Post-intensive care syndrome and health-related quality of life in long-term survivors of cardiac arrest: a prospective cohort study.

Patients discharged from intensive care are at risk for post-intensive care syndrome (PICS), which consists of physical, psychological, and/or neurological impairments. This study aimed to analyze PICS at 24 months follow-up, to identify potential risk factors for PICS, and to assess health-related quality of life in a long-term cohort of adult cardiac arrest survivors. This prospective cohort study included adult cardiac arrest survivors admitted to the intensive care unit of a Swiss tertiary academic medical center. The primary endpoint was the prevalence of PICS at 24 months follow-up, defined as impairments in physical (measured through the European Quality of Life 5-Dimensions-3-Levels instrument [EQ-5D-3L]), neurological (defined as Cerebral Performance Category Score > 2 or Modified Rankin Score > 3), and psychological (based on the Hospital Anxiety and Depression Scale and the Impact of Event Scale-Revised) domains. Among 107 cardiac arrest survivors that completed the 2-year follow-up, 46 patients (43.0%) had symptoms of PICS, with 41 patients (38.7%) experiencing symptoms in the physical domain, 16 patients (15.4%) in the psychological domain, and 3 patients (2.8%) in the neurological domain. Key predictors for PICS in multivariate analyses were female sex (adjusted odds ratio [aOR] 3.17, 95% CI 1.08 to 9.3), duration of no-flow interval during cardiac arrest (minutes) (aOR 1.17, 95% CI 1.02 to 1.33), post-discharge job-loss (aOR 31.25, 95% CI 3.63 to 268.83), need for ongoing psychological support (aOR 3.64, 95% CI 1.29 to 10.29) or psychopharmacologic treatment (aOR 9.49, 95% CI 1.9 to 47.3), and EQ-visual analogue scale (points) (aOR 0.88, 95% CI 0.84 to 0.93). More than one-third of cardiac arrest survivors experience symptoms of PICS 2 years after resuscitation, with the highest impairment observed in the physical and psychological domains. However, long-term survivors of cardiac arrest report intact health-related quality of life when compared to the general population. Future research should focus on appropriate prevention, screening, and treatment strategies for PICS in cardiac arrest patients.

Cardiopulmonary Resuscitation: Clinical Updates and Perspectives.

Cardiopulmonary resuscitation (CPR) stands as a cornerstone in emergency care, representing the crucial link between life and death for victims of cardiac arrest [...].

Efficacy and Tolerability of Intranasal Midazolam Administration for Antiseizure Treatment in Adults: A Systematic Review.

OBJECTIVE: The objective of this study was to assess the efficacy and tolerability of intranasal midazolam (in-MDZ) administration for antiseizure treatment in adults. METHODS: Embase and Medline literature databases were searched. We included randomized trials and cohort studies (excluding case series) of adult patients (≥ 18 years of age) examining in-MDZ administration for epilepsy, epileptic seizures, or status epilepticus published in English between 1985 and 2022. Studies were screened for eligibility based on predefined criteria. The primary outcome was the efficacy of in-MDZ administration, and the secondary outcome was its tolerability. Extracted data included study design, patient characteristics, intervention details, and outcomes. Risk of bias was assessed using the Cochrane Risk of Bias Tool. RESULTS: A total of 12 studies with 929 individuals treated with in-MDZ were included. Most studies were retrospective, with their number increasing over time. Administered in-MDZ doses ranged from 2.5 to 20 mg per single dose. The mean proportion of successful seizure termination after first in-MDZ administration was 72.7% (standard deviation [SD] 18%), and the proportion of seizure recurrence or persistent seizures ranged from 61 to 75%. Most frequent adverse reactions to in-MDZ were dizziness (mean 23.5% [SD 38.6%]), confusion (one study; 17.4%), local irritation (mean 16.6% [SD 9.6%]), and sedation (mean 12.7% [SD 9.7%]). CONCLUSIONS: Administration of in-MDZ seems promising for the treatment of prolonged epileptic seizures and seizure clusters in adults. Limited evidence suggests that intranasal administration is safe. Further research is warranted because of the heterogeneity of cohorts, the variation in dosages, and the lack of uniformity in defining successful seizure termination.

Prediction of outcomes after cardiac arrest by a generative artificial intelligence model.

Aims: To investigate the prognostic accuracy of a non-medical generative artificial intelligence model (Chat Generative Pre-Trained Transformer 4 - ChatGPT-4) as a novel aspect in predicting death and poor neurological outcome at hospital discharge based on real-life data from cardiac arrest patients. Methods: This prospective cohort study investigates the prognostic performance of ChatGPT-4 to predict outcomes at hospital discharge of adult cardiac arrest patients admitted to intensive care at a large Swiss tertiary academic medical center (COMMUNICATE/PROPHETIC cohort study). We prompted ChatGPT-4 with sixteen prognostic parameters derived from established post-cardiac arrest scores for each patient. We compared the prognostic performance of ChatGPT-4 regarding the area under the curve (AUC), sensitivity, specificity, positive and negative predictive values, and likelihood ratios of three cardiac arrest scores (Out-of-Hospital Cardiac Arrest [OHCA], Cardiac Arrest Hospital Prognosis [CAHP], and PROgnostication using LOGistic regression model for Unselected adult cardiac arrest patients in the Early stages [PROLOGUE score]) for in-hospital mortality and poor neurological outcome. Results: Mortality at hospital discharge was 43% (n = 309/713), 54% of patients (n = 387/713) had a poor neurological outcome. ChatGPT-4 showed good discrimination regarding in-hospital mortality with an AUC of 0.85, similar to the OHCA, CAHP, and PROLOGUE (AUCs of 0.82, 0.83, and 0.84, respectively) scores. For poor neurological outcome, ChatGPT-4 showed a similar prediction to the post-cardiac arrest scores (AUC 0.83). Conclusions: ChatGPT-4 showed a similar performance in predicting mortality and poor neurological outcome compared to validated post-cardiac arrest scores. However, more research is needed regarding illogical answers for potential incorporation of an LLM in the multimodal outcome prognostication after cardiac arrest.

Misconceptions and do-not-resuscitate preferences of healthcare professionals commonly involved in cardiopulmonary resuscitations: A national survey.

Aims: To assess the DNR preferences of critical care-, anesthesia- and emergency medicine practitioners, to identify factors influencing decision-making, and to raise awareness for misconceptions concerning CPR outcomes. Methods: A nationwide multicenter survey was conducted in Switzerland confronting healthcare professionals with a case vignette of an adult patient with an out-of-hospital cardiac arrest (OHCA). The primary outcome was the rate of DNR Code Status vs. CPR Code Status when taking the perspective from a clinical case vignette of a 70-year-old patient. Secondary outcomes were participants' personal preferences for DNR and estimates of survival with good neurological outcome after in- and out-of-hospital cardiac arrest. Results: Within 1803 healthcare professionals, DNR code status was preferred in 85% (n = 1532) in the personal perspective of the case vignette and 53.2% (n = 932) when making a decision for themselves. Main predictors for a DNR Code Status regarding the case vignette included preferences for DNR Code Status for themselves (n [%] 896 [58.5] vs. 87 [32.1]; adjusted odds ratio [OR] 2.97, 95% confidence interval [CI] 2.25-3.92; p < 0.001) and lower estimated OHCA survival (mean [±SD] 12.3% [±11.8] vs. 14.7%[±12.8]; adjusted OR 0.98, 95% CI 0.97-0.99; p = 0.001). Physicians chose a DNR order more often when compared to nurses and paramedics. Conclusions: The estimation of outcomes following cardiac arrest and personal living conditions are pivotal factors influencing code status preferences in healthcare professionals. Healthcare professionals should be aware of cardiac arrest prognosis and potential implications of personal preferences when engaging in code status- and end-of-life discussions with patients and their relatives.

Association Between Dose Escalation of Anesthetics and Outcomes in Patients With Refractory Status Epilepticus.

BACKGROUND AND OBJECTIVES: To investigate the association between dose escalation of continuously administered IV anesthetics and its duration with short-term outcomes in adult patients treated for refractory status epilepticus (RSE). METHODS: Clinical and electroencephalographic data of patients with RSE without hypoxic-ischemic encephalopathy who were treated with anesthetics at a Swiss academic medical center from 2011 to 2019 were assessed. The frequency of anesthetic dose escalation (i.e., dose increase) and its associations with in-hospital death or return to premorbid neurologic function were primary endpoints. Multivariable logistic regression analysis was performed to identify associations with endpoints. RESULTS: Among 111 patients with RSE, doses of anesthetics were escalated in 57%. Despite patients with dose escalation having a higher morbidity (lower Glasgow Coma Scale [GCS] score at status epilepticus [SE] onset, more presumably fatal etiologies, longer duration of SE and intensive care, more infections, and arterial hypotension) as compared with patients without, the primary endpoints did not differ between these groups in univariable analyses. Multivariable analyses revealed decreased odds for death with dose escalation (odds ratio 0.09, 95% CI 0.01-0.86), independent of initial GCS score, presumably fatal etiology, SE severity score, SE duration, and nonconvulsive SE with coma, with similar functional outcome among survivors compared with patients without dose escalation. DISCUSSION: Our study reveals that anesthetic dose escalation in adult patients with RSE is associated with decreased odds for death without increasing the proportion of surviving patients with worse neurofunctional state than before RSE. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that anesthetic dose escalation decreases the odds of death in patients with RSE.

Concurrence of seizures and peri-ictal delirium in the critically ill - its frequency, associated characteristics, and outcomes.

BACKGROUND: To assess the frequency, clinical features, and outcome of peri-ictal delirium in adult patients experiencing seizures during intensive care. METHODS: This observational study was conducted at a Swiss intensive care unit from 2015 to 2020. Patients aged ≥ 18 years with seizures were categorized as peri-ictal delirious (Intensive Care Delirium Screening Checklist [i.e., ICDSC] ≥ 4) or not (i.e., ICDSC < 4) within 24 h of seizures. The frequency of peri-ictal delirium and in-hospital death were defined as the primary endpoints. Illness severity and treatment characteristics between delirious and non-delirious patients were secondary endpoints. Logistic regression was used to compare in-hospital death and differences regarding clinical characteristics between delirious and non-delirious patients. RESULTS: 48% of 200 patients had peri-ictal delirium for a median of 3 days. Delirious patients were older (median age 69 vs. 62 years, p = 0.002), had lower Simplified Acute Physiology Scores II (SAPS II; median 43 vs. 54, p = 0.013), received neuroleptics more frequently (31 vs. 5%, p < 0.001), were mechanically ventilated less often (56% vs. 73%, p = 0.013) and shorter (median 3 vs. 5 days, p = 0.011), and had decreased odds for in-hospital death with delirium (OR = 0.41, 95% CI 0.20-0.84) in multivariable analyses. CONCLUSIONS: Delirium emerged in every second patient experiencing seizures and was associated with lower SAPS II, shorter mechanical ventilation, and better outcomes, contradicting assumptions that altered cerebral function, from seizures and delirium, are linked to unfavorable outcomes.

Venoarterial extracorporeal membrane oxygenation in combination with Levosimendan as a bridge to recovery for a case of severe yew intoxication in a 13-year-old patient.

In an adolescent patient with severe yew intoxication and consecutive cardiac arrest, non-responsive to conventional resuscitation necessitating extracorporeal life support, Levosimendan has been implemented in the early acute phase of hemodynamic stabilization, without obvious side effects. However, the additive value of this treatment in severe yew intoxication remains speculative.

Development and validation of the Workplace Learning Inventory in Health Sciences Education: a multimethod study.

Health sciences students face many challenges in regard to clinical practical learning. A better understanding of student learning is required to address student needs in this crucial phase. The theory of self-regulated learning provides a comprehensive view of learning and could serve as a basis for further research. There are instruments to assess self-regulated learning in preclinical academic learning. However, there are no such instruments for workplace learning. The aim of the present study is to provide a comprehensive inventory from which researchers can select those scales that are relevant to their research questions in the investigation of workplace learning. Hence, the aim is to develop and validate a set of scales to assess undergraduates' workplace learning in health sciences education in four areas (cognition, motivation, emotion, and context) on two levels (the learning process level and the metalevel). Study 1 is a qualitative multimethod study to identify indicators and develop items. It integrates the perspectives of students, teachers, and researchers and includes six steps: literature review, interviews, synthesis, item development, expert review, and cognitive pretesting. This study yields a set of scales for each area on both levels. Study 2 is a quantitative study to assess the psychometric properties. The results show acceptable values in terms of unidimensionality, reliability and validity for each of the 31 scales. The newly developed Workplace Learning Inventory is comprehensive; the scales are relevant to workplace learning and short enough that their administration is feasible in the workplace setting. The rigorous process of questionnaire development contributes to the validity of scales. By providing the Workplace Learning Inventory, we hope to encourage research on workplace learning in health sciences education from an educational psychology perspective.

Red blood cell distribution width for the prediction of outcomes after cardiac arrest.

The red blood cell distribution width (RDW) is a routinely available blood marker that measures the variation of the size/volume of red blood cells. The aim of our study was to investigate the prognostic value of RDW in cardiac arrest patients and to assess whether RDW improves the prognostic value of three cardiac arrest-specific risk scores. Consecutive adult cardiac arrest patients admitted to the ICU of a Swiss university hospital were included. The primary outcome was poor neurological outcome at hospital discharge assessed by Cerebral Performance Category. Of 702 patients admitted to the ICU after cardiac arrest, 400 patients (57.0%) survived, of which 323 (80.8%) had a good neurological outcome. Higher mean RDW values showed an independent association with poor neurological outcomes at hospital discharge (adjusted OR 1.27, 95% CI 1.14 to 1.41; p < 0.001). Adding the maximum RDW value to the OHCA- CAHP- and PROLOGUE cardiac arrest scores improved prognostic performance. Within this cohort of cardiac arrest patients, RDW was an independent outcome predictor and slightly improved three cardiac arrest-specific risk scores. RDW may therefore support clinical decision-making.

Sex-related differences in adult patients with status epilepticus: a seven-year two-center observation.

BACKGROUND: Conflicting findings exist regarding the influence of sex on the development, treatment, course, and outcome of status epilepticus (SE). Our study aimed to investigate sex-related disparities in adult SE patients, focusing on treatment, disease course, and outcome at two Swiss academic medical centers. METHODS: In this retrospective study, patients treated for SE at two Swiss academic care centers from Basel and Geneva from 2015 to 2021 were included. Primary outcomes were return to premorbid neurologic function, death during hospital stay and at 30 days. Secondary outcomes included characteristics of treatment and disease course. Associations with primary and secondary outcomes were assessed using multivariable logistic regression. Analysis using propensity score matching was performed to account for the imbalances regarding age between men and women. RESULTS: Among 762 SE patients, 45.9% were women. No sex-related differences were found between men and women, except for older age and lower frequency of intracranial hemorrhages in women. Compared to men, women had a higher median age (70 vs. 66, p = 0.003), had focal nonconvulsive SE without coma more (34.9% vs. 25.5%; p = 0.005) and SE with motor symptoms less often (52.3% vs. 63.6%, p = 0.002). With longer SE duration (1 day vs. 0.5 days, p = 0.011) and a similar proportion of refractory SE compared to men (36.9% vs. 36.4%, p = 0.898), women were anesthetized and mechanically ventilated less often (30.6% vs. 42%, p = 0.001). Age was associated with all primary outcomes in the unmatched multivariable analyses, but not female sex. In contrast, propensity score-matched multivariable analyses revealed decreased odds for return to premorbid neurologic function for women independent of potential confounders. At hospital discharge, women were sent home less (29.7% vs. 43.7%, p < 0.001) and to nursing homes more often (17.1% vs. 10.0%, p = 0.004). CONCLUSIONS: This study identified sex-related disparities in the clinical features, treatment modalities, and outcome of adult patients with SE with women being at a disadvantage, implying that sex-based factors must be considered when formulating strategies for managing SE and forecasting outcomes.

Effects of team leaders' position in cardiopulmonary resuscitation teams on leadership behavior and team performance: A prospective randomized interventional cross-over simulation-based trial.

BACKGROUND: Leadership is an important performance factor in resuscitation teams. Medical guidelines for cardiopulmonary resuscitation (CPR) advise team leaders to keep hands off patients. There is little evidence for this recommendation that is based purely on observational data. Accordingly, the aim of this trial was to investigate the effect of leaders' position during CPR on leadership behavior and team performance. METHOD: This is a prospective randomized interventional crossover simulation-based single center trial. Teams of 3 to 4 physicians each, representing a rapid response team, were confronted with a simulated cardiac arrest. Team leaders were randomly assigned and assigned team leaders were 1:1 randomized to 2 leadership positions: position at the patient's head; and hands-off position. Data analysis was performed from video-recordings. All utterances during the first 4 minutes of CPR were transcribed and coded based on a modified "Leadership Description Questionnaire." The primary endpoint was the number of leadership statements. Secondary outcomes included CPR related performance markers like hands-on time and chest compression rate, and the behavioral related endpoints Decision Making, Error Detection, and Situational Awareness. RESULTS: Data from 40 teams (143 participants) was analyzed. Leaders in hands-off position made more leadership statements (28 ± 8 vs 23 ± 8; P <.01) and contributed more to their team's leadership (59 ± 13% vs 50 ± 17%; P = .01) than leaders in the head position. Leaders' position had no significant effect on their teams' CPR performance, Decision Making, and Error Detection. Increased numbers of leadership statements lead to improved hands-on time ( R = 0.28; 95% confidence interval 0.05-0.48; P = .02). CONCLUSIONS: Team leaders in a hands-off position made more leadership statements and contributed more to their teams' leadership during CPR than team leaders actively involved in the head position. However, team leaders' position had no effect on their teams' CPR performance.

"Do-not-resuscitate" preferences of the general Swiss population: Results from a national survey.

AIMS: To assess the do-not-resuscitate preferences of the general Swiss population and to identify predictors influencing decision-making. Methods: A nationwide web-based survey was conducted in Switzerland on a representative sample of the adult population. The primary endpoint was the preference for a "Do Not Resuscitate" order (DNR Code Status) vs. cardiopulmonary resuscitation (CPR Code Status) in a clinical case vignette of an out-of-hospital cardiac arrest. Secondary endpoint were participants' own personal preferences for DNR. Results: 1138 subjects participated in the web-based survey, 1044 were included in the final analysis. Preference for DNR code status was found in 40.5% (n = 423) in the case vignette and in 20.3% (n = 209) when making a personal decision for themselves. Independent predictors for DNR Code Status for the case vignette were: Personal preferences for their own DNR Code Status (adjusted OR 2.44, 95%CI 1.67 to 3.55; p < 0.001), intubation following respiratory failure (adjusted OR 1.95, 95%CI 1.20 to 3.18; p = 0.007), time-period after which resuscitation should not be attempted (adjusted OR 0.91, 95%CI 0.89 to 0.93); p < 0.001), and estimated chance of survival in case of a cardiac arrest (adjusted OR per decile 0.91, 95%CI 0.84 to 0.99, p = 0.02; which was overestimated by all participants. Conclusions: Main predictors for a DNR Code Status were personal preferences and the overestimation of good neurological outcome after cardiac arrest. Overestimation of positive outcomes after cardiac arrest seems to influence patient opinion and should thus be addressed during code status discussions.

Early timing of anesthesia in status epilepticus is associated with complete recovery: A 7-year retrospective two-center study.

OBJECTIVE: This study was undertaken to investigate the efficacy, tolerability, and outcome of different timing of anesthesia in adult patients with status epilepticus (SE). METHODS: Patients with anesthesia for SE from 2015 to 2021 at two Swiss academic medical centers were categorized as anesthetized as recommended third-line treatment, earlier (as first- or second-line treatment), and delayed (later as third-line treatment). Associations between timing of anesthesia and in-hospital outcomes were estimated by logistic regression. RESULTS: Of 762 patients, 246 received anesthesia; 21% were anesthetized as recommended, 55% earlier, and 24% delayed. Propofol was preferably used for earlier (86% vs. 55.5% for recommended/delayed anesthesia) and midazolam for later anesthesia (17.2% vs. 15.9% for earlier anesthesia). Earlier anesthesia was statistically significantly associated with fewer infections (17% vs. 32.7%), shorter median SE duration (.5 vs. 1.5 days), and more returns to premorbid neurologic function (52.9% vs. 35.5%). Multivariable analyses revealed decreasing odds for return to premorbid function with every additional nonanesthetic antiseizure medication given prior to anesthesia (odds ratio [OR] = .71, 95% confidence interval [CI] = .53-.94) independent of confounders. Subgroup analyses revealed decreased odds for return to premorbid function with increasing delay of anesthesia independent of the Status Epilepticus Severity Score (STESS; STESS = 1-2: OR = .45, 95% CI = .27-.74; STESS > 2: OR = .53, 95% CI = .34-.85), especially in patients without potentially fatal etiology (OR = .5, 95% CI = .35-.73) and in patients experiencing motor symptoms (OR = .67, 95% CI = .48-.93). SIGNIFICANCE: In this SE cohort, anesthetics were administered as recommended third-line therapy in only every fifth patient and earlier in every second. Increasing delay of anesthesia was associated with decreased odds for return to premorbid function, especially in patients with motor symptoms and no potentially fatal etiology.

External validation of the PROLOGUE score to predict neurological outcome in adult patients after cardiac arrest: a prospective cohort study.

BACKGROUND: The PROLOGUE score (PROgnostication using LOGistic regression model for Unselected adult cardiac arrest patients in the Early stages) is a novel prognostic model for the prediction of neurological outcome after cardiac arrest, which showed exceptional performance in the internal validation. The aim of this study is to validate the PROLOGUE score in an independent cohort of unselected adult cardiac arrest patients and to compare it to the thoroughly validated Out-of-Hospital Cardiac Arrest (OHCA) and Cardiac Arrest Hospital Prognosis (CAHP) scores. METHODS: This study included consecutive adult cardiac arrest patients admitted to the intensive care unit (ICU) of a Swiss tertiary teaching hospital between October 2012 and July 2022. The primary endpoint was poor neurological outcome at hospital discharge, defined as a Cerebral Performance Category (CPC) score of 3 to 5 including death. RESULTS: Of 687 patients included in the analysis, 321 (46.7%) survived to hospital discharge with good neurological outcome, 68 (9.9%) survived with poor neurological outcome and 298 (43.4%) died. The PROLOGUE score showed an area under the receiver operating characteristic curve (AUROC) of 0.83 (95% CI 0.80 to 0.86) and good calibration for the prediction of the primary outcome. The OHCA and CAHP score showed similar performance (AUROC 0.83 and 0.84 respectively), the differences between the three scores were not significant (p = 0.495). In a subgroup analysis, the PROLOGUE score performed equally in out-of-hospital and in-hospital cardiac arrest patients whereas the OHCA and CAHP score performed significantly better in OHCA patients. CONCLUSION: The PROLOGUE score showed good prognostic accuracy for the early prediction of neurological outcome in adult cardiac arrest survivors in our cohort and might support early goals-of-care discussions in the ICU. Trial registration Not applicable.

Association Between Induced Burst Suppression and Clinical Outcomes in Patients With Refractory Status Epilepticus: A 9-Year Cohort Study.

BACKGROUND AND OBJECTIVES: To investigate the frequency of induced EEG burst suppression pattern during continuous IV anesthesia (IVAD) and associated outcomes in adult patients treated for refractory status epilepticus (RSE). METHODS: Patients with RSE treated with anesthetics at a Swiss academic care center from 2011 to 2019 were included. Clinical data and semiquantitative EEG analyses were assessed. Burst suppression was categorized as incomplete burst suppression (with ≥20% and <50% suppression proportion) or complete burst suppression (with ≥50% suppression proportion). The frequency of induced burst suppression and association of burst suppression with outcomes (persistent seizure termination, in-hospital survival, and return to premorbid neurologic function) were the endpoints. RESULTS: We identified 147 patients with RSE treated with IVAD. Among 102 patients without cerebral anoxia, incomplete burst suppression was achieved in 14 (14%) with a median of 23 hours (interquartile range [IQR] 1-29) and complete burst suppression was achieved in 21 (21%) with a median of 51 hours (IQR 16-104). Age, Charlson comorbidity index, RSE with motor symptoms, the Status Epilepticus Severity Score and arterial hypotension requiring vasopressors were identified as potential confounders in univariable comparisons between patients with and without any burst suppression. Multivariable analyses revealed no associations between any burst suppression and the predefined endpoints. However, among 45 patients with cerebral anoxia, induced burst suppression was associated with persistent seizure termination (72% without vs 29% with burst suppression, p = 0.004) and survival (50% vs 14% p = 0.005). DISCUSSION: In adult patients with RSE treated with IVAD, burst suppression with ≥50% suppression proportion was achieved in every fifth patient and not associated with persistent seizure termination, in-hospital survival, or return to premorbid neurologic function.

Comparing Patients With Isolated Seizures and Status Epilepticus in Intensive Care Units: An Observational Cohort Study.

BACKGROUND AND OBJECTIVES: To assess the frequency of status epilepticus (SE) among seizing critically ill adult patients and to determine clinical differences between patients with isolated seizures and patients with SE in the intensive care unit (ICU). METHODS: From 2015 to 2020, all consecutive adult ICU patients at a Swiss tertiary care center with isolated seizures or SE as reported by intensivists and/or consulting neurologists were identified by screening of all digital medical, ICU, and EEG records. Patients aged <18 years and patients with myoclonus due to hypoxic-ischemic encephalopathy but without seizures on EEG were excluded. The frequency of isolated seizures, SE, and clinical characteristics at seizure onset associated with SE were the primary outcomes. Uni- and multivariable logistic regression was performed to identify associations with the emergence of SE. RESULTS: Among 404 patients with seizures, 51% had SE. Compared with patients with isolated seizures, patients with SE had a lower median Charlson Comorbidity Index (CCI) (3 vs 5, p < 0.001), fewer fatal etiologies (43.6% vs 80.5%, p < 0.001), higher median Glasgow coma scores (7 vs 5, p < 0.001), fever more frequently (27.5% vs 7.5%, p < 0.001), shorter median ICU and hospital stay (ICU: 4 vs 5 days, p = 0.039; hospital stay: 13 vs 15 days, p = 0.045), and recovered to premorbid function more often (36.8% vs 17%, p < 0.001). Multivariable analyses revealed decreased odds ratios (ORs) for SE with increasing CCI (OR 0.91, 95% CI 0.83-0.99), fatal etiology (OR 0.15, 95% CI 0.08-0.29), and epilepsy (OR 0.32, 95% CI 0.16-0.63). Systemic inflammation was an additional association with SE after excluding patients with seizures as the reason for ICU admission (ORfor CRP 1.01, 95% CI 1.00-1.01; ORfor fever 7.35, 95% CI 2.84-19.0). Although fatal etiologies and increasing CCI remained associated with low odds for SE after excluding anesthetized patients and hypoxic-ischemic encephalopathy, inflammation remained associated in all subgroups except patients with epilepsy. DISCUSSION: Among all ICU patients with seizures, SE emerged frequently and seen in every second patient. Besides the unexpected low odds for SE with higher CCI, fatal etiology, and epilepsy, the association of inflammation with SE in the critically ill without epilepsy represents a potential treatment target and deserves further attention.

Procedures of brain death diagnosis and organ explantation in a tertiary medical centre - a retrospective eight-year cohort study.

AIM OF THE STUDY: To assess the frequency and variables associated with the need for ancillary tests to confirm suspected brain death in adult patients, and to assess the time from brain death to organ explantation in donors. We further sought to identify modifiable factors influencing the time between brain death and start of surgery. METHODS: Medical records and the Swiss organ allocation system registry were screened for all consecutive adult patients diagnosed with brain death at an intensive care unit of a Swiss tertiary medical centre from 2013 to 2020. The frequency and variables associated with the performance of ancillary tests (i.e., transcranial doppler, digital subtraction angiography, and computed tomography angiography) to confirm brain death were primary outcomes; the time from death to organ explantation as well as modifying factors were defined as secondary outcomes. RESULTS: Among 91 patients with a diagnosis of brain death, 15 were not explanted and did not undergo further ancillary tests. Of the remaining 76 patients, who became organ donors after brain death, ancillary tests were performed in 24%, most frequently in patients with hypoxic-ischaemic encephalopathy. The leading presumed causes of death (not mutually exclusive) were haemorrhagic strokes (49%), hypoxic-ischaemic encephalopathies (33%) and severe traumatic brain injuries (22%). Surgery for organ explantation was started within a median of 16 hours (interquartile range [IQR] 13-18) after death with delay increasing over time (nonparametric test for trend p = 0.05), mainly due to organ allocation procedures. Patients with brain death confirmed during night shifts were explanted earlier (during night shifts 14.3 hours, IQR 11.8-16.8 vs 16.3 hours, IQR 13.5-18.5 during day shifts; p = 0.05). CONCLUSIONS: Ancillary tests to confirm brain death are frequently performed, mainly in resuscitated patients. The delay to surgery for organ explantation after confirmed brain death was longer during day shifts, increased over time and was mainly determined by organ allocation procedures.

Predicting neurological outcome in adult patients with cardiac arrest: systematic review and meta-analysis of prediction model performance.

This work aims to assess the performance of two post-arrest (out-of-hospital cardiac arrest, OHCA, and cardiac arrest hospital prognosis, CAHP) and one pre-arrest (good outcome following attempted resuscitation, GO-FAR) prediction model for the prognostication of neurological outcome after cardiac arrest in a systematic review and meta-analysis. A systematic search was conducted in Embase, Medline, and Web of Science Core Collection from November 2006 to December 2021, and by forward citation tracking of key score publications. The search identified 1'021 records, of which 25 studies with a total of 124'168 patients were included in the review. A random-effects meta-analysis of C-statistics and overall calibration (total observed vs. expected [O:E] ratio) was conducted. Discriminatory performance was good for the OHCA (summary C-statistic: 0.83 [95% CI 0.81-0.85], 16 cohorts) and CAHP score (summary C-statistic: 0.84 [95% CI 0.82-0.87], 14 cohorts) and acceptable for the GO-FAR score (summary C-statistic: 0.78 [95% CI 0.72-0.84], five cohorts). Overall calibration was good for the OHCA (total O:E ratio: 0.78 [95% CI 0.67-0.92], nine cohorts) and the CAHP score (total O:E ratio: 0.78 [95% CI 0.72-0.84], nine cohorts) with an overestimation of poor outcome. Overall calibration of the GO-FAR score was poor with an underestimation of good outcome (total O:E ratio: 1.62 [95% CI 1.28-2.04], five cohorts). Two post-arrest scores showed good prognostic accuracy for predicting neurological outcome after cardiac arrest and may support early discussions about goals-of-care and therapeutic planning on the intensive care unit. A pre-arrest score showed acceptable prognostic accuracy and may support code status discussions.