Prognostic Value of Echocardiography for Left Ventricular Dysfunction After Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis

A Quality Improvement Initiative for Echocardiogram Ordering Patterns in an Academic Hospital

Background Appropriate Use Criteria (AUC) for echocardiography are a useful tool to deliver quality healthcare. Our quality-based interventional study was designed to assess the trends in appropriate utilization rates for echocardiography in our institution and improve adherence to the AUC criteria for transthoracic echocardiograms (TTE). Methodology A prospective, time series analysis was conducted at the Upstate University Hospital for the months of July 2019 and August 2020. A chart analysis was performed on 620 consecutive inpatients who underwent TTE for the month of July 2019. We assessed the trends of the appropriate ordering of TTEs. We then updated our order form incorporating the 42 most common appropriate indications. A post-intervention chart analysis was performed on all inpatient TTEs ordered for the month of August 2020 (n = 410). The appropriateness of the TTE for the entire group was determined based on the true indication per chart review. The primary outcome was the proportion of appropriate and inappropriate TTEs ordered. Secondary outcomes included assessing for concordance between the indication on the order requisition form and by chart review. A p-value <0.05 was considered significant. Results Using the 2011 AUC for the entire group, 81% of the pre-intervention TTEs and 79.5% of the post-intervention TTEs were appropriate (p = 0.55). There was a statistically significant reduction in the number of discordant TTE orders before and after the intervention (p < 0.01). In addition, we noted increased appropriateness of TTEs in the concordant group both pre and post-intervention. Conclusions Our study demonstrates a significant increase in the concordance between the TTE order sheet and actual indication per chart review with the intervention. This can translate into improved scanning and physician reading quality and time, thereby increasing focus on areas of interest according to the true indication. There was no significant increase in the appropriate TTEs ordered.

Relationship between Preoperative Echocardiographic Parameters and the Incidence of Postoperative Complications in Patients Undergoing Clipping of Unruptured Intracranial Aneurysms: A Retrospective Cohort Study

Background and Objectives: Preoperative echocardiography is widely performed in patients undergoing major surgeries to evaluate cardiac functions and detect structural abnormalities. However, studies on the clinical usefulness of preoperative echocardiography in patients undergoing cerebral aneurysm clipping are limited. Therefore, this study aimed to investigate the correlation between preoperative echocardiographic parameters and the incidence of postoperative complications in patients undergoing clipping of unruptured intracranial aneurysms. Materials and Methods: Electronic medical records of patients who underwent clipping of an unruptured intracranial aneurysm from September 2018 to April 2020 were retrospectively reviewed. Data on baseline characteristics, laboratory variables, echocardiographic parameters, postoperative complications, and hospital stays were obtained. Univariable and multivariable logistic regression analyses were performed to identify independent variables related to the occurrence of postoperative complications and prolonged hospital stay (≥8 d). Results: Among 531 patients included in the final analysis, 27 (5.1%) had postoperative complications. In multivariable logistic regression, the total amount of crystalloids infused (1.002 (1.001-1.003), p = 0.001) and E/e' ratio (1.17 (1.01-1.35), p = 0.031) were significant independent factors associated with the occurrence of a postoperative complication. Additionally, the maximal diameter of a cerebral aneurysm (1.13 (1.02-1.25), p = 0.024), total amount of crystalloids infused (1.001 (1.000-1.002), p = 0.031), E/A ratio (0.22 (0.05-0.95), p = 0.042), and E/e' ratio (1.16 (1.04-1.31), p = 0.011) were independent factors related to prolonged hospitalization. Conclusions: Echocardiographic parameters related to diastolic function might be associated with postoperative complications in patients undergoing clipping of unruptured intracranial aneurysms.

Neurologic Outcome Prediction in the Intensive Care Unit

PURPOSE OF REVIEW

The burden of severe and disabling neurologic injury on survivors, families, and society can be profound. Neurologic outcome prediction, or neuroprognostication, is a complex undertaking with many important ramifications. It allows patients with good prognoses to be supported aggressively, survive, and recover; conversely, it avoids inappropriate prolonged and costly care in those with devastating injuries.

RECENT FINDINGS

Striving to maintain a high prediction performance during prognostic assessments encompasses acknowledging the shortcomings of this task and the challenges created by advances in medicine, which constantly shift the natural history of neurologic conditions. Embracing the unknowns of outcome prediction and the boundaries of knowledge surrounding neurologic recovery and plasticity is a necessary step toward refining neuroprognostication practices and improving the accuracy of prognostic impressions. The pillars of modern neuroprognostication include comprehensive characterization of neurologic injury burden (primary and secondary injuries), gauging cerebral resilience and estimated neurologic reserve, and tying it all together with individual values surrounding the acceptable extent of disability and the difficulties of an arduous convalescence journey.

SUMMARY

Comprehensive multimodal frameworks of neuroprognostication using different prognostic tools to portray the burden of neurologic injury coupled with the characterization of individual values and the degree of cerebral reserve and resilience are the cornerstone of modern outcome prediction.

Neurogenic Stunned Myocardium: A Review

Neurogenic stunned myocardium is a form of stress cardiomyopathy. The disorder is sometimes referred to as atypical Takotsubo cardiomyopathy. The pathophysiology of neurogenic stunned myocardium is hypothesized to involve significant overdrive of the sympathetic nervous system after a brain injury. Treatment options for a patient with a brain injury who has progressed to cardiogenic shock remain controversial, with no consistent guidelines. A patient with subarachnoid hemorrhage who progresses to cardiogenic shock with concurrent cerebral vasospasm presents a special treatment challenge. Neurogenic stunned myocardium is reversible; however, it must be recognized immediately to avoid or manage potential complications, such as cardiogenic shock and pulmonary edema. A multifaceted treatment approach is needed for the patient with cardiogenic shock and concurrent vasospasm.