Risk Factors for External Ventricular Drainage-Related Infection: A Systematic Review and Meta-analysis

Human platelet lysate: a potential therapeutic for intracerebral hemorrhage

Intracerebral hemorrhage (ICH) is a major public health challenge worldwide, and is associated with elevated rates of mortality, disability, and morbidity, especially in low- and middle-income nations. However, our knowledge of the detailed molecular processes involved in ICH remains insufficient, particularly those involved in the secondary injury stage, resulting in a lack of effective treatments for ICH. Human platelet lysates (HPL) are abundant in bioactive factors, and numerous studies have demonstrated their beneficial effects on neurological diseases, including their anti-neuroinflammatory ability, anti-oxidant effects, maintenance of blood-brain barrier integrity, and promotion of neurogenesis. In this review, we thoroughly explore the potential of HPL for treating ICH from three critical perspectives: the rationale for selecting HPL as a treatment for ICH, the mechanisms through which HPL contributes to ICH management, and the additional measures necessary for HPL as a treatment for ICH. We elucidate the role of platelets in ICH pathophysiology and highlight the limitations of the current treatment options and advancements in preclinical research on the application of HPL in neurological disorders. Furthermore, historical developments and preparation methods of HPL in the field of biomedicine are discussed. Additionally, we summarize the bioactive molecules present in HPL and their potential therapeutic effects in ICH. Finally, we outline the issues that must be addressed regarding utilizing HPL as a treatment modality for ICH.

Evaluating the Benefits of Ventriculostomy Compared to Intracranial Pressure Monitoring for Severe Pediatric Traumatic Brain Injury

BACKGROUND

In this study, we compared outcomes between intracranial pressure monitoring (ICP) only versus ventriculostomy (VT) using a nationwide database of pediatric trauma patients.

METHODS

Pediatric patients (<18 years) with severe blunt TBI who underwent ICP monitoring with or without VT were identified from the 2017-2021 ACS Trauma Quality Programs. We excluded patients who experienced death or craniotomy/craniectomy within 48 h. The primary outcome was discharge disposition. Secondary outcomes were subsequent intracranial surgery, length of stay (LOS), and infectious complications. Competing risks survival analysis was used to evaluate the multivariable association between ICP vs. VT and outcomes.

RESULTS

Of 1719 eligible patients, 65.9% were male and 54.1% had VT. Between the ICP and VT groups, there were no differences in mean age (11.4 vs. 11.0 years, p = 0.145), injury severity score (30.9 vs. 30.9, p = 0.937), or median GCS (3 vs. 3, p = 0.120). Multivariable analysis showed a robust association between VT and discharge home (compared to rehabilitation center; sHR 0.85, 95% CI 0.74-0.97, p = 0.017). VT use was not associated with increased mortality compared to ICP (p = 0.342). Finally, VT patients had longer median LOS (20.5 vs. 18.0 days, p < 0.001) but there was no difference in subsequent craniotomy/craniectomy (8.6 vs. 6.5%, p = 0.096) or infectious complications (1.2 vs. 0.9%, p = 0.549).

CONCLUSION

VT was associated with greater discharge to home. Although VT patients had a greater LOS, the risk for other secondary outcomes did not vary, suggesting that VT may have benefits for the treatment of severe TBI with respect to discharge disposition.

LEVEL OF EVIDENCE

III.

Benzodiazepine receipt in adults with psychogenic non-epileptic seizures in the USA

Background

Characterising benzodiazepine (BZD) prescribing to individuals with psychogenic non-epileptic seizures (PNES) is important for optimising PNES outcomes, but existing data is lacking.

Methods

Using a nationwide administrative claims database (2016-2022), incident PNES was defined as an International classification of diseases, tenth revision, clinical modification (ICD-10-CM) diagnosis in an inpatient or outpatient healthcare encounter after a 1-year period with no documented diagnosis. We described clinical characteristics of adults with incident PNES and estimated the prevalence of outpatient BZD treatment in the baseline year and 30-day follow-up period, with secondary analyses stratifying by baseline ES, anxiety and/or insomnia diagnoses, representing common indications for BZD receipt. We used logistic regression to evaluate predictors of post-PNES BZD receipt.

Results

Among 20 848 adults with incident PNES diagnosis, 33.1% and 15.1% received BZDs in the year and month prior to PNES diagnosis, respectively, and 18.1% received BZDs in the month following a PNES diagnosis; 5.4% of those without prior BZD prescriptions received BZDs after diagnosis. The median days' supply was 30 days, with clonazepam, alprazolam and lorazepam representing the most common BZDs prescribed after PNES. Most people who received BZDs in the month prior to PNES diagnosis remained on BZDs in the month after PNES diagnosis (62.9%), with similar findings in the subcohorts without ES, anxiety and/or insomnia. Baseline BZD receipt and anxiety disorders, but not baseline ES diagnoses, were strong independent predictors of post-PNES BZD receipt.

Conclusions

While new BZD initiation is rare after PNES, most individuals with BZD scripts 1 month before PNES continue scripts after diagnosis.

Development of an Evidence-based Care Bundle for Prevention of External Ventricular Drain-related Infection: Results of a Single-center Prospective Cohort Study and Literature Review

Background

External ventricular drain (EVD)-related infection (ERI) is a common complication in cranial neurosurgery practice with high mortality. The risk factors associated with ERI are not well studied in low- and middle-income countries (LMIC) like India. Identifying the risk variables is a necessity to design robust evidence-based care bundles for ERI prevention.

Materials and methods

This is a single-center prospective cohort study. Patients with and without ERI during the 2-year study period were analyzed along with literature review to identify the risk variables associated with ERI. The Institute for Healthcare Improvement (IHI) comprehensive flowchart was used to develop the concept care bundle for ERI prevention.

Results

A total of 211 EVD were inserted during the study period. 15 ERI (7.1%) were identified based on IDSA criteria, with an average infection rate of 11.12 per 1000 EVD days. Gram negative bacteria (GNB) were the predominant pathogen (12/15, 80%), with Klebsiella pneumoniae (6/15, 40%) being the most common bacteria isolated. In multivariate analysis, the risk variables associated with ERI were use of broad spectrum pre-surgical antimicrobial prophylaxis for long duration, choice of posterior craniometric points for EVD insertion, EVD duration >7 days, EVD leak and surveillance cerebrospinal fluid (CSF) sampling at periodic intervals. Based on the risk variables identified in this study and literature review, a consensus decision on the care elements for the insertion and maintenance phases was chosen for the concept care bundle for ERI prevention.

Conclusion

An evidence-based concept care bundle for ERI prevention is proposed for further multicentric evaluation and validation.

How to cite this article

Ponnambath DK, Divakar G, Mamachan J, Biju S, Raja K, Abraham M. Development of an Evidence-based Care Bundle for Prevention of External Ventricular Drain-related Infection: Results of a Single-center Prospective Cohort Study and Literature Review. Indian J Crit Care Med 2024;28(8):760-768.

Infections Associated with Medtronic Duet External Ventricular Drains - Rhode Island Hospital, Providence, Rhode Island, January 2023-January 2024

External ventricular drains (EVDs) are medical devices that are inserted into the ventricles of the brain to drain excess fluid, manage intracranial hypertension, monitor intracranial pressure, and administer medications. Unintentional disconnections and breaks or fractures (breaks) of EVDs or associated drainage system components can result in cerebrospinal fluid (CSF) leakage and increased risk for EVD-associated infections. After replacement of Integra Life Sciences EVD systems with Medtronic Duet EVD systems at Rhode Island Hospital in mid-September 2023, a threefold increase was observed in the prevalence of positive CSF cultures, from 2.8 per 1,000 days with an EVD in place (EVD days) during January-September 2023 to 11.4 per 1,000 EVD days during October 2023-January 2024 (rate ratio [RR] = 5.7; 95% CI = 1.5-22.0; p = 0.01) and an eightfold increase in the prevalence of infections, from 0.7 to 6.5 per 1,000 EVD days (RR = 9.8; 95% CI = 1.1-87.3; p = 0.04). An investigation by Rhode Island Hospital Infection Control during December 2023-January 2024 identified frequent reports of disconnections and breaks of the Medtronic Duet EVD system. A search of the Food and Drug Administration Manufacturer and User Facility Device Experience database identified 326 reports nationwide of disconnection and breaks of components of the Duet EVD system, including 175 during 2023. A Medical Product Safety Network report was filed. The Duet EVD product was ultimately recalled in January 2024, citing disconnections of the EVD system and reports of CSF leakage and infection. Given the widespread use of EVD systems by neurosurgery centers and the risk for EVD-associated infections, a strategy for future consideration by hospital infection prevention and control programs might be inclusion of EVD-associated infections in hospital surveillance programs to rapidly identify increases in these events and determine factors related to such infections to prevent additional infections.