Admission viscoelastic hemostatic assay parameters predict poor long-term intracerebral hemorrhage outcomes.

Background: Viscoelastic hemostatic assays (VHA) provide more comprehensive assessments of coagulation compared to conventional coagulation assays. While VHAs have enabled guided hemorrhage control therapies, improving clinical outcomes in life-threatening hemorrhage, the role of VHAs in intracerebral hemorrhage (ICH) is unclear. If VHAs can identify coagulation abnormalities relevant for ICH outcomes, this would support the need to investigate the role of VHAs in ICH treatment paradigms. Thus, we investigated whether VHA assessments of coagulation relate to long-term ICH outcomes. Methods: Spontaneous ICH patients enrolled into a single-center cohort study receiving admission Rotational Thromboelastometry (ROTEM) VHA testing between 2013 and 2020 were assessed. Patients with prior anticoagulant use or coagulopathy on conventional coagulation assays were excluded. Primary ROTEM exposure variables were coagulation kinetics and clot strength assessments. Poor long-term outcome was defined as modified Rankin Scale ≥ 4 at 6 months. Logistic regression analyses assessed associations of ROTEM parameters with clinical outcomes after adjusting for ICH severity and hemoglobin concentration. Results: Of 44 patients analyzed, mean age was 64, 57% were female, and the median ICH volume was 23 mL. Poor 6-month outcome was seen in 64%. In our multivariable regression models, slower, prolonged coagulation kinetics (adjusted OR for every second increase in clot formation time: 1.04, 95% CI: 1.00-1.09, p = 0.04) and weaker clot strength (adjusted OR for every millimeter increase of maximum clot firmness: 0.84, 95% CI: 0.71-0.99, p = 0.03) were separately associated with poor long-term outcomes. Conclusions: Slower, prolonged coagulation kinetics and weaker clot strength on admission VHA ROTEM testing, not attributable to anticoagulant use, were associated with poor long-term outcomes after ICH. Further work is needed to clarify the generalizability and the underlying mechanisms of these VHA findings to assess whether VHA guided treatments should be incorporated into ICH care.

ABO blood type and thromboembolic complications after intracerebral hemorrhage: An exploratory analysis.

BACKGROUND AND PURPOSE: Non-O blood types are known to be associated with thromboembolic complications (TECs) in population-based studies. TECs are known drivers of morbidity and mortality in intracerebral hemorrhage (ICH) patients, yet the relationships of blood type on TECs in this patient population are unknown. We sought to explore the relationships between ABO blood type and TECs in ICH patients. METHODS: Consecutive adult ICH patients enrolled into a prospective observational cohort study with available ABO blood type data were analyzed. Patients with cancer history, prior thromboembolism, and baseline laboratory evidence of coagulopathy were excluded. The primary exposure variable was blood type (non-O versus O). The primary outcome was composite TEC, defined as pulmonary embolism, deep venous thrombosis, ischemic stroke or myocardial infarction, during the hospital stay. Relationships between blood type, TECs and clinical outcomes were separately assessed using logistic regression models after adjusting for sex, ethnicity and ICH score. RESULTS: Of 301 ICH patients included for analysis, 44% were non-O blood type. Non-O blood type was associated with higher admission GCS and lower ICH score on baseline comparisons. We identified TECs in 11.6% of our overall patient cohort. . Although TECs were identified in 9.9% of non-O blood type patients compared to 13.0% in O blood type patients, we did not identify a significant relationship of non-O blood type with TECs (adjusted OR=0.776, 95%CI: 0.348-1.733, p=0.537). The prevalence of specific TECs were also comparable in unadjusted and adjusted analyses between the two cohorts. In additional analyses, we identified that TECs were associated with poor 90-day mRS (adjusted OR=3.452, 95% CI: 1.001-11.903, p=0.050). We did not identify relationships between ABO blood type and poor 90-day mRS (adjusted OR=0.994, 95% CI:0.465-2.128, p=0.988). CONCLUSIONS: We identified that TECs were associated with worse ICH outcomes. However, we did not identify relationships in ABO blood type and TECs. Further work is required to assess best diagnostic and prophylactic and treatment strategies for TECs to improve ICH outcomes.

Lower perceived social support is significantly associated with elevated levels of psychological distress in racially and ethnically diverse close family members of cardiac arrest survivors.

Background: Poor perceived social support has been associated with worse psychological distress in close family members after their loved one's hospitalization with prolonged mechanical ventilation, but never been tested after cardiac arrest. Methods: Close family members of consecutive cardiac arrest patients hospitalized at an academic tertiary care center were recruited before hospital discharge, and perceived social support was assessed using the Multidimensional Scale of Perceived Social Support (MSPSS). Indicators of psychological distress were administered via telephone at 1 month after cardiac arrest. Multivariate linear regressions were used to estimate the associations between MSPSS total score and total Patient Health Questionnaire-8 (PHQ-8) score (primary outcome) and total PTSD (PCL-5) and generalized anxiety (GAD-2) scores, after adjusting for previously known covariates. Results: Of 102 close family members (mean age 52 ± 15 years, 70% female, 40% non-Hispanic white, 21% Black, 33% Hispanic/Latinx, 22% with pre-existing psychiatric illness) with complete data, the mean PHQ-8 total score at a median duration of 28.5 days (interquartile range 10-63 days) from cardiac arrest was 7± 6, and the mean MSPSS score was 69 ± 15. Lower perceived social support was significantly associated with elevated levels of depressive symptoms in univariate (ß=-0.11; p<0.01) and after adjusting for age, sex, race/ethnicity, and previous psychiatric history (ß=-0.11; p<0.01). Similar inverse associations were seen with 1 month PTSD and generalized anxiety symptoms as secondary outcomes. Conclusions: Close family members of cardiac arrest survivors' perception of poor social support during hospitalization is associated with increased levels of depressive symptoms at 1 month. Longitudinal studies understanding the temporal associations between social support and psychological distress are warranted.

A shift towards targeted post-ICU treatment: Multidisciplinary care for cardiac arrest survivors.

Intensive Care Unit (ICU) survivorship comprises a burgeoning area of critical care medicine, largely due to our improved understanding of and concern for patients' recovery trajectory, and efforts to mitigate the post-acute complications of critical illness. Expansion of care beyond hospitalization is necessary, yet evidence for post-ICU clinics remains limited and mixed, as both interventions and target populations studied to date are too heterogenous to meaningfully demonstrate efficacy. Here, we briefly present the existing evidence and limitations related to post-ICU clinics, identify cardiac arrest survivors as a unique ICU subpopulation warranting further investigation and treatment, and propose a clinical framework that addresses the multifaceted needs of this well-defined patient population.

Primary and Secondary Intracerebral Hemorrhage in Pregnant and Nonpregnant Young Adults by SMASH-UP Criteria.

BACKGROUND: Intracerebral hemorrhage (ICH) is a major cause of maternal morbidity, but its pathophysiology is poorly characterized. We investigated characteristics of pregnancy-associated ICH (P-ICH), compared with ICH in similar aged nonpregnant adults of both sexes. METHODS AND RESULTS: We performed a retrospective analysis of 134 adults aged 18 to 44 years admitted to our center with nontraumatic ICH from January 1, 2012, to December 31, 2021. We compared ICH characteristics among 3 groups: those with P-ICH (pregnant or within 12 months of end of pregnancy); nonpregnant women; and men. We categorized ICH pathogenesis according to a modified scheme, SMASH-UP (structural, medications, amyloid angiopathy, systemic, hypertension, undetermined, posterior reversible encephalopathy syndrome/reversible cerebral vasoconstriction syndrome), and calculated odds ratios and 95% CIs for primary (spontaneous small-vessel) ICH versus secondary ICH (structural lesions or coagulopathy related), using nonpregnant women as the reference. We also compared specific ICH pathogenesis by SMASH-UP criteria and functional outcomes between groups. Of 134 young adults with nontraumatic ICH, 25 (19%) had P-ICH, of which 60% occurred postpartum. Those with P-ICH had higher odds of primary ICH compared with nonpregnant women (adjusted odds ratio, 4.5 [95% CI, 1.4-14.7]). The odds of primary ICH did not differ between men and nonpregnant women. SMASH-UP pathogenesis for ICH differed significantly between groups (P<0.001). While the in-hospital mortality rate was lowest in the P-ICH group (4%) compared with nonpregnant women (13%) and men (24%), 1 in 4 patients with P-ICH were bedbound and dependent at the time of discharge. CONCLUSIONS: In our cohort of young adults with ICH, 1 in 5 was pregnancy related. P-ICH differed in pathogenesis compared with non-pregnancy-related ICH in young adults, suggesting unique pathophysiology.

Feasibility of a remote heart rate variability biofeedback intervention for reducing anxiety in cardiac arrest survivors: A pilot trial.

Background: Heart rate variability biofeedback (HRVB) is a promising non-pharmacologic approach for reducing anxiety. This intervention's feasibility needs testing in psychologically distressed cardiac patients for whom heart-related anxiety is a core concern. To enhance scalability and convenience, remote delivery of HRVB also needs to be assessed. Accordingly, we evaluated the feasibility of remote HRVB in survivors of cardiac arrest (CA) with elevated CA-related psychological distress. Methods: The intervention was comprised of daily sessions of diaphragmatic paced breathing and real-time monitoring of cardiac activity guided by a smartphone app and heart rate monitor. This single-arm feasibility trial assessed the percentage of eligible contacted patients who consented and engaged in the study and the self-reported acceptability, feasibility, appropriateness, and usability of the intervention. Exploratory analyses assessed pre-to-post changes in trait anxiety, negative affect, cardiac-related interoceptive fear, and resting-state HRV. Results: Of 12 eligible CA survivors contacted, 10 enrolled. All 10 patients completed the virtual study visits and the majority (>50 %) of prescribed training sessions. Ninety percent reported good scores for intervention acceptability and feasibility, and 80 % reported good scores for its appropriateness and usability for reducing fear. Trait anxiety decreased significantly pre-to-post intervention. There were no changes in negative affect, interoceptive fear, or resting state HRV. Conclusion: A remotely delivered HRVB intervention was acceptable, feasible, and useable for cardiac patients with CA-related psychological distress. A phase 2 randomized controlled trial evaluating the efficacy of HRVB on cardiac patients' psychological distress, health behaviors, and autonomic dysfunction may be warranted.

Association between cardiac event-induced PTSD symptoms and daily intrusive thoughts about cardiac risk: An ecological momentary assessment study.

OBJECTIVE: Posttraumatic stress symptoms (PSS) due to acute cardiac events are common and may lead patients to avoid secondary prevention behaviors. However, patients' daily experience of cardiac event-induced PSS has not been studied after a potentially traumatic cardiac hospitalization. METHOD: In an observational cohort study, 108 mostly male patients with coronary heart disease were recruited after evaluation for suspected acute coronary syndrome (ACS). One month later, PSS were assessed via telephone-administered PTSD Checklist for DSM-5 (PCL-5). The exposure of interest was elevated (PCL-5 ≥ 20) vs. non-elevated PSS (PCL-5 ≤ 5). The occurrence and severity of cardiac-related intrusive thoughts were assessed 5 times daily for 2 weeks via electronic surveys on a wrist-worn device. RESULTS: Moderate-to-severe intrusive thoughts were experienced by 48.1% of patients but more commonly by elevated-PSS (n = 36; 66.7%) than non-elevated-PSS (n = 72; 38.9%) patients. After adjustment for demographic and clinical characteristics, elevated- vs. non-elevated-PSS patients had a 9-fold higher odds of experiencing a moderate-to-severe intrusive thought during each 2-h assessment interval (adjusted OR = 9.14, 95% CI [2.99, 27.92], p < .01). After adjustment, intrusive thoughts on a 0-to-6 point scale were over two times as intense for elevated-PSS vs. non-elevated-PSS patients. CONCLUSIONS: Intrusive thoughts about cardiac risk were common in patients recently evaluated for ACS, but much more prevalent and intense in those with elevated vs non-elevated PSS.

Prioritizing intervention preferences to potentially reduce caregiver burden in racially and ethnically diverse close family members of cardiac arrest survivors.

AIM: Close family members of cardiac arrest patients who survive to hospital discharge have elevated levels of psychological distress and caregiver burden. We assessed their preferences toward needs during hospitalization and beyond to inform intervention development. METHODS: Through an online survey developed by a multidisciplinary team of researchers, clinicians, cardiac arrest survivors, and families, adult close family members recruited through advocacy organizations ranked top choice among 8 unique interventions addressing either information-based needs (n = 4) or well-being needs (n = 4). Logistic Regression analysis was conducted to assess the associations of family members' attributes, caregiving characteristics, and survivors' hospitalization factors with two intervention groups. RESULTS: Of 657 responses received, ranking data of 550 close family members (59% between 18-40 years of age, 65% female, 51% of minority race/ethnicity, 53% partners, provided a median of 8 hours of caregiving, for a median of 4.5 months) were analyzed. Information needs were the more commonly preferred intervention group (63%; n = 347), with education on the potential recovery of survivors ranking first (28%; n = 149). In a multivariate model, family members age >40 years, families witnessing the cardiac arrest, assuming the caregiver role either during hospitalization or within one month of hospital discharge, and discharging directly to home were significantly associated with prioritizing information needs over well-being needs, after adjusting for sex, race, intensity, and duration of caregiving. CONCLUSIONS: Interventions focusing on information needs are among the top priorities for families of cardiac arrest survivors. Prospective studies testing these hypotheses-generating findings are needed to inform further intervention development.

The Latest in Resuscitation Research: Highlights From the 2022 American Heart Association's Resuscitation Science Symposium.

BACKGROUND: Every year the American Heart Association's Resuscitation Science Symposium (ReSS) brings together a community of international resuscitation science researchers focused on advancing cardiac arrest care. METHODS AND RESULTS: The American Heart Association's ReSS was held in Chicago, Illinois from November 4th to 6th, 2022. This annual narrative review summarizes ReSS programming, including awards, special sessions and scientific content organized by theme and plenary session. CONCLUSIONS: By exploring both the science of resuscitation and important related topics including survivorship, disparities, and community-focused programs, this meeting provided important resuscitation updates.

Suboptimal Cerebral Perfusion is Associated with Ischemia After Intracerebral Hemorrhage.

BACKGROUND: Remote ischemic lesions on diffusion-weighted imaging (DWI) occur in one third of patients with intracerebral hemorrhage (ICH) and are associated with worse outcomes. The etiology is unclear and not solely due to blood pressure reduction. We hypothesized that impaired cerebrovascular autoregulation and hypoperfusion below individualized lower limits of autoregulation are associated with the presence of DWI lesions. METHODS: This was a retrospective, single-center study of all primary ICH with intraparenchymal pressure monitoring within 10 days from onset and subsequent magnetic resonance imaging. Pressure reactivity index was calculated as the correlation coefficient between mean arterial pressure and intracranial pressure. Optimal cerebral perfusion pressure (CPPopt) is the cerebral perfusion pressure (CPP) with the lowest corresponding pressure reactivity index. The difference between CPP and CPPopt, time spent below the lower limit of autoregulation (LLA), and time spent above the upper limit of autoregulation (ULA) were calculated by using mean hourly physiologic data. Univariate associations between physiologic parameters and DWI lesions were analyzed by using binary logistic regression. RESULTS: A total of 505 h of artifact-free data from seven patients without DWI lesions and 479 h from six patients with DWI lesions were analyzed. Patients with DWI lesions had higher intracranial pressure (17.50 vs. 10.92 mm Hg; odds ratio 1.14, confidence interval 1.01-1.29) but no difference in mean arterial pressure or CPP compared with patients without DWI lesions. The presence of DWI lesions was significantly associated with a greater percentage of time spent below the LLA (49.85% vs. 14.70%, odds ratio 5.77, confidence interval 1.88-17.75). No significant association was demonstrated between CPPopt, the difference between CPP and CPPopt, ULA, LLA, or time spent above the ULA between groups. CONCLUSIONS: Blood pressure reduction below the LLA is associated with ischemia after acute ICH. Individualized, autoregulation-informed targets for blood pressure reduction may provide a novel paradigm in acute management of ICH and require further study.

Acceptance and Mindfulness-Based Exposure Therapy for PTSD After Cardiac Arrest: An Open Feasibility Trial.

Background: Posttraumatic stress disorder (PTSD) is prevalent after surviving sudden cardiac arrest (SCA). SCA-induced PTSD is associated with increased mortality and cardiovascular risk, yet no psychotherapeutic treatment has been developed and tested for this population. Exposure therapy is standard treatment for PTSD, but its safety and efficacy remain unconfirmed for SCA survivors: current protocols do not address their specific disease course and have high attrition. Mindfulness-based interventions are typically well-tolerated and have shown promise in reducing PTSD symptoms from other traumas.Objective: This study sought to determine feasibility, safety, and preliminary efficacy of acceptance and mindfulness-based exposure therapy (AMBET), a novel SCA-specific psychotherapy protocol combining mindfulness and exposure-based interventions with cardiac focused psychoeducation to reduce symptoms and improve health behaviors in patients with post-SCA PTSD.Methods: We conducted an open feasibility pilot study from January 2021 to April 2022 with a small sample (N = 11) of SCA survivors meeting DSM-5 PTSD criteria. AMBET comprised eight 90-minute remotely delivered individual sessions. Clinical evaluators assessed PTSD symptoms using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) at baseline, midpoint, posttreatment, and 3-month follow-up.Results: Ten (91%) of 11 enrolled patients completed treatment. Satisfaction was high and patients reported no adverse events. PTSD symptoms significantly improved statistically (P < .001) and clinically with large effect sizes (g = 1.34-2.21) and treatment gains sustained at 3-month follow-up. Posttreatment, 80% of completers (n = 8) showed significant treatment response, 70% (n = 7) with PTSD diagnostic remission. No patient reported symptom increases.Conclusions: This initial trial found AMBET feasible, safe, and potentially efficacious in reducing PTSD following SCA. These encouraging pilot results warrant further research.Trial Registration: ClinicalTrials.gov identifier: NCT04596891.

ABO Blood Type and Thromboembolic Complications after Intracerebral Hemorrhage: an exploratory analysis.

Background and Purpose: Non-O blood types are known to be associated with thromboembolic complications (TECs) in population-based studies. TECs are known drivers of morbidity and mortality in intracerebral hemorrhage (ICH) patients, yet the relationships of blood type on TECs in this patient population are unknown. We sought to explore the relationships between ABO blood type and TECs in ICH patients. Methods: Consecutive adult ICH patients enrolled into a prospective observational cohort study with available ABO blood type data were analyzed. Patients with cancer history, prior thromboembolism, and baseline laboratory evidence of coagulopathy were excluded. The primary exposure variable was blood type (non-O versus O). The primary outcome was composite TEC, defined as pulmonary embolism, deep venous thrombosis, ischemic stroke or myocardial infarction, during the hospital stay. Relationships between blood type, TECs and clinical outcomes were separately assessed using logistic regression models after adjusting for sex, ethnicity and ICH score. Results: Of 301 ICH patients included for analysis, 44% were non-O blood type. Non-O blood type was associated with higher admission GCS and lower ICH score on baseline comparisons. We identified TECs in 11.6% of our overall patient cohort. Although TECs were identified in 9.9% of non-O blood type patients compared to 13.0% in O blood type patients, we did not identify a significant relationship of non-O blood type with TECs (adjusted OR = 0.776, 95%CI: 0.348-1.733, p = 0.537). The prevalence of specific TECs were also comparable in unadjusted and adjusted analyses between the two cohorts. In additional analyses, we identified that TECs were associated with poor 90-day mRS (adjusted OR = 3.452, 95% CI: 1.001-11.903, p = 0.050). We did not identify relationships between ABO blood type and poor 90-day mRS (adjusted OR = 0.994, 95% CI:0.465-2.128, p = 0.988). Conclusions: We identified that TECs were associated with worse ICH outcomes. However, we did not identify relationships in ABO blood type and TECs. Further work is required to assess best diagnostic and prophylactic and treatment strategies for TECs to improve ICH outcomes.

Heart rate and heart rate variability as a prognosticating feature for functional outcome after cardiac arrest: A scoping review.

Background: Despite significant progress in cardiopulmonary resuscitation and post-cardiac arrest care, favorable outcome in out-of hospital sudden cardiac arrest patients remains low. One of the main reasons for mortality in these patients is withdrawal of life-sustaining treatment. There is a need for precise and equitable prognostication tools to support families in avoiding premature or inappropriate WLST. Heart rate (HR) and heart rate variability (HRV) have been noted for their association with outcome, and are positioned to be a useful modality for prognostication. Objectives: The aim of this scoping review is to rigorously explore which electrocardiography features have been shown to predict functional outcome in post-cardiac arrest patients. Methods: The search was performed in Pubmed, EMBASE, and SCOPUS for studies published from January 1, 2011, to September 29, 2022, including papers in English or Korean. Results: Seven studies were included with a total of 1359 patients. Four studies evaluated HR, one study evaluated RR inverval, and two studies evaluated HRV. All studies were retrospective, with 3 multi-center and 4 single-center studies. All seven studies were inclusive of patients who underwent targeted temperature management (TTM) after cardiac arrest, and two studies included patients without TTM. Five studies used cerebral performance category to assess functional outcome, two studies used Glasgow outcome score, and one study used modified Rankin scale. Three studies measured outcome at hospital discharge, one study measured outcome at 14 days after return of spontaneous circulation, two studies measured outcome after 3 months, and one after 1 year. In all studies that evaluated HR, lower HR was associated with favorable functional outcome. Two studies found that higher complexity of HRV was associated with favorable functional outcome. Conclusion: HR and HRV showed clear associations with functional outcome in patients after CA, but cinilcial utility for prognostication is uncertain.

Injury patterns associated with cognitive motor dissociation.

In unconscious appearing patients with acute brain injury, wilful brain activation to motor commands without behavioural signs of command following, known as cognitive motor dissociation (CMD), is associated with functional recovery. CMD can be detected by applying machine learning to EEG recorded during motor command presentation in behaviourally unresponsive patients. Identifying patients with CMD carries clinical implications for patient interactions, communication with families, and guidance of therapeutic decisions but underlying mechanisms of CMD remain unknown. By analysing structural lesion patterns and network level dysfunction we tested the hypothesis that, in cases with preserved arousal and command comprehension, a failure to integrate comprehended motor commands with motor outputs underlies CMD. Manual segmentation of T2-fluid attenuated inversion recovery and diffusion weighted imaging sequences quantifying structural injury was performed in consecutive unresponsive patients with acute brain injury (n = 107) who underwent EEG-based CMD assessments and MRI. Lesion pattern analysis was applied to identify lesion patterns common among patients with (n = 21) and without CMD (n = 86). Thalamocortical and cortico-cortical network connectivity were assessed applying ABCD classification of power spectral density plots and weighted pairwise phase consistency (WPPC) to resting EEG, respectively. Two distinct structural lesion patterns were identified on MRI for CMD and three for non-CMD patients. In non-CMD patients, injury to brainstem arousal pathways including the midbrain were seen, while no CMD patients had midbrain lesions. A group of non-CMD patients was identified with injury to the left thalamus, implicating possible language comprehension difficulties. Shared lesion patterns of globus pallidus and putamen were seen for a group of CMD patients, which have been implicated as part of the anterior forebrain mesocircuit in patients with reversible disorders of consciousness. Thalamocortical network dysfunction was less common in CMD patients [ABCD-index 2.3 (interquartile range, IQR 2.1-3.0) versus 1.4 (IQR 1.0-2.0), P < 0.0001; presence of D 36% versus 3%, P = 0.0006], but WPPC was not different. Bilateral cortical lesions were seen in patients with and without CMD. Thalamocortical disruption did not differ for those with CMD, but long-range WPPC was decreased in 1-4 Hz [odds ratio (OR) 0.8; 95% confidence interval (CI) 0.7-0.9] and increased in 14-30 Hz frequency ranges (OR 1.2; 95% CI 1.0-1.5). These structural and functional data implicate a failure of motor command integration at the anterior forebrain mesocircuit level with preserved thalamocortical network function for CMD patients with subcortical lesions. Amongst patients with bilateral cortical lesions preserved cortico-cortical network function is associated with CMD detection. These data may allow screening for CMD based on widely available structural MRI and resting EEG.

Family-authored ICU diaries to reduce fear in patients experiencing a cardiac arrest (FAID fear): A pilot randomized controlled trial.

Survivors of cardiac arrest (CA) and their family members often experience significant fear-based distress (cardiac fear; i.e., fear about the CA survivor's heart). Fear-based distress after CA is associated with higher rates of cardiac event recurrence and mortality in CA survivors. As posited in Dyadic Disruption Theory (DDT), cardiac fear in family members may contribute to the development of distress in CA survivors via socially-based mechanisms. Thus, interventions to reduce family distress may improve CA survivors' outcomes. ICU diaries are easy to implement and scalable and show promise for reducing distress after CA but are primarily targeted towards survivors. The primary aim of the Family-Authored ICU Diaries to reduce Fear in Patients Experiencing a CA (FAID Fear) pilot randomized controlled trial was to test feasibility of an ICU diary intervention targeted towards family member distress alone. Family members of patients hospitalized after CA (N = 16) were randomized 2:1 to receive the FAID Fear intervention or usual care. Intervention participants were provided brief instructions and were asked to write in the diary twice per week until the end of hospital care. Assessments occurred at baseline enrollment, end of hospital care, and 30 days later. Participants' mean age was 50.73 years (SD = 13.41; 80% cis-gender female; 60% White). Recruitment (16/25 referred; 64.0%), retention (14/16 enrolled; 87.5%), and intervention adherence (7/10 completed; 70%) were promising. Most agreed that the ICU diary intervention was appropriate (7/10 completed; 70.0%), feasible (9/10 completed; 90.0%]), and acceptable (8/10 completed; 80.0%). Fear was nonsignificantly lower in intervention participants (v. control) at end of hospital care and 30 days later. FAID Fear represents a first step in building theory-based dyadic interventions that can be implemented to support family members of CA survivors in the ICU, with potential to improve outcomes in CA survivors.

Concordance Between Active Partial Thromboplastin Time and Anti-Factor Xa Assays in Neurocritically Ill Patients Receiving Subcutaneous Heparin Prophylaxis.

Background: Laboratory monitoring is not recommended when subcutaneous unfractionated heparin (SQ-UFH) is administered at prophylactic doses. However, aPTT prolongation and associated hemorrhage has been reported in the neurocritically ill. At our institution, Neuroscience Intensive Care Unit (Neuro-ICU) patients with prolonged aPTT are further evaluated with a follow up aPTT and anti-factor Xa. Purpose: The purpose of this study was to describe concordance between aPTT and anti-factor Xa in neurocritically ill patients receiving prophylactic SQ-UFH with evidence of aPTT prolongation. Methods: A retrospective chart review of adult patients admitted to the Neuro-ICU from June 2017 to June 2019 was performed. Patients were included if they received SQ-UFH with aPTT levels and at least one anti-factor Xa level drawn within one hour of each other. Concordance between paired aPTT and anti-factor Xa was evaluated using Cohen's weighted kappa. Results: Forty two patients with 56 paired aPTT and anti-factor Xa levels were included. The most prescribed SQ-UFH regimen was 5000 units every 8 hours (60.7%) and anti-factor Xa levels were drawn a median (IQR) of 5.7 (3.1-10.7) hours after the SQ-UFH dose. Only 16 (28.6%) pairs were in concordance. The analysis showed a weighted kappa of .09; 95% CI [-.05 to .22] indicating poor agreement. Conclusions: In neurocritically ill patients receiving prophylactic SQ-UFH with aPTT prolongation, there was poor concordance between aPTT and anti-factor Xa. This suggests that aPTT prolongation may not be solely driven by heparin activity and further evaluation of mechanistic drivers for coagulopathy in this population is necessary.

Automatic identification of intracranial pressure waveform during external ventricular drainage clamping: segmentation via wavelet analysis.

Objective. The objective of this study is to develop and validate a method for automatically identifying segments of intracranial pressure (ICP) waveform data from external ventricular drainage (EVD) recordings during intermittent drainage and closure.Methods. The proposed method uses time-frequency analysis through wavelets to distinguish periods of ICP waveform in EVD data. By comparing the frequency compositions of the ICP signals (when the EVD system is clamped) and the artifacts (when the system is open), the algorithm can detect short, uninterrupted segments of ICP waveform from the longer periods of non-measurement data. The method involves applying a wavelet transform, calculating the absolute power in a specific range, using Otsu thresholding to automatically identify a threshold, and performing a morphological operation to remove small segments. Two investigators manually graded the same randomly selected one-hour segments of the resulting processed data. Performance metrics were calculated as a percentage.Results. The study analyzed data from 229 patients who had EVD placed following subarachnoid hemorrhage between June 2006 and December 2012. Of these, 155 (67.7%) were female and 62 (27%) developed delayed cerebral ischemia. A total of 45 150 h of data were segmented. 2044 one-hour segments were randomly selected and evaluated by two investigators (MM and DN). Of those, the evaluators agreed on the classification of 1556 one-hour segments. The algorithm was able to correctly identify 86% (1338 h) of ICP waveform data. 8.2% (128 h) of the time the algorithm either partially or fully failed to segment the ICP waveform. 5.4% (84 h) of data, artifacts were mistakenly identified as ICP waveforms (false positives).Conclusion. The proposed algorithm automates the identification of valid ICP waveform segments of waveform in EVD data and thus enables the inclusion in real-time data analysis for decision support. It also standardizes and makes research data management more efficient.

Red Blood Cell Transfusions Are Not Associated With Incident Complications or Poor Outcomes in Patients With Intracerebral Hemorrhage.

Background Anemia is associated with poor intracerebral hemorrhage (ICH) outcomes, yet the relationship of red blood cell (RBC) transfusions to ICH complications and functional outcomes remains unclear. We investigated the impact of RBC transfusion on hospital thromboembolic and infectious complications and outcomes in patients with ICH. Methods and Results Consecutive patients with spontaneous ICH enrolled in a single-center, prospective cohort study from 2009 to 2018 were assessed. Primary analyses assessed relationships of RBC transfusions on incident thromboembolic and infectious complications occurring after the transfusion. Secondary analyses assessed relationships of RBC transfusions with mortality and poor discharge modified Rankin Scale score 4 to 6. Multivariable logistic regression models adjusted for baseline demographics and medical disease severity (Acute Physiology and Chronic Health Evaluation II), and ICH severity (ICH score).Of 587 patients with ICH analyzed, 88 (15%) received at least one RBC transfusion. Patients receiving RBC transfusions had worse medical and ICH severity. Though patients receiving RBC transfusions had more complications at any point during the hospitalization (64.8% versus 35.9%), we found no association between RBC transfusion and incident complications in our regression models (adjusted odds ratio [aOR], 0.71 [95% CI, 0.42-1.20]). After adjusting for disease severity and other relevant covariates, we found no significant association between RBC transfusion and mortality (aOR, 0.87 [95% CI, 0.45-1.66]) or poor discharge modified Rankin Scale score (aOR, 2.45 [95% CI, 0.80-7.61]). Conclusions In our cohort with ICH, RBC transfusions were expectedly given to patients with higher medical and ICH severity. Taking disease severity and timing of transfusions into account, RBC transfusion was not associated with incident hospital complications or poor clinical ICH outcomes.

A Deep Learning Framework for Deriving Noninvasive Intracranial Pressure Waveforms from Transcranial Doppler.

Increased intracranial pressure (ICP) causes disability and mortality in the neurointensive care population. Current methods for monitoring ICP are invasive. We designed a deep learning framework using a domain adversarial neural network to estimate noninvasive ICP, from blood pressure, electrocardiogram, and cerebral blood flow velocity. Our model had a mean of median absolute error of 3.88 ± 3.26 mmHg for the domain adversarial neural network, and 3.94 ± 1.71 mmHg for the domain adversarial transformers. Compared with nonlinear approaches, such as support vector regression, this was 26.7% and 25.7% lower. Our proposed framework provides more accurate noninvasive ICP estimates than currently available. ANN NEUROL 2023;94:196-202.

Family experiences and health outcomes following a loved ones' hospital discharge or death after cardiac arrest: A scoping review.

Aim: Synthesise the existing literature on experiences and health outcomes of family members of adult cardiac arrest patients either after hospital discharge or death and identify gaps and targets for future research. Methods: Following recommended scoping review guidelines and reporting framework, we developed an a priori protocol and searched five large biomedical databases for all relevant studies published in peer-reviewed journals in the English language through 8/8/2022. Studies reporting either on the experiences or health outcomes of family members of adult cardiac arrest patients who survived to hospital discharge (i.e., co-survivors) or bereaved family members were included. Study characteristics were extracted and findings were reviewed for co-survivors and bereaved family members. We summarised practice recommendations and evidence gaps as reported by the studies. Results: Of 44 articles representing 3,598 family members across 15 countries and 5 continents, 89% (n = 39) were observational. Co-survivors described caregiving challenges and difficulty transitioning to life at home after hospital discharge. Co-survivors as well as bereaved family members reported significant and persistent psychological burden. Enhanced communication, information on what to expect after hospital discharge or the death of their loved ones, and emotional support were among the top recommendations to improve family members' experiences and health outcomes. Conclusion: Family members develop significant emotional burdens and physical symptoms as they deal with their loved ones' critical illnesses and uncertain, unpredictable recovery. Interventions designed to reduce family members' psychological distress and uncertainty prevalent throughout the illness trajectory of their loved ones admitted with cardiac arrest are needed.