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BACKGROUND: Traumatic brain injury (TBI) is associated with the tauopathies Alzheimer's disease and chronic traumatic encephalopathy. Advanced immunoassays show significant elevations in plasma total tau (t-tau) early post-TBI, but concentrations subsequently normalise rapidly. Tau phosphorylated at serine-181 (p-tau181) is a well-validated Alzheimer's disease marker that could potentially seed progressive neurodegeneration. We tested whether post-traumatic p-tau181 concentrations are elevated and relate to progressive brain atrophy. METHODS: Plasma p-tau181 and other post-traumatic biomarkers, including total-tau (t-tau), neurofilament light (NfL), ubiquitin carboxy-terminal hydrolase L1 (UCH-L1) and glial fibrillary acidic protein (GFAP), were assessed after moderate-to-severe TBI in the BIO-AX-TBI cohort (first sample mean 2.7 days, second sample within 10 days, then 6 weeks, 6 months and 12 months, n=42). Brain atrophy rates were assessed in aligned serial MRI (n=40). Concentrations were compared patients with and without Alzheimer's disease, with healthy controls. RESULTS: Plasma p-tau181 concentrations were significantly raised in patients with Alzheimer's disease but not after TBI, where concentrations were non-elevated, and remained stable over one year. P-tau181 after TBI was not predictive of brain atrophy rates in either grey or white matter. In contrast, substantial trauma-associated elevations in t-tau, NfL, GFAP and UCH-L1 were seen, with concentrations of NfL and t-tau predictive of brain atrophy rates. CONCLUSIONS: Plasma p-tau181 is not significantly elevated during the first year after moderate-to-severe TBI and levels do not relate to neuroimaging measures of neurodegeneration.
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Enfermedad de Alzheimer , Lesiones Traumáticas del Encéfalo , Encefalopatía Traumática Crónica , Humanos , Biomarcadores , Proteínas tau , Imagen por Resonancia Magnética , Ubiquitina Tiolesterasa , Atrofia , Péptidos beta-AmiloidesRESUMEN
To determine how percutaneous tracheostomy (PT) impacts on respiratory system compliance (Crs) and end-expiratory lung volume (EELV) during volume control ventilation and to test whether a recruitment maneuver (RM) at the end of PT may reverse lung derecruitment. This is a single center, prospective, applied physiology study. 25 patients with acute brain injury who underwent PT were studied. Patients were ventilated in volume control ventilation. Electrical impedance tomography (EIT) monitoring and respiratory mechanics measurements were performed in three steps: (a) baseline, (b) after PT, and (c) after a standardized RM (10 sighs of 30 cmH2O lasting 3 s each within 1 min). End-expiratory lung impedance (EELI) was used as a surrogate of EELV. PT determined a significant EELI loss (mean reduction of 432 arbitrary units p = 0.049) leading to a reduction in Crs (55 ± 13 vs. 62 ± 13 mL/cmH2O; p < 0.001) as compared to baseline. RM was able to revert EELI loss and restore Crs (68 ± 15 vs. 55 ± 13 mL/cmH2O; p < 0.001). In a subgroup of patients (N = 8, 31%), we observed a gradual but progressive increase in EELI. In this subgroup, patients did not experience a decrease of Crs after PT as compared to patients without dynamic inflation. Dynamic inflation did not cause hemodynamic impairment nor raising of intracranial pressure. We propose a novel and explorative hyperinflation risk index (HRI) formula. Volume control ventilation did not prevent the PT-induced lung derecruitment. RM could restore the baseline lung volume and mechanics. Dynamic inflation is common during PT, it can be monitored real-time by EIT and anticipated by HRI. The presence of dynamic inflation during PT may prevent lung derecruitment.
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OBJECTIVES: To compare respiratory system compliance (C rs ) calculation during controlled mechanical ventilation (MV) and, subsequently, during assisted MV. DESIGN: This is a single-center, retrospective, observational study. SETTING: This study was conducted on patients admitted to Neuro-ICU of Niguarda Hospital (tertiary referral hospital). PATIENTS: We analyzed every patient greater than or equal to 18 years old having a C rs measurement in controlled and in assisted MV within 60 minutes. Plateau pressure (P plat ) was considered reliable if it was deemed visually stable for at least 2 seconds. INTERVENTIONS: Inspiratory pause was incorporated to detect P plat in controlled and assisted MV. Calculation of C rs and driving pressure were achieved. MEASUREMENTS AND MAIN RESULTS: A total of 101 patients were studied. An acceptable agreement was found (Bland-Altman plot bias -3.9, level of agreement upper 21.6, lower -29.6). C rs in assisted MV was 64.1 (52.6-79.3) and in controlled MV it was 61.2 (50-71.2) mL/cm H 2o ( p = 0.006). No statistical difference was found in C rs (assisted vs controlled MV) when peak pressure was lower than P plat nor when peak pressure was higher than P plat . CONCLUSIONS: A P plat visually stable for at least 2 seconds leads to reliable C rs calculation during assisted MV.
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Respiración Artificial , Sistema Respiratorio , Humanos , Estudios Retrospectivos , Reproducibilidad de los Resultados , Volumen de Ventilación PulmonarRESUMEN
BACKGROUND: Alternative noninvasive methods capable of excluding intracranial hypertension through use of transcranial Doppler (ICPtcd) in situations where invasive methods cannot be used or are not available would be useful during the management of acutely brain-injured patients. The objective of this study was to determine whether ICPtcd can be considered a reliable screening test compared to the reference standard method, invasive ICP monitoring (ICPi), in excluding the presence of intracranial hypertension. METHODS: This was a prospective, international, multicenter, unblinded, diagnostic accuracy study comparing the index test (ICPtcd) with a reference standard (ICPi), defined as the best available method for establishing the presence or absence of the condition of interest (i.e., intracranial hypertension). Acute brain-injured patients pertaining to one of four categories: traumatic brain injury (TBI), subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH) or ischemic stroke (IS) requiring ICPi monitoring, were enrolled in 16 international intensive care units. ICPi measurements (reference test) were compared to simultaneous ICPtcd measurements (index test) at three different timepoints: before, immediately after and 2 to 3 h following ICPi catheter insertion. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV) were calculated at three different ICPi thresholds (> 20, > 22 and > 25 mmHg) to assess ICPtcd as a bedside real-practice screening method. A receiver operating characteristic (ROC) curve analysis with the area under the curve (AUC) was used to evaluate the discriminative accuracy and predictive capability of ICPtcd. RESULTS: Two hundred and sixty-two patients were recruited for final analysis. Intracranial hypertension (> 22 mmHg) occurred in 87 patients (33.2%). The total number of paired comparisons between ICPtcd and ICPi was 687. The NPV was elevated (ICP > 20 mmHg = 91.3%, > 22 mmHg = 95.6%, > 25 mmHg = 98.6%), indicating high discriminant accuracy of ICPtcd in excluding intracranial hypertension. Concordance correlation between ICPtcd and ICPi was 33.3% (95% CI 25.6-40.5%), and Bland-Altman showed a mean bias of -3.3 mmHg. The optimal ICPtcd threshold for ruling out intracranial hypertension was 20.5 mmHg, corresponding to a sensitivity of 70% (95% CI 40.7-92.6%) and a specificity of 72% (95% CI 51.9-94.0%) with an AUC of 76% (95% CI 65.6-85.5%). CONCLUSIONS AND RELEVANCE: ICPtcd has a high NPV in ruling out intracranial hypertension and may be useful to clinicians in situations where invasive methods cannot be used or not available. TRIAL REGISTRATION: NCT02322970 .
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Hipertensión Intracraneal , Encéfalo , Humanos , Hipertensión Intracraneal/diagnóstico , Hipertensión Intracraneal/etiología , Presión Intracraneal , Estudios Prospectivos , Ultrasonografía Doppler Transcraneal/métodosRESUMEN
BACKGROUND: In traumatic brain injury (TBI) the patterns of intracranial pressure (ICP) waveforms may reflect pathological processes that ultimately lead to unfavorable outcome. In particular, ICP slow waves (sw) (0.005-0.05 Hz) magnitude and complexity have been shown to have positive association with favorable outcome. Mild-moderate hypocapnia is currently used for short periods to treat critical elevations in ICP. Our goals were to assess changes in the ICP sw activity occurring following sudden onset of mild-moderate hypocapnia and to examine the relationship between changes in ICP sw activity and other physiological variables during the hypocapnic challenge. METHODS: ICP, arterial blood pressure (ABP), and bilateral middle cerebral artery blood flow velocity (FV), were prospectively collected in 29 adult severe TBI patients requiring ICP monitoring and mechanical ventilation in whom a minute volume ventilation increase (15-20% increase in respiratory minute volume) was performed as part of a clinical CO2-reactivity test. The time series were first treated using FFT filter (pass-band set to 0.005-0.05 Hz). Power spectral density analysis was performed. We calculated the following: mean value, standard deviation, variance and coefficient of variation in the time domain; total power and frequency centroid in the frequency domain; cerebrospinal compliance (Ci) and compensatory reserve index (RAP). RESULTS: Hypocapnia led to a decrease in power and increase in frequency centroid and entropy of slow waves in ICP and FV (not ABP). In a multiple linear regression model, RAP at the baseline was the strongest predictor for the decrease in the power of ICP slow waves (p < 0.001). CONCLUSION: In severe TBI patients, a sudden mild-moderate hypocapnia induces a decrease in mean ICP and FV, but also in slow waves power of both signals. At the same time, it increases their higher frequency content and their morphological complexity. The difference in power of the ICP slow waves between the baseline and the hypocapnia period depends on the baseline cerebrospinal compensatory reserve as measured by RAP.
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Lesiones Traumáticas del Encéfalo/fisiopatología , Circulación Cerebrovascular , Hipocapnia/fisiopatología , Presión Intracraneal , Adulto , Presión Arterial , Velocidad del Flujo Sanguíneo , Lesiones Traumáticas del Encéfalo/terapia , Femenino , Humanos , Masculino , Arteria Cerebral Media/fisiopatología , Monitoreo FisiológicoRESUMEN
Despite the absence of responsiveness during anesthesia, conscious experience may persist. However, reliable, easily acquirable and interpretable neurophysiological markers of the presence of consciousness in unresponsive states are still missing. A promising marker is based on the decay-rate of the power spectral density (PSD) of the resting EEG. We acquired resting electroencephalogram (EEG) in three groups of healthy participants (nâ¯=â¯5 each), before and during anesthesia induced by either xenon, propofol or ketamine. Dosage of each anesthetic agent was tailored to yield unresponsiveness (Ramsay scoreâ¯=â¯6). Delayed subjective reports assessed whether conscious experience was present ('Conscious report') or absent/inaccessible to recall ('No Report'). We estimated the decay of the PSD of the resting EEG-after removing oscillatory peaks-via the spectral exponent ß, for a broad band (1-40â¯Hz) and narrower sub-bands (1-20â¯Hz, 20-40â¯Hz). Within-subject anesthetic changes in ß were assessed. Furthermore, based on ß, 'Conscious report' states were discriminated against 'no report' states. Finally, we evaluated the correlation of the resting spectral exponent with a recently proposed index of consciousness, the Perturbational Complexity Index (PCI), derived from a previous TMS-EEG study. The spectral exponent of the resting EEG discriminated states in which consciousness was present (wakefulness, ketamine) from states where consciousness was reduced or abolished (xenon, propofol). Loss of consciousness substantially decreased the (negative) broad-band spectral exponent in each subject undergoing xenon or propofol anesthesia-indexing an overall steeper PSD decay. Conversely, ketamine displayed an overall PSD decay similar to that of wakefulness-consistent with the preservation of consciousness-yet it showed a flattening of the decay in the high-frequencies (20-40â¯Hz)-consistent with its specific mechanism of action. The spectral exponent was highly correlated to PCI, corroborating its interpretation as a marker of the presence of consciousness. A steeper PSD of the resting EEG reliably indexed unconsciousness in anesthesia, beyond sheer unresponsiveness.
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Anestésicos Generales/farmacología , Estado de Conciencia/efectos de los fármacos , Electroencefalografía/efectos de los fármacos , Ketamina/farmacología , Propofol/farmacología , Inconsciencia/fisiopatología , Xenón/farmacología , Adolescente , Adulto , Ondas Encefálicas/efectos de los fármacos , Femenino , Humanos , Masculino , Inconsciencia/inducido químicamente , Adulto JovenRESUMEN
BACKGROUND: Procalcitonin (PCT) is a useful biomarker of bacterial infection and its use is associated to reduced duration of antibiotic therapy in the setting of intensive care medicine. To address the need of practical guidance for the use of PCT in various clinical settings, a group of experts was invited to participate at a consensus process with the aims of defining the rationale for appropriate use of PCT and for improving the management of critically ill patients with sepsis. METHODS: A group of 14 experts from anesthesiology and critical care, infectious diseases, internal medicine, pulmonology, clinical microbiology, laboratory medicine, clinical pharmacology and methodology provided expert opinion through a modified Delphi process, after a comprehensive literature review. RESULTS: The appropriateness of use of PCT in terms of diagnosis, prognosis and antimicrobial stewardship was assessed for different scenarios or settings such us management of infection in the emergency department, regular wards, surgical wards or in the intensive care unit. Similarly, appropriateness and timing of PCT measurement were evaluated. All the process consisted in three Delphi rounds. CONCLUSIONS: PCT use is appropriate in algorithms for antibiotic de-escalation and discontinuation. In this case, reproducible, high sensitive assays should be used. However, initiation or escalation of antibiotic therapy in specific scenarios, including acute respiratory infections, should not be based solely on PCT serum levels. Clinical and radiological findings, evaluation of severity of illness and of patient's characteristics should be taken into proper account in order to correctly interpret PCT results.
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Antibacterianos/uso terapéutico , Infecciones Bacterianas/tratamiento farmacológico , Biomarcadores/sangre , Análisis Químico de la Sangre/normas , Consenso , Polipéptido alfa Relacionado con Calcitonina/sangre , Pruebas Diagnósticas de Rutina/normas , Departamentos de Hospitales/normas , Humanos , Sepsis/diagnósticoRESUMEN
BACKGROUND: The outcome of patients with severe traumatic brain injury (TBI) and acute traumatic subdural hematoma (aSDH) admitted to the emergency room with bilaterally dilated, unreactive pupils (bilateral mydriasis) is notoriously poor. METHODS: Of 2074 TBI patients consecutively admitted to our facility between 1997 and 2012, 115 had a first CT scan with aSDH, unreactive bilateral mydriasis, and a Glasgow Coma Score of 3 or 4. Sixty-two patients were unoperated and died within hours or a few days. The remaining 53 patients (2.5% of the 2074 consecutive patients) were scheduled for emergent evacuation of the aSDH. We compared three different dosages of mannitol to landmark different comprehensive levels of treatment: (1) a "basic" level of treatment characterized by a single conventional dose (18 to 36 g), (2) "reinforced" treatment landmarked by a single high dose (54 to 72 g), and (3) "aggressive" treatment landmarked by a single high dose (90 to 106 g). Doses above 36 g were administered intravenously over a period of 5 min. RESULTS: Of the 53 selected patients, 7 were aggressively managed (13.2%) and 24 (45.3%) received reinforced treatment. Rates of hyperventilation and barbiturate bolus administration were appropriately associated with increasing doses of mannitol. After adjustment for age, aggressive management was significantly associated with a lower risk of death and persistent vegetative state [adjusted OR 0.016 (95% 0.001-0.405)]. Patients surviving after aggressive management suffered more severe disability at 1 year. CONCLUSION: The study shows an association between reduced mortality and persistent vegetative state, albeit at the cost of increased long-term severe disability in survivors, and aggressive medical preoperative management of mydriatic patients with aSDH following TBI.
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Craneotomía/métodos , Hematoma Subdural Agudo/cirugía , Estado Vegetativo Persistente/epidemiología , Complicaciones Posoperatorias/epidemiología , Adulto , Anciano , Estudios de Cohortes , Craneotomía/efectos adversos , Femenino , Hematoma Subdural Agudo/patología , Humanos , Masculino , Persona de Mediana Edad , Periodo PreoperatorioRESUMEN
INTRODUCTION: Little is known about hemodynamic disturbances affecting cerebral hemispheres in traumatic brain injury (TBI) after cranioplasty. METHODS: We prospectively investigated six stable TBI patients who underwent cranioplasty more than 90 days after effective decompressive craniectomy. Computerized tomography perfusion (CTP) studies and evaluation of clinical outcome were performed for each patient before cranioplasty and at 7 days and 3 months after surgery. Cerebral blood flow (CBF), cerebral blood volume (CBV) and mean transit time (MTT) were measured in multiple cortical circular regions positioned in cranioplasty-treated and contralateral hemispheres. RESULTS: Neither complications associated with cranioplasty nor changes in outcome were observed. On the treated side, CBF and CBV values were higher before and 7 days after cranioplasty than at 3 months after surgery, whereas MTT values were lower at 7 days than at 3 months after surgical treatment. CONCLUSIONS: Our results indicate that cortical perfusion progressively declines in the cranioplasty treated hemisphere but remains stable in the contralateral hemisphere after surgery and suggest that CTP can represent a promising tool for a longitudinal analysis of hemodynamic abnormalities occurring in TBI patients after cranioplasty. In addition, these data imply a possible role of cranioplasty in restoring flow to meet the prevailing metabolic demand.
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Lesiones Encefálicas/fisiopatología , Lesiones Encefálicas/cirugía , Circulación Cerebrovascular , Craneotomía/métodos , Craniectomía Descompresiva/métodos , Tomografía Computarizada por Rayos X/métodos , Adulto , Anciano , Velocidad del Flujo Sanguíneo , Lesiones Encefálicas/diagnóstico por imagen , Angiografía Cerebral/métodos , Terapia Combinada , Craneotomía/efectos adversos , Craniectomía Descompresiva/efectos adversos , Humanos , Masculino , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
Assessing quality of care is essential for improving the management of patients experiencing traumatic brain injury (TBI). This study aimed at devising a rigorous framework to evaluate the quality of TBI care provided by intensive care units (ICUs) and applying it to the Collaborative Research on Acute Traumatic Brain Injury in Intensive Care Medicine in Europe (CREACTIVE) consortium, which involved 83 ICUs from seven countries. The performance of the centers was assessed in terms of patients' outcomes, as measured by the 6-month Glasgow Outcome Scale-Extended (GOS-E). To account for the between-center differences in the characteristics of the admitted patients, we developed a multinomial logistic regression model estimating the probability of a four-level categorization of the GOS-E: good recovery (GR), moderate disability (MD), severe disability (SD), and death or vegetative state (D/VS). A total of 5928 patients admitted to the participating ICUs between March 2014 and March 2019 were analyzed. The model included 11 predictors and demonstrated good discrimination (area under the receiver operating characteristic [ROC] curve in the validation set for GR: 0.836, MD: 0.802, SD: 0.706, D/VS: 0.890) and calibration, both overall (Hosmer-Lemeshow test p value: 0.87) and in several subgroups, defined by prognostically relevant variables. The model was used as a benchmark for assessing quality of care by comparing the observed number of patients experiencing GR, MD, SD, and D/VS to the corresponding numbers expected in each category by the model, computing observed/expected (O/E) ratios. The four center-specific ratios were assembled with polar representations and used to provide a multidimensional assessment of the ICUs, overcoming the loss of information consequent to the traditional dichotomizations of the outcome in TBI research. The proposed framework can help in identifying strengths and weaknesses of current TBI care, triggering the changes that are necessary to improve patient outcomes.
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Lesiones Traumáticas del Encéfalo , Unidades de Cuidados Intensivos , Humanos , Lesiones Traumáticas del Encéfalo/terapia , Lesiones Traumáticas del Encéfalo/diagnóstico , Masculino , Femenino , Persona de Mediana Edad , Unidades de Cuidados Intensivos/normas , Adulto , Anciano , Calidad de la Atención de Salud/normas , Escala de Consecuencias de Glasgow , Evaluación de la Discapacidad , Europa (Continente) , Cuidados Críticos/normasRESUMEN
INTRODUCTION: Diffusion-weighted imaging (DWI) studies focusing on apparent diffusion coefficient (ADC) abnormalities have provided conflicting results about the nature and fate of perihematomal edema. METHODS: We investigated 35 patients with supratentorial spontaneous intracerebral hemorrhage (SICH) by using DWI scanning obtained at 48 h and 7 days after symptom onset. Regional ADC (rADC) values were measured in three manually outlined regions of interest: (1) the perihematomal hyperintense area, (2) 1 cm of normal appearing brain tissue surrounding the perilesional hyperintense rim, and (3) a mirror area, including the clot and the perihematomal region, located in the contralateral hemisphere. RESULTS: rADC mean levels were lower at 7 days than at 48 h in each ROI (p < 0.00001), showing a progressive normalization of initial vasogenic values. Perihematomal vasogenic rADC values were more frequent (p < 0.00001) at 48 h than at 7 days, whereas perihematomal cytotoxic and normal rADC levels were more represented (p < 0.02 and p < 0.001, respectively) at 7 days than at 48 h. A neurological worsening was more frequent (p < 0.02) in patients with than in those without perihematomal cytotoxic rADC values at 7 days. CONCLUSION: Our findings suggest that the transition from acute to subacute phases after SICH is characterized by a progressive resolution of perihematomal vasogenic edema associated with an increase in cytotoxic ADC values. In the subset of patients with perihematomal cytotoxic rADC levels in subacute stage after bleeding, irreversible damage development seems to be related to poor clinical outcome.
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Hemorragia Cerebral/complicaciones , Hemorragia Cerebral/diagnóstico , Imagen de Difusión por Resonancia Magnética/métodos , Hematoma Subdural Crónico/diagnóstico , Hematoma Subdural Crónico/etiología , Interpretación de Imagen Asistida por Computador/métodos , Enfermedad Aguda , Anciano , Femenino , Humanos , Masculino , Reproducibilidad de los Resultados , Sensibilidad y EspecificidadRESUMEN
Acute ischemic stroke (AIS) in childhood is a relatively rare but significant condition that can result in long-term disabilities. There is a lack of standardized strategies for diagnosing and treating pediatric AIS due to limited evidence-based data on thrombolytic and endovascular treatments in children. This comprehensive literature review focuses on the experience of a single center in Italy and aims to highlight the main peculiarities of endovascular treatment (EVT) for AIS in childhood. The review covers the diagnostic workup, the endovascular procedures, and the need for a specific thrombectomy program for pediatric AIS. The review discusses the indications and considerations for thrombectomy in children, including the risk of complications and the challenges of extrapolating results from adult studies. The diagnostic protocols for pediatric AIS are also discussed, emphasizing the use of MRI to avoid X-ray and contrast medium exposure in children. The combination of intravenous thrombolysis and mechanical thrombectomy has been examined, considering the differences between pediatric and adult thrombi. Technical considerations related to the size of pediatric patients are addressed, including the use of large bore catheters and potential concerns with access points. The organization of a thrombectomy program for pediatric AIS is discussed, emphasizing the need for specialized facilities and expertise. Although evidence for EVT in the pediatric population is based on case series, the importance of specialized centers and the lack of validated guidelines are evident.
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Prehospital field triage often fails to accurately identify the need for emergent surgical or non-surgical procedures, resulting in inefficient resource utilization and increased costs. This study aimed to analyze prehospital factors associated with the need for emergent procedures (such as surgery or interventional angiography) within 6 h of hospital admission. Additionally, our goal was to develop a prehospital triage tool capable of estimating the likelihood of requiring an emergent procedure following hospital admission. We conducted a retrospective observational study, analyzing both prehospital and in-hospital data obtained from the Lombardy Trauma Registry. We conducted a multivariable logistic regression analysis to identify independent predictors of emergency procedures within the first 6 h from admission. Subsequently, we developed and internally validated a triage score composed of factors associated with the probability of requiring an emergency procedure. The study included a total of 3985 patients, among whom 295 (7.4%) required an emergent procedure within 6 h. Age, penetrating injury, downfall, cardiac arrest, poor neurological status, endotracheal intubation, systolic pressure, diastolic pressure, shock index, respiratory rate and tachycardia were identified as predictors of requiring an emergency procedure. A triage score generated from these predictors showed a good predictive power (AUC of the ROC curve: 0.81) to identify patients requiring an emergent surgical or non-surgical procedure within 6 h from hospital admission. The proposed triage score might contribute to predicting the need for immediate resource availability in trauma patients.
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Importance: While the relationship between persistent elevations in intracranial pressure (ICP) and poorer outcomes is well established for patients with traumatic brain injury (TBI), there is no consensus on how ICP measurements should drive treatment choices, and the effectiveness of ICP monitoring remains unknown. Objective: To evaluate the effectiveness of ICP monitoring on short- and mid-term outcomes of patients with TBI. Design, Setting, and Participants: CREACTIVE was a prospective cohort study that started in March 2014 and lasted 5 years. More than 8000 patients with TBI were enrolled at 83 intensive care units (ICUs) from 7 countries who joined the CREACTIVE Consortium. Patients with TBI who met the Brain Trauma Foundation guidelines for ICP monitoring were selected for the current analyses, which were performed from January to November 2022. Exposure: Patients who underwent ICP monitoring within 2 days of injury (exposure group) were propensity score-matched to patients who were not monitored or who underwent monitoring 2 days after the injury (control group). Main Outcome and Measure: Functional disability at 6 months as indicated by Glasgow Outcome Scale-Extended (GOS-E) score. Results: A total of 1448 patients from 43 ICUs in Italy and Hungary were eligible for analysis. Of the patients satisfying the ICP-monitoring guidelines, 503 (34.7%) underwent ICP monitoring (median [IQR] age: 45 years [29-61 years]; 392 males [77.9%], 111 females [22.1%]) and 945 were not monitored (median [IQR] age: 66 years [48-78 years]; 656 males [69.4%], 289 females [30.6%]). After matching to balance the variables, worse 6-month recovery was observed for monitored patients compared with nonmonitored patients (death/vegetative state: 39.2% vs 40.6%; severe disability: 33.2% vs 25.4%; moderate disability: 15.7% vs 14.9%; good recovery: 11.9% vs 19.1%, respectively; P = .005). Monitored patients received medical therapies significantly more frequently. Conclusions and Relevance: In this cohort study, ICP monitoring was associated with poorer recovery and more frequent medical interventions with their relevant adverse effects. Optimizing the value of ICP monitoring for TBI requires further investigation on monitoring indications, clinical interventions, and management protocols.
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Lesiones Traumáticas del Encéfalo , Presión Intracraneal , Masculino , Femenino , Humanos , Persona de Mediana Edad , Anciano , Estudios de Cohortes , Estudios Prospectivos , Enfermedad Crítica/terapia , Lesiones Traumáticas del Encéfalo/complicacionesRESUMEN
BACKGROUND: Organ donation (OD) remains the only therapeutic option for end-stage disease in some cases. Unfortunately, the gap between donors and recipients is still substantial. Trauma patients represent a potential yet underestimated pool of organ donors. In this article, we present our data on OD after damage control strategy (DCS). MATERIALS AND METHODS: A retrospective, observational cohort study was conducted through a complete revision of data of consecutive adult trauma patients (>18 years old) who underwent OD after DCS between January 2018 and May 2021. Four subgroups were created [Liver (Li), Lungs (Lu), Heart (H), Kidneys (K)] to compare variables between those who donated the organ of interest and those who did not. RESULTS: Thirty-six patients underwent OD after DCS. Six patients (16.7%) were excluded: 2(5.6%) for missing data about admission; 4(11.1%) didn't receive DCS. Mean ISS was 47.2 (SD ± 17.4). Number of donated organs was 113 with an organs/patient ratio of 3.8. The functional response rate was 91.2%. Ten organs (8.8%) had primary nonfunction after transplantation: 2/15 hearts (13.3%), 1/28 livers (3.6%), 4/53 kidneys (7.5%) and 3/5 pancreases (60%). No lung primary nonfunction were registered. Complete results of subgroup analysis are reported in supplementary materials. CONCLUSION: Organ donation should be considered a possible outcome in any trauma patient. Aggressive damage control strategy doesn't affect the functional response rate of transplanted organs.
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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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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.