A population-based study on epidemiology of intensive care unit treated traumatic brain injury in Iceland

BACKGROUND

Traumatic brain injury is a worldwide health issue and a significant cause of preventable deaths and disabilities. We aimed to describe population-based data on intensive care treated traumatic brain injury in Iceland over 15 years period.

METHODS

Retrospective review of all intensive care unit admissions due to traumatic brain injury at The National University Hospital of Iceland 1999-2013. Data were collected on demographics, mechanism of injury, alcohol consumption, glasgow come scale upon admission, Injury Severity Scoring, acute physiology and chronic health evaluation II score, length of stay, interventions and mortality (defined as glasgow outcome score one). All computerized tomography scans were reviewed for Marshall score classification.

RESULTS

Intensive care unit admissions due to traumatic brain injury were 583. The incidence decreased significantly from 14/100.000/year to 12/100.000/year. Males were 72% and the mean age was 41 year. Majority of patients (42%) had severe traumatic brain injury. The most common mechanism of injury was a fall from low heights (36.3%). The mortality was 18.2%. Increasing age, injury severity score, Marshall score and acute physiology and chronic health evaluation II score are all independent risk factors for death. Glasgow coma scale was not an independent prognostic factor for outcome.

CONCLUSIONS

Incidence decreased with a shift in injury mechanism from road traffic accidents to falls and an increased rate of traumatic brain injury in older patients following a fall from standing or low heights. Mortality was higher in older patients falling from low heights than in younger patients suffering multiple injuries in road traffic accidents. Age, injury severity score, acute physiology and chronic health evaluation II score and Marshall score are good prognostic factors for outcome. Traumatic brain injury continues to be a considerable problem and the increase in severe traumatic brain injury in the middle age and older age groups after a seemingly innocent accident needs a special attention.

Severe sepsis and septic shock: a prospective population-based study in Icelandic intensive care units

BACKGROUND

The aims of our study were to describe the nationwide epidemiology of sepsis requiring intensive care during an entire year and to evaluate compliance with treatment guidelines.

METHODS

This was a prospective, observational study of all adult patients admitted to Icelandic intensive care units (ICUs), who were screened for the ACCP/SCCM criteria for severe sepsis or septic shock on admission. Data were collected from 1 April 2008 to 31 March 2009.

RESULTS

One thousand five hundred and twenty-four patients were admitted to the ICUs during the study year, 115 of them because of severe sepsis or septic shock. The incidence in Iceland was 0.48/1000 inhabitants ≥18 years per year [95% confidence intervals (CI) 0.42-0.55]. The mean APACHE II score was 20.7. Mortality was 24.6% (95% CI 17.5-33.3) at 28 days and 40.4% (95% CI 31.8-49.5) at 1 year. The main sources of infections were pulmonary (37%), abdominal (28%) and urinary tract (8%). Pathogens were gram-positive (39%), gram-negative (30%) and mixed (28%). No patient had sepsis caused by methicillin-resistant Staphylococcus aureus or a monomicrobial fungal infection. Pulmonary infections were an independent predictor of death. Compliance to the resuscitation goals of the Surviving Sepsis Campaign ranged from 60% to 72% and the 6-hour Sepsis Bundle was completed in 35% of patients.

CONCLUSIONS

This nationwide study showed an incidence of 0.48/1000 inhabitants for severe sepsis and septic shock requiring intensive care therapy. The 28-day mortality rate of 25 % was in the lower range of previous reports but the compliance to resuscitation goals and sepsis bundles was similar.

Induced hypothermia in comatose survivors of asphyxia: a case series of 14 consecutive cases

BACKGROUND

Induced hypothermia is widely used for comatose survivors of cardiac arrest. Other causes of hypoxic brain injury carry a poor prognosis when treated using traditional methods. At our hospital, hypothermia has also been used for the management of all comatose survivors of asphyxiation. The aim of the present study was to report the results of the management of these patients.

METHODS

Hospital charts of all patients admitted unconscious after asphyxiation during a 7-year period were reviewed. This included patients after hanging, drowning, carbon monoxide intoxication and other gas intoxications. In all patients, hypothermia with a target temperature of 32-34 degrees C was induced with external or intravascular cooling for 24 h. The primary outcome was neurologic function at discharge.

RESULTS

Fourteen male patients were treated with hypothermia, eight after hanging, three after drowning, two after carbon monoxide intoxication and one after methane intoxication. All were deeply comatose (Glasgow Coma Score 3-5) on arrival to hospital. Nine had been resuscitated from cardiac arrest. There were nine survivors (65%), all with good neurological recovery (Cerebral Performance Category 1-2). Four out of five non-survivors showed cerebral edema already on arrival computed tomographic (CT) scan while none of the nine survivors did.

CONCLUSIONS

The results of this study suggest that an early abnormal CT scan of the brain in patients resuscitated after asphyxiation carries an adverse prognosis. The favorable outcome of the patients in the present study suggests that a randomized clinical trial on the use of induced hypothermia in patients exposed to severe asphyxia might be warranted.

Electrical impedance tomography and heterogeneity of pulmonary perfusion and ventilation in porcine acute lung injury

BACKGROUND

The heterogeneity of pulmonary ventilation (V), perfusion (Q) and V/Q matching impairs gas exchange in an acute lung injury (ALI). This study investigated the feasibility of electrical impedance tomography (EIT) to assess the V/Q distribution and matching during an endotoxinaemic ALI in pigs.

METHODS

Mechanically ventilated, anaesthetised pigs (n=11, weight 30-36 kg) were studied during an infusion of endotoxin for 150 min. Impedance changes related to ventilation (Z(V)) and perfusion (Z(Q)) were monitored globally and bilaterally in four regions of interest (ROIs) of the EIT image. The distribution and ratio of Z(V) and Z(Q) were assessed. The alveolar-arterial oxygen difference, venous admixture, fractional alveolar dead space and functional residual capacity (FRC) were recorded, together with global and regional lung compliances and haemodynamic parameters. Values are mean+/-standard deviation (SD) and regression coefficients.

RESULTS

Endotoxinaemia increased the heterogeneity of Z(Q) but not Z(V). Lung compliance progressively decreased with a ventral redistribution of Z(V). A concomitant dorsal redistribution of Z(Q) resulted in mismatch of global (from Z(V)/Z(Q) 1.1+/-0.1 to 0.83+/-0.3) and notably dorsal (from Z(V)/Z(Q) 0.86+/-0.4 to 0.51+/-0.3) V and Q. Changes in global Z(V)/Z(Q) correlated with changes in the alveolar-arterial oxygen difference (r(2)=0.65, P<0.05), venous admixture (r(2)=0.66, P<0.05) and fractional alveolar dead space (r(2)=0.61, P<0.05). Decreased end-expiratory Z(V) correlated with decreased FRC (r(2)=0.74, P<0.05).

CONCLUSIONS

EIT can be used to assess the heterogeneity of regional pulmonary ventilation and perfusion and V/Q matching during endotoxinaemic ALI, identifying pivotal pathophysiological changes.

A practice survey on vasopressor and inotropic drug therapy in Scandinavian intensive care units

BACKGROUND

This practice survey was performed to analyse the indications for use of vasopressor/inotropic drugs, preferred drugs and doses as well as concomitant monitoring and desired haemodynamic target values in Scandinavian ICUs. An internet-based reporting system was implemented.

METHODS

A total of 223 ICUs were identified in the Scandinavian countries and invited to participate in a one-day point-prevalence study. An internet-based database was constructed and a practice survey protocol designed to identify haemodynamic monitoring, indications for vasopressor/inotropic drug-therapy, fluids used for volume loading, pretreatment circulatory state, actual and targeted haemodynamic variables. Patients were eligible for the study if on vasopressor/inotropic drug-therapy for more than 4 h.

RESULTS

A total of 114 ICUs participated. A total of 114 adult patients matched the inclusion criteria. Sixty-seven per cent of the patients had received vasopressor/inotropic drug-treatment for >24 h and 32% received more than one drug. Arterial hypotension (92%) and oliguria (50%) were most common indications. Fluid loading prior to therapy was reported in 87% of patients. Dopamine (47%) and noradrenaline (44%) were the most commonly used drugs followed by dobutamine (24%). No other drug exceeded 6%. Non-catecholamine drugs were rarely used even in cardiac failure patients. Invasive arterial pressure was monitored in 95% of patients, pulmonary artery catheters were used in 19%. Other cardiac output monitoring techniques were used in 8.5% of the patients.

CONCLUSION

Dopamine and noradrenaline seem to be the most commonly used inotropic/vasopressor drugs in Scandinavia. Traditional indications for inotropic/vasopressor support as hypotension and oliguria seem to be most common. Invasive monitoring was used in almost all patients, whereas a limited use of pulmonary artery catheters was noted. The internet-based reporting system proved to be an efficient tool for data collection.

[Postoperative restcurarization.]

OBJECTIVE

Muscle relaxants have been used during anesthesia for the past 50 years but in the last decades it has been realised that their use can lead to complications. Studies have shown 20-40% incidence of restcurarization in postanesthesia care units (PACU) even if neuromuscular monitors are used during anesthesia. The purpose of this study was to estimate the frequency of postoperative muscle weakness at the Reykjavik Hospital in Iceland.

MATERIAL AND METHODS

Sixty patients, operated for laparoscopic cholecystectomy or lumbal disc prolapse, given muscle relaxants (vecuronium or pancu notronium) during anesthesia were studied in the PACU. The 5-sec headlift test has been shown to be the best clinical sign of recovery and this sign was used to find patients with muscle weakness. Glasgow coma score (GCS) was used to evaluate if patients were too drowsy to co-operate and patients with GCS <12 were excluded. Measurements were made after arrival to the PACU and every 30 minutes thereafter until headlift was at least five seconds.

RESULTS

Incidence of restcurarization was 17% on arrival to the PACU and these patients were significantly lower in oxygen saturation before oxygen supplementation was started. Thirty minutes after arrival 6% were still restcurarized and 3% after 60 minutes. All patients had recovered after 90 minutes. No difference was found between patients given vecuronium or pancuronium in the first two measurements but those with longest duration of muscle weakness had received pancuronium.

CONCLUSION

The study shows that the incidence of muscle weakness is too high, which might increase the risk for complications such as hypoxia or respiratory failure. To increase patient safety, shorter acting drugs are recommended and the use of new nervestimulators giving the train-of-four(TOF)-ratio during muscle blockade could possibly improve the situation.