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1.
Crit Care ; 28(1): 314, 2024 Sep 20.
Artículo en Inglés | MEDLINE | ID: mdl-39304944

RESUMEN

AIMS: Cerebral complications after cardiac arrest (CA) remain a major problem worldwide. The aim was to test the effects of sodium-ß-hydroxybutyrate (SBHB) infusion on brain injury in a clinically relevant swine model of CA. RESULTS: CA was electrically induced in 20 adult swine. After 10 min, cardiopulmonary resuscitation was performed for 5 min. After return of spontaneous circulation (ROSC), the animals were randomly assigned to receive an infusion of balanced crystalloid (controls, n = 11) or SBHB (theoretical osmolarity 1189 mOsm/l, n = 8) for 12 h. Multimodal neurological and cardiovascular monitoring were implemented in all animals. Nineteen of the 20 animals achieved ROSC. Blood sodium concentrations, osmolarity and circulating KBs were higher in the treated animals than in the controls. SBHB infusion was associated with significantly lower plasma biomarkers of brain injury at 6 (glial fibrillary acid protein, GFAP and neuron specific enolase, NSE) and 12 h (neurofilament light chain, NFL, GFAP and NSE) compared to controls. The amplitude of the stereoelectroencephalograph (sEEG) increased in treated animals after ROSC compared to controls. Cerebral glucose uptake was lower in treated animals. CONCLUSIONS: In this experimental model, SBHB infusion after resuscitated CA was associated with reduced circulating markers of cerebral injury and increased sEEG amplitude.


Asunto(s)
Biomarcadores , Reanimación Cardiopulmonar , Modelos Animales de Enfermedad , Paro Cardíaco , Animales , Paro Cardíaco/tratamiento farmacológico , Paro Cardíaco/complicaciones , Paro Cardíaco/terapia , Porcinos , Biomarcadores/sangre , Biomarcadores/análisis , Reanimación Cardiopulmonar/métodos , Oxibato de Sodio/farmacología , Oxibato de Sodio/uso terapéutico , Oxibato de Sodio/administración & dosificación , Lesiones Encefálicas/tratamiento farmacológico , Ácido 3-Hidroxibutírico/sangre , Masculino
2.
Neurol Sci ; 45(3): 1135-1144, 2024 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-37828386

RESUMEN

BACKGROUND: Delayed cerebral ischemia (DCI) is a preventable cause of poor neurological outcome in aneurysmal subarachnoid hemorrhage (aSAH). Advances in radiological methods, such as cerebral perfusion computed tomography (CTP), could help diagnose DCI earlier and potentially improve outcomes in aSAH. The objective of this study was to assess whether the use of CTP to diagnose DCI early could reduce the risk of infarction related to DCI. METHODS: Retrospective cohort study of patients in the intensive care unit of Erasme Hospital (Brussels, Belgium) between 2004 and 2021 with aSAH who developed DCI. Patients were classified as: "group 1" - DCI diagnosed based on clinical deterioration or "group 2" - DCI diagnosed using CTP. The primary outcome was the development of infarction unrelated to the initial bleeding or surgery. RESULTS: 211 aSAH patients were diagnosed with DCI during the study period: 139 (66%) in group 1 and 72 (34%) in group 2. In group 1, 109 (78%) patients developed a cerebral infarction, compared to 45 (63%) in group 2 (p = 0.02). The adjusted cumulative incidence of DCI over time was lower in group 2 than in group 1 [hazard ratio 0.65 (95% CI 0.48-0.94); p = 0.02]. The use of CTP to diagnose DCI was not independently associated with mortality or neurological outcome. CONCLUSIONS: The use of CTP to diagnose DCI might help reduce the risk of developing cerebral infarction after aSAH, although the impact of such an approach on patient outcomes needs to be further demonstrated.


Asunto(s)
Isquemia Encefálica , Hemorragia Subaracnoidea , Humanos , Hemorragia Subaracnoidea/complicaciones , Hemorragia Subaracnoidea/diagnóstico por imagen , Estudios Retrospectivos , Tomografía Computarizada por Rayos X/métodos , Infarto Cerebral/etiología , Infarto Cerebral/complicaciones , Isquemia Encefálica/etiología , Isquemia Encefálica/complicaciones , Perfusión/efectos adversos
3.
J Cardiothorac Vasc Anesth ; 38(9): 1996-2001, 2024 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-38942684

RESUMEN

OBJECTIVE: The current work was designed to evaluate whether robotic-assisted mitral valve surgery is associated with a different incidence of early postoperative complications compared with the traditional minimally invasive approach. DESIGN: A retrospective monocentric cohort study was conducted. SETTING: The study was performed in an academic hospital. PARTICIPANTS: A total of 375 patients who underwent standard thoracoscopic minimally invasive mitral valve surgery and robotic-assisted mitral valve surgery between April 2014 and November 2022 were enrolled. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: After adjustment using propensity score analysis, 98 patients from each group were identified. Patients who underwent robotic surgery presented a similar rate of early complications to patients undergoing minimally invasive surgery. Nevertheless, they showed shorter intensive care unit and postoperative hospital stays. Finally, patients undergoing robotic-assisted surgery were more frequently discharged home. CONCLUSIONS: This study identified a similar incidence of early complications in robotic-assisted mitral valve surgery compared with minimally invasive mitral valve surgery; conversely, patients receiving robotic-assisted surgery were discharged earlier, and more frequently discharged home.


Asunto(s)
Procedimientos Quirúrgicos Mínimamente Invasivos , Válvula Mitral , Complicaciones Posoperatorias , Puntaje de Propensión , Procedimientos Quirúrgicos Robotizados , Humanos , Masculino , Estudios Retrospectivos , Femenino , Procedimientos Quirúrgicos Robotizados/efectos adversos , Procedimientos Quirúrgicos Robotizados/métodos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Persona de Mediana Edad , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Procedimientos Quirúrgicos Mínimamente Invasivos/efectos adversos , Válvula Mitral/cirugía , Anciano , Estudios de Cohortes , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Procedimientos Quirúrgicos Cardíacos/métodos , Incidencia
4.
Neurocrit Care ; 40(2): 750-758, 2024 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-37697127

RESUMEN

BACKGROUND: Cerebral hypoxia is a frequent cause of secondary brain damage in patients with acute brain injury. Although hypercapnia can increase intracranial pressure, it may have beneficial effects on tissue oxygenation. We aimed to assess the effects of hypercapnia on brain tissue oxygenation (PbtO2). METHODS: This single-center retrospective study (November 2014 to June 2022) included all patients admitted to the intensive care unit after acute brain injury who required multimodal monitoring, including PbtO2 monitoring, and who underwent induced moderate hypoventilation and hypercapnia according to the decision of the treating physician. Patients with imminent brain death were excluded. Responders to hypercapnia were defined as those with an increase of at least 20% in PbtO2 values when compared to their baseline levels. RESULTS: On a total of 163 eligible patients, we identified 23 (14%) patients who underwent moderate hypoventilation (arterial partial pressure of carbon dioxide [PaCO2] from 44 [42-45] to 50 [49-53] mm Hg; p < 0.001) during the study period at a median of 6 (4-10) days following intensive care unit admission; six patients had traumatic brain injury, and 17 had subarachnoid hemorrhage. A significant overall increase in median PbtO2 values from baseline (21 [19-26] to 24 [22-26] mm Hg; p = 0.02) was observed. Eight (35%) patients were considered as responders, with a median increase of 7 (from 4 to 11) mm Hg of PbtO2, whereas nonresponders showed no changes (from - 1 to 2 mm Hg of PbtO2). Because of the small sample size, no variable independently associated with PbtO2 response was identified. No correlation between changes in PaCO2 and in PbtO2 was observed. CONCLUSIONS: In this study, a heterogeneous response of PbtO2 to induced hypercapnia was observed but without any deleterious elevations of intracranial pressure.


Asunto(s)
Lesiones Traumáticas del Encéfalo , Lesiones Encefálicas , Humanos , Estudios Retrospectivos , Hipercapnia/complicaciones , Hipoventilación/complicaciones , Oxígeno , Encéfalo , Lesiones Encefálicas/terapia , Lesiones Traumáticas del Encéfalo/complicaciones , Lesiones Traumáticas del Encéfalo/terapia , Presión Intracraneal/fisiología
5.
Neurocrit Care ; 40(2): 477-485, 2024 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-37378852

RESUMEN

Traumatic brain injury (TBI) is a significant public health issue because of its increasing incidence and the substantial short-term and long-term burden it imposes. This burden includes high mortality rates, morbidity, and a significant impact on productivity and quality of life for survivors. During the management of TBI, extracranial complications commonly arise during the patient's stay in the intensive care unit. These complications can have an impact on both mortality and the neurological outcome of patients with TBI. Among these extracranial complications, cardiac injury is a relatively frequent occurrence, affecting approximately 25-35% of patients with TBI. The pathophysiology underlying cardiac injury in TBI involves the intricate interplay between the brain and the heart. Acute brain injury triggers a systemic inflammatory response and a surge of catecholamines, leading to the release of neurotransmitters and cytokines. These substances have detrimental effects on the brain and peripheral organs, creating a vicious cycle that exacerbates brain damage and cellular dysfunction. The most common manifestation of cardiac injury in TBI is corrected QT (QTc) prolongation and supraventricular arrhythmias, with a prevalence up to 5 to 10 times higher than in the general adult population. Other forms of cardiac injury, such as regional wall motion alteration, troponin elevation, myocardial stunning, or Takotsubo cardiomyopathy, have also been described. In this context, the use of ß-blockers has shown potential benefits by intervening in this maladaptive process. ß-blockers can limit the pathological effects on cardiac rhythm, blood circulation, and cerebral metabolism. They may also mitigate metabolic acidosis and potentially contribute to improved cerebral perfusion. However, further clinical studies are needed to elucidate the role of new therapeutic strategies in limiting cardiac dysfunction in patients with severe TBI.


Asunto(s)
Lesiones Traumáticas del Encéfalo , Lesiones Encefálicas , Adulto , Humanos , Calidad de Vida , Lesiones Traumáticas del Encéfalo/complicaciones , Lesiones Traumáticas del Encéfalo/terapia , Lesiones Encefálicas/complicaciones , Lesiones Encefálicas/terapia , Encéfalo , Corazón
6.
Neurocrit Care ; 40(2): 633-644, 2024 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-37498454

RESUMEN

BACKGROUND: The aim of this study was to assess the prevalence of delayed deterioration of electroencephalogram (EEG) in patients with cardiac arrest (CA) without early highly malignant patterns and to determine their associations with clinical findings. METHODS: This was a retrospective study of adult patients with CA admitted to the intensive care unit (ICU) of a university hospital. We included all patients with CA who had a normal voltage EEG, no more than 10% discontinuity, and absence of sporadic epileptic discharges, periodic discharges, or electrographic seizures. Delayed deterioration was classified as the following: (1) epileptic deterioration, defined as the appearance, at least 24 h after CA, of sporadic epileptic discharges, periodic discharges, and status epilepticus; or (2) background deterioration, defined as increasing discontinuity or progressive attenuation of the background at least 24 h after CA. The end points were the incidence of EEG deteriorations and their association with clinical features and ICU mortality. RESULTS: We enrolled 188 patients in the analysis. The ICU mortality was 46%. Overall, 30 (16%) patients presented with epileptic deterioration and 9 (5%) patients presented with background deterioration; of those, two patients presented both deteriorations. Patients with epileptic deterioration more frequently had an out-of-hospital CA, and higher time to return of spontaneous circulation and less frequently had bystander resuscitation than others. Patients with background deterioration showed a predominantly noncardiac cause, more frequently developed shock, and had multiple organ failure compared with others. Patients with epileptic deterioration presented with a higher ICU mortality (77% vs. 41%; p < 0.01) than others, whereas all patients with background deterioration died in the ICU. CONCLUSIONS: Delayed EEG deterioration was associated with high mortality rate. Epileptic deterioration was associated with worse characteristics of CA, whereas background deterioration was associated with shock and multiple organ failure.


Asunto(s)
Epilepsia , Paro Cardíaco Extrahospitalario , Choque , Adulto , Humanos , Estudios de Cohortes , Estudios Retrospectivos , Insuficiencia Multiorgánica/complicaciones , Epilepsia/epidemiología , Electroencefalografía , Paro Cardíaco Extrahospitalario/complicaciones
7.
Transfusion ; 63(10): 1809-1820, 2023 10.
Artículo en Inglés | MEDLINE | ID: mdl-37668074

RESUMEN

BACKGROUND: Evidence-based recommendations for transfusion in patients with venoarterial extracorporeal membrane oxygenation (VA ECMO) are scarce. The current literature is limited to single-center studies with small sample sizes, therefore complicating generalizability. This study aims to create an overview of red blood cell (RBC) transfusion in VA ECMO patients. METHODS: This international mixed-method study combined a survey with a retrospective observational study in 16 centers. The survey inventoried local transfusion guidelines. Additionally, retrospective data of all adult patients with a VA ECMO run >24 h (January 2018 until July 2019) was collected of patient, ECMO, outcome, and daily transfusion parameters. All patients that received VA ECMO for primary cardiac support were included, including surgical (i.e., post-cardiotomy) and non-surgical (i.e., myocardial infarction) indications. The primary outcome was the number of RBC transfusions per day and in total. Univariable logistic regressions and a generalized linear mixed model (GLMM) were performed to assess factors associated with RBC transfusion. RESULTS: Out of 419 patients, 374 (89%) received one or more RBC transfusions. During a median ECMO run of 5 days (1st-3rd quartile 3-8), patients received a median total of eight RBC units (1st-3rd quartile 3-17). A lower hemoglobin (Hb) prior to ECMO, longer ECMO-run duration, and hemorrhage were associated with RBC transfusion. After correcting for duration and hemorrhage using a GLMM, a different transfusion trend was found among the regimens. No unadjusted differences were found in overall survival between either transfusion status or the different regimens, which remained after adjustment for potential confounders. CONCLUSION: RBC transfusion in patients on VA ECMO is very common. The sum of RBC transfusions increases rapidly after ECMO initiation, and is dependent on the Hb threshold applied. This study supports the rationale for prospective studies focusing on indications and thresholds for RBC transfusion.


Asunto(s)
Oxigenación por Membrana Extracorpórea , Adulto , Humanos , Oxigenación por Membrana Extracorpórea/métodos , Estudios Retrospectivos , Estudios Prospectivos , Eritrocitos , Hemorragia
8.
Crit Care ; 27(1): 161, 2023 04 22.
Artículo en Inglés | MEDLINE | ID: mdl-37087454

RESUMEN

INTRODUCTION: Prognosis after resuscitation from cardiac arrest (CA) remains poor, with high morbidity and mortality as a result of extensive cardiac and brain injury and lack of effective treatments. Hypertonic sodium lactate (HSL) may be beneficial after CA by buffering severe metabolic acidosis, increasing brain perfusion and cardiac performance, reducing cerebral swelling, and serving as an alternative energetic cellular substrate. The aim of this study was to test the effects of HSL infusion on brain and cardiac injury in an experimental model of CA. METHODS: After a 10-min electrically induced CA followed by 5 min of cardiopulmonary resuscitation maneuvers, adult swine (n = 35) were randomly assigned to receive either balanced crystalloid (controls, n = 11) or HSL infusion started during cardiopulmonary resuscitation (CPR, Intra-arrest, n = 12) or after return of spontaneous circulation (Post-ROSC, n = 11) for the subsequent 12 h. In all animals, extensive multimodal neurological and cardiovascular monitoring was implemented. All animals were treated with targeted temperature management at 34 °C. RESULTS: Thirty-four of the 35 (97.1%) animals achieved ROSC; one animal in the Intra-arrest group died before completing the observation period. Arterial pH, lactate and sodium concentrations, and plasma osmolarity were higher in HSL-treated animals than in controls (p < 0.001), whereas potassium concentrations were lower (p = 0.004). Intra-arrest and Post-ROSC HSL infusion improved hemodynamic status compared to controls, as shown by reduced vasopressor requirements to maintain a mean arterial pressure target > 65 mmHg (p = 0.005 for interaction; p = 0.01 for groups). Moreover, plasma troponin I and glial fibrillary acid protein (GFAP) concentrations were lower in HSL-treated groups at several time-points than in controls. CONCLUSIONS: In this experimental CA model, HSL infusion was associated with reduced vasopressor requirements and decreased plasma concentrations of measured biomarkers of cardiac and cerebral injury.


Asunto(s)
Reanimación Cardiopulmonar , Paro Cardíaco , Lesiones Cardíacas , Animales , Porcinos , Lactato de Sodio/farmacología , Lactato de Sodio/uso terapéutico , Paro Cardíaco/complicaciones , Paro Cardíaco/tratamiento farmacológico , Vasoconstrictores , Encéfalo/metabolismo , Biomarcadores/metabolismo , Modelos Animales de Enfermedad
9.
Crit Care ; 26(1): 35, 2022 02 07.
Artículo en Inglés | MEDLINE | ID: mdl-35130953

RESUMEN

INTRODUCTION: Brain multimodal monitoring including intracranial pressure (ICP) and brain tissue oxygen pressure (PbtO2) is more accurate than ICP alone in detecting cerebral hypoperfusion after traumatic brain injury (TBI). No data are available for the predictive role of a dynamic hyperoxia test in brain-injured patients from diverse etiology. AIM: To examine the accuracy of ICP, PbtO2 and the oxygen ratio (OxR) in detecting regional cerebral hypoperfusion, assessed using perfusion cerebral computed tomography (CTP) in patients with acute brain injury. METHODS: Single-center study including patients with TBI, subarachnoid hemorrhage (SAH) and intracranial hemorrhage (ICH) undergoing cerebral blood flow (CBF) measurements using CTP, concomitantly to ICP and PbtO2 monitoring. Before CTP, FiO2 was increased directly from baseline to 100% for a period of 20 min under stable conditions to test the PbtO2 catheter, as a standard of care. Cerebral monitoring data were recorded and samples were taken, allowing the measurement of arterial oxygen pressure (PaO2) and PbtO2 at FiO2 100% as well as calculation of OxR (= ΔPbtO2/ΔPaO2). Regional CBF (rCBF) was measured using CTP in the tissue area around intracranial monitoring by an independent radiologist, who was blind to the PbtO2 values. The accuracy of different monitoring tools to predict cerebral hypoperfusion (i.e., CBF < 35 mL/100 g × min) was assessed using area under the receiver-operating characteristic curves (AUCs). RESULTS: Eighty-seven CTPs were performed in 53 patients (median age 52 [41-63] years-TBI, n = 17; SAH, n = 29; ICH, n = 7). Cerebral hypoperfusion was observed in 56 (64%) CTPs: ICP, PbtO2 and OxR were significantly different between CTP with and without hypoperfusion. Also, rCBF was correlated with ICP (r = - 0.27; p = 0.01), PbtO2 (r = 0.36; p < 0.01) and OxR (r = 0.57; p < 0.01). Compared with ICP alone (AUC = 0.65 [95% CI, 0.53-0.76]), monitoring ICP + PbO2 (AUC = 0.78 [0.68-0.87]) or ICP + PbtO2 + OxR (AUC = 0.80 (0.70-0.91) was significantly more accurate in predicting cerebral hypoperfusion. The accuracy was not significantly different among different etiologies of brain injury. CONCLUSIONS: The combination of ICP and PbtO2 monitoring provides a better detection of cerebral hypoperfusion than ICP alone in patients with acute brain injury. The use of dynamic hyperoxia test could not significantly increase the diagnostic accuracy.


Asunto(s)
Lesiones Traumáticas del Encéfalo , Hiperoxia , Encéfalo/diagnóstico por imagen , Lesiones Traumáticas del Encéfalo/diagnóstico por imagen , Circulación Cerebrovascular , Humanos , Presión Intracraneal , Persona de Mediana Edad , Oxígeno
10.
Neurocrit Care ; 37(2): 547-557, 2022 10.
Artículo en Inglés | MEDLINE | ID: mdl-35641804

RESUMEN

BACKGROUND: Cerebral ischemia due to hypoxia is a major cause of secondary brain injury and is associated with higher morbidity and mortality in patients with acute brain injury. Hyperoxia could improve energetic dysfunction in the brain in this setting. Our objectives were to perform a systematic review and meta-analysis of the current literature and to assess the impact of normobaric hyperoxia on brain metabolism by using cerebral microdialysis. METHODS: We searched Medline and Scopus, following the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement; we searched for retrospective and prospective observational studies, interventional studies, and randomized clinical trials that performed a hyperoxia challenge in patients with acute brain injury who were concomitantly monitored with cerebral microdialysis. This study was registered in PROSPERO (CRD420211295223). RESULTS: We included a total of 17 studies, with a total of 311 patients. A statistically significant reduction in cerebral lactate values (pooled standardized mean difference [SMD] - 0.38 [- 0.53 to - 0.23]) and lactate to pyruvate ratio values (pooled SMD - 0.20 [- 0.35 to - 0.05]) was observed after hyperoxia. However, glucose levels (pooled SMD - 0.08 [- 0.23 to 0.08]) remained unchanged after hyperoxia. CONCLUSIONS: Normobaric hyperoxia may improve cerebral metabolic disturbances in patients with acute brain injury. The clinical impact of such effects needs to be further elucidated.


Asunto(s)
Lesiones Encefálicas , Hiperoxia , Lesiones Encefálicas/complicaciones , Glucosa , Humanos , Ácido Láctico/metabolismo , Microdiálisis , Estudios Observacionales como Asunto , Ácido Pirúvico/metabolismo , Estudios Retrospectivos
11.
BMC Neurol ; 21(1): 196, 2021 May 13.
Artículo en Inglés | MEDLINE | ID: mdl-33985460

RESUMEN

BACKGROUND: Neurological outcome and mortality of patients suffering from poor grade subarachnoid hemorrhage (SAH) may have changed over time. Several factors, including patients' characteristics, the presence of hydrocephalus and intraparenchymal hematoma, might also contribute to this effect. The aim of this study was to assess the temporal changes in mortality and neurologic outcome in SAH patients and identify their predictors. METHODS: We performed a single center retrospective cohort study from 2004 to 2018. All non-traumatic SAH patients with poor grade on admission (WFNS score of 4 or 5) who remained at least 24 h in the hospital were included. Time course was analyzed into four groups according to the years of admission (2004-2007; 2008-2011; 2012-2015 and 2016-2018). RESULTS: A total of 353 patients were included in this study: 202 patients died (57 %) and 260 (74 %) had unfavorable neurological outcome (UO) at 3 months. Mortality tended to decrease in in 2008-2011 and 2016-2018 periods (HR 0.55 [0.34-0.89] and HR 0.33 [0.20-0.53], respectively, when compared to 2004-2007). The proportion of patients with UO remained high and did not vary significantly over time. Patients with WFNS 5 had higher mortality (68 % vs. 34 %, p = 0.001) and more frequent UO (83 % vs. 54 %, p = 0.001) than those with WFNS 4. In the multivariable analysis, WFNS 5 was independently associated with mortality (HR 2.12 [1.43-3.14]) and UO (OR 3.23 [1.67-6.25]). The presence of hydrocephalus was associated with a lower risk of mortality (HR 0.60 [0.43-0.84]). CONCLUSIONS: Both hospital mortality and UO remained high in poor grade SAH patients. Patients with WFNS 5 on admission had worse prognosis than others; this should be taken into consideration for future clinical studies.


Asunto(s)
Hematoma/patología , Mortalidad Hospitalaria , Hemorragia Subaracnoidea/patología , Adulto , Anciano , Estudios de Cohortes , Femenino , Humanos , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Hemorragia Subaracnoidea/mortalidad , Resultado del Tratamiento
12.
Crit Care Med ; 48(11): e1087-e1090, 2020 11.
Artículo en Inglés | MEDLINE | ID: mdl-32769623

RESUMEN

OBJECTIVES: To assess the role of thromboprophylaxis regimens on the occurrence of pulmonary embolism in coronavirus disease 2019 patients. DESIGN: Retrospective analysis of prospectively collected data on coronavirus disease 2019 patients, included between March 10, and April 30, 2020. SETTING: ICU of an University Hospital in Belgium. PATIENTS AND INTERVENTIONS: Critically ill adult mechanically ventilated coronavirus disease 2019 patients were eligible if they underwent a CT pulmonary angiography, as part of the routine management in case of persistent hypoxemia or respiratory deterioration. The primary endpoint of this study was the occurrence of pulmonary embolism according to the use of standard thromboprophylaxis (i.e. subcutaneous enoxaparin 4,000 international units once daily) or high regimen thromboprophylaxis (i.e. subcutaneous enoxaparin 4,000 international units bid or therapeutic unfractioned heparin). MEASUREMENTS AND MAIN RESULTS: Of 49 mechanically ventilated coronavirus disease 2019, 40 underwent CT pulmonary angiography after a median of 7 days (4-8 d) since ICU admission and 12 days (9-16 d) days since the onset of symptoms. Thirteen patients (33%) were diagnosed of pulmonary embolism, which was bilateral in six patients and localized in the right lung in seven patients. D-dimers on the day of CT pulmonary angiography had a predictive accuracy of 0.90 (95% CIs: 0.78-1.00) for pulmonary embolism. The use of high-regimen thromboprophylaxis was associated with a lower occurrence of pulmonary embolism (2/18; 11%) than standard regimen (11/22, 50%-odds ratio 0.13 [0.02-0.69]; p = 0.02); this difference remained significant even after adjustment for confounders. Six patients with pulmonary embolism (46%) and 14 patients without pulmonary embolism (52%) died at ICU discharge (odds ratio 0.79 [0.24-3.26]; p = 0.99). CONCLUSIONS: In this study, one third of coronavirus disease 2019 mechanically ventilated patients have a pulmonary embolism visible on CT pulmonary angiography. High regimen thromboprophylaxis may decrease the occurrence of such complication.


Asunto(s)
Anticoagulantes/uso terapéutico , Infecciones por Coronavirus/tratamiento farmacológico , Enfermedad Crítica/terapia , Neumonía Viral/tratamiento farmacológico , Embolia Pulmonar/prevención & control , Trombosis de la Vena/prevención & control , Adulto , Betacoronavirus , COVID-19 , Infecciones por Coronavirus/complicaciones , Femenino , Humanos , Unidades de Cuidados Intensivos , Masculino , Persona de Mediana Edad , Pandemias , Neumonía Viral/complicaciones , Embolia Pulmonar/etiología , Estudios Retrospectivos , SARS-CoV-2 , Resultado del Tratamiento , Trombosis de la Vena/etiología
13.
Crit Care ; 24(1): 629, 2020 10 30.
Artículo en Inglés | MEDLINE | ID: mdl-33126887

RESUMEN

BACKGROUND: Neurologic injury is one of the most frequent causes of death in patients undergoing extracorporeal membrane oxygenation (ECMO). As neurological examination is often unreliable in sedated patients, additional neuromonitoring is needed. However, the value of electroencephalogram (EEG) in adult ECMO patients has not been well assessed. Therefore, the aim of this study was to assess the occurrence of electroencephalographic abnormalities in patients treated with extracorporeal membrane oxygenation (ECMO) and their association with 3-month neurologic outcome. METHODS: Retrospective analysis of all patients undergoing venous-venous (V-V) or venous-arterial (V-A) ECMO with a concomitant EEG recording (April 2009-December 2018), either recorded intermittently or continuously. EEG background was classified into four categories: mild/moderate encephalopathy (i.e., mostly defined by the presence of reactivity), severe encephalopathy (mostly defined by the absence of reactivity), burst-suppression (BS) and suppressed background. Epileptiform activity (i.e., ictal EEG pattern, sporadic epileptiform discharges or periodic discharges) and asymmetry were also reported. EEG findings were analyzed according to unfavorable neurological outcome (UO, defined as Glasgow Outcome Scale < 4) at 3 months after discharge. RESULTS: A total of 139 patients (54 [41-62] years; 60 (43%) male gender) out of 596 met the inclusion criteria and were analyzed. Veno-arterial (V-A) ECMO was used in 98 (71%); UO occurred in 99 (71%) patients. Continuous EEG was performed in 113 (81%) patients. The analysis of EEG background showed that 29 (21%) patients had severe encephalopathy, 4 (3%) had BS and 19 (14%) a suppressed background. In addition, 11 (8%) of patients had seizures or status epilepticus, 10 (7%) had generalized periodic discharges or lateralized periodic discharges, and 27 (19%) had asymmetry on EEG. In the multivariate analysis, the occurrence of ischemic stroke or intracranial hemorrhage (OR 4.57 [1.25-16.74]; p = 0.02) and a suppressed background (OR 10.08 [1.24-82.20]; p = 0.03) were independently associated with UO. After an adjustment for covariates, an increasing probability for UO was observed with more severe EEG background categories. CONCLUSIONS: In adult patients treated with ECMO, EEG can identify patients with a high likelihood of poor outcome. In particular, suppressed background was independently associated with unfavorable neurological outcome.


Asunto(s)
Electroencefalografía/estadística & datos numéricos , Oxigenación por Membrana Extracorpórea/instrumentación , Adulto , Bélgica , Electroencefalografía/métodos , Oxigenación por Membrana Extracorpórea/métodos , Oxigenación por Membrana Extracorpórea/estadística & datos numéricos , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Estadísticas no Paramétricas
14.
Crit Care ; 24(1): 495, 2020 08 12.
Artículo en Inglés | MEDLINE | ID: mdl-32787909

RESUMEN

BACKGROUND: Post-mortem studies can provide important information for understanding new diseases and small autopsy case series have already reported different findings in COVID-19 patients. METHODS: We evaluated whether some specific post-mortem features are observed in these patients and if these changes are related to the presence of the virus in different organs. Complete macroscopic and microscopic autopsies were performed on different organs in 17 COVID-19 non-survivors. Presence of SARS-CoV-2 was evaluated with immunohistochemistry (IHC) in lung samples and with real-time reverse-transcription polymerase chain reaction (RT-PCR) test in the lung and other organs. RESULTS: Pulmonary findings revealed early-stage diffuse alveolar damage (DAD) in 15 out of 17 patients and microthrombi in small lung arteries in 11 patients. Late-stage DAD, atypical pneumocytes, and/or acute pneumonia were also observed. Four lung infarcts, two acute myocardial infarctions, and one ischemic enteritis were observed. There was no evidence of myocarditis, hepatitis, or encephalitis. Kidney evaluation revealed the presence of hemosiderin in tubules or pigmented casts in most patients. Spongiosis and vascular congestion were the most frequently encountered brain lesions. No specific SARS-CoV-2 lesions were observed in any organ. IHC revealed positive cells with a heterogeneous distribution in the lungs of 11 of the 17 (65%) patients; RT-PCR yielded a wide distribution of SARS-CoV-2 in different tissues, with 8 patients showing viral presence in all tested organs (i.e., lung, heart, spleen, liver, colon, kidney, and brain). CONCLUSIONS: In conclusion, autopsies revealed a great heterogeneity of COVID-19-associated organ injury and the remarkable absence of any specific viral lesions, even when RT-PCR identified the presence of the virus in many organs.


Asunto(s)
Betacoronavirus/aislamiento & purificación , Infecciones por Coronavirus/virología , Neumonía Viral/virología , Anciano , Autopsia , Encéfalo/virología , COVID-19 , Colon/virología , Infecciones por Coronavirus/terapia , Femenino , Corazón/virología , Humanos , Riñón/virología , Hígado/virología , Pulmón/virología , Masculino , Persona de Mediana Edad , Pandemias , Neumonía Viral/terapia , Reacción en Cadena de la Polimerasa de Transcriptasa Inversa , SARS-CoV-2 , Bazo/virología
15.
Crit Care ; 23(1): 27, 2019 Jan 28.
Artículo en Inglés | MEDLINE | ID: mdl-30691512

RESUMEN

BACKGROUND: The potential benefit of extracorporeal cardiopulmonary resuscitation (ECPR) compared to conventional CPR (CCPR) for patients with refractory cardiac arrest (CA) remains unclear. METHODS: This study is a retrospective analysis of a prospective database of CA patients, which includes all consecutive adult patients admitted to the Department of Intensive Care after CA between January 2012 and December 2017. The decision to initiate ECPR was made by the attending physician and ECPR performed by the ECPR team, which is composed of ICU physicians. A propensity score was derived using a logistic regression model, including characteristics that varied between groups with a p <  0.10 and were potentially related to outcome. Primary outcomes were survival to ICU discharge and favorable 3-month neurologic outcome, assessed by a Cerebral Performance Category (CPC) score of 1-2. RESULTS: From a total of 635 patients with CA during the study period (ECPR, n = 112), 80 ECPR patients were matched to 80 CCPR patients. The time from arrest to termination of CPR (i.e., return of spontaneous circulation [ROSC], extracorporeal membrane oxygenation [ECMO] initiation, or death) was 54 ± 22 and 54 ± 19 min in the ECPR and CCPR groups, respectively. ROSC rates were 77/80 (96%) for ECPR and 30/80 (38%) for CCPR (p <  0.001). Survival to ICU discharge was 18/80 (23%) vs. 14/80 (18%) in the ECPR and CCPR groups, respectively (p = 0.42). At 3 months, 17/80 (21%) ECPR patients and 9/80 (11%) CCPR patients had a favorable outcome (p = 0.11). Cox regression analysis stratified by matched pairs showed a significantly higher neurologic outcome rate in the ECPR group than in the CCPR group (log-rank test p = 0.003). CONCLUSIONS: ECPR after CA may be associated with improved long-term neurological outcome.


Asunto(s)
Reanimación Cardiopulmonar/normas , Oxigenación por Membrana Extracorpórea/normas , Adulto , Anciano , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Paro Cardíaco Extrahospitalario/terapia , Puntaje de Propensión , Estudios Prospectivos , Estudios Retrospectivos , Factores de Tiempo , Resultado del Tratamiento
17.
Minerva Anestesiol ; 90(10): 892-900, 2024 10.
Artículo en Inglés | MEDLINE | ID: mdl-39381870

RESUMEN

BACKGROUND: Neurological complications have been observed in approximately 30% of hospitalized COVID-19 patients. The aim of this study was to evaluate whether early assessment of the Neurological Pupil Index (NPiTM) derived from an automated pupillometry could predict mortality in critically ill COVID-19 patients. METHODS: Retrospective cohort study of adult critically ill COVID-19 patients admitted to the intensive care unit of a University Hospital; patients without NPi measurement were excluded. The worst NPi (i.e. lowest value from one eye) was collected daily and then computed over the first five days of assessment. Mortality was assessed at hospital discharge. The secondary endpoint involved assessing differences in neurological assessments between patients who developed neurological complications and those who did not. RESULTS: A total of 217 patients were included over the study period (median age 61 [50-68] years), 70% were males. A total of 97 patients (45%) died during the hospital stay. Among all patients, 35 (16%) experienced neurological complications. Non-survivors showed significantly a lower overall NPi (3.0 [2.0-4.1] vs. 3.4 [2.7-4.2]; P=0.04) than survivors. At multivariate logistic regression NPi was not significantly associated with in-hospital mortality. Moreover, no differences in different NPi measurements were observed between patients with and without neurological complications. CONCLUSIONS: In this study, NPi values were not independent predictor of mortality and neurological complications in critically ill COVID-19 patients.


Asunto(s)
COVID-19 , Enfermedades del Sistema Nervioso , Humanos , Masculino , COVID-19/mortalidad , COVID-19/complicaciones , Estudios Retrospectivos , Femenino , Persona de Mediana Edad , Anciano , Pronóstico , Enfermedades del Sistema Nervioso/etiología , Enfermedad Crítica , Estudios de Cohortes , Mortalidad Hospitalaria , Examen Neurológico
18.
Curr Med Res Opin ; 40(7): 1155-1162, 2024 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-38773739

RESUMEN

Hepatorenal Syndrome is a critical complication of liver failure, mainly in cirrhotic patients and rarely in patients with acute liver disease. It is a complex spectrum of conditions that leads to renal dysfunction in the liver cirrhosis population; the pathophysiology is characterized by a specific triad: circulatory dysfunction, nitric oxide (NO) dysfunction and systemic inflammation but a specific kidney damage has never been demonstrated, in a clinicopathological study, kidney biopsies of patients with cirrhosis showed a wide spectrum of kidney damage. In addition, the absence of significant hematuria or proteinuria does not exclude renal damage. It is estimated that 40% of cirrhotic patients will develop hepatorenal syndrome with in-hospital mortality of about one-third of these patients. The burden of the problem is dramatic considering the worldwide prevalence of more than 10 million decompensated cirrhotic patients, and the age-standardized prevalence rate of decompensated cirrhosis has gone through a significant rise between 1990 and 2017. Given the syndrome's poor prognosis, the clinician must know how to manage early treatment and any complications. The widespread adoption of albumin and vasopressors has increased Hepatorenal syndrome-acute kidney injury reversal and may increase overall survival, as previously shown. Further research is needed to define whether the subclassification of patients may allow to find a personalized strategy to treat Hepatorenal Syndrome and to define the role of new molecules and extracorporeal treatment may allow better outcomes with a reduction in treatment-related adverse effects. This review aims to examine both pharmacological and non-pharmacological treatment of hepatorenal syndrome, with a particular focus on managing adverse events caused by treatment.


Asunto(s)
Síndrome Hepatorrenal , Síndrome Hepatorrenal/terapia , Síndrome Hepatorrenal/etiología , Síndrome Hepatorrenal/epidemiología , Síndrome Hepatorrenal/diagnóstico , Humanos , Cirrosis Hepática/complicaciones , Cirrosis Hepática/epidemiología , Cirrosis Hepática/terapia , Vasoconstrictores/uso terapéutico , Vasoconstrictores/efectos adversos
19.
J Clin Med ; 13(19)2024 Sep 26.
Artículo en Inglés | MEDLINE | ID: mdl-39407797

RESUMEN

Background/Objectives: Elevated RDW has emerged in cardiac surgery as a potential means of preoperative risk stratification with the capacity to predict short- and long-term postoperative mortality, acute kidney injury, and postoperative atrial fibrillation. The question as to whether perioperative hemodynamic instability may be predicted by such a marker remains a topic of ongoing debate. The aim of this study was to explore the relationship between preoperative RDW and prolonged postoperative catecholamine use in minimally invasive mitral valve surgery. Methods: We performed a retrospective monocentric cohort study in an academic hospital; we enrolled patients who had undergone minimally invasive mitral valve surgery (including both robot-assisted and non-robot-assisted procedures) between January 2019 and December 2022. We considered the use of inotropes and/or vasopressors for at least twelve hours after post-surgery ICU admission to qualify as the prolonged postoperative use of catecholamines (PPUC). The RDW was obtained from the routine full blood count analysis performed upon admission or a maximum of 72 h before surgery. We also performed a multivariable logistic regression analysis with PPUC as the dependent variable. Results: We finally enrolled 343 patients. Upon multivariate analysis, RDW >14.4% was independently associated with prolonged postoperative catecholamine use when compared to the reference group (OR 2.62 [1.06-4.84]; p = 0.03). Moreover, the EuroSCORE II score (OR 1.38 [1.03-1.85]; p = 0.03), the cross-clamp time (OR 1.01 [1.01-1.02]; p < 0.01), and robot-assisted mitral valve surgery (OR 0.53 [0.30-0.93]; p < 0.03) were independently associated with the prolonged postoperative use of catecholamines. Conclusions: This study identified that an elevated preoperative RDW (>14.4%), the EuroSCORE II score, and the cross-clamp time independently predict prolonged postoperative catecholamine use in minimally invasive mitral valve surgery patients. Conversely, the robot-assisted approach was associated with a smaller hemodynamic impairment.

20.
Life (Basel) ; 14(3)2024 Mar 18.
Artículo en Inglés | MEDLINE | ID: mdl-38541727

RESUMEN

We investigated independent factors predicting neurological outcome and death, comparing in-hospital (IHCA) and out-of-hospital cardiac arrest (OHCA) patients. The study was conducted in the mixed 34-bed Intensive Care Department at the Hôpital Universitaire de Bruxelles (HUB), Belgium. All adult consecutive cardiac arrest (CA) survivors were included between 2004 and 2022. For all patients, demographic data, medical comorbidities, CA baseline characteristics, treatments received during Intensive Care Unit stay, in-hospital major complications, and neurological outcome at three months after CA, using the Cerebral Performance Category (CPC) scale, were collected. In the multivariable analysis, in the IHCA group (n = 540), time to return of spontaneous circulation (ROSC), older age, unwitnessed CA, higher lactate on admission, asystole as initial rhythm, a non-cardiac cause of CA, the occurrence of shock, the occurrence of acute kidney injury (AKI), and the presence of previous neurological disease and of liver cirrhosis were independent predictors of an unfavorable neurological outcome. Among patients with OHCA (n = 567), time to ROSC, older age, higher lactate level on admission, unwitnessed CA, asystole or pulseless electrical activity (PEA) as initial rhythm, the occurrence of shock, a non-cardiac cause of CA, and a previous neurological disease were independent predictors of an unfavorable neurological outcome. To conclude, in our large cohort of mixed IHCA and OHCA patients, we observed numerous factors independently associated with a poor neurological outcome, with minimal differences between the two groups, reflecting the greater vulnerability of hospitalized patients.

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