Comparison of Glasgow Coma Scale Full Outline of UnResponsiveness and Glasgow Coma Scale: Pupils Score for Predicting Outcome in Patients with Traumatic Brain Injury.

Background: Glasgow coma scale (GCS) score is the most widely used clinical score for the initial assessment of neurologically injured patients and is also frequently used for prognostication. Other scores such as the Full Outline of UnResponsivness (FOUR) score and the Glasgow Coma Scale-Pupils (GCS-P) score have been more recently developed and are gaining popularity. This prospective cohort study was conducted to compare various scores in terms of their ability to predict outcomes at 3 months in patients with traumatic brain injury (TBI). Materials and methods: The study was carried out between October 2020 and March 2022. Patients who presented to the hospital with TBI were assessed for inclusion. Initial coma scores were assessed in the emergency department and again after 48 hours of admission. Outcome was assessed using the extended Glasgow outcome score (GOSE) at 3 months after injury. The receiver operating curve (ROC) was plotted to correlate coma scores with the outcome, and the area under the curve (AUC) was compared. Results: A total of 355 patients with TBI were assessed for eligibility, of which 204 patients were included in the study. The AUC values to predict poor outcomes for initial GCS, FOUR, and GCS-P scores were 0.75 each. The AUC values for 48-hour coma scores were 0.88, 0.87, and 0.88, respectively. Conclusion: The GCS, FOUR, and GCS-P scores were found to be comparable in predicting the functional outcome at 3 months as assessed by GOSE. However, coma scores assessed at 48 hours were better predictors of poor outcomes at 3 months than coma scores recorded initially at the time of hospital admission. How to cite this article: Chawnchhim AL, Mahajan C, Kapoor I, Sinha TP, Prabhakar H, Chaturvedi A. Comparison of Glasgow Coma Scale Full Outline of UnResponsiveness and Glasgow Coma Scale: Pupils Score for Predicting Outcome in Patients with Traumatic Brain Injury. Indian J Crit Care Med 2024;28(3):256-264.

Evaluation of the GCS-Pupils Score for PrOgnosis in trauMatic brAin injury- The COMA Study.

OBJECTIVES: Glasgow Coma Scale-Pupils (GCS-P) score has been found to be strongly related to in-hospital mortality in retrospective studies. We hypothesized that GCS-P would be better prognosticator than Glasgow Coma Scale (GCS) in patients with traumatic brain injury (TBI). METHODS: In this prospective, multicentric, observational study, GCS and GCS-P scores were noted in adult TBI patients at ICU admission. Demographic variables, relevant clinical history, clinical/radiological findings and ICU complications were also noted. Extended Glasgow Outcome scale was noted at hospital discharge and at 6 months post-injury. Logistic regression analysis was carried out to estimate the odds for poor outcome adjusted for covariates. Sensitivity, specificity, area under curve (AUC) and odds ratio are reported for poor outcome at estimated cutoff point. RESULTS: A total of 573 patients were included in this study. The predictive power for mortality, shown by the AUC, was 0.81 [95% CI: 0.77-0.85] for GCS and 0.81 [95% CI: 0.77-0.86] for GCS-P score, both being comparable. Similarly, the predictive ability for outcome at discharge and 6 months, the AUC-ROC for both GCS and GCS-P were comparable. CONCLUSIONS: GCS-P is a good predictor of mortality and poor outcome. However, the predictive performance of GCS and GCS-P for in-hospital mortality and functional outcome at discharge and at 6 months remains comparable.

Endocrine Dysfunction After Traumatic Brain Injury: An Ignored Clinical Syndrome?

Traumatic brain injury (TBI) incurs substantial health and economic burden, as it is the leading reason for death and disability globally. Endocrine abnormalities are no longer considered a rare complication of TBI. The reported prevalence is variable across studies, depending on the time frame of injury, time and type of testing, and variability in hormonal values considered normal across different studies. The present review reports evidence on the endocrine dysfunction that can occur after TBI. Several aspects, including the pathophysiological mechanisms, clinical consequences/challenges (in the acute and chronic phases), screening and diagnostic workup, principles of therapeutic management, and insights on future directions/research agenda, are presented. The management of hypopituitarism following TBI involves hormonal replacement therapy. It is essential for health care providers to be aware of this complication because at times, symptoms may be subtle and may be mistaken to be caused by brain injury itself. There is a need for stronger evidence for establishing recommendations for optimum management so that they can be incorporated as standard of care in TBI management.

A National Survey on Coma Epidemiology, Evaluation, and Therapy in India: Revisiting the Curing Coma Campaign Come Together Survey.

BACKGROUND: The limited representation from developing countries in the original COME TOGETHER survey gave us an impetus to conduct this survey in the Indian subcontinent. METHODS: This cross-sectional online survey was conducted from August through September 2022. Participants were health care physicians caring for patients with coma and disorders of consciousness. Fischer's exact test or the Mann-Whitney U-test was used to compare respondents who agreed or disagreed with the preestablished coma definition. Fleiss κ values were calculated to assess agreement among respondents. A p value less than 0.05 was considered statistically significant. RESULTS: The survey was completed by 130 physicians. We found substantial interrater agreement on absence of wakefulness (71.54%; κ = 0.71), Glasgow Coma Score ≤ 8 (78.46%; κ = 0.78), and failure to respond purposefully to visual, verbal, or tactile stimuli (66.15%; κ = 0.66). Reported common etiologies of coma included traumatic brain injury (50.76%), ischemic stroke (30%), and intracerebral hemorrhage (29.23%). The most common clinical assessment tools used for coma included the Glasgow Coma Score (92.3%) and neurological examination (60.8%). Neurological examination was the most common diagnostic tool used (100%), followed by magnetic resonance imaging (89.2%), basic laboratory studies (88.5%), and head computed tomography/angiography (86.9%). Pharmacological interventions used to stimulate arousal in patients with coma were sedation vacation (91.5%), electrolyte/endocrine correction (65.4%), osmotic therapy with mannitol (60%), hypertonic saline (54.6%), modafinil (46.9%), and antidote for drugs (45.4%). Among the nonpharmacological interventions, sensory stimulation (57.7%) was the most commonly used modality. The most common discharge disposition for comatose patients who survived hospitalization were home with or without services (70.0%). CONCLUSIONS: Differences from the global survey were noted regarding the following: traumatic brain injury being the most common etiology of coma in India, more frequent practice of sedation interruption, less frequent use of electroencephalography in India, rare use of pharmacological neurostimulants, and home being the most common discharge disposition in India.

Comparison between Transcranial Sonography and Computerized Tomography Scans to Assess the Midline Shift in Patients with Traumatic Brain Injury.

Background: Midline shift (MLS) of the brain is an important clinical finding diagnosed on computed tomography (CT) imaging and transcranial sonography (TCS) can help diagnose MLS at the bedside and facilitate interventions to improve outcomes. The study aimed to find an association between TCS- and CT-based assessments of MLS in patients with traumatic brain injury (TBI). Patients and methods: We included all adult patients with moderate-to-severe TBI of either gender, aged between 18 and 65 years, undergoing intracranial surgery under general anesthesia over a period of 3 months. Consciousness was assessed with the help of the Glasgow coma scale (GCS) and Glasgow coma scale-pupillary (GCS-P) score. We calculated MLS using a CT scan and TCS. Bland Altman graph along with Pearson's and Spearman's coefficient tests was used. Results: A total of 17 patients were analyzed in this study. The MLS was 0.52 ± 0.90 cm using TCS and 0.58 ± 0.39 cm using CT scan. The Pearson's correlation coefficient (r 2) of the difference between MLS measured by TCS and CT imaging was 0.002 (p < 0.05). Conclusion: Transcranial sonography could detect MLS in patients with TBI, provided a minimum time window is used between MLS measurements by TCS and CT scan. How to cite this article: Kapoor I, Pandit S, Prabhakar H, Mahajan C. Comparison between Transcranial Sonography and Computerized Tomography Scans to Assess the Midline Shift in Patients with Traumatic Brain Injury. Indian J Crit Care Med 2023;27(1):64-66.

The Curing Coma Campaign®: Concerns in the Indian Subcontinent.

Background: The Curing Coma Campaign (CCC) was launched by the Neurocritical Care Society (NCS) in 2019, with the purpose to bring together a diverse group of coma scientists, neurointensivists, and neurorehabilitationists. Methods: The aim of this campaign is to move beyond the limitations imposed by current definitions of coma and identify mechanisms to improve prognostication, identify test therapies, and impact outcomes. At the moment, whole approach of the CCC appears ambitiously challenging. Results: This could be true only for the Western world, such as the North America, Europe, and few developed countries. However, the whole concept of CCC may face potential challenges in the lower-middle income countries. India has several stumbling blocks that need to and can be addressed in the future, for a meaningful outcome, as envisaged in the CCC. Conclusion: India has several potential challenges, which we aim to discuss in this article. How to cite this article: Kapoor I, Mahajan C, Zirpe KG, Samavedam S, Sahoo TK, Sapra H, et al. The Curing Coma Campaign®: Concerns in the Indian Subcontinent. Indian J Crit Care Med 2023;27(2):89-92.

A Nationwide Survey on the Practice of End-of-life Care Issues in Critical Care Units in India.

Background: End-of-life (EOL) care is the care of terminally ill patients who are nearing their end. It includes important components like palliative care, supportive care, hospice care, patient's right to choose, and choice of medical intervention, including continuation of routine medical interventions. The aim of this survey was to assess the practices of EOL care in various critical care units in India. Methods: The participants included clinicians involved in EOL care of patients with advanced diseases in different hospital across India. We sent blast emails and posted links on social media for inviting participants to take the survey. Study data were collected and managed by using Google Forms. The collected information was automatically entered into a spread sheet and stored in a secure database. Results: In total, 91 clinicians took the survey. The years of experience, practice area, and setting had significant effect on the palliative care, terminal strategy, and prognostication in terminally ill patients (p < 0.05). Statistical analysis was done using software STATA. Descriptive statistics were performed, and results were presented as number (percentage). Conclusion: The years of work experience, the practice area, and the practice setting have a strong impact on EOL care management of terminally ill patients. There are a lot of gaps in providing EOL care for these patients. Many reforms are needed in the Indian health care system to make EOL care better. How to cite this article: Kapoor I, Prabhakar H, Mahajan C, Zirpe KG, Tripathy S, Wanchoo J, et al. A Nationwide Survey on the Practice of End-of-life Care Issues in Critical Care Units in India. Indian J Crit Care Med 2023;27(5):305-314.

Phenytoin Sodium and Acetate-Maleate Buffered Balanced Salt Solutions are Physically Incompatible!

How to cite this article: Mahajan C, Singh BP, Kapoor I, Prabhakar H. Phenytoin Sodium and Acetate-Maleate Buffered Balanced Salt Solutions are Physically Incompatible! Indian J Crit Care Med 2021;25(3):352.

Consensus Statement on Analgo-sedation in Neurocritical Care and Review of Literature.

AIM AND OBJECTIVE: Our main objective in developing this consensus is to bring together a set of most agreed-upon statements from a panel of global experts that would act as a guide for clinicians working in neurocritical care units (NCCUs). BACKGROUND: Given the physiological benefits of analgo-sedation in the NCCU, there is little information on their tailoring in the NCCU. This lack of evidence and guidelines on the use of sedation and analgesia in patients with neurological injury leads to a variation in clinical care based on patient requirements and institutional protocols. REVIEW RESULTS: Thirty-nine international experts agreed to be a member of this consensus panel. A Delphi method based on a Web-based questionnaire developed with Google Forms on a secure institute server was used to seek opinions of experts. Questions were related to sedation and analgesia in the neurocritical care unit. A predefined threshold of agreement was established as 70% to support any recommendation, strong, moderate, or weak. No recommendations were made below this threshold. Responses were collected from all the experts, summated, and expressed as percentage (%). After three rounds, consensus could be reached for 6 statements related to analgesia and 5 statements related to sedation. Consensus could not be reached for 10 statements related to analgesia and 5 statements related to sedation. CONCLUSION: This global consensus statement may help in guiding practitioners in clinical decision-making regarding analgo-sedation in the NCCUs, thereby helping in improving patient recovery profiles. CLINICAL SIGNIFICANCE: In the lack of high-level evidence, the recommendations may be seen as the current best clinical practice. HOW TO CITE THIS ARTICLE: Prabhakar H, Tripathy S, Gupta N, Singhal V, Mahajan C, Kapoor I, et al. Consensus Statement on Analgo-sedation in Neurocritical Care and Review of Literature. Indian J Crit Care Med 2021;25(2):126-133.

Effect of Percutaneous Tracheostomy on Optic Nerve Sheath Diameter [TONS Trial].

BACKGROUND: Elective percutaneous tracheostomy [PCT] is the widely performed procedure in neurocritically ill patients as an airway management choice in neurocritical care unit [NICU]. Intracranial pressure [ICP] is a vital parameter to be monitored in these patients while undergoing any surgical procedure including PCT. Optic nerve sheath diameter [ONSD], being a surrogate of ICP, can be done bedside and carries less complications than invasive ICP monitoring. The aim of our study was to assess the effect of PCT on ONSD at different stages of PCT. MATERIALS AND METHODS: A total of 158 patients with various intracranial pathologies scheduled for PCT in NICU were screened for eligibility in our study. We assessed mean values of ONSD, HR, MBP, and SpO2 for changes over various time points during PCT using generalized estimating equation (GEE). A p value of <0.05 was considered significant. RESULTS: A total of 135 patients who underwent PCT were analyzed for the study. The values of ONSD changed significantly at different stages of PCT procedure compared to baseline. The baseline ONSD value was 0.39 ± 0.05 cm. ONSD rose significantly to 0.40 ± 0.06 cm during positioning, 0.41 ± 0.06 cm during skin incision, 0.42 ± 0.07 cm during dilatation of tract, 0.41 ± 0.07 cm during insertion of tracheostomy, and 0.41 ± 0.06 cm at the end of the procedure. CONCLUSIONS: PCT leads to a significant rise of ONSD values during all stages of PCT. The available evidences point toward detrimental rise in ICP during PCT. ICP can be monitored noninvasively by measuring ONSD using bedside ultrasound. HOW TO CITE THIS ARTICLE: Kapoor I, Wanchoo J, Mahajan C, Singhal V, Roy H, Kumar S, et al. Effect of Percutaneous Tracheostomy on Optic Nerve Sheath Diameter [TONS Trial]. Indian J Crit Care Med 2021;25(4):382-387.

Postoperative Cognitive Dysfunction.

Cognitive dysfunction is a common complication in primary or metastatic brain tumors and can be correlated to disease itself or various treatment modalities. The symptoms of cognitive deficits may include problems with memory, attention and information processing. Primary brain tumors are highly associated with neurocognitive deficit and poor quality of life. This review discusses the pathophysiology, risk factors and assessment of cognitive dysfunction. It also gives an overview of the effect of anesthetics on postoperative cognitive dysfunction and its management.

Colistin for Treatment of Multidrug Resistant Central Nervous System Infection: A Triple Route Therapy!

How to cite this article: Shukla RK, Kapoor I, Mahajan C, Prabhakar H. Colistin for Treatment of Multidrug Resistant Central Nervous System Infection: A Triple Route Therapy!. Indian J Crit Care Med 2019;23(6):287.

Anesthesia for minimally invasive neurosurgery.

PURPOSE OF REVIEW: With an ultimate aim of improving patients overall outcome and satisfaction, minimally invasive surgical approach is becoming more of a norm. The related anesthetic evidence has not expanded at the same rate as surgical and technological advancement. This article reviews the recent evidence on anesthesia and perioperative concerns for patients undergoing minimally invasive neurosurgery. RECENT FINDINGS: Minimally invasive cranial and spinal surgeries have been made possible only by vast technological development. Points of surgical interest can be precisely located with the help of stereotaxy and neuronavigation and special endoscopes which decrease the tissue trauma. The principles of neuroanethesia remain the same, but few concerns are specific for each technique. Dexmedetomidine has a favorable profile for procedures carried out under sedation technique. As the new surgical techniques are coming up, lesser known anesthetic concerns may also come into light. SUMMARY: Over the last year, little new information has been added to existing literature regarding anesthesia for minimally invasive neurosurgeries. Neuroanesthesia goals remain the same and less invasive surgical techniques do not translate into safe anesthesia. Specific concerns for each procedure should be taken into consideration.