Parenteral diclofenac infusion significantly decreases brain-tissue oxygen tension in patients with poor-grade aneurysmal subarachnoid hemorrhage

Temperature Changes in Poor-Grade Aneurysmal Subarachnoid Hemorrhage: Relation to Injury Pattern, Intracranial Pressure Dynamics, Cerebral Energy Metabolism, and Clinical Outcome

BACKGROUND

The aim was to study the course of body temperature in the acute phase of poor-grade aneurysmal subarachnoid hemorrhage (aSAH) in relation to the primary brain injury, cerebral physiology, and clinical outcome.

METHODS

In this observational study, 166 patients with aSAH treated at the neurosurgery department at Uppsala University Hospital in Sweden between 2008 and2018 with temperature, intracranial pressure (ICP), and microdialysis (MD) monitoring were included. The first 10 days were divided into the early phase (days 1-3) and the vasospasm phase (days 4-10).

RESULTS

Normothermia (temperature = 36-38 °C) was most prevalent in the early phase. A lower mean temperature at this stage was univariately associated with a worse primary brain injury, with higher Fisher grade and higher MD glycerol concentration, as well as a worse neurological recovery at 1 year. There was otherwise no association between temperature and cerebral physiological variables in the early phase. There was a transition toward an increased burden of hyperthermia (temperature > 38 °C) in the vasospasm phase. This was associated with concurrent infections but not with neurological or radiological injury severity at admission. Elevated temperature was associated with higher MD pyruvate concentration, lower rate of an MD pattern indicative of ischemia, and higher rate of poor neurological recovery at 1 year. There was otherwise no association between temperature and cerebral physiological variables in the vasospasm phase. The associations between temperature and clinical outcome did not hold true in multiple logistic regression analyses.

CONCLUSIONS

Spontaneously low temperature in the early phase reflected a worse primary brain injury and indicated a worse outcome prognosis. Hyperthermia was common in the vasospasm phase and was more related to infections than primary injury severity but also with a more favorable energy metabolic pattern with better substrate supply, possibly related to hyperemia.

Diclofenac Sodium for Fever Control in Neurocritical Care: A Systematic Review

BACKGROUND

Fever is extremely common in neurocritical care patients and is independently associated with a worse outcome. Non-steroidal anti-inflammatory drugs (NSAIDs) lower the hypothalamic set point temperature through the inhibition of prostaglandin E2 synthesis, and they constitute a second line of pharmacological treatment for temperature control. This systematic review aims to evaluate the effectiveness of DCF in reducing body temperature and its effects on brain parameters.

METHODS

A comprehensive search of several databases was run in November 2022 in Ovid EBM (Evidence Based Medicine) Reviews, Cochrane library, Ovid Medline and Scopus (1980 onward). The outcome of interest included DCF control of body temperature and its impact on cerebral parameters.

RESULTS

A total of 113 titles were identified as potentially relevant. Six articles met eligible criteria and were reviewed. DCF induce a reduction in body temperature (MD, 1.10 [0.72, 1.49], p < 0.00001), a slight decrease in ICP (MD, 2.22 [-0.25, 4.68] IC 95%; p < 0.08) as well as in CPP and MAP (MD, 5.58 [0.43, 10.74] IC 95%; p < 0.03). The significant heterogeneity and possibility of publication bias reduces the strength of the available evidence.

CONCLUSIONS

Diclofenac sodium is effective in reducing body temperature in patients with brain injury, but data in the literature are scarce and further studies are needed to evaluate the benefits of DCF.

Fine tuning of neurointensive care in aneurysmal subarachnoid hemorrhage: From one-size-fits-all towards individualized care

Aneurysmal subarachnoid hemorrhage (aSAH) is a severe type of acute brain injury with high mortality and burden of neurological sequelae. General management aims at early aneurysm occlusion to prevent re-bleeding, cerebrospinal fluid drainage in case of increased intracranial pressure and/or acute hydrocephalus, and cerebral blood flow augmentation in case of delayed ischemic neurological deficits. In addition, the brain is vulnerable to physiological insults in the acute phase and neurointensive care (NIC) is important to optimize the cerebral physiology to avoid secondary brain injury. NIC has led to significantly better neurological recovery following aSAH, but there is still great room for further improvements. First, current aSAH NIC management protocols are to some extent extrapolated from those in traumatic brain injury, notwithstanding important disease-specific differences. Second, the same NIC management protocols are applied to all aSAH patients, despite great patient heterogeneity. Third, the main variables of interest, intracranial pressure and cerebral perfusion pressure, may be too superficial to fully detect and treat several important pathomechanisms. Fourth, there is a lack of understanding not only regarding physiological, but also cellular and molecular pathomechanisms and there is a need to better monitor and treat these processes. This narrative review aims to discuss current state-of-the-art NIC of aSAH, knowledge gaps in the field, and future directions towards a more individualized care in the future.

Non-steroidal anti-inflammatory drugs in the pathophysiology of vasospasms and delayed cerebral ischemia following subarachnoid hemorrhage: a critical review

Aneurysmal subarachnoid hemorrhage (aSAH) is a life-threatening condition associated with the development of early brain injury (EBI) and delayed cerebral ischemia (DCI). Pharmacological treatment of vasospasm following aSAH currently mainly comprises nimodipine administration. In the past few years, many drugs that can potentially benefit cases of subarachnoid hemorrhage have become available. The objective of this review is to critically assess the effects of non-steroidal anti-inflammatory drugs (NSAIDs) following aSAH. A systematic literature review was conducted following PRISMA guidelines. The search was aimed at studies addressing aSAH and NSAIDs during the 2010 to 2019 period, and it yielded 13 articles. Following the application of search criteria, they were divided into two groups, one containing 6 clinical articles and the other containing 7 experimental articles on animal models of aSAH. Inflammatory cerebral changes after aneurysm rupture contribute to the development of EBI, DCI and cerebral vasospasm. It appears that NSAIDs (especially coxibs) are even more effective in reducing vasospasm than nimodipine. Other beneficial effects of NSAIDs include reduction in mortality, improved functional outcome and increased hypoaggregability. However, despite these positive effects, there is only one randomized, double-blind, placebo-controlled trial showing a tendency towards a better outcome with lower incidence of vasospasm or mortality in patients following aSAH.

Continuous intravenous low-dose diclofenac sodium to control a central fever after ischemic stroke in the intensive care unit: a case report and review of the literature

Introduction

Elevation in body temperature within the first 24 hours of ischemic stroke is fairly common and known to be associated with worse outcomes. Only after thoroughly ruling out infection and the noninfectious etiologies and in the appropriate clinical setting should the diagnosis of central fever be made. Acetaminophen and nonsteroidal anti-inflammatory drugs are typical therapeutic options. External cooling is frequently used when pharmacologic interventions are inadequate. However, reports have suggested that neurogenic fevers are somewhat resistant to traditional pharmacologic therapies.

Case presentation

We describe a case of a Caucasian patient with central fever after ischemic stroke not responsive to acetaminophen administration and external cooling. After an initial bolus of diclofenac sodium (0.2 mg/kg in 100 ml of saline solution for 30 minutes), a continuous infusion (75 mg in 50 ml of saline solution) was started. After 5 days of treatment, the patient’s body temperature was below 37.5 °C, and the diclofenac sodium infusion was stopped.

Conclusions

We observed that a low-dose diclofenac sodium infusion was effective in treating fever without systemic side effects. This treatment may be suggested as an alternative to conventional antipyretic drugs, but additional clinical trials are required.

How to manage fever in brain-injured patients

Fever represents a frequent and dangerous secondary insult for the injured brain and is often associated with worsened neurological outcomes. The identification of fever in the Neuro-Intensive Care Unit requires careful monitoring and rapid and effective treatment. The main objective of this article was to provide practical information regarding temperature monitoring, triggers for intervention and fever management in brain injured patients.

Safety, Feasibility, and Efficiency of a New Cooling Device Using Intravenous Cold Infusions for Fever Control

BACKGROUND

Fever control plays a key role in therapy of patients with acute brain injury. The infusion of cold saline could serve as an alternative or additional method for targeted temperature management. However, it is difficult to estimate the amount of fluid required to achieve normothermia merely on the basis of body weight. There is no standardized load management regarding the administration of cold saline, and no closed-loop systems based on continuous temperature-controlled feedback are available. The primary purpose of the present study was to evaluate the feasibility, efficacy, and safety of a new automated fluid infusion system.

METHODS

Twelve patients with acute brain injury and febrile episodes were treated with the automated infusion device tempedy (seiratherm GmbH, Herzogenaurach, Germany). Patients were included if bladder temperature still was ≥ 37.9 °C after administration of antipyretic medication, cold washing solutions, and ice packs more than 2 h earlier. The efficacy was examined by measuring the time and amount of fluid needed to reach and maintain target temperature. Feasibility and safety were assessed based on recording any technical difficulties with the new device and the occurrence of clinical signs of fluid overload such as acute pulmonary edema, electrolyte disturbances, or acid-base dysfunction.

RESULTS

The mean time was 73 min (range from 15 to 330 min) and 1650 ml the mean amount of fluid (21.2 ml/kg; SD 28.5 ml/kg) to reach the target temperature. The mean total fluid balance to reach and maintain the target temperature in the first 12 h was 1350 ml (SD 1550 ml). In the first 12 h 89.4% of the time temperature values were in the target range (median 95.3%, range 83.8-10%). No clinical signs of fluid overload such as an acute pulmonary edema or device-related adverse events occurred.

CONCLUSION

Target temperature management with the new automated infusion device is feasible. Although we provided first data regarding safety, further controlled randomized studies are needed to evaluate the long-time safety, as well as the best indications and timing for this cooling device.

Brain Extracellular Interleukin-6 Levels Decrease Following Antipyretic Therapy with Diclofenac in Patients with Spontaneous Subarachnoid Hemorrhage

In patients with aneurysmal subarachnoid hemorrhage (aSAH), increased brain extracellular interleukin (IL)-6 levels measured by cerebral microdialysis (CMD) were associated with disease severity, early brain injury, delayed cerebral infarction, and axonal injury. In this study, we analyzed brain extracellular IL-6 levels of aSAH patients following parenteral diclofenac. Twenty-four mechanically ventilated poor-grade aSAH patients were included. Changes in cerebral metabolism, brain/body temperature, and CMD-IL-6 levels following intravenous diclofenac infusion (DCF; 75 mg diluted in 100 cc normal saline) were retrospectively analyzed from prospectively collected bedside data (at 1 hour before DCF = baseline; and at 2, 4, and 8 hours after DCF). Statistical analysis was performed using generalized estimating equations. Seventy-two events in 24 aSAH patients were analyzed. Median age was 60 years (interquartile range [IQR]: 52-67), admission Hunt & Hess grade was 4 (IQR: 3-5), and modified Fisher grade (mFisher) was 4 (IQR: 3-4). Higher CMD-IL-6 levels at baseline were linked to fever, higher mFisher, delayed cerebral infarction, and metabolic distress (p < 0.05). CMD-IL-6 levels at baseline were 281.4 pg/mL (IQR: 47-1866) and significantly (p < 0.001; Wald-X² = 106) decreased at 2 hours to 86.3 pg/mL (IQR: 7-1946), at 4 hours to 40.9 pg/mL (IQR: 4-1237), and at 8 hours to 53.5 pg/mL (IQR: 5-1085), independent of probe location or day after bleeding. Parenteral diclofenac may attenuate brain extracellular proinflammatory response in poor-grade aSAH patients.

The course of intracranial pressure after antipyretic therapy in acute brain injury

BACKGROUND

The present study was performed to evaluate intracranial pressure (ICP) variations after antipyretic therapy and their relationship to ICP at baseline (ICPbas) in acute brain injury (ABI) patients.

METHODS

We completed a retrospective analysis on data derived from 2 previously published prospective observational studies. The first study involved 32 ABI patients and was performed to elucidate the cerebral and hemodynamic effects of intravenous (IV) paracetamol. The second study involved 30 ABI patients and was performed to investigate cerebral and hemodynamic effects of intramuscular IM diclofenac sodium (DCF). Overall patient population was divided into 2 groups: 1) Group A (G-A) when ICPbas was ≤ 15 mmHg and 2) Group B (G-B) when ICPbas was > 15 mmHg. The main objective was to evaluate if ICPbas affects the time course of ICP after antipyretics administration.

RESULTS

Data from 62 ABI patients were analyzed. We failed to observe a significant change in ICP after antipyretic treatment in the overall group of patients (P1 = 0.486). A significant difference, however, was found between the two groups (P2 < 0.001). We observed that in the G-A, ICP increased in response to antipyretic administration, whereas in the G-B, ICP decreased. These opposite responses are reflected in the statistically significant interaction (P3 < 0.001).

CONCLUSIONS

Variation in ICP after antipyretic therapy is influenced by ICPbas. Specifically, patients with ICPbas ≤ 15 mmHg showed a significant increase in ICP after antipyretic therapy, while a significant reduction in ICP was observed in patients with ICPbas > 15 mmHg.

Clinical Use of Cerebral Microdialysis in Patients with Aneurysmal Subarachnoid Hemorrhage-State of the Art

Objective

To review the published literature on the clinical application of cerebral microdialysis (CMD) in aneurysmal subarachnoid hemorrhage (SAH) patients and to summarize the evidence relating cerebral metabolism to pathophysiology, secondary brain injury, and outcome.

Methods

Study selection: Two reviewers identified all manuscripts reporting on the clinical use of CMD in aneurysmal SAH patients from MEDLINE. All identified studies were grouped according to their focus on brain metabolic changes during the early and subacute phase after SAH, their association with mechanisms of secondary brain injury and outcome.

Results

The review demonstrated: (1) limited literature is available in the very early phase before the aneurysm is secured. (2) Brain metabolic changes related to early and delayed secondary injury mechanisms may be used in addition to other neuromonitoring parameters in the critical care management of SAH patients. (3) CMD markers of ischemia may detect delayed cerebral ischemia early (up to 16 h before onset), underlining the importance of trend analysis. (4) Various CMD-derived parameters may be associated with patient outcome at 3–12 months, including CMD-lactate-to-pyruvate-ratio, CMD-glucose, and CMD-glutamate.

Conclusion

The clinical use of CMD is an emerging area in the literature of aneurysmal SAH patients. Larger prospective multi-center studies on interventions based on CMD findings are needed.

Evaluating the Role of Reduced Oxygen Saturation and Vascular Damage in Traumatic Brain Injury Using Magnetic Resonance Perfusion-Weighted Imaging and Susceptibility-Weighted Imaging and Mapping

The cerebral vasculature, along with neurons and axons, is vulnerable to biomechanical insult during traumatic brain injury (TBI). Trauma-induced vascular injury is still an underinvestigated area in TBI research. Cerebral blood flow and metabolism could be important future treatment targets in neural critical care. Magnetic resonance imaging offers a number of key methods to probe vascular injury and its relationship with traumatic hemorrhage, perfusion deficits, venous blood oxygen saturation changes, and resultant tissue damage. They make it possible to image the hemodynamics of the brain, monitor regional damage, and potentially show changes induced in the brain's function not only acutely but also longitudinally following treatment. These methods have recently been used to show that even mild TBI (mTBI) subjects can have vascular abnormalities, and thus they provide a major step forward in better diagnosing mTBI patients.

Precision medicine of aneurysmal subarachnoid hemorrhage, vasospasm and delayed cerebral ischemia

INTRODUCTION

Precision medicine provides individualized treatment of diseases through leveraging patient-to-patient variation. Aneurysmal subarachnoid hemorrhage carries tremendous morbidity and mortality with cerebral vasospasm and delayed cerebral ischemia proving devastating and unpredictable. Lack of treatment measures for these conditions could be improved through precision medicine. Areas covered: Discussed are the pathophysiology of CV and DCI, treatment guidelines, and evidence for precision medicine used for prediction and prevention of poor outcomes following aSAH. A PubMed search was performed using keywords cerebral vasospasm or delayed cerebral ischemia and either biomarkers, precision medicine, metabolomics, proteomics, or genomics. Over 200 peer-reviewed articles were evaluated. The studies presented cover biomarkers identified as predictive markers or therapeutic targets following aSAH. Expert commentary: The biomarkers reviewed here correlate with CV, DCI, and neurologic outcomes after aSAH. Though practical use in clinical management of aSAH is not well established, using these biomarkers as predictive tools or therapeutic targets demonstrates the potential of precision medicine.

Effect of propofol and remifentanil on cerebral perfusion and oxygenation in pigs: a systematic review

The objective of this review is to evaluate the existing literature with regard to the influence of propofol and remifentanil total intravenous anaesthesia (TIVA) on cerebral perfusion and oxygenation in healthy pigs. Anaesthesia has influence on cerebral haemodynamics and it is important not only in human but also in veterinary anaesthesia to preserve optimal regulation of cerebral haemodynamics. Propofol and remifentanil are widely used in neuroanaesthesia and are increasingly used in experimental animal studies. In translational models, the pig has advantages compared to small laboratory animals because of brain anatomy, metabolism, neurophysiological maturation, and cerebral haemodynamics. However, reported effects of propofol and remifentanil on cerebral perfusion and oxygenation in pigs have not been reviewed. An electronic search identified 99 articles in English. Title and abstract screening selected 29 articles for full-text evaluation of which 19 were excluded with reasons. Of the 10 peer-reviewed articles included for review, only three had propofol or remifentanil anaesthesia as the primary study objective and only two directly investigated the effect of anaesthesia on cerebral perfusion and oxygenation (CPO). The evidence evaluated in this systematic review is limited, not focused on propofol and remifentanil and possibly influenced by factors of potential importance for CPO assessment. In one study of healthy pigs, CPO measures were within normal ranges following propofol-remifentanil anaesthesia, and addition of a single remifentanil bolus did not affect regional cerebral oxygen saturation (rSO2). Even though the pool of evidence suggests that propofol and remifentanil alone or in combination have limited effects on CPO in healthy pigs, confirmative evidence is lacking.

SPIRIT: Systematic Planning of Intelligent Reuse of Integrated Clinical Routine Data. A Conceptual Best-practice Framework and Procedure Model

BACKGROUND

Secondary use of clinical routine data is receiving an increasing amount of attention in biomedicine and healthcare. However, building and analysing integrated clinical routine data repositories are nontrivial, challenging tasks. As in most evolving fields, recognized standards, well-proven methodological frameworks, or accurately described best-practice approaches for the systematic planning of solutions for secondary use of routine medical record data are missing.

OBJECTIVE

We propose a conceptual best-practice framework and procedure model for the systematic planning of intelligent reuse of integrated clinical routine data (SPIRIT).

METHODS

SPIRIT was developed based on a broad literature overview and further refined in two case studies with different kinds of clinical routine data, including process-oriented nursing data from a large hospital group and high-volume multimodal clinical data from a neurologic intensive care unit.

RESULTS

SPIRIT aims at tailoring secondary use solutions to specific needs of single departments without losing sight of the institution as a whole. It provides a general conceptual best-practice framework consisting of three parts: First, a secondary use strategy for the whole organization is determined. Second, comprehensive analyses are conducted from two different viewpoints to define the requirements regarding a clinical routine data reuse solution at the system level from the data perspective (BOTTOM UP) and at the strategic level from the future users perspective (TOP DOWN). An obligatory clinical context analysis (IN BETWEEN) facilitates refinement, combination, and integration of the different requirements. The third part of SPIRIT is dedicated to implementation, which comprises design and realization of clinical data integration and management as well as data analysis solutions.

CONCLUSIONS

The SPIRIT framework is intended to be used to systematically plan the intelligent reuse of clinical routine data for multiple purposes, which often was not intended when the primary clinical documentation systems were implemented. SPIRIT helps to overcome this gap. It can be applied in healthcare institutions of any size or specialization and allows a stepwise setup and evolution of holistic clinical routine data reuse solutions.

Monitoring of brain and systemic oxygenation in neurocritical care patients

Maintenance of adequate oxygenation is a mainstay of intensive care, however, recommendations on the safety, accuracy, and the potential clinical utility of invasive and non-invasive tools to monitor brain and systemic oxygenation in neurocritical care are lacking. A literature search was conducted for English language articles describing bedside brain and systemic oxygen monitoring in neurocritical care patients from 1980 to August 2013. Imaging techniques e.g., PET are not considered. A total of 281 studies were included, the majority described patients with traumatic brain injury (TBI). All tools for oxygen monitoring are safe. Parenchymal brain oxygen (PbtO2) monitoring is accurate to detect brain hypoxia, and it is recommended to titrate individual targets of cerebral perfusion pressure (CPP), ventilator parameters (PaCO2, PaO2), and transfusion, and to manage intracranial hypertension, in combination with ICP monitoring. SjvO2 is less accurate than PbtO2. Given limited data, NIRS is not recommended at present for adult patients who require neurocritical care. Systemic monitoring of oxygen (PaO2, SaO2, SpO2) and CO2 (PaCO2, end-tidal CO2) is recommended in patients who require neurocritical care.

Tissue oxygen tension monitoring of organ perfusion: rationale, methodologies, and literature review

Tissue oxygen tension is the partial pressure of oxygen within the interstitial space of an organ bed. As it represents the balance between local oxygen delivery and consumption at any given time, it offers a ready monitoring capability to assess the adequacy of tissue perfusion relative to local demands. This review covers the various methodologies used to measure tissue oxygen tension, describes the underlying physiological and pathophysiological principles, and summarizes human and laboratory data published to date.

Major publications in the critical care pharmacotherapy literature: January-December 2013

PURPOSE

Ten recently published articles with important implications for critical care pharmacotherapy are summarized.

SUMMARY

The Critical Care Pharmacotherapy Literature Update (CCPLU) group is a national assembly of experienced intensive care unit (ICU) pharmacists across the United States. Group members monitor 25 peer-reviewed journals on an ongoing basis to identify literature relevant to pharmacy practice in the critical care setting. After evaluation by CCPLU group members, selected articles are chosen for summarization and distribution to group members nationwide based on (1) applicability to critical care practice, (2) relevance to pharmacy practitioners, and (3) quality of evidence or research methodology. Hundreds of relevant articles were evaluated by the group during the period January-December 2013, of which 98 were summarized and disseminated nationally to CCPLU group members. Among those 98 publications, 10 deemed to be of particularly high utility to critical care practitioners were included in this review. The 10 articles address topics such as rapid lowering of blood pressure in patients with intracranial hemorrhage, adjunctive therapy to prevent renal injury due to acute heart failure, triple-drug therapy to improve neurologic outcomes after cardiac arrest, and continuous versus intermittent infusion of β-lactam antibiotics in severe sepsis.

CONCLUSION

There were many important additions to the critical care pharmacotherapy literature in 2013, including an updated guideline on the management of myocardial infarction and reports on advances in research focused on improving outcomes in patients with stroke or cardiac arrest and preventing the spread of drug-resistant pathogens in the ICU.

Early brain injury after aneurysmal subarachnoid hemorrhage: a multimodal neuromonitoring study

Introduction

There is a substantial amount of evidence from animal models that early brain injury (EBI) may play an important role for secondary brain injury after aneurysmal subarachnoid hemorrhage (aSAH). Cerebral microdialysis (CMD) allows online measurement of brain metabolites, including the pro-inflammatory cytokine interleukin-6 (IL-6) and matrix metalloproteinase-9 (MMP-9), which is indicative for disruption of the blood-brain barrier.

Methods

Twenty-six consecutive poor-grade aSAH patients with multimodal neuromonitoring were analyzed for brain hemodynamic and metabolic changes, including CMD-IL-6 and CMD-MMP-9 levels. Statistical analysis was performed by using a generalized estimating equation with an autoregressive function.

Results

The baseline cerebral metabolic profile revealed brain metabolic distress and an excitatory response which improved over the following 5 days (P <0.001). Brain tissue hypoxia (brain tissue oxygen tension of less than 20 mm Hg) was common (more than 60% of patients) in the first 24 hours of neuromonitoring and improved thereafter (P <0.05). Baseline CMD-IL-6 and CMD-MMP-9 levels were elevated in all patients (median = 4,059 pg/mL, interquartile range (IQR) = 1,316 to 12,456 pg/mL and median = 851 pg/mL, IQR = 98 to 25,860 pg/mL) and significantly decreased over days (P <0.05). A higher pro-inflammatory response was associated with the development of delayed cerebral ischemia (P = 0.04), whereas admission disease severity and early brain tissue hypoxia were associated with higher CMD-MMP-9 levels (P <0.03). Brain metabolic distress and increased IL-6 levels were associated with poor functional outcome (modified Rankin Scale of more than 3, P ≤0.01). All models were adjusted for probe location, aneurysm securing procedure, and disease severity as appropriate.

Conclusions

Multimodal neuromonitoring techniques allow insight into pathophysiologic changes in the early phase after aSAH. The results may be used as endpoints for future interventions targeting EBI in poor-grade aSAH patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Take care when taking care of fever after aneurysmal subarachnoid hemorrhage

Fever is prevalent in the majority of patients after aneurysmal subarachnoid hemorrhage and is associated with worse outcome. Treatment of fever is highly recommended, but with low-grade evidence in current guidelines. The analysis by Schiefecker and colleagues reveals that the situation may be more complicated than at first glance and careless treatment may introduce further harm. The importance of this study lies in analyzing real-world multimodal neuromonitoring data, showing a pitfall in incautiously applied treatment paradigms.