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Tang J, Wu C, Zhong Z. Group-Based Trajectory Modeling of Fluid Balance in Elderly Patients with Acute Ischemic Stroke: Analysis from Multicenter ICUs. Neurol Ther 2024; 13:749-761. [PMID: 38635141 PMCID: PMC11136917 DOI: 10.1007/s40120-024-00612-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 03/21/2024] [Indexed: 04/19/2024] Open
Abstract
INTRODUCTION Acute ischemic stroke (AIS) significantly contributes to severe disability and mortality among the elderly. This study aims to explore the association between longitudinal fluid balance (FB) trajectories and clinical outcomes in elderly patients with AIS. Our hypothesis posits the existence of multiple latent trajectories of FB in patients with AIS during the initial 7 days following ICU admission. METHODS Patients (age ≥ 65 years) with AIS and continuous FB records were identified from two large databases. Group-based trajectory modeling identified latent groups with similar 7-day FB trajectories. Subsequently, multivariable logistic and quasi-Poisson regression were employed to evaluate the relationship between trajectory groups and outcomes. Additionally, nonlinear associations between maximum fluid overload (FO) and outcomes were analyzed using restricted cubic spline models. To further validate our findings, subgroup and sensitivity analysis were conducted. RESULTS A total of 1146 eligible patients were included in this study, revealing three trajectory patterns were identified: low FB (84.8%), decreasing FB (7.2%), and high FB (7.9%). High FB emerged as an independent risk factor for in-hospital mortality. Compared with those without FO, patients with FO had a 1.57-fold increased risk of hospital mortality (adjusted odd ratio (OR) 1.57, 95% confidence interval (CI) 1.08-2.27), 2.37-fold increased risk of adverse kidney event (adjusted OR 2.37, 95% CI 1.56-3.59), and 1.33-fold increased risk of prolonged ICU stay (adjusted incidence rate ratio (IRR) 1.33, 95% CI 1.19-1.48). The risk of hospital mortality and adverse kidney event increased linearly with rising maximum FO (P for non-linearity = 0.263 and 0.563, respectively). CONCLUSION Daily FB trajectories were associated with adverse outcomes in elderly patients with AIS. Regular assessment of daily fluid status and restriction of FO are crucial for the recovery of critically ill patients.
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Affiliation(s)
- Jia Tang
- Graduate School of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Changdong Wu
- Xinjiang Emergency Center, People's Hospital of Xinjiang Uygur Autonomous Region, No. 91, Tian-Chi Road, Tianshan District, Urumqi, 830001, Xinjiang, China.
| | - Zhenguang Zhong
- Department of Bioengineering, Imperial College London, London, UK
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Arabi YM, Belley-Cote E, Carsetti A, De Backer D, Donadello K, Juffermans NP, Hammond N, Laake JH, Liu D, Maitland K, Messina A, Møller MH, Poole D, Mac Sweeney R, Vincent JL, Zampieri FG, AlShamsi F. European Society of Intensive Care Medicine clinical practice guideline on fluid therapy in adult critically ill patients. Part 1: the choice of resuscitation fluids. Intensive Care Med 2024:10.1007/s00134-024-07369-9. [PMID: 38771364 DOI: 10.1007/s00134-024-07369-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 02/20/2024] [Indexed: 05/22/2024]
Abstract
PURPOSE This is the first of three parts of the clinical practice guideline from the European Society of Intensive Care Medicine (ESICM) on resuscitation fluids in adult critically ill patients. This part addresses fluid choice and the other two will separately address fluid amount and fluid removal. METHODS This guideline was formulated by an international panel of clinical experts and methodologists. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology was applied to evaluate the certainty of evidence and to move from evidence to decision. RESULTS For volume expansion, the guideline provides conditional recommendations for using crystalloids rather than albumin in critically ill patients in general (moderate certainty of evidence), in patients with sepsis (moderate certainty of evidence), in patients with acute respiratory failure (very low certainty of evidence) and in patients in the perioperative period and patients at risk for bleeding (very low certainty of evidence). There is a conditional recommendation for using isotonic saline rather than albumin in patients with traumatic brain injury (very low certainty of evidence). There is a conditional recommendation for using albumin rather than crystalloids in patients with cirrhosis (very low certainty of evidence). The guideline provides conditional recommendations for using balanced crystalloids rather than isotonic saline in critically ill patients in general (low certainty of evidence), in patients with sepsis (low certainty of evidence) and in patients with kidney injury (very low certainty of evidence). There is a conditional recommendation for using isotonic saline rather than balanced crystalloids in patients with traumatic brain injury (very low certainty of evidence). There is a conditional recommendation for using isotonic crystalloids rather than small-volume hypertonic crystalloids in critically ill patients in general (very low certainty of evidence). CONCLUSIONS This guideline provides eleven recommendations to inform clinicians on resuscitation fluid choice in critically ill patients.
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Affiliation(s)
- Yaseen M Arabi
- Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, King Abdullah International Medical Research Center, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
| | - Emilie Belley-Cote
- Divisions of Cardiology and Critical Care, McMaster University, Riyadh, Saudi Arabia
| | - Andrea Carsetti
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Katia Donadello
- Department of Surgery, Dentistry, Gynaecology and Paediatrics, University of Verona, Verona, Italy
- Anaesthesia and Intensive Care B Unit, AOUI-University Hospital Integrated Trust of Verona, Verona, Italy
| | - Nicole P Juffermans
- Department of Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Naomi Hammond
- Critical Care Program, The George Institute for Global Health and UNSW, Sydney, Australia
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney, Australia
| | - Jon Henrik Laake
- Department of Anaesthesiology and Intensive Care Medicine, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Dawei Liu
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Kathryn Maitland
- Institute of Global Health and Innovation, Division of Medicine, Imperial College, London, UK
| | - Antonio Messina
- IRCCS Humanitas Research Hospital, Department of Anesthesia and Intensive Care Medicine, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, København, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Daniele Poole
- Operative Unit of Anesthesia and Intensive Care, S. Martino Hospital, Belluno, Italy
| | - Rob Mac Sweeney
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, Northern Ireland
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Brussels, Belgium
| | - Fernando G Zampieri
- Department of Critical Care Medicine, University of Alberta, Edmonton, Canada
| | - Fayez AlShamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
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3
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Mikkonen E, Blixt J, Ercole A, Alpkvist P, Sköldbring R, Bellander BM, Weitzberg E, Nelson DW. A Solution to the Cerebral Perfusion Pressure Transducer Placement Conundrum in Neurointensive Care? The Dual Transducer. Neurocrit Care 2024; 40:391-394. [PMID: 37697130 PMCID: PMC10959835 DOI: 10.1007/s12028-023-01829-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 08/04/2023] [Indexed: 09/13/2023]
Abstract
Intracranial pressure is routinely monitored in most intensive care units caring for patients with severe neurological insults and, together with continuous arterial blood pressure measurement, allows for monitoring of cerebral perfusion pressure (CPP). CPP is the driving pressure of blood flow to the brain and is used to guide therapy. However, there is considerable inconsistency in the literature regarding how CPP is technically measured and, more specifically, the appropriate placement of the arterial pressure transducer. Depending on patient positioning and where the arterial pressure transducer is placed, the mean arterial pressure used for CPP calculation can vary widely by up to 15 mm Hg, which is greater than the acceptable variation in target ranges used clinically. Physiologically, the arterial pressure transducer should be placed at the level of the foramen of Monro for CPP measurement, but it is commonly set at the level of the right atrium for systematic measurement. Mean arterial pressure measurement at the level of the right atrium can lead to overestimation and potentially critically low actual CPP levels when the head is elevated, and measurement at the level of the foramen of Monro will underestimate systemic pressures, increasing the risk of excessive and unnecessary use of vasopressors and fluid. At the Karolinska University Hospital neurointensive care unit, we have used a split dual-transducer system, measuring arterial pressure both at the level of the foramen of Monro and at the level of the right atrium from a single arterial source. In doing so, we work with constants and can monitor and target optimum arterial pressures to better secure perfusion to all organs, with potentially less risk of cerebral ischemia or overuse of vasopressors and fluids, which may affect outcome.
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Affiliation(s)
- Era Mikkonen
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.
| | - Jonas Blixt
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Section of Perioperative Medicine and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge, Cambridge, UK
| | - Peter Alpkvist
- Section for Neurosurgery, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Robert Sköldbring
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Bo-Michael Bellander
- Section for Neurosurgery, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Eddie Weitzberg
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Section of Perioperative Medicine and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - David W Nelson
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Section of Perioperative Medicine and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
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Robba C, van der Jagt M, Taccone F, Citerio G, Messina A. Fluid Balance and Hemodynamic Monitoring of Traumatic Brain Injured Patients: An International Survey. J Neurosurg Anesthesiol 2024; 36:177-179. [PMID: 37317479 DOI: 10.1097/ana.0000000000000925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 05/05/2023] [Indexed: 06/16/2023]
Affiliation(s)
- Chiara Robba
- Department of Anesthesia and Intensive Care, IRCCS Policlinico San Martino, Genoa, Italy
- Department of Surgical Science and Diagnostic Integrated, University of Genoa, Italy
| | - Mathieu van der Jagt
- Department of Intensive Care Adults and Erasmus MC Stroke Center, Erasmus MC-University Medical Center, Rotterdam, The Netherlands
| | - Fabio Taccone
- Department of Intensive Care, Bruxelles University Hospital, University of Bruxelles, Belgium
| | - Giuseppe Citerio
- Department of neurocritical Care, School of Medicine and Surgery, University of Milano, Bicocca, Monza
| | - Antonio Messina
- Department of Anesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital-IRCCS, Humanitas University, Rozzano
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
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5
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Messina A, Chew MS, Poole D, Calabrò L, De Backer D, Donadello K, Hernandez G, Hamzaoui O, Jozwiak M, Lai C, Malbrain MLNG, Mallat J, Myatra SN, Muller L, Ospina-Tascon G, Pinsky MR, Preau S, Saugel B, Teboul JL, Cecconi M, Monnet X. Consistency of data reporting in fluid responsiveness studies in the critically ill setting: the CODEFIRE consensus from the Cardiovascular Dynamic section of the European Society of Intensive Care Medicine. Intensive Care Med 2024; 50:548-560. [PMID: 38483559 DOI: 10.1007/s00134-024-07344-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 01/31/2024] [Indexed: 04/16/2024]
Abstract
PURPOSE To provide consensus recommendations regarding hemodynamic data reporting in studies investigating fluid responsiveness and fluid challenge (FC) use in the intensive care unit (ICU). METHODS The Executive Committee of the European Society of Intensive Care Medicine (ESICM) commissioned and supervised the project. A panel of 18 international experts and a methodologist identified main domains and items from a systematic literature, plus 2 ancillary domains. A three-step Delphi process based on an iterative approach was used to obtain the final consensus. In the Delphi 1 and 2, the items were selected with strong (≥ 80% of votes) or week agreement (70-80% of votes), while the Delphi 3 generated recommended (≥ 90% of votes) or suggested (80-90% of votes) items (RI and SI, respectively). RESULTS We identified 5 main domains initially including 117 items and the consensus finally resulted in 52 recommendations or suggestions: 18 RIs and 2 SIs statements were obtained for the domain "ICU admission", 11 RIs and 1 SI for the domain "mechanical ventilation", 5 RIs for the domain "reason for giving a FC", 8 RIs for the domain pre- and post-FC "hemodynamic data", and 7 RIs for the domain "pre-FC infused drugs". We had no consensus on the use of echocardiography, strong agreement regarding the volume (4 ml/kg) and the reference variable (cardiac output), while weak on administration rate (within 10 min) of FC in this setting. CONCLUSION This consensus found 5 main domains and provided 52 recommendations for data reporting in studies investigating fluid responsiveness in ICU patients.
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Affiliation(s)
- Antonio Messina
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano (Milan), Italy.
- Department of Biomedical Sciences, Humanitas University, via Levi Montalcin,i 4, Pieve Emanuele (Milan), Italy.
| | - Michelle S Chew
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Daniele Poole
- Anesthesia and Intensive Care Operative Unit, S. Martino Hospital, Belluno, Italy
| | - Lorenzo Calabrò
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano (Milan), Italy
| | - Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Katia Donadello
- Department of Surgery, Dentistry, Gynecology and Paediatrics, University of Verona, Via Dell'artigliere 8, 37129, Verona, Italy
| | - Glenn Hernandez
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Olfa Hamzaoui
- Service de Médecine Intensive Réanimation Polyvalente, Robert Debré Hospital, University Hospitals of Reims, Unité HERVI « Hémostase et Remodelage Vasculaire Post-Ischémie » - EA 3801, University of Reims, Reims, France
| | - Mathieu Jozwiak
- Centre Hospitalier Universitaire L'Archet 1, Service de Médecine Intensive Réanimation, Nice, France
- Equipe 2 CARRES, UR2CA Unité de Recherche Clinique Université Côte d'Azur, Université Côte d'Azur, Nice, France
| | - Christopher Lai
- DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay, AP-HP, Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, Le Kremlin-Bicêtre, France
| | - Manu L N G Malbrain
- First Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland
| | - Jihad Mallat
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Sheyla Nainan Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Laurent Muller
- Department of Anaesthesia, Critical Care and Emergency Medicine, Nîmes University Hospital, Place du Professeur Debré, 30029, Nîmes, France
- Hôpital universitaire Carémeau, University of Montpellier (MUSE), Nîmes, France
| | - Gustavo Ospina-Tascon
- Department of Intensive Care, Fundación Valle del Lili - Universidad ICESI, Cali, Colombia
| | - Michael R Pinsky
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sebastian Preau
- Intensive Care Unit, Calmette Hospital, University Hospital of Lille, 59000, Lille, France
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jean-Louis Teboul
- DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay, AP-HP, Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, Le Kremlin-Bicêtre, France
| | - Maurizio Cecconi
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano (Milan), Italy
- Department of Biomedical Sciences, Humanitas University, via Levi Montalcin,i 4, Pieve Emanuele (Milan), Italy
| | - Xavier Monnet
- DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay, AP-HP, Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, Le Kremlin-Bicêtre, France
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6
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Robateau Z, Lin V, Wahlster S. Acute Respiratory Failure in Severe Acute Brain Injury. Crit Care Clin 2024; 40:367-390. [PMID: 38432701 DOI: 10.1016/j.ccc.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Acute respiratory failure is commonly encountered in severe acute brain injury due to a multitude of factors related to the sequelae of the primary injury. The interaction between pulmonary and neurologic systems in this population is complex, often with competing priorities. Many treatment modalities for acute respiratory failure can result in deleterious effects on cerebral physiology, and secondary brain injury due to elevations in intracranial pressure or impaired cerebral perfusion. High-quality literature is lacking to guide clinical decision-making in this population, and deliberate considerations of individual patient factors must be considered to optimize each patient's care.
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Affiliation(s)
- Zachary Robateau
- Department of Neurology, University of Washington, Seattle, USA.
| | - Victor Lin
- Department of Neurology, University of Washington, Seattle, USA
| | - Sarah Wahlster
- Department of Neurology, University of Washington, Seattle, USA; Department of Neurological Surgery, University of Washington, Seattle, USA; Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, USA
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Zheng J, Ouyang Y, Zhang K, Wang Z, Younsi A, Alhalabi O, Fu H. Early vs Late Fixation of Extremity Fractures Among Adults With Traumatic Brain Injury. JAMA Netw Open 2024; 7:e241556. [PMID: 38457181 PMCID: PMC10924246 DOI: 10.1001/jamanetworkopen.2024.1556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 01/18/2024] [Indexed: 03/09/2024] Open
Abstract
Importance The optimal timing for fixation of extremity fractures after traumatic brain injury (TBI) remains controversial. Objective To investigate whether patients who underwent extremity fixation within 24 hours of TBI experienced worse outcomes than those who had the procedure 24 hours or more after TBI. Design, Setting, and Participants This cohort study used data from the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. Patients 16 years or older with TBI who underwent internal extremity fixation met inclusion criteria. To compare outcomes, patients who underwent the procedure within 24 hours were propensity score matched with those who underwent it 24 hours or later. Patients were treated from December 9, 2014, to December 17, 2017. Data analysis was conducted between August 1, 2022, and December 25, 2023. Main Outcomes and Measures The primary outcome was an unfavorable functional status at 6 months (Glasgow Outcome Scale-Extended [GOSE] score ≤4). Results A total of 253 patients were included in this study. The median age was 41 (IQR, 27-57) years, and 184 patients (72.7%) were male. The median Injury Severity Score (ISS) was 41 (IQR, 27-49). Approximately half of the patients (122 [48.2%]) had a mild TBI while 120 (47.4%) had moderate to severe TBI. Seventy-four patients (29.2%) underwent an internal extremity fixation within 24 hours, while 179 (70.8%) had the procedure 24 hours or later. At 6 months, 86 patients (34.0%) had an unfavorable functional outcome. After propensity score matching, there were no statistically significant differences in unfavorable functional outcomes at 6 months (odds ratio [OR], 1.12 [95% CI, 0.51-1.99]; P = .77) in patients with TBI of any severity. Similar results were observed in patients with mild TBI (OR, 0.71 [95% CI, 0.22-2.29]; P = .56) and moderate to severe TBI (OR, 1.08 [95% CI, 0.32-3.70]; P = .90). Conclusions and Relevance The outcomes of extremity fracture fixation performed within 24 hours after TBI appear not to be worse than those of procedures performed 24 hours or later. This finding suggests that early fixation after TBI could be considered in patients with mild head injuries.
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Affiliation(s)
- Jiang Zheng
- Department of Anesthesiology, Chongqing Emergency Medical Center, Chongqing University Central Hospital, School of Medicine, Chongqing University, Chongqing, China
| | - Yufang Ouyang
- Department of Anesthesiology, Chongqing Emergency Medical Center, Chongqing University Central Hospital, School of Medicine, Chongqing University, Chongqing, China
| | - Ke Zhang
- Department of Anesthesiology, Chongqing Emergency Medical Center, Chongqing University Central Hospital, School of Medicine, Chongqing University, Chongqing, China
| | - Zhixing Wang
- Department of Anesthesiology, Chongqing Emergency Medical Center, Chongqing University Central Hospital, School of Medicine, Chongqing University, Chongqing, China
| | - Alexander Younsi
- Department of Neurosurgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Obada Alhalabi
- Department of Neurosurgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Hong Fu
- Department of Anesthesiology, Chongqing Emergency Medical Center, Chongqing University Central Hospital, School of Medicine, Chongqing University, Chongqing, China
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8
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Kim MS. Optimization of Patients Outcomes: Management Strategies for Polytrauma in the Neuro-ICU. Korean J Neurotrauma 2024; 20:3-4. [PMID: 38576500 PMCID: PMC10990696 DOI: 10.13004/kjnt.2024.20.e7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 03/06/2024] [Accepted: 03/06/2024] [Indexed: 04/06/2024] Open
Affiliation(s)
- Min Soo Kim
- Department of Neurosurgery, Ulsan University Hospital, University of Ulsan college of Medicine, Ulsan, Korea
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9
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Poh K, Bustam A, Hasan MS, Mohd Yunos N, Cham CY, Lim FJ, Ahmad Zahedi AZ, Zambri A, Noor Azhar M. Isotonic balanced fluid versus 0.9% saline in patients with moderate to severe traumatic brain injury: A double-blinded randomised controlled trial. Am J Emerg Med 2024; 77:106-114. [PMID: 38118385 DOI: 10.1016/j.ajem.2023.11.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 11/29/2023] [Accepted: 11/29/2023] [Indexed: 12/22/2023] Open
Abstract
BACKGROUND AND IMPORTANCE Traumatic brain injury (TBI) is a global health concern with significant economic impact. Optimal fluid therapy aims to restore intravascular volume, maintain cerebral perfusion pressure and blood flow, thus preventing secondary brain injury. While 0.9% saline (NS) is commonly used, concerns about acid-base and electrolyte imbalance and development of acute kidney injury (AKI) lead to consideration of balanced fluids as an alternative. OBJECTIVES This study aimed to compare the outcomes of patients with moderate to severe TBI treated with Sterofundin (SF) versus NS. DESIGN, SETTINGS AND PARTICIPANTS A double-blinded randomised controlled trial of patients aged 18 to 65 years with TBI was conducted at the University Malaya Medical Centre from February 2017 to November 2019. INTERVENTION OR EXPOSURE Patients were randomly assigned to receive either NS or SF. The study fluids were administered for 72 h as continuous infusions or boluses. Participants, investigators, and staff were blinded to the fluid type. OUTCOMES MEASURE AND ANALYSIS The primary outcome was in-hospital mortality. Relative risk (RR) with 95% confidence interval (CI) was calculated. MAIN RESULTS A total of 70 patients were included in the analysis, with 38 in the NS group and 32 in the SF group. The in-hospital mortality rate were 3 (7.9%) in the NS group vs. 4 (12.5%) in the SF group, RR = 1.29 (95% CI, 0.64 to 2.59; p = 0.695). No patients developed AKI and required renal replacement therapy. ICP on day 3 was significantly higher in the SF group (18.60 ± 9.26) compared to 12.77 ± 3.63 in the NS group, (95% CI, -11.46 to 0.20; p = 0.037). There were no significant differences in 3-day biochemical parameters and cerebral perfusion pressure, ventilator-free days, length of ICU stay, or Glasgow Outcome Scale-Extended (GOS-E) score at 6 months. CONCLUSIONS In patients with moderate to severe TBI, the use of SF was not associated with reduced in-hospital mortality, development of AKI, or improved 6-month GOS-E when compared to NS.
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Affiliation(s)
- Khadijah Poh
- Department of Emergency Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Aida Bustam
- Department of Emergency Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Mohd Shahnaz Hasan
- Department of Anaesthesiology, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Nor'azim Mohd Yunos
- Department of Anaesthesiology, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Chun Yoong Cham
- Division of Neurosurgery, Department of Surgery, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Fang Jen Lim
- Department of Emergency Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | | | - Aliyah Zambri
- Department of Emergency Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Muhaimin Noor Azhar
- Department of Emergency Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia.
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10
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Messina A, Uryga A, Giardina A, Ciliberti P, Battaglini D, Patroniti N, Czosnyka M, Monnet X, Cecconi M, Robba C. The effect of passive leg raising test on intracranial pressure and cerebral autoregulation in brain injured patients: a physiological observational study. Crit Care 2024; 28:23. [PMID: 38229147 PMCID: PMC10790469 DOI: 10.1186/s13054-023-04785-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 12/19/2023] [Indexed: 01/18/2024] Open
Abstract
BACKGROUND The use of the passive leg raising (PLR) is limited in acute brain injury (ABI) patients with increased intracranial pressure (ICP) since the postural change of the head may impact on ICP and cerebral autoregulation. However, the PLR use may prevent a positive daily fluid balance, which had been recently associated to worse neurological outcomes. We therefore studied early and delayed effects of PLR on the cerebral autoregulation of patients recovering from ABI. MATERIALS AND METHODS This is a Prospective, observational, single-center study conducted in critically ill patients admitted with stable ABI and receiving invasive ICP monitoring, multimodal neuromonitoring and continuous hemodynamic monitoring. The fluid challenge consisted of 500 mL of crystalloid over 10 min; fluid responsiveness was defined as cardiac index increase ≥ 10%. Comparisons between different variables at baseline and after PLR were made by paired Wilcoxon signed-rank test. The correlation coefficients between hemodynamic and neuromonitoring variables were assessed using Spearman's rank test. RESULTS We studied 23 patients [12 patients (52.2%) were fluid responders]. The PLR significantly increased ICP [from 13.7 (8.3-16.4) to 15.4 (12.0-19.2) mmHg; p < 0.001], cerebral perfusion pressure (CPP) [from 51.1 (47.4-55.6) to 56.4 (49.6-61.5) mmHg; p < 0.001] and the pressure reactivity index (PRx) [from 0.12 (0.01-0.24) to 0.43 (0.34-0.46) mmHg; p < 0.001]. Regarding Near Infrared Spectroscopy (NIRS)-derived parameters, PLR significantly increased the arterial component of regional cerebral oxygen saturation (O2Hbi) [from 1.8 (0.8-3.7) to 4.3 (2.5-5.6) μM cm; p < 0.001], the deoxygenated hemoglobin (HHbi) [from 1.6 (0.2-2.9) to 2.7 (1.4-4.0) μM cm; p = 0.007] and total hemoglobin (cHbi) [from 3.6 (1.9-5.3) to 7.8 (5.2-10.3): p < 0.001]. In all the patients who had altered autoregulation after PLR, these changes persisted ten minutes afterwards. After the PLR, we observed a significant correlation between MAP and CPP and PRx. CONCLUSIONS In ABI patient with stable ICP, PLR test increased ICP, but mostly within safety values and thresholds. Despite this, cerebral autoregulation was importantly impaired, and this persisted up to 10 min after the end of the maneuvre. Our results discourage the use of PLR test in ABI even when ICP is stable.
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Affiliation(s)
- Antonio Messina
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy.
- Department of Biomedical Sciences, Humanitas University, via Levi Montalcini 4, Pieve Emanuele, Milan, Italy.
| | - Agnieszka Uryga
- Department of Biomedical Engineering, Faculty of Fundamental Problems of Technology, Wroclaw University of Science and Technology, Wrocław, Poland
| | - Alberto Giardina
- Department of Surgical Sciences and Integrated Sciences, University of Genoa, Genoa, Italy
| | - Pietro Ciliberti
- Department of Surgical Sciences and Integrated Sciences, University of Genoa, Genoa, Italy
| | - Denise Battaglini
- Anaesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Nicolo' Patroniti
- Department of Surgical Sciences and Integrated Sciences, University of Genoa, Genoa, Italy
- Anaesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Marek Czosnyka
- Brain Physics Laboratory, Addenbrooke's Hospital, Cambridge, UK
| | - Xavier Monnet
- AP-HP, Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, DMU 4 CORREVE, Inserm UMR S_999, FHU SEPSIS, CARMAS, Université Paris-Saclay, 78 Rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
| | - Maurizio Cecconi
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, via Levi Montalcini 4, Pieve Emanuele, Milan, Italy
| | - Chiara Robba
- Department of Surgical Sciences and Integrated Sciences, University of Genoa, Genoa, Italy
- Anaesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
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11
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van Hal ST, van der Jagt M, van Genderen ME, Gommers D, Veenland JF. Using Artificial Intelligence to Predict Intracranial Hypertension in Patients After Traumatic Brain Injury: A Systematic Review. Neurocrit Care 2024:10.1007/s12028-023-01910-2. [PMID: 38212559 DOI: 10.1007/s12028-023-01910-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 12/01/2023] [Indexed: 01/13/2024]
Abstract
Intracranial hypertension (IH) is a key driver of secondary brain injury in patients with traumatic brain injury. Lowering intracranial pressure (ICP) as soon as IH occurs is important, but a preemptive approach would be more beneficial. We systematically reviewed the artificial intelligence (AI) models, variables, performances, risks of bias, and clinical machine learning (ML) readiness levels of IH prediction models using AI. We conducted a systematic search until 12-03-2023 in three databases. Only studies predicting IH or ICP in patients with traumatic brain injury with a validation of the AI model were included. We extracted type of AI model, prediction variables, model performance, validation type, and prediction window length. Risk of bias was assessed with the Prediction Model Risk of Bias Assessment Tool, and we determined the clinical ML readiness level. Eleven out of 399 nonduplicate publications were included. A gaussian processes model using ICP and mean arterial pressure was most common. The maximum reported area under the receiver operating characteristic curve was 0.94. Four studies conducted external validation, and one study a prospective clinical validation. The prediction window length preceding IH varied between 30 and 60 min. Most studies (73%) had high risk of bias. The highest clinical ML readiness level was 6 of 9, indicating "real-time model testing" stage in one study. Several IH prediction models using AI performed well, were externally validated, and appeared ready to be tested in the clinical workflow (clinical ML readiness level 5 of 9). A Gaussian processes model was most used, and ICP and mean arterial pressure were frequently used variables. However, most studies showed a high risk of bias. Our findings may help position AI for IH prediction on the path to ultimate clinical integration and thereby guide researchers plan and design future studies.
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Affiliation(s)
- S T van Hal
- Department of Adult Intensive Care, Erasmus MC University Medical Center, Room Ne-413, Doctor Molewaterplein 40, Rotterdam, 3015 GD, The Netherlands.
| | - M van der Jagt
- Department of Adult Intensive Care, Erasmus MC University Medical Center, Room Ne-413, Doctor Molewaterplein 40, Rotterdam, 3015 GD, The Netherlands
| | - M E van Genderen
- Department of Adult Intensive Care, Erasmus MC University Medical Center, Room Ne-413, Doctor Molewaterplein 40, Rotterdam, 3015 GD, The Netherlands
| | - D Gommers
- Department of Adult Intensive Care, Erasmus MC University Medical Center, Room Ne-413, Doctor Molewaterplein 40, Rotterdam, 3015 GD, The Netherlands
| | - J F Veenland
- Department of Medical Informatics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Radiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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12
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Mansouri A, Buzzi M, Gibot S, Charpentier C, Schneider F, Louis G, Outin H, Monnier A, Quenot JP, Badie J, Argaud L, Bruel C, Soudant M, Agrinier N. Fluid balance control in critically ill patients: results from as-treated analyses of POINCARE-2 randomized trial. Crit Care 2023; 27:426. [PMID: 37932787 PMCID: PMC10626740 DOI: 10.1186/s13054-023-04701-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 10/22/2023] [Indexed: 11/08/2023] Open
Abstract
BACKGROUND Intention-to-treat analyses of POINCARE-2 trial led to inconclusive results regarding the effect of a conservative fluid balance strategy on mortality in critically ill patients. The present as-treated analysis aimed to assess the effectiveness of actual exposure to POINCARE-2 strategy on 60-day mortality in critically ill patients. METHODS POINCARE‑2 was a stepped wedge randomized controlled trial. Eligible patients were ≥ 18 years old, under mechanical ventilation and had an expected length of stay in ICU > 24 h. POINCARE-2 strategy consisted of daily weighing over 14 days, and subsequent restriction of fluid intake, administration of diuretics, and/or ultrafiltration. We computed a score of exposure to the strategy based on deviations from the strategy algorithm. We considered patients with a score ≥ 75 as exposed to the strategy. We used logistic regression adjusted for confounders (ALR) or for an instrumental variable (IVLR). We handled missing data using multiple imputations. RESULTS A total of 1361 patients were included. Overall, 24.8% of patients in the control group and 69.4% of patients in the strategy group had a score of exposure ≥ 75. Exposure to the POINCARE-2 strategy was not associated with 60-day all-cause mortality (ALR: OR 1.2, 95% CI 0.85-1.55; IVLR: OR 1.0, 95% CI 0.76-1.33). CONCLUSION Actual exposure to POINCARE-2 conservative strategy was not associated with reduced mortality in critically ill patients. Trial registration POINCARE-2 trial is registered at ClinicalTrials.gov (NCT02765009). Registered 29 April 2016.
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Affiliation(s)
- Adil Mansouri
- CHRU Nancy Hôpitaux de Brabois, INSERM, CIC, Epidémiologie Clinique, Université de Lorraine, 9 Allée du Morvan, 54000, Vandœuvre-lès-Nancy, Nancy, France
| | - Marie Buzzi
- CHRU Nancy Hôpitaux de Brabois, INSERM, CIC, Epidémiologie Clinique, Université de Lorraine, 9 Allée du Morvan, 54000, Vandœuvre-lès-Nancy, Nancy, France.
- APEMAC, Université de Lorraine, 54500, Nancy, France.
| | - Sébastien Gibot
- Service de Réanimation Médicale, CHRU Nancy, Université de Lorraine, 54000, Nancy, France
| | - Claire Charpentier
- Service d'Anesthésie Réanimation Chirurgicale, CHRU Nancy, Université de Lorraine, 54000, Nancy, France
| | - Francis Schneider
- Service de Médecine Intensive-Réanimation, CHU Strasbourg, INSERM U 1121, Hôpital de Hautepierre, 67000, Strasbourg, France
| | - Guillaume Louis
- Service de Réanimation Polyvalente, CHR Metz-Thionville, 57000, Metz, France
| | - Hervé Outin
- Service de Réanimation, CHI Poissy Saint-Germain, 78303, Poissy, France
| | - Alexandra Monnier
- Service de Médecine Intensive-Réanimation Médicale, Nouvel Hôpital Civil, CHU Strasbourg, Université de Strasbourg, 67000, Strasbourg, France
| | - Jean-Pierre Quenot
- Service de Médecine Intensive-Réanimation, CHU Dijon-Bourgogne, 21000, Dijon, France
| | - Julio Badie
- Service de Réanimation Médicale, Hôpital Nord Franche-Comté, 90015, Belfort, France
| | - Laurent Argaud
- Service de Réanimation Médicale, Hospices Civils de Lyon, Hôpital Edouard Herriot, 69000, Lyon, France
| | - Cédric Bruel
- Service de Réanimation Polyvalente, Groupe Hospitalier Paris Saint-Joseph, 75000, Paris, France
| | - Marc Soudant
- CHRU Nancy Hôpitaux de Brabois, INSERM, CIC, Epidémiologie Clinique, Université de Lorraine, 9 Allée du Morvan, 54000, Vandœuvre-lès-Nancy, Nancy, France
| | - Nelly Agrinier
- CHRU Nancy Hôpitaux de Brabois, INSERM, CIC, Epidémiologie Clinique, Université de Lorraine, 9 Allée du Morvan, 54000, Vandœuvre-lès-Nancy, Nancy, France
- APEMAC, Université de Lorraine, 54500, Nancy, France
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13
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Esper Treml R, Caldonazo T, Filho PHA, Mori AL, Carvalho AS, Serrano JSF, Dall-Aglio PAT, Radermacher P, Manoel JS. Effect of restrictive cumulative fluid balance on 28-day survival in invasively ventilated patients with moderate to severe ARDS due to COVID-19. Sci Rep 2023; 13:18504. [PMID: 37898681 PMCID: PMC10613222 DOI: 10.1038/s41598-023-45483-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 10/19/2023] [Indexed: 10/30/2023] Open
Abstract
This study aimed to evaluate the effect of two restrictive cumulative fluid balance (CFB) trends on survival and on major clinical outcomes in invasively ventilated patients with moderate to severe respiratory distress syndrome (ARDS) due to SARS-CoV-2. Prospective data collection was conducted on patients in the intensive care unit (ICU) originating from a tertiary university hospital. The primary outcomes were the risk association between the CFB trend during D0 to D7 and 28-day survival. The secondary outcomes were ICU mortality, in-hospital mortality, the need for invasive ventilation at D28, administration of vasoactive drugs at D7, time on invasive ventilation after D7, and length of ICU and hospital stay. 171 patients were enrolled in the study and divided according to their CFB trends during seven days of follow-up using model-based clustering [median CFB negative trend (n = 89) - 279 ml (- 664 to 203) and (n = 82) median CFB positive trend 1362 ml (619-2026)]. The group with CFB negative trend showed a higher chance of surviving 28-day in the ICU (HR: 0.62, 95% CI 0.41-0.94, p = 0.038). Moreover, this group had a reduced length of stay in the ICU, 11 (8-19) days versus 16.5 (9-29) days p = 0.004 and presented lower rates (OR = 0.22; 95% CI 0.09-0.52) of invasive ventilation after 28-days in the ICU. In patients invasively ventilated with moderate to severe ARDS due to COVID-19, the collective who showed a negative trend in the CFB after seven days of invasive ventilation had a higher chance of surviving 28 days in the ICU and lower length of stay in the ICU.
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Affiliation(s)
- Ricardo Esper Treml
- Department of Anesthesiology and Intensive Care Medicine, Friedrich-Schiller-University, Jena, Germany
- Postgraduate Program, Department of Anesthesiology, University of São Paulo, Av. Dr. Arnaldo, 455, Cerqueira Cesar, São Paulo, SP, 01246-903, Brazil
| | - Tulio Caldonazo
- Department of Cardiothoracic Surgery, Friedrich-Schiller-University, Jena, Germany
| | - Pedro Hilton A Filho
- Department of Anesthesiology, Servidor Público Estadual Hospital, São Paulo, Brazil
| | - Andréia L Mori
- Department of Anesthesiology, Servidor Público Estadual Hospital, São Paulo, Brazil
| | - André S Carvalho
- Department of Anesthesiology, Servidor Público Estadual Hospital, São Paulo, Brazil
| | - Juliana S F Serrano
- Department of Anesthesiology, Servidor Público Estadual Hospital, São Paulo, Brazil
| | - Pedro A T Dall-Aglio
- Department of Anesthesiology, Servidor Público Estadual Hospital, São Paulo, Brazil
| | - Peter Radermacher
- Institute for Anesthesiological Pathophysiology and Process Development, Ulm University Hospital, Ulm, Germany
| | - João Silva Manoel
- Postgraduate Program, Department of Anesthesiology, University of São Paulo, Av. Dr. Arnaldo, 455, Cerqueira Cesar, São Paulo, SP, 01246-903, Brazil.
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14
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Ergezen S, Wiegers EJ, Klijn E, van der Jagt M. Fluid therapy in the acute brain injured patient. Minerva Anestesiol 2023; 89:936-944. [PMID: 37822149 DOI: 10.23736/s0375-9393.23.17328-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
Adequate fluid therapy in the acute brain injured (ABI) patient is essential for maintaining an adequate brain and systemic physiology and preventing intra- and extracranial complications. The target of euvolemia, implying avoidance of both hypovolemia and fluid overloading (or "hypervolemia," by definition associated with fluid extravasation leading to tissue edema) is of key importance. Primary brain injury can be aggravated by secondary brain injury and systemic deterioration through diverse pathways which can challenge appropriate fluid management, e.g. neuroendocrine and electrolyte disorders, stress cardiomyopathy (also known as cardiac stunning) and neurogenic pulmonary edema. This is an updated expert opinion aiming to provide a practical overview on fluid therapy in the ABI patient, partly based on more recent work and stressing the fact that intravenous fluids should be regarded as drugs, with their inherent potential for both benefit and (unintended) harm.
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Affiliation(s)
- Saliha Ergezen
- Department of Adults Intensive Care, Erasmus Medical Center, Rotterdam, the Netherlands -
- Department of Neurosurgery, Erasmus Medical Center, Rotterdam, the Netherlands -
| | - Eveline J Wiegers
- Department of Adults Intensive Care, Erasmus Medical Center, Rotterdam, the Netherlands
- Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Eva Klijn
- Department of Adults Intensive Care, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Mathieu van der Jagt
- Department of Adults Intensive Care, Erasmus Medical Center, Rotterdam, the Netherlands
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15
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Li P, Li S, Liu S, Li M. Modified Nutrition Risk in the Critically ill score and mortality in critically ill patients with traumatic brain injury. Nutr Clin Pract 2023; 38:1032-1044. [PMID: 37255501 DOI: 10.1002/ncp.11014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 04/18/2023] [Accepted: 04/24/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND Understanding the relationship between nutrition risk at admission to the intensive care unit (ICU) and the prognosis of patients with traumatic brain injury (TBI) may aid early recognition of high-risk patients. METHODS We extracted data from the Medical Information Mart for Intensive Care III and the electronic ICU Collaborative Research Databases. Using modified Nutrition Risk in the Critically ill score (mNUTRIC) within the first 24 h of ICU admission, 5153 patients were divided into three groups: low (≤1, n = 1765), moderate (2-4, n = 2574), and high (≥5, n = 814). The primary outcome was 28-day in-hospital mortality, and the secondary outcomes were 7-day in-hospital mortality, length of ICU stay, and duration of mechanical ventilation. RESULTS During the median follow-up time of 6.69 days, 647 deaths occurred in total. After adjustment for potential confounding factors, setting the low mNUTRIC group as a reference, the risk of 28-day mortality was increased in the high and moderate mNUTRIC groups (hazard ratio [HR]high vs low [95% CI]: 4.21 [2.70-6.58] and 2.84 [1.95-4.14], respectively). Similarly, high and moderate mNUTRIC scores are linked to a higher risk of 7-day mortality (PTrend < 0.001) and a longer duration of mechanical ventilation (PTrend < 0.001). The effect of mNUTRIC on mortality varied by serum glucose level (PInteraction = 0.01). Lastly, those whose mNUTRIC scores deteriorated within the first 3 days have a 1.46 times greater risk of dying compared with patients with improved mNUTRIC scores. CONCLUSIONS Nutrition risk screening by mNUTRIC score at the time of admission to the ICU may improve mortality prediction.
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Affiliation(s)
- Ping Li
- Key Laboratory of Biomedical Imaging of Guangdong Province, Guangdong Provincial Engineering Research Center of Molecular Imaging, The Fifth Affiliated Hospital at Sun Yat-sen University, Zhuhai, Guangdong, China
- Center for Interventional Medicine, The Fifth Affiliated Hospital at Sun Yat-Sen University, Zhuhai, Guangdong, China
| | - Sikai Li
- Key Laboratory of Biomedical Imaging of Guangdong Province, Guangdong Provincial Engineering Research Center of Molecular Imaging, The Fifth Affiliated Hospital at Sun Yat-sen University, Zhuhai, Guangdong, China
- Center for Interventional Medicine, The Fifth Affiliated Hospital at Sun Yat-Sen University, Zhuhai, Guangdong, China
| | - Shanshan Liu
- Department of Critical Illness, The Fifth Affiliated Hospital at Sun Yat-sen University, Zhuhai, Guangdong, China
| | - Man Li
- Key Laboratory of Biomedical Imaging of Guangdong Province, Guangdong Provincial Engineering Research Center of Molecular Imaging, The Fifth Affiliated Hospital at Sun Yat-sen University, Zhuhai, Guangdong, China
- Center for Interventional Medicine, The Fifth Affiliated Hospital at Sun Yat-Sen University, Zhuhai, Guangdong, China
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16
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Husain-Syed F, Takeuchi T, Neyra JA, Ramírez-Guerrero G, Rosner MH, Ronco C, Tolwani AJ. Acute kidney injury in neurocritical care. Crit Care 2023; 27:341. [PMID: 37661277 PMCID: PMC10475203 DOI: 10.1186/s13054-023-04632-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 08/30/2023] [Indexed: 09/05/2023] Open
Abstract
Approximately 20% of patients with acute brain injury (ABI) also experience acute kidney injury (AKI), which worsens their outcomes. The metabolic and inflammatory changes associated with AKI likely contribute to prolonged brain injury and edema. As a result, recognizing its presence is important for effectively managing ABI and its sequelae. This review discusses the occurrence and effects of AKI in critically ill adults with neurological conditions, outlines potential mechanisms connecting AKI and ABI progression, and highlights AKI management principles. Tailored approaches include optimizing blood pressure, managing intracranial pressure, adjusting medication dosages, and assessing the type of administered fluids. Preventive measures include avoiding nephrotoxic drugs, improving hemodynamic and fluid balance, and addressing coexisting AKI syndromes. ABI patients undergoing renal replacement therapy (RRT) are more susceptible to neurological complications. RRT can negatively impact cerebral blood flow, intracranial pressure, and brain tissue oxygenation, with effects tied to specific RRT methods. Continuous RRT is favored for better hemodynamic stability and lower risk of dialysis disequilibrium syndrome. Potential RRT modifications for ABI patients include adjusted dialysate and blood flow rates, osmotherapy, and alternate anticoagulation methods. Future research should explore whether these strategies enhance outcomes and if using novel AKI biomarkers can mitigate AKI-related complications in ABI patients.
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Affiliation(s)
- Faeq Husain-Syed
- Division of Nephrology, University of Virginia School of Medicine, 1300 Jefferson Park Avenue, Charlottesville, VA, 22908, USA
- Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus-Liebig-University Giessen, Klinikstrasse 33, 35392, Giessen, Germany
| | - Tomonori Takeuchi
- Division of Nephrology, University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL, 35294, USA
- Department of Health Policy and Informatics, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo Ku, Tokyo, 113-8510, Japan
| | - Javier A Neyra
- Division of Nephrology, University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL, 35294, USA
| | - Gonzalo Ramírez-Guerrero
- Critical Care Unit, Carlos Van Buren Hospital, San Ignacio 725, Valparaíso, Chile
- Dialysis and Renal Transplant Unit, Carlos Van Buren Hospital, San Ignacio 725, Valparaíso, Chile
- Department of Medicine, Universidad de Valparaíso, Hontaneda 2653, Valparaíso, Chile
| | - Mitchell H Rosner
- Division of Nephrology, University of Virginia School of Medicine, 1300 Jefferson Park Avenue, Charlottesville, VA, 22908, USA
| | - Claudio Ronco
- Department of Medicine (DIMED), Università di Padova, Via Giustiniani, 2, 35128, Padua, Italy
- International Renal Research Institute of Vicenza, Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Via Rodolfi, 37, 36100, Vicenza, Italy
| | - Ashita J Tolwani
- Division of Nephrology, University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL, 35294, USA.
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de Carvalho EB, Battaglini D, Robba C, Malbrain MLNG, Pelosi P, Rocco PRM, Silva PL. Fluid management strategies and their interaction with mechanical ventilation: from experimental studies to clinical practice. Intensive Care Med Exp 2023; 11:44. [PMID: 37474816 PMCID: PMC10359242 DOI: 10.1186/s40635-023-00526-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 05/31/2023] [Indexed: 07/22/2023] Open
Abstract
Patients on mechanical ventilation may receive intravenous fluids via restrictive or liberal fluid management. A clear and objective differentiation between restrictive and liberal fluid management strategies is lacking in the literature. The liberal approach has been described as involving fluid rates ranging from 1.2 to 12 times higher than the restrictive approach. A restrictive fluid management may lead to hypoperfusion and distal organ damage, and a liberal fluid strategy may result in endothelial shear stress and glycocalyx damage, cardiovascular complications, lung edema, and distal organ dysfunction. The association between fluid and mechanical ventilation strategies and how they interact toward ventilator-induced lung injury (VILI) could potentiate the damage. For instance, the combination of a liberal fluids and pressure-support ventilation, but not pressure control ventilation, may lead to further lung damage in experimental models of acute lung injury. Moreover, under liberal fluid management, the application of high positive end-expiratory pressure (PEEP) or an abrupt decrease in PEEP yielded higher endothelial cell damage in the lungs. Nevertheless, the translational aspects of these findings are scarce. The aim of this narrative review is to provide better understanding of the interaction between different fluid and ventilation strategies and how these interactions may affect lung and distal organs. The weaning phase of mechanical ventilation and the deresuscitation phase are not explored in this review.
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Affiliation(s)
- Eduardo Butturini de Carvalho
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- University of Vassouras, Rio de Janeiro, Brazil
| | | | - Chiara Robba
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Manu L. N. G. Malbrain
- First Department of Anesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland
- International Fluid Academy, Lovenjoel, Belgium
| | - Paolo Pelosi
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Patricia Rieken Macedo Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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Benjamin ER, Demetriades D, Owattanapanich N, Shackelford SA, Roedel E, Polk TM, Biswas S, Rasmussen T. Therapeutic Interventions and Outcomes in Civilian and Military Isolated Gunshot Wounds to the Head: A Department of Defense Trauma Registry and ACS TQIP-matched Study. Ann Surg 2023; 278:e131-e136. [PMID: 35786669 DOI: 10.1097/sla.0000000000005496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The purpose of this study was to compare therapeutic strategies and outcomes, following isolated gunshot wounds of the head, between military and civilian populations. BACKGROUND Recent military conflicts introduced new concepts in trauma care, including aggressive surgical intervention in severe head trauma. METHODS This was a cohort-matched study, using the civilian Trauma Quality Improvement Program (TQIP) database of the American College of Surgeons (ACS) and the Department of Defense Trauma Registry (DoDTR), during the period 2013 to 2016. Included in the study were patients with isolated gunshots to the head. Exclusion criteria were dead on arrival, civilians transferred from other hospitals, and patients with major extracranial associated injuries (body area Abbreviated Injury Scale >3). Patients in the military database were propensity score-matched 1:3 with patients in the civilian database. RESULTS A total of 136 patients in the DoDTR database were matched for age, sex, year of injury, and head Abbreviated Injury Scale with 408 patients from TQIP. Utilization of blood products was significantly higher in the military population ( P <0.001). In the military group, patients were significantly more likely to have intracranial pressure monitoring (17% vs 6%, P <0.001) and more likely to undergo craniotomy or craniectomy (34% vs 13%, P <0.001) than in the civilian group. Mortality in the military population was significantly lower (27% vs 38%, P =0.013). CONCLUSIONS Military patients are more likely to receive blood products, have intracranial pressure monitoring and undergo craniectomy or craniotomy than their civilian counterparts after isolated head gunshot wounds. Mortality is significantly lower in the military population. LEVEL OF EVIDENCE Level III-therapeutic.
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Affiliation(s)
| | - Demetrios Demetriades
- Los Angeles County Medical Center, University of Southern California, Los Angeles, CA
| | | | | | - Erik Roedel
- Madigan Army Medical Center, Joint Base Lewis-McChord, WA
| | | | - Subarna Biswas
- Los Angeles County Medical Center, University of Southern California, Los Angeles, CA
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19
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Frisvold S, Coppola S, Ehrmann S, Chiumello D, Guérin C. Respiratory challenges and ventilatory management in different types of acute brain-injured patients. Crit Care 2023; 27:247. [PMID: 37353832 PMCID: PMC10290317 DOI: 10.1186/s13054-023-04532-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 06/15/2023] [Indexed: 06/25/2023] Open
Abstract
Acute brain injury (ABI) covers various clinical entities that may require invasive mechanical ventilation (MV) in the intensive care unit (ICU). The goal of MV, which is to protect the lung and the brain from further injury, may be difficult to achieve in the most severe forms of lung or brain injury. This narrative review aims to address the respiratory issues and ventilator management, specific to ABI patients in the ICU.
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Affiliation(s)
- S Frisvold
- Department of Anesthesia and Intensive Care, University Hospital of North Norway, Tromso, Norway
- Department of Clinical Medicine, UiT the Arctic University of Norway, Tromso, Norway
| | - S Coppola
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Milan, Italy
- Department of Health Sciences, University of Milan, Milan, Italy
- Coordinated Research Center On Respiratory Failure, University of Milan, Milan, Italy
| | - S Ehrmann
- CHRU Tours, Médecine Intensive Réanimation, CIC INSERM 1415, CRICS-TriggerSep F-CRIN Research Network, Tours, France
- INSERM, Centre d'étude Des Pathologies Respiratoires, U1100, Université de Tours, Tours, France
| | - D Chiumello
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Milan, Italy
- Department of Health Sciences, University of Milan, Milan, Italy
- Coordinated Research Center On Respiratory Failure, University of Milan, Milan, Italy
| | - Claude Guérin
- Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, 8 Avenue Rockefeller, 69008, Lyon, France.
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20
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Huet O, Chapalain X, Vermeersch V, Moyer JD, Lasocki S, Cohen B, Dahyot-Fizelier C, Chalard K, Seguin P, Hourmant Y, Asehnoune K, Roquilly A. Impact of continuous hypertonic (NaCl 20%) saline solution on renal outcomes after traumatic brain injury (TBI): a post hoc analysis of the COBI trial. Crit Care 2023; 27:42. [PMID: 36707841 PMCID: PMC9881296 DOI: 10.1186/s13054-023-04311-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 01/07/2023] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND To evaluate if the increase in chloride intake during a continuous infusion of 20% hypertonic saline solution (HSS) is associated with an increase in the incidence of acute kidney injury (AKI) compared to standard of care in traumatic brain injury patients. METHODS In this post hoc analysis of the COBI trial, 370 patients admitted for a moderate-to-severe TBI in the 9 participating ICUs were enrolled. The intervention consisted in a continuous infusion of HSS to maintain a blood sodium level between 150 and 155 mmol/L for at least 48 h. Patients enrolled in the control arm were treated as recommended by the latest Brain Trauma foundation guidelines. The primary outcome of this study was the occurrence of AKI within 28 days after enrollment. AKI was defined by stages 2 or 3 according to KDIGO criteria. RESULTS After exclusion of missing data, 322 patients were included in this post hoc analysis. The patients randomized in the intervention arm received a significantly higher amount of chloride during the first 4 days (intervention group: 97.3 ± 31.6 g vs. control group: 61.3 ± 38.1 g; p < 0.001) and had higher blood chloride levels at day 4 (117.9 ± 10.7 mmol/L vs. 111.6 ± 9 mmol/L, respectively, p < 0.001). The incidence of AKI was not statistically different between the intervention and the control group (24.5% vs. 28.9%, respectively; p = 0.45). CONCLUSIONS Despite a significant increase in chloride intake, a continuous infusion of HSS was not associated with AKI in moderate-to-severe TBI patients. Our study does not confirm the potentially detrimental effect of chloride load on kidney function in ICU patients. TRIAL REGISTRATION The COBI trial was registered on clinicaltrial.gov (Trial registration number: NCT03143751, date of registration: 8 May 2017).
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Affiliation(s)
- Olivier Huet
- Department of Anesthesiology and Surgical Intensive Care Unit, Brest University Hospital, Boulevard Tanguy Prigent, 29609, Brest, France.
| | - Xavier Chapalain
- Department of Anesthesiology and Surgical Intensive Care Unit, Brest University Hospital, Boulevard Tanguy Prigent, 29609, Brest, France
| | - Véronique Vermeersch
- Department of Anesthesiology and Surgical Intensive Care Unit, Brest University Hospital, Boulevard Tanguy Prigent, 29609, Brest, France
| | - Jean-Denis Moyer
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, Paris, France
| | - Sigismond Lasocki
- Department of Anesthesia and Intensive Care Unit, Angers Hospital, Angers, France
| | - Benjamin Cohen
- Department of Anesthesia and Intensive Care Unit, Tours Hospital, Tours, France
| | | | - Kevin Chalard
- Department of Anesthesia and Intensive Care Unit, Montpellier Hospital, Montpellier, France
| | - P Seguin
- Department of Anesthesia and Intensive Care Unit, Rennes Hospital, Rennes, France
| | - Y Hourmant
- Pôle Anesthésie Réanimations, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, Université de Nantes, CHU Nantes, Nantes, France
| | - Karim Asehnoune
- Pôle Anesthésie Réanimations, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, Université de Nantes, CHU Nantes, Nantes, France
| | - Antoine Roquilly
- Pôle Anesthésie Réanimations, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, Université de Nantes, CHU Nantes, Nantes, France
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21
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de Winkel J, Roozenbeek B. Response to "Flow Diversion in the Treatment of Intracranial Aneurysms: A Pragmatic Randomized Care Trial". AJNR Am J Neuroradiol 2023; 44:E7-E8. [PMID: 36574319 PMCID: PMC9835912 DOI: 10.3174/ajnr.a7718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- J de Winkel
- Department of NeurologyDepartment of Public HealthErasmus MC University Medical Center RotterdamRotterdam, the Netherlands
| | - B Roozenbeek
- Department of NeurologyErasmus MC University Medical Center RotterdamRotterdam, the Netherlands
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22
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Zeuthen E, Wichmann S, Schønemann-Lund M, Järvisalo MJ, Rubenson-Wahlin R, Sigurðsson MI, Holen E, Bestle MH. Nordic survey on assessment and treatment of fluid overload in intensive care. Front Med (Lausanne) 2022; 9:1067162. [PMID: 36507497 PMCID: PMC9732460 DOI: 10.3389/fmed.2022.1067162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 11/09/2022] [Indexed: 11/27/2022] Open
Abstract
Introduction Fluid overload in patients in the intensive care unit (ICU) is associated with higher mortality. There are few randomized controlled trials to guide physicians in treating patients with fluid overload in the ICU, and no guidelines exist. We aimed to elucidate how ICU physicians from Nordic countries define, assess, and treat fluid overload in the ICU. Materials and methods We developed an online questionnaire with 18 questions. The questions were pre-tested and revised by specialists in intensive care medicine. Through a network of national coordinators. The survey was distributed to a wide range of Nordic ICU physicians. The distribution started on January 5th, 2022 and ended on May 6th, 2022. Results We received a total of 1,066 responses from Denmark, Norway, Finland, Sweden, and Iceland. When assessing fluid status, respondents applied clinical parameters such as clinical examination findings, cumulative fluid balance, body weight, and urine output more frequently than cardiac/lung ultrasound, radiological appearances, and cardiac output monitoring. A large proportion of the respondents agreed that a 5% increase or more in body weight from baseline supported the diagnosis of fluid overload. The preferred de-resuscitation strategy was diuretics (91%), followed by minimization of maintenance (76%) and resuscitation fluids (71%). The majority declared that despite mild hypotension, mild hypernatremia, and ongoing vasopressor, they would not withhold treatment of fluid overload and would continue diuretics. The respondents were divided when it came to treating fluid overload with loop diuretics in patients receiving noradrenaline. Around 1% would not administer noradrenaline and diuretics simultaneously and 35% did not have a fixed upper limit for the dosage. The remaining respondents 63% reported different upper limits of noradrenaline infusion (0.05-0.50 mcg/kg/min) when administering loop diuretics. Conclusion Self-reported practices among Nordic ICU physicians when assessing, diagnosing, and treating fluid overload reveals variability in the practice. A 5% increase in body weight was considered a minimum to support the diagnosis of fluid overload. Clinical examination findings were preferred for assessing, diagnosing and treating fluid overload, and diuretics were the preferred treatment modality.
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Affiliation(s)
- Emilie Zeuthen
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital, North Zealand, Denmark,*Correspondence: Emilie Zeuthen,
| | - Sine Wichmann
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital, North Zealand, Denmark
| | - Martin Schønemann-Lund
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital, North Zealand, Denmark
| | - Mikko J. Järvisalo
- Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital, Turku, Finland,Kidney Center, Turku University Hospital, University of Turku, Turku, Finland
| | - Rebecka Rubenson-Wahlin
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden,Department of Anesthesia and Intensive Care, Södersjukhuset, Stockholm, Sweden
| | - Martin I. Sigurðsson
- Department of Anesthesia and Critical Care, Landspitali – The National University Hospital of Iceland, Reykjavík, Iceland,Faculty of Medicine, University of Iceland, Reykjavík, Iceland
| | - Erling Holen
- Department of Anesthesia and Intensive Care, Helse Stavanger University Hospital, Stavanger, Norway
| | - Morten H. Bestle
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital, North Zealand, Denmark,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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23
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Maas AIR, Menon DK, Manley GT, Abrams M, Åkerlund C, Andelic N, Aries M, Bashford T, Bell MJ, Bodien YG, Brett BL, Büki A, Chesnut RM, Citerio G, Clark D, Clasby B, Cooper DJ, Czeiter E, Czosnyka M, Dams-O’Connor K, De Keyser V, Diaz-Arrastia R, Ercole A, van Essen TA, Falvey É, Ferguson AR, Figaji A, Fitzgerald M, Foreman B, Gantner D, Gao G, Giacino J, Gravesteijn B, Guiza F, Gupta D, Gurnell M, Haagsma JA, Hammond FM, Hawryluk G, Hutchinson P, van der Jagt M, Jain S, Jain S, Jiang JY, Kent H, Kolias A, Kompanje EJO, Lecky F, Lingsma HF, Maegele M, Majdan M, Markowitz A, McCrea M, Meyfroidt G, Mikolić A, Mondello S, Mukherjee P, Nelson D, Nelson LD, Newcombe V, Okonkwo D, Orešič M, Peul W, Pisică D, Polinder S, Ponsford J, Puybasset L, Raj R, Robba C, Røe C, Rosand J, Schueler P, Sharp DJ, Smielewski P, Stein MB, von Steinbüchel N, Stewart W, Steyerberg EW, Stocchetti N, Temkin N, Tenovuo O, Theadom A, Thomas I, Espin AT, Turgeon AF, Unterberg A, Van Praag D, van Veen E, Verheyden J, Vyvere TV, Wang KKW, Wiegers EJA, Williams WH, Wilson L, Wisniewski SR, Younsi A, Yue JK, Yuh EL, Zeiler FA, Zeldovich M, Zemek R. Traumatic brain injury: progress and challenges in prevention, clinical care, and research. Lancet Neurol 2022; 21:1004-1060. [PMID: 36183712 PMCID: PMC10427240 DOI: 10.1016/s1474-4422(22)00309-x] [Citation(s) in RCA: 168] [Impact Index Per Article: 84.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 07/22/2022] [Indexed: 02/06/2023]
Abstract
Traumatic brain injury (TBI) has the highest incidence of all common neurological disorders, and poses a substantial public health burden. TBI is increasingly documented not only as an acute condition but also as a chronic disease with long-term consequences, including an increased risk of late-onset neurodegeneration. The first Lancet Neurology Commission on TBI, published in 2017, called for a concerted effort to tackle the global health problem posed by TBI. Since then, funding agencies have supported research both in high-income countries (HICs) and in low-income and middle-income countries (LMICs). In November 2020, the World Health Assembly, the decision-making body of WHO, passed resolution WHA73.10 for global actions on epilepsy and other neurological disorders, and WHO launched the Decade for Action on Road Safety plan in 2021. New knowledge has been generated by large observational studies, including those conducted under the umbrella of the International Traumatic Brain Injury Research (InTBIR) initiative, established as a collaboration of funding agencies in 2011. InTBIR has also provided a huge stimulus to collaborative research in TBI and has facilitated participation of global partners. The return on investment has been high, but many needs of patients with TBI remain unaddressed. This update to the 2017 Commission presents advances and discusses persisting and new challenges in prevention, clinical care, and research. In LMICs, the occurrence of TBI is driven by road traffic incidents, often involving vulnerable road users such as motorcyclists and pedestrians. In HICs, most TBI is caused by falls, particularly in older people (aged ≥65 years), who often have comorbidities. Risk factors such as frailty and alcohol misuse provide opportunities for targeted prevention actions. Little evidence exists to inform treatment of older patients, who have been commonly excluded from past clinical trials—consequently, appropriate evidence is urgently required. Although increasing age is associated with worse outcomes from TBI, age should not dictate limitations in therapy. However, patients injured by low-energy falls (who are mostly older people) are about 50% less likely to receive critical care or emergency interventions, compared with those injured by high-energy mechanisms, such as road traffic incidents. Mild TBI, defined as a Glasgow Coma sum score of 13–15, comprises most of the TBI cases (over 90%) presenting to hospital. Around 50% of adult patients with mild TBI presenting to hospital do not recover to pre-TBI levels of health by 6 months after their injury. Fewer than 10% of patients discharged after presenting to an emergency department for TBI in Europe currently receive follow-up. Structured follow-up after mild TBI should be considered good practice, and urgent research is needed to identify which patients with mild TBI are at risk for incomplete recovery. The selection of patients for CT is an important triage decision in mild TBI since it allows early identification of lesions that can trigger hospital admission or life-saving surgery. Current decision making for deciding on CT is inefficient, with 90–95% of scanned patients showing no intracranial injury but being subjected to radiation risks. InTBIR studies have shown that measurement of blood-based biomarkers adds value to previously proposed clinical decision rules, holding the potential to improve efficiency while reducing radiation exposure. Increased concentrations of biomarkers in the blood of patients with a normal presentation CT scan suggest structural brain damage, which is seen on MR scanning in up to 30% of patients with mild TBI. Advanced MRI, including diffusion tensor imaging and volumetric analyses, can identify additional injuries not detectable by visual inspection of standard clinical MR images. Thus, the absence of CT abnormalities does not exclude structural damage—an observation relevant to litigation procedures, to management of mild TBI, and when CT scans are insufficient to explain the severity of the clinical condition. Although blood-based protein biomarkers have been shown to have important roles in the evaluation of TBI, most available assays are for research use only. To date, there is only one vendor of such assays with regulatory clearance in Europe and the USA with an indication to rule out the need for CT imaging for patients with suspected TBI. Regulatory clearance is provided for a combination of biomarkers, although evidence is accumulating that a single biomarker can perform as well as a combination. Additional biomarkers and more clinical-use platforms are on the horizon, but cross-platform harmonisation of results is needed. Health-care efficiency would benefit from diversity in providers. In the intensive care setting, automated analysis of blood pressure and intracranial pressure with calculation of derived parameters can help individualise management of TBI. Interest in the identification of subgroups of patients who might benefit more from some specific therapeutic approaches than others represents a welcome shift towards precision medicine. Comparative-effectiveness research to identify best practice has delivered on expectations for providing evidence in support of best practices, both in adult and paediatric patients with TBI. Progress has also been made in improving outcome assessment after TBI. Key instruments have been translated into up to 20 languages and linguistically validated, and are now internationally available for clinical and research use. TBI affects multiple domains of functioning, and outcomes are affected by personal characteristics and life-course events, consistent with a multifactorial bio-psycho-socio-ecological model of TBI, as presented in the US National Academies of Sciences, Engineering, and Medicine (NASEM) 2022 report. Multidimensional assessment is desirable and might be best based on measurement of global functional impairment. More work is required to develop and implement recommendations for multidimensional assessment. Prediction of outcome is relevant to patients and their families, and can facilitate the benchmarking of quality of care. InTBIR studies have identified new building blocks (eg, blood biomarkers and quantitative CT analysis) to refine existing prognostic models. Further improvement in prognostication could come from MRI, genetics, and the integration of dynamic changes in patient status after presentation. Neurotrauma researchers traditionally seek translation of their research findings through publications, clinical guidelines, and industry collaborations. However, to effectively impact clinical care and outcome, interactions are also needed with research funders, regulators, and policy makers, and partnership with patient organisations. Such interactions are increasingly taking place, with exemplars including interactions with the All Party Parliamentary Group on Acquired Brain Injury in the UK, the production of the NASEM report in the USA, and interactions with the US Food and Drug Administration. More interactions should be encouraged, and future discussions with regulators should include debates around consent from patients with acute mental incapacity and data sharing. Data sharing is strongly advocated by funding agencies. From January 2023, the US National Institutes of Health will require upload of research data into public repositories, but the EU requires data controllers to safeguard data security and privacy regulation. The tension between open data-sharing and adherence to privacy regulation could be resolved by cross-dataset analyses on federated platforms, with the data remaining at their original safe location. Tools already exist for conventional statistical analyses on federated platforms, however federated machine learning requires further development. Support for further development of federated platforms, and neuroinformatics more generally, should be a priority. This update to the 2017 Commission presents new insights and challenges across a range of topics around TBI: epidemiology and prevention (section 1 ); system of care (section 2 ); clinical management (section 3 ); characterisation of TBI (section 4 ); outcome assessment (section 5 ); prognosis (Section 6 ); and new directions for acquiring and implementing evidence (section 7 ). Table 1 summarises key messages from this Commission and proposes recommendations for the way forward to advance research and clinical management of TBI.
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Affiliation(s)
- Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Mathew Abrams
- International Neuroinformatics Coordinating Facility, Karolinska Institutet, Stockholm, Sweden
| | - Cecilia Åkerlund
- Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Nada Andelic
- Division of Clinical Neuroscience, Department of Physical Medicine and Rehabilitation, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Marcel Aries
- Department of Intensive Care, Maastricht UMC, Maastricht, Netherlands
| | - Tom Bashford
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Michael J Bell
- Critical Care Medicine, Neurological Surgery and Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Yelena G Bodien
- Department of Neurology and Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA
| | - Benjamin L Brett
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - András Büki
- Department of Neurosurgery, Faculty of Medicine and Health Örebro University, Örebro, Sweden
- Department of Neurosurgery, Medical School; ELKH-PTE Clinical Neuroscience MR Research Group; and Neurotrauma Research Group, Janos Szentagothai Research Centre, University of Pecs, Pecs, Hungary
| | - Randall M Chesnut
- Department of Neurological Surgery and Department of Orthopaedics and Sports Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Giuseppe Citerio
- School of Medicine and Surgery, Universita Milano Bicocca, Milan, Italy
- NeuroIntensive Care, San Gerardo Hospital, Azienda Socio Sanitaria Territoriale (ASST) Monza, Monza, Italy
| | - David Clark
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Betony Clasby
- Department of Sociological Studies, University of Sheffield, Sheffield, UK
| | - D Jamie Cooper
- School of Public Health and Preventive Medicine, Monash University and The Alfred Hospital, Melbourne, VIC, Australia
| | - Endre Czeiter
- Department of Neurosurgery, Medical School; ELKH-PTE Clinical Neuroscience MR Research Group; and Neurotrauma Research Group, Janos Szentagothai Research Centre, University of Pecs, Pecs, Hungary
| | - Marek Czosnyka
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Kristen Dams-O’Connor
- Department of Rehabilitation and Human Performance and Department of Neurology, Brain Injury Research Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Véronique De Keyser
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Ramon Diaz-Arrastia
- Department of Neurology and Center for Brain Injury and Repair, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Thomas A van Essen
- Department of Neurosurgery, Leiden University Medical Center, Leiden, Netherlands
- Department of Neurosurgery, Medical Center Haaglanden, The Hague, Netherlands
| | - Éanna Falvey
- College of Medicine and Health, University College Cork, Cork, Ireland
| | - Adam R Ferguson
- Brain and Spinal Injury Center, Department of Neurological Surgery, Weill Institute for Neurosciences, University of California San Francisco and San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA
| | - Anthony Figaji
- Division of Neurosurgery and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Melinda Fitzgerald
- Curtin Health Innovation Research Institute, Curtin University, Bentley, WA, Australia
- Perron Institute for Neurological and Translational Sciences, Nedlands, WA, Australia
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati Gardner Neuroscience Institute, University of Cincinnati, Cincinnati, OH, USA
| | - Dashiell Gantner
- School of Public Health and Preventive Medicine, Monash University and The Alfred Hospital, Melbourne, VIC, Australia
| | - Guoyi Gao
- Department of Neurosurgery, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine
| | - Joseph Giacino
- Department of Physical Medicine and Rehabilitation, Harvard Medical School and Spaulding Rehabilitation Hospital, Charlestown, MA, USA
| | - Benjamin Gravesteijn
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Fabian Guiza
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Deepak Gupta
- Department of Neurosurgery, Neurosciences Centre and JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Mark Gurnell
- Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Juanita A Haagsma
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Flora M Hammond
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Rehabilitation Hospital of Indiana, Indianapolis, IN, USA
| | - Gregory Hawryluk
- Section of Neurosurgery, GB1, Health Sciences Centre, University of Manitoba, Winnipeg, MB, Canada
| | - Peter Hutchinson
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Mathieu van der Jagt
- Department of Intensive Care, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Sonia Jain
- Biostatistics Research Center, Herbert Wertheim School of Public Health, University of California, San Diego, CA, USA
| | - Swati Jain
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Ji-yao Jiang
- Department of Neurosurgery, Shanghai Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Hope Kent
- Department of Psychology, University of Exeter, Exeter, UK
| | - Angelos Kolias
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Erwin J O Kompanje
- Department of Intensive Care, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Fiona Lecky
- Centre for Urgent and Emergency Care Research, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Marc Maegele
- Cologne-Merheim Medical Center, Department of Trauma and Orthopedic Surgery, Witten/Herdecke University, Cologne, Germany
| | - Marek Majdan
- Institute for Global Health and Epidemiology, Department of Public Health, Faculty of Health Sciences and Social Work, Trnava University, Trnava, Slovakia
| | - Amy Markowitz
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Michael McCrea
- Department of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Geert Meyfroidt
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Ana Mikolić
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Stefania Mondello
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Pratik Mukherjee
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - David Nelson
- Section for Anesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Lindsay D Nelson
- Department of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Virginia Newcombe
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - David Okonkwo
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Matej Orešič
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Wilco Peul
- Department of Neurosurgery, Leiden University Medical Center, Leiden, Netherlands
| | - Dana Pisică
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
- Department of Neurosurgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Jennie Ponsford
- Monash-Epworth Rehabilitation Research Centre, Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, VIC, Australia
| | - Louis Puybasset
- Department of Anesthesiology and Intensive Care, APHP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - Rahul Raj
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Chiara Robba
- Department of Anaesthesia and Intensive Care, Policlinico San Martino IRCCS for Oncology and Neuroscience, Genova, Italy, and Dipartimento di Scienze Chirurgiche e Diagnostiche, University of Genoa, Italy
| | - Cecilie Røe
- Division of Clinical Neuroscience, Department of Physical Medicine and Rehabilitation, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Jonathan Rosand
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - David J Sharp
- Department of Brain Sciences, Imperial College London, London, UK
| | - Peter Smielewski
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Murray B Stein
- Department of Psychiatry and Department of Family Medicine and Public Health, UCSD School of Medicine, La Jolla, CA, USA
| | - Nicole von Steinbüchel
- Institute of Medical Psychology and Medical Sociology, University Medical Center Goettingen, Goettingen, Germany
| | - William Stewart
- Department of Neuropathology, Queen Elizabeth University Hospital and University of Glasgow, Glasgow, UK
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences Leiden University Medical Center, Leiden, Netherlands
| | - Nino Stocchetti
- Department of Pathophysiology and Transplantation, Milan University, and Neuroscience ICU, Fondazione IRCCS Ca Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nancy Temkin
- Departments of Neurological Surgery, and Biostatistics, University of Washington, Seattle, WA, USA
| | - Olli Tenovuo
- Department of Rehabilitation and Brain Trauma, Turku University Hospital, and Department of Neurology, University of Turku, Turku, Finland
| | - Alice Theadom
- National Institute for Stroke and Applied Neurosciences, Faculty of Health and Environmental Studies, Auckland University of Technology, Auckland, New Zealand
| | - Ilias Thomas
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Abel Torres Espin
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Alexis F Turgeon
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, CHU de Québec-Université Laval Research Center, Québec City, QC, Canada
| | - Andreas Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Dominique Van Praag
- Departments of Clinical Psychology and Neurosurgery, Antwerp University Hospital, and University of Antwerp, Edegem, Belgium
| | - Ernest van Veen
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | | | - Thijs Vande Vyvere
- Department of Radiology, Faculty of Medicine and Health Sciences, Department of Rehabilitation Sciences (MOVANT), Antwerp University Hospital, and University of Antwerp, Edegem, Belgium
| | - Kevin K W Wang
- Department of Psychiatry, University of Florida, Gainesville, FL, USA
| | - Eveline J A Wiegers
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - W Huw Williams
- Centre for Clinical Neuropsychology Research, Department of Psychology, University of Exeter, Exeter, UK
| | - Lindsay Wilson
- Division of Psychology, University of Stirling, Stirling, UK
| | - Stephen R Wisniewski
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Alexander Younsi
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - John K Yue
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Esther L Yuh
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Frederick A Zeiler
- Departments of Surgery, Human Anatomy and Cell Science, and Biomedical Engineering, Rady Faculty of Health Sciences and Price Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Marina Zeldovich
- Institute of Medical Psychology and Medical Sociology, University Medical Center Goettingen, Goettingen, Germany
| | - Roger Zemek
- Departments of Pediatrics and Emergency Medicine, University of Ottawa, Children’s Hospital of Eastern Ontario, ON, Canada
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Messina A, Villa F, Lionetti G, Galarza L, Meyfroidt G, van der Jagt M, Monnet X, Pelosi P, Cecconi M, Robba C. Hemodynamic management of acute brain injury caused by cerebrovascular diseases: a survey of the European Society of Intensive Care Medicine. Intensive Care Med Exp 2022; 10:42. [PMID: 36273067 PMCID: PMC9588138 DOI: 10.1186/s40635-022-00463-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 08/11/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The optimal hemodynamic targets and management of patients with acute brain injury are not completely elucidated, but recent evidence points to important impact on clinical outcomes. We performed an international survey with the aim to investigate the practice in the hemodynamic targets, monitoring, and management of patients with acute ischemic stroke (AIS), intracranial hemorrhage (ICH) and subarachnoid hemorrhage (SAH). METHODS This survey was endorsed by the European Society of Intensive Care (ESICM). An electronic questionnaire of 76 questions divided in 4 sections (general information, AIS, ICH, SAH specific questions) was available between January 2022 to March 2022 on the ESICM website. RESULTS One hundred fifty-four healthcare professionals from 36 different countries and at least 98 different institutions answered the survey. Routine echocardiography is routinely performed in 37% of responders in AIS, 34% in ICH and 38% in SAH. Cardiac output monitoring is used in less than 20% of cases by most of the responders. Cardiovascular complications are the main reason for using advanced hemodynamic monitoring, and norepinephrine is the most common drug used to increase arterial blood pressure. Most responders target fluid balance to neutral (62% in AIS, 59% in ICH,44% in SAH), and normal saline is the most common fluid used. Large variability was observed regarding the blood pressure targets. CONCLUSIONS Hemodynamic management and treatment in patients with acute brain injury from cerebrovascular diseases vary largely in clinical practice. Further research is required to provide clear guidelines to physicians for the hemodynamic optimization of this group of patients.
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Affiliation(s)
- Antonio Messina
- grid.452490.eDepartment of Anesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital – IRCCS, Humanitas University, via Alessandro Manzoni 56, 20089 Rozzano, Milan Italy ,grid.452490.eDepartment of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan Italy
| | - Federico Villa
- grid.452490.eDepartment of Anesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital – IRCCS, Humanitas University, via Alessandro Manzoni 56, 20089 Rozzano, Milan Italy
| | - Giulia Lionetti
- grid.452490.eDepartment of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan Italy
| | - Laura Galarza
- grid.470634.2Department of Intensive Care, Hospital General Universitario de Castellon, Castellon de la Plana, Spain
| | - Geert Meyfroidt
- grid.410569.f0000 0004 0626 3338Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Louvain, Belgium
| | - Mathieu van der Jagt
- grid.5645.2000000040459992XDepartment of Intensive Care Adults and Erasmus MC Stroke Center, Erasmus MC – University Medical Center, Rotterdam, The Netherlands
| | - Xavier Monnet
- grid.413784.d0000 0001 2181 7253Paris-Saclay University, AP-HP, Medical Intensive Care Unit, Bicêtre Hospital, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, CARMAS Research Team, Le Kremlin-Bicêtre, France
| | - Paolo Pelosi
- Anaesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy ,grid.5606.50000 0001 2151 3065Department of Surgical Sciences and Integrated Sciences, University of Genoa, Genoa, Italy
| | - Maurizio Cecconi
- grid.452490.eDepartment of Anesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital – IRCCS, Humanitas University, via Alessandro Manzoni 56, 20089 Rozzano, Milan Italy ,grid.452490.eDepartment of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan Italy
| | - Chiara Robba
- Anaesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy ,grid.5606.50000 0001 2151 3065Department of Surgical Sciences and Integrated Sciences, University of Genoa, Genoa, Italy
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Maas AIR, Fitzgerald M, Gao G, Gupta D, Hutchinson P, Manley GT, Menon DK. Traumatic brain injury over the past 20 years: research and clinical progress. Lancet Neurol 2022; 21:768-770. [DOI: 10.1016/s1474-4422(22)00307-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 07/19/2022] [Indexed: 11/24/2022]
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Brain-Lung Crosstalk: Management of Concomitant Severe Acute Brain Injury and Acute Respiratory Distress Syndrome. Curr Treat Options Neurol 2022; 24:383-408. [PMID: 35965956 PMCID: PMC9363869 DOI: 10.1007/s11940-022-00726-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2022] [Indexed: 12/15/2022]
Abstract
Purpose of Review To summarize pathophysiology, key conflicts, and therapeutic approaches in managing concomitant severe acute brain injury (SABI) and acute respiratory distress syndrome (ARDS). Recent Findings ARDS is common in SABI and independently associated with worse outcomes in all SABI subtypes. Most landmark ARDS trials excluded patients with SABI, and evidence to guide decisions is limited in this population. Potential areas of conflict in the management of patients with both SABI and ARDS are (1) risk of intracranial pressure (ICP) elevation with high levels of positive end-expiratory pressure (PEEP), permissive hypercapnia due to lung protective ventilation (LPV), or prone ventilation; (2) balancing a conservative fluid management strategy with ensuring adequate cerebral perfusion, particularly in patients with symptomatic vasospasm or impaired cerebrovascular blood flow; and (3) uncertainty about the benefit and harm of corticosteroids in this population, with a mortality benefit in ARDS, increased mortality shown in TBI, and conflicting data in other SABI subtypes. Also, the widely adapted partial pressure of oxygen (PaO2) target of > 55 mmHg for ARDS may exacerbate secondary brain injury, and recent guidelines recommend higher goals of 80–120 mmHg in SABI. Distinct pathophysiology and trajectories among different SABI subtypes need to be considered. Summary The management of SABI with ARDS is highly complex, and conventional ARDS management strategies may result in increased ICP and decreased cerebral perfusion. A crucial aspect of concurrent management is to recognize the risk of secondary brain injury in the individual patient, monitor with vigilance, and adjust management during critical time windows. The care of these patients requires meticulous attention to oxygenation and ventilation, hemodynamics, temperature management, and the neurological exam. LPV and prone ventilation should be utilized, and supplemented with invasive ICP monitoring if there is concern for cerebral edema and increased ICP. PEEP titration should be deliberate, involving measures of hemodynamic, pulmonary, and brain physiology. Serial volume status assessments should be performed in SABI and ARDS, and fluid management should be individualized based on measures of brain perfusion, the neurological exam, and cardiopulmonary status. More research is needed to define risks and benefits in corticosteroids in this population.
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Perkins GD, Horner D, Naisbitt MJ. Which treatments are safe and effective to reduce intracranial pressure following severe traumatic brain injury? BMJ 2022; 378:e061960. [PMID: 35922076 DOI: 10.1136/bmj-2020-061960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Gavin D Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Warwick, UK
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Wichmann S, Itenov TS, Berthelsen RE, Lange T, Perner A, Gluud C, Lawson-Smith P, Nebrich L, Wiis J, Brøchner AC, Hildebrandt T, Behzadi MT, Strand K, Andersen FH, Strøm T, Järvisalo M, Damgaard KAJ, Vang ML, Wahlin RR, Sigurdsson MI, Thormar KM, Ostermann M, Keus F, Bestle MH. Goal directed fluid removal with furosemide versus placebo in intensive care patients with fluid overload: a trial protocol for a randomised, blinded trial (GODIF Trial). Acta Anaesthesiol Scand 2022; 66:1138-1145. [PMID: 35898170 PMCID: PMC9541596 DOI: 10.1111/aas.14121] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 07/03/2022] [Indexed: 11/28/2022]
Abstract
Background Fluid overload is a risk factor for mortality in intensive care unit (ICU) patients. Administration of loop diuretics is the predominant treatment of fluid overload, but evidence for its benefit is very uncertain when assessed in a systematic review of randomised clinical trials. The GODIF trial will assess the benefits and harms of goal directed fluid removal with furosemide versus placebo in ICU patients with fluid overload. Methods An investigator‐initiated, international, randomised, stratified, blinded, parallel‐group trial allocating 1000 adult ICU patients with fluid overload to infusion of furosemide versus placebo. The goal is to achieve a neutral fluid balance. The primary outcome is days alive and out of hospital 90 days after randomisation. Secondary outcomes are all‐cause mortality at day 90 and 1‐year after randomisation; days alive at day 90 without life support; number of participants with one or more serious adverse events or reactions; health‐related quality of life and cognitive function at 1‐year follow‐up. A sample size of 1000 participants is required to detect an improvement of 8% in days alive and out of hospital 90 days after randomisation with a power of 90% and a risk of type 1 error of 5%. The conclusion of the trial will be based on the point estimate and 95% confidence interval; dichotomisation will not be used. ClinicalTrials.gov identifier: NCT04180397. Perspective The GODIF trial will provide important evidence of possible benefits and harms of fluid removal with furosemide in adult ICU patients with fluid overload.
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Affiliation(s)
- Sine Wichmann
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Hilleroed, Denmark
| | - Theis S Itenov
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Hilleroed, Denmark
| | - Rasmus E Berthelsen
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Hilleroed, Denmark
| | - Theis Lange
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.,Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Pia Lawson-Smith
- Department of Intensive Care, Odense University Hospital, Odense, Denmark
| | - Lars Nebrich
- Department of Anaesthesia and Intensive Care, Zealand University Hospital, Koege, Denmark
| | - Jørgen Wiis
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Anne C Brøchner
- Department of Anaesthesia and Intensive Care, University Hospital of Southern Denmark, Kolding, Denmark
| | - Thomas Hildebrandt
- Department of Anaesthesia and Intensive Care, Zealand University Hospital, Roskilde, Denmark
| | - Meike T Behzadi
- Department of Intensive Care, Aalborg University Hospital, Aalborg, Denmark
| | - Kristian Strand
- Department of Intensive Care, Stavanger University Hospital, Stavanger, Norway
| | - Finn H Andersen
- Department of Intensive Care, Ålesund Hospital, Møre and Romsdal Health Trust, Ålesund, Norway.,Department of Circulation and Medical Imaging, Faculty of medicine and health science, Norwegian University of Science and Technology, Trondheim, Norway
| | - Thomas Strøm
- Department of Anaesthesia and Intensive Care, Sygehus Sønderjylland, Aabenraa, Denmark
| | - Mikko Järvisalo
- Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital, Turku, Finland
| | - Kjeld A J Damgaard
- Department of Anaesthesia and Intensive Care, Regionshospital Nordjylland, Hjørring, Denmark
| | - Marianne L Vang
- Department of Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Rebecka R Wahlin
- Department of Anaesthesia and Intensive Care, Södersjukhuset AB, Stockholm, Sweden
| | - Martin I Sigurdsson
- Department of Anaesthesia and Intensive Care, Landspitali, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Icelandi
| | - Katrin M Thormar
- Department of Anaesthesia and Intensive Care, Landspitali, Reykjavik, Iceland
| | - Marlies Ostermann
- Department of Intensive Care, King's College London, Guy's & St. Thomas' Foundation Trust, London, UK
| | - Frederik Keus
- Department of Critical Care, University Medical Centre Groningen, Groningen, The Netherlands
| | - Morten H Bestle
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Hilleroed, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Wichmann S, Barbateskovic M, Liang N, Itenov TS, Berthelsen RE, Lindschou J, Perner A, Gluud C, Bestle MH. Loop diuretics in adult intensive care patients with fluid overload: a systematic review of randomised clinical trials with meta-analysis and trial sequential analysis. Ann Intensive Care 2022; 12:52. [PMID: 35696008 PMCID: PMC9192894 DOI: 10.1186/s13613-022-01024-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 05/12/2022] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Fluid overload is a risk factor for organ dysfunction and death in intensive care unit (ICU) patients, but no guidelines exist for its management. We systematically reviewed benefits and harms of a single loop diuretic, the predominant treatment used for fluid overload in these patients. METHODS We conducted a systematic review with meta-analysis and Trial Sequential Analysis (TSA) of a single loop diuretic vs. other interventions reported in randomised clinical trials, adhering to our published protocol, the Cochrane Handbook, and PRISMA statement. We assessed the risks of bias with the ROB2-tool and certainty of evidence with GRADE. This study was registered in the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42020184799). RESULTS We included 10 trials (804 participants), all at overall high risk of bias. For loop diuretics vs. placebo/no intervention, we found no difference in all-cause mortality (relative risk (RR) 0.72, 95% confidence interval (CI) 0.49-1.06; 4 trials; 359 participants; I2 = 0%; TSA-adjusted CI 0.15-3.48; very low certainty of evidence). Fewer serious adverse events were registered in the group treated with loop diuretics (RR 0.81, 95% CI 0.66-0.99; 6 trials; 476 participants; I2 = 0%; very low certainty of evidence), though contested by TSA (TSA-adjusted CI 0.55-1.20). CONCLUSIONS The evidence is very uncertain about the effect of loop diuretics on mortality and serious adverse events in adult ICU patients with fluid overload. Loop diuretics may reduce the occurrence of these outcomes, but large randomised placebo-controlled trials at low risk of bias are needed.
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Affiliation(s)
- Sine Wichmann
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Dyrehavevej 29, 3400, Hillerød, Denmark.
| | - Marija Barbateskovic
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital-Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Ning Liang
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, 16 Nanxiaojie, Dongzhimen, Beijing, 100700, China
| | - Theis Skovsgaard Itenov
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Dyrehavevej 29, 3400, Hillerød, Denmark
| | - Rasmus Ehrenfried Berthelsen
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Dyrehavevej 29, 3400, Hillerød, Denmark
| | - Jane Lindschou
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital-Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital-Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Campusvej 55, 5230, Odense, Denmark
| | - Morten Heiberg Bestle
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Dyrehavevej 29, 3400, Hillerød, Denmark
- Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen, Denmark
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Management of moderate to severe traumatic brain injury: an update for the intensivist. Intensive Care Med 2022; 48:649-666. [PMID: 35595999 DOI: 10.1007/s00134-022-06702-4] [Citation(s) in RCA: 47] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 04/09/2022] [Indexed: 01/04/2023]
Abstract
Traumatic brain injury (TBI) remains one of the most fatal and debilitating conditions in the world. Current clinical management in severe TBI patients is mainly concerned with reducing secondary insults and optimizing the balance between substrate delivery and consumption. Over the past decades, multimodality monitoring has become more widely available, and clinical management protocols have been published that recommend potential interventions to correct pathophysiological derangements. Even while evidence from randomized clinical trials is still lacking for many of the recommended interventions, these protocols and algorithms can be useful to define a clear standard of therapy where novel interventions can be added or be compared to. Over the past decade, more attention has been paid to holistic management, in which hemodynamic, respiratory, inflammatory or coagulation disturbances are detected and treated accordingly. Considerable variability with regards to the trajectories of recovery exists. Even while most of the recovery occurs in the first months after TBI, substantial changes may still occur in a later phase. Neuroprognostication is challenging in these patients, where a risk of self-fulfilling prophecies is a matter of concern. The present article provides a comprehensive and practical review of the current best practice in clinical management and long-term outcomes of moderate to severe TBI in adult patients admitted to the intensive care unit.
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Shao E, Hasanaly N, Venkatraghavan L. Year in Review: Synopsis of Selected Articles in Neuroanesthesia and Neurocritical Care from 2021. JOURNAL OF NEUROANAESTHESIOLOGY AND CRITICAL CARE 2022. [DOI: 10.1055/s-0042-1744045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
AbstractThis review is a synopsis of selected articles from neuroscience, neuroanesthesia, and neurocritical care from 2021 (January–December 2021). The journals reviewed include anesthesia journals, critical care medicine journals, neurology, and neurosurgical journals as well as high-impact medical journals such as the Lancet, Journal of American Medical Association, New England Journal of Medicine, and Stroke. This summary of important articles will serve to update the knowledge of anesthesiologists and other perioperative physicians who provide care to neurosurgical and neurocritical care patients. In addition, some of the important narrative reviews that are of interest to neuroanesthesiologists are also listed.
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Affiliation(s)
- Evan Shao
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Nahemah Hasanaly
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Lashmi Venkatraghavan
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada
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Challenges in the hemodynamic management of acute nontraumatic neurological injuries. Curr Opin Crit Care 2022; 28:138-144. [PMID: 35102071 DOI: 10.1097/mcc.0000000000000925] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To appraise the evidence from the literature and suggest an integrated hemodynamic approach of early and delayed phases of acute ischemic stroke (AIS), subarachnoid hemorrhage (SAH) and intracerebral hemorrhage (ICH). RECENT FINDINGS In AIS, the research aims to evaluate the optimal pressure control before, during and after the revascularization, to optimize the perfusion in the ischemic areas, minimizing the risk of hemorrhage or secondary damage to already infarcted areas. In the early phase of SAH, systemic pressure should be controlled to balance the risk of stroke, hypertension-related rebleeding, and maintenance of cerebral perfusion pressure. The late phase aims to minimize the risk of cerebral vasospasm by adapting systemic pressure and volemia to cerebral and systemic physiological hemodynamic targets. In the mild-to-moderate ICH, achieving SAP of less than 140 mmHg and greater than 110 mmHg may be considered as a beneficial target. Caution should be considered in lowering intensively SAP in severe ICH. SUMMARY In nontraumatic brain injuries, the hemodynamic management is strictly related to fluctuating physiology of these diseases, needing a strict control of pressure and flow variable to ensure both cerebral and systemic homeostasis.
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Abstract
PURPOSE OF REVIEW The aim of this study was to provide an overview on advances in intracranial pressure (ICP) protocols for care, moving from traditional to more recent concepts. RECENT FINDINGS Deep understanding of mechanics and dynamics of fluids and solids have been introduced for intracranial physiology. The amplitude or the harmonics of the cerebral-spinal fluid and the cerebral blood waves shows more information about ICP than just a numeric threshold. When the ICP overcome the compensatory mechanisms that maintain the compliance within the skull, an intracranial compartment syndrome (ICCS) is defined. Autoregulation monitoring emerge as critical tool to recognize CPP management. Measurement of brain tissue oxygen will be a critical intervention for diagnosing an ICCS. Surgical procedures focused on increasing the physiological compliance and increasing the volume of the compartments of the skull. SUMMARY ICP management is a complex task, moving far than numeric thresholds for activation of interventions. The interactions of intracranial elements requires new interpretations moving beyond classical theories. Most of the traditional clinical studies supporting ICP management are not generating high class evidence. Recommendations for ICP management requires better designed clinical studies using new concepts to generate interventions according to the new era of personalized medicine.
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Robba C, van Dijk EJ, van der Jagt M. Acute ischaemic stroke and its challenges for the intensivist. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:258-268. [PMID: 35134852 DOI: 10.1093/ehjacc/zuac004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 01/12/2022] [Accepted: 01/13/2022] [Indexed: 06/14/2023]
Abstract
Acute ischaemic stroke (AIS) is responsible for almost 90% of all strokes and is one of the leading causes of death and disability. Acute ischaemic stroke is caused by a critical alteration in focal cerebral blood flow (ischaemia) from a variety of causes, resulting in infarction. The primary cerebral injury due to AIS occurs in the first hours, therefore early reperfusion importantly impacts on patient outcome ('Time is brain' concept). Secondary cerebral damage progressively evolves over the following hours and days due to cerebral oedema, haemorrhagic transformation, and cerebral inflammation. Systemic complications, such as pneumonia, sepsis, and deep venous thrombosis, could also affect outcome. The risk of a recurrent ischaemic stroke is in particular high in the first days, which necessitate particular attention. The role of intensive care unit physicians is therefore to avoid or reduce the risk of secondary damage, especially in the areas where the brain is functionally impaired and 'at risk' of further injury. Therapeutic strategies therefore consist of restoration of blood flow and a bundle of medical, endovascular, and surgical strategies, which-when applied in a timely and consistent manner-can prevent secondary deterioration due to cerebral and systemic complications and recurrent stroke and improve short- and long-term outcomes. A multidisciplinary collaboration between neurosurgeons, interventional radiologists, neurologists, and intensivists is necessary to elaborate the best strategy for the treatment of these patients.
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Affiliation(s)
- Chiara Robba
- Department of Anaesthesia and Intensive Care, Policlinico San Martino, IRCCS for Oncology and Neuroscience, Genova, Italy
- Dipartimento di Scienze Chirurgiche Diagnostiche Integrate, University of Genova, Genova, Italy
| | - Ewoud J van Dijk
- Department of Neurology, Donders Institute for Brain Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Mathieu van der Jagt
- Department of Intensive Care Adults, Erasmus MC-University Medical Center, Rotterdam, The Netherlands
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35
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Weinberg L, Lee DK, Bergin H, Koshy AN, Tully PA, Meyerov J, Louis M, Yang BO, Grover-Johnson O, Scurrah N, Cosic L, Story D, Bellomo R. MEasuring the impact of Anesthetist-administered medications volumeS on intraoperative flUid balance duRing prolonged abdominal surgEry (MEASURE Study). Minerva Anestesiol 2022; 88:334-342. [PMID: 35164486 DOI: 10.23736/s0375-9393.22.15918-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND The contribution of intraoperative anesthetist-administered medications (IAAMs) to the total volume of intraoperative intravenous (IV) fluid therapy and their association with postoperative outcomes has never been formally investigated. METHODS We performed a retrospective study of adult patients undergoing pancreaticoduodenectomy. The volume of IAAMs, crystalloids and colloids, blood and blood products, blood loss, urine output and intraoperative fluid balance were collected. The contribution of IAAMs to the total intraoperative IV fluid volume and postoperative complications was evaluated. RESULTS A total of 152 consecutive patients were included. The median volume of IAAMs was 363.8 mL (interquartile range [IQR], (241.0-492.5) delivered at a median rate of 0.61 mL kg hr-1 (0.40-0.87) over a median duration of surgery of 489 minutes (416.3-605.3). This increased the total administered fluid volume by 5.2% (95% confidence intervals [CI]: 4.6, 5.9%) (Cohen's d=1.33, P<0.001). The volume of IAAMs was comparable to the intraoperative colloid volume administered (median colloid volume, 400 mL). Overall, fluid volumes correlated significantly with the severity of complications (P=0.011), and the correlation strength increased when the IAAMs volume was included (P=0.005). On addition of IAAMs, the area under the receiver operator characteristic curve for prediction of postoperative complications increased from 0.580 (95%CI: 0.458, 0.701) to 0.603 (95%CI: 0.483, 0.723), P=0.041). CONCLUSIONS IAAMs significantly increased the total administered fluid volume during pancreaticoduodenectomy. Their inclusion increases the accuracy of postoperative complications predictions. These findings support their inclusion in fluid volumes and balances in future interventional studies.
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Affiliation(s)
- Laurence Weinberg
- Department of Anesthesia, Austin Health, Victoria, Australia - .,Department of Critical Care, University of Melbourne, Victoria, Australia - .,Department of Surgery, University of Melbourne, Austin Health, Victoria, Australia -
| | - Dong-Kyu Lee
- Department of Anesthesiology and Pain Medicine, Dongguk University Ilsan Hospital, Goyang, South Korea
| | - Hannah Bergin
- Department of Anesthesia, Austin Health, Victoria, Australia
| | - Anoop N Koshy
- Department of Cardiology, Austin Health, Victoria, Australia
| | - Patrick A Tully
- Department of Anesthesia, Austin Health, Victoria, Australia
| | - Joshua Meyerov
- Department of Anesthesia, Austin Health, Victoria, Australia
| | - Maleck Louis
- Department of Anesthesia, Austin Health, Victoria, Australia
| | - Bobby Ou Yang
- Department of Anesthesia, Austin Health, Victoria, Australia
| | | | | | - Luka Cosic
- Department of Anesthesia, Austin Health, Victoria, Australia
| | - David Story
- Department of Anesthesia, Austin Health, Victoria, Australia.,Department of Critical Care, University of Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Critical Care, University of Melbourne, Victoria, Australia.,Department of Intensive Care, Austin Health, Victoria, Australia
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36
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El-Swaify ST, Refaat MA, Ali SH, Abdelrazek AEM, Beshay PW, Kamel M, Bahaa B, Amir A, Basha AK. Controversies and evidence gaps in the early management of severe traumatic brain injury: back to the ABCs. Trauma Surg Acute Care Open 2022; 7:e000859. [PMID: 35071780 PMCID: PMC8734008 DOI: 10.1136/tsaco-2021-000859] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 12/10/2021] [Indexed: 11/04/2022] Open
Abstract
Traumatic brain injury (TBI) accounts for around 30% of all trauma-related deaths. Over the past 40 years, TBI has remained a major cause of mortality after trauma. The primary injury caused by the injurious mechanical force leads to irreversible damage to brain tissue. The potentially preventable secondary injury can be accentuated by addressing systemic insults. Early recognition and prompt intervention are integral to achieve better outcomes. Consequently, surgeons still need to be aware of the basic yet integral emergency management strategies for severe TBI (sTBI). In this narrative review, we outlined some of the controversies in the early care of sTBI that have not been settled by the publication of the Brain Trauma Foundation’s 4th edition guidelines in 2017. The topics covered included the following: mode of prehospital transport, maintaining airway patency while securing the cervical spine, achieving adequate ventilation, and optimizing circulatory physiology. We discuss fluid resuscitation and blood product transfusion as components of improving circulatory mechanics and oxygen delivery to injured brain tissue. An outline of evidence-based antiplatelet and anticoagulant reversal strategies is discussed in the review. In addition, the current evidence as well as the evidence gaps for using tranexamic acid in sTBI are briefly reviewed. A brief note on the controversial emergency surgical interventions for sTBI is included. Clinicians should be aware of the latest evidence for sTBI. Periods between different editions of guidelines can have an abundance of new literature that can influence patient care. The recent advances included in this review should be considered both for formulating future guidelines for the management of sTBI and for designing future clinical studies in domains with clinical equipoise.
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Affiliation(s)
| | - Mazen A Refaat
- Department of surgery, Ain Shams University Hospital, Cairo, Egypt
| | - Sara H Ali
- Department of surgery, Ain Shams University Hospital, Cairo, Egypt
| | | | | | - Menna Kamel
- Department of surgery, Ain Shams University Hospital, Cairo, Egypt
| | - Bassem Bahaa
- Department of surgery, Ain Shams University Hospital, Cairo, Egypt
| | - Abdelrahman Amir
- Department of surgery, Ain Shams University Hospital, Cairo, Egypt
| | - Ahmed Kamel Basha
- Department of neurosurgery, Ain Shams University Faculty of Medicine, Cairo, Egypt
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37
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Picetti E, Rosenstein I, Balogh ZJ, Catena F, Taccone FS, Fornaciari A, Votta D, Badenes R, Bilotta F. Perioperative Management of Polytrauma Patients with Severe Traumatic Brain Injury Undergoing Emergency Extracranial Surgery: A Narrative Review. J Clin Med 2021; 11:18. [PMID: 35011760 PMCID: PMC8745292 DOI: 10.3390/jcm11010018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 12/17/2021] [Accepted: 12/18/2021] [Indexed: 01/28/2023] Open
Abstract
Managing the acute phase after a severe traumatic brain injury (TBI) with polytrauma represents a challenging situation for every trauma team member. A worldwide variability in the management of these complex patients has been reported in recent studies. Moreover, limited evidence regarding this topic is available, mainly due to the lack of well-designed studies. Anesthesiologists, as trauma team members, should be familiar with all the issues related to the management of these patients. In this narrative review, we summarize the available evidence in this setting, focusing on perioperative brain protection, cardiorespiratory optimization, and preservation of the coagulative function. An overview on simultaneous multisystem surgery (SMS) is also presented.
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Affiliation(s)
- Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, 43100 Parma, Italy; (E.P.); (A.F.)
| | - Israel Rosenstein
- Department of Anesthesiology and Critical Care, Policlinico Umberto I Hospital, La Sapienza University of Rome, 00161 Rome, Italy; (I.R.); (D.V.); (F.B.)
| | - Zsolt J. Balogh
- Department of Traumatology, John Hunter Hospital, University of Newcastle, Newcastle 2305, Australia;
| | - Fausto Catena
- Department of General and Emergency Surgery, Bufalini Hospital, 47521 Cesena, Italy;
| | - Fabio S. Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, 1070 Brussels, Belgium;
| | - Anna Fornaciari
- Department of Anesthesia and Intensive Care, Parma University Hospital, 43100 Parma, Italy; (E.P.); (A.F.)
| | - Danilo Votta
- Department of Anesthesiology and Critical Care, Policlinico Umberto I Hospital, La Sapienza University of Rome, 00161 Rome, Italy; (I.R.); (D.V.); (F.B.)
| | - Rafael Badenes
- Department of Anesthesiology and Intensive Care, Hospital Clìnico Universitario de Valencia, University of Valencia, 46010 Valencia, Spain
| | - Federico Bilotta
- Department of Anesthesiology and Critical Care, Policlinico Umberto I Hospital, La Sapienza University of Rome, 00161 Rome, Italy; (I.R.); (D.V.); (F.B.)
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38
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Kochanek PM, Jha RM. Fluid therapy after brain injury: the pendulum swings again. Lancet Neurol 2021; 20:587-589. [PMID: 34302775 DOI: 10.1016/s1474-4422(21)00204-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 06/14/2021] [Indexed: 11/16/2022]
Affiliation(s)
- Patrick M Kochanek
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Safar Center for Resuscitation Research, Rangos Research Center, Pittsburgh, PA, USA.
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