External ventriculostomy-associated infection reduction after updating a care bundle.

BACKGROUND: Despite the clinical benefits of external ventricular drains (EVD), these devices can lead to EVD-related infections (EVDRI). The drainage insertion technique and standardized guidelines can significantly reduce the risk of infection, mainly caused by gram-positive bacteria. However, gram-negative microorganisms are the most frequent causative microorganisms of EVDRI in our hospital. We aimed to determine whether a new bundle of measures for the insertion and maintenance of a drain could reduce the incidence of EVDRI. This cohort study of consecutive patients requiring EVD from 01/01/2015 to 12/31/2018 compared the patients' characteristics before and after introducing an updated protocol (UP) for EVD insertion and maintenance in 2017. RESULTS: From 204 consecutive patients, 198 requiring EVD insertion were included (54% females, mean age 55 ± 15 years). The before-UP protocol included 87 patients, and the after-UP protocol included 111 patients. Subarachnoid (42%) and intracerebral (24%) hemorrhage were the main diagnoses at admission. The incidence of EVDRI fell from 13.4 to 2.5 episodes per 1000 days of catheter use. Gram-negative bacteria were the most frequent causative microorganisms. Previous craniotomy remained the only independent risk factor for EVDRI. EVDRI patients had increased mechanical ventilation durations, hospital and ICU stays, and percutaneous tracheostomy requirements. CONCLUSIONS: A care bundle focusing on fewer catheter sampling and more accurate antiseptic measures can significantly decrease the incidence of EVDRI. After implementing the management protocol, a decreased incidence of infections caused by gram-negative and gram-positive bacteria and reduced ICU and hospital lengths of stay were observed.

Physiological and Biological Responses to Short-Term Intermittent Hypobaric Hypoxia Exposure: From Sports and Mountain Medicine to New Biomedical Applications.

In recent years, the altitude acclimatization responses elicited by short-term intermittent exposure to hypoxia have been subject to renewed attention. The main goal of short-term intermittent hypobaric hypoxia exposure programs was originally to improve the aerobic capacity of athletes or to accelerate the altitude acclimatization response in alpinists, since such programs induce an increase in erythrocyte mass. Several model programs of intermittent exposure to hypoxia have presented efficiency with respect to this goal, without any of the inconveniences or negative consequences associated with permanent stays at moderate or high altitudes. Artificial intermittent exposure to normobaric hypoxia systems have seen a rapid rise in popularity among recreational and professional athletes, not only due to their unbeatable cost/efficiency ratio, but also because they help prevent common inconveniences associated with high-altitude stays such as social isolation, nutritional limitations, and other minor health and comfort-related annoyances. Today, intermittent exposure to hypobaric hypoxia is known to elicit other physiological response types in several organs and body systems. These responses range from alterations in the ventilatory pattern to modulation of the mitochondrial function. The central role played by hypoxia-inducible factor (HIF) in activating a signaling molecular cascade after hypoxia exposure is well known. Among these targets, several growth factors that upregulate the capillary bed by inducing angiogenesis and promoting oxidative metabolism merit special attention. Applying intermittent hypobaric hypoxia to promote the action of some molecules, such as angiogenic factors, could improve repair and recovery in many tissue types. This article uses a comprehensive approach to examine data obtained in recent years. We consider evidence collected from different tissues, including myocardial capillarization, skeletal muscle fiber types and fiber size changes induced by intermittent hypoxia exposure, and discuss the evidence that points to beneficial interventions in applied fields such as sport science. Short-term intermittent hypoxia may not only be useful for healthy people, but could also be considered a promising tool to be applied, with due caution, to some pathophysiological states.

Circulating progenitor cells during exercise, muscle electro-stimulation and intermittent hypobaric hypoxia in patients with traumatic brain injury: a pilot study.

BACKGROUND: Circulating progenitor cells (CPC) treatments may have great potential for the recovery of neurons and brain function. OBJECTIVE: To increase and maintain CPC with a program of exercise, muscle electro-stimulation (ME) and/or intermittent-hypobaric-hypoxia (IHH), and also to study the possible improvement in physical or psychological functioning of participants with Traumatic Brain Injury (TBI). METHODS: Twenty-one participants. Four groups: exercise and ME group (EEG), cycling group (CyG), IHH and ME group (HEG) and control group (CG). Psychological and physical stress tests were carried out. CPC were measured in blood several times during the protocol. RESULTS: Psychological tests did not change. In the physical stress tests the VO2 uptake increased in the EEG and the CyG, and the maximal tolerated workload increased in the HEG. CPC levels increased in the last three weeks in EEG, but not in CyG, CG and HEG. CONCLUSIONS: CPC levels increased in the last three weeks of the EEG program, but not in the other groups and we did not detect performed psychological test changes in any group. The detected aerobic capacity or workload improvement must be beneficial for the patients who have suffered TBI, but exercise type and the mechanisms involved are not clear.

Combined intermittent hypobaric hypoxia and muscle electro-stimulation: a method to increase circulating progenitor cell concentration?

BACKGROUND: Our goal was to test whether short-term intermittent hypobaric hypoxia (IHH) at a level well tolerated by healthy humans could, in combination with muscle electro-stimulation (ME), mobilize circulating progenitor cells (CPC) and increase their concentration in peripheral circulation. METHODS: Nine healthy male subjects were subjected, as the active group (HME), to a protocol involving IHH plus ME. IHH exposure consisted of four, three-hour sessions at a barometric pressure of 540 hPa (equivalent to an altitude of 5000 m). These sessions took place on four consecutive days. ME was applied in two separate 20-minute periods during each IHH session. Blood samples were obtained from an antecubital vein on three consecutive days immediately before the experiment, and then 24 h, 48 h, 4 days, 7 days and 14 days after the last day of hypoxic exposure. Four months later a control study was carried out involving seven of the original subjects (CG), who underwent the same protocol of blood samples but without receiving any special stimulus. RESULTS: In comparison with the CG the HME group showed only a non-significant increase in the number of CPC CD34+ cells on the fourth day after the combined IHH and ME treatment. CONCLUSION: CPC levels oscillated across the study period and provide no firm evidence to support an increased CPC count after IHH plus ME, although it is not possible to know if this slight increase observed is physiologically relevant. Further studies are required to understand CPC dynamics and the physiology and physiopathology of the hypoxic stimulus.

Impact of non-neurological complications in severe traumatic brain injury outcome.

INTRODUCTION: Non-neurological complications in patients with severe traumatic brain injury (TBI) are frequent, worsening the prognosis, but the pathophysiology of systemic complications after TBI is unclear. The purpose of this study was to analyze non-neurological complications in patients with severe TBI admitted to the ICU, the impact of these complications on mortality, and their possible correlation with TBI severity. METHODS: An observational retrospective cohort study was conducted in one multidisciplinary ICU of a university hospital (35 beds); 224 consecutive adult patients with severe TBI (initial Glasgow Coma Scale (GCS) < 9) admitted to the ICU were included. Neurological and non-neurological variables were recorded. RESULTS: Sepsis occurred in 75% of patients, respiratory infections in 68%, hypotension in 44%, severe respiratory failure (arterial oxygen pressure/oxygen inspired fraction ratio (PaO2/FiO2) < 200) in 41% and acute kidney injury (AKI) in 8%. The multivariate analysis showed that Glasgow Outcome Score (GOS) at one year was independently associated with age, initial GCS 3 to 5, worst Traumatic Coma Data Bank (TCDB) first computed tomography (CT) scan and the presence of intracranial hypertension but not AKI. Hospital mortality was independently associated with initial GSC 3 to 5, worst TCDB first CT scan, the presence of intracranial hypertension and AKI. The presence of AKI regardless of GCS multiplied risk of death 6.17 times (95% confidence interval (CI): 1.37 to 27.78) (P < 0.02), while ICU hypotension increased the risk of death in patients with initial scores of 3 to 5 on the GCS 4.28 times (95% CI: 1.22 to 15.07) (P < 0.05). CONCLUSIONS: Low initial GCS, worst first CT scan, intracranial hypertension and AKI determined hospital mortality in severe TBI patients. Besides the direct effect of low GCS on mortality, this neurological condition also is associated with ICU hypotension which increases hospital mortality among patients with severe TBI. These findings add to previous studies that showed that non-neurological complications increase the length of stay and morbidity in the ICU but do not increase mortality, with the exception of AKI and hypotension in low GCS (3 to 5).

Refractory nonconvulsive status epilepticus in Creutzfeldt-Jakob disease.

Creutzfeldt-Jakob disease (CJD) is a rare human transmissible spongiform subacute encephalopathy. The most common clinical manifestations of CJD include rapidly progressive dementia, behavioural changes, cerebellar dysfunction and myoclonus. Other seizure types are rare and nonconvulsive status epilepticus (SE) is exceptional. We report a case of a 44-year-old man who presented a psychotic episode followed by akinetic mutism and refractory nonconvulsive SE. The final diagnosis was CJD. Continuous video-EEG monitoring revealed the ictal pattern of nonconvulsive SE to be periodic sharp wave complexes characteristic of CJD. [Published with video sequences].

First CT findings and improvement in GOS and GOSE scores 6 and 12 months after severe traumatic brain injury.

PRIMARY OBJECTIVE: To analyse the association between individual initial computerized tomography (CT) scan characteristics and Glasgow Outcome Scale (GOS) and Extended Glasgow Outcome Scale (GOSE) improvement between 6 months and 1 year. METHODS AND PROCEDURES: Two hundred and twenty-four adult patients with severe traumatic brain injury and Glasgow Coma Scale (GCS) score of 8 or less who were admitted to an intensive care unit were studied. GOS and GOSE scores were obtained 6 and 12 months after injury in 203 subjects. Patients were predominantly male (84%) and median age was 35 years. MAIN OUTCOMES AND RESULTS: Traumatic Coma Data Bank (TCDB) CT classification was associated with GOS/GOSE improvement between 6 months and 1 year, with diffuse injury type I, type II and evacuated mass improving more than diffuse injury type III, type IV and non-evacuated mass; for GOS 43/155 (28%) vs 3/48 (6%) (chi(2) = 9.66, p < 0.01) and for GOSE 71/155 (46%) vs 7/48 (15%) (chi(2) = 15.1, p < 0.01). CT individual abnormalities were not associated with GOS/GOSE improvement, with the exception of subarachnoid haemorrhage, which showed a negative association with GOSE improvement (chi(2) = 4.08, p < 0.05). CONCLUSIONS: TCDB CT scan classification and subarachnoid haemorrhage were associated with GOS/GOSE improvement from 6-12 months, but individual CT abnormalities were not associated.

Is C-reactive protein a biomarker for immediate clinical outcome after cardiac surgery?

OBJECTIVE: The purpose of this study was to determine the possible correlation between inflammatory activation after cardiac surgery with cardiopulmonary bypass, measured by postoperative C-reactive protein concentrations, and immediate intensive care unit outcome. DESIGN: A prospective, clinical cohort study. SETTING: A 10-bed surgical intensive care unit at a tertiary university hospital. PATIENTS: Two hundred sixteen consecutive patients undergoing nonemergency cardiac surgery with cardiopulmonary bypass. MEASUREMENTS AND MAIN RESULTS: Parsonnet and Acute Physiology and Chronic Health Evaluation scores, characteristics of the surgical intervention, intensive care unit length of stay, and mortality were recorded along with the following variables: cardiac (hours requiring inotropic support and new atrial fibrillation), respiratory (oxygenation index and hours requiring intubation), renal (difference between serum creatinine at admission and maximum creatinine), and analytic (C-reactive protein at admission and 6, 24, and 48 hours later; troponin I; CK-MB; and lactate). RESULTS: Postoperative C-reactive protein concentrations did not correlate with variables such as time requiring inotropic support or intubation, oxygenation index, delta serum creatinine, and intensive care unit length of stay (with the exception of cardiopulmonary bypass time and the more frequent norepinephrine requirement in patients with higher C-reactive protein concentration at 48 hours); nor did C-reactive protein correlate with the analytic variables (with the exception of the lactate peak and C-reactive protein concentrations at 24 and 48 hours). There was no correlation between C-reactive protein and postoperative variables for coronary artery bypass graft surgery and valvular groups analyzed separately. CONCLUSION: Postoperative C-reactive protein does not seem to be a useful marker in predicting outcome after 48 hours in the intensive care unit.

Improvement in GOS and GOSE scores 6 and 12 months after severe traumatic brain injury.

PRIMARY OBJECTIVE: To assess improvements in Glasgow Outcome Scale (GOS) and GOS extended (GOSE) scores between 6 months and 1 year following severe traumatic brain injury (TBI). METHODS AND PROCEDURES: One studied 214 adult patients with severe TBI with Glasgow Coma Scale (GCS) <9 admitted to Intensive Care Unit (ICU). GOS scores were obtained 6 and 12 months after injury in 195 subjects. Patients were predominantly male (84%) and median age was 35 years. MAIN OUTCOMES AND RESULTS: Outcome (GOS and GOSE at 6 months and 1 year) was better in the high GCS score at admission (6-8) group than in the low score group (3-5). The improvement in GOS scores between 6 months and 1 year was greater in the high GCS score at admission group than in the low score group. At 6 months, 75 patients had died and 120 survived. None died between the 6-12-month assessments; at 12 months, 36% had improved GOS score. CONCLUSIONS: GOS scores improved between 6-12 months after severe TBI in 36% of survivors and it is concluded that the expectancy of improvement is incomplete at 6 months. This improvement was greater in patients with better GCS scores (6-8) at admission than in those with worse GCS scores (3-5).