EEG in the Pediatric Intensive Care Unit: An Irish Experience.

INTRODUCTION: Evidence for continuous EEG monitoring in the pediatric intensive care unit (PICU) is increasing. However, 24/7 access to EEG is not routinely available in most centers, and clinical management is often informed by more limited EEG resources. The experience of EEG was reviewed in a tertiary PICU where 24/7 EEG cover is unavailable. METHODS: Retrospective EEG and clinical review of 108 PICU patients. Correlations were carried out between EEG and clinical variables including mortality. The role of EEG in clinical decision making was documented. RESULTS: One hundred ninety-six EEGs were carried out in 108 PICU patients over 2.5 years (434 hours of recording). After exclusion of 1 outlying patient with epileptic encephalopathy, 136 EEGs (median duration, 65 minutes; range, 20 minutes to 4 hours 40 minutes) were included. Sixty-two patients (57%) were less than 12 months old. Seizures were detected in 18 of 107 patients (17%); 74% of seizures were subclinical; 72% occurred within the first 30 minutes of recording. Adverse EEG findings were associated with high mortality. Antiepileptic drug use was high in the studied population irrespective of EEG seizure detection. Prevalence of epileptiform discharges and EEG seizures diminished with increasing levels of sedation. CONCLUSIONS: EEG provides important diagnostic information in a large proportion of PICU patients. In the absence of 24/7 EEG availability, empirical antiepileptic drug utilization is high.

Investigating the Role of Near-Infrared Spectroscopy in Neonatal Medicine.

Near-infrared spectroscopy (NIRS) is a clinical tool that provides a bedside method of noninvasively measuring continuous, "real-time" oxygen consumption and monitoring for potential ischemia of somatic tissues, particularly the brain, kidneys, and intestine in neonates. Although the concept of NIRS seems promising, its implementation into clinical practice has been inconsistent for various reasons, including difficulty in interpreting regional oxygen saturation (rSO2), the wide variation in types of NIRS monitors and probes, the cost of new equipment, different monitoring modalities, large discrepancies in both intra- and interindividual use, a lack of defined universal normative values, and little to no data on outcomes or potentially harmful interventions made based on rSO2 readings. We combine findings from previously published informational articles and studies on the use of NIRS in neonatal medicine to provide a comprehensive overview of this tool and identify potential indications for clinical use.

The impact of self-monitoring in chronic illness on healthcare utilisation: a systematic review of reviews.

BACKGROUND: Self-management interventions have been found to reduce healthcare utilisation in people with long-term conditions, but further work is needed to identify which components of these interventions are most effective. Self-monitoring is one such component and is associated with significant clinical benefits. The aim of this systematic review of reviews is to assess the impact of self-monitoring interventions on healthcare utilisation across a range of chronic illnesses. METHODS: An overview of published systematic reviews and meta-analyses. Multiple databases were searched (MEDLINE, CINAHL, PsycINFO, EMBASE, AMED, EBM and HMIC) along with the reference lists of included reviews. A narrative synthesis was performed, accompanied by calculation of the Corrected Cover Area to understand the impact of overlapping primary research papers. RESULTS: A total of 17 systematic reviews and meta-analyses across three chronic conditions, heart failure, hypertension and chronic obstructive pulmonary disease, were included. Self-monitoring was associated with significant reductions in hospitalisation and re-admissions to hospital. CONCLUSIONS: Self-monitoring has the potential to reduce the pressure placed on secondary care services, but this may lead to increase in services elsewhere in the system. Further work is needed to determine how these findings affect healthcare costs.

More fateful than fruitful? Intracranial pressure monitoring in elderly patients with traumatic brain injury is associated with worse outcomes.

BACKGROUND: In an expanding elderly population, traumatic brain injury (TBI) remains a significant cause of death and disability. Guidelines for management of TBI, according to the Brain Trauma Foundation (BTF), include intracranial pressure (ICP) monitoring. Whether ICP monitoring contributes to outcomes in the elderly patients with TBI has not been explored. METHODS: This is a retrospective study extracted from the National Trauma Database 2007-2008 research datasets. Patients were included if aged >55 y and they met BTF indications for ICP monitoring. Patients that had nonsurvivable injuries (any body region, abbreviated injury score = 6), were dead on arrival, had withdrawal of care, or length of stay <48 h were excluded. Outcomes were then stratified based on ICP monitoring. The primary outcomes were inhospital mortality and favorable discharge. Logistic regression was used to analyze the effect of ICP monitoring on outcomes. RESULTS: A total of 4437 patients were included with 11.2% having an ICP monitor placed. Patients requiring an ICP monitor were younger overall, more likely to present hypertensive, had higher injury severity, and more likely to require operative intervention. Median initial Glasgow coma scale (3) was similar between groups. Of those patients with ICP monitoring, overall mortality was significantly higher, and they were less likely to have favorable discharge status. Craniotomy itself was not associated with increased mortality (P = 0.450). CONCLUSIONS: Our findings suggest that the use of ICP monitoring according to BTF guidelines in elderly TBI patients does not provide outcomes superior to treatment without monitoring. The ideal group to benefit from ICP monitor placement remains to be elucidated.

Increasing use of less-invasive hemodynamic monitoring in 3 specialty surgical intensive care units: a 5-year experience at a tertiary medical center.

INTRODUCTION: Less-invasive hemodynamic monitoring (eg, esophageal doppler monitoring [EDM] and arterial pressure contour analysis, FloTrac) is increasingly used as an alternative to pulmonary artery catheters (PACs) in critically ill intensive care unit (ICU). HYPOTHESIS: The decrease in use of PACs is not associated with increased mortality. METHODS: Five-year retrospective review of 1894 hemodynamically monitored patients admitted to 3 surgical ICUs in a university-affiliate, tertiary care urban hospital. Data included the number of admissions, diagnosis-related group discharge case mix, length of stay, insertion of monitoring devices (PAC, EDM, and FloTrac probes), administered intravenous vasoactive agents (ß-predominant agonists--dobutamine, epinephrine, and dopamine; vasopressors--norepinephrine and phenylephrine), and mortality. Data from hospital administrative databases were compiled to create patient characteristic and monitoring variables across a 5-year time period, 2005 to 2009 inclusive. Chi-square for independent proportions, 1-way analysis of variance, and Kruskal-Wallis tests were used; tests for trend were conducted. An α level of .05 was considered significant. Statistical Package for the Social Sciences v14 was used for all statistical testing. RESULTS: There was a significant change in the type of hemodynamic monitors inserted in 2 of the 3 surgical ICUs (in the general surgery and neurointensive care but not in the cardiac ICU) from PACs to less-invasive devices (FloTrac or EDM) during the 5-year study period (P < .001). There was no change in mortality rate over the time period (P = .492). There was an overall increase in the proportion of monitored patients who received intravenous vasoactive agents (P < .001) with a progressive shift from ß-agonists to vasopressors (P < .002). Multivariate analyses indicated that age, case mix, and use of vasoactive agents were all independent predictors of inhospital mortality (P = .001) but that type of monitoring was not (P = .638). CONCLUSIONS: In a 5-year period, the decreased insertions of PACs were replaced by increased utilization of less-invasive hemodynamic monitoring devices. This change in practice did not adversely impact mortality.

The effects of intracranial pressure monitoring in patients with traumatic brain injury.

BACKGROUND: Although international guideline recommended routine intracranial pressure (ICP) monitoring for patients with severe traumatic brain injury(TBI), there were conflicting outcomes attributable to ICP monitoring according to the published studies. Hence, we conducted a meta-analysis to evaluate the efficacy and safety of ICP monitoring in patients with TBI. METHODS: Based on previous reviews, PubMed and two Chinese databases (Wangfang and VIP) were further searched to identify eligible studies. The primary outcome was mortality. Secondary outcomes included unfavourable outcome, adverse events, length of ICU stay and length of hospital stay. Weighted mean difference (WMD), odds ratio (OR) and 95% confidence intervals (CIs) were calculated and pooled using fixed-effects or random-effects model. RESULTS: two randomized controlled trials (RCTs) and seven cohort studies involving 11,038 patients met the inclusion criteria. ICP monitoring was not associated with a significant reduction in mortality (OR, 1.16; 95% CI, 0.87-1.54), with substantial heterogeneity (I(2) = 80%, P<0.00001), which was verified by the sensitivity analyses. No significant difference was found in the occurrence of unfavourable outcome (OR, 1.40; 95% CI, 0.99-1.98; I(2) = 4%, P = 0.35) and adverse events (OR, 1.04; 95% CI, 0.64-1.70; I(2) = 78%, P = 0.03). However, we should be cautious to the result of adverse events because of the substantial heterogeneity in the comparison. Furthermore, longer ICU and hospital stay were the consistent tendency according to the pooled studies. CONCLUSIONS: No benefit was found in patients with TBI who underwent ICP monitoring. Considering substantial clinical heterogeneity, further large sample size RCTs are needed to confirm the current findings.

Analysis of ventilatory ratio as a novel method to monitor ventilatory adequacy at the bedside.

INTRODUCTION: Due to complexities in its measurement, adequacy of ventilation is seldom used to categorize disease severity and guide ventilatory strategies. Ventilatory ratio (VR) is a novel index to monitor ventilatory adequacy at the bedside. VR=(VEmeasured × PaCO2measured)/(VEpredicted × PaCO2ideal). VEpredicted is 100 mL.Kg-1.min-1 and PaCO2ideal is 5 kPa. Physiological analysis shows that VR is influenced by dead space (VD/VT) and CO2 production (VCO2). Two studies were conducted to explore the physiological properties of VR and assess its use in clinical practice. METHODS: Both studies were conducted in adult mechanically ventilated ICU patients. In Study 1, volumetric capnography was used to estimate daily VD/VT and measure VCO2 in 48 patients. Simultaneously, ventilatory ratio was calculated using arterial blood gas measurements alongside respiratory and ventilatory variables. This data was used to explore the physiological properties of VR. In Study 2, 224 ventilated patients had daily VR and other respiratory variables, baseline characteristics, and outcome recorded. The database was used to examine the prognostic value of VR. RESULTS: Study 1 showed that there was significant positive correlation between VR and VD/VT (modified r = 0.71) and VCO2 (r = 0.14). The correlation between VR and VD/VT was stronger in mandatory ventilation compared to spontaneous ventilation. Linear regression analysis showed that VD/VT had a greater influence on VR than VCO2 (standardized regression coefficient 1/1-VD/VT: 0.78, VCO2: 0.44). Study 2 showed that VR was significantly higher in non-survivors compared to survivors (1.55 vs. 1.32; P < 0.01). Univariate logistic regression showed that higher VR was associated with mortality (OR 2.3, P < 0.01), this remained the case after adjusting for confounding variables (OR 2.34, P = 0.04). CONCLUSIONS: VR is an easy to calculate bedside index of ventilatory adequacy and appears to yield clinically useful information.

Predictive monitoring for early detection of subacute potentially catastrophic illnesses in critical care.

We wish to save lives of patients admitted to ICUs. Their mortality is high enough based simply on the severity of the original injury or illness, but is further raised by events during their stay. We target those events that are subacute but potentially catastrophic, such as infection. Sepsis, for example, is a bacterial infection of the bloodstream, that is common in ICU patients and has a >25% risk of death. Logically, early detection and treatment with antibiotics should improve outcomes. Our fundamental precepts are (1) some potentially catastrophic medical and surgical illnesses have subclinical phases during which early diagnosis and treatment might have life-saving effects, (2) these phases are characterized by changes in the normal highly complex but highly adaptive regulation and interaction of the nervous system and other organs such as the heart and lungs, (3) teams of clinicians and quantitative scientists can work together to identify clinically important abnormalities of monitoring data, to develop algorithms that match the clinicians' eye in detecting abnormalities, and to undertake the clinical trials to test their impact on outcomes.

Association of clinic vascular access monitoring practices with clinical outcomes in hemodialysis patients.

BACKGROUND: Early identification of access dysfunctions may be associated with improved patient outcomes. We examined whether patient outcomes were associated with vascular access monitoring practices in an incident dialysis cohort. METHODS: We conducted a national prospective cohort study and analyzed 363 hemodialysis patients who had a first permanent vascular access (arteriovenous fistula or graft) by 6 months after the start of dialysis. Multivariate methods were used to examine associations between monitoring practices and 6-month Kt/V (reaching Kt/V >/=1.2), access intervention, access failure, and 2-year septicemia and all-cause hospitalization and mortality. RESULTS: Patients who received monitoring weekly or more often (49%) were more likely to have an access intervention (adjusted RH = 1.40, 95% CI, 1.07-1.84) than those who received monitoring less frequently. Additionally, patients treated at clinics that reported performing regular access monitoring (80% of patients) were less likely to be hospitalized for septicemia (IRR = 0.35, 95% CI, 0.21-0.61) or for any cause (IRR = 0.77, 95% CI, 0.60-0.99). There were no statistically significant differences between patients exposed to different vascular access monitoring practices in access failure, achievement of Kt/V, or survival. CONCLUSION: Frequent monitoring of dialysis access may initially increase the number of interventions but is beneficial to longer-term outcomes, including septicemia-related and all-cause hospitalization.

Reduced mortality rate in patients with severe traumatic brain injury treated with brain tissue oxygen monitoring.

OBJECT: An intracranial pressure (ICP) monitor, from which cerebral perfusion pressure (CPP) is estimated, is recommended in the care of severe traumatic brain injury (TBI). Nevertheless, optimal ICP and CPP management may not always prevent cerebral ischemia, which adversely influences patient outcome. The authors therefore determined whether the addition of a brain tissue oxygen tension (PO2) monitor in the treatment of TBI was associated with an improved patient outcome. METHODS: Patients with severe TBI (Glasgow Coma Scale [GCS] score < 8) who had been admitted to a Level I trauma center were evaluated as part of a prospective observational database. Patients treated with ICP and brain tissue PO2 monitoring were compared with historical controls matched for age, pathological features, admission GCS score, and Injury Severity Score who had undergone ICP monitoring alone. Therapy in both patient groups was aimed at maintaining an ICP less than 20 mm Hg and a CPP greater than 60 mm Hg. Among patients whose brain tissue PO2 was monitored, oxygenation was maintained at levels greater than 25 mm Hg. Twenty-five patients with a mean age of 44 +/- 14 years were treated using an ICP monitor alone. Twenty-eight patients with a mean age of 38 +/- 18 years underwent brain tissue PO2-directed care. The mean daily ICP and CPP levels were similar in each group. The mortality rate in patients treated using conventional ICP and CPP management was 44%. Patients who also underwent brain tissue PO2 monitoring had a significantly reduced mortality rate of 25% (p < 0.05). CONCLUSIONS: The use of both ICP and brain tissue PO2 monitors and therapy directed at brain tissue PO2 is associated with reduced patient death following severe TBI.

Delayed hemodynamic monitoring with pulmonary artery catheter is a non-essential care in severe sepsis and septico shock

Objective: Prompt adequate antibiotic therapy, eradication of infection, fluids and vasoactive drugs are themain strategies for initial resuscitation of septic shock. Once initial resuscitative efforts are not effective,invasive hemodynamic monitoring (HM) with pulmonary artery catheter (PAC) has been frequently used toguide filling pressures and optimal doses of vasoactive agents. However, the evidence of benefit from PACuse in septic shock is still a matter of debate. We aimed to determine whether early compared to delayplacement of PAC could have influenced outcome.Methods: Retrospective analysis in a 24-bed general ICU tertiary care university hospital. From January 1999to December 2000, patients admitted with severe sepsis and septic shock and having a PAC inserted werestudied. Early invasive HM was defined whenever a PAC was placed in the first 48 hours, and delayedinvasive HM was placed more than 48 hours after the diagnosis of severe sepsis or septic shock. Organ failurewas defined as a SOFA score of > 3 points.Results. Among 104 patients submitted to invasive monitoring with PAC, 56 patients had sepsis. Fifty-twopatients with severe sepsis (5, 9.6 por cento) and septic shock (47, 90.4 por cento) were enrolled. Thirty-six patients (69 por cento) hadearly HM and 16 (21 por cento) delayed HM. Overall in-hospital mortality was 69 por cento. The groups had similar APACHEII score (18.6 ± 8.0, early HM; 18.5 ± 3.8, delayed HM), SOFA score (9.4 ± 3.2, early HM; 9.9 ± 4.4, delayed HM)and number of organs failure (1.6 ± 0.9, early HM; 1.8 ± 1.4, delayed HM) at the onset of severe sepsis/septicshock. The in-hospital mortality rate was significantly higher in delayed HM group (87.5 por cento) compared withearly HM (61.3 por cento) (RR: 0.70, CI 95 por cento 0.50-0.96, p < 0.05). Compared with delayed HM, early HM patientsreceived significantly higher amount of fluids (10.3 ± 3.6 L vs 6.8 ± 3.5 L, p = 0.002) within 48 hours from onsetof severe sepsis/septic shock.Conclusion. Delayed monitoring with PAC patients with severe sepsis/septic shock is associated with a veryhigh risk of death and might be considered a non-essential care.

Monitoreo del paciente pediátrico de alto riesgo

Para el monitoreo de los niños se usan los mismos principios básicos y equipos que se usan para monitorizar adultos. La morbimortalidad perioperatoria durante la niñez es muy alta y se atribuye principalmente a eventos hipóxicos. El uso rutinario del oxígeno de pulso junto con el capnógrfo han disminuido notablemente la aparición de dichos eventos y percances de la vía aérea, contituyéndose en el más importante avance en el monitoreo del paciente pediátrico desde la introducción del fonendoscopio precordial