The incidence of cerebral arterial vasospasm following aneurysmal subarachnoid haemorrhage: a systematic review and meta-analysis.

PURPOSE: To describe a pooled estimated incidence of cerebral arterial vasospasm (aVSP) following aneurysmal subarachnoid haemorrhage (aSAH) and to describe sources of variation in the reported incidence. METHODS: We performed a systematic review and meta-analysis of randomised clinical trials (RCTs) and cohort studies. The primary outcome was the proportion of study participants diagnosed with aVSP. We assessed for heterogeneity based on mode of imaging, indication for imaging, study design and clinical characteristics at a study level. RESULTS: We identified 120 studies, including 19,171 participants. More than 40 different criteria were used to diagnose aVSP. The pooled estimate of the proportion of patients diagnosed with aVSP was 0.42 (95% CI 0.39 to 0.46, I2 = 96.5%). There was no evidence that the incidence aVSP was different, nor that heterogeneity was reduced, when the estimate was assessed by study type, imaging modalities, the proportion of participants with high grade CT scores or poor grade clinical scores. The pooled estimate of the proportion of study participants diagnosed with aVSP was higher in studies with routine imaging (0.47, 95% CI 0.43 to 0.52, I2 = 96.5%) compared to those when imaging was performed when indicated (0.30, 95% CI 0.25 to 0.36, I2 = 94.0%, p for between-group difference < 0.0005). CONCLUSION: The incidence of cerebral arterial vasospasm following aSAH varies widely from 9 to 93% of study participants. Heterogeneity in the reported incidence may be due to variation in the criteria used to diagnose aVSP. A standard set of diagnostic criteria is necessary to resolve the role that aVSP plays in delayed neurological deterioration following aSAH. PROSPERO REGISTRATION: CRD42020191895.

Intensive care doctors and nurses personal preferences for Intensive Care, as compared to the general population: a discrete choice experiment.

BACKGROUND: To test the hypothesis that Intensive Care Unit (ICU) doctors and nurses differ in their personal preferences for treatment from the general population, and whether doctors and nurses make different choices when thinking about themselves, as compared to when they are treating a patient. METHODS: Cross sectional, observational study conducted in 13 ICUs in Australia in 2017 using a discrete choice experiment survey. Respondents completed a series of choice sets, based on hypothetical situations which varied in the severity or likelihood of: death, cognitive impairment, need for prolonged treatment, need for assistance with care or requiring residential care. RESULTS: A total of 980 ICU staff (233 doctors and 747 nurses) participated in the study. ICU staff place the highest value on avoiding ending up in a dependent state. The ICU staff were more likely to choose to discontinue therapy when the prognosis was worse, compared with the general population. There was consensus between ICU staff personal views and the treatment pathway likely to be followed in 69% of the choices considered by nurses and 70% of those faced by doctors. In 27% (1614/5945 responses) of the nurses and 23% of the doctors (435/1870 responses), they felt that aggressive treatment would be continued for the hypothetical patient but they would not want that for themselves. CONCLUSION: The likelihood of returning to independence (or not requiring care assistance) was reported as the most important factor for ICU staff (and the general population) in deciding whether to receive ongoing treatments. Goals of care discussions should focus on this, over likelihood of survival.

Impact of the coronavirus disease 2019 pandemic on critical care healthcare workers' depression, anxiety, and stress levels.

AIM: The aim of the study was to determine levels of depression, anxiety, and stress symptoms and factors associated with psychological burden amongst critical care healthcare workers in the early stages of the coronavirus disease 2019 pandemic. METHODS: An anonymous Web-based survey distributed in April 2020. All healthcare workers employed in a critical care setting were eligible to participate. Invitations to the survey were distributed through Australian and New Zealand critical care societies and social media platforms. The primary outcome was the proportion of healthcare workers who reported moderate to extremely severe scores on the Depression, Anxiety, and Stress Scale-21 (DASS-21). RESULTS: Of the 3770 complete responses, 3039 (80.6%) were from Australia. A total of 2871 respondents (76.2%) were women; the median age was 41 years. Nurses made up 2269 (60.2%) of respondents, with most (2029 [53.8%]) working in intensive care units. Overall, 813 (21.6%) respondents reported moderate to extremely severe depression, 1078 (28.6%) reported moderate to extremely severe anxiety, and 1057 (28.0%) reported moderate to extremely severe stress scores. Mean ± standard deviation values of DASS-21 depression, anxiety, and stress scores amongst woman vs men was as follows: 8.0 ± 8.2 vs 7.1 ± 8.2 (p = 0.003), 7.2 ± 7.5 vs 5.0 ± 6.7 (p < 0.001), and 14.4 ± 9.6 vs 12.5 ± 9.4 (p < 0.001), respectively. After adjusting for significant confounders, clinical concerns associated with higher DASS-21 scores included not being clinically prepared (ß = 4.2, p < 0.001), an inadequate workforce (ß = 2.4, p = 0.001), having to triage patients owing to lack of beds and/or equipment (ß = 2.6, p = 0.001), virus transmission to friends and family (ß = 2.1, p = 0.009), contracting coronavirus disease 2019 (ß = 2.8, p = 0.011), being responsible for other staff members (ß = 3.1, p < 0.001), and being asked to work in an area that was not in the respondents' expertise (ß = 5.7, p < 0.001). CONCLUSION: In this survey of critical care healthcare workers, between 22 and 29% of respondents reported moderate to extremely severe depression, anxiety, and stress symptoms, with women reporting higher scores than men. Although female gender appears to play a role, modifiable factors also contribute to psychological burden and should be studied further.

A comparison of manual pupil examination versus an automated pupillometer in a specialised neurosciences intensive care unit.

BACKGROUND: The assessment of pupil size and reaction to light is a fundamental part of the neurological assessment; however, manual examination is prone to inaccuracies. The use of an automated infrared pupillometer is one strategy to limit error in pupil examination. OBJECTIVE: The main objective was to assess agreement between manual examination and examination using an automated infrared pupillometer in relation to pupil reaction and size in a specialised neurosciences intensive care unit. METHODS: We conducted a single-centre prospective observational study in a specialised tertiary neurosciences intensive care unit. Participants' pupils were examined hourly for 24 h by both manual examination using a pen torch and examination using an automated infrared pupillometer. RESULTS: Twenty-two participants were enrolled. A total of 935 paired pupil observations were obtained for both pupil reaction and size. There was no statistically significant disagreement in assessing pupil reaction (McNemar's test p = 0.106). Percentage agreement was 96.68% for pupil reaction, with Kappa coefficient, 0.841 (95% confidence interval: 0.7864-0.8956). For all participants, the mean difference in pupil size was 0.154 mm, with limits of agreement of -1.294 mm to +1.603 mm. CONCLUSION: There was no significant disagreement between manual and automated pupillometer observations for pupil reaction. The mean difference in measurement of pupil size was small.

Functional outcomes at 12 months for patients with traumatic brain injury, intracerebral haemorrhage and subarachnoid haemorrhage treated in an Australian neurocritical care unit: A prospective cohort study.

BACKGROUND: Acute severe brain injury is associated with significant morbidity and mortality. Patients and their families need accurate information regarding expected outcomes. Few studies have reported the long-term functional outcome of patients with acute severe brain injury treated in an Australian neurocritical care unit. OBJECTIVE: The objective of this study was to describe 12-month functional outcomes (using the extended Glasgow Outcome Scale) of patients with acute severe brain injury treated in an Australian neurocritical care unit. METHODS: This was a single-centre prospective cohort study. Patients with a diagnosis of traumatic brain injury, subarachnoid haemorrhage or intracranial haemorrhage admitted between 2015 and 2019 were enrolled. RESULTS: In total, 915 participants were enrolled during the 51-month study period. Of the cohort, 403 (44%) were admitted after traumatic brain injury, 274 (30%) after subarachnoid haemorrhage and 238 (26%) after intracranial haemorrhage. The median duration of intensive care admission was 5 days (interquartile range: 2-13), 458 (50%) received invasive ventilation, 417 (46%) received vasopressor support and 286 (31%) received an external ventricular drain. At discharge from intensive care, 150 of 915 (16.4%) had died, and the in-hospital mortality was seen in 191 of 915 patients (20.9%). Favourable functional outcome, as defined by an extended Glasgow Outcome Scale score of 5-8, was reported in 358 of available 795 patients (45.0%) at six months and in 311 of 672 available patients (46.3%) at 12 months. Those with intracranial haemorrhage reported the highest rates of unfavourable outcomes with 112 of 166 patients (67.4%) at 12 months. CONCLUSIONS: In this selected population, admission to a neurocritical care unit was associated with significant resource use. At 12 months after admission, almost half of those admitted to an Australian neurocritical unit with traumatic brain injury, subarachnoid haemorrhage and intracerebral haemorrhage report a good functional outcome.

Emergency and acute care management of traumatic spinal cord injury: a survey of current practice among senior clinicians across Australia.

BACKGROUND: To describe pre-hospital, emergency department and acute care assessment and management practices of senior clinicians for patients with acute traumatic spinal cord injury (TSCI) across Australia; and to describe clinical practice variation. METHODS: We used a descriptive, cross-sectional study design to survey senior clinicians (greater than 10 years practice in this field) caring for patients with acute TSCI. The assessment, management and referral practices of prehospital, emergency department/trauma and surgical expert clinicians, across prehospital, early hospital care, diagnostic imaging and haemodynamic management were surveyed. RESULTS: We invited 95 eligible senior clinicians; the response rate was 75%. Survey findings demonstrated overall lack of awareness or consistent use of evidence based published guidelines; many clinicians following 'locally written' or 'no particular' guideline. Practitioners were conflicted across multiple areas including patient assessment and diagnosis, treatment and transport decisions. Reported spinal immobilisation practices differed substantially, as did target setting for blood pressure; the majority of clinicians actively monitored risk of respiratory deterioration. Specialist care consult and specialist service bed availability was reported as problematic by more than one third of clinicians. CONCLUSIONS: Unwarranted clinical practice variation is known to contribute to different health outcomes for patients with similar etiologies. Clinical practice guidelines offer evidence based, best practice standards, however are only effective if adopted throughout the healthcare system. Wide variability in acute care practices, pathways and timing to specialist centres for TSCI was evidenced by this survey despite seniority among clinicians. This devastating injury requires prompt, consistent, evidence based care from the moment of first responder. Improved outcomes for patients with TSCI would be more likely with standardised care across pre-hospital, emergency and acute care phases of care.

Human Albumin Use in Adults in U.S. Academic Medical Centers.

OBJECTIVE: To determine rates and predictors of albumin administration, and estimated costs in hospitalized adults in the United States. DESIGN: Cohort study of adult patients from the University HealthSystem Consortium database from 2009 to 2013. SETTING: One hundred twenty academic medical centers and 299 affiliated hospitals. PATIENTS: A total of 12,366,264 hospitalization records. INTERVENTIONS: Analysis of rates and predictors of albumin administration, and estimated costs. MEASUREMENTS AND MAIN RESULTS: Overall the proportion of admissions during which albumin was administered increased from 6.2% in 2009 to 7.5% in 2013; absolute difference 1.3% (95% CI, 1.30-1.40%; p < 0.0001). The increase was greater in surgical patients from 11.7% in 2009 to 15.1% in 2013; absolute difference 3.4% (95% CI, 3.26-3.46%; p < 0.0001). Albumin use varied geographically being lowest with no increase in hospitals in the North Eastern United States (4.9% in 2009 and 5.3% in 2013) and was more common in bigger (> 750 beds; 5.2% in 2009 and 7.3% in 2013) compared to smaller hospitals (< 250 beds; 4.4% in 2009 to 6.2% in 2013). Factors independently associated with albumin use were appropriate indication for albumin use (odds ratio, 65.220; 95% CI, 62.459-68.103); surgical admission (odds ratio, 7.942; 95% CI, 7.889-7.995); and high severity of illness (odds ratio, 8.933; 95% CI, 8.825-9.042). Total estimated albumin cost significantly increased from $325 million in 2009 to $468 million in 2013; (absolute increase of $233 million), p value less than 0.0001. CONCLUSIONS: The proportion of hospitalized adults in the United States receiving albumin has increased, with marked, and currently unexplained, geographic variability and variability by hospital size.

Subarachnoid Hemorrhage Patients Admitted to Intensive Care in Australia and New Zealand: A Multicenter Cohort Analysis of In-Hospital Mortality Over 15 Years.

OBJECTIVE: The primary aim of this study was to describe in-hospital mortality in subarachnoid hemorrhage patients requiring ICU admission. Secondary aims were to identify clinical characteristics associated with inferior outcomes, to compare subarachnoid hemorrhage mortality with other neurological diagnoses, and to explore the variability in subarachnoid hemorrhage standardized mortality ratios. DESIGN: Multicenter, binational, retrospective cohort study. SETTING: Data were extracted from the Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation Adult Patient Database. PATIENTS: All available records for the period January 2000 to June 2015. INTERVENTIONS: Nil. MEASUREMENTS AND MAIN RESULTS: A total of 11,327 subarachnoid hemorrhage patients were identified in the Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation Adult Patient Database. The overall case fatality rate was 29.2%, which declined from 35.4% in 2000 to 27.2% in 2015 (p = 0.01). Older age, nonoperative admission, mechanical ventilation, higher Acute Physiology and Chronic Health Evaluation III scores, lower Glasgow Coma Scale, and admission prior to 2004 were all associated with lower hospital survival in multivariable analysis (p < 0.05). In comparison with other neurological diagnoses, subarachnoid hemorrhage patients had significantly greater risk-adjusted in-hospital mortality (odds ratio, 1.89 [95% CI, 1.79-2.00]). Utilizing data from the 5 most recent complete years (2010-2014), three sites had higher and four (including the two largest centers) had lower standardized mortality ratios than might be expected due to chance. CONCLUSIONS: Subarachnoid hemorrhage patients admitted to ICU in Australia and New Zealand have a high mortality rate. Year of admission beyond 2003 did not impact risk-adjusted in-hospital mortality. Significant variability was noted between institutions. This implies an urgent need to systematically evaluate many aspects of the critical care provided to this patient group.

Emergency Neurological Life Support: Acute Non-traumatic Weakness.

Acute non-traumatic weakness may be life-threatening if it involves the respiratory muscles and/or is associated with autonomic dysfunction. Most patients presenting with acute muscle weakness have a worsening neurological disorder that requires a rapid, systematic evaluation and detailed neurological exam to localize the disorder. Urgent laboratory tests and neuroimaging are needed to confirm the diagnosis. Because acute weakness is a common presenting sign of neurological emergencies, it was chosen as an Emergency Neurological Life Support protocol. Causes of acute non-traumatic weakness are discussed here by both presenting clinical signs and anatomical location. For each diagnosis, key features of the history, examination, investigations, and treatment are outlined in the included tables or in the "Appendix".

Emergency Neurological Life Support: Acute Non-traumatic Weakness.

Acute non-traumatic weakness may be life threatening if it involves the respiratory muscles or is associated with autonomic dysfunction. Most patients presenting with acute muscle weakness have a worsening neurological disorder that requires a rapid, systematic evaluation, and detailed neurological exam to localize the disorder. Urgent laboratory tests and neuroimaging are needed in many patients to make the diagnosis. Because acute weakness is a common presenting sign of neurological emergencies, it was chosen as an Emergency Neurological Life Support protocol. Causes of acute non-traumatic weakness are discussed by both presenting clinical signs and anatomical location. For each diagnosis, key features of the history, examination, investigations, and treatment are outlined in the included tables.

Human albumin administration in subarachnoid hemorrhage: results of an international survey.

BACKGROUND: Subarachnoid hemorrhage (SAH) is a devastating disease. Nimodipine is the only medical treatment shown to improve outcome of SAH patients. Human albumin (ALB) may exert neuroprotection in SAH. However, current usage of ALB in SAH is not known. We conducted an international survey of clinicians involved in the care of SAH patients to determine current practice of ALB administration in SAH. METHODS: We constructed a 27-question survey. Our sampling frame consisted of neurointensivists, general intensivists, neurocritical care nurses, critical care pharmacists, and neurosurgeons. The survey was available from 11/15/2012 to 12/15/2012. We performed mostly descriptive statistical analysis. RESULTS: We obtained 362 responses from a diverse range of world regions. Most respondents were intensivist physicians (88 %), who worked in academic institutions (73.5 %) with a bed capacity >500 (64.1 %) and an established institutional management protocol for SAH patients (70.2 %). Most respondents (83.5 %) indicated that their institutions do not incorporate ALB in their protocol, but half of them (45.9 %) indicated using ALB outside it. ALB administration is influenced by several factors: geographic variation (more common among US respondents); institutions with a dedicated neuroICU; and availability of SAH management protocol. Most respondents (75 %) indicated that a clinical trial to test the efficacy of ALB in SAH is needed. CONCLUSIONS: In this survey we found that ALB administration in SAH patients is common and influenced by several factors. Majority of respondents support a randomized clinical trial to determine the safety and efficacy of ALB administration in SAH patients.

The incidence of ventriculostomy-related infections as diagnosed by 16S rRNA polymerase chain reaction: A prospective observational study.

BACKGROUND: Ventriculostomy-related infections (VRIs) are reported in about 10 % of patients with external ventricular drains (EVDs). VRIs are difficult to diagnose due to clinical and laboratory abnormalities caused by the primary neurological injury which led to insertion of the EVD. Polymerase chain reaction (PCR) of the cerebrospinal fluid (CSF) may enable more accurate diagnosis of VRI. We performed a prospective cohort study to measure the incidence of VRI as diagnosed by 16S rRNA PCR. METHODS: Patients admitted to intensive care with a primary diagnosis of subarachnoid haemorrhage (SAH), traumatic brain injury (TBI), or intracerebral haemorrhage (ICH), who required an EVD, were assessed for inclusion in this study. Data were extracted from the electronic medical record, bedside charts, or from a prospectively collected database, the Neuroscience Outcomes in Intensive CarE database (NOICE). 16S rRNA PCR was performed on routinely collected CSF as per laboratory protocol. VRI was also diagnosed based on pre-existing definitions. RESULTS: 237 CSF samples from 39 patients were enrolled in the study. The mean patient age was 55.7 years, and 56.4 % were female. The most common primary neurological diagnosis was SAH (61.5 %). The incidence of a positive PCR was 2.6 % of patients (1 in 39) and 0.8 % of CSF samples (2 in 237). The incidence of VRI according to pre-published diagnostic criteria was 2.6 % - 41 % of patients and 0.4 % - 17.6 % of CSF samples. 28.2 % of patients were treated for VRI. Pre-published definitions which relied on CSF culture results had higher specificity and lower false positive rates for predicting a PCR result when compared to definitions incorporating non-microbiological markers of VRI. In CSF samples with a negative 16S rRNA PCR, there was a high proportion of non-microbiological markers of infection, and a high incidence of fever on the day the CSF sample was taken. CONCLUSIONS: The incidence of VRI as defined as a positive PCR was lower than the incidence of VRI according to several published definitions, and lower than the incidence of VRI as defined as treatment by the clinical team. Non-microbiological markers of VRI may be less reliable than a positive CSF culture in diagnosing VRI.

The association between ventriculostomy - Related infection and clinical outcomes: A systematic review and meta-analysis.

BACKGROUND: Ventriculostomy - related infection (VRI) is a common complication of patients who require placement of an external ventricular drain (EVD). The clinical outcomes of people who are diagnosed with VRI is poorly characterised. We performed a systematic review and meta-analysis to assess the association between VRI, and clinical outcomes and resource use, in patients treated with an EVD. METHODS: We searched MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of clinical trials to identify clinical trial and cohort studies that reported outcomes including mortality, functional outcome, duration of EVD insertion, and intensive care and hospital length of stay. Inclusion criteria and data extraction were conducted in duplicate. Where sufficient data were available, data synthesis was conducted using a random effects model to provide a pooled estimate of the association between VRI and clinical outcomes and resource use. We also pooled data to provide an estimate of the incidence of VRI in this population. RESULTS: Nineteen studies including 38,247 patients were included in the meta-analysis. There were twelve different definitions of VRI in the included studies. The pooled estimate of the incidence of VRI was 11 % (95 % confidence interval (CI), 9 % to 14 %). A diagnosis of VRI was not associated with an increase in the estimated odds ratio (OR) for mortality (OR 1.07, 95 % CI 0.59 to 1.92, p = 0.83 I2 = 83.5 %), nor was a diagnosis of VRI associated with changes in neurological outcome (OR 1.42, 95 % CI 0.36 to 5.56, p = 0.89, I2 = 0.3 %). Those diagnosed with VRI had longer intensive care unit length of stay (estimated pooled mean difference 8.4 days 95 % CI 3.4 to 13.4 days, p = 0.0009, I2 = 78.7 %) an increase in hospital length of stay (estimated mean difference 16.4 days. 95 % CI 11.6 to 21.2 days, p < 0.0005, I2 = 76.6 %), a prolonged duration of EVD placement (mean difference 5.24 days, 95 % CI 3.05 to 7.43, I2 = 78.2 %, p < 0.01), and an increased requirement for an internal ventricular shunt (OR 1.80, 95 % CI 1.32 to 2.46, I2 = 8.92 %, p < 0.01). CONCLUSIONS: Ventriculostomy related infection is not associated with increased mortality or an increased risk of poor neurological outcome, but is associated with prolonged duration of EVD placement, prolonged duration of ICU and hospital admission, and an increased rate of internal ventricular shunt placement.

Acute assessment of spinal cord injury in New South Wales: A retrospective study of current practice in two spinal cord injury referral centers.

INTRODUCTION: Interventions provided in the early phases after spinal cord injury (SCI) may improve neurological recovery and provide for best possible functional outcomes. Knowing this relies on early and clear documentation of the level and grade of the spinal cord injury. Guidelines advocate for early documentation of neurological status within 72 h of injury to allow early prognostication and to help guide initial management. It is unclear whether this is current practice in New South Wales (NSW). METHODS: Patients with acute SCI who were admitted to two SCI referral centers during 2018-2019 in NSW were included. Data relating to documentation of neurological status, timing of imaging, surgery and transfer to spinal cord injury center were collected and summarized using descriptive statistics. RESULTS: Only 18 percent of patients had an acceptable neurological examination according to the International Standards for Classification of Spinal Cord Injury (ISNCSCI) within 72 h of injury (either not done, or unable to determine the neurological level of injury). At the first neurological examination, the neurological level of injury and grade was unable to be determined in 26.8% of patients and 29.9% of patients respectively. At discharge from acute care and transfer to rehabilitation, the neurological level was undetermined in 28.9% of patients and grade undetermined in 26.8%. ISNCSCI examination was most commonly performed by spinal rehabilitation doctors after patients were discharged from the intensive care unit (ICU). CONCLUSIONS: Documentation of neurological level and grade of SCI within 72 h of injury is not being performed in the large majority of this cohort, which may impede evaluation of neurological improvement in response to acute treatment, and hinder prognostication.

Emergency neurological life support: acute non-traumatic weakness.

Acute non-traumatic weakness may be life-threatening if it involves respiratory muscles or is associated with dysautonomia. Most patients presenting with an acute muscle weakness have a worsening neurologic disorder that requires a rapid, systematic approach, and detailed neurologic localization of the findings. In many patients, urgent laboratory tests are needed and may involve neuroimaging. Because acute weakness is a common presenting sign of neurological emergencies, it was chosen as an Emergency Neurological Life Support protocol. An inclusive list of causes of acute weakness is explored, both by presenting complaint and anatomical location, with an outline of the key features of the history, examination, investigations, and treatment for each diagnosis.

Head CT for the intensivist: 10 tips and pearls.

Head imaging is an essential diagnostic tool for the management of patients with most acute neurological emergencies involving the brain. While numerous modalities including magnetic resonance imaging and catheter angiography play a role, computed tomography (CT) of the brain is far and away the most widely utilized technique because of its widespread availability and the fact that it is usually easier to implement in critically ill and potentially unstable patients. CT is particularly useful in identifying acute intracranial hemorrhage and this makes it often indispensable in the management of patients with traumatic brain injury and hemorrhagic stroke. However, shortcomings in identifying early ischemia on non-contrast CT mean that care must be taken in considering findings early after symptom onset, with newer CT sequences such as CT angiography and CT perfusion adding value. The critical role played by intensivists in managing neurocritical care patients necessitates familiarity and ability with viewing and understanding the advantages and shortcomings of head CT imaging and under which circumstances other modalities may be appropriate to obtain. This manuscript provides ten different circumstances commonly encountered in neurocritical care and how intensivists can use CT for the benefit of their patients.

Everyone’s a winner if we test less: the CODA action plan.

In this era of 'Choosing Wisely,' we present a four-step action plan to reduce unnecessary pathology testing and the associated patient harm (blood loss through repeated phlebotomy), economic cost and environmental impact. The authors are experts from the CODA group; a medical education and health-promotion charity that aims to build on the Choosing Wisely initiative to provide meaningful and sustainable actions to reduce the carbon footprint of healthcare, globally. Pathology testing is expensive and carbon-intensive, with as many as half of all tests being not clinically indicated. Reducing unnecessary testing is the only effective way to decrease the carbon footprint and other associated costs, as opportunities to reuse and recycle pathology specimens are limited. The four key steps for action are (i) auditing local practice; (ii) defining unnecessary testing including developing a clinical guideline for rational ordering; (iii) educating stakeholders; and (iv) measuring the impact of the intervention through re-audit. This proven method is designed to be used in any healthcare setting around the world; having a small group of passionate 'champions' is thought to be as important as strong clinical governance and more important than access to sophisticated equipment. Electronic medical record systems and other technological solutions offer new ways to help establish a sustainability mindset and reduce unnecessary testing. The Codachange.org/coda-earth/ website provides a dynamic crowdsourcing platform through which we can collectively learn to meet the diverse needs of our international medical community. Self-reported outcomes are gamified through collaborative feedback, amplification via social media and the ability to earn rewards, be uploaded to the CODA website, or added to the template as a success story. By combining our existing local networks with the emerging international CODA community, we can initiate meaningful change now and enter the era of environmental stewardship.

A multicentre observational study of the use of antiseizure medication in patients with aneurysmal subarachnoid haemorrhage in the PROMOTE-SAH study.

Our objective was to describe antiseizure medication (ASM) prescription patterns, and associations between ASM use and death and disability outcomes in patients with aneurysmal subarachnoid haemorrhage (aSAH) admitted to ICU. This was a multi-centre prospective observational study. The study took place in eleven ICUs across Australia and New Zealand. Data was collected from 1 April 2017 to 1 October 2018. Three hundred and fifty-seven adult patients with aSAH were enrolled. The primary outcome was to describe patterns of ASM prescription. The secondary outcome of interest was death or disability (modified Rankin Scale (mRS) score ≥ 4) at six months, and its association with ASM therapy, and relevant clinical subgroups. Forty percent of patients received an ASM and the most commonly used agent was levetiracetam. The median length of ASM administration was eight days (IQR 4.5-12.5). A number of patients with prehospital seizures did not receive ASM therapy (14/55, 2725%). There was a tendency towards ASM prescription with both higher radiological and clinical grade aSAH. There was no significant association between death or disability at six month (mRS ≥ 4) and ASM vs No ASM prescription. Testing for an interaction effect between ASM administration and WFNS grade suggested inferior outcomes with ASM use in lower aSAH grades (p = 0.04). In conclusion, the prescription of ASM for aSAH in Australia is variable across and within sites, with the majority of patients not receiving ASM chemoprophylaxis. We demonstrated no significant association between death or disability at six months and the use of ASM. There may be an association with poorer outcomes in patients with lower grade aSAH. This finding requires further exploration.

The acute management of intracerebral hemorrhage.

PURPOSE OF REVIEW: Spontaneous intracerebral hemorrhage (ICH) is associated with high morbidity and mortality, providing substantial scope for improvements in outcome. This review will discuss recent developments and present consensus evidence for the management of ICH. RECENT FINDINGS: Intracranial management strategies focus on preventing further bleeding and minimizing the risk of hematoma expansion and cerebral ischemia. Known coagulopathies should be corrected and oral anticoagulation reversed, but there is no evidence for the routine transfusion of platelets in patients taking aspirin or clopidogrel. Recombinant factor VIIa reduces hematoma expansion after ICH, but does not improve outcome and is associated with thromboembolic complications. The role and type of surgical interventions remain controversial. Early aggressive treatment, including meticulous control of blood pressure and other systemic physiological variables, improves outcome as does management in a specialized neurointensive care unit. Thromboembolic prophylaxis is routine but prophylactic antiepileptic drugs confer no benefit. Ongoing research seeks to define optimal blood pressure, glucose and temperature targets, the role and type of surgery, and potential neuroprotective strategies. SUMMARY: Well organized, multimodal therapy optimizing intracranial and systemic physiological variables improves outcome after ICH. Recent guidelines provide a useful consensus evidence-based framework for the management of acute ICH.