

Both the maximum and minimum PaCO₂ levels during ICU management in patients with SAH were significantly associated with unfavorable neurological outcomes. Further prospective studies are required to validate our findings and explore their clinical implications. Our findings may provide a scientific rationale for these future prospective studies.

Electronic supplementary material

The online version of this article (10.1186/s40560-018-0353-1) contains supplementary material, which is available to authorized users.

Safety and efficacy of applying sufficient analgesia combined with a minimal sedation program as an early antihypertensive treatment for spontaneous intracerebral hemorrhage: a randomized controlled trial

Background

Spontaneous intracerebral hemorrhage (ICH) is a serious threat to human health. Although early blood pressure (BP) elevation is closely associated with a poor prognosis, the optimal antihypertensive regimen for acute-phase ICH remains controversial. In ICH, pain, sleep deprivation, and stress are usually the main causes of dramatic BP increases. While traditional antihypertensive treatment resolves the increased BP, it does not address the root cause of the disease. Remifentanil relieves pain and, when combined with dexmedetomidine’s antisympathetic action, can restore elevated BP to normal levels. Here, we seek to validate the efficacy and safety of applying sufficient analgesia in combination with a minimal sedation program versus antihypertensive drug therapy for the early and rapid stabilization of BP in ICH patients.

Methods/design

We are conducting a multicenter, prospective, randomized controlled, single-blinded, superiority clinical trial across 15 hospitals. We will enroll 354 subjects in mainland China, and all subjects will be randomized into experimental and control groups in which they will be given remifentanil combined with dexmedetomidine or antihypertensive drugs (urapidil, nicardipine, and labetalol). The primary endpoint will be the systolic BP control rate within 1 h of treatment initiation, and the efficacy and safety of the antihypertensive regimens will be compared between the two groups. Secondary endpoints include the incidence rate of early hemorrhage growth, neurological function, duration of intensive care unit (ICU) stay, and staff satisfaction with the treatment process.

Discussion

We hypothesize that applying sufficient analgesia in combination with minimal sedation will act as an effective and safe antihypertensive strategy in ICH and that this treatment strategy could, therefore, be widely used as an ICH acute-phase therapy.

Trial registration

ClinicalTrials.gov, ID: NCT03207100. Registered on 22 July 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2943-6) contains supplementary material, which is available to authorized users.

The shifting burden of neurosurgical disease: Vietnam and the middle-income nations

OBJECTIVE

The Global Burden of Disease (GBD) is an international collaboration and the largest comprehensive investigation of global health disease burden ever conducted. It has been particularly insightful for understanding disease demographics in middle-income nations undergoing rapid development, such as Vietnam, where 6 of the top 10 causes of death are relevant to the neurosurgeon. The burden of stroke—the number one cause of death in Vietnam—is particularly impressive. Likewise, road injuries, with a disproportionate rate of traumatic brain injury, continue to increase in Vietnam following economic development. Low-back and neck pain is the number one cause of disability. Simultaneously, more patients have access to care, and healthcare spending is increased.

METHODS

It is imperative that neurosurgical capital and infrastructure keep pace with Vietnam’s growth. The authors searched the existing literature for assessments of neurosurgical infrastructure or initiatives to address neurosurgical disease burden. Using GBD data, the authors also abstracted data for death by cause and prevalence of years of life lost due to disability (YLD) for common neurosurgical pathologies for Vietnam and comparison nations.

RESULTS

Interventions aimed at primary prevention of risk factors for neurosurgical disease and focused on the transference of self-sustainable technical skills were found to be analogous to those that have been successful in other regions. Efforts toward stroke prevention have been focused on causal risk factors. Multiple investigators have found that interventions aimed at increasing helmet use were successful in preventing traumatic brain injury. Government-led reforms and equipment donation programs have improved technical capacity. Nevertheless, Vietnam lags behind other nations in neurosurgeons per capita; cause-attributable death and YLD attributable to neurosurgical disease are considerably higher in Vietnam and middle-income nations compared to both lower-income nations and upper-income nations.

CONCLUSIONS

More than two-thirds of deaths attributable to neurosurgical pathologies in Vietnam and other middle-income nations were due to stroke, and one-fifth of both cause-attributable death and YLD was associated with neurosurgical pathologies. Vietnam and other middle-income nations continue to assume a global burden of disease profile that ever more closely resembles that of developed nations, with particular cerebrovascular, neurotrauma, and spinal disease burdens, leading to exponentially increased demand for neurosurgeons that threatens to outpace the training of neurosurgeons.

Improved Outcomes following the Establishment of a Neurocritical Care Unit in Saudi Arabia

Background

Dedicated neurocritical care units have dramatically improved the management and outcome following brain injury worldwide.

Aim

This is the first study in the Middle East to evaluate the clinical impact of a neurocritical care unit (NCCU) launched within the diverse clinical setting of a polyvalent intensive care unit (ICU).

Design and Methods

A retrospective before and after cohort study comparing the outcomes of neurologically injured patients. Group one met criteria for NCCU admission but were admitted to the general ICU as the NCCU was not yet operational (group 1). Group two were subsequently admitted thereafter to the NCCU once it had opened (group 2). The primary outcome was all-cause ICU and hospital mortality. Secondary outcomes were ICU length of stay (LOS), predictors of ICU and hospital discharge, ICU discharge Glasgow Coma Scale (GCS), frequency of tracheostomies, ICP monitoring, and operative interventions.

Results

Admission to NCCU was a significant predictor of increased hospital discharge with an odds ratio of 2.3 (95% CI: 1.3–4.1; p=0.005). Group 2 (n = 208 patients) compared to Group 1 (n = 364 patients) had a significantly lower ICU LOS (15 versus 21.4 days). Group 2 also had lower ICU and hospital mortality rates (5.3% versus 10.2% and 9.1% versus 19.5%, respectively; all p < 0.05). Group 2 patients had higher discharge GCS and underwent fewer tracheostomies but more interventional procedures (all p < 0.05).

Conclusion

Admission to NCCU, within a polyvalent Middle Eastern ICU, was associated with significantly decreased mortality and increased hospital discharge.

Aneurysmal subarachnoid hemorrhage: intensive care for improving neurological outcome

Background

Aneurysmal subarachnoid hemorrhage is a life-threatening disease requiring neurocritical care. Delayed cerebral ischemia is a well-known complication that contributes to unfavorable neurological outcomes. Cerebral vasospasm has been thought to be the main cause of delayed cerebral ischemia, and although several studies were able to decrease cerebral vasospasm, none showed improved neurological outcomes. Our target is not cerebral vasospasm but improving neurological outcomes. The purpose of this review is to discuss what intensivists should know and can do to improve clinical outcomes in subarachnoid hemorrhage patients.

Main body of the abstract

Delayed cerebral ischemia is thought to be due to not only vasospasm but also multifactorial mechanisms. Additionally, the concept of early brain injury, which occurs within the first 72 h after the hemorrhage, has become an important concern. Increasing sympathetic activity after the hemorrhage is associated with cardiopulmonary complications and poor outcomes. Serum lactate measurement may be a valuable marker reflecting the severity of sympathetic activity. The transpulmonary thermodilution method will bring about an advanced understanding of hemodynamic management. Fever is a well-recognized symptom and targeted temperature management is an anticipated intervention. To avoid hyperglycemia and hypoglycemia, performing moderate glucose control and minimizing glucose variability are important concepts in glycemic management, but the optimal target range remains unknown. Dysnatremia seems to be associated with negative outcomes. It is not clear yet that maintaining normonatremia actively improves neurological outcomes. Optimal duration of intensive care management has not been determined.

Short conclusion

Although we have an advanced understanding of the pathophysiology and clinical characteristics of subarachnoid hemorrhage, there are many controversies in the intensive care unit management of subarachnoid hemorrhage. With an awareness of not only delayed cerebral ischemia but also early brain injury, more attention should be given to various aspects to improve neurological outcomes.

Serial blood lactate measurements and its prognostic significance in intensive care unit management of aneurysmal subarachnoid hemorrhage patients

PURPOSE

This study assesses the behavior of serial blood lactate measurements during intensive care unit (ICU) stay to identify prognostic factors of unfavorable neurological outcomes (UO) in patients with aneurysmal subarachnoid hemorrhage (SAH).

METHODS

We retrospectively reviewed all patients who were consecutively hospitalized with SAH between 2009 and 2016. Arterial blood lactate levels were routinely obtained on admission and every 6h in the ICU. Univariate/multivariate analyses were performed to identify independent predictors of UO (modified Rankin scale of 3-6 upon hospital discharge).

RESULTS

There were 145 patients with 46% of UO. Initially, increased lactate levels reached maximum levels during the first 24h and then decreased to within the normal range. Then, the levels slightly increased again to within the normal range for the next 24h, especially in UO. On multiple regression analysis, lactate levels measured at 24h, and 48h after admission were strong predictors of UO. Lactate level measured at 48h after admission demonstrated the greatest accuracy and the highest specificity (area under the curve, 0.716; sensitivity, 40%; specificity, 92.1%).

CONCLUSIONS

The lactate level at 48h after admission was the most accurate predictor of UO with a high specificity in SAH patients.

The Role of the Neurointensive Care Nursery for Neonatal Encephalopathy

Neonatal encephalopathy due to intrapartum events is estimated at 1 to 2 per 1000 live births in high-income countries. Outcomes have improved over the past decade due to implementation of therapeutic hypothermia, the only clinically available neuroprotective strategy for hypoxic-ischemic encephalopathy. Neonatal encephalopathy is the most common condition treated within a neonatal neurocritical care unit. Neonates with encephalopathy benefit from a neurocritical care approach due to prevention of secondary brain injury through attention to basic physiology, earlier recognition and treatment of neurologic complications, consistent management using guidelines and protocols, and use of optimized teams at dedicated referral centers.

Current practice in neurocritical care of patients with subarachnoid haemorrhage and severe traumatic brain injury : Results of the Austrian Neurosurvey Study

OBJECTIVES

The task force Neuroanaesthesia of the Austrian Society of Anaesthesiology, Resuscitation and Intensive Care Medicine (ÖGARI) is aiming to develop and provide recommendations in order to improve neurocritical care in Austria. Thus, a survey on neurocritical care concepts in Austria regarding intensive care of subarachnoid haemorrhage (SAH) and severe traumatic brain injury (TBI) was performed to assess the current status.

METHODS

An online internet questionnaire comprising 59 items on current concepts of SAH and TBI critical care was sent to 117 anaesthesiology departments.

RESULTS

The survey was answered by 30 (25.6 %) of the hospitals, 24 (80 %) of them treating patients with SAH and/or TBI. Data from ten SAH centres reveal that definitive care was achieved within 24 h in all hospitals; a case load >50 per year is noted in 70 % of intensive care units (ICU). In all, 50 % of departments employ written protocols for treatment. Regarding the treatment of TBI patients, 14 answers were received, indicating that 42.9 % of departments provide care for >50 patients per year. Time between arrival and CT scan is <30 min in all hospitals, and 28.6 % of departments rely on written protocols. Only 14.3 % of hospitals report about routine morbidity and mortality rounds. While the neurologic status is assessed at discharge from the ICU, there is no evaluation of 1‑year outcome.

CONCLUSIONS

Definitive care of SAH and TBI patients is achieved timely in Austria. When compared with SAH, more hospitals with lower case loads take care of TBI patients. Written guidelines and protocols at institutional level are often missing. Since routine morbidity and mortality conferences are sparse, and long-term outcome is not assessed, there is room for improvement.

Clinical characteristics of non-convulsive status epilepticus diagnosed by simplified continuous electroencephalogram monitoring at an emergency intensive care unit

Aim

The present study aimed to elucidate the clinical characteristics of non‐convulsive status epilepticus (NCSE) in patients with altered mental status (AMS).

Methods

This single‐center retrospective study comprised 149 patients who were hospitalized between March 1, 2015 and September 30, 2015 at the emergency intensive care unit (ICU) of the Kagawa University Hospital (Kagawa, Japan). The primary outcome was NCSE incidence. The secondary outcome was the comparison of duration of ICU stay, hospital stay, and a favorable neurological outcome, as assessed using the modified Rankin Scale score, at discharge from our hospital between patients with and without NCSE. Favorable neurological outcome and poor neurological outcome were defined as modified Rankin Scale scores of 0–2 and 3–6, respectively.

Results

Simplified continuous electroencephalogram was used to monitor 36 patients (median age, 68 years; 69.4% males) with acute AMS; among them, NCSE was observed in 11 (30.1%) patients. Rates of favorable neurological outcome, duration of ICU stay, and hospital stay were not significantly different between the NCSE and non‐NCSE groups (P = 0.45, P = 0.30, and P = 0.26, respectively).

Conclusion

Approximately 30% of the patients with AMS admitted to emergency ICUs developed NCSE. The outcomes of AMS patients with and without NCSE did not differ significantly when appropriate medical attention and antiepileptic drugs were initiated. Simplified continuous electroencephalogram monitoring may be recommended in patients with AMS in emergency ICU to obtain early detection of NCSE followed by appropriate intervention.