Steps to consider in the approach and management of critically ill patient with spontaneous intracerebral hemorrhage.

Spontaneous intracerebral hemorrhage is a type of stroke associated with poor outcomes. Mortality is elevated, especially in the acute phase. From a pathophysiological point of view the bleeding must traverse different stages dominated by the possibility of re-bleeding, edema, intracranial hypertension, inflammation and neurotoxicity due to blood degradation products, mainly hemoglobin and thrombin. Neurological deterioration and death are common in early hours, so it is a true neurological-neurosurgical emergency. Time is brain so that action should be taken fast and accurately. The most significant prognostic factors are level of consciousness, location, volume and ventricular extension of the bleeding. Nihilism and early withdrawal of active therapy undoubtedly influence the final result. Although there are no proven therapeutic measures, treatment should be individualized and guided preferably by pathophysiology. The multidisciplinary teamwork is essential. Results of recently completed studies have birth to promising new strategies. For correct management it's important to establish an orderly and systematic strategy based on clinical stabilization, evaluation and establishment of prognosis, avoiding secondary insults and adoption of specific individualized therapies, including hemostatic therapy and intensive control of elevated blood pressure. Uncertainty continues regarding the role of surgery.

Hyperglycemia in nondiabetic patients during the acute phase of stroke.

OBJECTIVE: To determine patterns of hyperglycemic (HG) control in acute stroke. METHODS: Anonymous survey through Internet questionnaire. Participants included Latin-American physicians specialized in neurocritical care. RESULTS: The response rate was 74%. HG definition varied widely. Fifty per cent considered it when values were >140 mg/dL (7.8 mmol/L). Intravenous (IV) regular insulin was the drug of choice for HG correction. One fifth of the respondents expressed adherence to a protocol. Intensive insulin therapy (IIT) was used by 23%. Glucose levels were measured in all participants at admission. Routine laboratory test was the preferred method for monitoring. Reactive strips were more frequently used when monitoring was intensive. Most practitioners (56.7%) monitored glucose more than two times daily throughout the Intensive Care Unit stay. CONCLUSIONS: There is considerable variability and heterogeneity in the management of elevated blood glucose during acute phase of stroke by the surveyed Latin-American physicians.

Hyperglycemia in nondiabetic patients during the acute phase of stroke / Hiperglucemia en no diabéticos durante fase aguda del ictus

OBJECTIVE: To determine patterns of hyperglycemic (HG) control in acute stroke. METHODS: Anonymous survey through Internet questionnaire. Participants included Latin-American physicians specialized in neurocritical care. RESULTS: The response rate was 74 percent. HG definition varied widely. Fifty per cent considered it when values were >140 mg/dL (7.8 mmol/L). Intravenous (IV) regular insulin was the drug of choice for HG correction. One fifth of the respondents expressed adherence to a protocol. Intensive insulin therapy (IIT) was used by 23 percent. Glucose levels were measured in all participants at admission. Routine laboratory test was the preferred method for monitoring. Reactive strips were more frequently used when monitoring was intensive. Most practitioners (56.7 percent) monitored glucose more than two times daily throughout the Intensive Care Unit stay. CONCLUSIONS: There is considerable variability and heterogeneity in the management of elevated blood glucose during acute phase of stroke by the surveyed Latin-American physicians.

OBJETIVO: Determinar patrones de control de hiperglucemia (HG) en el ictus agudo. MÉTODOS: Encuesta anónima, mediante cuestionario vía Internet. Los participantes incluyan médicos latinoamericanos especializados en cuidados neurocríticos. RESULTADOS: Las encuestas fueron respondidas por el 74 por cento de los convocados. Las definiciones de hiperglucemia fueron variadas. El 50 por cento de los que respondieron consideran HG cuando glucemia >140 mg/dL (7.8 mmol/L). Insulina regular intravenosa fue la droga de elección para su control. Solo la quinta parte de los encuestados manifestaron adherencia a un protocolo. El 23 por cento emplea el régimen insulínico intensivo (TII). Glucemia fue obtenida a la admisión a la Unidad de Terapia Intensiva (UCI) por el total de los participantes. Test rutinario de laboratorio fue el método preferido para la monitorización. Tiras reactivas fueron utilizadas con mayor frecuencia cuando se aplicó monitoreo intensivo. El 56.7 por cento monitoriza glucemia más de dos veces al día durante la estadía en UCI. CONCLUSIONES: Existe una considerable variabilidad y heterogeneidad en el manejo de la hiperglucemia durante la fase aguda del ictus entre los médicos latinoamericanos encuestados.

Reingresos hospitalarios tempranos y su asociación con morbimortalidad: ¿cuál es nuestra realidad? / Early hospital re-entries and their association with morbi-mortality: what is our reality?

En Argentina existe escasa información que indique cuál es la proporción de reinternación hospitalaria y su relación con la morbimortalidad. Objetivo: analizar el porcentaje de reinternación y su asociación con la mortalidad y las complicaciones relacionadas con la internación previa. Materiales y Métodos: Estudio prospectivo, observacional de corte transversal. Población: > de 14 años que reingresaron dentro de los 15 días del alta médica, desde 1/07/08 al 30/06/09; se excluyeron pacientes que ingresaron en forma programada. Los datos obtenidos de la intranet se procesaron en SPSS 11.0. Resultados: Fueron dados de alta a su domicilio 4933 pacientes, de los cuales reingresaron 390 (7,9%); 40 cirugías programadas fueron excluidas, resultando en 350 (7%) la población estudiada. El sexo masculino fue del 56,6% (N=198) y la edad promedio de 59,6 años (19,6 + SD). El 87% (N=304) se reinternaron por causas directamente relacionadas con su patología de base y 30% (N=106) por complicación asociada a la internación previa. La mortalidad global fue del 15,1% (N=53). Conclusiones: El porcentaje de pacientes que reingresaron dentro de los quince días fue similar a otras series; 8 de cada 10 pacientes ingresan por alguna relación con su enfermedad de base y 3 de cada 10 por una complicación relacionada con la internación previa.

In Argentina there is scarce information showing the hospital re-entry ratio and its relation to morbi-mortality. Objective: to analyze the hospital re-entry percentage and its association with mortality and those complications related to previous hospitalizations. Materials and Methods: Prospective, observational, cross-sectional study. Population: patients > 14 years of age with hospital re-entry within 15 days of medical discharge from July 1, 2008 to June 30, 2009; patients hospitalized for scheduled surgical procedures were excluded. Data obtained from the intranet were processed in SPSS 11.0. Results: 4,933 patients were discharged from hospital; of these patients, 390 (7.9%) reentered; 40 scheduled surgeries were excluded, thus the population under study was reduced to 350 patients (7%). Males represented 56.6% (N=198) and the average age was 59.6 years (19,6 + SD). 87% (N=304) re-entered hospital for reasons directly related to their underlying pathology and 30 % (N=106) due to complications associated to previous hospitalization. Global mortality represented 15.1% (N=53). Conclusions: The percentage of patients that re-entered hospital within fifteen days of discharge was similar to other series; 8 out of 10 patients are hospitalized due to some kind of relation with their underlying disease and 3 out of 10 due to complications related to previous hospitalization.

Hyperglycemia and short-term outcome in patients with spontaneous intracerebral hemorrhage.

BACKGROUND: Hyperglycemia has a detrimental effect in several acute neurological critical illnesses. No consensus exists on the optimal management of hyperglycemia in spontaneous intracerebral hemorrhage (sICH). Our aim was to determine whether blood glucose (BG) would predict 30-day mortality in sICH. METHODS: All patients with a well-defined diagnosis of sICH admitted into 24 h in three primary referred centers were included in this prospective observational follow-up study. Patients had extensive monitoring of BG values and those with BG values >8.29 mmol/l (150 mg/dl) received a variable intravenous insulin dose to maintain BG concentrations during the first 72 h after sICH between 3.32 and 8.29 mmol/l (60-150 mg/dl) using pre-specified insulin dosing schedule protocol. RESULTS: Between January 1, 2002, and December 31, 2003, 295 consecutive patients (mean +/- SD age 66 +/- 12 years) were prospectively included. A 1.0 mmol/l (18 mg/dl) increase in the BG concentration at admission was associated with a 33% mortality increase (OR: 1.33; 95%CI: 1.22-1.46; P < 0.0001). Adjusting for demographics, risk factors, stroke severity, and surgery there was no change in the increased risk. During the first 12 h after sICH, the insulin treatment protocol was enabling to reduce mortality (OR: 1.36, 95%CI: 1.14-1.61; P = 0.0005, per 1 IU increase) while thereafter this association was greatly attenuated and not more significant. CONCLUSIONS: Hyperglycemia is a common condition after sICH and may worsen prognosis. Very early insulin therapy apparently does not improve prognosis. These results raise concern about routine clinical practice implementation of this intervention without any evidence from randomized trials.

Predicting mortality in spontaneous intracerebral hemorrhage: can modification to original score improve the prediction?

BACKGROUND AND PURPOSE: A clinical grading scale for intracerebral hemorrhage (ICH), formally ICH score, was recently developed showing to predict 30-day mortality in a simple and reliable manner. The aim of the present study was to validate the original ICH (oICH) score in an independent cohort of patients from a developing country assessing 30-day mortality and 6-month functional outcome and whether its modifications can improve prediction. METHODS: Consecutive patients admitted with acute ICH between January 1, 2003, and July 31, 2004, were prospectively included. oICH score was applied and 2 modified ICH (mICH) scores were created with the same variables, except localization, of the oICH score but with different cutoff values. Outcome was assessed as 30-day mortality and 6-month good outcome (Glasgow Outcome Scale [GOS] 4 to 5). RESULTS: A total of 153 patients were included during study period. Thirty-day mortality rate was 34.6% (n=53), and 59 patients (38.6%) had good functional outcome (GOS 4 to 5) at 6 months. The oICH and mICH scores predicted mortality equally well. According to Youden's index (J), the oICH score was a reliable predictor for mortality (J=0.59) but less reliable for predicting good outcome (J=0.54). The mICH scores were equal in predicting mortality but better for predicting good outcome than the oICH score (J=0.60). CONCLUSIONS: oICH score also confirms its validity in a socially and culturally different population. Modifications of oICH do not improve its 30-day mortality prediction but improve its ability to predict good functional outcome at 6 months.

Utilidad de tiras reactivas de orina en el diagnóstico rápido de anormalidades del líquido cefalorraquídeo / Usefulness of urine test strips in the rapid diagnosis of cerebrospinal fluid abnormalities

El procesamiento de las muestras de líquido cefalorraquídeo (LCR) en nuestro medio requiere aproximadamente sesenta minutos. Llegar al diagnóstico en el menor tiempo posible es de gran utilidad en aquellas entidades donde un tratamiento inmediato, permite mejorar el pronóstico del paciente. Objetivos: evaluar la sensibilidad y especificidad de la tira reactiva de orina Combur 10 para diagnóstico rápido de alteraciones del LCR. Correlacionar, por medio de tirillas, los datos de pacientes de quienes se sospecha un caso de meningitis bacteriana, con los datos bacteriológicos y clínicos de cada paciente. Elaborar una hipótesis de trabajo para diagnóstico rápido de meningitis. Material y métodos: se incluyeron 56 muestras de LCR introducidas en el laboratorio de bacteriología, entre junio de 1996 y junio de 1997, en que se realizó el corte del estudio (programado para evaluar 200 muestras). Se registraron, con la tira reactiva para análisis de orina Combur 10, los datos de leucocitos, proteínas y glucosa. Estos resultados fueron leídos por dos observadores designados previamente. En forma independiente y ciega, a todas las muestras procesadas, se les realizaba el examen físicoquímico, técnicas de Gram y cultivo. Resultados: durante un período de un año, 56 muestras fueron incluidas. La tira reactiva determinó 31 LCR normales (55,3%) y 25 anormales (44,7%). El laboratorio informó como normales 30 LCR (53,5%) y 26 como anormales (46,5%). La sensibilidad de la tira fue del 96,1% y la especificidad del 100%. Las coincidencias observadas entre los informes de la tirilla y el laboratorio fueron: 89,3% para los valores de glucosa y el 96,4%, tanto para valores de leucocitos como para los de proteínas. De las 56 muestras, 10 presentaron un perfil compatible con meningitis bacteriana (MB); de éstas, 9 (90%) tuvieron diagnóstico bacteriológico positivo de MB. Ninguno de los 47 LCR desarrollaron germen. Discusión: la alta sensibilidad y especificidad de la tira para determinar alteraciones del LCR, la convierte en un elemento de utilidad, ya que brinda en forma inmediata, resultados de gran valor en la toma de actitudes terapéuticas. Además, su bajo costo permite utilizarla como un examen de rutina para LCR, en sitios donde los recursos en salud son escasos. Si bien el número de pacientes incluidos que presentaron meningitis bacteriana es muy pequeño, los resultados obtenidos alientan a seguir nuestro estudio.