Factors Associated with the Need for Intensive Care Unit Admission Following Supratentorial Intracerebral Hemorrhage: The Triage ICH Model

Background

Providing the correct level of care for patients with intracerebral hemorrhage (ICH) is crucial, but the level of care needed at initial presentation may not be clear. This study evaluated factors associated with admission to intensive care unit (ICU) level of care.

Methods

This is an observational study of all adult patients admitted to our institution with non-traumatic supratentorial ICH presenting within 72 h of symptom onset between 2009–2012 (derivation cohort) and 2005–2008 (validation cohort). Factors associated with neuroscience ICU admission were identified via logistic regression analysis, from which a triage model was derived, refined, and retrospectively validated.

Results

For the derivation cohort, 229 patients were included, of whom 70 patients (31 %) required ICU care. Predictors of neuroscience ICU admission were: younger age [odds ratio (OR) 0.94, 95 % CI 0.91–0.97; p = 0.0004], lower Full Outline of UnResponsiveness (FOUR) score (0.39, 0.28–0.54; p < 0.0001) or Glasgow Coma Scale (GCS) score (0.55, 0.45–0.67; p < 0.0001), and larger ICH volume (1.04, 1.03–1.06; p < 0.0001). The model was further refined with clinician input and the addition of intraventricular hemorrhage (IVH). GCS was chosen for the model rather than the FOUR score as it is more widely used. The proposed triage ICH model utilizes three variables: ICH volume ≥30 cc, GCS score <13, and IVH. The triage ICH model predicted the need for ICU admission with a sensitivity of 94.3 % in the derivation cohort [area under the curve (AUC) = 0.88; p < 0.001] and 97.8 % (AUC = 0.88) in the validation cohort.

Conclusions

Presented are the derivation, refinement, and validation of the triage ICH model. This model requires prospective validation, but may be a useful tool to aid clinicians in determining the appropriate level of care at the time of initial presentation for a patient with a supratentorial ICH.

     

Cost and Utility of Microbiological Cultures Early After Intensive Care Unit Admission for Intracerebral Hemorrhage

Background

Fever is common among intensive care unit (ICU) patients. Clinicians may use microbiological cultures to differentiate infectious and aseptic fever. However, their utility depends on the prevalence of infection; and false-positive results might adversely affect patient care. We sought to quantify the cost and utility of microbiological cultures in a cohort of ICU patients with spontaneous intracerebral hemorrhage (ICH).

Methods

We performed a secondary analysis of a cohort with spontaneous ICH requiring mechanical ventilation. We collected baseline data, measures of systemic inflammation, microbiological culture results for the first 48 h, and daily antibiotic usage. Two physicians adjudicated true-positive and false-positive culture results using standard criteria. We calculated the cost per true-positive result and used logistic regression to test the association between false-positive results with subsequent antibiotic exposure.

Results

Overall, 697 subjects were included. A total of 233 subjects had 432 blood cultures obtained, with one true-positive (diagnostic yield 0.1 %, $22,200 per true-positive) and 11 false-positives. True-positive urine cultures (5 %) and sputum cultures (13 %) were more common but so were false-positives (6 and 17 %, respectively). In adjusted analysis, false-positive blood and sputum results were associated with increased antibiotic exposure.

Conclusions

The yield of blood cultures early after spontaneous ICH was very low. False-positive results significantly increased the odds of antibiotic exposure. Our results support limiting the use of blood cultures in the first two days after ICU admission for spontaneous ICH.

     

Correlation of Noninvasive Blood Pressure and Invasive Intra-arterial Blood Pressure in Patients Treated with Vasoactive Medications in a Neurocritical Care Unit

Background

The correlation between noninvasive (oscillometric) blood pressure (NBP) and intra-arterial blood pressure (IAP) in critically ill patients receiving vasoactive medications in a Neurocritical Care Unit has not been systematically studied. The purpose of this study is to examine the relationship between simultaneously measured NBP and IAP recordings in these patients.

Methods

Prospective observational study of patients (N = 70) admitted to a neurocritical care unit receiving continuous vasopressor or antihypertensive infusions. Paired NBP/IAP observations along with covariate and demographic data were abstracted via chart audit. Analysis was performed using SAS v9.4.

Results

A total of 2177 paired NBP/IAP observations from 70 subjects (49% male, 63% white, mean age 59 years) receiving vasopressors (n = 21) or antihypertensive agents (n = 49) were collected. Paired t test analysis showed significant differences between NBP versus IAP readings: ([systolic blood pressure (SBP): mean = 136 vs. 140 mmHg; p < 0.0001], [diastolic blood pressure (DBP): mean = 70 vs. 68 mmHg, p < 0.0001], [mean arterial blood pressure (MAP): mean = 86 vs. 90 mmHg, p < 0.0001]). Bland–Altman plots for MAP, SBP, and DBP demonstrate good inter-method agreement between paired measures (excluding outliers) and demonstrate NBP–IAP SBP differences at extremes of blood pressures. Pearson correlation coefficients show strong positive correlations for paired MAP (r = 0.82), SBP (r = 0.84), and DBP (r = 0.73) recordings. An absolute NBP–IAP SBP difference of > 20 mmHg was seen in ~ 20% of observations of nicardipine, ~ 25% of observations of norepinephrine, and ~ 35% of observations of phenylephrine. For MAP, the corresponding numbers were ~ 10, 15, and 25% for nicardipine, norepinephrine, and phenylephrine, respectively.

Conclusion

Despite overall strong positive correlations between paired NBP and IAP readings of MAP and SBP, clinically relevant differences in blood pressure are frequent. When treating with vasoactive infusions targeted to a specific BP goal, it is important to keep in mind that NBP and IAP values are not interchangeable.

     

A Population-Based Analysis of Ethnic Differences in Admission to the Intensive Care Unit after Stroke

Background

Mexican?CAmericans (MAs) have shown lower post-stroke mortality compared to non-hispanic whites (NHWs). Limited evidence suggests race/ethnic differences exist in intensive care unit (ICU) admissions following stroke. Our objective was to investigate the association of ethnicity with admission to the ICU following stroke.

Methods

Cases of intracerebral hemorrhage and acute ischemic stroke were prospectively ascertained as part of the Brain Attack Surveillance in Corpus Christi (BASIC) project for the period of January 2000 through December 2009. Logistic regression models fitted within the generalized additive model framework were used to test associations between ethnicity and ICU admission and potential confounders. An interaction term between age and ethnicity was investigated in the final model.

Results

A total 1,464 cases were included in analysis. MAs were younger, more likely to have diabetes, and less likely to have atrial fibrillation, health insurance, or high school diploma than NHWs. On unadjusted analysis, there was a trend toward MAs being more likely to be admitted to ICU than NHWs (34.6 vs 30.3?%; OR?=?1.22; 95?% CI 0.98?C1.52; p?=?0.08). However, on adjusted analysis, no overall association between MA ethnicity and ICU admission (OR?=?1.13; 95?% CI 0.85?C1.50) was found. When an interaction term for age and ethnicity was added to this model, there was only borderline evidence for effect modification by age of the ethnicity/ICU relationship (p?=?0.16).

Conclusions

No overall association between ethnicity and ICU admission was observed in this community. ICU utilization alone does not likely explain ethnic differences in survival following stroke between MAs and NHWs.     

Relationship Between Satisfaction,Patient-Centered Care,Adherence and Outcomes Among Patients in A Collaborative Care Trial for Depression

Collaborative care is known to improve satisfaction, patient-centered care, adherence, and depression symptom severity. However, associations among these outcomes have not been examined. Outcomes were measured at 6 months for 360 primary care patients with depression enrolled in a randomized trial of collaborative care. Main effects and mediation effects were examined using logistic regression analyses. Collaborative care significantly improved both satisfaction and patient-centered care. Patient-centered care did not mediate the positive effect that collaborative care had on satisfaction. Improvements in symptom severity partially mediated collaborative care’s effect on satisfaction. Satisfaction did not mediate collaborative care’s positive effect on antidepressant adherence.     

The Utility of Routine Intensive Care Admission for Patients Undergoing Intracranial Neurosurgical Procedures: A Systematic Review

Background

Patients who have undergone intracranial neurosurgical procedures have traditionally been admitted to an intensive care unit (ICU) for close postoperative neurological observation. The purpose of this study was to systematically review the evidence for routine ICU admission in patients undergoing intracranial neurosurgical procedures and to evaluate the safety of alternative postoperative pathways.

Methods

We were interested in identifying studies that examined selected patients who presented for elective, non-emergent intracranial surgery whose postoperative outcomes were compared as a function of ICU versus non-ICU admission. A systematic review was performed in July 2016 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist of the Medline database. The search strategy was created based on the following key words: “craniotomy,” “neurosurgical procedure,” and “intensive care unit.”

Results

The nine articles that satisfied the inclusion criteria yielded a total of 2227 patients. Of these patients, 879 were observed in a non-ICU setting. The most frequent diagnoses were supratentorial brain tumors, followed by patients with cerebrovascular diseases and infratentorial brain tumors. Three percent (30/879) of the patients originally assigned to floor or intermediate care status were transferred to the ICU. The most frequently observed neurological complications leading to ICU transfer were delayed postoperative neurological recovery, seizures, worsening of neurological deficits, hemiparesis, and cranial nerves deficits.

Conclusion

Our systematic review demonstrates that routine postoperative ICU admission may not benefit carefully selected patients who have undergone elective intracranial neurosurgical procedures. In addition, limiting routine ICU admission may result in significant cost savings.

     

Withdrawal of Life-Sustaining Treatment in a Mixed Intensive Care Unit: Most Common in Patients with Catastropic Brain Injury

Objective  

To determine the incidence of withdrawal of life-sustaining treatment in various groups of patients in a mixed intensive care unit (ICU).     

Clevidipine Versus Nicardipine for Acute Blood Pressure Reduction in a Neuroscience Intensive Care Population

Background

Currently, a lack of published literature exists regarding the use of clevidipine in the neuroscience population. This agent may be preferred in some patients because of its short half-life, potentially leading to more narrow blood pressure (BP) control in comparison with other agents. The purpose of this study was to compare the difference in time to achieve target systolic blood pressure (SBP) goals with clevidipine versus nicardipine infusions in patients admitted to the neuroscience intensive care unit (NSICU) at our institution.

Methods

A retrospective review was performed on patients receiving clevidipine or nicardipine infusions while in the NSICU between July 1, 2011 and June 30, 2014. Patients were matched based on indication for BP lowering and target SBP. Primary endpoints included time to target SBP and percentage of time within target BP range.

Results

Of the 57 patients included in the study, the median time to target SBP was 30 min in the clevidipine group and 46 min in the nicardipine group (p = 0.13). The percentage of time spent within target BP range was 79 versus 78% (p = 0.64). Clevidipine administration resulted in significantly less volume administered per patient versus nicardipine (530 vs. 1254 mL, p = 0.02).

Conclusions

There were no statistically significant differences in acute BP management between the two agents; however, there was a trend toward shorter time to target and significantly less volume administered in the clevidipine group. Either agent should be considered a viable option in a NSICU population.

     

Continuous Video EEG for Patients with Acute Encephalopathy in a Pediatric Intensive Care Unit

Objectives

In this study, we aimed to determine the incidence of electrographic seizures among patients in a pediatric intensive care unit (PICU) presenting with acute encephalopathy. Risk factors and duration of continuous EEG monitoring needed to capture electrographic seizures were also assessed.

Study Design

Based on a NeuroICU clinical care pathway, all patients with acute encephalopathy admitted to the PICU are monitored with continuous video electroencephalogram (cVEEG) for 48?h or until the encephalopathy improves. Ninety-four consecutive patients included on the pathway over a year were identified. Mean age was 6.7?years (range 32?days?C17.9?years). Data pertaining to patient clinical information and electrographic seizures, including non-convulsive seizures (NCS) and non-convulsive status epilepticus (NCSE), were extracted from a prospective database.

Results

Thirty percent (28/94) had seizures captured on cVEEG including 17 patients (18?%) with NCSE. Variables associated with electrographic seizures were age <24?months and clinical seizure(s) prior to EEG placement. The first seizure captured on cVEEG occurred in the first 24?h for the majority of patients (97?%). Acute brain injury and electrographic seizures were associated with worse outcome.

Conclusions

Electrographic seizures are common in pediatric patients with acute encephalopathy. This study supports the practice of cVEEG monitoring for at least 24?h in pediatric patients with acute encephalopathy, particularly if they are less then 24?months of age and/or if a clinical event suspicious for seizure precedes the encephalopathy.     

Safety and Efficacy of Lacosamide in the Intensive Care Unit

Background  

Seizures are common in critically ill patients and can impact morbidity and mortality. Traditional anti-epileptic drugs (AEDs) in this setting are not always effective and are associated with adverse events and drug interactions. Lacosamide (LCM) is a new AED which is available in parental form although few studies have evaluated the safety and efficacy of LCM in critically ill patients.     

The Impact of Hyperthermia and Infection on Acute Ischemic Stroke Patients in the Intensive Care Unit

Introduction  Despite the recognized deleterious effects of hyperthermia on critically ill neurological patients, few investigations have studied hyperthermia after an ischemic stroke in the intensive care unit (ICU) setting. Methods   Acute ischemic stroke patients admitted to the ICU were assigned to one of three groups: normothermia, mild hyperthermia (MH), or severe hyperthermia (SH). The etiology of hyperthermia was further divided into infectious and non-infectious groups. Results   Among the 150 patients included in the study, MH and SH were observed in 15 and 40 patients, respectively. Hyperthermia and the Glasgow coma scale (GCS) score were independently related to in-hospital mortality and increased length of stay in the ICU (ILOS, ≥4 days). Discussion   Infection (39 patients) was more prevalent in the SH group than in the MH group and was associated with greater ILOS. Conclusions  Monitoring and managing infection and reducing body temperature may be important factors for determining the outcomes of patients with acute ischemic stroke admitted to the ICU.     

Gender Differences in Longitudinal Associations Between Intimate Care,Resiliency, and Depression Among Informal Caregivers of Patients Surviving the Neuroscience Intensive Care Unit

Neurocritical Care - Informal caregivers (e.g., family and friends) are at risk for developing depression, which can be detrimental to both caregiver and patient functioning. Initial evidence...     

Serotonin Syndrome in the Intensive Care Unit: Clinical Presentations and Precipitating Medications

Background

Serotonin syndrome (SS) is becoming a more frequent diagnosis in the intensive care unit (ICU). We sought to determine the clinical presentation, drug exposures, and outcomes of SS in critically ill patients.

Methods

A retrospective study of 33 consecutive ICU patients with SS between March 2007 and March 2012 in ICUs in a large teaching hospital. SS was defined using the Hunter Serotonin Toxicity Criteria.

Results

Seventeen patients (52 %) were admitted for mental status changes, including seven patients (21 %) with drug overdose and four cases (12 %) in which SS was considered the primary admission diagnosis. In 13 patients (39 %) the features of SS developed only after a mean of 6.8 ± 9 days of hospitalization. Most received multiple serotonergic drugs upon diagnosis (median three drugs, range 1–5). Antidepressants were the serotonergic medications most often used before admission, and opioids (principally fentanyl) and antiemetics were the most frequently prescribed new serotonin-enhancing medications. Altered mental status was present in all patients and myoclonus, rigidity, and hyperreflexia were the most prevalent examination signs. All but one patient had documented recovery. The mean time to neurological improvement was 56 ± 5 h, but ranged from 8 to 288 h. There were no cases of renal failure related to rhabdomyolysis, or death or persistent disability caused by SS.

Conclusion

SS in the ICU occurs most often because of exposure to multiple serotonergic agents. Continuation of antidepressants plus the addition of opioids and antiemetics during hospitalization are most commonly responsible for this complication.     

Blood Pressure and Hospital Discharge Outcomes in Acute Ischemic Stroke Patients Undergoing Reperfusion Therapy

IntroductionAcute management of blood pressure in ischemic stroke treated with reperfusion therapy remains uncertain. We evaluated blood pressures during the first 24-hours after reperfusion therapy in relation to in-hospital outcomes.MethodsWe conducted a single-center retrospective study of blood pressure in the first 24 hours among ischemic stroke patients who underwent reperfusion therapy with intravenous thrombolysis (IVT) or mechanical thrombectomy (MT) at a tertiary referral center. Blood pressure variability was expressed as the range between the highest and the lowest pressures. Outcomes of interest were discharge disposition and in-hospital mortality. Favorable outcome was defined as a discharge destination to home or inpatient rehabilitation facility (IRF). Multivariable logistic regression analysis was performed with adjustment for age, National Institutes of Health Stroke Scale score, and patients receiving reperfusion therapy.ResultsAmong the 140 ischemic stroke patients (117 IVT, 84 MT and 61 both), 95 (67.8%) had favorable discharge disposition and 24 (17.1%) died. Higher 24-hour peak systolic blood pressures (SBPs) and peak mean arterial pressures (MAPs) were independently associated with a lower likelihood of favorable discharge disposition, with an adjusted odds ratio (aOR) 0.868, 95 % CI 0.760 - 0.990 per 10 mm Hg for SBP and aOR 0.710, 95% CI 0.515 - 0.980 for MAP, and with increased odds of death aOR 1.244, 95% CI 1.056-1.467 and aOR 1.760, 95% CI 1.119 - 2.769 respectively. Greater variability of SBP and MAP was also associated with odds of death aOR 1.327, 95% CI 1.104 - 1.595 and aOR 1.577, 95% CI 1.060- 2.345 respectively, without a significant effect on discharge disposition.ConclusionIn the first 24 hours after reperfusion therapy, higher peak and variable blood pressures are associated with unfavorable discharge outcomes and increased in-hospital mortality. Further studies in stroke patients undergoing reperfusion therapy might target blood pressure reduction and variability to improve patient outcomes.     

Real-World Evidence for the Association Between Pneumonia-Related Intensive Care Unit Stay and Dementia

Objective There is limited clarity concerning the risk of dementia after pneumonia with intensive care unit (ICU) stay. We conducted a nationwide cohort study, which aimed to investigate the impact of dementia after pneumonia with and without intensive care unit admission. Methods Data was obtained from Taiwan’s National Health Insurance Research Database between 2000 and 2015. A total of 7,473 patients were identified as having pneumonia required ICU stay, along with 22,419 controls matched by sex and age. After adjusting for confounding factors, multivariate Cox regression model analysis was used to compare the risk of developing dementia during the 15-years follow-up period. Results The enrolled pneumonia patients with ICU admission had a dementia rate of 9.89%. Pneumonia patients without ICU admission had a dementia rate of 9.21%. The multivariate Cox regression model analysis revealed that the patients with ICU stay had the higher risk of dementia, with a crude hazard ratio of 3.371 (95% confidence interval, 3.093–3.675; p<0.001). Conclusion This study indicated that pneumonia with ICU stay is associated with an increased risk of dementia. A 3-fold risk of dementia was observed in patients admitted to the ICU compared to the control group.     

Preventive Antibiotics and Delayed Cerebral Ischaemia in Patients with Aneurysmal Subarachnoid Haemorrhage Admitted to the Intensive Care Unit

Introduction

Delayed cerebral ischemia (DCI) is an important contributor to poor outcome after aneurysmal subarachnoid haemorrhage (aSAH). Development of DCI is multifactorial, and inflammation, with or without infection, is one of the factors independently associated with development of DCI and poor outcome. We thus postulated that preventive antibiotics might be associated with a reduced risk of DCI and subsequent poor outcome in aSAH patients.

Methods

We performed a retrospective cohort-study in intensive care units (ICU) of three university hospitals in The Netherlands. We included consecutive aSAH patients with minimal ICU stay of 72 h who received either preventive antibiotics (SDD: selective digestive tract decontamination including systemic cefotaxime or SOD: selective oropharyngeal decontamination) or no preventive antibiotics. DCI was defined as a new hypodensity on CT with no other explanation than DCI. Hazard ratio’s (HR) for DCI and risk ratio’s (RR) for 28-day case-fatality and poor outcome at 3 months were calculated, with adjustment (aHR/aRR) for clinical condition on admission, recurrent bleeding, aneurysm treatment modality and treatment site.

Results

Of 459 included patients, 274 received preventive antibiotics (SOD or SDD) and 185 did not. With preventive antibiotics, the aHR for DCI was 1.0 (95 % CI 0.6–1.8), the aRR for 28-day case-fatality was 1.1 (95 % CI 0.7–1.9) and the aRR for poor functional outcome 1.2 (95 % CI 1.0–1.4).

Conclusions

Preventive antibiotics were not associated with reduced risk of DCI or poor outcome in aSAH patients in the ICU.