Prognostic value of high-sensitivity troponin T in aneurysmal subarachnoid hemorrhage: a prospective observational study.

Objective: To evaluate the prognostic value of high-sensitivity troponin (hsT) in severe aneurysmal subarachnoid hemorrhage (aSAH). Methods: This prospective non-interventional study was performed at a surgical intensive care unit (ICU) from 2012 to 2015. Consecutive patients who had severe aSAH were included. A modified Rankin Scale score ≥ 4 or death within 3 months defined a poor outcome. hsT levels were measured at ICU admission and 72 hours following symptom onset. Results: A total of 137 patients were analyzed. The median hsT level was 29 ng/L (range: 7-4485). The best threshold level of hsT for predicting a poor outcome was 22 ng/L. At this threshold, the sensitivity was 71% (95% confidence interval [CI]: 58%-81%) and the specificity was 58% (95%CI: 46%-70%). The area under the ROC curve was 0.61 (95%CI: 0.52-0.71). Based on a multivariate analysis, the independent factors for a poor neurological prognosis were a World Federation of Neurologic Surgeons (WFNS) score ≥ 4 (odds ratio [OR]: 2.61; 95%CI: 1.04-6.56) and an hsT level > 22 ng/L (OR: 2.80; 95%CI: 1.18-6.64). Conclusion: In patients with severe aSAH, with regard for the severity of disease (assessed by the WFNS score), an hsT level > 22 ng/L at ICU admission was associated with poor outcomes.

Interest of low-dose hydrocortisone therapy during brain-dead organ donor resuscitation: the CORTICOME study.

INTRODUCTION: Circulatory failure during brain death organ donor resuscitation is a problem that compromises recovery of organs. Combined administration of steroid, thyroxine and vasopressin has been proposed to optimize the management of brain deceased donors before recovery of organs. However the single administration of hydrocortisone has not been rigorously evaluated in any trial. METHODS: In this prospective multicenter cluster study, 259 subjects were included. Administration of low-dose steroids composed the steroid group (n = 102). RESULTS: Although there were more patients in the steroid group who received norepinephrine before brain death (80% vs. 66%: P = 0.03), mean dose of vasopressor administered after brain death was significantly lower than in the control group (1.18 ± 0.92 mg/H vs. 1.49 ± 1.29 mg/H: P = 0.03), duration of vasopressor support use was shorter (874 min vs. 1160 min: P < 0.0001) and norepinephrine weaning before aortic clamping was more frequent (33.8% vs. 9.5%: P < 0.0001). Using a survival approach, probability of norepinephrine weaning was significantly different between the two groups (P < 0.0001) with a probability of weaning 4.67 times higher in the steroid group than in the control group (95% CI: 2.30 - 9.49). CONCLUSIONS: Despite no observed benefits of the steroid administration on primary function recovery of transplanted grafts, administration of glucocorticoids should be a part of the resuscitation management of deceased donors with hemodynamic instability.

The accuracy of transcutaneous PCO2 in subjects with severe brain injury: a comparison with end-tidal PCO2.

BACKGROUND: In patients suffering from brain injury, end-tidal PCO2 (PETCO2 ) monitoring is controversial, but transcutaneous PCO2 (PtcCO2 ), which is noninvasive and utilizes immediate display, may be an alternative method. We hypothesized that PtcCO2 would be more accurate than PETCO2 for monitoring PaCO2 in patients with severe brain injury. METHODS: A prospective observational study included consecutive mechanically ventilated adult subjects who had acute brain injury and an arterial catheter in place. When an arterial blood gas analysis was required, the PETCO2 and PtcCO2 values were simultaneously recorded. The agreement between the PETCO2 , PtcCO2 , and PaCO2 measurements (reference) was determined using the Bland-Altman method. The number of outliers defined by the formula ([PETCO2 or PtcCO2 ] - PaCO2 ) > ± 4 mm Hg indicated the proportion of measurements that were considered clinically unacceptable. RESULTS: A total of 25 subjects were included in the study, and 85 simultaneous measurements of PaCO2 , PtcCO2 , and PETCO2 were obtained. The bias and precision between PaCO2 and PtcCO2 were -0.75 and 6.23 mm Hg, respectively. The limits of agreement ranged from -12.97 to 11.47 mm Hg. The bias and precision between PaCO2 and PETCO2 were 0.68 and 5.82 mm Hg, respectively. The limits of agreement ranged from -10.72 to 12.08 mm Hg. There were 34 (40%) outliers for the PtcCO2 sensor and 34 (40%) outliers for the PETCO2 sensor (P > .99). CONCLUSIONS: The accuracy of PtcCO2 was not superior to that of PETCO2 for assessing PCO2 levels and should not be used to monitor these levels in subjects with severe brain injury.

Cerebral microdialysis effects of propofol versus midazolam in severe traumatic brain injury.

Propofol, an anesthetic agent acting as an analogue of vitamin E, has been advocated to be an ideal neuroprotective agent both in animal models and in clinical practice, due to its positive effects on oxidative stress. Nevertheless, no studies have compared this agent to another sedative agent used for sedation after traumatic brain injury (TBI). The objective was to compare the effects of propofol to midazolam on cerebral biomarkers at the acute phase of severe TBI patients. Thirty patients aged 35±18 years were prospectively randomized to receive propofol or midazolam and 29 were analyzed (n=15 for propofol, and n=14 for midazolam). A cerebral microdialysis catheter was used to measure the lactate:pyruvate (L:P) ratio, glutamate, glycerol, and glucose for 72 h. No difference between groups was observed for the L:P ratio (time effect p=0.201, treatment effect p=0.401, time×treatment interaction p=0.101). Similarly, no difference was observed for glutamate (time effect p=0.930, treatment effect p=0.651, time×treatment interaction p=0.353), glycerol (time effect p=0.223, treatment effect p=0.922, time×treatment interaction p=0.308), or glucose (time effect p=0.116, treatment effect p=0.088, time×treatment interaction p=0.235). These results do not support a difference between propofol and midazolam for sedation for the cerebral metabolic profile in severe TBI.

Effects of price information on test ordering in an intensive care unit.

OBJECTIVE: To determine if daily information on the price of common laboratory tests and chest X-ray could significantly influence test ordering by physicians and decrease the costs. DESIGN: A prospective observational and sequential study. SETTING: A 21-bed surgical intensive care unit of a university hospital. PATIENTS: All patients admitted during a 4-month period. INTERVENTIONS: A 2-month period served as control (period I). During a consecutive 2-month period (period II) physicians were informed about the costs of seven common diagnostic tests (plasma and urinary electrolytes, arterial blood gases, blood count, coagulation test, liver function test and chest X-ray). The number of tests ordered and costs during the two periods were compared. MEASUREMENTS AND RESULTS: A total of 287 patients were included (128 in period I and 159 in period II). Information about age, gender, Severe Acute Physiologic Score II, McCabe score, intensive care unit length of stay and mortality were collected and were not statistically different between the two study periods. Except for liver function tests, all the tests evaluated were less frequently prescribed when physicians were aware of the charges, irrespective of whether the tests were routine or requested during an emergency. Nevertheless, a significant reduction was obtained only for arterial blood gases and urinary electrolytes. Overall analysis of the expenditures (in Euros) showed a significant 22% decrease in period II (341+/-500 versus 266+/-372 Euros, p<0.05). CONCLUSION: Providing price information to physicians was associated with a significant reduction for arterial blood gases and urinary electrolytes tests ordered and was significantly cost-saving.