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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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Labib H, Tjerkstra MA, Coert BA, Post R, Vandertop WP, Verbaan D, Müller MCA. Sodium and Its Impact on Outcome After Aneurysmal Subarachnoid Hemorrhage in Patients With and Without Delayed Cerebral Ischemia. Crit Care Med 2024; 52:752-763. [PMID: 38206089 PMCID: PMC11008454 DOI: 10.1097/ccm.0000000000006182] [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: 01/12/2024]
Abstract
OBJECTIVES To perform a detailed examination of sodium levels, hyponatremia and sodium fluctuations, and their association with delayed cerebral ischemia (DCI) and poor outcome after aneurysmal subarachnoid hemorrhage (aSAH). DESIGN An observational cohort study from a prospective SAH Registry. SETTING Tertiary referral center focused on SAH treatment in the Amsterdam metropolitan area. PATIENTS A total of 964 adult patients with confirmed aSAH were included between 2011 and 2021. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 277 (29%) developed DCI. Hyponatremia occurred significantly more often in DCI patients compared with no-DCI patients (77% vs. 48%). Sodium levels, hyponatremia, hypernatremia, and sodium fluctuations did not predict DCI. However, higher sodium levels were significantly associated with poor outcome in DCI patients (DCI onset -7, DCI +0, +1, +2, +4, +5, +8, +9 d), and in no-DCI patients (postbleed day 6-10 and 12-14). Also, hypernatremia and greater sodium fluctuations were significantly associated with poor outcome in both DCI and no-DCI patients. CONCLUSIONS Sodium levels, hyponatremia, and sodium fluctuations were not associated with the occurrence of DCI. However, higher sodium levels, hypernatremia, and greater sodium fluctuations were associated with poor outcome after aSAH irrespective of the presence of DCI. Therefore, sodium levels, even with mild changes in levels, warrant close attention.
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Affiliation(s)
- Homeyra Labib
- Department of Neurosurgery, Amsterdam UMC location University of Amsterdam, Neurosurgery, Amsterdam, The Netherlands
- Amsterdam Neurosciences, Neurovascular Disorders, Amsterdam, The Netherlands
| | - Maud A Tjerkstra
- Department of Neurosurgery, Amsterdam UMC location University of Amsterdam, Neurosurgery, Amsterdam, The Netherlands
- Amsterdam Neurosciences, Neurovascular Disorders, Amsterdam, The Netherlands
| | - Bert A Coert
- Department of Neurosurgery, Amsterdam UMC location University of Amsterdam, Neurosurgery, Amsterdam, The Netherlands
- Amsterdam Neurosciences, Neurovascular Disorders, Amsterdam, The Netherlands
| | - René Post
- Department of Neurosurgery, Amsterdam UMC location University of Amsterdam, Neurosurgery, Amsterdam, The Netherlands
- Amsterdam Neurosciences, Neurovascular Disorders, Amsterdam, The Netherlands
| | - W Peter Vandertop
- Department of Neurosurgery, Amsterdam UMC location University of Amsterdam, Neurosurgery, Amsterdam, The Netherlands
- Amsterdam Neurosciences, Neurovascular Disorders, Amsterdam, The Netherlands
| | - Dagmar Verbaan
- Department of Neurosurgery, Amsterdam UMC location University of Amsterdam, Neurosurgery, Amsterdam, The Netherlands
- Amsterdam Neurosciences, Neurovascular Disorders, Amsterdam, The Netherlands
| | - Marcella C A Müller
- Department of Intensive Care, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
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Figueiredo R, Castro C, Fernandes JB. Nursing Interventions to Prevent Secondary Injury in Critically Ill Patients with Traumatic Brain Injury: A Scoping Review. J Clin Med 2024; 13:2396. [PMID: 38673667 PMCID: PMC11051360 DOI: 10.3390/jcm13082396] [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: 03/22/2024] [Revised: 04/09/2024] [Accepted: 04/18/2024] [Indexed: 04/28/2024] Open
Abstract
Background: Traumatic brain injury is a prevalent health issue with significant social and economic impacts. Nursing interventions are crucial in preventing secondary injury and improving patient prognosis. This scoping seeks to map and analyze the existing scientific evidence on nursing interventions aimed at preventing secondary injuries in critically ill patients with traumatic brain injury. Methods: The review was conducted according to Arksey and O'Malley's methodological framework. The electronic databases Pubmed, MEDLINE Complete, CINAHL Complete, Nursing & Allied Health Collection: Comprehensive, Cochrane Central Register of Controlled Trials, and Cochrane Clinical Answers were consulted in May 2023. We included articles published in English and Portuguese between 2010 and 2023. Results: From the initial search, 277 articles were identified, with 15 meeting the inclusion criteria for the review. Nursing interventions for TBI patients include neuromonitoring, therapeutics, analytical surveillance, professional training, and family support. Nurses play a crucial role in detecting neurological changes, administering treatments, monitoring metabolic markers, training staff, and involving families. These interventions aim to prevent secondary injury and improve patient outcomes. Conclusions: By prioritizing evidence-based practice and utilizing innovative technologies, nurses enhance TBI patient care and contribute to overall well-being.
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Affiliation(s)
- Rita Figueiredo
- Department of Nursing, Almada-Seixal Local Health Unit, 2805-267 Almada, Portugal;
- Nurs * Lab, Caparica, 2829-511 Almada, Portugal;
- Egas Moniz Center for Interdisciplinary Research (CiiEM), Egas Moniz School of Health & Science, Caparica, 2829-511 Almada, Portugal
| | - Cidália Castro
- Nurs * Lab, Caparica, 2829-511 Almada, Portugal;
- Egas Moniz Center for Interdisciplinary Research (CiiEM), Egas Moniz School of Health & Science, Caparica, 2829-511 Almada, Portugal
| | - Júlio Belo Fernandes
- Nurs * Lab, Caparica, 2829-511 Almada, Portugal;
- Egas Moniz Center for Interdisciplinary Research (CiiEM), Egas Moniz School of Health & Science, Caparica, 2829-511 Almada, Portugal
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Zavriyev AI, Kaya K, Wu KC, Pierce ET, Franceschini MA, Robinson MB. Measuring pulsatile cortical blood flow and volume during carotid endarterectomy. BIOMEDICAL OPTICS EXPRESS 2024; 15:1355-1369. [PMID: 38495722 PMCID: PMC10942688 DOI: 10.1364/boe.507730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/01/2023] [Accepted: 12/02/2023] [Indexed: 03/19/2024]
Abstract
Carotid endarterectomy (CEA) involves removal of plaque in the carotid artery to reduce the risk of stroke and improve cerebral perfusion. This study aimed to investigate the utility of assessing pulsatile blood volume and flow during CEA. Using a combined near-infrared spectroscopy/diffuse correlation spectroscopy instrument, pulsatile hemodynamics were assessed in 12 patients undergoing CEA. Alterations to pulsatile amplitude, pulse transit time, and beat morphology were observed in measurements ipsilateral to the surgical side. The additional information provided through analysis of pulsatile hemodynamic signals has the potential to enable the discovery of non-invasive biomarkers related to cortical perfusion.
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Affiliation(s)
- Alexander I Zavriyev
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kutlu Kaya
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kuan Cheng Wu
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Eric T Pierce
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Maria Angela Franceschini
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mitchell B Robinson
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Coughlan C, Jäger HR, Brealey D, Carletti F, Hyare H, Pattnaik R, Sahu PK, Mohanty S, Logan S, Hoffmann A, Wassmer SC, Checkley AM. Adult Cerebral Malaria: Acute and Subacute Imaging Findings, Long-term Clinical Consequences. Clin Infect Dis 2024; 78:457-460. [PMID: 37897407 PMCID: PMC10874268 DOI: 10.1093/cid/ciad651] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 09/28/2023] [Accepted: 10/27/2023] [Indexed: 10/30/2023] Open
Abstract
Cerebral malaria is an important cause of mortality and neurodisability in endemic regions. We show magnetic resonance imaging (MRI) features suggestive of cytotoxic and vasogenic cerebral edema followed by microhemorrhages in 2 adult UK cases, comparing them with an Indian cohort. Long-term follow-up images correlate ongoing changes with residual functional impairment.
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Affiliation(s)
- Charles Coughlan
- Department of Infectious Diseses, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Hans Rolf Jäger
- Department of Radiology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
- Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, London, United Kingdom
- Neuroradiological Academic Unit, Queen Square Institute of Neurology, London, United Kingdom
| | - David Brealey
- Department of Intensive Care Medicine, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Francesco Carletti
- Department of Radiology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
- Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Harpreet Hyare
- Department of Radiology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | | | - Praveen K Sahu
- Center for the Study of Complex Malaria in India, Community Welfare Society Hospital, Rourkela, India
| | - Sanjib Mohanty
- Center for the Study of Complex Malaria in India, Community Welfare Society Hospital, Rourkela, India
| | - Sarah Logan
- Department of Infectious Diseses, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Angelika Hoffmann
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Samuel C Wassmer
- Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Anna M Checkley
- Department of Infectious Diseses, University College London Hospitals NHS Foundation Trust, London, United Kingdom
- Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
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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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Gopal J, Srivastava S, Singh N, Haldar R, Verma R, Gupta D, Mishra P. Pulse Pressure Variance (PPV)-Guided Fluid Management in Adult Patients Undergoing Supratentorial Tumor Surgeries: A Randomized Controlled Trial. Asian J Neurosurg 2023; 18:508-515. [PMID: 38152505 PMCID: PMC10749863 DOI: 10.1055/s-0043-1771364] [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] [Indexed: 12/29/2023] Open
Abstract
Objective Appropriate fluid management in neurosurgery is critical due to the risk of secondary brain injury. Determination of volume status is challenging with static variables being unreliable. Goal-directed fluid therapy with dynamic variables allows reliable determination of fluid responsiveness and promises better outcomes. We aimed to compare the intraoperative fluid requirement between conventional central venous pressure (CVP)-guided and pulse pressure variance (PPV)-guided fluid management in supratentorial tumor surgeries. Materials and Methods This prospective, randomized, double-blind, single-center trial was conducted with 72 adults undergoing supratentorial tumor surgery in a supine position. Patients were divided into two groups of 36 patients each receiving CVP- and PPV-guided fluid therapy. The CVP-guided group received boluses to target CVP greater than 8 mm Hg along with hourly replacement of intraoperative losses and maintenance fluids. The PPV-guided group received boluses to target PPV less than 13% in addition to maintenance fluids. Total intraoperative fluids administered and the incidence of hypotension was recorded along with the brain relaxation score. Postoperatively, serum lactate levels, periorbital and conjunctival edema, as well as postoperative nausea and vomiting were assessed. Statistical Analyses All statistical analyses were performed with Statistical Package for Social Sciences, version-20 (SPSS-20, IBM, Chicago, Illinois, United States). To compare the means between the two groups (CVP vs. PPV), independent samples t -test was used for normal distribution data and Mann-Whitney U test for nonnormal distribution data. The chi-square test or Fischer's exact test was used for categorical variables. Results The CVP group received significantly more intraoperative fluids than the PPV group (4,340 ± 1,010 vs. 3,540 ± 740 mL, p < 0.01). Incidence of hypotension was lower in the PPV group (4 [11.1%] vs. 0 [0%], p = 0.04). Brain relaxation scores, serum lactate levels, periorbital and conjunctival edema, and incidence of postoperative nausea and vomiting were comparable between the groups. Conclusion The requirement for intraoperative fluids was less in PPV-guided fluid management with better hemodynamic stability, adequate brain conditions, and no compromise of perfusion.
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Affiliation(s)
- Janani Gopal
- Department of Anesthesiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Shashi Srivastava
- Department of Anesthesiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Nidhi Singh
- Department of Anesthesiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Rudrashish Haldar
- Department of Anesthesiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Ruchi Verma
- Department of Anesthesiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Devendra Gupta
- Department of Anesthesiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Prabhakar Mishra
- Department of Biostatistics & Health Informatics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Nwafor DC, Kirby BD, Ralston JD, Colantonio MA, Ibekwe E, Lucke-Wold B. Neurocognitive Sequelae and Rehabilitation after Subarachnoid Hemorrhage: Optimizing Outcomes. JOURNAL OF VASCULAR DISEASES 2023; 2:197-211. [PMID: 37082756 PMCID: PMC10111247 DOI: 10.3390/jvd2020014] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
Subarachnoid hemorrhage (SAH) is a medical emergency that requires immediate intervention. The etiology varies between cases; however, rupture of an intracranial aneurysm accounts for 80% of medical emergencies. Early intervention and treatment are essential to prevent long-term complications. Over the years, treatment of SAH has drastically improved, which is responsible for the rapid rise in SAH survivors. Post-SAH, a significant number of patients exhibit impairments in memory and executive function and report high rates of depression and anxiety that ultimately affect daily living, return to work, and quality of life. Given the rise in SAH survivors, rehabilitation post-SAH to optimize patient outcomes becomes crucial. The review addresses the current rehabilitative strategies to combat the neurocognitive and behavioral issues that may arise following SAH.
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Affiliation(s)
- Divine C. Nwafor
- Department of Neuroscience, West Virginia University Health Science Center, Morgantown, WV 26506, USA
- Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV 26506, USA
| | - Brandon D. Kirby
- Department of Neuroscience, West Virginia University Health Science Center, Morgantown, WV 26506, USA
- Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV 26506, USA
| | - Jacob D. Ralston
- Department of Neuroscience, West Virginia University Health Science Center, Morgantown, WV 26506, USA
| | - Mark A. Colantonio
- Department of Neuroscience, West Virginia University Health Science Center, Morgantown, WV 26506, USA
| | - Elochukwu Ibekwe
- Department of Neurology and Neurocritical Care, The Ohio State University, Columbus, OH 43210, USA
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, FL 32611, USA
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Barkas F, Anastasiou G, Liamis G, Milionis H. A step-by-step guide for the diagnosis and management of hyponatraemia in patients with stroke. Ther Adv Endocrinol Metab 2023; 14:20420188231163806. [PMID: 37033701 PMCID: PMC10074625 DOI: 10.1177/20420188231163806] [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: 10/02/2022] [Accepted: 02/27/2023] [Indexed: 04/07/2023] Open
Abstract
Hyponatraemia is common in patients with stroke and associated with adverse outcomes and increased mortality risk. The present review presents the underlying causes and provides a thorough algorithm for the diagnosis and management of hyponatraemia in stroke patients. Concomitant diseases and therapies, such as diabetes, chronic kidney disease and heart failure, along with diuretics, antidepressants and proton pump inhibitors are the most common causes of hyponatraemia in community. In the setting of acute stroke, the emergence of hyponatraemia might be attributed to the administration of hypotonic solutions and drugs (ie. mannitol and antiepileptics), poor solute intake, infections, as well as stroke-related conditions or complications, such as the syndrome of inappropriate secretion of antidiuretic hormone, cerebral salt wasting syndrome and secondary adrenal insufficiency. Diagnostically, the initial step is to differentiate hypotonic from non-hypotonic hyponatraemia, usually caused by hyperglycaemia or recent mannitol administration in patients with stroke. Determining urine osmolality, urine sodium level and volume status are the following steps in the differentiation of hypotonic hyponatraemia. Of note, specific parameters, such as fractional uric acid and urea excretion, along with plasma copeptin concentration, may further improve the diagnostic yield. Therapeutic options are based on the duration and symptoms of hyponatremia. In the case of acute or symptomatic hyponatraemia, hypertonic saline administration is recommended. Hypovolaemic chronic hyponatremia is treated with isotonic solution administration. Although fluid restriction remains the first-line treatment for the rest forms of chronic hyponatraemia, therapies increasing renal free water excretion may be necessary. Loop diuretics and urea serve this purpose in patients with stroke, whereas sodium-glucose transport protein-2 inhibitors appear to be a promising therapy. Nevertheless, it is yet unclear whether the appropriate restoration of sodium level improves outcomes in such patients. Randomized trials designed to compare therapeutic strategies in managing hyponatraemia in patients with stroke are required.
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Affiliation(s)
- Fotios Barkas
- Department of Hygiene and Epidemiology, Faculty of
Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Georgia Anastasiou
- Department of Internal Medicine, Faculty of Medicine,
School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - George Liamis
- Department of Internal Medicine, Faculty of Medicine,
School of Health Sciences, University of Ioannina, Ioannina, Greece
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Carr JR, Hawkins WA, Newsome AS, Smith SE, Clemmons AB, Bland CM, Branan TN. Fluid Stewardship of Maintenance Intravenous Fluids. J Pharm Pract 2022; 35:769-782. [PMID: 33827313 PMCID: PMC8497650 DOI: 10.1177/08971900211008261] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Despite the frequent use of maintenance intravenous fluids (mIVF) in critically ill patients, limited guidance is available. Notably, fluid overload secondary to mIVF mismanagement is associated with significant adverse patient outcomes. The Four Rights (right drug, right dose, right duration, right patient) construct of fluid stewardship has been proposed for the safe evaluation and use of fluids. The purpose of this evidence-based review is to offer practical insights for the clinician regarding mIVF selection, dosing, and duration in line with the Four Rights of Fluid Stewardship.
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Affiliation(s)
- John R. Carr
- Department of Pharmacy, St. Joseph’s/Candler Health System, Savannah, GA, USA
| | - W. Anthony Hawkins
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Albany, GA, USA
- Department of Pharmacology and Toxicology, Medical College of Georgia at Augusta University, Albany, GA, USA
| | - Andrea Sikora Newsome
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA, USA
- Department of Pharmacy, Augusta University Medical Center, Augusta, GA, USA
| | - Susan E. Smith
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Athens, GA, USA
| | - Amber B Clemmons
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA, USA
- Department of Pharmacy, Augusta University Medical Center, Augusta, GA, USA
| | - Christopher M. Bland
- Department of Pharmacy, St. Joseph’s/Candler Health System, Savannah, GA, USA
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Savannah, GA, USA
| | - Trisha N. Branan
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Athens, GA, USA
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11
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The Brain–Gut Axis in Traumatic Brain Injury: Implications for Nutrition Support. CURRENT SURGERY REPORTS 2022. [DOI: 10.1007/s40137-022-00325-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Abstract
Purpose of Review
Early enteral nutrition improves outcomes following traumatic brain injury (TBI). This can prove difficult due to TBI-induced feeding intolerance secondary to disruption of the brain-gut axis, a network composed of central nervous system (CNS) input, autonomic signaling, and immunologic regulation that controls gut and CNS homeostasis. Here, we discuss the pathophysiology of brain–gut axis dysregulation and outline nutrition strategies in patients with TBI.
Recent Findings
Feeding intolerance following TBI is multifactorial; complex signaling between the CNS, sympathetic nervous system, parasympathetic nervous system, and enteric nervous system that controls gut homeostasis is disrupted within hours post-injury. This has profound effects on the immune system and gut microbiome, further complicating post-TBI recovery. Despite this disruption, calorie and protein requirements increase considerably following TBI, and early nutritional supplementation improves survival following TBI. Enteral nutrition has proven more efficacious than parenteral nutrition in TBI patients and should be initiated within 48 hours following admission. Immune-fortified nutrition reduces CNS and gut inflammation and may improve outcomes in TBI patients.
Summary
Although autonomic dysregulation of the brain–gut axis results in feeding intolerance following TBI, early enteral nutrition is of paramount importance. Enteral nutrition reduces post-TBI inflammation and enhances immunologic and gut function. When feasible, enteral nutrition should be initiated within 48 hours following injury.
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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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13
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Makowska M, Smolarz B, Romanowicz H. microRNAs in Subarachnoid Hemorrhage (Review of Literature). J Clin Med 2022; 11:jcm11154630. [PMID: 35956244 PMCID: PMC9369929 DOI: 10.3390/jcm11154630] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 07/25/2022] [Accepted: 08/05/2022] [Indexed: 11/16/2022] Open
Abstract
Recently, many studies have shown that microRNAs (miRNAs) in extracellular bioliquids are strongly associated with subarachnoid hemorrhage (SAH) and its complications. The article presents issues related to the occurrence of subarachnoid hemorrhage (epidemiology, symptoms, differential diagnosis, examination, and treatment of the patient) and a review of current research on the correlation between miRNAs and the complications of SAH. The potential use of miRNAs as biomarkers in the treatment of SAH is presented.
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Affiliation(s)
- Marianna Makowska
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Beata Smolarz
- Laboratory of Cancer Genetics, Department of Pathology, Polish Mother’s Memorial Hospital Research Institute, Rzgowska 281/289, 93-338 Lodz, Poland
- Correspondence: ; Tel.: +48-42-271-12-90
| | - Hanna Romanowicz
- Laboratory of Cancer Genetics, Department of Pathology, Polish Mother’s Memorial Hospital Research Institute, Rzgowska 281/289, 93-338 Lodz, Poland
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14
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Mistry AM, Magarik JA, Feldman MJ, Wang L, Lindsell CJ, Fusco MR, Chitale RV, Bernard GR, Self WH, Rice TW, Hughes CG, Mistry EA, Semler MW. Saline versus Balanced Crystalloids for Adults with Aneurysmal Subarachnoid Hemorrhage: A Subgroup Analysis of the SMART Trial. STROKE (HOBOKEN, N.J.) 2022; 2:e000128. [PMID: 36186896 PMCID: PMC9518828 DOI: 10.1161/svin.121.000128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND Whether the composition of intravenous crystalloid solutions affects outcomes in adults with aneurysmal subarachnoid hemorrhage (aSAH) remains unknown. Therefore, we determined whether the use of saline is associated with lower risk of disability and death in aSAH patients compared to balanced crystalloids. METHODS We conducted a post hoc subgroup analysis of the Isotonic Solutions and Major Adverse Renal Events Trial (SMART), a pragmatic, unblinded, cluster-randomized, multiple-crossover clinical trial that enrolled 15,802 adults between June 2015 and April 2017. We compared intravenous administration of saline to balanced crystalloids in consecutively enrolled aSAH patients aged 18 years or older whose ruptured aneurysm was procedurally secured at a single academic center in the United States. The primary outcome was the score on the modified Rankin scale (mRS, range, 0 [no symptoms] to 6 [death]) at 90 days obtained from a prospective institutional stroke registry. Secondary outcome included death by 90 days. Logistic or proportional odds regression models were used to test for between-group differences adjusted for age, hypertension, aSAH grade, and procedure type. RESULTS Of the 79 aSAH patients procedurally treated during the SMART study period, 78 were enrolled (median age, 58 years; IQR, 49 to 64.5; 64% female), with 41 (53%) assigned to saline and 37 (47%) to balanced crystalloids. Plasma-Lyte was the primary balanced crystalloid used. Among 72 patients with 90-day mRS assessment, the adjusted common odds ratio, aOR, for mRS was 0.68 (95% CI, 0.28-1.63; P=0.39), with values less than 1.0 favoring saline. By 90 days, 2/39 patients (5%) in the saline group and 9/35 (26%) in the balanced-crystalloids group had died (aOR, 0.06; 95% CI, 0.00-0.50; P=0.02). CONCLUSIONS Among procedurally treated aSAH patients, the risk of disability or death at 90 days did not significantly differ between saline and balanced crystalloids. Death occurred less frequently with saline than balanced crystalloids.
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Affiliation(s)
| | - Jordan A. Magarik
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael J. Feldman
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Li Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Matthew R. Fusco
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Rohan V. Chitale
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gordon R. Bernard
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Wesley H. Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Todd W. Rice
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christopher G. Hughes
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Eva A. Mistry
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew W. Semler
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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Rodrigues-Gomes RM, Martí JD, Rolán RM, Gelabert-González M. Rapid chest compression effects on intracranial pressure in patients with acute cerebral injury. Trials 2022; 23:312. [PMID: 35428364 PMCID: PMC9012060 DOI: 10.1186/s13063-022-06189-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 03/20/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients with acute brain injury often require invasive mechanical ventilation, increasing the risk of developing complications such as respiratory secretions retention. Rapid chest compression is a manual chest physiotherapy technique that aims to improve clearance of secretions in these patients. However, the rapid chest compression technique has been suggested to be associated with increased intracranial pressure in patients with acute brain injury. The aim of this work is to elucidate the effects of the technique on intracranial pressure in mechanically ventilated patients with acute brain injury. Furthermore, the effects of the technique in different volumes and flows recorded by the ventilator and the relationship between the pressure applied in the intervention group and the different variables will also be studied. METHODS Randomized clinical trial, double-blinded. Patients with acute brain injury on invasive mechanical ventilation > 48 h will be included and randomized in two groups. In the control group, a technique of passive hallux mobilization will be applied, and in the intervention group, it will be performed using the rapid chest compression technique. Intracranial pressure (main variable) will be collected with an intracranial pressure monitoring system placed at the lateral ventricles (Integra Camino). DISCUSSION The safety of chest physiotherapy techniques in patients at risk of intracranial hyperpressure is still uncertain. The aim of this study is to identify if the rapid manual chest compression technique is safe in ventilated patients with acute brain injury. TRIAL REGISTRATION NCT03609866 . Registered on 08/01/2018.
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16
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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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Jonna D. Abstract No.: ABS0639: A comparison of the total intraoperative fluid administered by goal directed fluid therapy and conventional fluid therapy in isolated traumatic brain injury patients undergoing early decompressive craniectomy- a prospective randomised controlled trial. Indian J Anaesth 2022. [PMCID: PMC9116774 DOI: 10.4103/0019-5049.340693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022] Open
Abstract
Background & Aims: Traumatic brain injury patients are prone to osmotic and electrolyte disturbances, hence require a unique approach to fluid management. Primary aim of the study is to compare goal-directed therapy and conventional hemodynamic based therapy on total intra-operative fluid administered during decompressive craniectomy Methods: Prospective randomised controlled trial was conducted at PGIMER, accruing 64 adult patients with TBI undergoing decompressive craniectomy Goal directed fluid therapy (GDT) used Flo Trac, EV-1000 device (Edwards Lifesciences, Irvine, CA) to monitor Stroke volume variation, Cardiac index and mean arterial pressure Conventional fluid therapyutilisedcrystalloids infused at a rate of 2 ml/kg/hour with target MAP >70 mm of Hg. Quantitative variables were compared using unpaired t test if normally distributed, Mann Whitney U test was used for non-normally distributed quantitative and ordinal data. A P < 0.05 was considered statistically significant. The statistical analysis was done using IBM SPSS version 25. Results: There was a numerical difference in total fluid administered between both the groups but did not prove to be statistically significant (p=0.511). No significant difference in intraoperative blood loss (p=0.776), urine output (p=0.230), total ventilator days (p=0.30), total ICU days (p=0.34), total hospital days (p=0.57) and GCS at discharge (0.53). There was significant difference in levels of hematocrit (p=0.00) and levels of lactate (p=0.00) within both the groups and GCS pre- and post-surgery (p=0.04) Conclusion: No statistically significant difference between the total intraoperative fluid administered between both the groups was observed. Quest for methods to improve outcome in traumatic brain injury patients it still ongoing.
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Focused Management of Patients With Severe Acute Brain Injury and ARDS. Chest 2022; 161:140-151. [PMID: 34506794 PMCID: PMC8423666 DOI: 10.1016/j.chest.2021.08.066] [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: 02/12/2021] [Revised: 08/04/2021] [Accepted: 08/25/2021] [Indexed: 02/04/2023] Open
Abstract
Considering the COVID-19 pandemic where concomitant occurrence of ARDS and severe acute brain injury (sABI) has increasingly coemerged, we synthesize existing data regarding the simultaneous management of both conditions. Our aim is to provide readers with fundamental principles and concepts for the management of sABI and ARDS, and highlight challenges and conflicts encountered while managing concurrent disease. Up to 40% of patients with sABI can develop ARDS. Although there are trials and guidelines to support the mainstays of treatment for ARDS and sABI independently, guidance on concomitant management is limited. Treatment strategies aimed at managing severe ARDS may at times conflict with the management of sABI. In this narrative review, we discuss the physiological basis and risks involved during simultaneous management of ARDS and sABI, summarize evidence for treatment decisions, and demonstrate these principles using hypothetical case scenarios. Use of invasive or noninvasive monitoring to assess brain and lung physiology may facilitate goal-directed treatment strategies with the potential to improve outcome. Understanding the pathophysiology and key treatment concepts for comanagement of these conditions is critical to optimizing care in this high-acuity patient population.
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20
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Rass V, Bogossian EG, Ianosi BA, Peluso L, Kofler M, Lindner A, Schiefecker AJ, Putnina L, Gaasch M, Hackl WO, Beer R, Pfausler B, Taccone FS, Helbok R. The effect of the volemic and cardiac status on brain oxygenation in patients with subarachnoid hemorrhage: a bi-center cohort study. Ann Intensive Care 2021; 11:176. [PMID: 34914011 PMCID: PMC8677880 DOI: 10.1186/s13613-021-00960-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 11/28/2021] [Indexed: 12/23/2022] Open
Abstract
Background Fluid management in patients after subarachnoid hemorrhage (SAH) aims at the optimization of cerebral blood flow and brain oxygenation. In this study, we investigated the effects of hemodynamic management on brain oxygenation by integrating advanced hemodynamic and invasive neuromonitoring. Methods This observational cohort bi-center study included data of consecutive poor-grade SAH patients who underwent pulse contour cardiac output (PiCCO) monitoring and invasive neuromonitoring. Fluid management was guided by the transpulmonary thermodilution system and aimed at euvolemia (cardiac index, CI ≥ 3.0 L/min/m2; global end-diastolic index, GEDI 680–800 mL/m2; stroke volume variation, SVV < 10%). Patients were managed using a brain tissue oxygenation (PbtO2) targeted protocol to prevent brain tissue hypoxia (BTH, PbtO2 < 20 mmHg). To assess the association between CI and PbtO2 and the effect of fluid challenges on CI and PbtO2, we used generalized estimating equations to account for repeated measurements. Results Among a total of 60 included patients (median age 56 [IQRs 47–65] years), BTH occurred in 23% of the monitoring time during the first 10 days since admission. Overall, mean CI was within normal ranges (ranging from 3.1 ± 1.3 on day 0 to 4.1 ± 1.1 L/min/m2 on day 4). Higher CI levels were associated with higher PbtO2 levels (Wald = 14.2; p < 0.001). Neither daily fluid input nor fluid balance was associated with absolute PbtO2 levels (p = 0.94 and p = 0.85, respectively) or the occurrence of BTH (p = 0.68 and p = 0.71, respectively). PbtO2 levels were not significantly different in preload dependent patients compared to episodes of euvolemia. PbtO2 increased as a response to fluid boluses only if BTH was present at baseline (from 13 ± 6 to 16 ± 11 mmHg, OR = 13.3 [95% CI 2.6–67.4], p = 0.002), but not when all boluses were considered (p = 0.154). Conclusions In this study a moderate association between increased cardiac output and brain oxygenation was observed. Fluid challenges may improve PbtO2 only in the presence of baseline BTH. Individualized hemodynamic management requires advanced cardiac and brain monitoring in critically ill SAH patients. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-021-00960-z.
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Affiliation(s)
- Verena Rass
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
| | - Elisa Gouvea Bogossian
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Bogdan-Andrei Ianosi
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.,Institute of Medical Informatics, UMIT: University for Health Sciences, Medical Informatics and Technology, Eduard Wallnoefer-Zentrum 1, 6060, Hall, Austria
| | - Lorenzo Peluso
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Mario Kofler
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Anna Lindner
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Alois J Schiefecker
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Lauma Putnina
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Max Gaasch
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Werner O Hackl
- Institute of Medical Informatics, UMIT: University for Health Sciences, Medical Informatics and Technology, Eduard Wallnoefer-Zentrum 1, 6060, Hall, Austria
| | - Ronny Beer
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Bettina Pfausler
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Raimund Helbok
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
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21
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Ma HK, Bebawy JF. Albumin Use in Brain-injured and Neurosurgical Patients: Concepts, Indications, and Controversies. J Neurosurg Anesthesiol 2021; 33:293-299. [PMID: 31929351 DOI: 10.1097/ana.0000000000000674] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 12/09/2019] [Indexed: 11/25/2022]
Abstract
Human albumin has been used extensively for decades as a nonwhole blood plasma replacement fluid in the perioperative and critical care setting. Its potential advantages as a highly effective volume expander must be weighed, however, against its potential harm for patients in the context of various neurological states and for various neurosurgical interventions. This narrative review explores the physiological considerations of intravenous human albumin as a replacement fluid and examines the extant clinical evidence for and against its use within the various facets of modern neuroanesthesia and neurocritical care practice.
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Affiliation(s)
- Heung Kan Ma
- Northwestern University Feinberg School of Medicine, Chicago, IL
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22
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Abstract
PURPOSE OF REVIEW We define dehydration and its relationship to pain physiology including both primary and secondary headache disorders. RECENT FINDINGS Intravenous fluids administered for acute migraine attacks in an emergency department setting have not been shown to improve pain outcomes. However, increased intravascular volume before diagnostic lumbar puncture may reduce the frequency of post-lumbar puncture headache from iatrogenic spinal fluid leak. Maintenance of euhydration can help treat orthostatic and "coat-hanger" headache due to autonomic disorders. Similarly, prevention of fluid losses can mitigate secondary headaches provoked by dehydration such as cerebral venous thrombosis or pituitary apoplexy. Dehydration alone may cause headache, but oftentimes exacerbates underlying medical conditions such as primary headache disorders or other conditions dependent on fluid balance.
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Affiliation(s)
- Karissa N Arca
- Mayo Clinic Arizona, 13400 E Shea Blvd, Scottsdale, AZ, 85259, USA.
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23
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Ottolini KM, Basu SK, Herrera N, Govindan V, Mashat S, Vezina G, Ridore M, Bost J, Chang T, Massaro AN. Positive fluid balance is associated with death and severity of brain injury in neonates with hypoxic-ischemic encephalopathy. J Perinatol 2021; 41:1331-1338. [PMID: 33649446 PMCID: PMC10363283 DOI: 10.1038/s41372-021-00988-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 01/15/2021] [Accepted: 02/03/2021] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To investigate the association between fluid balance during therapeutic hypothermia (TH) and severity of brain injury on magnetic resonance imaging (MRI) in neonates with hypoxic-ischemic encephalopathy (HIE). STUDY DESIGN This is a secondary analysis of data from a prospective observational study in neonates with HIE. Daily net positive fluid balance during TH was investigated for association with the adverse primary outcome of death or moderate-to-severe brain injury on MRI using multivariable logistic regression. RESULTS Of the 150 neonates included, 50 suffered adverse outcome and had significantly higher net positive fluid balance (53 vs. 19 ml/kg/day, p < 0.01) during first 24 hours of TH. Neonates with a net positive fluid balance (>25 ml/kg/day) at 24 hours of TH had 3.4 (95% CI 1.3-9) times higher odds of adverse outcome. CONCLUSIONS Positive fluid balance during TH in neonates with HIE is independently associated with death or moderate-to-severe brain injury on MRI.
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Affiliation(s)
- Katherine M Ottolini
- Division of Neonatology, Children's National Hospital, Washington, DC, USA
- Department of Neonatology, 18th Healthcare Operations Squadron, Kadena AB, Okinawa, Japan
- Department of Pediatrics, Division of Neonatology, Uniformed Services University, Bethesda, MD, USA
| | - Sudeepta K Basu
- Division of Neonatology, Children's National Hospital, Washington, DC, USA
- Department of Pediatrics, The George Washington University School of Medicine, Washington, DC, USA
| | - Nicole Herrera
- Division of Biostatistics and Study Methodology, Children's National Hospital, Washington, DC, USA
| | - Vedavalli Govindan
- Division of Fetal and Transitional Medicine, Children's National Hospital, Washington, DC, USA
| | - Suleiman Mashat
- Division of Neonatology, Children's National Hospital, Washington, DC, USA
| | - Gilbert Vezina
- Department of Pediatrics, The George Washington University School of Medicine, Washington, DC, USA
- Division of Diagnostic Imaging and Radiology, Children's National Hospital, Washington, DC, USA
| | - Michelande Ridore
- Division of Neonatology, Children's National Hospital, Washington, DC, USA
| | - James Bost
- Department of Pediatrics, The George Washington University School of Medicine, Washington, DC, USA
- Division of Biostatistics and Study Methodology, Children's National Hospital, Washington, DC, USA
| | - Taeun Chang
- Department of Pediatrics, The George Washington University School of Medicine, Washington, DC, USA
- Division of Epilepsy, Neurophysiology & Critical Care, Children's National Hospital, Washington, DC, USA
| | - An N Massaro
- Division of Neonatology, Children's National Hospital, Washington, DC, USA.
- Department of Pediatrics, The George Washington University School of Medicine, Washington, DC, USA.
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24
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Gwak DS, Chung I, Kim BK, Lee S, Jeong HG, Kim YS, Chae H, Park CY, Han MK. High Chloride Burden and Clinical Outcomes in Critically Ill Patients With Large Hemispheric Infarction. Front Neurol 2021; 12:604686. [PMID: 34093385 PMCID: PMC8172791 DOI: 10.3389/fneur.2021.604686] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 04/14/2021] [Indexed: 11/13/2022] Open
Abstract
Background: In general, disease severity has been found to be associated with abnormal chloride levels in critically ill patients, but hyperchloremia is associated with mixed results regarding patient-centered clinical outcomes. We aimed to investigate the impact of maximum serum chloride concentration on the clinical outcomes of critically ill patients with large hemispheric infarction (LHI). Methods: We conducted a retrospective observational cohort study using prospective institutional neurocritical care registry data from 2013 to 2018. Patients with LHIs involving over two-thirds of middle cerebral artery territory, with or without infarction of other vascular territories, and a baseline National Institutes of Health Stroke Scale score of ≥13 were assessed. Those with a baseline creatinine clearance of <15 mL/min and required neurocritical care for <72 h were excluded. Primary outcome was in-hospital mortality. Secondary outcomes included 3-month mortality and acute kidney injury (AKI) occurrence. Outcomes were compared to different maximum serum chloride levels (5 mmol/L increases) during the entire hospitalization period using multivariable logistic regression analyses. Results: Of 90 patients, 20 (22.2%) died in-hospital. Patients who died in-hospital had significantly higher maximum serum chloride levels than did those who survived up to hospital discharge (139.7 ± 8.1 vs. 119.1 ± 10.4 mmol/L; p < 0.001). After adjusting for age, sex, and Glasgow coma scale score, each 5-mmol/L increase in maximum serum chloride concentration was independently associated with an increased risk of in-hospital mortality (adjusted odds ratio (aOR), 4.34; 95% confidence interval [CI], 1.98–9.50; p < 0.001). Maximum serum chloride level was also an independent risk factor for 3-month mortality (aOR, 1.99 [per 5 mmol/L increase]; 95% CI, 1.42–2.79; p < 0.001) and AKI occurrence (aOR, 1.57 [per 5 mmol/L increase]; 95% CI, 1.18–2.08; p = 0.002). Conclusions: High maximum serum chloride concentrations were associated with poor clinical outcomes in critically ill patients with LHI. This study highlights the importance of monitoring serum chloride levels and avoiding hyperchloremia in this patient population.
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Affiliation(s)
- Dong-Seok Gwak
- Department of Neurology, Kyungpook National University Hospital, Daegu, South Korea
| | - Inyoung Chung
- Department of Neurology, Nowon Eulji Medical Center, Seoul, South Korea
| | - Baik-Kyun Kim
- Department of Neurology, Chungbuk National University Hospital, Cheongju-si, South Korea
| | - Sukyoon Lee
- Department of Neurology, Inje University Busan Paik Hospital, Busan, South Korea
| | - Han-Gil Jeong
- Division of Neurocritical Care, Department of Neurosurgery and Neurology, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Yong Soo Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Heeyun Chae
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Chan-Young Park
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Moon-Ku Han
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, South Korea.,Department of Neurology, Seoul National University College of Medicine, Seoul, South Korea
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25
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Anderson NM, Bond GY, Joffe AR, MacDonald C, Robertson C, Urschel S, Morgan CJ. Post-operative fluid overload as a predictor of hospital and long-term outcomes in a pediatric heart transplant population. Pediatr Transplant 2021; 25:e13897. [PMID: 33131128 DOI: 10.1111/petr.13897] [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: 01/15/2020] [Revised: 09/27/2020] [Accepted: 10/02/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Pediatric patients undergoing heart transplant have a number of factors predisposing them to become fluid-overloaded, including capillary leak syndrome. Capillary leak and FO are associated with organ injury and may influence both short- and long-term outcomes. This study aimed to 1) determine the extent, timing, and predictors of post-operative FO and 2) investigate the association of FO with clinically important outcomes. METHODS Between 2000 and 2012, 70 children less than 6 years old had a heart transplant at our institution. This was a secondary analysis of data from an ongoing prospective cohort study. RESULTS FO, defined as cumulative fluid balance greater than 10% of body weight in the first 5 post-operative days, occurred in 16/70 patients (23%); 7 of these had more than 20% FO. Shorter donor ischemic time and longer cardiopulmonary bypass time were independently associated with increased risk of FO. FO >20% was a statistically significant independent predictor of mortality (P = .005), ventilation time, and PICU length of stay. There was no statistically significant association between identified neurodevelopment domains and FO. CONCLUSIONS Our single-center experience demonstrates that FO was common after pediatric heart transplant and was associated with worse clinical outcomes. FO is a potentially modifiable factor, and research is needed to better determine risk factors and whether intervention to reduce FO can improve outcomes in pediatric heart transplant patients.
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Affiliation(s)
- Nicole M Anderson
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Gwen Y Bond
- Glenrose Rehabilitation Hospital, Edmonton, AB, Canada
| | - Ari R Joffe
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | | | - Charlene Robertson
- Glenrose Rehabilitation Hospital, Edmonton, AB, Canada.,Division of Developmental Pediatrics, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Simon Urschel
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
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de Winkel J, van der Jagt M, Lingsma HF, Roozenbeek B, Calvillo E, Chou SHY, Dziedzic PH, Etminan N, Huang J, Ko NU, Loch MacDonald R, Martin RL, Potu NR, Venkatasubba Rao CP, Vergouwen MDI, Suarez JI. International Practice Variability in Treatment of Aneurysmal Subarachnoid Hemorrhage. J Clin Med 2021; 10:jcm10040762. [PMID: 33672807 PMCID: PMC7917699 DOI: 10.3390/jcm10040762] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 02/03/2021] [Accepted: 02/07/2021] [Indexed: 12/18/2022] Open
Abstract
Prior research suggests substantial between-center differences in functional outcome following aneurysmal subarachnoid hemorrhage (aSAH). One hypothesis is that these differences are due to practice variability. To characterize practice variability, we sent a survey to 230 centers, of which 145 (63%) responded. Survey respondents indicated that an estimated 65% of ruptured aneurysms were treated endovascularly. Sixty-five percent of aneurysms were treated within 24 h of symptom onset, 18% within 24–48 h, and eight percent within 48–72 h. Centers in the United States (US) and Europe (EU) treat aneurysms more often endovascularly (72% and 70% vs. 51%, respectively, US vs. other p < 0.001, and EU vs. other p < 0.01) and more often within 24 h (77% and 64% vs. 46%, respectively, US vs. other p < 0.001, EU vs. other p < 0.01) compared to other centers. Most centers aim for euvolemia (96%) by administrating intravenous fluids to 0 (53%) or +500 mL/day (41%) net fluid balance. Induced hypertension is more often used in US centers (100%) than in EU (87%, p < 0.05) and other centers (81%, p < 0.05), and endovascular therapies for cerebral vasospasm are used more often in US centers than in other centers (91% and 60%, respectively, p < 0.05). We observed significant practice variability in aSAH treatment worldwide. Future comparative effectiveness research studies are needed to investigate how practice variation leads to differences in functional outcome.
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Affiliation(s)
- Jordi de Winkel
- Department of Neurology, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands; (J.d.W.); (B.R.)
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands;
| | - Mathieu van der Jagt
- Department of Intensive Care Adults, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands;
| | - Hester F. Lingsma
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands;
| | - Bob Roozenbeek
- Department of Neurology, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands; (J.d.W.); (B.R.)
| | - Eusebia Calvillo
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (E.C.); (P.H.D.); (N.R.P.)
| | - Sherry H-Y. Chou
- Departments of Critical Care Medicine, Neurology, and Neurosurgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15260, USA;
| | - Peter H. Dziedzic
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (E.C.); (P.H.D.); (N.R.P.)
| | - Nima Etminan
- Department of Neurosurgery, University of Heidelberg School of Medicine, 69117 Mannheim, Germany;
| | - Judy Huang
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA;
| | - Nerissa U. Ko
- Department of Neurology, UCSF Weill Institute for Neurosciences, UCSF School of Medicine, San Francisco, CA 94143, USA;
| | - Robert Loch MacDonald
- UCSF Fresno Department of Neurosurgery, UCSF School of Medicine, University Neuroscience Institute, Fresno, CA 93701, USA;
| | - Renee L. Martin
- Department of Biostatistics and Epidemiology, Medical University of South Carolina, Charleston, SC 29425, USA;
| | - Niteesh R. Potu
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (E.C.); (P.H.D.); (N.R.P.)
| | - Chethan P. Venkatasubba Rao
- Departments of Neurology, Neurosurgery, and Center for Space medicine, Baylor College of Medicine, Houston, TX 77030, USA;
| | - Mervyn D. I. Vergouwen
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, 3508 GA Utrecht, The Netherlands;
| | - Jose I. Suarez
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Correspondence:
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Zhao S, Xu D, Li R, Zou Q, Chen Z, Wang H, He X. [Clinical efficacy of restrictive fluid management in patients with severe traumatic brain injury]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2021; 41:111-115. [PMID: 33509762 DOI: 10.12122/j.issn.1673-4254.2021.01.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To investigate the effects of restrictive fluid management in patients with severe traumatic brain injury (sTBI). METHODS Between January, 2019 and June, 2020, we randomly assigned 51 postoperative patients (stay in the ICU of no less than 7 days) with sTBI into treatment group (n=25) with restrictive fluid management and the control group (n=26) with conventional fluid management. The data of optic nerve sheath diameter (ONSD), middle cerebral artery pulsatility index (MAC- PI), neuron-specific enolase (NSE) level, inferior vena cava (IVC) diameter, Glascow Coma Scale (GCS) score, mean arterial blood pressure, heart rate, and fluid balance of the patients were collected at ICU admission and at 1, 3 and 7 days after ICU admission, and the duration of mechanical ventilation, ICU stay, and 28-day mortality were recorded. RESULTS The cumulative fluid balance of the two groups were positive on day 1 and negative on days 3 and 7 after ICU admission; at the same time points, the patients in the treatment group had significantly greater negative fluid balance than those in the control group (P < 0.05). In both of the groups, the ONSD and MCA-PI values were significantly higher on day 1 than the baseline (P < 0.05), reached the peak levels on day 3, and decreased on day 7; at the same time point, these values were significantly lower in the treatment group than in the control group (P < 0.05). No significant difference was found in NSE level on day 1 between the two groups (P>0.05); on day 3, NSE level reached the peak level and was significantly higher in the control group (P < 0.05); on day 7, NSE level was lowered the level of day 1 in the treatment group but remained higher than day 1 level in the control group. The 28-day mortality rate did not differ significantly between the two groups (16.00% vs 23.08%, P>0.05); the duration of mechanical ventilation, length of ICU stay, and the number of tracheotomy were all significantly shorter or lower in the treatment group than in the control group (P < 0.05). CONCLUSIONS Restrictive fluid management can reduce cerebral edema and improve the prognosis but does not affect the 28-day mortality of patients with sTBI.
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Affiliation(s)
- Shibing Zhao
- Department of Critical Medicine, First Affiliated Hospital of Bengbu Medical College, Bengbu 233004, China
| | - Decai Xu
- Department of Neurosurgery, First Affiliated Hospital of Bengbu Medical College, Bengbu 233004, China
| | - Rui Li
- Department of Critical Medicine, First Affiliated Hospital of Bengbu Medical College, Bengbu 233004, China
| | - Qi Zou
- Department of Critical Medicine, First Affiliated Hospital of Bengbu Medical College, Bengbu 233004, China
| | - Zhenzhen Chen
- Department of Critical Medicine, First Affiliated Hospital of Bengbu Medical College, Bengbu 233004, China
| | - Huaxue Wang
- Department of Critical Medicine, First Affiliated Hospital of Bengbu Medical College, Bengbu 233004, China
| | - Xiandi He
- Department of Critical Medicine, First Affiliated Hospital of Bengbu Medical College, Bengbu 233004, China
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Chow RS. Terms, Definitions, Nomenclature, and Routes of Fluid Administration. Front Vet Sci 2021; 7:591218. [PMID: 33521077 PMCID: PMC7844884 DOI: 10.3389/fvets.2020.591218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 12/02/2020] [Indexed: 12/14/2022] Open
Abstract
Fluid therapy is administered to veterinary patients in order to improve hemodynamics, replace deficits, and maintain hydration. The gradual expansion of medical knowledge and research in this field has led to a proliferation of terms related to fluid products, fluid delivery and body fluid distribution. Consistency in the use of terminology enables precise and effective communication in clinical and research settings. This article provides an alphabetical glossary of important terms and common definitions in the human and veterinary literature. It also summarizes the common routes of fluid administration in small and large animal species.
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Affiliation(s)
- Rosalind S Chow
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, University of Minnesota, St. Paul, MI, United States
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29
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Ndieugnou Djangang N, Ramunno P, Izzi A, Garufi A, Menozzi M, Diaferia D, Peluso L, Prezioso C, Talamonti M, Njimi H, Schuind S, Vincent JL, Creteur J, Taccone FS, Gouvea Bogossian E. The Prognostic Role of Lactate Concentrations after Aneurysmal Subarachnoid Hemorrhage. Brain Sci 2020; 10:brainsci10121004. [PMID: 33348866 PMCID: PMC7766816 DOI: 10.3390/brainsci10121004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/04/2020] [Accepted: 12/16/2020] [Indexed: 12/14/2022] Open
Abstract
Blood lactate concentrations are often used to assess global tissue perfusion in critically ill patients; however, there are scarce data on lactate concentrations after subarachnoid hemorrhage (SAH). We aimed to assess the prognostic role of serial blood lactate measurements on hospital mortality and neurological outcomes at 3 months after SAH. We reviewed all SAH patients admitted to the intensive care unit from 2007 to 2019 and recorded the highest daily arterial lactate concentration for the first 6 days. Patients with no lactate concentration were excluded. Hyperlactatemia was defined as a blood lactate concentration >2.0 mmol/L. A total of 456 patients were included: 158 (35%) patients died in hospital and 209 (46%) had an unfavorable outcome (UO) at 3 months. The median highest lactate concentration was 2.7 (1.8–3.9) mmol/L. Non-survivors and patients with UO had significantly higher lactate concentrations compared to other patients. Hyperlactatemia increased the chance of dying (OR 4.19 (95% CI 2.38–7.39)) and of having UO in 3 months (OR 4.16 (95% CI 2.52–6.88)) after adjusting for confounding factors. Therefore, initial blood lactate concentrations have prognostic implications in patients with SAH; their role in conjunction with other prognostic indicators should be evaluated in prospective studies.
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Affiliation(s)
- Narcisse Ndieugnou Djangang
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808 1070 Brussels, Belgium; (N.N.D.); (P.R.); (A.I.); (A.G.); (M.M.); (D.D.); (L.P.); (C.P.); (M.T.); (H.N.); (J.-L.V.); (J.C.); (F.S.T.)
| | - Pamela Ramunno
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808 1070 Brussels, Belgium; (N.N.D.); (P.R.); (A.I.); (A.G.); (M.M.); (D.D.); (L.P.); (C.P.); (M.T.); (H.N.); (J.-L.V.); (J.C.); (F.S.T.)
| | - Antonio Izzi
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808 1070 Brussels, Belgium; (N.N.D.); (P.R.); (A.I.); (A.G.); (M.M.); (D.D.); (L.P.); (C.P.); (M.T.); (H.N.); (J.-L.V.); (J.C.); (F.S.T.)
| | - Alessandra Garufi
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808 1070 Brussels, Belgium; (N.N.D.); (P.R.); (A.I.); (A.G.); (M.M.); (D.D.); (L.P.); (C.P.); (M.T.); (H.N.); (J.-L.V.); (J.C.); (F.S.T.)
| | - Marco Menozzi
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808 1070 Brussels, Belgium; (N.N.D.); (P.R.); (A.I.); (A.G.); (M.M.); (D.D.); (L.P.); (C.P.); (M.T.); (H.N.); (J.-L.V.); (J.C.); (F.S.T.)
| | - Daniela Diaferia
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808 1070 Brussels, Belgium; (N.N.D.); (P.R.); (A.I.); (A.G.); (M.M.); (D.D.); (L.P.); (C.P.); (M.T.); (H.N.); (J.-L.V.); (J.C.); (F.S.T.)
| | - Lorenzo Peluso
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808 1070 Brussels, Belgium; (N.N.D.); (P.R.); (A.I.); (A.G.); (M.M.); (D.D.); (L.P.); (C.P.); (M.T.); (H.N.); (J.-L.V.); (J.C.); (F.S.T.)
| | - Chiara Prezioso
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808 1070 Brussels, Belgium; (N.N.D.); (P.R.); (A.I.); (A.G.); (M.M.); (D.D.); (L.P.); (C.P.); (M.T.); (H.N.); (J.-L.V.); (J.C.); (F.S.T.)
| | - Marta Talamonti
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808 1070 Brussels, Belgium; (N.N.D.); (P.R.); (A.I.); (A.G.); (M.M.); (D.D.); (L.P.); (C.P.); (M.T.); (H.N.); (J.-L.V.); (J.C.); (F.S.T.)
| | - Hassane Njimi
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808 1070 Brussels, Belgium; (N.N.D.); (P.R.); (A.I.); (A.G.); (M.M.); (D.D.); (L.P.); (C.P.); (M.T.); (H.N.); (J.-L.V.); (J.C.); (F.S.T.)
| | - Sophie Schuind
- Department of Neurosurgery, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808 1070 Brussels, Belgium;
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808 1070 Brussels, Belgium; (N.N.D.); (P.R.); (A.I.); (A.G.); (M.M.); (D.D.); (L.P.); (C.P.); (M.T.); (H.N.); (J.-L.V.); (J.C.); (F.S.T.)
| | - Jacques Creteur
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808 1070 Brussels, Belgium; (N.N.D.); (P.R.); (A.I.); (A.G.); (M.M.); (D.D.); (L.P.); (C.P.); (M.T.); (H.N.); (J.-L.V.); (J.C.); (F.S.T.)
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808 1070 Brussels, Belgium; (N.N.D.); (P.R.); (A.I.); (A.G.); (M.M.); (D.D.); (L.P.); (C.P.); (M.T.); (H.N.); (J.-L.V.); (J.C.); (F.S.T.)
| | - Elisa Gouvea Bogossian
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808 1070 Brussels, Belgium; (N.N.D.); (P.R.); (A.I.); (A.G.); (M.M.); (D.D.); (L.P.); (C.P.); (M.T.); (H.N.); (J.-L.V.); (J.C.); (F.S.T.)
- Correspondence:
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30
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Quiñones-Ossa GA, Shrivastava A, Perdomo WAF, Moscote-Salazar LR, Agrawal A. Immunomodulatory Effect of Hypertonic Saline Solution in Traumatic Brain-Injured Patients and Intracranial Hypertension. INDIAN JOURNAL OF NEUROTRAUMA 2020. [DOI: 10.1055/s-0040-1713329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
AbstractTraumatic brain injury (TBI) is often associated with an increase in the intracranial pressure (ICP). This increase in ICP can cross the physiological range and lead to a reduction in cerebral perfusion pressure (CPP) and the resultant cerebral blood flow (CBF). It is this reduction in the CBF that leads to the secondary damage to the neural parenchyma along with the physical axonal and neuronal damage caused by the mass effect. In certain cases, a surgical intervention may be required to either remove the mass lesion (hematoma of contusion evacuation) or provide more space to the insulted brain to expand (decompressive craniectomy). Whether or not a surgical intervention is performed, all these patients require some form of pharmaceutical antiedema agents to bring down the raised ICP. These agents have been broadly classified as colloids (e.g., mannitol, glycerol, urea) and crystalloids (e.g., hypertonic saline), and have been used since decades. Even though mannitol has been the workhorse for ICP reduction owing to its unique properties, crystalloids have been found to be the preferred agents, especially when long-term use is warranted. The safest and most widely used agent is hypertonic saline in various concentrations. Whatever be the concentration, hypertonic saline has created special interest among physicians owing to its additional property of immunomodulation and neuroprotection. In this review, we summarize and understand the various mechanism by which hypertonic saline exerts its immunomodulatory effects that helps in neuroprotection after TBI.
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Affiliation(s)
| | - Adesh Shrivastava
- Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | | | - Luis R. Moscote-Salazar
- Department of Neurocritical Care, Faculty of Medicine, University of Cartagena, Cartagena, Colombia
| | - Amit Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
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31
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Park SH, Kim TJ, Jeong HB, Ko SB. Lack of Association between Low Cumulative Dose of Hydroxyethyl Starch and Acute Kidney Injury in Patients with Acute Ischemic Stroke. J Korean Med Sci 2020; 35:e325. [PMID: 33075852 PMCID: PMC7572228 DOI: 10.3346/jkms.2020.35.e325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 08/04/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Hydroxyethyl starch (HES, 6% 130/0.4) has been used as a volume expander for the treatment of cerebral hypoperfusion in acute ischemic stroke. Although HES use was associated with renal failure in sepsis or critical illness, it still remains to be elucidated whether HES is linked to renal adverse events in patients with acute ischemic stroke. METHODS A total of 524 patients with acute ischemic stroke within 7 days of onset were included between January 2012 and May 2016. Renal function on admission and follow-up on day 7 ± 2 was assessed using serum creatinine (SCr) and estimated glomerular filtration rate (eGFR). Propensity score matching (PSM) was used to perform a 1:1 matched-pair analysis to minimize the group differences caused by covariates. The percentage of patients with new-onset acute renal injury (AKI) using the Kidney Disease: Improving Global Outcomes or good functional outcome (modified Rankin Scale 0-2) at 90 days were compared between HES cohort and controls. RESULTS Among the included patients (mean age, 68.6 years; male, 56.5%), 81 patients (15.5%) were HES cohort (median cumulative dose, 1,450 mL). Baseline renal function was better in HES cohort compared to that in the controls (SCr, 0.87 ± 0.43 mg/dL vs. 1.15 ± 1.15 mg/dL, P < 0.001; eGFR, 86.91 ± 24.27 mL/min vs. 74.55 ± 29.58 mL/min, P < 0.001), which became not significant in PSM cohort (72 pairs). The percentage of new-onset AKI did not differ between the HES cohort and controls (1.4% vs. 1.4%, P = 1.000). In addition, new-onset AKI was not related to HES (odds ratio, 1.422; 95% confidence interval, 0.072-28.068; P = 0.817) after adjusting for confounders. HES cohort tended to have higher percentage of good functional outcome at 90 days compared to controls, which failed to reach statistical significance (68.1% vs. 54.2%, P = 0.087). CONCLUSION A low cumulative dose of HES was not associated with renal adverse events in patients with acute ischemic stroke.
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Affiliation(s)
- Soo Hyun Park
- Department of Neurology, Inha University Hospital, Incheon, Korea
- Department of Critical Care Medicine, Inha University Hospital, Incheon, Korea
- Department of Hospital Medicine, Inha University Hospital, Incheon, Korea
| | - Tae Jung Kim
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea
| | - Hae Bong Jeong
- Department of Neurology, Chung-Ang University Hospital, Seoul, Korea
| | - Sang Bae Ko
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea.
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Schupper AJ, Eagles ME, Neifert SN, Mocco J, Macdonald RL. Lessons from the CONSCIOUS-1 Study. J Clin Med 2020; 9:jcm9092970. [PMID: 32937959 PMCID: PMC7564635 DOI: 10.3390/jcm9092970] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/02/2020] [Accepted: 09/09/2020] [Indexed: 12/25/2022] Open
Abstract
After years of research on treatment of aneurysmal subarachnoid hemorrhage (aSAH), including randomized clinical trials, few treatments have been shown to be efficacious. Nevertheless, reductions in morbidity and mortality have occurred over the last decades. Reasons for the improved outcomes remain unclear. One randomized clinical trial that has been examined in detail with these questions in mind is Clazosentan to Overcome Neurological Ischemia and Infarction Occurring After Subarachnoid Hemorrhage (CONSCIOUS-1). This was a phase-2 trial testing the effect of clazosentan on angiographic vasospasm (aVSP) in patients with aSAH. Clazosentan decreased moderate to severe aVSP. There was no statistically significant effect on the extended Glasgow outcome score (GOS), although the study was not powered for this endpoint. Data from the approximately 400 patients in the study were detailed, rigorously collected and documented and were generously made available to one investigator. Post-hoc analyses were conducted which have expanded our knowledge of the management of aSAH. We review those analyses here.
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Affiliation(s)
- Alexander J. Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (A.J.S.); (S.N.N.); (J.M)
| | - Matthew E. Eagles
- Department of Clinical Neurosciences, Division of Neurosurgery, Alberta Children’s Hospital, University of Calgary, Alberta, AB T3B 6A8, Canada;
| | - Sean N. Neifert
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (A.J.S.); (S.N.N.); (J.M)
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (A.J.S.); (S.N.N.); (J.M)
| | - R. Loch Macdonald
- Department of Neurological Surgery, UCSF Fresno, Fresno, CA 93701, USA
- Correspondence: ; Tel.: +1 (559) 459-3705
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Beaubien-Souligny W, Cavayas YA, Denault A, Lamarche Y. First step toward uncovering perioperative congestive encephalopathy. J Thorac Cardiovasc Surg 2020; 161:S0022-5223(20)31087-4. [PMID: 32624312 DOI: 10.1016/j.jtcvs.2020.02.146] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 02/05/2020] [Accepted: 02/05/2020] [Indexed: 12/18/2022]
Affiliation(s)
- William Beaubien-Souligny
- Department of Anesthesiology, Intensive Care Unit, Montreal Heart Institute, Université de Montréal, Montreal, Québec, Canada; Division of Nephrology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - Yiorgos Alexandros Cavayas
- Department of Cardiac Surgery, Intensive Care Unit, Montreal Heart Institute, Université de Montréal, Montreal, Québec, Canada; Department of Medicine, Hôpital Sacré-Coeur de Montréal, Montreal, Québec, Canada
| | - André Denault
- Department of Anesthesiology, Intensive Care Unit, Montreal Heart Institute, Université de Montréal, Montreal, Québec, Canada; Division of Intensive Care, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - Yoan Lamarche
- Department of Cardiac Surgery, Intensive Care Unit, Montreal Heart Institute, Université de Montréal, Montreal, Québec, Canada; Department of Cardiac Surgery, Hôpital Sacré-Coeur de Montréal, Montreal, Québec, Canada.
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Kurtz P, Rocha EEM. Nutrition Therapy, Glucose Control, and Brain Metabolism in Traumatic Brain Injury: A Multimodal Monitoring Approach. Front Neurosci 2020; 14:190. [PMID: 32265626 PMCID: PMC7105880 DOI: 10.3389/fnins.2020.00190] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 02/21/2020] [Indexed: 12/19/2022] Open
Abstract
The goal of neurocritical care in patients with traumatic brain injury (TBI) is to prevent secondary brain damage. Pathophysiological mechanisms lead to loss of body mass, negative nitrogen balance, dysglycemia, and cerebral metabolic dysfunction. All of these complications have been shown to impact outcomes. Therapeutic options are available that prevent or mitigate their negative impact. Nutrition therapy, glucose control, and multimodality monitoring with cerebral microdialysis (CMD) can be applied as an integrated approach to optimize systemic immune and organ function as well as adequate substrate delivery to the brain. CMD allows real-time bedside monitoring of aspects of brain energy metabolism, by measuring specific metabolites in the extracellular fluid of brain tissue. Sequential monitoring of brain glucose and lactate/pyruvate ratio may reveal pathologic processes that lead to imbalances in supply and demand. Early recognition of these patterns may help individualize cerebral perfusion targets and systemic glucose control following TBI. In this direction, recent consensus statements have provided guidelines and recommendations for CMD applications in neurocritical care. In this review, we summarize data from clinical research on patients with severe TBI focused on a multimodal approach to evaluate aspects of nutrition therapy, such as timing and route; aspects of systemic glucose management, such as intensive vs. moderate control; and finally, aspects of cerebral metabolism. Research and clinical applications of CMD to better understand the interplay between substrate supply, glycemic variations, insulin therapy, and their effects on the brain metabolic profile were also reviewed. Novel mechanistic hypotheses in the interpretation of brain biomarkers were also discussed. Finally, we offer an integrated approach that includes nutritional and brain metabolic monitoring to manage severe TBI patients.
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Affiliation(s)
- Pedro Kurtz
- Department of Neurointensive Care, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil.,Department of Intensive Care Medicine, Hospital Copa Star, Rio de Janeiro, Brazil
| | - Eduardo E M Rocha
- Department of Intensive Care Medicine, Hospital Copa Star, Rio de Janeiro, Brazil
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The Effect of Fluid Loading and Hypertonic Saline Solution on Cortical Cerebral Microcirculation and Glycocalyx Integrity. J Neurosurg Anesthesiol 2020; 31:434-443. [PMID: 30015696 DOI: 10.1097/ana.0000000000000528] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Fluid loading and hyperosmolar solutions can modify the cortical brain microcirculation and the endothelial glycocalyx (EG). This study compared the short-term effects of liberal fluid loading with a restrictive fluid intake followed by osmotherapy with hypertonic saline (HTS) on cerebral cortical microcirculation and EG integrity in a rabbit craniotomy model. METHODS The experimental rabbits were allocated randomly to receive either <2 mL/kg/h (group R, n=14) or 30 mL/kg/h (group L, n=14) of balanced isotonic fluids for 1 hour. Then, the animals were randomized to receive 5 mL/kg intravenous infusion of either 3.2% saline (group HTS, n=14) or 0.9% saline (group normal saline, n=13) in a 20-minute infusion. Microcirculation in the cerebral cortex based on sidestream dark-field imaging, a morphologic index of glycocalyx damage to sublingual and cortical brain microcirculation (the perfused boundary region), and serum syndecan-1 levels were evaluated. RESULTS Lower cortical brain perfused small vessel density (P=0.0178), perfused vessel density (P=0.0286), and total vessel density (P=0.0447) were observed in group L, compared with group R. No differences were observed between the HTS and normal saline groups after osmotherapy. Cerebral perfused boundary region values (P=0.0692) and hematocrit-corrected serum syndecan-1 levels (P=0.0324) tended to be higher in group L than in group R animals. CONCLUSIONS Liberal fluid loading was associated with altered cortical cerebral microcirculation and EG integrity parameters. The 3.2% saline treatment did not affect cortical cerebral microcirculation or EG integrity markers.
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Performance of Electrical Velocimetry for Noninvasive Cardiac Output Measurements in Perioperative Patients After Subarachnoid Hemorrhage. J Neurosurg Anesthesiol 2020; 31:422-427. [PMID: 29939977 DOI: 10.1097/ana.0000000000000519] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Fluid therapy guided by cardiac output measurements is of particular importance for adequate cerebral perfusion and oxygenation in neurosurgical patients. We examined the usefulness of a noninvasive electrical velocimetry (EV) device based on the thoracic bioimpedance method for perioperative hemodynamic monitoring in patients after aneurysmal subarachnoid hemorrhage. PATIENTS AND METHODS In total, 18 patients who underwent surgical clipping or endovascular coiling for ruptured aneurysms were examined prospectively. Simultaneous cardiac index (CI) measurements obtained with EV (CIEV) and reference transpulmonary thermodilution (CITPTD) were compared. A total of 223 pairs of data were collected. RESULTS A significant correlation was found between CIEV and CITPTD (r=0.86; P<0.001). Bland and Altman analysis revealed a bias between CIEV and CITPTD of -0.06 L/min/m, with limits of agreement of ±1.14 L/min/m and a percentage error of 33%. Although the percentage error for overall data was higher than the acceptable limit of 30%, subgroup analysis during the postoperative phase showed better agreement (23% vs. 42% during the intraprocedure phase). Four-quadrant plot and polar plot analyses showed fair-to-poor trending abilities (concordance rate of 90% to 91%, angular bias of +17 degrees, radial limits of agreement between ±37 and ±40 degrees, and polar concordance rate of 72% to 75%), including the subgroup analysis. CONCLUSIONS Absolute CI values obtained from EV and TPTD are not interchangeable with TPTD for perioperative use in subarachnoid hemorrhage patients. However, considering the moderate levels of agreement with marginal trending ability during the early postoperative phase, this user-friendly device can provide an attractive monitoring option during neurocritical care.
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Vergouw LJM, Egal M, Bergmans B, Dippel DWJ, Lingsma HF, Vergouwen MDI, Willems PWA, Oldenbeuving AW, Bakker J, van der Jagt M. High Early Fluid Input After Aneurysmal Subarachnoid Hemorrhage: Combined Report of Association With Delayed Cerebral Ischemia and Feasibility of Cardiac Output-Guided Fluid Restriction. J Intensive Care Med 2020; 35:161-169. [PMID: 28934895 PMCID: PMC6927070 DOI: 10.1177/0885066617732747] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Revised: 08/01/2017] [Accepted: 08/31/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND Guidelines on the management of aneurysmal subarachnoid hemorrhage (aSAH) recommend euvolemia, whereas hypervolemia may cause harm. We investigated whether high early fluid input is associated with delayed cerebral ischemia (DCI), and if fluid input can be safely decreased using transpulmonary thermodilution (TPT). METHODS We retrospectively included aSAH patients treated at an academic intensive care unit (2007-2011; cohort 1) or managed with TPT (2011-2013; cohort 2). Local guidelines recommended fluid input of 3 L daily. More fluids were administered when daily fluid balance fell below +500 mL. In cohort 2, fluid input in high-risk patients was guided by cardiac output measured by TPT per a strict protocol. Associations of fluid input and balance with DCI were analyzed with multivariable logistic regression (cohort 1), and changes in hemodynamic indices after institution of TPT assessed with linear mixed models (cohort 2). RESULTS Cumulative fluid input 0 to 72 hours after admission was associated with DCI in cohort 1 (n=223; odds ratio [OR] 1.19/L; 95% confidence interval 1.07-1.32), whereas cumulative fluid balance was not. In cohort 2 (23 patients), using TPT fluid input could be decreased from 6.0 ± 1.0 L before to 3.4 ± 0.3 L; P = .012), while preload parameters and consciousness remained stable. CONCLUSION High early fluid input was associated with DCI. Invasive hemodynamic monitoring was feasible to reduce fluid input while maintaining preload. These results indicate that fluid loading beyond a normal preload occurs, may increase DCI risk, and can be minimized with TPT.
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Affiliation(s)
- Leonie J. M. Vergouw
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Mohamud Egal
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Bas Bergmans
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Diederik W. J. Dippel
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Hester F. Lingsma
- Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Mervyn D. I. Vergouwen
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Peter W. A. Willems
- Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Jan Bakker
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Mathieu van der Jagt
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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Dhara S, Moore EE, Yaffe MB, Moore HB, Barrett CD. Modern Management of Bleeding, Clotting, and Coagulopathy in Trauma Patients: What Is the Role of Viscoelastic Assays? CURRENT TRAUMA REPORTS 2020; 6:69-81. [PMID: 32864298 DOI: 10.1007/s40719-020-00183-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Purpose of Review The purpose of this review is to briefly outline the current state of hemorrhage control and resuscitation in trauma patients with a specific focus on the role viscoelastic assays have in this complex management, to include indications for use across all phases of care in the injured patient. Recent Findings Viscoelastic assay use to guide blood-product resuscitation in bleeding trauma patients can reduce mortality by up to 50%. Viscoelastic assays also reduce total blood products transfused, reduce ICU length of stay, and reduce costs. There are a large number of observational and retrospective studies evaluating viscoelastic assay use in the initial trauma resuscitation, but only one randomized control trial. There is a paucity of data evaluating use of viscoelastic assays in the operating room, post-operatively, and during ICU management in trauma patients, rendering their use in these settings extrapolative/speculative based on theory and data from other surgical disciplines and settings. Summary Both hypocoagulable and hypercoagulable states exist in trauma patients, and better indicate what therapy may be most appropriate. Further study is needed, particularly in the operating room and post-operative/ICU settings in trauma patients.
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Affiliation(s)
- Sanjeev Dhara
- University of Chicago School of Medicine, Chicago, IL
| | - Ernest E Moore
- Department of Surgery, University of Colorado Denver, Denver, CO
| | - Michael B Yaffe
- Koch Institute for Integrative Cancer Research, Center for Precision Cancer Medicine, Massachusetts Institute of Technology, Cambridge, MA
| | - Hunter B Moore
- Department of Surgery, University of Colorado Denver, Denver, CO
| | - Christopher D Barrett
- Koch Institute for Integrative Cancer Research, Center for Precision Cancer Medicine, Massachusetts Institute of Technology, Cambridge, MA
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de Oliveira Manoel AL, van der Jagt M, Amin-Hanjani S, Bambakidis NC, Brophy GM, Bulsara K, Claassen J, Connolly ES, Hoffer SA, Hoh BL, Holloway RG, Kelly AG, Mayer SA, Nakaji P, Rabinstein AA, Vajkoczy P, Vergouwen MDI, Woo H, Zipfel GJ, Suarez JI. Common Data Elements for Unruptured Intracranial Aneurysms and Aneurysmal Subarachnoid Hemorrhage: Recommendations from the Working Group on Hospital Course and Acute Therapies-Proposal of a Multidisciplinary Research Group. Neurocrit Care 2020; 30:36-45. [PMID: 31119687 DOI: 10.1007/s12028-019-00726-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
INTRODUCTION The Common Data Elements (CDEs) initiative is a National Institute of Health/National Institute of Neurological Disorders and Stroke (NINDS) effort to standardize naming, definitions, data coding, and data collection for observational studies and clinical trials in major neurological disorders. A working group of experts was established to provide recommendations for Unruptured Aneurysms and Aneurysmal Subarachnoid Hemorrhage (SAH) CDEs. METHODS This paper summarizes the recommendations of the Hospital Course and Acute Therapies after SAH working group. Consensus recommendations were developed by assessment of previously published CDEs for traumatic brain injury, stroke, and epilepsy. Unruptured aneurysm- and SAH-specific CDEs were also developed. CDEs were categorized into "core", "supplemental-highly recommended", "supplemental" and "exploratory". RESULTS We identified and developed CDEs for Hospital Course and Acute Therapies after SAH, which included: surgical and procedure interventions; rescue therapy for delayed cerebral ischemia (DCI); neurological complications (i.e. DCI; hydrocephalus; rebleeding; seizures); intensive care unit therapies; prior and concomitant medications; electroencephalography; invasive brain monitoring; medical complications (cardiac dysfunction; pulmonary edema); palliative comfort care and end of life issues; discharge status. The CDEs can be found at the NINDS Web site that provides standardized naming, and definitions for each element, and also case report form templates, based on the CDEs. CONCLUSION Most of the recommended Hospital Course and Acute Therapies CDEs have been newly developed. Adherence to these recommendations should facilitate data collection and data sharing in SAH research, which could improve the comparison of results across observational studies, clinical trials, and meta-analyses of individual patient data.
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Affiliation(s)
- Airton Leonardo de Oliveira Manoel
- Neuroscience Research Program in the Keenan Research Centre for Biomedical Science of St. Michael's Hospital, University of Toronto, Toronto, Canada. .,Adult Critical Care Unit, Department of Critical Care Medicine, Hospital Paulistano - UnitedHealth Group Brazil, Rua Martiniano de Carvalho, 741, Bela Vista, São Paulo, SP, 01321-001, Brazil.
| | - Mathieu van der Jagt
- Department of Intensive Care Adults, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | - Nicholas C Bambakidis
- Department of Neurological Surgery, UH Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Gretchen M Brophy
- Department of Pharmacotherapy and Outcomes Science, School of Pharmacy, Richmond, VA, USA
| | - Ketan Bulsara
- Department of Neurosurgery, University of Connecticut, Farmington, CT, USA
| | | | | | - S Alan Hoffer
- Department of Neurological Surgery, UH Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Brian L Hoh
- Department of Neurosurgery, University of Florida, Gainesville, FL, USA
| | - Robert G Holloway
- Department of Neurology, University of Rochester, Rochester, NY, USA
| | - Adam G Kelly
- Department of Neurology, University of Rochester, Rochester, NY, USA
| | - Stephan A Mayer
- Department of Neurology, Henry Ford Health System, Detroit, MI, USA
| | - Peter Nakaji
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | | | - Peter Vajkoczy
- Department of Neurosurgery, Charite Hospital, Universitatsmedizin, Berlin, Germany
| | - Mervyn D I Vergouwen
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Henry Woo
- Department of Neurosurgery and Radiology, Zucker School of Medicine at Hofstra/Northwell Health, New York, NY, USA
| | | | - Jose I Suarez
- Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, USA
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Optimización del manejo del paciente neuroquirúrgico en Medicina Intensiva. Med Intensiva 2019; 43:489-496. [DOI: 10.1016/j.medin.2019.02.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 02/18/2019] [Accepted: 02/21/2019] [Indexed: 01/26/2023]
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Suero Molina E, Di Somma A, Stummer W, Briganti F, Cavallo LM. Clinical Vasospasm After an Extended Endoscopic Endonasal Approach for Recurrent Pituitary Adenoma: Illustrative Case and Systematic Review of the Literature. World Neurosurg 2019; 128:29-36. [DOI: 10.1016/j.wneu.2019.04.046] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 04/03/2019] [Accepted: 04/04/2019] [Indexed: 11/15/2022]
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Pelz JO, Fischer MM, Bungert-Kahl P, Lindner D, Fricke C, Michalski D. Fluid Balance Variations During the Early Phase of Large Hemispheric Stroke Are Associated With Patients' Functional Outcome. Front Neurol 2019; 10:720. [PMID: 31333571 PMCID: PMC6616133 DOI: 10.3389/fneur.2019.00720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Accepted: 06/18/2019] [Indexed: 12/23/2022] Open
Abstract
Background: From the variety of factors underlying the ischemia-associated edema formation in large hemispheric stroke (LHS), an increased brain water content during the early phase seems to have a pivotal role for long-lasting tissue damage. However, the importance of the fluid management during the acute phase of LHS has so far not been adequately studied. Therefore, this study explored the association between the fluid balance and functional outcome in patients suffering from LHS. Methods: We analyzed hospital-based medical records of 39 consecutive patients with LHS and decompressive hemicraniectomy. Over the first 10 days after admission, the volumes of all administered fluids were assessed daily and corrected for daily urinary output and insensible loss. Functional outcome at 3 months was assessed with the modified Rankin Scale (mRS) and dichotomized into an acceptable (mRS ≤ 4) vs. a poor outcome (mRS ≥ 5). Results: Compared to patients with a poor functional outcome (n = 19), those with an acceptable outcome (n = 20) were characterized by a significantly lower cumulative net fluid balance at day 5 (1.6 ± 2.5 vs. 3.4 ± 4.4 l), day 7 (2.0 ± 2.9 vs. 4.6 ± 5.2 l), and day 10 (0 ± 2.5 vs. 5.6 ± 6.2 l). In addition to age, only the cumulative net fluid balance at day 10 served as an independent factor for poor functional outcome in multiple regression analyses. Conclusion: These data provide evidence for a critical role of the early phase net fluid balance with respect to the functional outcome after LHS. This observation leads to the hypothesis that patients with LHS might benefit from a more restrictive volume therapy. However, prospective studies are warranted to establish a causal relationship and recommendations for treatment strategies.
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Affiliation(s)
- Johann Otto Pelz
- Department of Neurology, University of Leipzig, Leipzig, Germany
| | | | - Peggy Bungert-Kahl
- Neurologisches Rehabilitationszentrum Leipzig, University of Leipzig, Leipzig, Germany
| | - Dirk Lindner
- Department of Neurosurgery, University of Leipzig, Leipzig, Germany
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Lima MF, Neville IS, Cavalheiro S, Bourguignon DC, Pelosi P, Malbouisson LMS. Balanced Crystalloids Versus Saline for Perioperative Intravenous Fluid Administration in Children Undergoing Neurosurgery: A Randomized Clinical Trial. J Neurosurg Anesthesiol 2019; 31:30-35. [PMID: 29912723 DOI: 10.1097/ana.0000000000000515] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Balanced crystalloid solutions induce less hyperchloremia than normal saline, but their role as primary fluid replacement for children undergoing surgery is unestablished. We hypothesized that balanced crystalloids induce less chloride and metabolic derangements than 0.9% saline solutions in children undergoing brain tumor resection. METHODS In total, 53 patients (age range, 6 mo to 12 y) were randomized to receive balanced crystalloid (balanced group) or 0.9% saline solution (saline group) during and after (for 24 h) brain tumor resection. Serum electrolyte and arterial blood gas analyses were performed at the beginning of surgery (baseline), after surgery, and at postoperative day 1. The primary trial outcome was the absolute difference in serum chloride concentrations (post-preopΔCl) measured after surgery and at baseline. Secondary outcomes included the post-preopΔ of other electrolytes and base excess (BE); hyperchloremic acidosis incidence; and the brain relaxation score, a 4-point scale evaluated by the surgeon for assessing brain edema. RESULTS Saline infusion increased post-preopΔCl (6 [3.5; 8.5] mmol/L) compared with balanced crystalloid (0 [-1.0; 3.0] mmol/L; P<0.001). Saline use also resulted in increased post-preopΔBE (-4.4 [-5.0; -2.3] vs. -0.4 [-2.7; 1.3] mmol/L; P<0.001) and hyperchloremic acidosis incidence (6/25 [24%] vs. 0; P=0.022) compared with balanced crystalloid. Brain relaxation score was comparable between groups. CONCLUSIONS In children undergoing brain tumor resection, saline infusion increased variation in serum chloride compared with balanced crystalloid. These findings support the use of balanced crystalloid solutions in children undergoing brain tumor resection.
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Affiliation(s)
- Mariana F Lima
- Departments of Anesthesiology.,Department of Anesthesiology
| | - Iuri S Neville
- Neurosurgery, Hospital das Clínicas, University of São Paulo
| | - Sergio Cavalheiro
- Department of Neurosurgery, Federal University of São Paulo, São Paulo, Brazil
| | | | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, San Martino Policlinico Hospital, IRCCS for Oncology, Genoa, Italy
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Chacón-Lozsán F, Pacheco C. Fluid management in the neurointensive care patient using transcranial doppler ultrasound: Preliminary study. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2019. [DOI: 10.1016/j.tacc.2018.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Rossi S, Picetti E, Zoerle T, Carbonara M, Zanier ER, Stocchetti N. Fluid Management in Acute Brain Injury. Curr Neurol Neurosci Rep 2018; 18:74. [PMID: 30206730 DOI: 10.1007/s11910-018-0885-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
PURPOSE OF THE REVIEW The aims of fluid management in acute brain injury are to preserve or restore physiology and guarantee appropriate tissue perfusion, avoiding potential iatrogenic effects. We reviewed the literature, focusing on the clinical implications of the selected papers. Our purposes were to summarize the principles regulating the distribution of water between the intracellular, interstitial, and plasma compartments in the normal and the injured brain, and to clarify how these principles could guide fluid administration, with special reference to intracranial pressure control. RECENT FINDINGS Although a considerable amount of research has been published on this topic and in general on fluid management in acute illness, the quality of the evidence tends to vary. Intravascular volume management should aim for euvolemia. There is evidence of harm with aggressive administration of fluid aimed at achieving hypervolemia in cases of subarachnoid hemorrhage. Isotonic crystalloids should be the preferred agents for volume replacement, while colloids, glucose-containing hypotonic solutions, and other hypotonic solutions or albumin should be avoided. Osmotherapy seems to be effective in intracranial hypertension management; however, there is no clear evidence regarding the superiority of hypertonic saline over mannitol. Fluid therapy plays an important role in the management of acute brain injury patients. However, fluids are a double-edged weapon because of the potential risk of hyper-hydration, hypo- or hyper-osmolar conditions, which may unfavorably affect the clinical course and the outcome.
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Affiliation(s)
- Sandra Rossi
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43100, Parma, Italy.
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43100, Parma, Italy
| | - Tommaso Zoerle
- Neuro ICU, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marco Carbonara
- Neuro ICU, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Elisa R Zanier
- Department of Neuroscience, Laboratory of Acute Brain Injury and Therapeutic Strategies, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Nino Stocchetti
- Neuro ICU, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Physiopathology and Transplantation, Milan University, Milan, Italy
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Thompson M, McIntyre L, Hutton B, Tran A, Wolfe D, Hutchison J, Fergusson D, Turgeon AF, English SW. Comparison of crystalloid resuscitation fluids for treatment of acute brain injury: a clinical and pre-clinical systematic review and network meta-analysis protocol. Syst Rev 2018; 7:125. [PMID: 30115113 PMCID: PMC6097326 DOI: 10.1186/s13643-018-0790-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 07/30/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Current guidelines identify the choice of fluid resuscitation as important in minimizing the incidence of secondary brain injury from cerebral edema. It is widely accepted that isotonic crystalloid resuscitation fluids, specifically normal saline (NS), are optimal for resuscitation and that other relatively hypotonic fluids, such as Ringer's lactate (RL), should be avoided in this patient population. The aim of this review is to systematically compare the use of relatively hypotonic versus isotonic crystalloid resuscitation fluids in clinical and pre-clinical models of acute brain injury and their effect on outcomes. In recognition of the potential need for a network meta-analysis (NMA), we have also included all other relevant crystalloid resuscitation fluids as interventions of relevance to potentially inform indirect comparisons. METHODS Systematic searches of MEDLINE, Embase, and Web of Science BIOSIS Previews® will be used to identify eligible clinical and pre-clinical studies, which included studies examining acute brain injury (human and in vivo animal brain injury models) within the first 7 days of therapy. The intervention of interest is the intravenous use of relatively hypotonic crystalloid resuscitation fluids (e.g., Ringer's lactate, Hartmann's or Plasma Lyte® fluids). The main comparator of interest is an isotonic crystalloid resuscitation fluid, specifically normal saline (0.9%). Other crystalloid resuscitation fluids (e.g., hypertonic saline (3-23.4%)) will also be included as an additional intervention of interest. The primary outcome measures of interest are intracranial pressure (ICP) and cerebral perfusion pressure (CPP). Secondary outcomes include the effect of resuscitation on cerebral edema, brain and serum osmolarity, and electrolyte concentrations and clinical outcomes including modified Rankin Scale (mRS), (extended) Glasgow Outcome Scale (GOS/eGOS), and mortality. Separate meta-analyses will be conducted to quantify the effects of the different fluid resuscitation on acute brain injury outcomes in clinical and pre-clinical populations. Network meta-analyses to compare interventions will also be performed to compare the effects of different interventions. DISCUSSION This systematic review will comprehensively summarize the difference in treatment efficacy of various crystalloid resuscitation fluids in acute brain injury. This review is essential to underscore the evidence, or lack thereof, present in the literature to date to support current preference-driven practice and to direct future study. SYSTEMATIC REVIEW REGISTRATION PROSPERO #CRD42016042960.
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Affiliation(s)
- Mary Thompson
- Clinical Epidemiology Program (CEP), Ottawa Hospital Research Institute, Ottawa, Ontario Canada
| | - Lauralyn McIntyre
- Clinical Epidemiology Program (CEP), Ottawa Hospital Research Institute, Ottawa, Ontario Canada
- Department of Medicine (Critical Care), University of Ottawa, CPCR Building, 501 Smyth Rd, CPCR Box 201B, Ottawa, Ontario K1H 8L6 Canada
| | - Brian Hutton
- Clinical Epidemiology Program (CEP), Ottawa Hospital Research Institute, Ottawa, Ontario Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario Canada
| | - Alexandre Tran
- Department of General Surgery, University of Ottawa, Ottawa, Ontario Canada
| | - Dianna Wolfe
- Clinical Epidemiology Program (CEP), Ottawa Hospital Research Institute, Ottawa, Ontario Canada
| | - Jamie Hutchison
- Department of Critical Care, Sick Kids Hospital, Toronto, Ontario Canada
| | - Dean Fergusson
- Clinical Epidemiology Program (CEP), Ottawa Hospital Research Institute, Ottawa, Ontario Canada
| | - Alexis F. Turgeon
- Clinical Epidemiology Program (CEP), Ottawa Hospital Research Institute, Ottawa, Ontario Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Quebec City, Quebec Canada
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Unit (Trauma - Emergency - Critical Care Medicine), CHU de Québec, Université Laval (Hôpital de L’Enfant-Jésus), Quebec City, Quebec Canada
| | - Shane W. English
- Clinical Epidemiology Program (CEP), Ottawa Hospital Research Institute, Ottawa, Ontario Canada
- Department of Medicine (Critical Care), University of Ottawa, CPCR Building, 501 Smyth Rd, CPCR Box 201B, Ottawa, Ontario K1H 8L6 Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario Canada
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Huang K, Hu Y, Wu Y, Ji Z, Wang S, Lin Z, Pan S. Hyperchloremia Is Associated With Poorer Outcome in Critically Ill Stroke Patients. Front Neurol 2018; 9:485. [PMID: 30018587 PMCID: PMC6037722 DOI: 10.3389/fneur.2018.00485] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 06/04/2018] [Indexed: 12/31/2022] Open
Abstract
Background and Purpose: This study aims to explore the cause and predictive value of hyperchloremia in critically ill stroke patients. Materials and Methods: We conducted a retrospective study of a prospectively collected database of adult patients with first-ever acute ischemic stroke (AIS) or intracerebral hemorrhage (ICH) admitted to the neurointensive care unit (NICU) of a university-affiliated hospital, between January 2013 and December 2016. Patients were excluded if admitted beyond 72 h from onset, if they required neurocritical care for less than 72 h, and were treated with hypertonic saline within 72 h or had creatinine clearance less than 15 mL/min. Results: Of 405 eligible patients, the prevalence of hyperchloremia ([Cl−] ≥ 110 mmol/L) was 8.6% at NICU admission ([Cl−]0) and 17.0% within 72 h ([Cl−]max). Thirty-eight (9.4%) patients had new-onset hyperchloremia and 110 (27.1%) had moderate increase in chloride (Δ[Cl−] ≥ 5 mmol/L; Δ[Cl−] = [Cl−]max − [Cl−]0) in the first 72 h after admission, which were found to be determined by the sequential organ failure assessment score in multivariate logistic regression analysis. Neither total fluid input nor cumulative fluid balance had significant association with such chloride disturbance. New-onset hyperchloremia and every 5 mmol/L increment in Δ[Cl−] were both associated with increased odds of 30-day mortality and 6-month poor outcome, although no independent significance was found in multivariate models. Conclusion: Hyperchloremia tends to occur in patients more severely affected by AIS and ICH. Although no independent association was found, new-onset hyperchloremia and every 5 mmol/L increment in Δ[Cl−] were related to poorer outcome in critically ill AIS and ICH patients. Subject terms: clinical studies, intracranial hemorrhage, ischemic stroke, mortality/survival, quality and outcomes.
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Affiliation(s)
- Kaibin Huang
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yanhong Hu
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yongming Wu
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhong Ji
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shengnan Wang
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhenzhou Lin
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Suyue Pan
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
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Abstract
PURPOSE OF REVIEW Subarachnoid hemorrhage from a ruptured aneurysm (aSAH) is a complex disorder with the potential to have devastating effects on the brain as well as other organ systems. After more than 3 decades of research, the underlying pathophysiologic mechanisms remain incompletely understood and important questions remain regarding the evaluation and management of these patients. The purpose of this review is to analyze the recent literature and improve our understanding of certain key clinical aspects. RECENT FINDINGS Growing body of evidence highlights the usefulness of CT perfusion scans in the diagnosis of vasospasm and delayed cerebral ischemia (DCI). Hypervolemia leads to worse cardiopulmonary outcomes and does not improve DCI. The traditional triple H therapy is falling out of favor with hemodynamic augmentation alone now considered the mainstay of medical management. Randomized controlled trials have shown that simvastatin and intravenous magnesium do not prevent DCI or improve functional outcomes after aneurysmal subarachnoid hemorrhage (aSAH). Emerging data using multimodality monitoring has further advanced our understanding of the pathophysiology of DCI in poor grade aSAH. SUMMARY The brief review will focus on the postinterventional care of aSAH patients outlining the recent advances over the past few years.
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Update on the Treatment of Spontaneous Intraparenchymal Hemorrhage: Medical and Interventional Management. Curr Treat Options Neurol 2018; 20:1. [PMID: 29397452 DOI: 10.1007/s11940-018-0486-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW Spontaneous intraparenchymal hemorrhage (IPH) is a prominent challenge faced globally by neurosurgeons, neurologists, and intensivists. Over the past few decades, basic and clinical research efforts have been undertaken with the goal of delineating biologically and evidence-based practices aimed at decreasing mortality and optimizing the likelihood of meaningful functional outcome for patients afflicted with this devastating condition. Here, the authors review the medical and surgical approaches available for the treatment of spontaneous intraparenchymal hemorrhage, identifying areas of recent progress and ongoing research to delineate the scope and scale of IPH as it is currently understood and treated. RECENT FINDINGS The approaches to IPH have broadly focused on arresting expansion of hemorrhage using a number of approaches. Recent trials have addressed the effectiveness of rapid blood pressure lowering in hypertensive patients with IPH, with rapid lowering demonstrated to be safe and at least partially effective in preventing hematoma expansion. Hemostatic therapy with platelet transfusion in patients on anti-platelet medications has been recently demonstrated to have no benefit and may be harmful. Hemostasis with administration of clotting complexes has not been shown to be effective in reducing hematoma expansion or improving outcomes although correcting these abnormalities as soon as possible remains good practice until further data are available. Stereotactically guided drainage of IPH with intraventricular hemorrhage (IVH) has been shown to be safe and to improve outcomes. Research on new stereotactic surgical methods has begun to show promise. Patients with IPH should have rapid and accurate diagnosis with neuroimaging with computed tomography (CT) and computed tomography angiography (CTA). Early interventions should include control of hypertension to a systolic BP in the range of 140 mmHg for small hemorrhages without intracranial hypertension with beta blockers or calcium channel blockers, correction of any coagulopathy if present, and assessment of the need for surgical intervention. IPH and FUNC (Functional Outcome in Patients with Primary Intracerebral Hemorrhage) scores should be assessed. Patients should be dispositioned to a dedicated neurologic ICU if available. Patients should be monitored for seizures and intracranial pressure issues. Select patients, particularly those with intraventricular extension, may benefit from evacuation of hematoma with a ventriculostomy or stereotactically guided catheter. Once stabilized, patients should be reassessed with CT imaging and receive ongoing management of blood pressure, cerebral edema, ICP issues, and seizures as they arise. The goal of care for most patients is to regain capacity to receive multidisciplinary rehabilitation to optimize functional outcome.
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Asehnoune K, Lasocki S, Seguin P, Geeraerts T, Perrigault PF, Dahyot-Fizelier C, Paugam Burtz C, Cook F, Demeure dit latte D, Cinotti R, Mahe PJ, Fortuit C, Pirracchio R, Feuillet F, Sébille V, Roquilly A. Association between continuous hyperosmolar therapy and survival in patients with traumatic brain injury - a multicentre prospective cohort study and systematic review. Crit Care 2017; 21:328. [PMID: 29282104 PMCID: PMC5745762 DOI: 10.1186/s13054-017-1918-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 12/05/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Intracranial hypertension (ICH) is a major cause of death after traumatic brain injury (TBI). Continuous hyperosmolar therapy (CHT) has been proposed for the treatment of ICH, but its effectiveness is controversial. We compared the mortality and outcomes in patients with TBI with ICH treated or not with CHT. METHODS We included patients with TBI (Glasgow Coma Scale ≤ 12 and trauma-associated lesion on brain computed tomography (CT) scan) from the databases of the prospective multicentre trials Corti-TC, BI-VILI and ATLANREA. CHT consisted of an intravenous infusion of NaCl 20% for 24 hours or more. The primary outcome was the risk of survival at day 90, adjusted for predefined covariates and baseline differences, allowing us to reduce the bias resulting from confounding factors in observational studies. A systematic review was conducted including studies published from 1966 to December 2016. RESULTS Among the 1086 included patients, 545 (51.7%) developed ICH (143 treated and 402 not treated with CHT). In patients with ICH, the relative risk of survival at day 90 with CHT was 1.43 (95% CI, 0.99-2.06, p = 0.05). The adjusted hazard ratio for survival was 1.74 (95% CI, 1.36-2.23, p < 0.001) in propensity-score-adjusted analysis. At day 90, favourable outcomes (Glasgow Outcome Scale 4-5) occurred in 45.2% of treated patients with ICH and in 35.8% of patients with ICH not treated with CHT (p = 0.06). A review of the literature including 1304 patients from eight studies suggests that CHT is associated with a reduction of in-ICU mortality (intervention, 112/474 deaths (23.6%) vs. control, 244/781 deaths (31.2%); OR 1.42 (95% CI, 1.04-1.95), p = 0.03, I 2 = 15%). CONCLUSIONS CHT for the treatment of posttraumatic ICH was associated with improved adjusted 90-day survival. This result was strengthened by a review of the literature.
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Affiliation(s)
- Karim Asehnoune
- Intensive Care Unit, Anaesthesia and Critical Care Department, Hôtel Dieu - HME, CHU Nantes, Nantes, France
- CHU de Nantes, Service d’Anesthésie Réanimation, 1 place Alexis Ricordeau, 44093 Nantes, Cedex 1, France
| | - Sigismond Lasocki
- Department of Anaesthesiology and Critical Care Department, University Hospital of Angers, Angers, France
| | - Philippe Seguin
- Intensive Care Unit, Anaesthesia and Critical Care Department, Pontchaillou, University Hospital of Rennes, Rennes, France
| | - Thomas Geeraerts
- Anaesthesia and Critical Care Department, University Hospital of Toulouse, Toulouse, France
| | - Pierre François Perrigault
- Intensive Care Unit, Anaesthesia and Critical Care Department, Gui Chauliac University Hospital of Montpellier, Montpellier, France
| | - Claire Dahyot-Fizelier
- Neuro-Intensive Care Unit, Anaesthesia and Critical Care Department, Poitiers, University Hospital of Poitiers, Poitiers, France
| | - Catherine Paugam Burtz
- Intensive Care Unit, Anaesthesia and Critical Care Department, Beaujon, University Hospital of Beaujon (AP-HP), Beaujon, France
| | - Fabrice Cook
- Intensive Care Unit, Anaesthesia and Critical Care Department, Henri Mondor, University Hospital of Créteil (AP-HP), Créteil, France
| | | | - Raphael Cinotti
- Intensive Care Unit, Anaesthesia and Critical Care Department, Hôtel Dieu - HME, CHU Nantes, Nantes, France
| | - Pierre Joachim Mahe
- Intensive Care Unit, Anaesthesia and Critical Care Department, Hôtel Dieu - HME, CHU Nantes, Nantes, France
| | - Camille Fortuit
- Intensive Care Unit, Anaesthesia and Critical Care Department, Hôtel Dieu - HME, CHU Nantes, Nantes, France
| | - Romain Pirracchio
- Department of Anesthesia and Critical care Medicine, Hôpital Européen Georges Pompidou, Paris 5 Descartes, Sorbonne Paris Cité, Paris, France
- NSERM UMR-S1153, Team ECSTRA, Hôpital Saint Louis, Paris, France
| | - Fanny Feuillet
- UMR 1246 SPHERE “methodS in Patients-centered outcomes and HEalth ResEarch”, Nantes University, Nantes, France
| | - Véronique Sébille
- UMR 1246 SPHERE “methodS in Patients-centered outcomes and HEalth ResEarch”, Nantes University, Nantes, France
- Plateforme de Biométrie, Département Promotion de la Recherche Clinique, University Hospital of Nantes, Nantes, France
| | - Antoine Roquilly
- Intensive Care Unit, Anaesthesia and Critical Care Department, Hôtel Dieu - HME, CHU Nantes, Nantes, France
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