Quantitative Assessment of Electroencephalogram Reactivity in Comatose Patients on Extracorporeal Membrane Oxygenation.

Objective assessment of the brain's responsiveness in comatose patients on Extracorporeal Membrane Oxygenation (ECMO) support is essential to clinical care, but current approaches are limited by subjective methodology and inter-rater disagreement. Quantitative electroencephalogram (EEG) algorithms could potentially assist clinicians, improving diagnostic accuracy. We developed a quantitative, stimulus-based algorithm to assess EEG reactivity features in comatose patients on ECMO support. Patients underwent a stimulation protocol of increasing intensity (auditory, peripheral, and nostril stimulation). A total of 129 20-s EEG epochs were collected from 24 patients (age [Formula: see text], 10 females, 14 males) on ECMO support with a Glasgow Coma Scale[Formula: see text]8. EEG reactivity scores ([Formula: see text]-scores) were calculated using aggregated spectral power and permutation entropy for each of five frequency bands ([Formula: see text], [Formula: see text], [Formula: see text], [Formula: see text], [Formula: see text]. Parameter estimation techniques were applied to [Formula: see text]-scores to identify properties that replicate the decision process of experienced clinicians performing visual analysis. Spectral power changes from audio stimulation were concentrated in the [Formula: see text] band, whereas peripheral stimulation elicited an increase in spectral power across multiple bands, and nostril stimulation changed the entropy of the [Formula: see text] band. The findings of this pilot study on [Formula: see text]-score lay a foundation for a future prediction tool with clinical applications.

Serious adverse events and deaths linked to poor ventilator use: A report of four closed claims.

Through this series of four closed claims, we highlight examples of accidents stemming from poor ventilator use. We then review the main issues in this regard as reported in the literature and by learned societies. This case series has led us to emphasise the need for safety procedures involving systematic checks prior to use, declaration and analysis of the risk, as well as feedback and teaching regarding ventilation systems.

Effect of target temperature management at 32-34 °C in cardiac arrest patients considering assessment by regional cerebral oxygen saturation: A multicenter retrospective cohort study.

AIM: Target temperature management (TTM) is used in comatose post-cardiac arrest patients, but the recommended temperature range is wide. This study aimed to assess the effectiveness of TTM at 32-34 °C while considering the degree of cerebral injury and cerebral circulation, as assessed by regional cerebral oxygen saturation (rSO2). METHODS: This is a secondary analysis of prospectively collected registry data from comatose patients who were transferred to 15 hospitals in Japan after out-of-hospital cardiac arrest (OHCA) from 2011 to 2013. The primary outcome was all-cause mortality at 90 days after OHCA, and the secondary outcome was favorable neurological outcomes as evaluated according to the Cerebral Performance Category. We monitored rSO2 noninvasively with near-infrared spectroscopy, which could assess cerebral perfusion and the balance of oxygen delivery and uptake. RESULTS: We stratified 431 study patients into three groups according to rSO2 on hospital arrival: rSO2 ≤40% (n = 296), rSO2 41-60% (n = 67), and rSO2 ≥61% (n = 68). Propensity score analysis revealed that TTM at 32-34 °C decreased all-cause mortality in patients with rSO2 41-60% (average treatment effect on treated [ATT] by propensity score matching [PSM] -0.51, 95%CI -0.70 to -0.33; ATT by inverse probability of treatment weighting [IPW] -0.52, 95%CI -0.71 to -0.34), and increased favorable neurological outcomes in patients with rSO2 41-60% (ATT by PSM 0.50, 95%CI 0.32-0.68; ATT by IPW 0.52, 95%CI 0.35-0.69). CONCLUSION: TTM at 32-34 °C effectively decreased all-cause mortality in comatose OHCA patients with rSO2 41-60% on hospital arrival in Japan.

Application of ERPs neuromarkers for assessment and treatment of a patient with chronic crossed aphasia after severe TBI and long-term coma - Case Report.

 Objective. The study aimed to evaluate the application of ERPs neuromarkers for the assessment and treatment of a patient with chronic crossed aphasia after severe TBI and a long-term coma. CASE REPORT: An ambidextrous female patient, aged 29, suffered from posttraumatic chronic crossed aphasia, severe TBI and a prolonged coma after a car accident. The patient took part in two differentiated rehabilitation programmes of neurotherapy included 20 sessions of relative beta training and 20 sessions of rTMS; both programmes were combined with behavioural training. The patient was tested 3 times: before the experiment, after completion of programme A, and after completion of programme B. RESULTS: In the 1st recording, the neuromarker of aphasia was found - an excess of the P2 wave over the left temporal area. There was a cognitive control deficit - an excess of omission errors and an increase of RT variability - all indexes of sporadic ADHD. In the 2nd recording, slight improvements in cognitive control, and language functions were found. In the 3rd recording, after the rTMS sessions most of her cognitive dysfunctions had been resolved, including language functions. It should be stressed that the activation (especially the increase in the ERP potential of the right side over the frontal lobe) was found. The neuromarker of aphasia did not change, only the location had slightly moved frontally. CONCLUSIONS: The application of ERP neuromarkers assists in the diagnosis, treatment, and academic success of an ambidextrous patient with chronic posttraumatic aphasia and sporadic ADHD. ERPs can be used to assess the functional brain changes induced by neurotherapeutical programmes.

[Prognostic assessment as the basis for limiting therapy in unconscious patients after cardiopulmonary resuscitation]. / Prognostische Einschätzung als Grundlage für die Therapiebegrenzung bewusstloser Patienten nach kardiopulmonaler Reanimation.

BACKGROUND: The prognosis of patients who have been resuscitated after cardiac arrest is still unfavourable and long-term results have only slightly improved. As a consequence, intensivists are frequently confronted with the question of limiting active therapeutic efforts for patients in prolonged coma. The history of the patient and circumstances of the resuscitation are of limited value with regard to reliable decisions. THERAPEUTIC DECISION-MAKING: Clinical and electrophysiological neurologic techniques as well as biomarkers and diagnostic imaging are, therefore, the basis for prognostication and potential consecutive therapeutic decisions. Sedation, relaxation and particularly therapeutic hypothermia have great influence on the test results. These influences have to be excluded before results can be validated. With regard to therapeutic hypothermia a reliable neurologic evaluation as a basis for limiting treatment is only possible after rewarming. Moreover results of multiple tests should be in agreement before a decision to limit treatment can be made. Finally it must be kept in mind that the absence of unfavourable test results is not proof of a good prognosis. CONCLUSION: The decision to limit treatment can not be made on the basis of a single adverse prognostic sign, but requires a comprehensive clinical diagnostic assessment.

Medicine versus religion in the surgical intensive care unit: who is in charge?

The chief of surgery at a large academic medical center is approached by a vascular surgical faculty member. After a repair of an aortic dissection, an elderly man has remained comatose and has worsened over several weeks, developing multiple system organ failure. Statistically, his chance of leaving the hospital alive is <1%. The family is deeply religious, and the minister and various elders, deacons, and members of their church have been vigilant in constant prayerful attendance. The attending's tactful suggestions that the time is coming when nature should be allowed to take its course was not well received. The family and their support group are convinced that their fervor will summon a miracle. A large group complained to patient affairs and was taken to the medical center director's office. Today, the director told the attending that the hospital would absorb the overall cost until the patient dies and that the unfavorable press from stopping care is unacceptable. The chief of surgery should:

The incidence of delirium in Norwegian intensive care units; deep sedation makes assessment difficult.

BACKGROUND: Delirium in critically ill patients is associated with increased length of hospital stay, mortality and costs, and may lead to long-term cognitive impairment. It is often overlooked by clinicians if structured observation is not performed routinely. A national Norwegian survey reported that systematic screening and assessment of delirium were never or seldom performed. The purpose of this study was to test the usefulness of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and to describe the incidence of delirium in critically ill patients at two Norwegian hospitals. METHODS: We conducted a two-site, prospective, descriptive study including patients between 18 and 80 years, intubated or mask ventilated at admission, with an ICU stay > 48 h. The CAM-ICU was scored three times daily. In addition, illness severity, sedation level, pain assessment, drug use and other treatment factors were systematically assessed. RESULTS: Total ICU stays of 139 patients were studied and covered 958 patient days. The incidence of delirium was 23%. Thirty per cent of the patients representing 407 patient days were unable to be assessed at any assessment, mainly due to deep sedation. The patients were delirium and coma free in 45.9% of total days. CONCLUSION: Of the patients, 23% were classed as delirious (CAM-ICU positive) at least once during their stay. The CAM-ICU was difficult to use in patients with sedation so deep that they hardly gave eye contact and responded only weakly to verbal stimulation. Focusing on less sedation and further modifications to the CAM-ICU may benefit ICU patients in the future.

[Gastrocolocutaneous fistula: an uncommon complication of percutaneous endoscopic gastrostomy]. / Fístula gastrocolocutánea: una infrecuente complicación de la gastrostomía endoscópica percutánea.

Endoscopic percutaneous gastrostomy is a safe technique although with potential complications before which the clinician has to be on alert in order to early detect them even after a long period of normal functioning. Most of them represent minor problems. Gastrocolocutaneous fistula is a rare but severe complication favored by some risk factors such as previous post-surgical adherences, deformities of the spine, or excessive gastric inflation at the time of performing the technique. We present the case of a patient with PEG with this complication that occurred after the first tube replacement. Our goal was in two senses: on the one hand, to analyze the preventive aspects and basic guidelines for a safe PEG placement to minimize the risks; on the other hand, to alert on the possible presence of this entity to prevent a progressive nutritional impairment. This complication ought to be included in the differential diagnosis of the diarrhea syndrome in the patient carrying a PEG. The diagnostic techniques of choice are radiologic tests such as CT scan and contrast media administration through the tube. Surgical therapy should be reserved to patients with acute peritonitis in order to perform a new gastrostomy.

Empirical hospital and professional charges for patient care associated with out of hospital cardiac arrest before and after implementation of therapeutic hypothermia for comatose survivors.

OBJECTIVE: The objectives of this study are to characterize the total hospital and professional charges for patients with out of hospital cardiac arrest both with and without therapeutic hypothermia treatment. METHODS: Retrospective cohort study of all adult patients with non-traumatic out of hospital cardiac arrest brought to the ED of a single tertiary care hospital over 20 months preceding and 20 months following implementation of therapeutic hypothermia for comatose survivors. Billing and clinical data were obtained from administrative databases and the electronic medical record using explicit audited abstraction. Demographic, payer characteristics, median charges and reimbursements with interquartile ranges are described before and after implementation, stratified by patient outcome. RESULTS: Two hundred and twenty-three patients met study criteria. The median charge was $3,112 among the 135 patients (60.5%) that did not survive to admission and $94,916 among the 88 (39.5%) that did. Median charges before and after implementation of therapeutic hypothermia were $6,324 and $15,537 respectively. Medicare was the most frequent payer. Good neurological outcome occurred in 11/115 patients (9.6%) prior to implementation and 22/108 patients (20.4%) after. Among 23 patients treated with hypothermia, good neurological outcome occurred in 11 patients (47.8%). Good neurological outcome and treatment with hypothermia were associated with increased procedure utilization and higher charges. CONCLUSION: Empirical patient level data confirm that charges for patients with out of hospital cardiac arrest are substantial, even among patients that do not survive to hospital admission. Treatment with therapeutic hypothermia is associated with better outcomes, more procedures, and higher charges.

Critical care transport of patients who have acute neurological emergencies.

This article reviews the special questions and issues in critical care transport related specifically to the care of patients who have neurologic emergencies. It first considers potential indications for transport and reviews attempts to create a hierarchical stroke center system akin to that developed for trauma care. It then discusses therapeutic concerns relating to the transport environment and the use of specific interventions, including the effects of end-tidal CO(2) monitoring on intracranial pressure, patient outcomes after traumatic brain injury, and opportunities to initiate therapeutic hypothermia in comatose survivors of cardiac arrest during transport. Finally, the cost of critical care transport of patients who have neurologic emergencies is considered.

Estimulação multissensorial em pacientes comatosos: uma revisão da literatura / Estímulo multi-sensorial en pacientes comatosos: encuesta sobre la literatura / Multisensorial stimulation in comatose patients: a literature survey

O estado de coma é uma situação que se caracteriza pelo extremo rebaixamento do nível de consciência, em que o indivíduo permanece com os olhos fechados, sem percepção alguma do meio externo, incapaz de se comunicar, responder a comandos e emitir comportamentos elaborados. O nível de consciência, ou seja, o estado de alerta comportamental que nos mantém despertos, depende do Sistema Ativador Reticular Ascendente (SARA), que é localizado na região pontomesencefálica do tronco encefálico. O coma pode ser gerado por diversas etiologias, causando prejuízos na ação de ativação cortical desempenhada pelo Sistema Ativador Reticular Ascendente. Com intuito de facilitar a recuperação do estado de coma, foram criados programas de estimulação multissensorial, visando a estimular o Sistema Ativador Reticular Ascendente e, assim, auxiliar na recuperação do nível de consciência de pacientes comatosos. Desta forma, o objetivo destetrabalho foi analisar o que a literatura mostra sobre a influência da estimulação multissensorial sobre o nível de consciência de pacientes em estado de coma. Foi realizada uma revisão de literatura nas bases de dados eletrônicos Medline, Cochrane, Scielo e Lilacs, nos sites de pesquisas Pubmed e Highwire. Foram selecionados artigos científicos de 1983 a 2007. Os descritores utilizados foram: coma, estimulação sensorial, percepção e reabilitação. Foram incluídos ensaios clínicos enfocando a estimulação multissensorial em pacientes comatosos, e foram excluídos artigos que estudaram outras formas de tratamento realizadas em pacientes em coma que não objetivaram o aumento do nível de consciência. Palavras-chave: Coma-reabilitação. Coma-terapia. Transtornos da consciência-reabilitação

A coma is a situation of extreme degradation of the level of consciousness where the individual remains with closed eyes, with no perception of the external world, incapable of communicating, answering to commands and having elaborated behaviors. The level of consciousness, that is, the alert state that keeps us awaken, depends on Ascendant Reticular Activating System, which is located at the core of the brainstem between the myelencephalon and the mesencephalon. Coma may be generated by several etiologies, causing damages in ARAS’s cortical activation. With the intention of facilitating the recovery from coma, programs of multisensorial stimulation (MS) were created aiming to stimulate ARAS and thus to assist in the recovery of the level of conscience of comatose patients. In view of this, the objective of this work was to analyze what the literature shows about the influence of multisensorial stimulation on the level of consciousness of coma patients. We did a literature survey in the electronic databases Medline, Cochrane, Scielo and Lilacs and in Pubmed and Highwire search sites. Articles selected cover the period 1983- 2007. Keywords used were: coma, sensorial stimulation, perception and rehabilitation. We included clinical assays focusing in MS for comatose patients, and excluded articles that had studied other forms of treatment in comatose patients that did not aimed at increasing the level of consciousness. Twenty scientific articles were analyzed that presented controversial results regarding the type of stimulation, time of duration of the therapy and results reached after the application of the multisensorial stimulation program in comatose patients. KEYWORDS: Coma-rehabilitation. Coma-therapy. Disturbances of consciousness-rehabilitation

Therapeutic hypothermia in comatose patients after out-of-hospital cardiac arrest.

Our intensive care unit has been treating comatose patients, following an out-of-hospital cardiac arrest, with therapeutic hypothermia since 2002. In all, 139 out-of-hospital cardiac arrest patients were admitted in the 4-year period 2002-5. Of these, 27% had a favourable outcome (discharged home or to rehabilitation). Forty-one per cent of patients presenting with ventricular fibrillation (VF) and 7% of non-VF patients had a favourable outcome. No patient with an estimated time from collapse to first attempt at cardiopulmonary resuscitation over 12 min survived to hospital discharge. Twenty-two per cent of patients over 70 years were discharged home, suggesting age was not a barrier to surviving out-of-hospital cardiac arrest. The introduction of a therapeutic hypothermia clinical pathway, at the end of 2003 improved the efficiency of cooling. The percentage of patients cooled to below 34 degrees C within 4 h increased from 15 to 51% and those cooled for more than 12 h increased from 30 to 83%.

[Ethical and legal points concerning minimally conscious state and permanent vegetative state]. / Aspects éthiques et juridiques posés par les états paucirelationnels et l'état végétatif chronique.

The ethical and legal problems posed by severe outcome of coma are complex and their analysis requires a multi-disciplinary approach. Three aspects have been particularly studied in this paper. The first is a reminder of the medical definitions of the concepts of vegetative state and minimally conscious state. The second focuses on the analysis of the ethical and legal debate of these conditions at an international level. Finally, the third concerns the wealth prospects, proposed, in France, by the circular letter dated May 3, 2002.

Immediate assessment and management of acute medical emergencies.

The pre-hospital management of acute medical emergencies can be difficult. Critically ill patients must be evaluated quickly and accurately to ensure that immediately life-threatening problems are identified and treated. Figure 1 and Box 2 provide a structured method for rapid assessment in the pre-hospital phase. Although the majority of medically unwell patients will not require an aggressive resuscitation phase during the primary survey, the use of the structured approach in all patients will ensure that 'time critical' pre-hospital medical emergencies are identified. This approach also emphasizes that once immediately correctable problems have been treated, the priority is transfer the patient to the nearest resuscitation facility.

Evaluating the comatose patient. Rapid neurologic assessment is key to appropriate management.

Coma is defined as a sleeplike state in which the patient is unresponsive to self and the environment. Coma should be distinguished from the persistent vegetative state and locked-in syndrome. It is important to obtain a carefully taken history from eyewitnesses and to perform a rapid neurologic examination focusing on pupillary responses, eye movements, and motor responses. Pupils reactive to light usually indicate metabolic or medical coma; cerebellar infarction or hemorrhage is a notable exception. A pupil unreactive to light often points to a structural brain lesion and the need for urgent neurosurgical consultation. The prognosis for coma depends on the cause.