Thromboelastometry-Based Prophylaxis for Venous Thromboembolism in the Acute Period Following Isolated Severe Traumatic Brain Injury.

Objective: Traumatic brain injury (TBI) is an independent risk factor for venous thromboembolism (VTE). This study aimed to determine the optimal timing for initiating pharmacological thromboprophylaxis for VTE in patients with isolated severe TBI using rotational thromboelastometry (ROTEM). Methods: This single-center observational study enrolled 115 patients aged 18-59 years with isolated severe TBI within the first 48 hours after injury. Results: Using ROTEM data, we identified hypercoagulation due to an increase in clot density (MCF EXTEM >72), which was attributed to fibrinogen (MCF FIBTEM >25). From day 4, hypercoagulation occurred in 14.8% of the patients. By day 7, these changes were observed in 85.2% of patients. According to brain computed tomography findings, patients who received early VTE chemoprophylaxis on days 3-4 after severe TBI did not experience progression of hemorrhagic foci. Conclusion: Our results emphasize the clinical significance of thromboelastometry in patients with isolated severe traumatic TBI. Anticoagulant prophylaxis started on 3-4 days after severe TBI was relatively safe, and most patients did not experience hemorrhagic foci progression. The data acquired in this study may enable the optimization of VTE chemoprophylactic approaches, thereby reducing the associated risks to patients.

Multidrug-Resistant and Extensively Drug-Resistant Acinetobacter baumannii Causing Nosocomial Meningitis in the Neurological Intensive Care Unit.

Acinetobacter baumannii is one of the significant healthcare-associated meningitis agents characterized by multidrug resistance and a high mortality risk. Thirty-seven A. baumannii strains were isolated from thirty-seven patients of Moscow neuro-ICU with meningitis in 2013-2020. The death rate was 37.8%. Strain susceptibility to antimicrobials was determined on the Vitek-2 instrument. Whole-genome sequencing was conducted using Illumina technology; the sequence types (ST), capsular types (KL), lipooligosaccharide outer core locus (OCL), antimicrobial resistance genes, and virulence genes were identified. The prevalent ST was ST2, belonging to the international clone IC2, and rarer, ST1, ST19, ST45, ST78, ST106, and ST400, with prevalence of KL9 and OCL1. Twenty-nine strains belonged to multidrug-resistant (MDR) and eight extensively drug-resistant (XDR) categories. Genes conferring resistance to beta-lactams (blaPER, blaGES, blaADC, blaCARB, blaCTX-M, blaTEM, and blaOXA-types), aminoglycosides (aac, aad, ant, aph, and arm), tetracyclines (tet), macrolides (msr and mph), phenicols (cml, cat, and flo), sulfonamides (dfr and sul), rifampin (arr), and antiseptics (qac) were identified. Virulence genes of nine groups (Adherence, Biofilm formation, Enzymes, Immune evasion, Iron uptake, Regulation, Serum resistance, Stress adaptation, and Antiphagocytosis) were detected. The study highlights the heterogeneity in genetic clones, antimicrobial resistance, and virulence genes variability among the agents of A. baumannii meningitis, with the prevalence of the dominant international clone IC2.

High-Molecular-Weight Plasmids Carrying Carbapenemase Genes blaNDM-1, blaKPC-2, and blaOXA-48 Coexisting in Clinical Klebsiella pneumoniae Strains of ST39.

BACKGROUND: Klebsiella pneumoniae, a member of the ESKAPE group of bacterial pathogens, has developed multi-antimicrobial resistance (AMR), including resistance to carbapenems, which has increased alarmingly due to the acquisition of carbapenemase genes located on specific plasmids. METHODS: Four clinical K. pneumoniae isolates were collected from four patients of a neuro-intensive care unit in Moscow, Russia, during the point prevalence survey. The AMR phenotype was estimated using the Vitec-2 instrument, and whole genome sequencing (WGS) was done using Illumina and Nanopore technologies. RESULTS: All strains were resistant to beta-lactams, nitrofurans, fluoroquinolones, sulfonamides, aminoglycosides, and tetracyclines. WGS analysis revealed that all strains were closely related to K. pneumoniae ST39, capsular type K-23, with 99.99% chromosome identity. The novelty of the study is the description of the strains carrying simultaneously three large plasmids of the IncHI1B, IncC, and IncFIB groups carrying the carbapenemase genes of three types, blaOXA-48, blaNDM-1, and blaKPC-2, respectively. The first of them, highly identical in all strains, was a hybrid plasmid that combined two regions of the resistance genes (blaOXA-48 and blaTEM-1 + blaCTX-M-15 + blaOXA-1 + catB + qnrS1 + int1) and a region of the virulence genes (iucABCD, iutA, terC, and rmpA2::IS110). CONCLUSION: The spread of K. pneumoniae strains carrying multiple plasmids conferring resistance even to last-resort antibiotics is of great clinical concern.

Rectal and Tracheal Carriage of Carbapenemase Genes and Class 1 and 2 Integrons in Patients in Neurosurgery Intensive Care Unit.

The spread of multidrug-resistant Gram-negative bacteria, which is associated with the distribution of beta-lactamase genes and class 1 and 2 integrons, is a global problem. In this study, in the Moscow neurosurgery intensive care unit (neuro-ICU), the high prevalence of the above-stated genes was found to be associated with intestinal and tracheal carriage. Seven-point prevalence surveys, which included 60 patients in the neuro-ICU, were conducted weekly in the period from Oct. to Nov. 2019. A total of 293 clinical samples were analyzed, including 146 rectal and 147 tracheal swabs; 344 Gram-negative bacteria isolates were collected. Beta-lactamase genes (n = 837) were detected in the isolates, including beta-lactamase blaTEM (n = 162), blaSHV (n = 145), cephalosporinase blaCTX-M (n = 228), carbapenemase blaNDM (n = 44), blaKPC (n = 25), blaOXA-48 (n = 126), blaOXA-51-like (n = 54), blaOXA-40-like (n = 43), blaOXA-23-like (n = 8), and blaVIM (n = 2), as well as class 1 (n = 189) and class 2 (n = 12) integrons. One extensively drug-resistant Klebsiella pneumoniae strain (sequence type ST39 and capsular type K23), simultaneously carried beta-lactamase genes, blaSHV-40 and blaTEM-1B, three carbapenemase genes, blaNDM, blaKPC, and blaOXA-48, the cephalosporinase gene blaCTX-M, and two class 1 integrons. Before this study, such heavily armed strains have not been reported, suggesting the ongoing evolution of antibiotic resistance.

Multidrug-Resistant Klebsiella pneumoniae Causing Severe Infections in the Neuro-ICU.

The purpose of this study was the identification of genetic lineages and antimicrobial resistance (AMR) and virulence genes in Klebsiella pneumoniae isolates associated with severe infections in the neuro-ICU. Susceptibility to antimicrobials was determined using the Vitek-2 instrument. AMR and virulence genes, sequence types (STs), and capsular types were identified by PCR. Whole-genome sequencing was conducted on the Illumina MiSeq platform. It was shown that K. pneumoniae isolates of ST14K2, ST23K57, ST39K23, ST76K23, ST86K2, ST218K57, ST219KL125/114, ST268K20, and ST2674K47 caused severe systemic infections, including ST14K2, ST39K23, and ST268K20 that were associated with fatal incomes. Moreover, eight isolates of ST395K2 and ST307KL102/149/155 were associated with manifestations of vasculitis and microcirculation disorders. Another 12 K. pneumoniae isolates of ST395K2,KL39, ST307KL102/149/155, and ST147K14/64 were collected from patients without severe systemic infections. Major isolates (n = 38) were XDR and MDR. Beta-lactamase genes were identified: blaSHV (n = 41), blaCTX-M (n = 28), blaTEM (n = 21), blaOXA-48 (n = 21), blaNDM (n = 1), and blaKPC (n = 1). The prevalent virulence genes were wabG (n = 41), fimH (n = 41), allS (n = 41), and uge (n = 34), and rarer, detected only in the genomes of the isolates causing severe systemic infections-rmpA (n = 8), kfu (n = 6), iroN (n = 5), and iroD (n = 5) indicating high potential of the isolates for hypervirulence.

Thromboelastometry as a Comprehensive Assessment of Hypercoagulation After Aneurysmal Subarachnoid Hemorrhage: A Case Report and Literature Review.

Subarachnoid hemorrhage after cerebral aneurysm rupture (aSAH) leads to delayed cerebral ischemia (DCI) in 25-35% of surviving patients. It is believed that DCI has a multifactorial etiology, including vasospasm. Furthermore, aSAH is associated with the development of hypercoagulation and microthrombosis; thus, its pharmacological correction may help to prevent DCI. We encountered a case where hypercoagulation was detected using rotational thromboelastometry (ROTEM), although the standard coagulation test results were within the normal ranges. Based on reviews of viscoelastic tests in cases of aSAH, ROTEM could be more sensitive to hypercoagulation after aSAH, compared to standard coagulation testing.

Postsurgical meningitis complicated by severe refractory intracranial hypertension with limited treatment options: the role of mild therapeutic hypothermia.

Intracranial hypertension is a commonly encountered neurocritical care problem. If first-tier therapy is ineffective, second-tier therapy must be initiated. In many cases, the full arsenal of established treatment options is available. However, situations occasionally arise in which only a narrow range of options is available to neurointensivists. We present a rare clinical scenario in which therapeutic hypothermia was the only available method for controlling intracranial pressure and that demonstrates the efficacy and safety of the Thermogard (Zoll, Chelmsford, Massachusetts, United States) cooling system in creating and maintaining a prolonged hypothermic state. The lifesaving effect of hypothermia was overshadowed by the unfavorable neurologic outcome observed (minimally conscious state on intensive care unit discharge). These results add further evidence to support the role of therapeutic hypothermia in managing intracranial pressure and provide motivation for finding new strategies in combination with hypothermia to improve neurologic outcomes.

Intra-abdominal hypertension in patients with sellar region tumors.

BACKGROUND: Data on intra-abdominal hypertension [IAH] and secondary abdominal compartment syndrome [ACS] due to neurological insults are limited. METHODS: This was a prospective observational study conducted between January 2010 and January 2011 in the neurological ICU [NICU]. Forty-one consecutive patients with sellar region tumors [SRT] were enrolled into the study. If conservative therapy was ineffective in patients with ACS, thoracic epidural anesthesia [EA] was performed. Primary endpoint was defined as the efficacy of conservative treatment and EA in patients with IAH and ACS; secondary endpoint, the influence of IAH and ACS on outcomes. RESULTS: Of the 41 patients, 13 (31.7%) had normal intra-abdominal pressure and 28 (68.3%) developed IAH, of whom 9 (22%) had ACS (group II). On average, IAH developed on the second postoperative day, while ACS, between the third and the fifth day. Multiple organ dysfunction developed in 3 (23.1%) patients of group I and in 23 (82%) patients of group II (p = 0.0003). Ileus due to gastrointestinal dysmotility was present in 6 (46.2%) patients of group I and in all patients of group II (p = 0.0001). Significant risk factors for ileus were diencephalon dysfunction (whole group - in 33 patients (80.5%); group I - in 6 patients (46.2%); group II - in 27 patients (96.4%), p = 0.0002) and sepsis (whole group - in 8 patients (19.5%); group I - no cases; group II - in 8 patients (28.6%), p = 0.03). Conservative treatment was effective in the majority of patients (78.9%) with IAH and only in 3 (33%) patients with ACS. Thoracic EA was performed in four patients with ACS with success. Length of stay in the NICU was 6.5 ± 4.6 days in group I and 24.1 ± 25.7 (p = 0.02) days in group II. Five out of nine (55.6%) patients with ACS died. None of these patients received EA. All patients with EA had favorable outcomes. CONCLUSION: The development of IAH is common after SRT surgery. If conservative treatment is ineffective, EA can be considered in patients with secondary ACS. Further studies are warranted.