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Robba C, Graziano F, Picetti E, Åkerlund C, Addis A, Pastore G, Sivero M, Rebora P, Galimberti S, Stocchetti N, Maas A, Menon DK, Citerio G. Early systemic insults following traumatic brain injury: association with biomarker profiles, therapy for intracranial hypertension, and neurological outcomes-an analysis of CENTER-TBI data. Intensive Care Med 2024; 50:371-384. [PMID: 38376517 PMCID: PMC10955000 DOI: 10.1007/s00134-024-07324-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 01/13/2024] [Indexed: 02/21/2024]
Abstract
PURPOSE We analysed the impact of early systemic insults (hypoxemia and hypotension, SIs) on brain injury biomarker profiles, acute care requirements during intensive care unit (ICU) stay, and 6-month outcomes in patients with traumatic brain injury (TBI). METHODS From patients recruited to the Collaborative European neurotrauma effectiveness research in TBI (CENTER-TBI) study, we documented the prevalence and risk factors for SIs and analysed their effect on the levels of brain injury biomarkers [S100 calcium-binding protein B (S100B), neuron-specific enolase (NSE), neurofilament light (NfL), glial fibrillary acidic protein (GFAP), ubiquitin carboxy-terminal hydrolase L1 (UCH-L1), and protein Tau], critical care needs, and 6-month outcomes [Glasgow Outcome Scale Extended (GOSE)]. RESULTS Among 1695 TBI patients, 24.5% had SIs: 16.1% had hypoxemia, 15.2% had hypotension, and 6.8% had both. Biomarkers differed by SI category, with higher S100B, Tau, UCH-L1, NSE and NfL values in patients with hypotension or both SIs. The ratio of neural to glial injury (quantified as UCH-L1/GFAP and Tau/GFAP ratios) was higher in patients with hypotension than in those with no SIs or hypoxia alone. At 6 months, 380 patients died (22%), and 759 (45%) had GOSE ≤ 4. Patients who experienced at least one SI had higher mortality than those who did not (31.8% vs. 19%, p < 0.001). CONCLUSION Though less frequent than previously described, SIs in TBI patients are associated with higher release of neuronal than glial injury biomarkers and with increased requirements for ICU therapies aimed at reducing intracranial hypertension. Hypotension or combined SIs are significantly associated with adverse 6-month outcomes. Current criteria for hypotension may lead to higher biomarker levels and more negative outcomes than those for hypoxemia suggesting a need to revisit pressure targets in the prehospital settings.
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Affiliation(s)
- Chiara Robba
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
- IRCCS Policlinico San Martino, Genoa, Italy
| | - Francesca Graziano
- Biostatistics and Clinical Epidemiology, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
- Bicocca Bioinformatics Biostatistics and Bioimaging Center B4, School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Cecilia Åkerlund
- Section of Anesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Alberto Addis
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- NeuroIntensive Care Unit, Neuroscience Department, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Giuseppe Pastore
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Mattia Sivero
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Paola Rebora
- Biostatistics and Clinical Epidemiology, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
- Bicocca Bioinformatics Biostatistics and Bioimaging Center B4, School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Stefania Galimberti
- Biostatistics and Clinical Epidemiology, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
- Bicocca Bioinformatics Biostatistics and Bioimaging Center B4, School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Nino Stocchetti
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Physiopathology and Transplant, Milan University, Milan, Italy
| | - Andrew Maas
- Department of Neurosurgery, Antwerp University Hospital, Edegem, Belgium
| | - David K Menon
- Neurocritical Care Unit, Addenbrooke's Hospital, Cambridge, UK
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.
- NeuroIntensive Care Unit, Neuroscience Department, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy.
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Åkerlund CAI, Holst A, Bhattacharyay S, Stocchetti N, Steyerberg E, Smielewski P, Menon DK, Ercole A, Nelson DW. Clinical descriptors of disease trajectories in patients with traumatic brain injury in the intensive care unit (CENTER-TBI): a multicentre observational cohort study. Lancet Neurol 2024; 23:71-80. [PMID: 37977157 DOI: 10.1016/s1474-4422(23)00358-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 08/31/2023] [Accepted: 09/08/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Patients with traumatic brain injury are a heterogeneous population, and the most severely injured individuals are often treated in an intensive care unit (ICU). The primary injury at impact, and the harmful secondary events that can occur during the first week of the ICU stay, will affect outcome in this vulnerable group of patients. We aimed to identify clinical variables that might distinguish disease trajectories among patients with traumatic brain injury admitted to the ICU. METHODS We used data from the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) prospective observational cohort study. We included patients aged 18 years or older with traumatic brain injury who were admitted to the ICU at one of the 65 CENTER-TBI participating centres, which range from large academic hospitals to small rural hospitals. For every patient, we obtained pre-injury data and injury features, clinical characteristics on admission, demographics, physiological parameters, laboratory features, brain biomarkers (ubiquitin carboxy-terminal hydrolase L1 [UCH-L1], S100 calcium-binding protein B [S100B], tau, neurofilament light [NFL], glial fibrillary acidic protein [GFAP], and neuron-specific enolase [NSE]), and information about intracranial pressure lowering treatments during the first 7 days of ICU stay. To identify clinical variables that might distinguish disease trajectories, we applied a novel clustering method to these data, which was based on a mixture of probabilistic graph models with a Markov chain extension. The relation of clusters to the extended Glasgow Outcome Scale (GOS-E) was investigated. FINDINGS Between Dec 19, 2014, and Dec 17, 2017, 4509 patients with traumatic brain injury were recruited into the CENTER-TBI core dataset, of whom 1728 were eligible for this analysis. Glucose variation (defined as the difference between daily maximum and minimum glucose concentrations) and brain biomarkers (S100B, NSE, NFL, tau, UCH-L1, and GFAP) were consistently found to be the main clinical descriptors of disease trajectories (ie, the leading variables contributing to the distinguishing clusters) in patients with traumatic brain injury in the ICU. The disease trajectory cluster to which a patient was assigned in a model was analysed as a predictor together with variables from the IMPACT model, and prediction of both mortality and unfavourable outcome (dichotomised GOS-E ≤4) was improved. INTERPRETATION First-day ICU admission data are not the only clinical descriptors of disease trajectories in patients with traumatic brain injury. By analysing temporal variables in our study, variation of glucose was identified as the most important clinical descriptor that might distinguish disease trajectories in the ICU, which should direct further research. Biomarkers of brain injury (S100B, NSE, NFL, tau, UCH-L1, and GFAP) were also top clinical descriptors over time, suggesting they might be important in future clinical practice. FUNDING European Union 7th Framework program, Hannelore Kohl Stiftung, OneMind, Integra LifeSciences Corporation, and NeuroTrauma Sciences.
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Affiliation(s)
- Cecilia A I Åkerlund
- Department of Physiology and Pharmacology, Section of Anaesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden; Function Perioperative Medicine and Intensive Care, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Anders Holst
- School of Electrical Engineering and Computer Science, KTH Royal Institute of Technology, Stockholm, Sweden
| | | | - Nino Stocchetti
- Department of Physiopathology and Transplant, Milan University, Milan, Italy; Fondazione IRCCS, Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Ewout Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Netherlands
| | | | - David K Menon
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Ari Ercole
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK; Centre for Artificial Intelligence in Medicine, University of Cambridge, Cambridge, UK
| | - David W Nelson
- Department of Physiology and Pharmacology, Section of Anaesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden; Function Perioperative Medicine and Intensive Care, Karolinska University Hospital Solna, Stockholm, Sweden.
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Zanier ER, Pischiutta F, Rulli E, Vargiolu A, Elli F, Gritti P, Gaipa G, Belotti D, Basso G, Zoerle T, Stocchetti N, Citerio G. MesenchymAl stromal cells for Traumatic bRain Injury (MATRIx): a study protocol for a multicenter, double-blind, randomised, placebo-controlled phase II trial. Intensive Care Med Exp 2023; 11:56. [PMID: 37620640 PMCID: PMC10449745 DOI: 10.1186/s40635-023-00535-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 07/07/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Traumatic brain injury (TBI) is a significant cause of death and disability, with no effective neuroprotective drugs currently available for its treatment. Mesenchymal stromal cell (MSC)-based therapy shows promise as MSCs release various soluble factors that can enhance the injury microenvironment through processes, such as immunomodulation, neuroprotection, and brain repair. Preclinical studies across different TBI models and severities have demonstrated that MSCs can improve functional and structural outcomes. Moreover, clinical evidence supports the safety of third-party donor bank-stored MSCs in adult subjects. Building on this preclinical and clinical data, we present the protocol for an academic, investigator-initiated, multicenter, double-blind, randomised, placebo-controlled, adaptive phase II dose-finding study aiming to evaluate the safety and efficacy of intravenous administration of allogeneic bone marrow-derived MSCs to severe TBI patients within 48 h of injury. METHODS/DESIGN The study will be conducted in two steps. Step 1 will enrol 42 patients, randomised in a 1:1:1 ratio to receive 80 million MSCs, 160 million MSCs or a placebo to establish safety and identify the most promising dose. Step 2 will enrol an additional 36 patients, randomised in a 1:1 ratio to receive the selected dose of MSCs or placebo. The activity of MSCs will be assessed by quantifying the plasmatic levels of neurofilament light (NfL) at 14 days as a biomarker of neuronal damage. It could be a significant breakthrough if the study demonstrates the safety and efficacy of MSC-based therapy for severe TBI patients. The results of this trial could inform the design of a phase III clinical trial aimed at establishing the efficacy of the first neurorestorative therapy for TBI. DISCUSSION Overall, the MATRIx trial is a critical step towards developing an effective treatment for TBI, which could significantly improve the lives of millions worldwide affected by this debilitating condition. Trial Registration EudraCT: 2022-000680-49.
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Affiliation(s)
- Elisa R Zanier
- Department of Acute Brain and Cardiovascular Injury, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Francesca Pischiutta
- Department of Acute Brain and Cardiovascular Injury, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Eliana Rulli
- Department of Clinical Oncology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Alessia Vargiolu
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Francesca Elli
- Neurological Intensive Care Unit, Department of Neurosciences, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Paolo Gritti
- Department of Anesthesia, Emergency and Critical Care Medicine, ASST Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Giuseppe Gaipa
- M. Tettamanti Research Center, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Daniela Belotti
- M. Tettamanti Research Center, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Gianpaolo Basso
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Department of Neurosciences, Neuroradiology, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Tommaso Zoerle
- Neuroscience Intensive Care Unit, Department of Anaesthesia and Critical Care, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplants, University of Milan, Milan, Italy
| | - Nino Stocchetti
- Neuroscience Intensive Care Unit, Department of Anaesthesia and Critical Care, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplants, University of Milan, Milan, Italy
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.
- Neurological Intensive Care Unit, Department of Neurosciences, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy.
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Magatti M, Pischiutta F, Ortolano F, Pasotti A, Caruso E, Cargnoni A, Papait A, Capuzzi F, Zoerle T, Carbonara M, Stocchetti N, Borsa S, Locatelli M, Erba E, Prati D, Silini AR, Zanier ER, Parolini O. Systemic immune response in young and elderly patients after traumatic brain injury. Immun Ageing 2023; 20:41. [PMID: 37573338 PMCID: PMC10422735 DOI: 10.1186/s12979-023-00369-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 08/07/2023] [Indexed: 08/14/2023]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a leading cause of death and long-term disability worldwide. In addition to primary brain damage, systemic immune alterations occur, with evidence for dysregulated immune responses in aggravating TBI outcome and complications. However, immune dysfunction following TBI has been only partially understood, especially in the elderly who represent a substantial proportion of TBI patients and worst outcome. Therefore, we aimed to conduct an in-depth immunological characterization of TBI patients, by evaluating both adaptive (T and B lymphocytes) and innate (NK and monocytes) immune cells of peripheral blood mononuclear cells (PBMC) collected acutely (< 48 h) after TBI in young (18-45 yo) and elderly (> 65 yo) patients, compared to age-matched controls, and also the levels of inflammatory biomarkers. RESULTS Our data show that young respond differently than elderly to TBI, highlighting the immune unfavourable status of elderly compared to young patients. While in young only CD4 T lymphocytes are activated by TBI, in elderly both CD4 and CD8 T cells are affected, and are induced to differentiate into subtypes with low cytotoxic activity, such as central memory CD4 T cells and memory precursor effector CD8 T cells. Moreover, TBI enhances the frequency of subsets that have not been previously investigated in TBI, namely the double negative CD27- IgD- and CD38-CD24- B lymphocytes, and CD56dim CD16- NK cells, both in young and elderly patients. TBI reduces the production of pro-inflammatory cytokines TNF-α and IL-6, and the expression of HLA-DM, HLA-DR, CD86/B7-2 in monocytes, suggesting a compromised ability to drive a pro-inflammatory response and to efficiently act as antigen presenting cells. CONCLUSIONS We described the acute immunological response induced by TBI and its relation with injury severity, which could contribute to pathologic evolution and possibly outcome. The focus on age-related immunological differences could help design specific therapeutic interventions based on patients' characteristics.
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Affiliation(s)
- Marta Magatti
- Centro di Ricerca E. Menni, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy.
| | - Francesca Pischiutta
- Department of Acute Brain Injury, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
| | - Fabrizio Ortolano
- Dipartimento di Anestesia-Rianimazione e Emergenza Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Anna Pasotti
- Centro di Ricerca E. Menni, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy
| | - Enrico Caruso
- Department of Acute Brain Injury, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
- Dipartimento di Anestesia-Rianimazione e Emergenza Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Anna Cargnoni
- Centro di Ricerca E. Menni, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy
| | - Andrea Papait
- Scienze della Vita e Sanità Pubblica, Università Cattolica del Sacro Cuore Facoltà di Medicina e Chirurgia, Roma, Italy
| | - Franco Capuzzi
- Dipartimento Medicina di Laboratorio, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy
| | - Tommaso Zoerle
- Dipartimento di Anestesia-Rianimazione e Emergenza Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milano, Italy
| | - Marco Carbonara
- Dipartimento di Anestesia-Rianimazione e Emergenza Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Nino Stocchetti
- Dipartimento di Anestesia-Rianimazione e Emergenza Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milano, Italy
| | - Stefano Borsa
- Unit of Neurosurgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Marco Locatelli
- Department of Pathophysiology and Transplantation, University of Milan, Milano, Italy
- Unit of Neurosurgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Elisa Erba
- Department of Transfusion Medicine and Hematology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Daniele Prati
- Department of Transfusion Medicine and Hematology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Antonietta R Silini
- Centro di Ricerca E. Menni, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy
| | - Elisa R Zanier
- Department of Acute Brain Injury, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
| | - Ornella Parolini
- Scienze della Vita e Sanità Pubblica, Università Cattolica del Sacro Cuore Facoltà di Medicina e Chirurgia, Roma, Italy
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Roma, Italy
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Sarigul B, Bell RS, Chesnut R, Aguilera S, Buki A, Citerio G, Cooper DJ, Diaz-Arrastia R, Diringer M, Figaji A, Gao G, Geocadin RG, Ghajar J, Harris O, Hoffer A, Hutchinson P, Joseph M, Kitagawa R, Manley G, Mayer SA, Menon DK, Meyfroidt G, Michael DB, Oddo M, Okonkwo DO, Patel MB, Robertson C, Rosenfeld JV, Rubiano AM, Sahuquillo J, Servadei F, Shutter L, Stein DD, Stocchetti N, Taccone FS, Timmons SD, Tsai E, Ullman JS, Vespa P, Videtta W, Wright DW, Zammit C, Hawryluk GWJ. Prognostication and Goals of Care Decisions in Severe Traumatic Brain Injury: A Survey of The Seattle International Severe Traumatic Brain Injury Consensus Conference Working Group. J Neurotrauma 2023; 40:1707-1717. [PMID: 36932737 DOI: 10.1089/neu.2022.0414] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2023] Open
Abstract
Abstract Best practice guidelines have advanced severe traumatic brain injury (TBI) care; however, there is little that currently informs goals of care decisions and processes despite their importance and frequency. Panelists from the Seattle International severe traumatic Brain Injury Consensus Conference (SIBICC) participated in a survey consisting of 24 questions. Questions queried use of prognostic calculators, variability in and responsibility for goals of care decisions, and acceptability of neurological outcomes, as well as putative means of improving decisions that might limit care. A total of 97.6% of the 42 SIBICC panelists completed the survey. Responses to most questions were highly variable. Overall, panelists reported infrequent use of prognostic calculators, and observed variability in patient prognostication and goals of care decisions. They felt that it would be beneficial for physicians to improve consensus on what constitutes an acceptable neurological outcome as well as what chance of achieving that outcome is acceptable. Panelists felt that the public should help to define what constitutes a good outcome and expressed some support for a "nihilism guard." More than 50% of panelists felt that if it was certain to be permanent, a vegetative state or lower severe disability would justify a withdrawal of care decision, whereas 15% felt that upper severe disability justified such a decision. Whether conceptualizing an ideal or existing prognostic calculator to predict death or an unacceptable outcome, on average a 64-69% chance of a poor outcome was felt to justify treatment withdrawal. These results demonstrate important variability in goals of care decision making and a desire to reduce this variability. Our panel of recognized TBI experts opined on the neurological outcomes and chances of those outcomes that might prompt consideration of care withdrawal; however, imprecision of prognostication and existing prognostication tools is a significant impediment to standardizing the approach to care-limiting decisions.
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Affiliation(s)
| | - Randy S Bell
- Uniformed Services University of Health Sciences, Avera Brain and Spine Institute, Sioux Falls, South Dakota, USA
| | - Randall Chesnut
- Departments of Neurological Surgery and Orthopaedic Surgery, School of Global Health, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | | | - Andras Buki
- Department of Neurosurgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
- NeuroIntensive Care, Department of Neuroscience, IRCCS Fondazione San Gerardo dei Tintori, Monza, Italy
| | - D Jamie Cooper
- Intensive Care Medicine, Australian and New Zealand Intensive Care Research Centre, Alfred Hospital, Melbourne, Victoria, Australia
| | - Ramon Diaz-Arrastia
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania, USA
| | - Michael Diringer
- Department of Neurology, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - Anthony Figaji
- Department of Neurosurgery, Division of Neurosurgery and Neuroscience Institute, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
| | - Guoyi Gao
- Division of Neurotrauma, Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Romergryko G Geocadin
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jamshid Ghajar
- Department of Neurosurgery, Stanford Neuroscience Health Center, Palo Alto, California, USA
| | | | - Alan Hoffer
- University Hospitals of Cleveland, Cleveland, Ohio, USA
| | - Peter Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Mathew Joseph
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Ryan Kitagawa
- Vivian L Smith Department of Neurosurgery, McGovern Medical School at UTHealth, Houston, Texas, USA
| | - Geoffrey Manley
- Department of Neurosurgery, University of California San Francisco, San Francisco General Hospital & Trauma Center, San Francisco, California, USA
| | - Stephan A Mayer
- Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - David K Menon
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Geert Meyfroidt
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Daniel B Michael
- Department of Neurosurgery, Oakland University William Beaumont School of Medicine, Beaumont Health, Michigan Head & Spine Institute, Southfield, Michigan, USA
| | - Mauro Oddo
- Directorate of Innovation and Clinical Research, CHUV-Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - David O Okonkwo
- Departments of Neurological Surgery, Neurology and Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Mayur B Patel
- Critical Illness, Brain Dysfunction, and Survivorship Center; Center for Health Services Research; Tennessee Valley Healthcare System, Veterans Affairs Medical Center; Section of Surgical Sciences, Department of Surgery, Division of Acute Care Surgery Vanderbilt University Medical Center, Nashville, Tennessee
| | - Claudia Robertson
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Jeffrey V Rosenfeld
- Department of Neurosurgery, The Alfred Hospital, Melbourne, Victoria, Australia
- Department of Surgery, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Andres M Rubiano
- INUB/MEDITECH Research Group, Neurosciences Institute, El Bosque University, Bogotá, Colombia
- MEDITECH Foundation, Clinical Research, Cali, Colombia
| | - Juan Sahuquillo
- Department of Neurosurgery, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Spain
| | - Franco Servadei
- Department of Neurosurgery, IRCCS Humanitas Research Hospital and Humanitas University, Milano, Italy
| | - Lori Shutter
- Critical Care Medicine, Neurology and Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Deborah D Stein
- Program in Trauma, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Nino Stocchetti
- Department of Pathophysiology and Transplantation, Dipartimento Fisiopatologia e Trapianti Universita di Milano, Scuola di Specializzazione Anestesia, Rianimazione, Terapia Intensiva e del Dolore, Neurorianimazione, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milano, Milano, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hospital Erasme, Université Libre de Bruxelles (ULB) Brussels, Belgium
| | - Shelly D Timmons
- Department of Neurological Surgery, Indiana University School of Medicine, Indiana, USA
| | - Eve Tsai
- Division of Neurosurgery, Department of Surgery, University of Ottawa, The Ottawa Hospital, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Jamie S Ullman
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Paul Vespa
- Department of Neurosurgery and Neurology, UCLA School of Medicine, Neurocritical Care, Ronald Reagan UCLA Medical Center, UCLA Medical Center, Santa Monica, California, USA
| | - Walter Videtta
- Intensive Care Medicine, Posadas Hospital, Buenos Aires, Argentina
| | - David W Wright
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Christopher Zammit
- Department of Emergency Medicine, University of Rochester Medical Center, School of Medicine and Dentistry, Rochester, New York, USA
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Chesnut RM, Aguilera S, Buki A, Bulger EM, Citerio G, Cooper DJ, Arrastia RD, Diringer M, Figaji A, Gao G, Geocadin RG, Ghajar J, Harris O, Hawryluk GWJ, Hoffer A, Hutchinson P, Joseph M, Kitagawa R, Manley G, Mayer S, Menon DK, Meyfroidt G, Michael DB, Oddo M, Okonkwo DO, Patel MB, Robertson C, Rosenfeld JV, Rubiano AM, Sahuquillo J, Servadei F, Shutter L, Stein DM, Stocchetti N, Taccone FS, Timmons SD, Tsai EC, Ullman JS, Videtta W, Wright DW, Zammit C. Perceived Utility of Intracranial Pressure Monitoring in Traumatic Brain Injury: A Seattle International Brain Injury Consensus Conference Consensus-Based Analysis and Recommendations. Neurosurgery 2023; 93:399-408. [PMID: 37171175 PMCID: PMC10319366 DOI: 10.1227/neu.0000000000002516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 01/02/2023] [Indexed: 05/13/2023] Open
Abstract
BACKGROUND Intracranial pressure (ICP) monitoring is widely practiced, but the indications are incompletely developed, and guidelines are poorly followed. OBJECTIVE To study the monitoring practices of an established expert panel (the clinical working group from the Seattle International Brain Injury Consensus Conference effort) to examine the match between monitoring guidelines and their clinical decision-making and offer guidance for clinicians considering monitor insertion. METHODS We polled the 42 Seattle International Brain Injury Consensus Conference panel members' ICP monitoring decisions for virtual patients, using matrices of presenting signs (Glasgow Coma Scale [GCS] total or GCS motor, pupillary examination, and computed tomography diagnosis). Monitor insertion decisions were yes, no, or unsure (traffic light approach). We analyzed their responses for weighting of the presenting signs in decision-making using univariate regression. RESULTS Heatmaps constructed from the choices of 41 panel members revealed wider ICP monitor use than predicted by guidelines. Clinical examination (GCS) was by far the most important characteristic and differed from guidelines in being nonlinear. The modified Marshall computed tomography classification was second and pupils third. We constructed a heatmap and listed the main clinical determinants representing 80% ICP monitor insertion consensus for our recommendations. CONCLUSION Candidacy for ICP monitoring exceeds published indicators for monitor insertion, suggesting the clinical perception that the value of ICP data is greater than simply detecting and monitoring severe intracranial hypertension. Monitor insertion heatmaps are offered as potential guidance for ICP monitor insertion and to stimulate research into what actually drives monitor insertion in unconstrained, real-world conditions.
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Affiliation(s)
- Randall M. Chesnut
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
- Department of Orthopaedic Surgery, University of Washington, Seattle, Washington, USA
- School of Global Health, University of Washington, Seattle, Washington, USA
- Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Sergio Aguilera
- Almirante Nef Naval Hospital, Valparaiso University, Viña Del Mar, Chile
- Valparaiso University, Valparaiso, Chile
| | - Andras Buki
- Department of Neurosurgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Eileen M. Bulger
- Department of Surgery, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Neuroscience Department, NeuroIntensive Care Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Monza, Italy
| | - D. Jamie Cooper
- Intensive Care Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, VIC, Australia
| | - Ramon Diaz Arrastia
- Department of Neurology, Penn Presbyterian Medical Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Michael Diringer
- Department of Neurology, Washington University School of Medicine, St Louis, USA
- Department of Neurology, Barnes-Jewish Hospital, St Louis, Missouri, USA
| | - Anthony Figaji
- Division of Neurosurgery and Neuroscience Institute, Groote Schuur Hospital, University of Cape Town, Observatory 7925, South Africa
| | - Guoyi Gao
- Department of Neurosurgery, Renji Hospital, Shanghai Institute of Head Trauma, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Romergryko G. Geocadin
- Departments of Neurology, Neurological Surgery, Anesthesiology-Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jamshid Ghajar
- Department of Neurosurgery, Stanford Neuroscience Health Center, Palo Alto, California, USA
| | - Odette Harris
- Department of Neurosurgery, Stanford University School of Medicine, Center for Academic Medicine, Stanford, California, USA
| | - Gregory W. J. Hawryluk
- Cleveland Clinic Akron General Neurosciences Center, Fairlawn, Ohio, USA
- Uniformed Services University, Bethesda, Maryland, USA
- Brain Trauma Foundation, New York City, New York, USA
| | - Alan Hoffer
- UH Cleveland Medical Center, Cleveland, Ohio, USA
| | - Peter Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge and Cambridge Biomedical Campus, Cambridge, UK
| | - Mathew Joseph
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Ryan Kitagawa
- Vivian L Smith Department of Neurosurgery, McGovern Medical School at UTHealth, Houston, Texas, USA
| | - Geoffrey Manley
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
- Department of Neurosurgery, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
| | - Stephan Mayer
- Westchester Health Network, New York Medical College, Valhalla, New York, USA
| | - David K Menon
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge and Addenbrooke's Hospital, Cambridge, UK
| | - Geert Meyfroidt
- Department of Intensive Care Medicine, University Hospitals Leuven and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Daniel B. Michael
- Department of Neurosurgery, Beaumont Health, Michigan Head and Spine Institute, Oakland University William Beaumont School of Medicine, Southfield, Michigan, USA
| | - Mauro Oddo
- CHUV Medical Directorate and Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - David O. Okonkwo
- Department of Neurosurgery, University of Pittsburgh Medical Center Presbyterian, Pittsburgh, Pennsylvania, USA
| | - Mayur B. Patel
- Department of Surgery, Division of Acute Care Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Claudia Robertson
- Department of Neurosurgery, Baylor College of Medicine, One Baylor Plaza, Houston, Texas, USA
| | - Jeffrey V. Rosenfeld
- Department of Neurosurgery, Alfred Hospital, Melbourne, Australia
- Department of Surgery, Monash University, Melbourne, Australia
| | - Andres M. Rubiano
- INUB/MEDITECH Research Group, Neurosciences Institute, El Bosque University, Bogotá, Colombia
- MEDITECH Foundation, Clinical Research, Cali, Colombia
| | - Juain Sahuquillo
- Department of Neurosurgery, Vall d’Hebron University Hospital, Universitat Autònoma de Barcelona: Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d’Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Franco Servadei
- Department of Biomedical Sciences, Humanitas University and IRCCS Humanitas Research Hospital, Milano, Italy
| | - Lori Shutter
- Department of Critical Care Medicine, Neurology and Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Deborah M. Stein
- University of Maryland School of Medicine, Adult Critical Care Services, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Nino Stocchetti
- Department of Physiopathology and Transplantation, Milan University, Milan, Italy
- Neuroscience Intensive Care Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Shelly D. Timmons
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Eve C. Tsai
- Suruchi Bhargava Chair in Spinal Cord and Brain Regeneration Research, The Ottawa Hospital, Department of Surgery, Division of Neurosurgery, University of Ottawa, Civic Campus, Ottawa, Ontario, Canada
| | - Jamie S. Ullman
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, New York, USA
| | - Walter Videtta
- Intensive Care, Posadas Hospital, Buenos Aires, Argentina
| | - David W. Wright
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Christopher Zammit
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York, USA
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Mangioni D, Chatenoud L, Colombo J, Palomba E, Guerrero FA, Bolis M, Bottino N, Breda G, Chiaruttini MV, Fior G, Marotta M, Massobrio G, Matinato C, Muscatello A, Previtali P, Santambrogio S, Tardini F, Zuglian G, Grasselli G, Fumagalli R, Gori A, Stocchetti N, Monti G, Bandera A. Multidrug-Resistant Bacterial Colonization and Infections in Large Retrospective Cohort of Mechanically Ventilated COVID-19 Patients 1. Emerg Infect Dis 2023; 29:1598-1607. [PMID: 37486196 PMCID: PMC10370845 DOI: 10.3201/eid2908.230115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2023] Open
Abstract
Few data are available on incidence of multidrug-resistant organism (MDRO) colonization and infections in mechanically ventilated patients, particularly during the COVID-19 pandemic. We retrospectively evaluated all patients admitted to the COVID-19 intensive care unit (ICU) of Hub Hospital in Milan, Italy, during October 2020‒May 2021. Microbiologic surveillance was standardized with active screening at admission and weekly during ICU stay. Of 435 patients, 88 (20.2%) had MDROs isolated ≤48 h after admission. Of the remaining patients, MDRO colonization was diagnosed in 173 (51.2%), MDRO infections in 95 (28.1%), and non-MDRO infections in 212 (62.7%). Non-MDRO infections occurred earlier than MDRO infections (6 days vs. 10 days; p<0.001). Previous exposure to antimicrobial drugs within the ICU was higher in MDRO patients than in non-MDRO patients (116/197 [58.9%] vs. 18/140 [12.9%]; p<0.001). Our findings might serve as warnings for future respiratory viral pandemics and call for increased measures of antimicrobial stewardship and infection control.
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Zoerle T, Birg T, Carbonara M, Smielewski P, Placek MM, Zanier ER, Åkerlund CAI, Ortolano F, Stocchetti N. Accuracy of Manual Intracranial Pressure Recording Compared to a Computerized High-Resolution System: A CENTER-TBI Analysis. Neurocrit Care 2023; 38:781-790. [PMID: 36922475 PMCID: PMC10241732 DOI: 10.1007/s12028-023-01697-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 02/09/2023] [Indexed: 03/17/2023]
Abstract
BACKGROUND Monitoring intracranial pressure (ICP) and cerebral perfusion pressure (CPP) is crucial in the management of the patient with severe traumatic brain injury (TBI). In several institutions ICP and CPP are summarized hourly and entered manually on bedside charts; these data have been used in large observational and interventional trials. However, ICP and CPP may change rapidly and frequently, so data recorded in medical charts might underestimate actual ICP and CPP shifts. The aim of this study was to evaluate the accuracy of manual data annotation for proper capturing of ICP and CPP. For this aim, we (1) compared end-hour ICP and CPP values manually recorded (MR) with values recorded continuously by computerized high-resolution (HR) systems and (2) analyzed whether MR ICP and MR CPP are reliable indicators of the burden of intracranial hypertension and low CPP. METHODS One hundred patients were included. First, we compared the MR data with the values stored in the computerized system during the first 7 days after admission. For this point-to-point analysis, we calculated the difference between end-hour MR and HR ICP and CPP. Then we analyzed the burden of high ICP (> 20 mm Hg) and low CPP (< 60 mm Hg) measured by the computerized system, in which continuous data were stored, compared with the pressure-time dose based on end-hour measurements. RESULTS The mean difference between MR and HR end-hour values was 0.02 mm Hg for ICP (SD 3.86 mm Hg) and 1.54 mm Hg for CPP (SD 8.81 mm Hg). ICP > 20 mm Hg and CPP < 60 mm Hg were not detected by MR in 1.6% and 5.8% of synchronized measurements, respectively. Analysis of the pathological ICP and CPP throughout the recording, however, indicated that calculations based on manual recording seriously underestimated the ICP and CPP burden (in 42% and 28% of patients, respectively). CONCLUSIONS Manual entries fairly represent end-hour HR ICP and CPP. However, compared with a computerized system, they may prove inadequate, with a serious risk of underestimation of the ICP and CPP burden.
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Affiliation(s)
- Tommaso Zoerle
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| | - Tatiana Birg
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marco Carbonara
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Peter Smielewski
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Michal M Placek
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Elisa R Zanier
- Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Cecilia A I Åkerlund
- Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Fabrizio Ortolano
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nino Stocchetti
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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9
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Biagianti B, Lisi I, Di Liberto A, Turtulici N, Foti G, Zito S, Ginex V, Fornoni C, Gallo F, Cantù F, Tombola V, Di Fede V, Rossetti MG, Colombo E, Stocchetti N, Zanier ER, Bellani M, Bressi C, Brambilla P. Feasibility and preliminary efficacy of brief tele-psychotherapy for COVID-19 patients and their first-degree relatives. J Affect Disord 2023; 330:300-308. [PMID: 36934855 PMCID: PMC10022466 DOI: 10.1016/j.jad.2023.03.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 03/01/2023] [Accepted: 03/11/2023] [Indexed: 03/19/2023]
Abstract
BACKGROUND The SARS-CoV-2 pandemic compromised the mental health of COVID-19 patients and their family members. Due to social distancing and lockdown measures, a remote, tele-psychotherapy program for former or current COVID-19 patients and their relatives was implemented. OBJECTIVE The primary goal of this project was to evaluate intervention feasibility. The secondary aim was to assess the impact of the intervention by means of pre-post psychological changes. METHODS After a phone-based eligibility screening and remote neuropsychological testing, participants completed online self-reports assessing baseline COVID-related psychopathology. Next, participants attended eight tele-psychotherapy sessions. After treatment, the online self-reports were completed again. RESULTS Of 104 enrolled participants, 88 completed the intervention (84.6 % completion rate). Significant pre-post improvements were observed for generalized anxiety (d = 0.38), depression (d = 0.37), insomnia (d = 0.43), post-traumatic psychopathology (d = 0.54), and general malaise (d = 0.31). Baseline cluster analysis revealed a subgroup of 41 subjects (47.6 %) with no psychopathology, and a second subgroup of 45 subject (52.3 %) with moderate severity. Thirty-three percent of the second group reached full symptom remission, while 66 % remained symptomatic after treatment. CONCLUSIONS Remote brief tele-psychotherapy for COVID-19 patients and their first-degree relatives is feasible and preliminary efficacious at reducing COVID-related psychopathology in a subgroup of patients. Further research is needed to investigate distinct profiles of treatment response.
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Affiliation(s)
- Bruno Biagianti
- Department of Psychology, University of Milan Bicocca, 20126, Milano, Italy
| | - Ilaria Lisi
- Laboratory of Acute Brain Injury and Therapeutic Strategies, Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20156 Milano, Italy
| | - Asia Di Liberto
- Department of Neurosciences and Mental Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Nunzio Turtulici
- Department of Neurosciences and Mental Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Giuseppe Foti
- Department of Psychology, University of Milan Bicocca, 20126, Milano, Italy
| | - Silvana Zito
- Department of Neurosciences and Mental Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Valeria Ginex
- Department of Neurosciences and Mental Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Chiara Fornoni
- Department of Neurosciences and Mental Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Francesca Gallo
- Department of Neurosciences and Mental Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Filippo Cantù
- Department of Psychology, University of Milan Bicocca, 20126, Milano, Italy
| | - Valentina Tombola
- Department of Neurosciences and Mental Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Viviana Di Fede
- Department of Neurosciences and Mental Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Maria Gloria Rossetti
- Department of Neurosciences and Mental Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Elisa Colombo
- Department of Neurosciences and Mental Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Nino Stocchetti
- Department of Anaesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Elisa R Zanier
- Laboratory of Acute Brain Injury and Therapeutic Strategies, Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20156 Milano, Italy
| | - Marcella Bellani
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, 37134 Verona, Italy
| | - Cinzia Bressi
- Department of Psychology, University of Milan Bicocca, 20126, Milano, Italy; Department of Neurosciences and Mental Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Paolo Brambilla
- Department of Psychology, University of Milan Bicocca, 20126, Milano, Italy; Department of Neurosciences and Mental Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy.
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Beqiri E, Zeiler FA, Ercole A, Placek MM, Tas J, Donnelly J, Aries MJH, Hutchinson PJ, Menon D, Stocchetti N, Czosnyka M, Smielewski P. The lower limit of reactivity as a potential individualised cerebral perfusion pressure target in traumatic brain injury: a CENTER-TBI high-resolution sub-study analysis. Crit Care 2023; 27:194. [PMID: 37210526 PMCID: PMC10199598 DOI: 10.1186/s13054-023-04485-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 05/11/2023] [Indexed: 05/22/2023] Open
Abstract
BACKGROUND A previous retrospective single-centre study suggested that the percentage of time spent with cerebral perfusion pressure (CPP) below the individual lower limit of reactivity (LLR) is associated with mortality in traumatic brain injury (TBI) patients. We aim to validate this in a large multicentre cohort. METHODS Recordings from 171 TBI patients from the high-resolution cohort of the CENTER-TBI study were processed with ICM+ software. We derived LLR as a time trend of CPP at a level for which the pressure reactivity index (PRx) indicates impaired cerebrovascular reactivity with low CPP. The relationship with mortality was assessed with Mann-U test (first 7-day period), Kruskal-Wallis (daily analysis for 7 days), univariate and multivariate logistic regression models. AUCs (CI 95%) were calculated and compared using DeLong's test. RESULTS Average LLR over the first 7 days was above 60 mmHg in 48% of patients. %time with CPP < LLR could predict mortality (AUC 0.73, p = < 0.001). This association becomes significant starting from the third day post injury. The relationship was maintained when correcting for IMPACT covariates or for high ICP. CONCLUSIONS Using a multicentre cohort, we confirmed that CPP below LLR was associated with mortality during the first seven days post injury.
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Affiliation(s)
- Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.
| | - Frederick A Zeiler
- Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
- Department of Clinical Neuroscience, Karolinska Intitutet, Stockholm, Sweden
| | - Ari Ercole
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Michal M Placek
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Jeanette Tas
- School for Mental Health and Neuroscience (MHeNS), University Maastricht, Maastricht, The Netherlands
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Joseph Donnelly
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
- Department of Clinical Neuroscience, Karolinska Intitutet, Stockholm, Sweden
- School for Mental Health and Neuroscience (MHeNS), University Maastricht, Maastricht, The Netherlands
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Marcel J H Aries
- School for Mental Health and Neuroscience (MHeNS), University Maastricht, Maastricht, The Netherlands
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge, CB2 0QQ, UK
| | - David Menon
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Nino Stocchetti
- Neuroscience Intensive Care Unit, Department of Anaesthesia and Critical Care, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplants, University of Milan, Milan, Italy
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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Beqiri E, Ercole A, Aries MJH, Placek MM, Tas J, Czosnyka M, Stocchetti N, Smielewski P. Towards autoregulation-oriented management after traumatic brain injury: increasing the reliability and stability of the CPPopt algorithm. J Clin Monit Comput 2023:10.1007/s10877-023-01009-1. [PMID: 37119323 PMCID: PMC10371880 DOI: 10.1007/s10877-023-01009-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 04/01/2023] [Indexed: 05/01/2023]
Abstract
PURPOSE CPPopt denotes a Cerebral Perfusion Pressure (CPP) value at which the Pressure-Reactivity index, reflecting the global state of Cerebral Autoregulation, is best preserved. CPPopt has been investigated as a potential dynamically individualised CPP target in traumatic brain injury patients admitted in intensive care unit. The prospective bedside use of the concept requires ensured safety and reliability of the CPP recommended targets based on the automatically-generated CPPopt. We aimed to: Increase stability and reliability of the CPPopt automated algorithm by fine-tuning; perform outcome validation of the adjusted algorithm in a multi-centre TBI cohort. METHODS ICM + software was used to derive CPPopt and fine-tune the algorithm. Parameters for improvement of the algorithm were selected based on qualitative and quantitative assessment of stability and reliability metrics. Patients enrolled in the Collaborative European Neuro Trauma Effectiveness Research in TBI (CENTER-TBI) high-resolution cohort were included for retrospective validation. Yield and stability of the new algorithm were compared to the previous algorithm using Mann-U test. Area under the curves for mortality prediction at 6 months were compared with the DeLong Test. RESULTS CPPopt showed higher stability (p < 0.0001), but lower yield compared to the previous algorithm [80.5% (70-87.5) vs 85% (75.7-91.2), p < 0.001]. Deviation of CPPopt could predict mortality with an AUC of [AUC = 0.69 (95% CI 0.59-0.78), p < 0.001] and was comparable with the previous algorithm. CONCLUSION The CPPopt calculation algorithm was fine-tuned and adapted for prospective use with acceptable lower yield, improved stability and maintained prognostic power.
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Affiliation(s)
- Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge, Cambridge, UK
| | - Marcel J H Aries
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
- School of Mental Health and Neurosciences, Maastricht University, Maastricht, The Netherlands
| | - Michal M Placek
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Jeanette Tas
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
- School of Mental Health and Neurosciences, Maastricht University, Maastricht, The Netherlands
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
| | - Nino Stocchetti
- Department of Anaesthesia and Critical Care, Neuroscience Intensive Care Unit, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplants, University of Milan, Milan, Italy
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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Olasveengen TM, Stocchetti N. Prehospital ventilation targets in severe traumatic brain injury. Intensive Care Med 2023; 49:554-555. [PMID: 37060441 DOI: 10.1007/s00134-023-07044-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 03/18/2023] [Indexed: 04/16/2023]
Affiliation(s)
- Theresa Mariero Olasveengen
- Department of Anesthesiology and Intensive Care, Institute of Clinical Medicine, Oslo University Hospital, University of Oslo, Oslo, Norway.
| | - Nino Stocchetti
- Fondazione IRCCS Cà Granda Ospedale Maggior Policlinico, Milan and Department of Physiopathology and Transplant, Milan University, Milan, Italy
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13
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Zoerle T, Birg T, Carbonara M, Smielewski P, Placek MM, Zanier ER, Åkerlund CAI, Ortolano F, Stocchetti N. Correction: Accuracy of Manual Intracranial Pressure Recording Compared to a Computerized High-Resolution System: A CENTER-TBI Analysis. Neurocrit Care 2023:10.1007/s12028-023-01722-4. [PMID: 37059959 DOI: 10.1007/s12028-023-01722-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Affiliation(s)
- Tommaso Zoerle
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| | - Tatiana Birg
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marco Carbonara
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Peter Smielewski
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Michal M Placek
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Elisa R Zanier
- Department of Neuroscience, Istituto Di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Cecilia A I Åkerlund
- Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Fabrizio Ortolano
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nino Stocchetti
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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14
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van Veen E, Nieboer D, Kompanje E, Citerio G, Stocchetti N, Gommers D, Menon D, Ercole A, Maas A, Lingsma HF, van der Jagt M. Comparative Effectiveness of Mannitol versus Hypertonic Saline in Traumatic Brain Injury patients: a CENTER-TBI study. J Neurotrauma 2023. [PMID: 37014076 DOI: 10.1089/neu.2022.0465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
Abstract
Increased intracranial pressure (ICP) is one of the most important modifiable and immediate threats to critically ill patients suffering from traumatic brain injury (TBI). Two hyperosmolar agents (HOA), mannitol and hypertonic saline (HTS) are routinely used in clinical practice to treat increased ICP. We aimed to assess whether a preference for mannitol, HTS or their combined use translated into differences in outcome. The CENTER-TBI Study is a prospective multicenter cohort study. For this study, patients with TBI, admitted to the ICU, treated with mannitol and/or HTS, aged ≥16, were included. Patients and centers were differentiated based on treatment preference with mannitol and/or HTS based on structured, data-driven criteria such as first administered HOA in the ICU. We assessed influence of center and patient characteristics in the choice of agent using adjusted multivariate models. Furthermore, we assessed the influence of HOA preference on outcome using adjusted ordinal and logistic regression models, and instrumental variable analyses. In total, 2056 patients were assessed. Of these, 502 (24%) patients received mannitol and/or HTS in the ICU. The first received HOA was HTS for 287 (57%) patients, mannitol for 149 (30%) patients, or both mannitol and HTS on the same day for 66 (13%) patients. Two unreactive pupils were more common for patients receiving both (13, 21%), compared to patients receiving HTS (40, 14%), or mannitol (22, 16%). Center, rather than patient characteristics, was independently associated with the preferred choice of HOA (p-value < 0.05). ICU mortality and 6-month outcome were similar between patients preferably treated with mannitol compared to HTS (OR = 1.0, CI = 0.4 - 2.2; OR = 0.9, CI = 0.5 - 1.6 respectively). Patients who received both also had a similar ICU mortality and 6-month outcome compared to patients receiving HTS (OR = 1.8, CI = 0.7 - 5.0; OR = 0.6, CI = 0.3 - 1.7 respectively). We found between center variability regarding HOA preference. Moreover, we found that center is a more important driver of the choice of HOA than patient characteristics. However, our study indicates that this variability is an acceptable practice given absence of differences in outcomes associated with a specific HOA. Traumatic brain injury, critical care, intensive care unit, osmolar therapy.
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Affiliation(s)
- Ernest van Veen
- Erasmus MC University Medical Center, Doctor Molewaterplein 40, Rotterdam, Netherlands, 3000 CA;
| | - Daan Nieboer
- Erasmus MC, Public Health, Room AE-138, PO BOX 2040, Rotterdam, Netherlands, 3000 CA;
| | - Erwin Kompanje
- Erasmus MC University Medical Center, Intensive Care Medicine, p.o. Box 2040, Rotterdam, Netherlands, 3000 CA;
| | - Giuseppe Citerio
- Azienda Ospedaliera San Gerardo, 9265, Perioperative Medicine and Intensive Care Medicine, Cadore, Monza, Lombardia, Italy, 20060;
| | - Nino Stocchetti
- Ospedale Policlinico, Neurorianimazione Beretta Neuro, via F.Sforza, 22, Milano, Italy, 20122;
| | - Diederik Gommers
- Erasmus MC University Medical Center, Intensive Care Medicine, Rotterdam, Netherlands;
| | - David Menon
- University of Cambridge, Head, Division of Anaesthesia, Box 93, Addenbrooke's Hospital, Hills Road, Cambridge, Cambs, United Kingdom of Great Britain and Northern Ireland, CB2 2QQ;
| | - Ari Ercole
- Cambridge University, Division of Anaesthesia, Box 93, Box 93 Addenbrooke's Hospital,, Hill's Road, CB2 0QQ, Cambridge, Cambridgeshire, United Kingdom of Great Britain and Northern Ireland, CB2 0QQ;
| | - Andrew Maas
- University Hospital Antwerp, Neurosurgery, Wilrijkstraat 10, Edegem, Belgium, 2650
- Netherlands;
| | - Hester F Lingsma
- Erasmus MC, Public Health, Room AE-138, PO BOX 2040, Rotterdam, Netherlands, 3000 CA
- Netherlands;
| | - Mathieu van der Jagt
- Erasmus MC, 6993, Intensive Care (Office Ne-415) and Erasmus MC Stroke Center, Erasmus Medical Center Rotterdam, Dr Molewaterplein 40, Rotterdam, Zuid-Holland, Netherlands, 3015GD;
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15
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Mangioni D, Fox V, Chatenoud L, Bolis M, Bottino N, Cariani L, Gentiloni Silverj F, Matinato C, Monti G, Muscatello A, Teri A, Terranova L, Piatti A, Gori A, Grasselli G, Stocchetti N, Alteri C, Bandera A. Genomic Characterization of Carbapenem-Resistant Acinetobacter baumannii (CRAB) in Mechanically Ventilated COVID-19 Patients and Impact of Infection Control Measures on Reducing CRAB Circulation during the Second Wave of the SARS-CoV-2 Pandemic in Milan, Italy. Microbiol Spectr 2023; 11:e0020923. [PMID: 36976013 PMCID: PMC10100775 DOI: 10.1128/spectrum.00209-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 03/06/2023] [Indexed: 03/29/2023] Open
Abstract
COVID-19 has significantly affected hospital infection prevention and control (IPC) practices, especially in intensive care units (ICUs). This frequently caused dissemination of multidrug-resistant organisms (MDROs), including carbapenem-resistant Acinetobacter baumannii (CRAB). Here, we report the management of a CRAB outbreak in a large ICU COVID-19 hub Hospital in Italy, together with retrospective genotypic analysis by whole-genome sequencing (WGS). Bacterial strains obtained from severe COVID-19 mechanically ventilated patients diagnosed with CRAB infection or colonization between October 2020 and May 2021 were analyzed by WGS to assess antimicrobial resistance and virulence genes, along with mobile genetic elements. Phylogenetic analysis in combination with epidemiological data was used to identify putative transmission chains. CRAB infections and colonization were diagnosed in 14/40 (35%) and 26/40 (65%) cases, respectively, with isolation within 48 h from admission in 7 cases (17.5%). All CRAB strains belonged to Pasteur sequence type 2 (ST2) and 5 different Oxford STs and presented blaOXA-23 gene-carrying Tn2006 transposons. Phylogenetic analysis revealed the existence of four transmission chains inside and among ICUs, circulating mainly between November and January 2021. A tailored IPC strategy was composed of a 5-point bundle, including ICU modules' temporary conversion to CRAB-ICUs and dynamic reopening, with limited impact on ICU admission rate. After its implementation, no CRAB transmission chains were detected. Our study underlies the potentiality of integrating classical epidemiological studies with genomic investigation to identify transmission routes during outbreaks, which could represent a valuable tool to ensure IPC strategies and prevent the spread of MDROs. IMPORTANCE Infection prevention and control (IPC) practices are of paramount importance for preventing the spread of multidrug-resistant organisms (MDROs) in hospitals, especially in the intensive care unit (ICU). Whole-genome sequencing (WGS) is seen as a promising tool for IPC, but its employment is currently still limited. COVID-19 pandemics have posed dramatic challenges in IPC practices, causing worldwide several outbreaks of MDROs, including carbapenem-resistant Acinetobacter baumannii (CRAB). We present the management of a CRAB outbreak in a large ICU COVID-19 hub hospital in Italy using a tailored IPC strategy that allowed us to contain CRAB transmission while preventing ICU closure during a critical pandemic period. The analysis of clinical and epidemiological data coupled with retrospective genotypic analysis by WGS identified different putative transmission chains and confirmed the effectiveness of the IPC strategy implemented. This could be a promising approach for future IPC strategies.
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Affiliation(s)
- Davide Mangioni
- Infectious Diseases Unit, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milano, Milan, Italy
| | - Valeria Fox
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | | | - Matteo Bolis
- Infectious Diseases Unit, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Nicola Bottino
- Department of Anaesthesia, Critical Care and Emergency, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Lisa Cariani
- Microbiology Laboratory, Clinical Laboratory, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | | | - Caterina Matinato
- Microbiology Laboratory, Clinical Laboratory, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Gianpaola Monti
- Department of Anesthesia and Intensive Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Antonio Muscatello
- Infectious Diseases Unit, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Antonio Teri
- Microbiology Laboratory, Clinical Laboratory, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Leonardo Terranova
- Department of Internal Medicine, Respiratory Unit and Adult Cystic Fibrosis Center, Foundation IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alessandra Piatti
- Medical Direction, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Andrea Gori
- Infectious Diseases Unit, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milano, Milan, Italy
| | - Giacomo Grasselli
- Department of Pathophysiology and Transplantation, University of Milano, Milan, Italy
- Department of Anaesthesia, Critical Care and Emergency, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Nino Stocchetti
- Department of Pathophysiology and Transplantation, University of Milano, Milan, Italy
- Department of Anaesthesia and Critical Care, Neuroscience Intensive Care Unit, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Claudia Alteri
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Alessandra Bandera
- Infectious Diseases Unit, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milano, Milan, Italy
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16
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Hawryluk GWJ, Citerio G, Hutchinson P, Kolias A, Meyfroidt G, Robba C, Stocchetti N, Chesnut R. Correction: Intracranial pressure: current perspectives on physiology and monitoring. Intensive Care Med 2023; 49:384. [PMID: 36735001 DOI: 10.1007/s00134-023-06977-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Gregory W J Hawryluk
- Section of Neurosurgery, University of Manitoba, GB1, 820 Sherbrook Street, Winnipeg, MB, R3A 1R9, Canada.
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.,Neuro-Intensive Care, Department of Neurosciences, San Gerardo Hospital, ASST-MONZA, Monza, Italy
| | - Peter Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB20QQ, UK
| | - Angelos Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB20QQ, UK
| | - Geert Meyfroidt
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Herestraat 49, Box 7003, 63 3000, Leuven, Belgium
| | - Chiara Robba
- Anaesthesia and Intensive Care, San Martino Research Hospital, Genoa, Italy
| | - Nino Stocchetti
- Anesthesia and Intensive Care, Department of Physiopathology and Transplantation, Milan University, Milan, Italy.,Department of Anaesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Randall Chesnut
- Neurosurgery, Neurotrauma, Department of Neurological Surgery, Department of Orthopaedic Surgery, School of Global Health, Harborview Medical Center, University of Washington, 325 Ninth Ave, Mailstop 359766, Seattle, WA, 98104-2499, USA
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17
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Biffi A, Porcu G, Castellini G, Napoletano A, Coclite D, D’Angelo D, Fauci AJ, Iacorossi L, Latina R, Salomone K, Iannone P, Gianola S, Chiara O, Medici A, Mazzola A, Coniglio C, De Blasio E, Flego G, Geraci M, Maccauro G, Rampoldi A, Santolini F, Tacconi C, Tugnoli G, Stocchetti N, Fabbri A, Ruggeri MP, Seta MD, Pizzarelli S, Cammarano RR. Systemic hemostatic agents initiated in trauma patients in the pre-hospital setting: a systematic review. Eur J Trauma Emerg Surg 2022; 49:1259-1270. [DOI: 10.1007/s00068-022-02185-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 11/24/2022] [Indexed: 12/23/2022]
Abstract
Abstract
Purpose
The effect of systemic hemostatic agents initiated during pre-hospital care of severely injured patients with ongoing bleeding or traumatic brain injury (TBI) remains controversial. A systematic review and meta-analysis was therefore conducted to assess the effectiveness and safety of systemic hemostatic agents as an adjunctive therapy in people with major trauma and hemorrhage or TBI in the context of developing the Italian National Institute of Health guidelines on major trauma integrated management.
Methods
PubMed, Embase, and Cochrane Library databases were searched up to October 2021 for studies that investigated pre-hospital initiated treatment with systemic hemostatic agents. The certainty of evidence was evaluated with the Grading of Recommendations Assessment, Development, and Evaluation approach, and the quality of each study was determined with the Cochrane risk-of-bias tool. The primary outcome was overall mortality, and secondary outcomes included cause-specific mortality, health-related quality of life, any adverse effects and blood product use, hemorrhage expansion, and patient-reported outcomes.
Results
Five trials of tranexamic acid (TXA) met the inclusion criteria for this meta-analysis. With a high certainty of evidence, when compared to placebo TXA reduced mortality at 24 h (relative risk = 0.83, 95% confidence interval = 0.73–0.94) and at 1 month among trauma patients (0.91, 0.85–0.97). These results depend on the subgroup of patients with significant hemorrhage because in the subgroup of TBI there are no difference between TXA and placebo. TXA also reduced bleeding death and multiple organ failure whereas no difference in health-related quality of life.
Conclusion
Balancing benefits and harms, TXA initiated in the pre-hospital setting can be used for patients experiencing major trauma with significant hemorrhage since it reduces the risk of mortality at 24 h and one month with no difference in terms of adverse effects when compared to placebo. Considering the subgroup of severe TBI, no difference in mortality rate was found at 24 h and one month. These results highlight the need to conduct future studies to investigate the role of other systemic hemostatic agents in the pre-hospital settings.
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18
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Bonetto V, Pasetto L, Lisi I, Carbonara M, Zangari R, Ferrari E, Punzi V, Luotti S, Bottino N, Biagianti B, Moglia C, Fuda G, Gualtierotti R, Blasi F, Canetta C, Montano N, Tettamanti M, Camera G, Grimoldi M, Negro G, Rifino N, Calvo A, Brambilla P, Biroli F, Bandera A, Nobili A, Stocchetti N, Sessa M, Zanier ER. Markers of blood-brain barrier disruption increase early and persistently in COVID-19 patients with neurological manifestations. Front Immunol 2022; 13:1070379. [PMID: 36591311 PMCID: PMC9798841 DOI: 10.3389/fimmu.2022.1070379] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 12/02/2022] [Indexed: 12/23/2022] Open
Abstract
Background Coronavirus disease 2019 (COVID-19) caused by SARS-CoV-2 infection is associated with disorders affecting the peripheral and the central nervous system. A high number of patients develop post-COVID-19 syndrome with the persistence of a large spectrum of symptoms, including neurological, beyond 4 weeks after infection. Several potential mechanisms in the acute phase have been hypothesized, including damage of the blood-brain-barrier (BBB). We tested weather markers of BBB damage in association with markers of brain injury and systemic inflammation may help in identifying a blood signature for disease severity and neurological complications. Methods Blood biomarkers of BBB disruption (MMP-9, GFAP), neuronal damage (NFL) and systemic inflammation (PPIA, IL-10, TNFα) were measured in two COVID-19 patient cohorts with high disease severity (ICUCovid; n=79) and with neurological complications (NeuroCovid; n=78), and in two control groups free from COVID-19 history, healthy subjects (n=20) and patients with amyotrophic lateral sclerosis (ALS; n=51). Samples from COVID-19 patients were collected during the first and the second wave of COVID-19 pandemic in Lombardy, Italy. Evaluations were done at acute and chronic phases of the COVID-19 infection. Results Blood biomarkers of BBB disruption and neuronal damage are high in COVID-19 patients with levels similar to or higher than ALS. NeuroCovid patients display lower levels of the cytokine storm inducer PPIA but higher levels of MMP-9 than ICUCovid patients. There was evidence of different temporal dynamics in ICUCovid compared to NeuroCovid patients with PPIA and IL-10 showing the highest levels in ICUCovid patients at acute phase. On the contrary, MMP-9 was higher at acute phase in NeuroCovid patients, with a severity dependency in the long-term. We also found a clear severity dependency of NFL and GFAP levels, with deceased patients showing the highest levels. Discussion The overall picture points to an increased risk for neurological complications in association with high levels of biomarkers of BBB disruption. Our observations may provide hints for therapeutic approaches mitigating BBB disruption to reduce the neurological damage in the acute phase and potential dysfunction in the long-term.
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Affiliation(s)
| | - Laura Pasetto
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Ilaria Lisi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Marco Carbonara
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Rosalia Zangari
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Erica Ferrari
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Veronica Punzi
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Silvia Luotti
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Nicola Bottino
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Bruno Biagianti
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Cristina Moglia
- “Rita Levi Montalcini”, Department of Neuroscience, University of Turin, Turin, Italy,AOU Città della Salute e della Scienza Hospital, Turin, Italy
| | - Giuseppe Fuda
- “Rita Levi Montalcini”, Department of Neuroscience, University of Turin, Turin, Italy
| | | | - Francesco Blasi
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Ciro Canetta
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nicola Montano
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Mauro Tettamanti
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Giorgia Camera
- Department of Neurology, Papa Giovanni XXIII Hospital, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Maria Grimoldi
- Department of Neurology, Papa Giovanni XXIII Hospital, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Giulia Negro
- Neurology Section, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Nicola Rifino
- Division of Neurology, University of Milano-Bicocca, Milan, Italy
| | - Andrea Calvo
- “Rita Levi Montalcini”, Department of Neuroscience, University of Turin, Turin, Italy,AOU Città della Salute e della Scienza Hospital, Turin, Italy
| | - Paolo Brambilla
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Francesco Biroli
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Alessandra Bandera
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | | | - Nino Stocchetti
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy,*Correspondence: Nino Stocchetti, ; Maria Sessa, ; Elisa R. Zanier,
| | - Maria Sessa
- Department of Neurology, Papa Giovanni XXIII Hospital, ASST Papa Giovanni XXIII, Bergamo, Italy,*Correspondence: Nino Stocchetti, ; Maria Sessa, ; Elisa R. Zanier,
| | - Elisa R. Zanier
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy,*Correspondence: Nino Stocchetti, ; Maria Sessa, ; Elisa R. Zanier,
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19
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Picetti E, Barbanera A, Bernucci C, Bertuccio A, Bilotta F, Boccardi EP, Cafiero T, Caricato A, Castioni CA, Cenzato M, Chieregato A, Citerio G, Gritti P, Lanterna L, Menozzi R, Munari M, Panni P, Rossi S, Stocchetti N, Sturiale C, Zoerle T, Zona G, Rasulo F, Robba C. Early management of patients with aneurysmal subarachnoid hemorrhage in a hospital with neurosurgical/neuroendovascular facilities: a consensus and clinical recommendations of the Italian Society of Anesthesia and Intensive Care (SIAARTI)–Part 1. J Anesth Analg Crit Care 2022; 2:13. [PMCID: PMC10245531 DOI: 10.1186/s44158-022-00042-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 03/21/2022] [Indexed: 06/16/2023]
Abstract
Abstract
Background
Issues remain on the optimal management of subarachnoid hemorrhage (SAH) patients once they are admitted to the referring center, before and after the aneurysm treatment. To address these issues, we created a consensus of experts endorsed by the Italian Society of Anesthesia and Intensive Care (SIAARTI). In this manuscript, we aim to provide a list of experts’ recommendations regarding the early management of SAH patients from hospital admission, in a center with neurosurgical/neuro-endovascular facilities, until securing of the bleeding aneurysm.
Methods
A multidisciplinary consensus panel composed of 24 physicians selected for their established clinical and scientific expertise in the acute management of SAH patients with different background (anesthesia/intensive care, neurosurgery, and interventional neuroradiology) was created. A modified Delphi approach was adopted.
Results
Among 19 statements discussed. The consensus was reached on 18 strong recommendations. In one case, consensus could not be agreed upon and no recommendation was provided.
Conclusions
This consensus provides practical recommendations for the management of SAH patients in hospitals with neurosurgical/neuroendovascular facilities until aneurysm securing. It is intended to support clinician’s decision-making and not to mandate a standard of practice.
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Maas AIR, Menon DK, Manley GT, Abrams M, Åkerlund C, Andelic N, Aries M, Bashford T, Bell MJ, Bodien YG, Brett BL, Büki A, Chesnut RM, Citerio G, Clark D, Clasby B, Cooper DJ, Czeiter E, Czosnyka M, Dams-O’Connor K, De Keyser V, Diaz-Arrastia R, Ercole A, van Essen TA, Falvey É, Ferguson AR, Figaji A, Fitzgerald M, Foreman B, Gantner D, Gao G, Giacino J, Gravesteijn B, Guiza F, Gupta D, Gurnell M, Haagsma JA, Hammond FM, Hawryluk G, Hutchinson P, van der Jagt M, Jain S, Jain S, Jiang JY, Kent H, Kolias A, Kompanje EJO, Lecky F, Lingsma HF, Maegele M, Majdan M, Markowitz A, McCrea M, Meyfroidt G, Mikolić A, Mondello S, Mukherjee P, Nelson D, Nelson LD, Newcombe V, Okonkwo D, Orešič M, Peul W, Pisică D, Polinder S, Ponsford J, Puybasset L, Raj R, Robba C, Røe C, Rosand J, Schueler P, Sharp DJ, Smielewski P, Stein MB, von Steinbüchel N, Stewart W, Steyerberg EW, Stocchetti N, Temkin N, Tenovuo O, Theadom A, Thomas I, Espin AT, Turgeon AF, Unterberg A, Van Praag D, van Veen E, Verheyden J, Vyvere TV, Wang KKW, Wiegers EJA, Williams WH, Wilson L, Wisniewski SR, Younsi A, Yue JK, Yuh EL, Zeiler FA, Zeldovich M, Zemek R. Traumatic brain injury: progress and challenges in prevention, clinical care, and research. Lancet Neurol 2022; 21:1004-1060. [PMID: 36183712 PMCID: PMC10427240 DOI: 10.1016/s1474-4422(22)00309-x] [Citation(s) in RCA: 168] [Impact Index Per Article: 84.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 07/22/2022] [Indexed: 02/06/2023]
Abstract
Traumatic brain injury (TBI) has the highest incidence of all common neurological disorders, and poses a substantial public health burden. TBI is increasingly documented not only as an acute condition but also as a chronic disease with long-term consequences, including an increased risk of late-onset neurodegeneration. The first Lancet Neurology Commission on TBI, published in 2017, called for a concerted effort to tackle the global health problem posed by TBI. Since then, funding agencies have supported research both in high-income countries (HICs) and in low-income and middle-income countries (LMICs). In November 2020, the World Health Assembly, the decision-making body of WHO, passed resolution WHA73.10 for global actions on epilepsy and other neurological disorders, and WHO launched the Decade for Action on Road Safety plan in 2021. New knowledge has been generated by large observational studies, including those conducted under the umbrella of the International Traumatic Brain Injury Research (InTBIR) initiative, established as a collaboration of funding agencies in 2011. InTBIR has also provided a huge stimulus to collaborative research in TBI and has facilitated participation of global partners. The return on investment has been high, but many needs of patients with TBI remain unaddressed. This update to the 2017 Commission presents advances and discusses persisting and new challenges in prevention, clinical care, and research. In LMICs, the occurrence of TBI is driven by road traffic incidents, often involving vulnerable road users such as motorcyclists and pedestrians. In HICs, most TBI is caused by falls, particularly in older people (aged ≥65 years), who often have comorbidities. Risk factors such as frailty and alcohol misuse provide opportunities for targeted prevention actions. Little evidence exists to inform treatment of older patients, who have been commonly excluded from past clinical trials—consequently, appropriate evidence is urgently required. Although increasing age is associated with worse outcomes from TBI, age should not dictate limitations in therapy. However, patients injured by low-energy falls (who are mostly older people) are about 50% less likely to receive critical care or emergency interventions, compared with those injured by high-energy mechanisms, such as road traffic incidents. Mild TBI, defined as a Glasgow Coma sum score of 13–15, comprises most of the TBI cases (over 90%) presenting to hospital. Around 50% of adult patients with mild TBI presenting to hospital do not recover to pre-TBI levels of health by 6 months after their injury. Fewer than 10% of patients discharged after presenting to an emergency department for TBI in Europe currently receive follow-up. Structured follow-up after mild TBI should be considered good practice, and urgent research is needed to identify which patients with mild TBI are at risk for incomplete recovery. The selection of patients for CT is an important triage decision in mild TBI since it allows early identification of lesions that can trigger hospital admission or life-saving surgery. Current decision making for deciding on CT is inefficient, with 90–95% of scanned patients showing no intracranial injury but being subjected to radiation risks. InTBIR studies have shown that measurement of blood-based biomarkers adds value to previously proposed clinical decision rules, holding the potential to improve efficiency while reducing radiation exposure. Increased concentrations of biomarkers in the blood of patients with a normal presentation CT scan suggest structural brain damage, which is seen on MR scanning in up to 30% of patients with mild TBI. Advanced MRI, including diffusion tensor imaging and volumetric analyses, can identify additional injuries not detectable by visual inspection of standard clinical MR images. Thus, the absence of CT abnormalities does not exclude structural damage—an observation relevant to litigation procedures, to management of mild TBI, and when CT scans are insufficient to explain the severity of the clinical condition. Although blood-based protein biomarkers have been shown to have important roles in the evaluation of TBI, most available assays are for research use only. To date, there is only one vendor of such assays with regulatory clearance in Europe and the USA with an indication to rule out the need for CT imaging for patients with suspected TBI. Regulatory clearance is provided for a combination of biomarkers, although evidence is accumulating that a single biomarker can perform as well as a combination. Additional biomarkers and more clinical-use platforms are on the horizon, but cross-platform harmonisation of results is needed. Health-care efficiency would benefit from diversity in providers. In the intensive care setting, automated analysis of blood pressure and intracranial pressure with calculation of derived parameters can help individualise management of TBI. Interest in the identification of subgroups of patients who might benefit more from some specific therapeutic approaches than others represents a welcome shift towards precision medicine. Comparative-effectiveness research to identify best practice has delivered on expectations for providing evidence in support of best practices, both in adult and paediatric patients with TBI. Progress has also been made in improving outcome assessment after TBI. Key instruments have been translated into up to 20 languages and linguistically validated, and are now internationally available for clinical and research use. TBI affects multiple domains of functioning, and outcomes are affected by personal characteristics and life-course events, consistent with a multifactorial bio-psycho-socio-ecological model of TBI, as presented in the US National Academies of Sciences, Engineering, and Medicine (NASEM) 2022 report. Multidimensional assessment is desirable and might be best based on measurement of global functional impairment. More work is required to develop and implement recommendations for multidimensional assessment. Prediction of outcome is relevant to patients and their families, and can facilitate the benchmarking of quality of care. InTBIR studies have identified new building blocks (eg, blood biomarkers and quantitative CT analysis) to refine existing prognostic models. Further improvement in prognostication could come from MRI, genetics, and the integration of dynamic changes in patient status after presentation. Neurotrauma researchers traditionally seek translation of their research findings through publications, clinical guidelines, and industry collaborations. However, to effectively impact clinical care and outcome, interactions are also needed with research funders, regulators, and policy makers, and partnership with patient organisations. Such interactions are increasingly taking place, with exemplars including interactions with the All Party Parliamentary Group on Acquired Brain Injury in the UK, the production of the NASEM report in the USA, and interactions with the US Food and Drug Administration. More interactions should be encouraged, and future discussions with regulators should include debates around consent from patients with acute mental incapacity and data sharing. Data sharing is strongly advocated by funding agencies. From January 2023, the US National Institutes of Health will require upload of research data into public repositories, but the EU requires data controllers to safeguard data security and privacy regulation. The tension between open data-sharing and adherence to privacy regulation could be resolved by cross-dataset analyses on federated platforms, with the data remaining at their original safe location. Tools already exist for conventional statistical analyses on federated platforms, however federated machine learning requires further development. Support for further development of federated platforms, and neuroinformatics more generally, should be a priority. This update to the 2017 Commission presents new insights and challenges across a range of topics around TBI: epidemiology and prevention (section 1 ); system of care (section 2 ); clinical management (section 3 ); characterisation of TBI (section 4 ); outcome assessment (section 5 ); prognosis (Section 6 ); and new directions for acquiring and implementing evidence (section 7 ). Table 1 summarises key messages from this Commission and proposes recommendations for the way forward to advance research and clinical management of TBI.
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Affiliation(s)
- Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Mathew Abrams
- International Neuroinformatics Coordinating Facility, Karolinska Institutet, Stockholm, Sweden
| | - Cecilia Åkerlund
- Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Nada Andelic
- Division of Clinical Neuroscience, Department of Physical Medicine and Rehabilitation, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Marcel Aries
- Department of Intensive Care, Maastricht UMC, Maastricht, Netherlands
| | - Tom Bashford
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Michael J Bell
- Critical Care Medicine, Neurological Surgery and Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Yelena G Bodien
- Department of Neurology and Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA
| | - Benjamin L Brett
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - András Büki
- Department of Neurosurgery, Faculty of Medicine and Health Örebro University, Örebro, Sweden
- Department of Neurosurgery, Medical School; ELKH-PTE Clinical Neuroscience MR Research Group; and Neurotrauma Research Group, Janos Szentagothai Research Centre, University of Pecs, Pecs, Hungary
| | - Randall M Chesnut
- Department of Neurological Surgery and Department of Orthopaedics and Sports Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Giuseppe Citerio
- School of Medicine and Surgery, Universita Milano Bicocca, Milan, Italy
- NeuroIntensive Care, San Gerardo Hospital, Azienda Socio Sanitaria Territoriale (ASST) Monza, Monza, Italy
| | - David Clark
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Betony Clasby
- Department of Sociological Studies, University of Sheffield, Sheffield, UK
| | - D Jamie Cooper
- School of Public Health and Preventive Medicine, Monash University and The Alfred Hospital, Melbourne, VIC, Australia
| | - Endre Czeiter
- Department of Neurosurgery, Medical School; ELKH-PTE Clinical Neuroscience MR Research Group; and Neurotrauma Research Group, Janos Szentagothai Research Centre, University of Pecs, Pecs, Hungary
| | - Marek Czosnyka
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Kristen Dams-O’Connor
- Department of Rehabilitation and Human Performance and Department of Neurology, Brain Injury Research Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Véronique De Keyser
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Ramon Diaz-Arrastia
- Department of Neurology and Center for Brain Injury and Repair, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Thomas A van Essen
- Department of Neurosurgery, Leiden University Medical Center, Leiden, Netherlands
- Department of Neurosurgery, Medical Center Haaglanden, The Hague, Netherlands
| | - Éanna Falvey
- College of Medicine and Health, University College Cork, Cork, Ireland
| | - Adam R Ferguson
- Brain and Spinal Injury Center, Department of Neurological Surgery, Weill Institute for Neurosciences, University of California San Francisco and San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA
| | - Anthony Figaji
- Division of Neurosurgery and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Melinda Fitzgerald
- Curtin Health Innovation Research Institute, Curtin University, Bentley, WA, Australia
- Perron Institute for Neurological and Translational Sciences, Nedlands, WA, Australia
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati Gardner Neuroscience Institute, University of Cincinnati, Cincinnati, OH, USA
| | - Dashiell Gantner
- School of Public Health and Preventive Medicine, Monash University and The Alfred Hospital, Melbourne, VIC, Australia
| | - Guoyi Gao
- Department of Neurosurgery, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine
| | - Joseph Giacino
- Department of Physical Medicine and Rehabilitation, Harvard Medical School and Spaulding Rehabilitation Hospital, Charlestown, MA, USA
| | - Benjamin Gravesteijn
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Fabian Guiza
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Deepak Gupta
- Department of Neurosurgery, Neurosciences Centre and JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Mark Gurnell
- Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Juanita A Haagsma
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Flora M Hammond
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Rehabilitation Hospital of Indiana, Indianapolis, IN, USA
| | - Gregory Hawryluk
- Section of Neurosurgery, GB1, Health Sciences Centre, University of Manitoba, Winnipeg, MB, Canada
| | - Peter Hutchinson
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Mathieu van der Jagt
- Department of Intensive Care, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Sonia Jain
- Biostatistics Research Center, Herbert Wertheim School of Public Health, University of California, San Diego, CA, USA
| | - Swati Jain
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Ji-yao Jiang
- Department of Neurosurgery, Shanghai Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Hope Kent
- Department of Psychology, University of Exeter, Exeter, UK
| | - Angelos Kolias
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Erwin J O Kompanje
- Department of Intensive Care, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Fiona Lecky
- Centre for Urgent and Emergency Care Research, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Marc Maegele
- Cologne-Merheim Medical Center, Department of Trauma and Orthopedic Surgery, Witten/Herdecke University, Cologne, Germany
| | - Marek Majdan
- Institute for Global Health and Epidemiology, Department of Public Health, Faculty of Health Sciences and Social Work, Trnava University, Trnava, Slovakia
| | - Amy Markowitz
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Michael McCrea
- Department of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Geert Meyfroidt
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Ana Mikolić
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Stefania Mondello
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Pratik Mukherjee
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - David Nelson
- Section for Anesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Lindsay D Nelson
- Department of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Virginia Newcombe
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - David Okonkwo
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Matej Orešič
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Wilco Peul
- Department of Neurosurgery, Leiden University Medical Center, Leiden, Netherlands
| | - Dana Pisică
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
- Department of Neurosurgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Jennie Ponsford
- Monash-Epworth Rehabilitation Research Centre, Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, VIC, Australia
| | - Louis Puybasset
- Department of Anesthesiology and Intensive Care, APHP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - Rahul Raj
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Chiara Robba
- Department of Anaesthesia and Intensive Care, Policlinico San Martino IRCCS for Oncology and Neuroscience, Genova, Italy, and Dipartimento di Scienze Chirurgiche e Diagnostiche, University of Genoa, Italy
| | - Cecilie Røe
- Division of Clinical Neuroscience, Department of Physical Medicine and Rehabilitation, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Jonathan Rosand
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - David J Sharp
- Department of Brain Sciences, Imperial College London, London, UK
| | - Peter Smielewski
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Murray B Stein
- Department of Psychiatry and Department of Family Medicine and Public Health, UCSD School of Medicine, La Jolla, CA, USA
| | - Nicole von Steinbüchel
- Institute of Medical Psychology and Medical Sociology, University Medical Center Goettingen, Goettingen, Germany
| | - William Stewart
- Department of Neuropathology, Queen Elizabeth University Hospital and University of Glasgow, Glasgow, UK
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences Leiden University Medical Center, Leiden, Netherlands
| | - Nino Stocchetti
- Department of Pathophysiology and Transplantation, Milan University, and Neuroscience ICU, Fondazione IRCCS Ca Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nancy Temkin
- Departments of Neurological Surgery, and Biostatistics, University of Washington, Seattle, WA, USA
| | - Olli Tenovuo
- Department of Rehabilitation and Brain Trauma, Turku University Hospital, and Department of Neurology, University of Turku, Turku, Finland
| | - Alice Theadom
- National Institute for Stroke and Applied Neurosciences, Faculty of Health and Environmental Studies, Auckland University of Technology, Auckland, New Zealand
| | - Ilias Thomas
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Abel Torres Espin
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Alexis F Turgeon
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, CHU de Québec-Université Laval Research Center, Québec City, QC, Canada
| | - Andreas Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Dominique Van Praag
- Departments of Clinical Psychology and Neurosurgery, Antwerp University Hospital, and University of Antwerp, Edegem, Belgium
| | - Ernest van Veen
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | | | - Thijs Vande Vyvere
- Department of Radiology, Faculty of Medicine and Health Sciences, Department of Rehabilitation Sciences (MOVANT), Antwerp University Hospital, and University of Antwerp, Edegem, Belgium
| | - Kevin K W Wang
- Department of Psychiatry, University of Florida, Gainesville, FL, USA
| | - Eveline J A Wiegers
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - W Huw Williams
- Centre for Clinical Neuropsychology Research, Department of Psychology, University of Exeter, Exeter, UK
| | - Lindsay Wilson
- Division of Psychology, University of Stirling, Stirling, UK
| | - Stephen R Wisniewski
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Alexander Younsi
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - John K Yue
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Esther L Yuh
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Frederick A Zeiler
- Departments of Surgery, Human Anatomy and Cell Science, and Biomedical Engineering, Rady Faculty of Health Sciences and Price Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Marina Zeldovich
- Institute of Medical Psychology and Medical Sociology, University Medical Center Goettingen, Goettingen, Germany
| | - Roger Zemek
- Departments of Pediatrics and Emergency Medicine, University of Ottawa, Children’s Hospital of Eastern Ontario, ON, Canada
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Zadek F, Giudici G, Ferraris Fusarini C, Ambrosini MT, di Modugno A, Scaravilli V, Zanella A, Fumagalli R, Stocchetti N, Calderini E, Langer T. Cerebrospinal fluid and arterial acid-base equilibria in spontaneously breathing third-trimester pregnant women. Br J Anaesth 2022; 129:726-733. [PMID: 36096944 PMCID: PMC9642833 DOI: 10.1016/j.bja.2022.07.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 06/17/2022] [Accepted: 07/10/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Acid-base status in full-term pregnant women is characterised by hypocapnic alkalosis. Whether this respiratory alkalosis is primary or consequent to changes in CSF electrolytes is not clear. METHODS We enrolled third-trimester pregnant women (pregnant group) and healthy, non-pregnant women of childbearing age (controls) undergoing spinal anaesthesia for Caesarean delivery and elective surgery, respectively. Electrolytes, strong ion difference (SID), partial pressure of carbon dioxide ( [Formula: see text] ), and pH were measured in simultaneously collected CSF and arterial blood samples. RESULTS All pregnant women (20) were hypocapnic, whilst only four (30%) of the controls (13) had an arterial [Formula: see text] <4.7 kPa (P<0.001). The incidence of hypocapnic alkalosis was higher in the pregnant group (65% vs 8%; P=0.001). The CSF-to-plasma Pco2 difference was significantly higher in pregnant women (1.5 [0.3] vs 1.0 [0.4] kPa; P<0.001), mainly because of a decrease in arterial Pco2 (3.9 [0.3] vs 4.9 [0.5] kPa; P<0.001). Similarly, the CSF-to-plasma difference in SID was less negative in pregnant women (-7.8 [1.4] vs -11.4 [2.3] mM; P<0.001), mainly because of a decreased arterial SID (31.5 [1.2] vs 36.1 [1.9] mM; P<0.001). The major determinant of the reduced plasma SID of pregnant women was a relative increase in plasma chloride compared with sodium. CONCLUSIONS Primary hypocapnic alkalosis characterises third-trimester pregnant women leading to chronic acid-base adaptations of CSF and plasma. The compensatory SID reduction, mainly sustained by an increase in chloride concentration, is more pronounced in plasma than in CSF, as the decrease in Pco2 is more marked in this compartment. CLINICAL TRIAL REGISTRATION NCT03496311.
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Affiliation(s)
- Francesco Zadek
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Giorgio Giudici
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | | | - Maria T. Ambrosini
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Adriana di Modugno
- Central Laboratory, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Vittorio Scaravilli
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy,Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Alberto Zanella
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy,Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Roberto Fumagalli
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy,Department of Anesthesia and Intensive Care Medicine, Niguarda Ca’ Granda, Milan, Italy
| | - Nino Stocchetti
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy,Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Edoardo Calderini
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Thomas Langer
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy,Department of Anesthesia and Intensive Care Medicine, Niguarda Ca’ Granda, Milan, Italy,Corresponding author.
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Hawryluk GWJ, Citerio G, Hutchinson P, Kolias A, Meyfroidt G, Robba C, Stocchetti N, Chesnut R. Intracranial pressure: current perspectives on physiology and monitoring. Intensive Care Med 2022; 48:1471-1481. [PMID: 35816237 DOI: 10.1007/s00134-022-06786-y] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 06/08/2022] [Indexed: 02/06/2023]
Abstract
Intracranial pressure (ICP) monitoring is now viewed as integral to the clinical care of many life-threatening brain insults, such as severe traumatic brain injury, subarachnoid hemorrhage, and malignant stroke. It serves to warn of expanding intracranial mass lesions, to prevent or treat herniation events as well as pressure elevation which impedes nutrient delivery to the brain. It facilitates the calculation of cerebral perfusion pressure (CPP) and the estimation of cerebrovascular autoregulatory status. Despite advancements in our knowledge emanating from a half century of experience with this technology, important controversies remain related even to fundamental aspects of ICP measurements, including indications for monitoring, ICP treatment thresholds, and management of intracranial hypertension. Here, we review the history of ICP monitoring, the underlying pathophysiology as well as current perspectives on why, when and how ICP monitoring is best used. ICP is typically assessed invasively but a number of emerging, non-invasive technologies with inherently lower risk are showing promise. In selected cases, additional neuromonitoring can be used to assist in the interpretation of ICP monitoring information and adapt directed treatment accordingly. Additional efforts to expand the evidence base relevant to ICP monitoring, related technologies and management remain a high priority in neurosurgery and neurocritical care.
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Affiliation(s)
- Gregory W J Hawryluk
- Section of Neurosurgery, University of Manitoba, GB1, 820 Sherbrook Street, Winnipeg, MB, R3A 1R9, Canada.
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.,Neuro-Intensive Care, Department of Neurosciences, San Gerardo Hospital, ASST-MONZA, Monza, Italy
| | - Peter Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB20QQ, UK
| | - Angelos Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB20QQ, UK
| | - Geert Meyfroidt
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Herestraat 49, Box 7003, 63 3000, Leuven, Belgium
| | - Chiara Robba
- Anaesthesia and Intensive Care, San Martino Research Hospital, Genoa, Italy
| | - Nino Stocchetti
- Anesthesia and Intensive Care, Department of Physiopathology and Transplantation, Milan University, Milan, Italy.,Department of Anaesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Randall Chesnut
- Neurosurgery, Neurotrauma, Department of Neurological Surgery, Department of Orthopaedic Surgery, School of Global Health, Harborview Medical Center, University of Washington, 325 Ninth Ave, Mailstop 359766, Seattle, WA, 98104-2499, USA
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Åkerlund CAI, Holst A, Stocchetti N, Steyerberg EW, Menon DK, Ercole A, Nelson DW. Clustering identifies endotypes of traumatic brain injury in an intensive care cohort: a CENTER-TBI study. Crit Care 2022; 26:228. [PMID: 35897070 PMCID: PMC9327174 DOI: 10.1186/s13054-022-04079-w] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 07/02/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND While the Glasgow coma scale (GCS) is one of the strongest outcome predictors, the current classification of traumatic brain injury (TBI) as 'mild', 'moderate' or 'severe' based on this fails to capture enormous heterogeneity in pathophysiology and treatment response. We hypothesized that data-driven characterization of TBI could identify distinct endotypes and give mechanistic insights. METHODS We developed an unsupervised statistical clustering model based on a mixture of probabilistic graphs for presentation (< 24 h) demographic, clinical, physiological, laboratory and imaging data to identify subgroups of TBI patients admitted to the intensive care unit in the CENTER-TBI dataset (N = 1,728). A cluster similarity index was used for robust determination of optimal cluster number. Mutual information was used to quantify feature importance and for cluster interpretation. RESULTS Six stable endotypes were identified with distinct GCS and composite systemic metabolic stress profiles, distinguished by GCS, blood lactate, oxygen saturation, serum creatinine, glucose, base excess, pH, arterial partial pressure of carbon dioxide, and body temperature. Notably, a cluster with 'moderate' TBI (by traditional classification) and deranged metabolic profile, had a worse outcome than a cluster with 'severe' GCS and a normal metabolic profile. Addition of cluster labels significantly improved the prognostic precision of the IMPACT (International Mission for Prognosis and Analysis of Clinical trials in TBI) extended model, for prediction of both unfavourable outcome and mortality (both p < 0.001). CONCLUSIONS Six stable and clinically distinct TBI endotypes were identified by probabilistic unsupervised clustering. In addition to presenting neurology, a profile of biochemical derangement was found to be an important distinguishing feature that was both biologically plausible and associated with outcome. Our work motivates refining current TBI classifications with factors describing metabolic stress. Such data-driven clusters suggest TBI endotypes that merit investigation to identify bespoke treatment strategies to improve care. Trial registration The core study was registered with ClinicalTrials.gov, number NCT02210221 , registered on August 06, 2014, with Resource Identification Portal (RRID: SCR_015582).
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Affiliation(s)
- Cecilia A I Åkerlund
- Section of Perioperative Medicine and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden. .,School of Electrical Engineering and Computer Science, KTH Royal Institute of Technology, Stockholm, Sweden.
| | - Anders Holst
- School of Electrical Engineering and Computer Science, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Nino Stocchetti
- Neuroscience Intensive Care Unit, Department of Pathophysiology and Transplants, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - David K Menon
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Ari Ercole
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK.,Centre for Artificial Intelligence in Medicine, University of Cambridge, Cambridge, UK
| | - David W Nelson
- Section of Perioperative Medicine and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
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Volovici V, Pisică D, Gravesteijn BY, Dirven CMF, Steyerberg EW, Ercole A, Stocchetti N, Nelson D, Menon DK, Citerio G, van der Jagt M, Maas AIR, Haitsma IK, Lingsma HF, Åkerlund C, Amrein K, Andelic N, Andreassen L, Audibert G, Azouvi P, Azzolini ML, Bartels R, Beer R, Bellander BM, Benali H, Berardino M, Beretta L, Beqiri E, Blaabjerg M, Lund SB, Brorsson C, Buki A, Cabeleira M, Caccioppola A, Calappi E, Calvi MR, Cameron P, Lozano GC, Castaño-León AM, Cavallo S, Chevallard G, Chieregato A, Coburn M, Coles J, Cooper JD, Correia M, Czeiter E, Czosnyka M, Dahyot-Fizelier C, Dark P, De Keyser V, Degos V, Corte FD, Boogert HD, Depreitere B, Dilvesi D, Dixit A, Dreier J, Dulière GL, Ezer E, Fabricius M, Foks K, Frisvold S, Furmanov A, Galanaud D, Gantner D, Ghuysen A, Giga L, Golubovic J, Gomez PA, Grossi F, Gupta D, Haitsma I, Helseth E, Hutchinson PJ, Jankowski S, Johnson F, Karan M, Kolias AG, Kondziella D, Koraropoulos E, Koskinen LO, Kovács N, Kowark A, Lagares A, Laureys S, Ledoux D, Lejeune A, Lightfoot R, Manara A, Martino C, Maréchal H, Mattern J, McMahon C, Menovsky T, Misset B, Muraleedharan V, Murray L, Negru A, Newcombe V, Nyirádi J, Ortolano F, Payen JF, Perlbarg V, Persona P, Piippo-Karjalainen A, Ples H, Pomposo I, Posti JP, Puybasset L, Radoi A, Ragauskas A, Raj R, Rhodes J, Richter S, Rocka S, Roe C, Roise O, Rosenfeld JV, Rosenlund C, Rosenthal G, Rossaint R, Rossi S, Sahuquillo J, Sandrød O, Sakowitz O, Sanchez-Porras R, Schirmer-Mikalsen K, Schou RF, Smielewski P, Sorinola A, Stamatakis E, Sundström N, Takala R, Tamás V, Tamosuitis T, Tenovuo O, Thomas M, Tibboel D, Tolias C, Trapani T, Tudora CM, Vajkoczy P, Vallance S, Valeinis E, Vámos Z, Van der Steen G, van Wijk RPJ, Vargiolu A, Vega E, Vik A, Vilcinis R, Vulekovic P, Williams G, Winzeck S, Wolf S, Younsi A, Zeiler FA, Ziverte A, Clusmann H, Voormolen D, van Dijck JTJM, van Essen TA. Comparative effectiveness of intracranial hypertension management guided by ventricular versus intraparenchymal pressure monitoring: a CENTER-TBI study. Acta Neurochir (Wien) 2022; 164:1693-1705. [PMID: 35648213 PMCID: PMC9233652 DOI: 10.1007/s00701-022-05257-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 05/11/2022] [Indexed: 12/04/2022]
Abstract
OBJECTIVE To compare outcomes between patients with primary external ventricular device (EVD)-driven treatment of intracranial hypertension and those with primary intraparenchymal monitor (IP)-driven treatment. METHODS The CENTER-TBI study is a prospective, multicenter, longitudinal observational cohort study that enrolled patients of all TBI severities from 62 participating centers (mainly level I trauma centers) across Europe between 2015 and 2017. Functional outcome was assessed at 6 months and a year. We used multivariable adjusted instrumental variable (IV) analysis with "center" as instrument and logistic regression with covariate adjustment to determine the effect estimate of EVD on 6-month functional outcome. RESULTS A total of 878 patients of all TBI severities with an indication for intracranial pressure (ICP) monitoring were included in the present study, of whom 739 (84%) patients had an IP monitor and 139 (16%) an EVD. Patients included were predominantly male (74% in the IP monitor and 76% in the EVD group), with a median age of 46 years in the IP group and 48 in the EVD group. Six-month GOS-E was similar between IP and EVD patients (adjusted odds ratio (aOR) and 95% confidence interval [CI] OR 0.74 and 95% CI [0.36-1.52], adjusted IV analysis). The length of intensive care unit stay was greater in the EVD group than in the IP group (adjusted rate ratio [95% CI] 1.70 [1.34-2.12], IV analysis). One hundred eighty-seven of the 739 patients in the IP group (25%) required an EVD due to refractory ICPs. CONCLUSION We found no major differences in outcomes of patients with TBI when comparing EVD-guided and IP monitor-guided ICP management. In our cohort, a quarter of patients that initially received an IP monitor required an EVD later for ICP control. The prevalence of complications was higher in the EVD group. PROTOCOL The core study is registered with ClinicalTrials.gov , number NCT02210221, and the Resource Identification Portal (RRID: SCR_015582).
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25
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Biagianti B, Di Liberto A, Nicolò Edoardo A, Lisi I, Nobilia L, de Ferrabonc GD, Zanier ER, Stocchetti N, Brambilla P. Cognitive Assessment in SARS-CoV-2 Patients: A Systematic Review. Front Aging Neurosci 2022; 14:909661. [PMID: 35847679 PMCID: PMC9283975 DOI: 10.3389/fnagi.2022.909661] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 05/30/2022] [Indexed: 12/15/2022] Open
Abstract
Background Patients with post-infective severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) often show both short- and long-term cognitive deficits within the dysexecutive/inattentive spectrum. However, little is known about which cognitive alterations are commonly found in patients recovered from SARS-CoV-2, and which psychometric tools clinicians should consider when assessing cognition in this population. The present work reviewed published studies to provide a critical narrative of neuropsychological (NPs) deficits commonly observed after SARS-CoV-2 infection and the tests most suited for detecting such cognitive sequelae depending on illness severity. Methods This review followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines and was pre-registered on Prospective Register of Systematic Reviews (PROSPERO) (CRD42021253079). Observational studies quantitatively assessing cognition in patients with post-infective SARS-CoV-2 were considered. From 711 retrieved articles, 19 studies conducted on patients with SARS-CoV-2 without medical comorbidities were included and stratified by disease severity. Results The majority of studies (N = 13) adopted first-level tests. The most frequently administered screeners were the Montreal Cognitive Assessment (MoCA) and the Mini-Mental State Examination (MMSE)—with the former more likely to detect mild, and the latter moderate/severe deficits. Among second-level tests, those assessing attention and executive functions (EFs) were highly represented. Remotely-delivered tests yielded lower percentages of cognitive impairment. Overall, cognitive domains often found to be impaired were EFs, attention, and memory. Conclusion Cognitive sequelae in patients with post-infective SARS-CoV-2 can be detected with NPs testing. Depending on the psychometric test features, the likelihood of observing cognitive deficits can vary. Further studies on larger sample sizes are needed to investigate the clinical usefulness of second-level tools. The primary goal of preventative health services should be the early detection and intervention of emerging cognitive deficits.
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Affiliation(s)
- Bruno Biagianti
- Department of Neurosciences and Mental Health, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- *Correspondence: Bruno Biagianti, , orcid.org/0000-0002-5955-3019
| | - Asia Di Liberto
- Department of Neurosciences and Mental Health, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Aiello Nicolò Edoardo
- University of Milano-Bicocca, Milan, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Ilaria Lisi
- Laboratory of Acute Brain Injury and Therapeutic Strategies, Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Letizia Nobilia
- Department of Psychology, University of Milano-Bicocca, Milan, Italy
| | - Giulia Delor de Ferrabonc
- Department of Neurosciences and Mental Health, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Elisa R. Zanier
- Laboratory of Acute Brain Injury and Therapeutic Strategies, Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Nino Stocchetti
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Department of Anaesthesia and Critical Care, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Paolo Brambilla
- Department of Neurosciences and Mental Health, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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26
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Moschetti G, Vasco C, Clemente F, Galeota E, Carbonara M, Pluderi M, Locatelli M, Stocchetti N, Abrignani S, Zanier ER, Ortolano F, Zoerle T, Geginat J. Deep Phenotyping of T-Cells Derived From the Aneurysm Wall in a Pediatric Case of Subarachnoid Hemorrhage. Front Immunol 2022; 13:866558. [PMID: 35711453 PMCID: PMC9197186 DOI: 10.3389/fimmu.2022.866558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 04/28/2022] [Indexed: 11/13/2022] Open
Abstract
Intracranial aneurysms (IAs) are very rare in children, and the characteristics of the T-cells in the IA wall are largely unknown. A comatose 7-years-old child was admitted to our center because of a subarachnoid hemorrhage due to a ruptured giant aneurysm of the right middle cerebral artery. Two days after the aneurysm clipping the patient was fully awake with left hemiparesis. T-cells from the IA wall and from peripheral blood of this patient were analyzed by multi-dimensional flow cytometry. Unbiased analysis, based on the use of FlowSOM clustering and dimensionality reduction technique UMAP, indicated that there was virtually no overlap between circulating and tissue-infiltrating T-cells. Thus, naïve T-cells and canonical memory T-cells were largely restricted to peripheral blood, while CD4-CD8-T-cells were strongly enriched in the IA wall. The unique CD4+, CD8+ and CD4-CD8-T-cell clusters from the IA wall expressed high levels of CCR5, Granzyme B and CD69, displaying thus characteristics of cytotoxic and tissue-resident effector cells. Low Ki67 expression indicated that they were nevertheless in a resting state. Among regulatory T-cell subsets, Eomes+Tr1-like cells were strongly enriched in the IA wall. Finally, analysis of cytokine producing capacities unveiled that the IA wall contained poly-functional T-cells, which expressed predominantly IFN-γ, TNF and IL-2. CD4+T-cells co-expressed also CD40L, and produced some IL-17, GM-CSF and IL-10. This report provides to our knowledge the first detailed characterization of the human T-cell compartment in the IA wall.
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Affiliation(s)
| | - Chiara Vasco
- National Institute for Molecular Genetics (INGM), Milan, Italy
| | | | - Eugenia Galeota
- National Institute for Molecular Genetics (INGM), Milan, Italy
| | - Marco Carbonara
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Mauro Pluderi
- Department of Neurosurgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marco Locatelli
- Department of Neurosurgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Nino Stocchetti
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Sergio Abrignani
- National Institute for Molecular Genetics (INGM), Milan, Italy.,Department of Clinical Sciences and Community Health University Milan, Milan, Italy
| | - Elisa R Zanier
- Laboratory of Acute Brain Injury and Therapeutic Strategies, Department of Neuroscience, Mario Negri Institute for Pharmacological Research IRCCS, Milan, Italy
| | - Fabrizio Ortolano
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Tommaso Zoerle
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Jens Geginat
- National Institute for Molecular Genetics (INGM), Milan, Italy.,Department of Clinical Sciences and Community Health University Milan, Milan, Italy
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27
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Picetti E, Barbanera A, Bernucci C, Bertuccio A, Bilotta F, Boccardi EP, Cafiero T, Caricato A, Castioni CA, Cenzato M, Chieregato A, Citerio G, Gritti P, Lanterna L, Menozzi R, Munari M, Panni P, Rossi S, Stocchetti N, Sturiale C, Zoerle T, Zona G, Rasulo F, Robba C. Early management of patients with aneurysmal subarachnoid hemorrhage in a hospital with neurosurgical/neuroendovascular facilities: a consensus and clinical recommendations of the Italian Society of Anesthesia and Intensive Care (SIAARTI)-part 2. J Anesth Analg Crit Care 2022; 2:21. [PMID: 37386571 DOI: 10.1186/s44158-022-00049-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 04/27/2022] [Indexed: 07/01/2023]
Abstract
BACKGROUND Questions remain on the optimal management of subarachnoid hemorrhage (SAH) patients once they are admitted to the referring center, before and after the aneurysm treatment. To address these issues, we created a consensus of experts endorsed by the Italian Society of Anesthesia and Intensive Care (SIAARTI) to provide clinical guidance regarding this topic. Specifically, in this manuscript (part 2), we aim to provide a list of experts' recommendations regarding the management of SAH patients in a center with neurosurgical/neuroendovascular facilities after aneurysm treatment. METHODS A multidisciplinary consensus panel composed by 24 physicians selected for their established clinical and scientific expertise in the acute management of SAH patients with different specializations (anesthesia/intensive care, neurosurgery, and interventional neuroradiology) was created. A modified Delphi approach was adopted. RESULTS A total of 33 statements were discussed, voted, and approved. Consensus was reached on 30 recommendations (28 strong and 2 weak). In 3 cases, where consensus could not be agreed upon, no recommendation was provided. CONCLUSIONS This consensus provides practical recommendations (and not mandatory standard of practice) to support clinician's decision-making in the management of SAH patients in centers with neurosurgical/neuroendovascular facilities after aneurysm securing.
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Affiliation(s)
- Edoardo Picetti
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy.
| | - Andrea Barbanera
- Department of Neurosurgery, "SS Antonio e Biagio e Cesare Arrigo" Hospital, Alessandria, Italy
| | - Claudio Bernucci
- Department of Neuroscience and Surgery of the Nervous System, ASST Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Alessandro Bertuccio
- Department of Neurosurgery, "SS Antonio e Biagio e Cesare Arrigo" Hospital, Alessandria, Italy
| | - Federico Bilotta
- Department of Anesthesiology and Critical Care, Policlinico Umberto I Hospital, La Sapienza University of Rome, Rome, Italy
| | - Edoardo Pietro Boccardi
- Department of Interventional Neuroradiology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Tullio Cafiero
- Department of Anesthesia and Intensive Care Unit, AORN Cardarelli, Naples, Italy
| | - Anselmo Caricato
- Department of Anesthesia and Critical Care, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Carlo Alberto Castioni
- Department of Anesthesia and Intensive Care, IRCCS Institute of Neurological Sciences of Bologna, Bologna, Italy
| | - Marco Cenzato
- Department of Neurosurgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Arturo Chieregato
- Neurointensive Care Unit, Department of Neuroscience and Department of Anesthesiology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Giuseppe Citerio
- School of Medicine and Surgery, University Milano - Bicocca, Milan, Italy
| | - Paolo Gritti
- Department of Anesthesia and Critical Care Medicine, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Luigi Lanterna
- Department of Neuroscience and Surgery of the Nervous System, ASST Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Roberto Menozzi
- Interventional Neuroradiology Unit, University Hospital of Parma, Parma, Italy
| | - Marina Munari
- Anesthesia and Intensive Care, Padua University Hospital, Padua, Italy
| | - Pietro Panni
- Department of Neuroradiology, San Raffaele Hospital, Milan, Italy
| | - Sandra Rossi
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Nino Stocchetti
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Carmelo Sturiale
- Neurosurgery Unit, IRCCS Istituto delle Scienze Neurologiche Ospedale Bellaria di Bologna, Bologna, Italy
| | - Tommaso Zoerle
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Gianluigi Zona
- Department of Neurosurgery, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Frank Rasulo
- Department of Anesthesia, Intensive Care and Emergency Medicine, Spedali Civili University Hospital, Brescia, Italy
| | - Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
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van Essen TA, Lingsma HF, Pisică D, Singh RD, Volovici V, den Boogert HF, Younsi A, Peppel LD, Heijenbrok-Kal MH, Ribbers GM, Walchenbach R, Menon DK, Hutchinson P, Depreitere B, Steyerberg EW, Maas AIR, de Ruiter GCW, Peul WC, Åkerlund C, Amrein K, Andelic N, Andreassen L, Anke A, Antoni A, Audibert G, Azouvi P, Azzolini ML, Bartels R, Barzó P, Beauvais R, Beer R, Bellander BM, Belli A, Benali H, Berardino M, Beretta L, Blaabjerg M, Bragge P, Brazinova A, Brinck V, Brooker J, Brorsson C, Buki A, Bullinger M, Cabeleira M, Caccioppola A, Calappi E, Calvi MR, Cameron P, Carbayo Lozano G, Carbonara M, Castaño-León AM, Cavallo S, Chevallard G, Chieregato A, Citerio G, Clusmann H, Coburn MS, Coles J, Cooper JD, Correia M, Čović A, Curry N, Czeiter E, Czosnyka M, Dahyot-Fizelier C, Dark P, Dawes H, De Keyser V, Degos V, Della Corte F, Đilvesi Đ, Dixit A, Donoghue E, Dreier J, Dulière GL, Ercole A, Esser P, Ezer E, Fabricius M, Feigin VL, Foks K, Frisvold S, Furmanov A, Gagliardo P, Galanaud D, Gantner D, Gao G, George P, Ghuysen A, Giga L, Glocker B, Golubović J, Gomez PA, Gratz J, Gravesteijn B, Grossi F, Gruen RL, Gupta D, Haagsma JA, Haitsma I, Helbok R, Helseth E, Horton L, Huijben J, Jacobs B, Jankowski S, Jarrett M, Jiang JY, Johnson F, Jones K, Karan M, Kolias AG, Kompanje E, Kondziella D, Kornaropoulos E, Koskinen LO, Kovács N, Lagares A, Lanyon L, Laureys S, Lecky F, Ledoux D, Lefering R, Legrand V, Lejeune A, Levi L, Lightfoot R, Maegele M, Majdan M, Manara A, Manley G, Maréchal H, Martino C, Mattern J, McMahon C, Melegh B, Menovsky T, Mikolic A, Misset B, Muraleedharan V, Murray L, Nair N, Negru A, Nelson D, Newcombe V, Nieboer D, Nyirádi J, Oresic M, Ortolano F, Otesile O, Palotie A, Parizel PM, Payen JF, Perera N, Perlbarg V, Persona P, Piippo-Karjalainen A, Pirinen M, Ples H, Polinder S, Pomposo I, Posti JP, Puybasset L, Rădoi A, Ragauskas A, Raj R, Rambadagalla M, Rehorčíková V, Retel Helmrich I, Rhodes J, Richardson S, Richter S, Ripatti S, Rocka S, Roe C, Roise O, Rosand J, Rosenfeld J, Rosenlund C, Rosenthal G, Rossaint R, Rossi S, Rueckert D, Rusnák M, Sahuquillo J, Sakowitz O, Sanchez-Porras R, Sandor J, Schäfer N, Schmidt S, Schoechl H, Schoonman G, Schou RF, Schwendenwein E, Sewalt C, Skandsen T, Smielewski P, Sorinola A, Stamatakis E, Stanworth S, Kowark A, Stevens R, Stewart W, Stocchetti N, Sundström N, Takala R, Tamás V, Tamosuitis T, Taylor MS, Te Ao B, Tenovuo O, Theadom A, Thomas M, Tibboel D, Timmers M, Tolias C, Trapani T, Tudora CM, Unterberg A, Vajkoczy P, Valeinis E, Vallance S, Vámos Z, Van der Jagt M, van der Naalt J, Van der Steen G, van Dijck JT, Van Hecke W, van Heugten C, Van Praag D, Van Veen E, van Wijk R, Vande Vyvere T, Vargiolu A, Vega E, Velt K, Verheyden J, Vespa PM, Vik A, Vilcinis R, von Steinbüchel N, Voormolen D, Vulekovic P, Wang KK, Wiegers E, Williams G, Wilson L, Winzeck S, Wolf S, Yang Z, Ylén P, Zeiler FA, Ziverte A, Zoerle T. Surgery versus conservative treatment for traumatic acute subdural haematoma: a prospective, multicentre, observational, comparative effectiveness study. Lancet Neurol 2022; 21:620-631. [DOI: 10.1016/s1474-4422(22)00166-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 04/04/2022] [Accepted: 04/06/2022] [Indexed: 01/05/2023]
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Cantù F, Biagianti B, Lisi I, R Zanier E, Bottino N, Fornoni C, Gallo F, Ginex V, Tombola V, Zito S, Colombo E, Stocchetti N, Brambilla P. Psychotherapeutic and psychiatric intervention in COVID-19 patients and their relatives: the DigiCOVID trial protocol (Preprint). JMIR Res Protoc 2022; 11:e39080. [PMID: 36228130 PMCID: PMC9674079 DOI: 10.2196/39080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 06/07/2022] [Accepted: 06/16/2022] [Indexed: 12/02/2022] Open
Abstract
Background The COVID-19 pandemic is negatively impacting the mental health of both patients with COVID-19 and the general population. As current guidelines are limiting in-person contacts to reduce the spread of the virus, the development of a digital approach to implement in psychiatric and psychological consultations is needed. In this paper, we present the DigiCOVID protocol, a digital approach to offer remote, personalized psychological and psychiatric support to former or current patients with COVID-19 and their relatives. Objective The main goal of this project is to evaluate the feasibility, acceptability, and usability of the DigiCOVID protocol. Furthermore, we also aim to assess the impact of the abovementioned protocol by means of pre-post changes in psychological clinical variables. Methods Participants undergo an initial telephonic screening to ensure inclusion criteria are met. Secondly, participants complete a video-assisted neuropsychological IQ test as well as web-based self-reports of health and general well-being. Participants are then assigned to a psychotherapist who offers 8 teletherapy sessions. At the end of the therapy cycle, the web-based questionnaires are administered for a posttreatment evaluation. Results As of April 2022, we enrolled a total of 122 participants, of which 94 have completed neuropsychological tests and web-based questionnaires. Conclusions Our study aims at testing the feasibility and preliminary efficacy of DigiCOVID, a remote telemedicine protocol for the improvement of psychological and psychiatric health in patients with COVID-19 and their relatives. To date, the approach used seems to be feasible and highly customizable to patients’ needs, and therefore, the DigiCOVID protocol might pave the way for future telepsychiatry-based interventions. Trial Registration ClinicalTrials.gov NCT05231018; https://clinicaltrials.gov/ct2/show/NCT05231018?term=NCT05231018 &draw=2&rank=1 International Registered Report Identifier (IRRID) DERR1-10.2196/39080
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Affiliation(s)
- Filippo Cantù
- Department of Pathophysiology and Transplantation, University of Milan, Milano, Italy
| | - Bruno Biagianti
- Department of Pathophysiology and Transplantation, University of Milan, Milano, Italy
- Department of Research and Development, Posit Science Corporation, San Francisco, CA, United States
| | - Ilaria Lisi
- Laboratory of Acute Brain Injury and Therapeutic Strategies, Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri Istituto di Ricovero e Cura a Carattere Scientifico, Milano, Italy
| | - Elisa R Zanier
- Laboratory of Acute Brain Injury and Therapeutic Strategies, Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri Istituto di Ricovero e Cura a Carattere Scientifico, Milano, Italy
| | - Nicola Bottino
- Department of Anaesthesia and Critical Care, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Chiara Fornoni
- Department of Neurosciences and Mental Health, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Francesca Gallo
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Valeria Ginex
- Department of Neurosciences and Mental Health, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Valentina Tombola
- Department of Neurosciences and Mental Health, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Silvana Zito
- Department of Neurosciences and Mental Health, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Elisa Colombo
- Department of Neurosciences and Mental Health, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Nino Stocchetti
- Department of Pathophysiology and Transplantation, University of Milan, Milano, Italy
- Department of Anaesthesia and Critical Care, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Paolo Brambilla
- Department of Pathophysiology and Transplantation, University of Milan, Milano, Italy
- Department of Neurosciences and Mental Health, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
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Langer T, Zadek F, Carbonara M, Caccioppola A, Brusatori S, Zoerle T, Bottazzini F, Ferraris Fusarini C, di Modugno A, Zanella A, Zanier ER, Fumagalli R, Pesenti A, Stocchetti N. Cerebrospinal Fluid and Arterial Acid-Base Equilibrium of Spontaneously Breathing Patients with Aneurismal Subarachnoid Hemorrhage. Neurocrit Care 2022; 37:102-110. [PMID: 35199305 PMCID: PMC9283163 DOI: 10.1007/s12028-022-01450-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 01/12/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Hyperventilation resulting in hypocapnic alkalosis (HA) is frequently encountered in spontaneously breathing patients with acute cerebrovascular conditions. The underlying mechanisms of this respiratory response have not been fully elucidated. The present study describes, applying the physical-chemical approach, the acid-base characteristics of cerebrospinal fluid (CSF) and arterial plasma of spontaneously breathing patients with aneurismal subarachnoid hemorrhage (SAH) and compares these results with those of control patients. Moreover, it investigates the pathophysiologic mechanisms leading to HA in SAH. METHODS Patients with SAH admitted to the neurological intensive care unit and patients (American Society of Anesthesiologists physical status of 1 and 2) undergoing elective surgery under spinal anesthesia were enrolled. CSF and arterial samples were collected simultaneously. Electrolytes, strong ion difference (SID), partial pressure of carbon dioxide (PCO2), weak noncarbonic acids (ATOT), and pH were measured in CSF and arterial blood samples. RESULTS Twenty spontaneously breathing patients with SAH and 25 controls were enrolled. The CSF of patients with SAH, as compared with controls, was characterized by a lower SID (23.1 ± 2.3 vs. 26.5 ± 1.4 mmol/L, p < 0.001) and PCO2 (40 ± 4 vs. 46 ± 3 mm Hg, p < 0.001), whereas no differences in ATOT (1.2 ± 0.5 vs. 1.2 ± 0.2 mmol/L, p = 0.95) and pH (7.34 ± 0.06 vs. 7.35 ± 0.02, p = 0.69) were observed. The reduced CSF SID was mainly caused by a higher lactate concentration (3.3 ± 1.3 vs. 1.4 ± 0.2 mmol/L, p < 0.001). A linear association (r = 0.71, p < 0.001) was found between CSF SID and arterial PCO2. A higher proportion of patients with SAH were characterized by arterial HA, as compared with controls (40 vs. 4%, p = 0.003). A reduced CSF-to-plasma difference in PCO2 was observed in nonhyperventilating patients with SAH (0.4 ± 3.8 vs. 7.8 ± 3.7 mm Hg, p < 0.001). CONCLUSIONS Patients with SAH have a reduction of CSF SID due to an increased lactate concentration. The resulting localized acidifying effect is compensated by CSF hypocapnia, yielding normal CSF pH values and resulting in a higher incidence of arterial HA.
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Affiliation(s)
- Thomas Langer
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy.
- Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milan, Italy.
| | - Francesco Zadek
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Marco Carbonara
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alessio Caccioppola
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Serena Brusatori
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Tommaso Zoerle
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesco Bottazzini
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Adriana di Modugno
- Central Laboratory, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alberto Zanella
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Elisa R Zanier
- Laboratory of Acute Brain Injury and Therapeutic Strategies, Department of Neuroscience, Istituto Di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Roberto Fumagalli
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
- Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milan, Italy
| | - Antonio Pesenti
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nino Stocchetti
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Van Praag DL, Wouters K, Van Den Eede F, Wilson L, Maas AI, Åkerlund C, Amrein K, Andelic N, Andreassen L, Anke A, Antoni A, Audibert G, Azouvi P, Azzolini ML, Bartels R, Barzó P, Beauvais R, Beer R, Bellander BM, Belli A, Benali H, Berardino M, Beretta L, Blaabjerg M, Bragge P, Brazinova A, Brinck V, Brooker J, Brorsson C, Buki A, Bullinger M, Cabeleira M, Caccioppola A, Calappi E, Calvi MR, Cameron P, Lozano GC, Carbonara M, Cavallo S, Chevallard G, Chieregato A, Citerio G, Ceyisakar I, Clusmann H, Coburn M, Coles J, Cooper JD, Correia M, Čović A, Curry N, Czeiter E, Czosnyka M, Dahyot-Fizelier C, Dark P, Dawes H, De Keyser V, Degos V, Della Corte F, Boogert HD, Depreitere B, Đilvesi Đ, Dixit A, Donoghue E, Dreier J, Dulière GL, Ercole A, Esser P, Ezer E, Fabricius M, Feigin VL, Foks K, Frisvold S, Furmanov A, Gagliardo P, Galanaud D, Gantner D, Gao G, George P, Ghuysen A, Giga L, Glocker B, Golubovic J, Gomez PA, Gratz J, Gravesteijn B, Grossi F, Gruen RL, Gupta D, Haagsma JA, Haitsma I, Helbok R, Helseth E, Horton L, Huijben J, Hutchinson PJ, Jacobs B, Jankowski S, Jarrett M, Jiang JY, Johnson F, Jones K, Karan M, Kolias AG, Kompanje E, Kondziella D, Koraropoulos E, Koskinen LO, Kovács N, Kowark A, Lagares A, Lanyon L, Laureys S, Lecky F, Ledoux D, Lefering R, Legrand V, Lejeune A, Levi L, Lightfoot R, Lingsma H, Maas AI, Castaño-León AM, Maegele M, Majdan M, Manara A, Manley G, Martino C, Maréchal H, Mattern J, McMahon C, Melegh B, Menon D, Menovsky T, Mikolic A, Misset B, Muraleedharan V, Murray L, Negru A, Nelson D, Newcombe V, Nieboer D, Nyirádi J, Olubukola O, Oresic M, Ortolano F, Palotie A, Parizel PM, Payen JF, Perera N, Perlbarg V, Persona P, Peul W, Piippo-Karjalainen A, Pirinen M, Ples H, Polinder S, Pomposo I, Posti JP, Puybasset L, Radoi A, Ragauskas A, Raj R, Rambadagalla M, Rhodes J, Richardson S, Richter S, Ripatti S, Rocka S, Roe C, Roise O, Rosand J, Rosenfeld JV, Rosenlund C, Rosenthal G, Rossaint R, Rossi S, Rueckert D, Rusnák M, Sahuquillo J, Sakowitz O, Sanchez-Porras R, Sandor J, Schäfer N, Schmidt S, Schoechl H, Schoonman G, Schou RF, Schwendenwein E, Sewalt C, Skandsen T, Smielewski P, Sorinola A, Stamatakis E, Stanworth S, Stevens R, Stewart W, Steyerberg EW, Stocchetti N, Sundström N, Synnot A, Takala R, Tamás V, Tamosuitis T, Taylor MS, Ao BT, Tenovuo O, Theadom A, Thomas M, Tibboel D, Timmers M, Tolias C, Trapani T, Tudora CM, Unterberg A, Vajkoczy P, Vallance S, Valeinis E, Vámos Z, van der Jagt M, Van der Steen G, van der Naalt J, van Dijck JT, van Essen TA, Van Hecke W, van Heugten C, Van Praag D, Vyvere TV, van Wijk RP, Vargiolu A, Vega E, Velt K, Verheyden J, Vespa PM, Vik A, Vilcinis R, Volovici V, von Steinbüchel N, Voormolen D, Vulekovic P, Wang KK, Wiegers E, Williams G, Wilson L, Winzeck S, Wolf S, Yang Z, Ylén P, Younsi A, Zeiler FA, Zelinkova V, Ziverte A, Zoerle T. Neurocognitive correlates of probable posttraumatic stress disorder following traumatic brain injury. Brain and Spine 2022; 2:100854. [PMID: 36248103 PMCID: PMC9560676 DOI: 10.1016/j.bas.2021.100854] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 12/07/2021] [Accepted: 12/16/2021] [Indexed: 01/17/2023]
Abstract
Introduction Neurocognitive problems associated with posttraumatic stress disorder (PTSD) can interact with impairment resulting from traumatic brain injury (TBI). Research question We aimed to identify neurocognitive problems associated with probable PTSD following TBI in a civilian sample. Material and methods The study is part of the CENTER-TBI project (Collaborative European Neurotrauma Effectiveness Research) that aims to better characterize TBI. For this cross-sectional study, we included patients of all severities aged over 15, and a Glasgow Outcome Score Extended (GOSE) above 3. Participants were assessed at six months post-injury on the PTSD Checklist-5 (PCL-5), the Trail Making Test (TMT), the Rey Auditory Verbal Learning Test (RAVLT) and the Cambridge Neuropsychological Test Automated Battery (CANTAB). Primary analysis was a complete case analysis. Regression analyses were performed to investigate the association between the PCL-5 and cognition. Results Of the 1134 participants included in the complete case analysis, 13.5% screened positive for PTSD. Probable PTSD was significantly associated with higher TMT-(B-A) (OR = 1.35, 95% CI: 1.14–1.60, p < .001) and lower RAVLT-delayed recall scores (OR = 0.74, 95% CI: 0.61–0.91, p = .004) after controlling for age, sex, psychiatric history, baseline Glasgow Coma Scale and education. Discussion and conclusion Poorer performance on cognitive tests assessing task switching and, to a lesser extent, delayed verbal recall is associated with probable PTSD in civilians who have suffered TBI. Six months after traumatic brain injury 13.5% of people screen positive for PTSD. Task switching performance and verbal memory are related to probable PTSD. PTSD severity is related to processing speed and task switching performance.
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Huijben JA, Pisica D, Ceyisakar I, Stocchetti N, Citerio G, Maas AI, Steyerberg EW, Menon DK, van der Jagt M, Lingsma HF. Pharmaceutical Venous Thrombosis Prophylaxis in Critically Ill Traumatic Brain Injury Patients. Neurotrauma Rep 2022; 2:4-14. [PMID: 35112104 PMCID: PMC8804253 DOI: 10.1089/neur.2021.0037] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The aims of this study are to describe the use of pharmaceutical venous thromboembolism (pVTE) prophylaxis in patients with traumatic brain injury (TBI) in Europe and study the association of pVTE prophylaxis with outcome. We included 2006 patients ≥18 years of age admitted to the intensive care unit from the CENTER-TBI study. VTE events were recorded based on clinical symptoms. Variation between 54 centers in pVTE prophylaxis use was assessed with a multi-variate random-effect model and quantified with the median odds ratio (MOR). The association between pVTE prophylaxis and outcome (Glasgow Outcome Scale-Extended at 6 months) was assessed at center level with an instrumental variable analysis and at patient level with a multi-variate proportional odds regression analysis and a propensity-matched analysis. A time-dependent Cox survival regression analysis was conducted to determine the effect of pVTE prophylaxis on survival during hospital stay. The association between VTE prophylaxis and computed tomography (CT) progression was assessed with a logistic regression analysis. Overall, 56 patients (2%) had a VTE during hospital stay. The majority, 1279 patients (64%), received pVTE prophylaxis, with substantial between-center variation (MOR, 2.7; p < 0.001). A moderate association with improved outcome was found at center level (odds ratio [OR], 1.2 [0.7–2.1]) and patient level (multi-variate adjusted OR, 1.4 [1.1–1.7], and propensity adjusted OR, 1.5 [1.1–2.0]), with similar results in subgroup analyses. Survival was higher with the use of pVTE prophylaxis (p < 0.001). We found no clear effect on CT progression (OR, 0.9; CI [0.6–1.2]). Overall, practice policies for pVTE prophylaxis vary substantially between European centers, whereas pVTE prophylaxis may contribute to improved outcome. Trial registration number is NCT02210221 at ClinicalTrials.gov, registered on August 6, 2014 (first patient enrollment on December 19, 2014).
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Affiliation(s)
- Jilske A. Huijben
- Center for Medical Decision Sciences, Department of Public Health, Erasmus MC–University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Dana Pisica
- Center for Medical Decision Sciences, Department of Public Health, Erasmus MC–University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Iris Ceyisakar
- Center for Medical Decision Sciences, Department of Public Health, Erasmus MC–University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Nino Stocchetti
- Department of Pathophysiology and Transplants, University of Milan, Milan, Italy
- Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
- Neurointensive Care, San Gerardo Hospital, ASST-Monza, Monza, Italy
| | - Andrew I.R. Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Ewout W. Steyerberg
- Center for Medical Decision Sciences, Department of Public Health, Erasmus MC–University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - David K. Menon
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Mathieu van der Jagt
- Department of Intensive Care Adults, Erasmus MC–University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Hester F. Lingsma
- Center for Medical Decision Sciences, Department of Public Health, Erasmus MC–University Medical Center Rotterdam, Rotterdam, The Netherlands
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Picetti E, Berardino M, Bertuccio A, Bertuetti R, Boccardi EP, Caricato A, Castioni CA, Cenzato M, Chieregato A, Citerio G, Gritti P, Longhi L, Martino C, Munari M, Rossi S, Stocchetti N, Zoerle T, Rasulo F, Robba C. Early management of patients with aneurysmal subarachnoid hemorrhage in a hospital without neurosurgical/neuroendovascular facilities: a consensus and clinical recommendations of the Italian Society of Anesthesia and Intensive Care (SIAARTI). J Anesth Analg Crit Care 2021; 1:10. [PMCID: PMC10245649 DOI: 10.1186/s44158-021-00012-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 10/11/2021] [Indexed: 06/16/2023]
Abstract
Abstract
Background
The immediate management of subarachnoid hemorrhage (SAH) patients in hospitals without neurosurgical/neurointerventional facilities and their transfer to a specialized center is challenging and not well covered in existing guidelines. To address these issues, we created a consensus of experts endorsed by the Italian Society of Anesthesia and Intensive Care (SIAARTI) to provide clinical guidance.
Methods
A multidisciplinary consensus panel composed by 19 physicians selected for their established clinical and scientific expertise in the acute management of SAH patients with different specializations (anesthesia/intensive care, neurosurgery and interventional neuroradiology) was created. A modified Delphi approach was adopted.
Results
A total of 14 statements have been discussed. Consensus was reached on 11 strong recommendations and 2 weak recommendations. In one case, where consensus could not be agreed upon, no recommendation could be provided.
Conclusions
Management of SAH in a non-specialized setting and early transfer are difficult and may have a critical impact on outcome. Clinical advice, based on multidisciplinary consensus, might be helpful. Our recommendations cover most, but not all, topics of clinical relevance.
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Pischiutta F, Caruso E, Lugo A, Cavaleiro H, Stocchetti N, Citerio G, Salgado A, Gallus S, Zanier ER. Systematic review and meta-analysis of preclinical studies testing mesenchymal stromal cells for traumatic brain injury. NPJ Regen Med 2021; 6:71. [PMID: 34716332 PMCID: PMC8556393 DOI: 10.1038/s41536-021-00182-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 09/30/2021] [Indexed: 12/13/2022] Open
Abstract
Mesenchymal stromal cells (MSCs) are widely used in preclinical models of traumatic brain injury (TBI). Results are promising in terms of neurological improvement but are hampered by wide variability in treatment responses. We made a systematic review and meta-analysis: (1) to assess the quality of evidence for MSC treatment in TBI rodent models; (2) to determine the effect size of MSCs on sensorimotor function, cognitive function, and anatomical damage; (3) to identify MSC-related and protocol-related variables associated with greater efficacy; (4) to understand whether MSC manipulations boost therapeutic efficacy. The meta-analysis included 80 studies. After TBI, MSCs improved sensorimotor and cognitive deficits and reduced anatomical damage. Stratified meta-analysis on sensorimotor outcome showed similar efficacy for different MSC sources and for syngeneic or xenogenic transplants. Efficacy was greater when MSCs were delivered in the first-week post-injury, and when implanted directly into the lesion cavity. The greatest effect size was for cells embedded in matrices or for MSC-derivatives. MSC therapy is effective in preclinical TBI models, improving sensorimotor, cognitive, and anatomical outcomes, with large effect sizes. These findings support clinical studies in TBI.
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Affiliation(s)
- Francesca Pischiutta
- Laboratory of Acute Brain Injury and Therapeutic Strategies, Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Enrico Caruso
- Laboratory of Acute Brain Injury and Therapeutic Strategies, Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy.,Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alessandra Lugo
- Laboratory of Lifestyle Epidemiology, Department of Environmental Health Sciences, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Helena Cavaleiro
- Laboratory of Acute Brain Injury and Therapeutic Strategies, Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy.,Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal.,Stemmatters, Biotechnology and Regenerative Medicine, Guimarães, Portugal
| | - Nino Stocchetti
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplants, University of Milan, Milan, Italy
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - António Salgado
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Silvano Gallus
- Laboratory of Lifestyle Epidemiology, Department of Environmental Health Sciences, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Elisa R Zanier
- Laboratory of Acute Brain Injury and Therapeutic Strategies, Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy.
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Dimitri GM, Beqiri E, Placek MM, Czosnyka M, Stocchetti N, Ercole A, Smielewski P, Lió P. Modeling Brain-Heart Crosstalk Information in Patients with Traumatic Brain Injury. Neurocrit Care 2021; 36:738-750. [PMID: 34642842 PMCID: PMC9110542 DOI: 10.1007/s12028-021-01353-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 09/09/2021] [Indexed: 11/28/2022]
Abstract
Background Traumatic brain injury (TBI) is an extremely heterogeneous and complex pathology that requires the integration of different physiological measurements for the optimal understanding and clinical management of patients. Information derived from intracranial pressure (ICP) monitoring can be coupled with information obtained from heart rate (HR) monitoring to assess the interplay between brain and heart. The goal of our study is to investigate events of simultaneous increases in HR and ICP and their relationship with patient mortality.. Methods In our previous work, we introduced a novel measure of brain–heart interaction termed brain–heart crosstalks (ctnp), as well as two additional brain–heart crosstalks indicators [mutual information (\documentclass[12pt]{minimal}
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\begin{document}$$mi_{ct}$$\end{document}mict) and average edge overlap (ωct)] obtained through a complex network modeling of the brain–heart system. These measures are based on identification of simultaneous increase of HR and ICP. In this article, we investigated the relationship of these novel indicators with respect to mortality in a multicenter TBI cohort, as part of the Collaborative European Neurotrauma Effectiveness Research in TBI high-resolution work package. Results A total of 226 patients with TBI were included in this cohort. The data set included monitored parameters (ICP and HR), as well as laboratory, demographics, and clinical information. The number of detected brain–heart crosstalks varied (mean 58, standard deviation 57). The Kruskal–Wallis test comparing brain–heart crosstalks measures of survivors and nonsurvivors showed statistically significant differences between the two distributions (p values: 0.02 for \documentclass[12pt]{minimal}
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\begin{document}$$mi_{ct}$$\end{document}mict, 0.005 for ctnp and 0.006 for ωct). An inverse correlation was found, computed using the point biserial correlation technique, between the three new measures and mortality: − 0.13 for ctnp (p value 0.04), − 0.19 for ωct (p value 0.002969) and − 0.09 for \documentclass[12pt]{minimal}
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\begin{document}$$mi_{ct}$$\end{document}mict (p value 0.1396). The measures were then introduced into the logistic regression framework, along with a set of input predictors made of clinical, demographic, computed tomography (CT), and lab variables. The prediction models were obtained by dividing the original cohort into four age groups (16–29, 30–49, 50–65, and 65–85 years of age) to properly treat with the age confounding factor. The best performing models were for age groups 16–29, 50–65, and 65–85, with the deviance of ratio explaining more than 80% in all the three cases. The presence of an inverse relationship between brain–heart crosstalks and mortality was also confirmed. Conclusions The presence of a negative relationship between mortality and brain–heart crosstalks indicators suggests that a healthy brain–cardiovascular interaction plays a role in TBI.
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Affiliation(s)
- Giovanna Maria Dimitri
- Computer Laboratory, University of Cambridge, Cambridge, UK. .,DIISM, University of Siena, Siena, Italy.
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.,Department of Physiology and Transplantation, University of Milan, Milan, Italy
| | - Michal M Placek
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.,Faculty of Fundamental Problems of Technology, Department of Biomedical Engineering, Wroclaw University of Science and Technology, Wrocław, Poland
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Nino Stocchetti
- Department of Physiology and Transplantation, University of Milan, Milan, Italy
| | - Ari Ercole
- Division of Anesthesia, University of Cambridge, Cambridge, UK
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Pietro Lió
- Computer Laboratory, University of Cambridge, Cambridge, UK
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Lecky FE, Otesile O, Marincowitz C, Majdan M, Nieboer D, Lingsma HF, Maegele M, Citerio G, Stocchetti N, Steyerberg EW, Menon DK, Maas AIR. The burden of traumatic brain injury from low-energy falls among patients from 18 countries in the CENTER-TBI Registry: A comparative cohort study. PLoS Med 2021; 18:e1003761. [PMID: 34520460 PMCID: PMC8509890 DOI: 10.1371/journal.pmed.1003761] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 10/12/2021] [Accepted: 08/06/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Traumatic brain injury (TBI) is an important global public health burden, where those injured by high-energy transfer (e.g., road traffic collisions) are assumed to have more severe injury and are prioritised by emergency medical service trauma triage tools. However recent studies suggest an increasing TBI disease burden in older people injured through low-energy falls. We aimed to assess the prevalence of low-energy falls among patients presenting to hospital with TBI, and to compare their characteristics, care pathways, and outcomes to TBI caused by high-energy trauma. METHODS AND FINDINGS We conducted a comparative cohort study utilising the CENTER-TBI (Collaborative European NeuroTrauma Effectiveness Research in TBI) Registry, which recorded patient demographics, injury, care pathway, and acute care outcome data in 56 acute trauma receiving hospitals across 18 countries (17 countries in Europe and Israel). Patients presenting with TBI and indications for computed tomography (CT) brain scan between 2014 to 2018 were purposively sampled. The main study outcomes were (i) the prevalence of low-energy falls causing TBI within the overall cohort and (ii) comparisons of TBI patients injured by low-energy falls to TBI patients injured by high-energy transfer-in terms of demographic and injury characteristics, care pathways, and hospital mortality. In total, 22,782 eligible patients were enrolled, and study outcomes were analysed for 21,681 TBI patients with known injury mechanism; 40% (95% CI 39% to 41%) (8,622/21,681) of patients with TBI were injured by low-energy falls. Compared to 13,059 patients injured by high-energy transfer (HE cohort), the those injured through low-energy falls (LE cohort) were older (LE cohort, median 74 [IQR 56 to 84] years, versus HE cohort, median 42 [IQR 25 to 60] years; p < 0.001), more often female (LE cohort, 50% [95% CI 48% to 51%], versus HE cohort, 32% [95% CI 31% to 34%]; p < 0.001), more frequently taking pre-injury anticoagulants or/and platelet aggregation inhibitors (LE cohort, 44% [95% CI 42% to 45%], versus HE cohort, 13% [95% CI 11% to 14%]; p < 0.001), and less often presenting with moderately or severely impaired conscious level (LE cohort, 7.8% [95% CI 5.6% to 9.8%], versus HE cohort, 10% [95% CI 8.7% to 12%]; p < 0.001), but had similar in-hospital mortality (LE cohort, 6.3% [95% CI 4.2% to 8.3%], versus HE cohort, 7.0% [95% CI 5.3% to 8.6%]; p = 0.83). The CT brain scan traumatic abnormality rate was 3% lower in the LE cohort (LE cohort, 29% [95% CI 27% to 31%], versus HE cohort, 32% [95% CI 31% to 34%]; p < 0.001); individuals in the LE cohort were 50% less likely to receive critical care (LE cohort, 12% [95% CI 9.5% to 13%], versus HE cohort, 24% [95% CI 23% to 26%]; p < 0.001) or emergency interventions (LE cohort, 7.5% [95% CI 5.4% to 9.5%], versus HE cohort, 13% [95% CI 12% to 15%]; p < 0.001) than patients injured by high-energy transfer. The purposive sampling strategy and censorship of patient outcomes beyond hospital discharge are the main study limitations. CONCLUSIONS We observed that patients sustaining TBI from low-energy falls are an important component of the TBI disease burden and a distinct demographic cohort; further, our findings suggest that energy transfer may not predict intracranial injury or acute care mortality in patients with TBI presenting to hospital. This suggests that factors beyond energy transfer level may be more relevant to prehospital and emergency department TBI triage in older people. A specific focus to improve prevention and care for patients sustaining TBI from low-energy falls is required.
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Affiliation(s)
- Fiona E. Lecky
- Centre for Urgent and Emergency Care Research, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
- Emergency Department, Salford Royal Hospital, Salford, United Kingdom
- * E-mail:
| | - Olubukola Otesile
- Centre for Urgent and Emergency Care Research, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Carl Marincowitz
- Centre for Urgent and Emergency Care Research, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Marek Majdan
- Department of Public Health, University of Trnava, Trnava, Slovakia
| | - Daan Nieboer
- Department of Public Health, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Hester F. Lingsma
- Department of Public Health, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Marc Maegele
- Institute for Research in Operative Medicine, Witten/Herdecke University, Köln, Germany
| | - Giuseppe Citerio
- Neurointensive Care, Azienda Socio Sanitaria Territoriale di Monza, Monza, Italy
- School of Medicine and Surgery, Università degli Studi di Milano–Bicocca, Milan, Italy
| | - Nino Stocchetti
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Neuroscience Intensive Care Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Ewout W. Steyerberg
- Department of Public Health, Erasmus University Medical Center, Rotterdam, Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Netherlands
| | - David K. Menon
- University of Cambridge, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Andrew I. R. Maas
- Department of Neurosurgery, Antwerp University Hospital, Edegem, Belgium
- University of Antwerp, Edegem, Belgium
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37
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Wiegers EJA, Lingsma HF, Huijben JA, Cooper DJ, Citerio G, Frisvold S, Helbok R, Maas AIR, Menon DK, Moore EM, Stocchetti N, Dippel DW, Steyerberg EW, van der Jagt M. Fluid balance and outcome in critically ill patients with traumatic brain injury (CENTER-TBI and OzENTER-TBI): a prospective, multicentre, comparative effectiveness study. Lancet Neurol 2021; 20:627-638. [PMID: 34302787 DOI: 10.1016/s1474-4422(21)00162-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 04/22/2021] [Accepted: 05/07/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Fluid therapy-the administration of fluids to maintain adequate organ tissue perfusion and oxygenation-is essential in patients admitted to the intensive care unit (ICU) with traumatic brain injury. We aimed to quantify the variability in fluid management policies in patients with traumatic brain injury and to study the effect of this variability on patients' outcomes. METHODS We did a prospective, multicentre, comparative effectiveness study of two observational cohorts: CENTER-TBI in Europe and OzENTER-TBI in Australia. Patients from 55 hospitals in 18 countries, aged 16 years or older with traumatic brain injury requiring a head CT, and admitted to the ICU were included in this analysis. We extracted data on demographics, injury, and clinical and treatment characteristics, and calculated the mean daily fluid balance (difference between fluid input and loss) and mean daily fluid input during ICU stay per patient. We analysed the association of fluid balance and input with ICU mortality and functional outcome at 6 months, measured by the Glasgow Outcome Scale Extended (GOSE). Patient-level analyses relied on adjustment for key characteristics per patient, whereas centre-level analyses used the centre as the instrumental variable. FINDINGS 2125 patients enrolled in CENTER-TBI and OzENTER-TBI between Dec 19, 2014, and Dec 17, 2017, were eligible for inclusion in this analysis. The median age was 50 years (IQR 31 to 66) and 1566 (74%) of patients were male. The median of the mean daily fluid input ranged from 1·48 L (IQR 1·12 to 2·09) to 4·23 L (3·78 to 4·94) across centres. The median of the mean daily fluid balance ranged from -0·85 L (IQR -1·51 to -0·49) to 1·13 L (0·99 to 1·37) across centres. In patient-level analyses, a mean positive daily fluid balance was associated with higher ICU mortality (odds ratio [OR] 1·10 [95% CI 1·07 to 1·12] per 0·1 L increase) and worse functional outcome (1·04 [1·02 to 1·05] per 0·1 L increase); higher mean daily fluid input was also associated with higher ICU mortality (1·05 [1·03 to 1·06] per 0·1 L increase) and worse functional outcome (1·04 [1·03 to 1·04] per 1-point decrease of the GOSE per 0·1 L increase). Centre-level analyses showed similar associations of higher fluid balance with ICU mortality (OR 1·17 [95% CI 1·05 to 1·29]) and worse functional outcome (1·07 [1·02 to 1·13]), but higher fluid input was not associated with ICU mortality (OR 0·95 [0·90 to 1·00]) or worse functional outcome (1·01 [0·98 to 1·03]). INTERPRETATION In critically ill patients with traumatic brain injury, there is significant variability in fluid management, with more positive fluid balances being associated with worse outcomes. These results, when added to previous evidence, suggest that aiming for neutral fluid balances, indicating a state of normovolaemia, contributes to improved outcome. FUNDING European Commission 7th Framework program and the Australian Health and Medical Research Council.
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Affiliation(s)
| | - Hester Floor Lingsma
- Department of Public Health, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Jilske Antonia Huijben
- Department of Public Health, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - David James Cooper
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, MB, Italy; Neurointensive Care Unit, San Gerardo Hospital, ASST-Monza, Monza, MB, Italy
| | - Shirin Frisvold
- Department of Intensive Care Medicine, University Hospital of North Norway, Tromsø, Norway; UiT The Arctic University of Norway, Tromsø, Norway
| | - Raimund Helbok
- Department of Neurology, Neurocritical Care, Medical University of Innsbruck, Anichstrasse, Innsbruck, Austria
| | - Andrew Ian Ramsay Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - David Krishna Menon
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Elizabeth Madeleine Moore
- Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Nino Stocchetti
- Neuroscience Intensive Care Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Ewout Willem Steyerberg
- Department of Public Health, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands; Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Netherlands
| | - Mathieu van der Jagt
- Department of Intensive Care Adults, Erasmus MC - University Medical Center, Rotterdam, Netherlands.
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38
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Sewalt CA, Gravesteijn BY, Menon D, Lingsma HF, Maas AIR, Stocchetti N, Venema E, Lecky FE. Primary versus early secondary referral to a specialized neurotrauma center in patients with moderate/severe traumatic brain injury: a CENTER TBI study. Scand J Trauma Resusc Emerg Med 2021; 29:113. [PMID: 34348784 PMCID: PMC8340517 DOI: 10.1186/s13049-021-00930-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 07/27/2021] [Indexed: 11/23/2022] Open
Abstract
Background Prehospital care for patients with traumatic brain injury (TBI) varies with some emergency medical systems recommending direct transport of patients with moderate to severe TBI to hospitals with specialist neurotrauma care (SNCs). The aim of this study is to assess variation in levels of early secondary referral within European SNCs and to compare the outcomes of directly admitted and secondarily transferred patients. Methods Patients with moderate and severe TBI (Glasgow Coma Scale < 13) from the prospective European CENTER-TBI study were included in this study. All participating hospitals were specialist neuroscience centers. First, adjusted between-country differences were analysed using random effects logistic regression where early secondary referral was the dependent variable, and a random intercept for country was included. Second, the adjusted effect of early secondary referral on survival to hospital discharge and functional outcome [6 months Glasgow Outcome Scale Extended (GOSE)] was estimated using logistic and ordinal mixed effects models, respectively. Results A total of 1347 moderate/severe TBI patients from 53 SNCs in 18 European countries were included. Of these 1347 patients, 195 (14.5%) were admitted after early secondary referral. Secondarily referred moderate/severe TBI patients presented more often with a CT abnormality: mass lesion (52% vs. 34%), midline shift (54% vs. 36%) and acute subdural hematoma (77% vs. 65%). After adjusting for case-mix, there was a large European variation in early secondary referral, with a median OR of 1.69 between countries. Early secondary referral was not associated with functional outcome (adjusted OR 1.07, 95% CI 0.78–1.69), nor with survival at discharge (1.05, 0.58–1.90). Conclusions Across Europe, substantial practice variation exists in the proportion of secondarily referred TBI patients at SNCs that is not explained by case mix. Within SNCs early secondary referral does not seem to impact functional outcome and survival after stabilisation in a non-specialised hospital. Future research should identify which patients with TBI truly benefit from direct transportation. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-021-00930-1.
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Affiliation(s)
- Charlie Aletta Sewalt
- Department of Public Health, Erasmus MC Medical Center, Postbus 2040, 3000 CA, Rotterdam, The Netherlands.
| | - Benjamin Yaël Gravesteijn
- Department of Public Health, Erasmus MC Medical Center, Postbus 2040, 3000 CA, Rotterdam, The Netherlands.,Department of Anesthesiology, Erasmus MC Medical Center, Rotterdam, The Netherlands
| | - David Menon
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Hester Floor Lingsma
- Department of Public Health, Erasmus MC Medical Center, Postbus 2040, 3000 CA, Rotterdam, The Netherlands
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital, and University of Antwerp, Edegem, Belgium
| | - Nino Stocchetti
- Department of Pathophysiology and Transplantation, Milan University, and Neuroscience ICU, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Esmee Venema
- Department of Public Health, Erasmus MC Medical Center, Postbus 2040, 3000 CA, Rotterdam, The Netherlands.,Department of Neurology, Erasmus MC Medical Center, Rotterdam, The Netherlands
| | - Fiona E Lecky
- Center for Urgent and Emergency Care Research (CURE), Health Services Research Section, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Citerio G, Robba C, Rebora P, Petrosino M, Rossi E, Malgeri L, Stocchetti N, Galimberti S, Menon DK. Management of arterial partial pressure of carbon dioxide in the first week after traumatic brain injury: results from the CENTER-TBI study. Intensive Care Med 2021; 47:961-973. [PMID: 34302517 PMCID: PMC8308080 DOI: 10.1007/s00134-021-06470-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 06/26/2021] [Indexed: 11/24/2022]
Abstract
Purpose To describe the management of arterial partial pressure of carbon dioxide (PaCO2) in severe traumatic brain-injured (TBI) patients, and the optimal target of PaCO2 in patients with high intracranial pressure (ICP). Methods Secondary analysis of CENTER-TBI, a multicentre, prospective, observational, cohort study. The primary aim was to describe current practice in PaCO2 management during the first week of intensive care unit (ICU) after TBI, focusing on the lowest PaCO2 values. We also assessed PaCO2 management in patients with and without ICP monitoring (ICPm), and with and without intracranial hypertension. We evaluated the effect of profound hyperventilation (defined as PaCO2 < 30 mmHg) on long-term outcome. Results We included 1100 patients, with a total of 11,791 measurements of PaCO2 (5931 lowest and 5860 highest daily values). The mean (± SD) PaCO2 was 38.9 (± 5.2) mmHg, and the mean minimum PaCO2 was 35.2 (± 5.3) mmHg. Mean daily minimum PaCO2 values were significantly lower in the ICPm group (34.5 vs 36.7 mmHg, p < 0.001). Daily PaCO2 nadir was lower in patients with intracranial hypertension (33.8 vs 35.7 mmHg, p < 0.001). Considerable heterogeneity was observed between centers. Management in a centre using profound hyperventilation (HV) more frequently was not associated with increased 6 months mortality (OR = 1.06, 95% CI = 0.77–1.45, p value = 0.7166), or unfavourable neurological outcome (OR 1.12, 95% CI = 0.90–1.38, p value = 0.3138). Conclusions Ventilation is manipulated differently among centers and in response to intracranial dynamics. PaCO2 tends to be lower in patients with ICP monitoring, especially if ICP is increased. Being in a centre which more frequently uses profound hyperventilation does not affect patient outcomes. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-021-06470-7.
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Affiliation(s)
- Giuseppe Citerio
- School of Medicine and Surgery, University of Milano - Bicocca, Monza, Italy. .,Neurointensive Care Unit, Ospedale San Gerardo, Azienda Socio-Sanitaria Territoriale Di Monza, Monza, Italy.
| | - Chiara Robba
- Anesthesia and Intensive Care, Policlinico San Martino, IRCCS for Oncology and Neuroscience, Genoa, Italy.,Department of Surgical Science and Integrated Diagnostic, University of Genoa, Genoa, Italy
| | - Paola Rebora
- School of Medicine and Surgery, University of Milano - Bicocca, Monza, Italy.,Bicocca Bioinformatics Biostatistics and Bioimaging Center B4, School of Medicine and Surgery, University of Milano - Bicocca, Milan, Italy
| | - Matteo Petrosino
- Bicocca Bioinformatics Biostatistics and Bioimaging Center B4, School of Medicine and Surgery, University of Milano - Bicocca, Milan, Italy
| | - Eleonora Rossi
- Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, Unit of Anaesthesia and Intensive Care, University of Pavia, Pavia, Italy
| | - Letterio Malgeri
- Anesthesia and Intensive Care, School of Medicine, Messina, Italy
| | - Nino Stocchetti
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Physiopathology and Transplantation, Milan University, Milan, Italy
| | - Stefania Galimberti
- School of Medicine and Surgery, University of Milano - Bicocca, Monza, Italy.,Bicocca Bioinformatics Biostatistics and Bioimaging Center B4, School of Medicine and Surgery, University of Milano - Bicocca, Milan, Italy
| | - David K Menon
- Neurocritical Care Unit, Addenbrooke's Hospital, Cambridge, UK
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Robba C, Graziano F, Rebora P, Elli F, Giussani C, Oddo M, Meyfroidt G, Helbok R, Taccone FS, Prisco L, Vincent JL, Suarez JI, Stocchetti N, Citerio G. Intracranial pressure monitoring in patients with acute brain injury in the intensive care unit (SYNAPSE-ICU): an international, prospective observational cohort study. Lancet Neurol 2021; 20:548-558. [PMID: 34146513 DOI: 10.1016/s1474-4422(21)00138-1] [Citation(s) in RCA: 87] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 04/27/2021] [Accepted: 04/27/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND The indications for intracranial pressure (ICP) monitoring in patients with acute brain injury and the effects of ICP on patients' outcomes are uncertain. The aims of this study were to describe current ICP monitoring practises for patients with acute brain injury at centres around the world and to assess variations in indications for ICP monitoring and interventions, and their association with long-term patient outcomes. METHODS We did a prospective, observational cohort study at 146 intensive care units (ICUs) in 42 countries. We assessed for eligibility all patients aged 18 years or older who were admitted to the ICU with either acute brain injury due to primary haemorrhagic stroke (including intracranial haemorrhage or subarachnoid haemorrhage) or traumatic brain injury. We included patients with altered levels of consciousness at ICU admission or within the first 48 h after the brain injury, as defined by the Glasgow Coma Scale (GCS) eye response score of 1 (no eye opening) and a GCS motor response score of at least 5 (not obeying commands). Patients not admitted to the ICU or with other forms of acute brain injury were excluded from the study. Between-centre differences in use of ICP monitoring were quantified by using the median odds ratio (MOR). We used the therapy intensity level (TIL) to quantify practice variations in ICP interventions. Primary endpoints were 6 month mortality and 6 month Glasgow Outcome Scale Extended (GOSE) score. A propensity score method with inverse probability of treatment weighting was used to estimate the association between use of ICP monitoring and these 6 month outcomes, independently of measured baseline covariates. This study is registered with ClinicalTrial.gov, NCT03257904. FINDINGS Between March 15, 2018, and April 30, 2019, 4776 patients were assessed for eligibility and 2395 patients were included in the study, including 1287 (54%) with traumatic brain injury, 587 (25%) with intracranial haemorrhage, and 521 (22%) with subarachnoid haemorrhage. The median age of patients was 55 years (IQR 39-69) and 1567 (65%) patients were male. Considerable variability was recorded in the use of ICP monitoring across centres (MOR 4·5, 95% CI 3·8-4·9 between two randomly selected centres for patients with similar covariates). 6 month mortality was lower in patients who had ICP monitoring (441/1318 [34%]) than in those who were not monitored (517/1049 [49%]; p<0·0001). ICP monitoring was associated with significantly lower 6 month mortality in patients with at least one unreactive pupil (hazard ratio [HR] 0·35, 95% CI 0·26-0·47; p<0·0001), and better neurological outcome at 6 months (odds ratio 0·38, 95% CI 0·26-0·56; p=0·0025). Median TIL was higher in patients with ICP monitoring (9 [IQR 7-12]) than in those who were not monitored (5 [3-8]; p<0·0001) and an increment of one point in TIL was associated with a reduction in mortality (HR 0·94, 95% CI 0·91-0·98; p=0·0011). INTERPRETATION The use of ICP monitoring and ICP management varies greatly across centres and countries. The use of ICP monitoring might be associated with a more intensive therapeutic approach and with lower 6-month mortality in more severe cases. Intracranial hypertension treatment guided by monitoring might be considered in severe cases due to the potential associated improvement in long-term clinical results. FUNDING University of Milano-Bicocca and the European Society of Intensive Care Medicine.
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Affiliation(s)
- Chiara Robba
- Anesthesia and Intensive Care, Policlinico San Martino, IRCCS for Oncology and Neuroscience, Genoa, Italy; Department of Surgical Science and Integrated Diagnostic, University of Genoa, Genoa, Italy
| | - Francesca Graziano
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Bicocca Bioinformatics Biostatistics and Bioimaging Center B4, School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Paola Rebora
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Bicocca Bioinformatics Biostatistics and Bioimaging Center B4, School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Francesca Elli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Carlo Giussani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Neurosurgery, Ospedale San Gerardo, Azienda Socio-Sanitaria Territoriale di Monza, Monza, Italy
| | - Mauro Oddo
- Department of Intensive Care Medicine, CHUV-Lausanne University Hospital, Lausanne, Switzerland
| | - Geert Meyfroidt
- Department of Intensive Care Medicine, University Hospitals, Leuven, Belgium
| | - Raimund Helbok
- Department of Neurology, Neurocritical Care Unit, Medical University of Innsbruck, Innsbruck, Austria
| | - Fabio S Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Lara Prisco
- Nuffield Department of Clinical Neurosciences, Oxford University Hospitals Trust, Oxford, UK
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jose I Suarez
- Division of Neurosciences Critical Care, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nino Stocchetti
- Department of Physiopathology and Transplant, Università degli Studi di Milano, Milan, Italy; Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Neurointensive Care Unit, Ospedale San Gerardo, Azienda Socio-Sanitaria Territoriale di Monza, Monza, Italy.
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Gianola S, Castellini G, Biffi A, Porcu G, Fabbri A, Ruggieri MP, Stocchetti N, Napoletano A, Coclite D, D'Angelo D, Fauci AJ, Iacorossi L, Latina R, Salomone K, Gupta S, Iannone P, Chiara O. Accuracy of pre-hospital triage tools for major trauma: a systematic review with meta-analysis and net clinical benefit. World J Emerg Surg 2021; 16:31. [PMID: 34112209 PMCID: PMC8193906 DOI: 10.1186/s13017-021-00372-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 05/18/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND We conducted a systematic review to evaluate and compare the accuracy of pre-hospital triage tools for major trauma in the context of the development of the Italian National Institute of Health guidelines on major trauma integrated management. METHODS PubMed, Embase, and CENTRAL were searched up to November 2019 for studies investigating pre-hospital triage tools. The ROC (receiver operating characteristics) curve and net clinical benefit for all selected triage tools were performed. Quality assessment was performed using the Quality Assessment of Diagnostic Accuracy Studies-2. Certainty of the evidence was judged with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. RESULTS We found 15 observational studies of 13 triage tools for adults and 11 for children. In adults, according to the ROC curve and the net clinical benefit, the most reliable tool was the Northern French Alps Trauma System (TRENAU), adopting injury severity score (ISS) > 15 as reference (sensitivity (Sn), 0.92; specificity (Sp), 0.41; 1 study; sample size, 2572; high certainty of the evidence). When mortality as reference was considered, the pre-hospital triage tool with the best net clinical benefit trajectory was the New Trauma Score (NTS) < 18 (Sn, 0.82; Sp, 0.86; 1 study; sample size, 1001; moderate certainty of the evidence). In children, high variability among all triage tools for sensitivity and specificity was found. CONCLUSION Sensitivity and specificity varied across all available pre-hospital trauma triage tools. TRENAU and NTS are the best accurate triage tools for adults, whereas in the pediatric area a large variability prevents any firm conclusion.
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Affiliation(s)
- Silvia Gianola
- Unit of Clinical Epidemiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Greta Castellini
- Unit of Clinical Epidemiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy.
| | - Annalisa Biffi
- National Centre for Healthcare Research and Pharmacoepidemiology, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
- Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Gloria Porcu
- National Centre for Healthcare Research and Pharmacoepidemiology, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
- Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Andrea Fabbri
- Emergency Department, AUSL della Romagna, Forlì, Italy
| | | | - Nino Stocchetti
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Antonello Napoletano
- Centro Eccellenza Clinica Qualità e Sicurezza delle Cure, Istituto Superiore di Sanità, Rome, Italy
| | - Daniela Coclite
- Centro Eccellenza Clinica Qualità e Sicurezza delle Cure, Istituto Superiore di Sanità, Rome, Italy
| | - Daniela D'Angelo
- Centro Eccellenza Clinica Qualità e Sicurezza delle Cure, Istituto Superiore di Sanità, Rome, Italy
| | - Alice Josephine Fauci
- Centro Eccellenza Clinica Qualità e Sicurezza delle Cure, Istituto Superiore di Sanità, Rome, Italy
| | - Laura Iacorossi
- Centro Eccellenza Clinica Qualità e Sicurezza delle Cure, Istituto Superiore di Sanità, Rome, Italy
| | - Roberto Latina
- Centro Eccellenza Clinica Qualità e Sicurezza delle Cure, Istituto Superiore di Sanità, Rome, Italy
| | - Katia Salomone
- Centro Eccellenza Clinica Qualità e Sicurezza delle Cure, Istituto Superiore di Sanità, Rome, Italy
| | - Shailvi Gupta
- Adams Cowley Shock Trauma Center, University of Maryland, Baltimora, MD, USA
| | - Primiano Iannone
- Centro Eccellenza Clinica Qualità e Sicurezza delle Cure, Istituto Superiore di Sanità, Rome, Italy
| | - Osvaldo Chiara
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- General Surgery and Trauma Team, ASST Grande Ospedale Metropolitano Niguarda, University of Milan, Piazza Ospedale Maggiore, Milan, Milano, Italy
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Stocchetti N, Segre G, Zanier ER, Zanetti M, Campi R, Scarpellini F, Clavenna A, Bonati M. Burnout in Intensive Care Unit Workers during the Second Wave of the COVID-19 Pandemic: A Single Center Cross-Sectional Italian Study. Int J Environ Res Public Health 2021; 18:6102. [PMID: 34198849 PMCID: PMC8201217 DOI: 10.3390/ijerph18116102] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 06/01/2021] [Accepted: 06/03/2021] [Indexed: 01/16/2023]
Abstract
The COVID-19 pandemic had a massive impact on the Italian healthcare systems, which became overwhelmed, leading to an increased risk of psychological pressure on ICU workers. The present study aimed to investigate the prevalence of distress (anxiety, depression and insomnia symptoms), burnout syndrome and resilience in healthcare workers during the COVID-19 pandemic and to detect potential factors associated with their psychological response. This cross-sectional, survey-based study enrolled 136 healthcare workers assisting COVID-19 patients in the new COVID-19 ward (Intensive Care Unit), at Milano Fiera, Lombardy. Participants completed an online survey that comprised different validated and standardized questionnaires: Maslach Burnout Inventory (MBI), Resilience Scale for adults (RSA), Hospital Anxiety and Depression scale (HADS) and Insomnia Severity Index (ISI). Socio-demographic and work characteristics were also collected. Out of 136 ICU specialists, there were 84 nurses (62%) and 52 physicians (38%). Over half (60%) met the criteria for burnout, with nearly the same percentages among nurses and physicians. Nurses reported significantly higher scores of anxiety and insomnia levels. Forty-five percent of participants reported symptoms of depression (of whom 13.9% in the clinical range) and most of the staff showed moderate to high levels (82.4%) of resilience. The COVID-19 pandemic can have a significant impact on ICU staff. Effective interventions are needed to maintain healthcare professionals' mental health and relieve burnout. Follow-up and tailored procedures should be provided to alleviate the psychological burden in the frontline staff at highest risk.
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Affiliation(s)
- Nino Stocchetti
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy
| | - Giulia Segre
- Laboratory for Mother and Child Health, Department of Public Health, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20156 Milan, Italy; (G.S.); (M.Z.); (R.C.); (F.S.); (A.C.)
| | - Elisa R. Zanier
- Laboratory of Acute Brain Injury and Therapeutic Strategies, Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20156 Milan, Italy;
| | - Michele Zanetti
- Laboratory for Mother and Child Health, Department of Public Health, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20156 Milan, Italy; (G.S.); (M.Z.); (R.C.); (F.S.); (A.C.)
| | - Rita Campi
- Laboratory for Mother and Child Health, Department of Public Health, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20156 Milan, Italy; (G.S.); (M.Z.); (R.C.); (F.S.); (A.C.)
| | - Francesca Scarpellini
- Laboratory for Mother and Child Health, Department of Public Health, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20156 Milan, Italy; (G.S.); (M.Z.); (R.C.); (F.S.); (A.C.)
| | - Antonio Clavenna
- Laboratory for Mother and Child Health, Department of Public Health, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20156 Milan, Italy; (G.S.); (M.Z.); (R.C.); (F.S.); (A.C.)
| | - Maurizio Bonati
- Laboratory for Mother and Child Health, Department of Public Health, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20156 Milan, Italy; (G.S.); (M.Z.); (R.C.); (F.S.); (A.C.)
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43
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Protti A, Porta V, Severgnini P, Monti G, Bottino N, Rondelli E, Dei Poli M, Stocchetti N. Family access to critically ill patients with COVID-19: a noble but demanding goal. Minerva Anestesiol 2021; 87:956-958. [PMID: 33688706 DOI: 10.23736/s0375-9393.21.15663-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Alessandro Protti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy - .,Department of Anaesthesia and Critical Care, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy -
| | - Virginia Porta
- Department of Anaesthesia and Critical Care, ASST Ovest Milanese, Legnano, Milan, Italy
| | - Paolo Severgnini
- Department of Biotechnology and Sciences of Life, Insubria University, Varese, Italy.,Department of Anaesthesia and Critical Care, ASST Sette Laghi, Varese, Italy
| | - Gianpaola Monti
- Department of Anaesthesia and Intensive Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Nicola Bottino
- Department of Anaesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Egle Rondelli
- Department of Anaesthesia and Critical Care, ASST Monza San Gerardo, Monza, Italy
| | - Marco Dei Poli
- Department of Anaesthesia and Critical Care, IRCCS Policlinico San Donato, San Donato, Milan, Italy
| | - Nino Stocchetti
- Department of Anaesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Physiopathology and Transplantation, Milan University, Milan, Italy
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44
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Huijben JA, Dixit A, Stocchetti N, Maas AIR, Lingsma HF, van der Jagt M, Nelson D, Citerio G, Wilson L, Menon DK, Ercole A. Use and impact of high intensity treatments in patients with traumatic brain injury across Europe: a CENTER-TBI analysis. Crit Care 2021; 25:78. [PMID: 33622371 PMCID: PMC7901510 DOI: 10.1186/s13054-020-03370-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 11/03/2020] [Indexed: 01/09/2023] Open
Abstract
PURPOSE To study variation in, and clinical impact of high Therapy Intensity Level (TIL) treatments for elevated intracranial pressure (ICP) in patients with traumatic brain injury (TBI) across European Intensive Care Units (ICUs). METHODS We studied high TIL treatments (metabolic suppression, hypothermia (< 35 °C), intensive hyperventilation (PaCO2 < 4 kPa), and secondary decompressive craniectomy) in patients receiving ICP monitoring in the ICU stratum of the CENTER-TBI study. A random effect logistic regression model was used to determine between-centre variation in their use. A propensity score-matched model was used to study the impact on outcome (6-months Glasgow Outcome Score-extended (GOSE)), whilst adjusting for case-mix severity, signs of brain herniation on imaging, and ICP. RESULTS 313 of 758 patients from 52 European centres (41%) received at least one high TIL treatment with significant variation between centres (median odds ratio = 2.26). Patients often transiently received high TIL therapies without escalation from lower tier treatments. 38% of patients with high TIL treatment had favourable outcomes (GOSE ≥ 5). The use of high TIL treatment was not significantly associated with worse outcome (285 matched pairs, OR 1.4, 95% CI [1.0-2.0]). However, a sensitivity analysis excluding high TIL treatments at day 1 or use of metabolic suppression at any day did reveal a statistically significant association with worse outcome. CONCLUSION Substantial between-centre variation in use of high TIL treatments for TBI was found and treatment escalation to higher TIL treatments were often not preceded by more conventional lower TIL treatments. The significant association between high TIL treatments after day 1 and worse outcomes may reflect aggressive use or unmeasured confounders or inappropriate escalation strategies. TAKE HOME MESSAGE Substantial variation was found in the use of highly intensive ICP-lowering treatments across European ICUs and a stepwise escalation strategy from lower to higher intensity level therapy is often lacking. Further research is necessary to study the impact of high therapy intensity treatments. TRIAL REGISTRATION The core study was registered with ClinicalTrials.gov, number NCT02210221, registered 08/06/2014, https://clinicaltrials.gov/ct2/show/NCT02210221?id=NCT02210221&draw=1&rank=1 and with Resource Identification Portal (RRID: SCR_015582).
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Affiliation(s)
- Jilske A Huijben
- Center for Medical Decision Sciences, Department of Public Health, Erasmus MC- University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Abhishek Dixit
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Nino Stocchetti
- Department of Pathophysiology and Transplants, University of Milan, Milan, Italy
- Fondazione IRCCS Ca'Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Hester F Lingsma
- Center for Medical Decision Sciences, Department of Public Health, Erasmus MC- University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Mathieu van der Jagt
- Department of Intensive Care Adults, Erasmus MC- University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - David Nelson
- Section for Perioperative Medicine and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
- Neurointensive Care, San Gerardo Hospital, ASST-Monza, Monza, Italy
| | - Lindsay Wilson
- Division of Psychology, University of Stirling, Stirling, UK
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
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45
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Depreitere B, Citerio G, Smith M, Adelson PD, Aries MJ, Bleck TP, Bouzat P, Chesnut R, De Sloovere V, Diringer M, Dureanteau J, Ercole A, Hawryluk G, Hawthorne C, Helbok R, Klein SP, Neumann JO, Robba C, Steiner L, Stocchetti N, Taccone FS, Valadka A, Wolf S, Zeiler FA, Meyfroidt G. Cerebrovascular Autoregulation Monitoring in the Management of Adult Severe Traumatic Brain Injury: A Delphi Consensus of Clinicians. Neurocrit Care 2021; 34:731-738. [PMID: 33495910 PMCID: PMC8179892 DOI: 10.1007/s12028-020-01185-x] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 12/31/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Several methods have been proposed to measure cerebrovascular autoregulation (CA) in traumatic brain injury (TBI), but the lack of a gold standard and the absence of prospective clinical data on risks, impact on care and outcomes of implementation of CA-guided management lead to uncertainty. AIM To formulate statements using a Delphi consensus approach employing a group of expert clinicians, that reflect current knowledge of CA, aspects that can be implemented in TBI management and CA research priorities. METHODS A group of 25 international academic experts with clinical expertise in the management of adult severe TBI patients participated in this consensus process. Seventy-seven statements and multiple-choice questions were submitted to the group in two online surveys, followed by a face-to-face meeting and a third online survey. Participants received feedback on average scores and the rationale for resubmission or rephrasing of statements. Consensus on a statement was defined as agreement of more than 75% of participants. RESULTS Consensus amongst participants was achieved on the importance of CA status in adult severe TBI pathophysiology, the dynamic non-binary nature of CA impairment, its association with outcome and the inadvisability of employing universal and absolute cerebral perfusion pressure targets. Consensus could not be reached on the accuracy, reliability and validation of any current CA assessment method. There was also no consensus on how to implement CA information in clinical management protocols, reflecting insufficient clinical evidence. CONCLUSION The Delphi process resulted in 25 consensus statements addressing the pathophysiology of impaired CA, and its impact on cerebral perfusion pressure targets and outcome. A research agenda was proposed emphasizing the need for better validated CA assessment methods as well as the focused investigation of the application of CA-guided management in clinical care using prospective safety, feasibility and efficacy studies.
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Affiliation(s)
- B Depreitere
- Neurosurgery, University Hospitals Leuven, Herestraat 49, B-3000, Leuven, Belgium.
| | - G Citerio
- Intensive Care Medicine, School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - M Smith
- Neurocritical Care Unit, National Hospital for Neurology and Neurosurgery, University College London, London, UK
| | - P David Adelson
- Barrow Neurological Institute At Phoenix Childrens Hospital, Department of Child Health/Neurosurgery, University of Arizona College of Medicine, Tucson, AZ, USA
- Department of Neurosurgery, Mayo Clinic School of Medicine, School of Biological and Health Systems Engineering, Arizona State University, Tempe, AZ, USA
| | - M J Aries
- Department of Intensive Care, Maastricht University Medical Center, University of Maastricht, Maastricht, The Netherlands
| | - T P Bleck
- Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - P Bouzat
- Grenoble Alps Trauma Center, Department of Anesthesiology and Intensive Care Medicine, Grenoble University Hospital, Grenoble, France
| | - R Chesnut
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - V De Sloovere
- Anesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - M Diringer
- Department of Neurology, Barnes-Jewish Hospital, Washington University School of Medicine, St. Louis, MO, USA
| | - J Dureanteau
- Université Paris Sud - Hôpitaux Universitaires Paris-Sud, Paris, France
| | - A Ercole
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - G Hawryluk
- Section of Neurosurgery, University of Manitoba, Winnipeg, MB, Canada
| | - C Hawthorne
- Head and Neck Anaesthesia and Neurocritical Care, Institute of Neurological Sciences, Glasgow, UK
| | - R Helbok
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - S P Klein
- Neurosurgery, University Hospital Brussels, Brussels, Belgium
| | - J O Neumann
- Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany
| | - C Robba
- Policlinico San Martino, IRCCS for Oncology and Neuroscience, Genova, Italy
| | - L Steiner
- Anesthesiology, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - N Stocchetti
- Department of Physiopathology and Transplant, Milan University and Neuro ICU Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - F S Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - A Valadka
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, VA, USA
| | - S Wolf
- Department of Neurosurgery, University Hospital Berlin Charité, Berlin, Germany
| | - F A Zeiler
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Department of Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada
- Centre on Aging, University of Manitoba, Winnipeg, Canada
| | - G Meyfroidt
- Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
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Dijkland SA, Helmrich IRAR, Nieboer D, van der Jagt M, Dippel DWJ, Menon DK, Stocchetti N, Maas AIR, Lingsma HF, Steyerberg EW. Outcome Prediction after Moderate and Severe Traumatic Brain Injury: External Validation of Two Established Prognostic Models in 1742 European Patients. J Neurotrauma 2020; 38:1377-1388. [PMID: 33161840 DOI: 10.1089/neu.2020.7300] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
The International Mission on Prognosis and Analysis of Clinical Trials in Traumatic Brain Injury (IMPACT) and Corticoid Randomisation After Significant Head injury (CRASH) prognostic models predict functional outcome after moderate and severe traumatic brain injury (TBI). We aimed to assess their performance in a contemporary cohort of patients across Europe. The Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) core study is a prospective, observational cohort study in patients presenting with TBI and an indication for brain computed tomography. The CENTER-TBI core cohort consists of 4509 TBI patients available for analyses from 59 centers in 18 countries across Europe and Israel. The IMPACT validation cohort included 1173 patients with GCS ≤12, age ≥14, and 6-month Glasgow Outcome Scale-Extended (GOSE) available. The CRASH validation cohort contained 1742 patients with GCS ≤14, age ≥16, and 14-day mortality or 6-month GOSE available. Performance of the three IMPACT and two CRASH model variants was assessed with discrimination (area under the receiver operating characteristic curve; AUC) and calibration (comparison of observed vs. predicted outcome rates). For IMPACT, model discrimination was good, with AUCs ranging between 0.77 and 0.85 in 1173 patients and between 0.80 and 0.88 in the broader CRASH selection (n = 1742). For CRASH, AUCs ranged between 0.82 and 0.88 in 1742 patients and between 0.66 and 0.80 in the stricter IMPACT selection (n = 1173). Calibration of the IMPACT and CRASH models was generally moderate, with calibration-in-the-large and calibration slopes ranging between -2.02 and 0.61 and between 0.48 and 1.39, respectively. The IMPACT and CRASH models adequately identify patients at high risk for mortality or unfavorable outcome, which supports their use in research settings and for benchmarking in the context of quality-of-care assessment.
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Affiliation(s)
- Simone A Dijkland
- Department of Public Health, Center for Medical Decision Making, Erasmus MC-University Medical Center, Rotterdam, the Netherlands
| | - Isabel R A Retel Helmrich
- Department of Public Health, Center for Medical Decision Making, Erasmus MC-University Medical Center, Rotterdam, the Netherlands
| | - Daan Nieboer
- Department of Public Health, Center for Medical Decision Making, Erasmus MC-University Medical Center, Rotterdam, the Netherlands
| | - Mathieu van der Jagt
- 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
| | - David K Menon
- Division of Anesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Nino Stocchetti
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.,Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Department of Anesthesia and Critical Care, Neuroscience Intensive Care Unit, Milan, Italy
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Hester F Lingsma
- Department of Public Health, Center for Medical Decision Making, Erasmus MC-University Medical Center, Rotterdam, the Netherlands
| | - Ewout W Steyerberg
- Department of Public Health, Center for Medical Decision Making, Erasmus MC-University Medical Center, Rotterdam, the Netherlands.,Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
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47
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Åkerlund CAI, Donnelly J, Zeiler FA, Helbok R, Holst A, Cabeleira M, Güiza F, Meyfroidt G, Czosnyka M, Smielewski P, Stocchetti N, Ercole A, Nelson DW. Impact of duration and magnitude of raised intracranial pressure on outcome after severe traumatic brain injury: A CENTER-TBI high-resolution group study. PLoS One 2020; 15:e0243427. [PMID: 33315872 PMCID: PMC7735618 DOI: 10.1371/journal.pone.0243427] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 11/21/2020] [Indexed: 12/19/2022] Open
Abstract
Magnitude of intracranial pressure (ICP) elevations and their duration have been associated with worse outcomes in patients with traumatic brain injuries (TBI), however published thresholds for injury vary and uncertainty about these levels has received relatively little attention. In this study, we have analyzed high-resolution ICP monitoring data in 227 adult patients in the CENTER-TBI dataset. Our aim was to identify thresholds of ICP intensity and duration associated with worse outcome, and to evaluate the uncertainty in any such thresholds. We present ICP intensity and duration plots to visualize the relationship between ICP events and outcome. We also introduced a novel bootstrap technique to evaluate uncertainty of the equipoise line. We found that an intensity threshold of 18 ± 4 mmHg (2 standard deviations) was associated with worse outcomes in this cohort. In contrast, the uncertainty in what duration is associated with harm was larger, and safe durations were found to be population dependent. The pressure and time dose (PTD) was also calculated as area under the curve above thresholds of ICP. A relationship between PTD and mortality could be established, as well as for unfavourable outcome. This relationship remained valid for mortality but not unfavourable outcome after adjusting for IMPACT core variables and maximum therapy intensity level. Importantly, during periods of impaired autoregulation (defined as pressure reactivity index (PRx)>0.3) ICP events were associated with worse outcomes for nearly all durations and ICP levels in this cohort and there was a stronger relationship between outcome and PTD. Whilst caution should be exercised in ascribing causation in observational analyses, these results suggest intracranial hypertension is poorly tolerated in the presence of impaired autoregulation. ICP level guidelines may need to be revised in the future taking into account cerebrovascular autoregulation status considered jointly with ICP levels.
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Affiliation(s)
- Cecilia AI Åkerlund
- Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
- School of Computer Science and Communication, KTH Royal Institute of Technology, Stockholm, Sweden
- * E-mail:
| | - Joseph Donnelly
- Clinical Neuroscience, University of Cambridge, Cambridge, United Kingdom
| | - Frederick A. Zeiler
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
- Centre on Aging, University of Manitoba, Winnipeg, Manitoba, Canada
- Division of Anaesthesia, University of Cambridge, Cambridge, United Kingdom
| | - Raimund Helbok
- Department of Neurology, Neurological Intensive Care Unit, Medical University of Innsbruck, Innsbruck, Austria
| | - Anders Holst
- School of Computer Science and Communication, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Manuel Cabeleira
- Clinical Neuroscience, University of Cambridge, Cambridge, United Kingdom
| | - Fabian Güiza
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Geert Meyfroidt
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Marek Czosnyka
- Clinical Neuroscience, University of Cambridge, Cambridge, United Kingdom
- Institute of Electronic Systems, Warsaw University of Technolology, Warszawa, Poland
| | - Peter Smielewski
- Clinical Neuroscience, University of Cambridge, Cambridge, United Kingdom
| | - Nino Stocchetti
- Department of Pathophysiology and Transplants, University of Milan, and Neuroscience Intensive Care Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge, Cambridge, United Kingdom
| | - David W. Nelson
- Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
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48
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Zeiler FA, Mathieu F, Monteiro M, Glocker B, Ercole A, Cabeleira M, Stocchetti N, Smielewski P, Czosnyka M, Newcombe V, Menon DK. Systemic Markers of Injury and Injury Response Are Not Associated with Impaired Cerebrovascular Reactivity in Adult Traumatic Brain Injury: A Collaborative European Neurotrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) Study. J Neurotrauma 2020; 38:870-878. [PMID: 33096953 DOI: 10.1089/neu.2020.7304] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The role of extra-cranial injury burden and systemic injury response on cerebrovascular response in traumatic brain injury (TBI) is poorly documented. This study preliminarily assesses the association between admission features of extra-cranial injury burden on cerebrovascular reactivity. Using the Collaborative European Neurotrauma Effectiveness Research in TBI High-Resolution ICU (HR ICU) sub-study cohort, we evaluated those patients with both archived high-frequency digital intra-parenchymal intra-cranial pressure monitoring data of a minimum of 6 h in duration, and the presence of a digital copy of their admission computed tomography (CT) scan. Digital physiologic signals were processed for pressure reactivity index (PRx) and both the percent time above defined PRx thresholds and mean hourly dose above threshold. This was conducted for both the first 72 h and entire duration of recording. Admission extra-cranial injury characteristics and CT injury scores were obtained from the database, with quantitative contusion, edema, intraventricular hemorrhage, and extra-axial lesion volumes were obtained via semi-automated segmentation. Comparison between admission extra-cranial markers of injury and PRx metrics was conducted using Mann-Whitney U testing, and logistic regression techniques, adjusting for known CT injury metrics associated with impaired PRx. A total of 165 patients were included. Evaluating the entire ICU recording period, there was limited association between metrics of extra-cranial injury burden and impaired cerebrovascular reactivity. Using the first 72 h of recording, admission temperature (p = 0.042) and white blood cell % (WBC %; p = 0.013) were statistically associated with impaired cerebrovascular reactivity on Mann-Whitney U and univariate logistic regression. After adjustment for admission age, pupillary status, GCS motor score, pre-hospital hypoxia/hypotension, and intra-cranial CT characteristics associated with impaired reactivity, temperature (p = 0.021) and WBC % (p = 0.013) remained significantly associated with mean PRx values above +0.25 and +0.35, respectively. Markers of extra-cranial injury burden and systemic injury response do not appear to be strongly associated with impaired cerebrovascular reactivity in TBI during both the initial and entire ICU stay.
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Affiliation(s)
- Frederick A Zeiler
- Division of Anesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom.,Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada.,Department of Human Anatomy and Cell Science, University of Manitoba, Winnipeg, Manitoba, Canada.,Department of Biomedical Engineering, University of Manitoba, Winnipeg, Manitoba, Canada.,Center on Aging, University of Manitoba, Winnipeg, Manitoba, Canada
| | - François Mathieu
- Division of Anesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom.,Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Miguel Monteiro
- Biomedical Image Analysis Group, Imperial College London, London, United Kingdom
| | - Ben Glocker
- Biomedical Image Analysis Group, Imperial College London, London, United Kingdom
| | - Ari Ercole
- Division of Anesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Manuel Cabeleira
- Brain Physics Laboratory, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Nino Stocchetti
- Neuro ICU Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Physiopathology and Transplantation, Milan University, Milan, Italy
| | - Peter Smielewski
- Brain Physics Laboratory, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Marek Czosnyka
- Brain Physics Laboratory, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom.,Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
| | - Virginia Newcombe
- Division of Anesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - David K Menon
- Division of Anesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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49
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Rass V, Huber L, Ianosi BA, Kofler M, Lindner A, Picetti E, Ortolano F, Beer R, Rossi S, Smielewski P, Stocchetti N, Helbok R. The Effect of Temperature Increases on Brain Tissue Oxygen Tension in Patients with Traumatic Brain Injury: A Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury Substudy. Ther Hypothermia Temp Manag 2020; 11:122-131. [PMID: 33202157 DOI: 10.1089/ther.2020.0027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Fever may aggravate secondary brain injury after traumatic brain injury (TBI). The aim of this study was to identify episodes of temperature increases through visual plot analysis and algorithm supported detection, and to describe associated patterns of changes in on brain tissue oxygen tension (PbtO2). Data derive from the high-resolution cohort of the multicenter prospective Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) study. Temperature increases (≥0.5°C) were visually identified in 33 patients within the first 11 days of monitoring. Generalized estimating equations were used to detect significant changes of systemic and neuromonitoring parameters from baseline to the highest temperature. Patients were median 50 (interquartile range [IQR], 35-62) years old, and presented with a Glasgow Coma Scale (GCS) of 8 (IQR, 4-10). In 202 episodes of temperature increases, mean temperature rose by 1.0°C ± 0.5°C within 4 hours. Overall, PbtO2 slightly increased (ΔPbtO2 = 0.9 ± 6.1 mmHg, p = 0.022) during temperature increases. PbtO2 increased in 35% (p < 0.001), was stable in 49% (p = 0.852), and decreased in 16% (p < 0.001) of episodes. During episodes of temperature increases and simultaneous drops in PbtO2, cerebral perfusion pressure (CPP) decreased (ΔCPP -6.3 ± 11.5 mmHg; p < 0.001). Brain tissue hypoxia (PbtO2 <20 mmHg) developed during 27/164 (17%) episodes of effervescences, in the remaining 38/202 episodes baseline PbtO2 was already <20 mmHg. Comparable results were found when using algorithm-supported detection of temperature increases. In conclusion, during effervescences, PbtO2 was mostly stable or slightly increased. A decrease of PbtO2 was observed in every sixth episode, where it was associated with a decrease in CPP. Our data highlight the need for special attention to CPP monitoring and maintenance during episodes of fever.
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Affiliation(s)
- Verena Rass
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Lukas Huber
- Institute of Medical Informatics, UMIT: University for Health Sciences, Medical Informatics and Technology, Hall, Austria
| | - Bogdan-Andrei Ianosi
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria.,Institute of Medical Informatics, UMIT: University for Health Sciences, Medical Informatics and Technology, Hall, Austria
| | - Mario Kofler
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Anna Lindner
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Fabrizio Ortolano
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Ronny Beer
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Sandra Rossi
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Nino Stocchetti
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplants, University of Milan, Milan, Italy
| | - Raimund Helbok
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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50
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Zeiler FA, Ercole A, Cabeleira M, Stocchetti N, Hutchinson PJ, Smielewski P, Czosnyka M. Descriptive analysis of low versus elevated intracranial pressure on cerebral physiology in adult traumatic brain injury: a CENTER-TBI exploratory study. Acta Neurochir (Wien) 2020; 162:2695-2706. [PMID: 32886226 PMCID: PMC7550280 DOI: 10.1007/s00701-020-04485-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/06/2020] [Indexed: 12/20/2022]
Abstract
Background To date, the cerebral physiologic consequences of persistently elevated intracranial pressure (ICP) have been based on either low-resolution physiologic data or retrospective high-frequency data from single centers. The goal of this study was to provide a descriptive multi-center analysis of the cerebral physiologic consequences of ICP, comparing those with normal ICP to those with elevated ICP. Methods The Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) High-Resolution Intensive Care Unit (HR-ICU) sub-study cohort was utilized. The first 3 days of physiologic recording were analyzed, evaluating and comparing those patients with mean ICP < 15 mmHg versus those with mean ICP > 20 mmHg. Various cerebral physiologic parameters were derived and evaluated, including ICP, brain tissue oxygen (PbtO2), cerebral perfusion pressure (CPP), pulse amplitude of ICP (AMP), cerebrovascular reactivity, and cerebral compensatory reserve. The percentage time and dose above/below thresholds were also assessed. Basic descriptive statistics were employed in comparing the two cohorts. Results 185 patients were included, with 157 displaying a mean ICP below 15 mmHg and 28 having a mean ICP above 20 mmHg. For admission demographics, only admission Marshall and Rotterdam CT scores were statistically different between groups (p = 0.017 and p = 0.030, respectively). The high ICP group displayed statistically worse CPP, PbtO2, cerebrovascular reactivity, and compensatory reserve. The high ICP group displayed worse 6-month mortality (p < 0.0001) and poor outcome (p = 0.014), based on the Extended Glasgow Outcome Score. Conclusions Low versus high ICP during the first 72 h after moderate/severe TBI is associated with significant disparities in CPP, AMP, cerebrovascular reactivity, cerebral compensatory reserve, and brain tissue oxygenation metrics. Such ICP extremes appear to be strongly related to 6-month patient outcomes, in keeping with previous literature. This work provides multi-center validation for previously described single-center retrospective results.
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Affiliation(s)
- Frederick A. Zeiler
- Department of Physical Medicine and Rehabilitation, University hospital Northern Norway, Tromsø, Norway
- Department of Neurology, Neurological Intensive Care Unit, Medical University of Innsbruck, Innsbruck, Austria
- Department of Neurosurgery & Anesthesia & intensive care medicine, Karolinska University Hospital, Stockholm, Sweden
- NeuroIntensive Care, Niguarda Hospital, Milan, Italy
- Department of Neurosurgery, Medical School, University of Pécs, Hungary and Neurotrauma Research Group, János Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - Ari Ercole
- Department of Physical Medicine and Rehabilitation, University hospital Northern Norway, Tromsø, Norway
| | - Manuel Cabeleira
- Brain Physics Lab, Division of Neurosurgery, Dept of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Nino Stocchetti
- Neuro ICU, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
- NeuroIntensive Care Unit, Department of Anesthesia & Intensive Care, ASST di Monza, Monza, Italy
| | | | - Peter Smielewski
- Brain Physics Lab, Division of Neurosurgery, Dept of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Marek Czosnyka
- Brain Physics Lab, Division of Neurosurgery, Dept of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
- Department of Neurosurgery, Medical Faculty RWTH Aachen University, Aachen, Germany
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