Risk factors for 1-year mortality in patients with nontraumatic intracranial hemorrhage requiring intensive care.

BACKGROUND: Mortality in patients with intracranial hemorrhage remains high. The aim of this study was to determine the 1-year survival and potential risk factors for 1-year mortality in patients with nontraumatic intracranial hemorrhage requiring intensive care. METHODS: This was a 3-year (2005-2007) retrospective study in a university-level intensive care unit (ICU). Patient characteristics, level of consciousness, and radiological findings of the primary head computed tomography were recorded on admission. Sequential Organ Failure Assessment scores were recorded during the ICU stay. Patients were divided into two groups: subarachnoid hemorrhage (SAH) group and intracerebral hemorrhage (ICH) group. Kaplan-Meier survival curves were constructed, and independent risk factors were determined using Cox proportional hazards regression analyses. RESULTS: Two hundred twenty-nine patients were analyzed. The 1-year mortality rate was 32% in patients with SAH and 44% in patients with ICH. The risk factors for 1-year mortality in both groups were unconsciousness on admission [SAH: hazard ratio (HR) 6.2, P = 0.017 and ICH: HR 3.0, P = 0.004] and renal failure during the ICU stay (SAH: HR 2.5, P = 0.021 and ICH: HR 3.6, P = 0.021). Risk factors specific to the type of hemorrhage were the presence of ICH (HR 2.0, P = 0.033) and diffuse cerebral edema (HR 2.3, P = 0.017) in the SAH group and a prior use of warfarin (HR 5.1, P = 0.016) in the ICH group. CONCLUSIONS: In addition to decreased level of consciousness on admission, renal failure during the ICU stay is an independent risk factor for 1-year mortality in nontraumatic SAH as well as ICH.

Uncalibrated arterial pressure waveform analysis for cardiac output monitoring is biased by low peripheral resistance in patients with intracranial haemorrhage.

BACKGROUND: Cardiac output (CO) monitoring by uncalibrated arterial pressure waveform analysis (APCO) using the FloTrac/Vigileo™ is feasible in patients with intracranial haemorrhage, but the results of validation studies are contradictory. The aim of the present study was to analyse the clinical agreement between the intermittent bolus thermodilution technique (TDCO) and APCO in patients with non-traumatic intracranial haemorrhage. METHODS: This was a prospective observational clinical study in a university level intensive care unit. We studied patients who underwent CO monitoring according to clinical indications using TDCO. Simultaneously, APCO was applied using the radial arterial pressure curve. The difference in CO values measured by APCO with a mid-chest calibration level was compared with a calibration level at the angle of the eye. RESULTS: A total of 407 data pairs from 16 patients were obtained. The mean CO(TDCO) was 7.6 litre min(-1) and CO(APCO) was 6.0 litre min(-1), with a bias corrected for repeated measures of 1.5 litre min(-1) and 95% limits of agreement of -2.4 to 5.4 litre min(-1). The percentage error was 58%. The increasing bias correlated with low peripheral resistance (ρ=-0.53, P=0.036). The calibration level at the patient's eye angle did not affect CO values (median bias 0 litre min(-1) with 25th-75th percentile -0.1 to 0.2 litre min(-1)). CONCLUSIONS: The second generation of FloTrac(®)/Vigileo(®) monitoring system underestimates the TDCO in patients with non-traumatic intracranial haemorrhage. The bias correlates with measured systemic vascular resistance. The upper calibration level does not affect the results.

A comparison of paracervical block with single-shot spinal for labour analgesia in multiparous women: a randomised controlled trial.

BACKGROUND: Epidural and spinal analgesia may be contraindicated or unavailable in labour. This randomised controlled study examined the suitability of paracervical block as an alternative method of labour analgesia. METHODS: Multiparous women in labour were randomised to receive either paracervical block or single-shot spinal analgesia. Pain was quantified using a numerical rating scale. Subsequent analgesia, progress of labour, and mode of delivery were noted. Fetal heart rate patterns were reviewed. Apgar scores and umbilical artery pH measurements were collected. Parturients' satisfaction and willingness to have the same method of labour analgesia again were recorded. RESULTS: 122 parturients were randomised with data available on 104. Median pain scores decreased significantly in both groups; this was greater with single-shot spinal analgesia (difference between means 2.7; 95% CI 1.9-3.5; P(g)<0.001). Parturients receiving paracervical block received subsequent analgesia more often (23/56 vs. 3/48, P<0.001). Progress of labour, instrumental delivery rates, detected abnormal decelerations in cardiotocography and neonatal outcome were similar between groups. Shivering (P<0.04) and pruritus (P<0.001) were more common with single-shot spinal analgesia. Parturients in the paracervical block group were less satisfied (median 7.0, IQR 3.0-8.0 vs. median 9.0, IQR 8.0-10.0; P<0.001) and less willing (28/55 vs. 39/48, P=0.002) to have the same labour analgesia again. CONCLUSIONS: Paracervical block was less effective than single-shot spinal analgesia. Both methods were associated with a low incidence of fetal bradycardia but maternal side effects were more common with single-shot spinal analgesia.