Background Optic nerve sheath diameter (ONSD) is an emerging non-invasive, easily accessible, and possibly useful measurement for evaluating changes in intracranial pressure (ICP). The utilization of bedside ultrasonography (USG) to measure ONSD has garnered increased attention due to its portability, real-time capability, and lack of ionizing radiation. The primary aim of the study was to assess whether bedside USG-guided ONSD measurement can reliably predict increased ICP in traumatic brain injury (TBI) patients. Methods: A total of 95 patients admitted to the trauma intensive care unit was included in this cross sectional study. Patient brain computed tomography (CT) scans and Glasgow Coma Scale (GCS) scores were assessed at the time of admission. Bedside USG-guided binocular ONSD was measured and the mean ONSD was noted. Microsoft Excel was used for statistical analysis. Results: Patients with low GCS had higher mean ONSD values (6.4±1.0 mm). A highly significant association was found among the GCS, CT results, and ONSD measurements (P<0.001). Compared to CT scans, the bedside USG ONSD had 86.42% sensitivity and 64.29% specificity for detecting elevated ICP. The positive predictive value of ONSD to identify elevated ICP was 93.33%, and its negative predictive value was 45.00%. ONSD measurement accuracy was 83.16%. Conclusions: Increased ICP can be accurately predicted by bedside USG measurement of ONSD and can be a valuable adjunctive tool in the management of TBI patients.
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Measurement of Optic Nerve Sheath Diameter by Bedside Ultrasound in Patients With Traumatic Brain Injury Presenting to Emergency Department: A Review Preethy Koshy, Charuta Gadkari Cureus.2024;[Epub] CrossRef
Background Extracorporeal blood-purification techniques are frequently needed in the pediatric intensive care unit (PICU), yet data on their clinical application are lacking. This study aims to review the indications, rate of application, clinical characteristics, complications, and outcomes of patients undergoing extracorporeal blood purification (i.e., by continuous renal replacement therapy [CRRT] or therapeutic plasma exchange [TPE]) in our PICU, including before the coronavirus disease 2019 (COVID-19) pandemic in 2019 and during the pandemic from 2020 to 2022. Methods: This study included children admitted for extracorporeal blood-purification therapy in the PICU. The indications for TPE were analyzed and compared to the American Society for Apheresis categories. Results: In 82 children, 380 TPE sessions and 37 CRRT sessions were carried out children, with 65 patients (79%) receiving TPE, 17 (20.7%) receiving CRRT, and four (4.8%) receiving both therapies. The most common indications for TPE were neurological diseases (39/82, 47.5%), followed by hematological diseases (18/82, 21.9%). CRRT was mainly performed for patients suffering from acute kidney injury. Patients with neurological diseases received the greatest number of TPE sessions (295, 77.6%). Also, the year 2022 contained the greatest number of patients receiving extracorporeal blood-purification therapy (either CRRT or TPE). Conclusions: The use of extracorporeal blood-purification techniques increased from 2019 through 2022 due to mainly autoimmune dysregulation among affected patients. TPE can be safely used in an experienced PICU. No serious adverse events were observed in the patients that received TPE, and overall survival over the 4 years was 86.5%.
Extracorporeal membrane oxygenation (ECMO) is a life-saving intervention for patients with refractory cardiorespiratory failure. Despite its benefits, ECMO carries a significant risk of neurological complications, including acute brain injury (ABI). Although standardized neuromonitoring and neurological care have been shown to improve early detection of ABI, the inability to perform neuroimaging in a timely manner is a major limitation in the accurate diagnosis of neurological complications. Therefore, blood-based biomarkers capable of detecting ongoing brain injury at the bedside are of great clinical significance. This review aims to provide a concise review of the current literature on plasma biomarkers for ABI in patients on ECMO support.
Background Coronavirus disease 2019 (COVID-19) infection is associated with significant morbidity and mortality. Some patients develop severe acute respiratory distress syndrome and kidney failure requiring the combination of extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT).
Methods Retrospective cohort study of 127 consecutive patients requiring combined ECMO and CRRT support in intensive care units at an ECMO center in Marietta, GA, United States.
Results Sixty and 67 patients with and without COVID-19, respectively, required ECMO-CRRT support. After adjusting for confounding variables, patients with COVID-19 had increased mortality at 30 days (hazard ratio [HR], 5.19; 95% confidence interval [CI], 2.51–10.7; P<0.001) and 90 days (HR, 6.23; 95% CI, 2.60–14.9; P<0.001).
Conclusions In this retrospective study, patients with COVID-19 who required ECMO-CRRT had increased mortality when compared to patients without COVID-19.
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Factors associated with post-hospitalization dialysis dependence in ECMO patients who required continuous renal replacement therapy Carlos Rodrigo Franco Palacios, Rudiona Hoxhaj, Catlyn Thigpen, Jeffrey Jacob Renal Failure.2024;[Epub] CrossRef
Louis Boutin, Louis Morisson, Florence Riché, Romain Barthélémy, Alexandre Mebazaa, Philippe Soyer, Benoit Gallix, Anthony Dohan, Benjamin G Chousterman
Acute Crit Care. 2023;38(3):343-352. Published online August 21, 2023
Background Sepsis is a severe and common cause of admission to the intensive care unit (ICU). Radiomic analysis (RA) may predict organ failure and patient outcomes. The objective of this study was to assess a model of RA and to evaluate its performance in predicting in-ICU mortality and acute kidney injury (AKI) during abdominal sepsis.
Methods This single-center, retrospective study included patients admitted to the ICU for abdominal sepsis. To predict in-ICU mortality or AKI, elastic net regularized logistic regression and the random forest algorithm were used in a five-fold cross-validation set repeated 10 times.
Results Fifty-five patients were included. In-ICU mortality was 25.5%, and 76.4% of patients developed AKI. To predict in-ICU mortality, elastic net and random forest models, respectively, achieved areas under the curve (AUCs) of 0.48 (95% confidence interval [CI], 0.43–0.54) and 0.51 (95% CI, 0.46–0.57) and were not improved combined with Simplified Acute Physiology Score (SAPS) II. To predict AKI with RA, the AUC was 0.71 (95% CI, 0.66–0.77) for elastic net and 0.69 (95% CI, 0.64–0.74) for random forest, and these were improved combined with SAPS II, respectively; AUC of 0.94 (95% CI, 0.91–0.96) and 0.75 (95% CI, 0.70–0.80) for elastic net and random forest, respectively.
Conclusions This study suggests that RA has poor predictive performance for in-ICU mortality but good predictive performance for AKI in patients with abdominal sepsis. A secondary validation cohort is needed to confirm these results and the assessed model.
Mobilization in traumatic brain injury (TBI) have shown the improvement of length of stay, infection, long term weakness, and disability. Primary damage as a result of trauma’s direct effect (skull fracture, hematoma, contusion, laceration, and nerve damage) and secondary damage caused by trauma’s indirect effect (microvasculature damage and pro-inflammatory cytokine) result in reduced tissue perfusion & edema. These can be facilitated through mobilization, but several precautions must be recognized as mobilization itself may further deteriorate patient’s condition. Very few studies have discussed in detail regarding mobilizing patients in TBI cases. Therefore, the scope of this review covers the detail of physiological effects, guideline, precautions, and technique of mobilization in patients with TBI.
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Acute orthostatic responses during early mobilisation of patients with acquired brain injury - Innowalk pro versus standing frame Matthijs F Wouda, Espen I Bengtson, Ellen Høyer, Alhed P Wesche, Vivien Jørgensen Journal of Rehabilitation and Assistive Technologies Engineering.2024;[Epub] CrossRef
Background This study aimed to determine the predictive power of the Full Outline of Unresponsiveness (FOUR) score and the Glasgow Coma Scale Pupil (GCS-P) score in determining outcomes for traumatic brain injury (TBI) patients. The Glasgow Outcome Scale (GOS) was used to evaluate patients at 1 month and 6 months after the injury. Methods: We conducted a 15-month prospective observational study. It included 50 TBI patients admitted to the ICU who met our inclusion criteria. We used Pearson’s correlation coefficient to relate coma scales and outcome measures. The predictive value of these scales was determined using the receiver operating characteristic (ROC) curve, calculating the area under the curve with a 99% confidence interval. All hypotheses were two-tailed, and significance was defined as P<0.01. Results: In the present study, the GCS-P and FOUR scores among all patients on admission as well as in the subset of patients who were mechanically ventilated were statistically significant and strongly correlated with patient outcomes. The correlation coefficient of the GCS score compared to GCS-P and FOUR scores was higher and statistically significant. The areas under the ROC curve for the GCS, GCS-P, and FOUR scores and the number of computed tomography abnormalities were 0.912, 0.905, 0.937, and 0.324, respectively. Conclusions: The GCS, GCS-P, and FOUR scores are all excellent predictors with a strong positive linear correlation with final outcome prediction. In particular, the GCS score has the best correlation with final outcome.
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Development of a Novel Neurological Score Combining GCS and FOUR Scales for Assessment of Neurosurgical Patients with Traumatic Brain Injury: GCS-FOUR Scale Ali Ansari, Sina Zoghi, Amirabbas Khoshbooei, Mohammad Amin Mosayebi, Maryam Feili, Omid Yousefi, Amin Niakan, Seyed Amin Kouhpayeh, Reza Taheri, Hosseinali Khalili World Neurosurgery.2024; 182: e866. CrossRef
Comparison of Glasgow Coma Scale Full Outline of UnResponsiveness and Glasgow Coma Scale: Pupils Score for Predicting Outcome in Patients with Traumatic Brain Injury Indu Kapoor, Hemanshu Prabhakar, Arvind Chaturvedi, Charu Mahajan, Abraham L Chawnchhim, Tej P Sinha Indian Journal of Critical Care Medicine.2024; 28(3): 256. CrossRef
Machine learning for the prediction of in-hospital mortality in patients with spontaneous intracerebral hemorrhage in intensive care unit Baojie Mao, Lichao Ling, Yuhang Pan, Rui Zhang, Wanning Zheng, Yanfei Shen, Wei Lu, Yuning Lu, Shanhu Xu, Jiong Wu, Ming Wang, Shu Wan Scientific Reports.2024;[Epub] CrossRef
Background Polytrauma from road accidents is a common cause of hospital admissions and deaths, frequently leading to acute kidney injury (AKI) and impacting patient outcomes. Methods: This retrospective, single-center study included polytrauma victims with an Injury Severity Score (ISS) >25 at a tertiary healthcare center in Dubai. Results: The incidence of AKI in polytrauma victims is 30.5%, associated with higher Carlson comorbidity index (P=0.021) and ISS (P=0.001). Logistic regression shows a significant relationship between ISS and AKI (odds ratio [OR], 1.191; 95% confidence interval [CI], 1.150–1.233; P<0.05). The main causes of trauma-induced AKI are hemorrhagic shock (P=0.001), need for massive transfusion (P<0.001), rhabdomyolysis (P=0.001), and abdominal compartment syndrome (ACS; P<0.001). On multivariate logistic regression AKI can be predicated by higher ISS (OR, 1.08; 95% CI, 1.00–1.17; P=0.05) and low mixed venous oxygen saturation (OR, 1.13; 95% CI, 1.05–1.22; P<0.001). The development of AKI after polytrauma increases length of stay (LOS)-hospital (P=0.006), LOS-intensive care unit (ICU; P=0.003), need for mechanical ventilation (MV) (P<0.001), ventilator days (P=0.001), and mortality (P<0.001). Conclusions: After polytrauma, the occurrence of AKI leads to prolonged hospital and ICU stays, increased need for mechanical ventilation, more ventilator days, and a higher mortality rate. AKI could significantly impact their prognosis.
Pierre Basse, Louis Morisson, Romain Barthélémy, Nathan Julian, Manuel Kindermans, Magalie Collet, Benjamin Huot, Etienne Gayat, Alexandre Mebazaa, Benjamin G. Chousterman
Acute Crit Care. 2023;38(2):172-181. Published online May 25, 2023
Background The role of positive pressure ventilation, central venous pressure (CVP) and inflammation on the occurrence of acute kidney injury (AKI) have been poorly described in mechanically ventilated patient secondary to coronavirus disease 2019 (COVID-19). Methods: This was a monocenter retrospective cohort study of consecutive ventilated COVID-19 patients admitted in a French surgical intensive care unit between March 2020 and July 2020. Worsening renal function (WRF) was defined as development of a new AKI or a persistent AKI during the 5 days after mechanical ventilation initiation. We studied the association between WRF and ventilatory parameters including positive end-expiratory pressure (PEEP), CVP, and leukocytes count. Results: Fifty-seven patients were included, 12 (21%) presented WRF. Daily PEEP, 5 days mean PEEP and daily CVP values were not associated with occurrence of WRF. 5 days mean CVP was higher in the WRF group compared to patients without WRF (median [IQR], 12 mm Hg [11-13] vs. 10 mm Hg [9–12]; P=0.03). Multivariate models with adjustment on leukocytes and Simplified Acute Physiology Score (SAPS) II confirmed the association between CVP value and risk of WRF (odd ratio, 1.97; 95% confidence interval, 1.12–4.33). Leukocytes count was also associated with occurrence of WRF in the WRF group (14 G/L [11–18]) and the no-WRF group (9 G/L [8–11]) (P=0.002). Conclusions: In mechanically ventilated COVID-19 patients, PEEP levels did not appear to influence occurrence of WRF. High CVP levels and leukocytes count are associated with risk of WRF.
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Bidirectional pressure: a mini review of ventilator-lung-kidney interactions Avnee Kumar, Katie Epler, Sean DeWolf, Laura Barnes, Mark Hepokoski Frontiers in Physiology.2024;[Epub] CrossRef
Background In patients with severe trauma, the diagnosis of acute kidney injury (AKI) is important because it is a predictive factor for poor prognosis and can affect patient care. The diagnosis and staging of AKI are based on change in serum creatinine (SCr) levels from baseline. However, baseline creatinine levels in patients with traumatic injuries are often unknown, making the diagnosis of AKI in trauma patients difficult. This study aimed to enhance the accuracy of AKI diagnosis in trauma patients by presenting an appropriate reference creatinine estimate (RCE). Methods: We reviewed adult patients with severe trauma requiring intensive care unit admission between 2015 and 2019 (n=3,228) at a single regional trauma center in South Korea. AKI was diagnosed based on the current guideline published by the Kidney Disease: Improving Global Outcomes organization. AKI was determined using the following RCEs: estimated SCr75-modification of diet in renal disease (MDRD), trauma MDRD (TMDRD), admission creatinine level, and first-day creatinine nadir. We assessed inclusivity, prognostic ability, and incrementality using the different RCEs. Results: The incidence of AKI varied from 15% to 46% according to the RCE used. The receiver operating characteristic curve of TMDRD used to predict mortality and the need for renal replacement therapy (RRT) had the highest value and was statistically significant (0.797, P<0.001; 0.890, P=0.002, respectively). In addition, the use of TMDRD resulted in a mortality prognostic ability and the need for RRT was incremental with AKI stage. Conclusions: In this study, TMDRD was feasible as a RCE, resulting in optimal post-traumatic AKI diagnosis and prognosis.
Christopher S. Hong, Muhammad K. Effendi, Abdalla A. Ammar, Kent A. Owusu, Mahmoud A. Ammar, Andrew B. Koo, Layton A. Lamsam, Aladine A. Elsamadicy, Gregory A. Kuzmik, Maxwell Laurans, Michael L. DiLuna, Mark L. Landreneau
Received December 3, 2021 Accepted September 14, 2022 Published online December 7, 2022
Hypotension secondary to autonomic dysfunction is a common complication of acute spinal cord injury (SCI) that may worsen neurologic outcomes. Midodrine, an enteral α-1 agonist, is often used to facilitate weaning intravenous (IV) vasopressors, but its use can be limited by reflex bradycardia. Alternative enteral agents to facilitate this wean in the acute post-SCI setting have not been described. We aim to describe novel application of droxidopa, an enteral precursor of norepinephrine that is approved to treat neurogenic orthostatic hypotension, in the acute post-SCI setting. Droxidopa may be an alternative enteral therapy for those intolerant of midodrine due to reflex bradycardia. We describe two patients suffering traumatic cervical SCI who were successfully weaned off IV vasopressors with droxidopa after failing with midodrine. The first patient was a 64-year-old male who underwent C3–6 laminectomies and fusion after a ten-foot fall resulting in quadriparesis. Post-operatively, the addition of midodrine in an attempt to wean off IV vasopressors resulted in significant reflexive bradycardia. Treatment with droxidopa facilitated rapidly weaning IV vasopressors and transfer to a lower level of care within 72 hours of treatment initiation. The second patient was a 73-year-old male who underwent C3–5 laminectomies and fusion for a traumatic hyperflexion injury causing paraplegia. The addition of midodrine resulted in severe bradycardia, prompting consideration of pacemaker placement. However, with the addition of droxidopa, this was avoided, and the patient was weaned off IV vasopressors on dual oral therapy with midodrine and droxidopa. Droxidopa may be a viable enteral therapy to treat hypotension in patients after acute SCI who are otherwise not tolerating midodrine in order to wean off IV vasopressors. This strategy may avoid pacemaker placement and facilitate shorter stays in the intensive care unit, particularly for patients who are stable but require continued intensive care unit admission for IV vasopressors, which can be cost ineffective and human resource depleting.
Traumatic brain injury (TBI) is a critical cause of disability and death worldwide. Many studies have been conducted aimed at achieving favorable neurologic outcomes by reducing secondary brain injury in TBI patients. However, ground-breaking outcomes are still insufficient so far. Because mild-to-moderate hypothermia (32°C–35°C) has been confirmed to help neurological recovery for recovered patients after circulatory arrest, it has been recognized as a major neuroprotective treatment plan for TBI patients. Thereafter, many clinical studies about the effect of therapeutic hypothermia (TH) on severe TBI have been conducted. However, efficacy and safety have not been demonstrated in many large-scale randomized controlled studies. Rather, some studies have demonstrated an increase in mortality rate due to complications such as pneumonia, so it is not highly recommended for severe TBI patients. Recently, some studies have shown results suggesting TH may help reperfusion/ischemic injury prevention after surgery in the case of mass lesions, such as acute subdural hematoma, and it has also been shown to be effective in intracranial pressure control. In conclusion, TH is still at the center of neuroprotective therapeutic studies regarding TBI. If proper measures can be taken to mitigate the many adverse events that may occur during the course of treatment, more positive efficacy can be confirmed. In this review, we look into adverse events that may occur during the process of the induction, maintenance, and rewarming of targeted temperature management and consider ways to prevent and address them.
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Severe traumatic brain injury in adults: a review of critical care management Siobhan McLernon British Journal of Neuroscience Nursing.2023; 19(6): 206. CrossRef
Background The transition of dialysis modalities from continuous renal replacement therapy (CRRT) to intermittent hemodialysis (iHD) is frequently conducted during the recovery phase of critically ill patients with acute kidney injury. Herein, we addressed the occurrence of intradialytic hypotension (IDH) after this transition, and its association with the mortality risk. Methods: A total of 541 patients with acute kidney injury who attempted to transition from CRRT to iHD at Seoul National University Hospital, Korea from 2010 to 2020 were retrospectively collected. IDH was defined as a discontinuation of dialysis because of hemodynamic instability plus a nadir systolic blood pressure <90 mm Hg or a decrease in systolic blood pressure ≥30 mm Hg during the first session of iHD. Odds ratios (ORs) of outcomes, such as in-hospital mortality and weaning from RRT, were measured using a logistic regression model after adjusting for multiple variables. Results: IDH occurred in 197 patients (36%), and their mortality rate (44%) was higher than that of those without IDH (19%; OR, 2.64; 95% confidence interval [CI], 1.70–4.08). For patients exhibiting IDH, the iHD sessions delayed successful weaning from RRT (OR, 0.62; 95% CI, 0.43–0.90) compared with sessions on those without IDH. Factors such as low blood pressure, high pulse rate, low urine output, use of mechanical ventilations and vasopressors, and hypoalbuminemia were associated with IDH risk. Conclusions: IDH occurrence following the transition from CRRT to iHD is associated with high mortality and delayed weaning from RRT.
Background
Prediction of intensive care unit (ICU) mortality in traumatic brain injury (TBI), which is a common cause of death in children and young adults, is important for injury management. Neuroinflammation is responsible for both primary and secondary brain injury, and C-reactive protein-albumin ratio (CAR) has allowed use of biomarkers such as procalcitonin (PCT) in predicting mortality. Here, we compared the performance of CAR and PCT in predicting ICU mortality in TBI.
Methods Adults with TBI were enrolled in our study. The medical records of 82 isolated TBI patients were reviewed retrospectively.
Results The mean patient age was 49.0 ± 22.69 years; 59 of all patients (72%) were discharged, and 23 (28%) died. There was a statistically significant difference between PCT and CAR values according to mortality (P<0.05). The area under the curve (AUC) was 0.646 with 0.071 standard error for PCT and 0.642 with 0.066 standard error for CAR. The PCT showed a similar AUC of the receiver operating characteristic to CAR.
Conclusions This study shows that CAR and PCT are usable biomarkers to predict ICU mortality in TBI. When the determined cut-off values are used to predict the course of the disease, the CAR and PCT biomarkers will provide more effective information for treatment planning and for preparation of the family for the treatment process and to manage their outcome expectations.
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Background Severe acute pancreatitis (SAP) is a systemic inflammatory disease, and it can often complicate into acute kidney injury (AKI) and acute lung injury/acute respiratory distress syndrome (ALI/ARDS). This study aimed to evaluate the clinical effectiveness of blood purification using a polymethylmethacrylate (PMMA) hemofilter.
Methods We retrospectively examined 54 patients, who were diagnosed with SAP according to the Japanese criteria from January 2011 to December 2019.
Results Of a total of 54 SAP patients, 26 patients progressively developed AKI and required continuous hemodialysis with a PMMA membrane hemofilter (PMMA-CHD). Acute Physiology and Chronic Health Evaluation (APACHE) II score and Sequential Organ Failure Assessment (SOFA) score were significantly higher in patients requiring PMMA-CHD than in patients not requiring hemodialysis. The lung injury scores were also significantly higher in patients requiring PMMA-CHD. Of the 26 patients, 16 patients developed ALI/ARDS and required mechanical ventilation. A total of seven patients developed severe ALI/ARDS and received additional intermittent hemodiafiltration using a PMMA hemofilter (PMMA-HDF). Although the length of intensive care unit stay was significantly longer in patients with severe ALI/ARDS, blood purification therapy was discontinued in all the patients. The survival rates at the time of discharge were 92.3% and 92.9% in patients with and without PMMA-CHD, respectively. These real mortality ratios were obviously lower than the estimated mortality ratios predicted by APACHE II scores.
Conclusions These finding suggest that the blood purification using a PMMA hemofilter would be effective for the treatment of AKI and ALI/ARDS in SAP patients.
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