Elevated Intracranial Pressure Level Is a Risk Factor for Sepsis-associated Encephalopathy: A Prospective Cohort Study.

BACKGROUND/AIM: Cerebral edema is common in patients with sepsis-associated encephalopathy (SAE) and is a major cause of elevated intracranial pressure (ICP); however, the relationship between elevated ICP and SAE is unclear. The aim of this study was to investigate the association between optic nerve sheath diameter (ONSD), a surrogate of ICP, and the incidence of SAE. PATIENTS AND METHODS: A prospective observational study was performed in a medical-surgical adult intensive care unit (ICU). All patients in the ICU who were consecutively diagnosed with sepsis during the study period were evaluated for eligibility. Ultrasound measurements of ONSD were performed within 6 h of enrollment and every two days thereafter until the patient developed SAE. Clinical and blood test data were collected throughout this period. Patients underwent a daily conscious and cognitive assessment. SAE was diagnosed as delirium or Glasgow Coma Scale (GCS) <15 points. Multivariate modified Poisson regression analysis was performed to identify risk factors for SAE. RESULTS: A total of 123 patients with sepsis were included in the analysis. 58 patients (47.2%) developed SAE. The levels of ONSD0 (the first measured value) and ONSDmax (the maximum measured value) in the SAE group were significantly higher than those in the non-SAE group (5.23±0.52 mm vs. 5.85±0.54 mm for ONSD0 and 5.41±0.46 mm vs. 6.09±0.58 mm for ONSDmax, respectively; all p-values <0.001). The area under the curves (AUCs) for the ONSD0 and ONSDmax values in predicting SAE were 0.801 (95%CI=0.723-0.880, p<0.001) and 0.829 (95%CI=0.754-0.903, p<0.001), respectively. A higher ONSD0 level was significantly associated with an increased risk of SAE (adjusted risk ratio 3.241; 95%CI=1.686-6.230, p<0.001). CONCLUSION: The levels of ONSD correlate with risk of SAE, indicating that increased ICP level is an independent risk factor for the development of SAE. Dynamic monitoring of ONSD/ICP has a high predictive value for SAE. Measures to prevent increases in ICP are helpful to reduce the incidence of SAE in sepsis patients.

[Investigation of intracranial pressure in intensive care unit patients with delirium assessed by bedside ultrasound].

OBJECTIVE: To explore the changes of intracranial pressure in intensive care unit (ICU) patients during the occurrence and evolution of delirium by using bedside ultrasound to measure the optic nerve sheath diameter (ONSD) to evaluate intracranial pressure. METHODS: A retrospective observational study was conducted. Adult patients who developed delirium during hospitalization in the general ICU of Beihai People's Hospital from October 2020 to November 2021 were enrolled, and patients who did not have ultrasonographic ONSD records within 24 hours after the diagnosis of delirium were excluded. The ONSD measured before delirium was recorded as ONSD0, the ONSD measured within 24 hours of the onset of delirium recorded as ONSD1, and the ONSD reexamined after ONSD1 recorded as ONSD2. Patients were divided into intracranial hypertension group (ONSD1 > 5 mm) and normal intracranial pressure group (ONSD1 ≤ 5 mm) according to the size of ONSD1. According to the outcome of delirium, the patients were divided into cured, improved, and non-improved groups. The reduction ratio of ONSD2 to ONSD1 in the three groups were calculated and compared. Pearson correlation test was used to analyze the correlation between fluid balance and ONSD changes after delirium. RESULTS: There were 43 patients, including 40 cases in the intracranial hypertension group (the incidence rate was 93.0%), 3 cases in the normal intracranial pressure group, 23 cases were cured, 13 cases were improved, and 7 cases were not improved. In the intracranial hypertension group, 11 cases had ONSD0 and ONSD1 records, and ONSD1 was significantly higher than ONSD0 [mm: 5.88±0.61 vs. 5.34±0.57, 95% confidence interval (95%CI) -0.85 to -0.23, P = 0.003]. The reduction ratio of ONSD2 to ONSD1 in the cured group was significantly higher than that in the improved group and the non-improved group [(12.04±6.20)% vs. (5.68±4.10)%, (0.17±3.96)%; 95%CI were 2.37 to 10.33, 6.41 to 17.31, P values were 0.003 and 0.000, respectively]. The correlation analysis showed that the reduction ratio of ONSD2 to ONSD1 was negatively correlated with fluid balance (r = -0.42, 95%CI was -0.66 to -0.10, P = 0.012). CONCLUSIONS: The incidence of intracranial hypertension in ICU delirium patients is high. A more pronounced decrease in intracranial pressure predicts a better delirium outcome. Dynamic ONSD measurement can provide valuable information for the prevention and treatment of delirium.

[Application of thromboelastography combined with point-of-care ultrasound to prevent internal jugular vein catheterization related thrombosis].

OBJECTIVE: To investigate the effect of thromboelastography (TEG) combined with point-of-care ultrasound (POCUS) guidance on the prevention of internal jugular vein catheterization related thrombosis. METHODS: The patients who required internal jugular vein catheterization admitted to the department of critical medicine of Beihai People's Hospital from December 2018 to April 2020 were enrolled. Patients were divided into two groups according to the random number table method. For the combined cathetherization group, ultrasound was used to examine bilateral internal jugular veins before catheterization. The larger diameter and better filled vein and site were selected for puncture. If both internal jugular veins were not fulfilled well, puncture were performed after fluid administration. At the same time, anticoagulant, antiplatelet or reducing blood viscosity drugs were used according to coagulation function and bleeding risk under the monitoring of TEG. The hemodynamic state of the internal jugular vein was monitored by ultrasound every day. If the vein collapsed or the blood flow was slow, the cause should be tried to be found and improved. Once thrombosis was found, the catheter should be removed. For the routine cathetherization group, the right side internal jugular vein was prior to be punctured according to body surface symbols. The other treatment of the two groups were the same as routine treatment. The conditions of thrombosis and bleeding were recorded. RESULTS: Ninety-seven patients were selected, 51 cases in the combined cathetherization group and 46 cases in the routine cathetherization group. There was no significant differences in gender, age, acute physiology and chronic health evaluation II (APACHE II), risk of deep vein thrombosis score (Caprini), CRUSADE bleeding risk score, the proportion of high bleeding risk, disease types, the proportion of coagulation disorder and catheterization time between the two groups, but the anticoagulation treatment proportion in the combined cathetherization group was higher than that in the routine cathetherization group (66.7% vs. 30.4%, P < 0.01). The incidence of thrombosis in the combined cathetherization group was lower than that of the routine cathetherization group (39.2% vs. 78.3%, P < 0.01), and the thrombus of the combined cathetherization group was smaller than that of the routine cathetherization group [cm3: 0.077 (0.047, 0.089) vs. 0.341 (0.070, 0.378), P < 0.01]. There were no major bleeding events in the two groups. CONCLUSIONS: Based on TEG and POCUS, the antithrombotic bundles can reduce the incidence of thrombosis after internal jugular vein catheterization and the thrombus size, and does not increase the risk of bleeding, which is worthy of clinical application.