Clinical usefulness of early serial measurements of C-reactive protein as outcome predictors in patients with subarachnoid hemorrhage.

BACKGROUND: The purpose of this study was to evaluate the role of C-reactive protein (CRP) in predicting neurological outcomes of patients with subarachnoid hemorrhage (SAH). METHODS: In this retrospective, observational study of adult patients with SAH treated between January 2012 and June 2017. Initial CRP levels collected within 24 h from the onset of SAH, the follow-up CRP levels were measured. The primary outcome was neurological status at six-month follow-up assessed with the Glasgow Outcome Scale (GOS, 1 to 5). RESULTS: Among 156 patients with SAH, 145 (92.9%) survived until discharge. Of these survivors, 109 (69.9%) manifested favorable neurological outcomes (GOS of 4 or 5). Initial CRP levels on admission and maximal CRP levels within four days were significantly higher in the group with poor neurological outcome compared with those manifesting favorable neurological outcomes (P = 0.022, P < 0.001, respectively). However, the clearance of CRPs did not differ significantly between the two groups (P = 0.785). Analysis of the receiver operating characteristic curve for prediction of poor neurological outcome showed that the performance of the maximal CRP was significantly better compared with the initial CRP or the clearance of CRP (P = 0.007, P < 0.001, respectively). In this study, the effect of CRP on neurological outcomes differed according to surgical clipping. The maximal CRP levels within four days facilitate the prediction of neurological outcomes of SAH patients without surgical clipping (C-statistic: 0.856, 95% confidence interval [CI]: 0.767-0.921). However, they were poorly associated with neurological prognoses in SAH patients who underwent surgical clipping (C-statistic: 0.562, 95% CI: 0.399-0.716). Multivariable logistic regression analysis revealed that age (adjusted odds ratio [OR]: 1.10, 95% CI: 1.052-1.158), initial Glasgow Coma Scale (adjusted OR: 0.74, 95% CI: 0.647-0.837), and maximal CRP without surgical clipping (adjusted OR: 1.27, 95% CI: 1.066-1.516) were significantly associated with poor neurological outcomes in SAH patients. CONCLUSIONS: Early serial measurements of CRP may be used to predict neurological outcomes of SAH patients. Furthermore, maximal CRP levels within four days post-SAH are significantly correlated with poor neurological outcomes.

Severe pain-related adverse events of percutaneous dilatational tracheostomy performed by a neurointensivist compared with conventional surgical tracheostomy in neurocritically ill patients.

BACKGROUND: We evaluated severe pain-related adverse events (SAE) during the percutaneous dilatational tracheostomy (PDT) procedure performed by a neurointensivist and compared the outcomes with that of conventional surgical tracheostomy in neurocritically ill patients. METHODS: This was a retrospective and observational study of adult patients who were admitted to the neurosurgical intensive care unit between January 2014 and March 2018 and underwent tracheostomy. In this study, primary endpoints were incidence of SAE: cardiac arrest, arrhythmias, hypertension, hypotension, desaturation, bradypnea, or ventilatory distress. The secondary endpoint was procedure-induced complications. RESULTS: A total of 156 patients underwent tracheostomy during the study. Elective surgery of brain tumors (34.0%) and intracranial hemorrhage (20.5%) were the most common reasons for admission. The most common reasons for tracheostomy were difficult ventilator weaning or prolonged intubation (42.9%) and sedative reduction (23.7%). Tachycardia (30.1%) and hypertension (30.1%) were the most common SAE. Incidence of SAE was more common in conventional tracheostomy compared to PDT (67.1% vs. 42.3%, P = 0.002). The total duration of SAE (19.8 ± 23.0 min vs. 3.4 ± 5.3 min, P < 0.001) and procedural time (42.2 ± 21.8 min vs. 17.7 ± 9.2 min, P < 0.001) were longer in conventional tracheostomy compared to PDT. Multivariable adjustment revealed that only PDT by a neurointensivist significantly reduced the incidence of SAE by one third (adjusted odds ratio [OR]: 0.36, 95% confidence interval [CI]: 0.187-0.691). In addition, PDT by a neurointensivist deceased the duration of SAE by 8.64 min (ß: -8.64, 95% CI: - 15.070 - -2.205, P = 0.009) and prolonging the procedure time by every one minute significantly increased the duration of SAE by 6.38 min (ß: 6.38, 95% CI: 0.166-0.470, P < 0.001). Procedure-induced complications were more common in conventional tracheostomy compared to PDT (23.5% vs. 11.3%, P = 0.047). CONCLUSIONS: This retrospective and exploratory study of our single-center limited cohort of tracheostomy patients revealed that decreased SAE may be associated with short procedural time during the PDT procedure performed by a neurointensivist. It is proposed that PDT by a neurointensivist may be safe and feasible in neurocritically ill patients.

The prognostic value of optic nerve sheath diameter in patients with subarachnoid hemorrhage.

BACKGROUND: We evaluated the role of optic nerve sheath diameter (ONSD) using brain computed tomography (CT) in predicting neurological outcomes of patients with subarachnoid hemorrhage (SAH). METHODS: This was a retrospective, multicenter, observational study of adult patients with SAH admitted between January 2012 and June 2017. Initial brain CT was performed within 12 h from onset of SAH, and follow-up brain CT was performed within 24 h from treatment of a ruptured aneurysm. Primary outcome was neurological status at 6-month follow-up assessed with the Glasgow Outcome Scale (GOS, 1 to 5). RESULTS: Among 223 SAH patients, 202 (90.6%) survived until discharge. Of these survivors, 186 (83.4%) manifested favorable neurological outcomes (GOS of 3, 4, or 5). In this study, the ONSDs in the group of patients with poor neurological outcome were significantly greater than those in the favorable neurological outcome group (all p < 0.01). Intracranial pressure (ICP) was monitored in 21 (9.4%) patients during the follow-up CT. A linear correlation existed between the average ONSD and ICP in simple correlation analysis (r = 0.525, p = 0.036). Analysis of the receiver  operating characteristic curve for prediction of poor neurological outcome showed that ONSD had considerable predictive value (C-statistics, 0.735 to 0.812). In addition, the performance of a composite of Hunt and Hess grade and ONSD was increasingly associated with poor neurological outcomes than the use of each marker alone. CONCLUSIONS: ONSD measured with CT may be used in combination with clinical grading scales to improve prognostic accuracy in SAH patients.

Target Temperature Management May Not Improve Clinical Outcomes of Extracorporeal Cardiopulmonary Resuscitation.

PURPOSE: Target temperature management (TTM) and extracorporeal cardiopulmonary resuscitation (ECPR) have been established as important interventions during cardiopulmonary arrest. However, the impact of combined TTM and ECPR on clinical outcomes has not been studied in detail. METHODS: We reviewed the records of 245 patients who received extracorporeal life support (ECLS) between January 2012 and June 2015. Exclusion criteria were as follows: Extracorporeal life support performed for reasons other than cardiac arrest, age less than 18 years, and death within 24 hours. A total of 101 patients were finally included in the study. Twenty-five patients underwent TTM, and 76 patients did not. RESULTS: The patients' mean age was 55 ± 16.7 years. The mean cardiac arrest time was 44.6 ± 33.5 minutes. There were 84 patients whose cardiac arrest was due to a cardiac cause (83.2%) and 79 patients with in-hospital cardiac arrest (78.2%). There was a significant difference in average body temperature during the first 24 hours following ECPR (33.4°C vs 35.6°C; P = .001). The overall favorable neurological outcome rate was 34% and hospital survival rate was 47%. There was no difference in favorable neurological outcomes and hospital survival between the TTM and non-TTM groups (P = .91 and .84, respectively). On multivariate analysis of neurological outcomes and hospital survival, TTM was not a significant prognostic factor. CONCLUSION: We did not observe any benefits of TTM in patients undergoing ECPR. Natural hypothermia or normothermia related to ECLS may explain this result. Further research is needed to understand the role of TTM in ECPR.

Prognostic value of computed tomography score in patients after extracorporeal cardiopulmonary resuscitation.

BACKGROUND: We evaluated whether Alberta Stroke Program Early Computed Tomography Score (ASPECTS) with some modifications could be used to predict neurological outcomes in patients after extracorporeal cardiopulmonary resuscitation (ECPR). METHODS: This was a retrospective, multicenter, observational study of adult unconscious patients who were evaluated by brain computed tomography (CT) within 48 hours after ECPR between May 2010 and December 2016. ASPECTS, bilateral ASPECTS (ASPECTS-b), and modified ASPECTS (mASPECTS) were assessed by ROC curves to predict neurological outcomes. The primary outcome was neurological status upon hospital discharge assessed with the Cerebral Performance Categories (CPC) scale. RESULTS: Among 58 unconscious patients, survival to discharge was identified in 25 (43.1%) patients. Of these 25 survivors, 19 (32.8%) had good neurological outcomes (CPC score of 1 or 2). Interrater reliability of CT scores was excellent. Intraclass correlation coefficients of ASPECTS, ASPECTS-b, and mASPECTS were 0.918 (95% CI, 0.865-0.950), 0.918 (95% CI, 0.866-0.951), and 0.915 (95% CI, 0.860-0.949), respectively. The predictive performance of mASPECTS for poor neurological outcome was better than that of ASPECTS or ASPECTS-b (C-statistic for mASPECTS vs. ASPECTS, 0.922 vs. 0.812, p = 0.004; mASPECTS vs. ASPECTS-b, 0.922 vs. 0.818, p = 0.003). A cutoff of 25 for poor neurological outcome had a sensitivity of 84.6% (95% CI, 69.5-94.1%) and a specificity of 89.5% (95% CI, 66.9-98.7%) in mASPECTS. CONCLUSIONS: mASPECTS might be useful for predicting neurological outcomes in patients after ECPR.

D-dimer levels and cerebral infarction in critically ill cancer patients.

BACKGROUND: D-dimer levels have been used in the diagnosis of a variety of thrombosis-related diseases. In this study, we evaluated whether measuring D-dimer levels can help to diagnose cerebral infarction (CI) in critically ill cancer patients. METHODS: We retrospectively evaluated all cancer patients who underwent brain magnetic resonance imaging (MRI) between March 2010 and February 2014 at the medical oncology intensive care unit (ICU) of Samsung Medical Center. Brain MRI scanning was performed when CI was suspected due to acute neurological deficits. We compared D-dimer levels between patients ultimately diagnosed as having or not having CI and analyzed diffusion-weighted imaging (DWI) lesion patterns. RESULTS: A total of 88 patients underwent brain MRI scanning due to clinical suspicion of CI; altered mental status and unilateral hemiparesis were the most common neurological deficits. CI was ultimately diagnosed in 43 (49%) patients. According to the DWI patterns, multiple arterial infarctions (40%) were more common than single arterial infarctions (9%). Cryptogenic stroke etiologies were more common (63%) than determined etiologies. There was no significant difference in D-dimer levels between patients with and without CI (P = 0.319). Although D-dimer levels were not helpful in diagnosing CI, D-dimer levels were associated with cryptogenic etiologies in critically ill cancer patients; D-dimer levels were higher in the cryptogenic etiology group than in the determined etiology group or the non-infarction group (P = 0.001). In multivariate analysis, elevated D-dimer levels (> 8.89 µg/mL) were only associated with cryptogenic stroke (adjusted OR 5.46; 95% confidence interval, 1.876-15.857). CONCLUSIONS: Abnormal D-dimer levels may support the diagnosis of cryptogenic stroke in critically ill cancer patients.

The association of findings on brain computed tomography with neurologic outcomes following extracorporeal cardiopulmonary resuscitation.

BACKGROUND: Limited data are available on imaging predictors of neurological outcomes after extracorporeal cardiopulmonary resuscitation (ECPR). We investigated the association of initial brain computed tomography (CT) findings with neurological outcomes following ECPR. METHODS: Between February 2005 and December 2015, a total of 42 patients who underwent brain CT scans within 48 h after ECPR were analyzed. Loss of the boundary between gray matter and white matter (LOB) or cortical sulcal effacement (SE), gray-to-white matter ratio (GWR), and optic nerve sheath diameter (ONSD) were measured on initial brain CT. The primary outcome was the Cerebral Performance Categories (CPC) scale at discharge. RESULTS: Of the 42 adult ECPR patients, 23 (54.8%) patients survived to discharge and 19 (45.2%) patients had good neurological outcomes (CPC 1 and 2). The area under the curve (AUC) of GWR in the basal ganglia (GWR-BG) was 0.792 (95% confidence interval (CI), 0.639-0.901, p = 0.001). ONSD (AUC 0.745; 95% CI, 0.587 - 0.867, p = 0.007) was 5.57 (interquartile range (IQR) 5.14 - 5.98) mm in the good neurological outcome group versus 6.07 (IQR 5.71 - 6.64) mm in the poor outcome group. LOB or SE were more often detected in the poor neurological outcome group (AUC 0.817; 95% CI, 0.682-0.952, p <0.001). The predictive performance of poor neurological outcomes of a composite of GWR-BG, ONSD, and LOB/SE was significantly improved (AUC 0.904; 95% CI, 0.773-0.973) compared to when each brain CT marker was considered separately (GWR-BG, p = 0.048; ONSD, p = 0.026; LOB/SE, p = 0.028). CONCLUSIONS: GWR, ONSD, and LOB/SE on initial brain CT scans are associated with neurological prognosis in patients who underwent ECPR. The new risk prediction model, which uses a composite of GWR, ONCD, and LOB/SE, could provide better information on neurologic outcomes in patients underwent ECPR.

Impact of Neurointensivist Co-management on the Clinical Outcomes of Patients Admitted to a Neurosurgical Intensive Care Unit.

Limited data are available on improved outcomes after initiation of neurointensivist co-management in neurosurgical intensive care units (NSICUs) in Korea. We evaluated the impact of a newly appointed neurointensivist on the outcomes of neurosurgical patients admitted to an intensive care unit (ICU). This retrospective observational study involved neurosurgical patients admitted to the NSICU at Samsung Medical Center between March 2013 and May 2016. Neurointensivist co-management was initiated in October 1 2014. We compared the outcomes of neurosurgical patients before and after neurointensivist co-management. The primary outcome was ICU mortality. A total of 571 patients were admitted to the NSICU during the study period, 291 prior to the initiation of neurointensivist co-management and 280 thereafter. Intracranial hemorrhage (29.6%) and traumatic brain injury (TBI) (26.6%) were the most frequent reasons for ICU admission. TBI was the most common cause of death (39.0%). There were no significant differences in mortality rates and length of ICU stay before and after co-management. However, the rates of ICU and 30-day mortality among the TBI patients were significantly lower after compared to before initiation of neurointensivist co-management (8.5% vs. 22.9%; P = 0.014 and 11.0% vs. 27.1%; P = 0.010, respectively). Although overall outcomes were not different after neurointensivist co-management, initiation of a strategy of routine involvement of a neurointensivist significantly reduced the ICU and 30-day mortality rates of TBI patients.

Spontaneous intracranial haemorrhage in critically ill patients with malignancies.

PURPOSE: Limited data are available on the intracranial haemorrhage (ICH) developed in critically ill cancer patients during their stay in the intensive care unit (ICU). METHODS: All consecutive patients who underwent brain CT for suspicion of spontaneous intracerebral haemorrhage (ICH) with acute neurologic symptoms or signs developed during their ICU stay were retrospectively evaluated to identify predictors of ICH. RESULTS: Over the study period, a total of 273 patients underwent brain CT scanning for suspicion of ICH, with altered mentality in 202 (74 %), seizure in 43 (16 %), and hemiparesis in 34 (13 %). However, only 49 (18 %) patients had a final diagnosis of ICH. The most common type of haemorrhage was intracerebral in 34 patients (69 %), followed by subarachnoidal haemorrhage in 17 (35 %). In multiple logistic regression analysis, anisocoric pupils or abnormal pupil reflex (adjusted OR 7.939; 95 % CI, 2.315-27.228) was an independent predictor of ICH. In addition, higher positive end-expiratory pressure (adjusted OR 1.204; 95 % CI, 1.065-1.361) was significantly associated with ICH. However, platelet count was inversely associated with ICH (adjusted OR 0.993; 95 % CI 0.988-0.999). CONCLUSION: Brain CT scanning should be performed even in critically ill cancer patients, especially with risk factors and acute neurologic changes.

Clinical usefulness of capnographic monitoring when inserting a feeding tube in critically ill patients: retrospective cohort study.

BACKGROUND: It is not rare for a small-bore feeding tube to be inserted incorrectly into the respiratory system in critically ill patients. Thus, monitoring is necessary to prevent respiratory malplacement of the tube. We investigated the utility of capnographic monitoring to prevent respiratory complications due to feeding tube mispositioning in critically ill patients. METHODS: This study was a pre and post-interventional study, including 445 feeding tube placements events studied retrospectively in the medical and surgical intensive care units of the Samsung Medical Center. We compared outcomes between time periods before and after capnographic monitoring and documented any respiratory complications. RESULTS: Feeding tubes were inserted in 275 cases without capnographic monitoring. Capnographic monitoring was performed in 170 cases. Sixteen patients (4%) had respiratory complications of all tube placements. Feeding tube was inserted into the trachea in 11 (2%) patients and for a pneumothorax in five (1%) patients. Fourteen cases of respiratory complications were detected in the control group (14/275, 5%, 10 tracheal insertions and four pneumothoraxes). Two respiratory complications were detected in the capnographic monitoring group (2/170, 1%, one tracheal insertion and one pneumothorax). Respiratory complications were detected less frequently in the capnographic monitoring group than that in the control group (P = 0.035). CONCLUSIONS: Capnographic monitoring is simple, easy to learn, and may be useful to prevent respiratory complications when placing a feeding tube in a critically ill patient.

Effect of Early Intervention on Long-Term Outcomes of Critically Ill Cancer Patients Admitted to ICUs.

OBJECTIVES: The objective of this observational study was to evaluate whether early intervention was associated with improved long-term outcomes in critically ill patients with cancer. DESIGN: Retrospective analysis with prospectively collected data. SETTING: A university-affiliated, tertiary referral hospital. PATIENTS: Consecutive critically ill cancer patients who were managed by a medical emergency team before ICU admission between January 2010 and December 2012. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: During the study period, 525 critically ill cancer patients were admitted to the ICU with respiratory failure (41.7%) and severe sepsis or septic shock (40.6%) following medical intervention by a medical emergency team. Of 356 ICU survivors, 161 (45.2%) received additional treatment for cancer after ICU discharge. Mortality was 66.1% at 6 months and 72.8% at 1 year. Median time from physiological derangement to intervention before ICU admission was significantly shorter in 1-year survivors (1.3 hr; interquartile range, 0.5-4.8 hr) than it was in nonsurvivors (2.9 hr; interquartile range, 0.8-9.6 hr) (p< 0.001). Additionally, the early intervention (≤ 1.5 hr) group had a lower 30-day mortality rate than the late intervention (> 1.5 hr) group (29.0% vs 55.3%; p < 0.001) and a similar difference in mortality rate was observed up to 1 year. Other factors associated with 1-year mortality were illness severity, performance status, malignancy status, presence of more than three abnormal physiological variables, time from derangement to ICU admission, and the need for mechanical ventilation. Even after adjusting for potential confounding factors, early intervention was significantly associated with 1-year mortality (adjusted hazard ratio, 0.456; 95% CI, 0.348-0.597; p < 0.001). CONCLUSION: Early intervention for clinical derangement on general wards was significantly associated with long-term outcomes in critically ill cancer patients.

Risk factors for acquisition of multidrug-resistant bacteria in patients with anastomotic leakage after colorectal cancer surgery.

PURPOSE: The risk factors for acquiring an infection with multidrug-resistant (MDR) bacteria in patients with anastomotic leakage after colorectal cancer surgery are poorly understood. We evaluated the risk factors associated with the initial acquisition of MDR pathogens in patients with anastomotic leakage after colorectal cancer surgery. METHODS: This study was a retrospective review of prospectively collected data at a university affiliated-tertiary referral hospital in South Korea. From January 2009 to April 2013, a total of 6767 consecutive patients with colorectal cancer who underwent surgery were registered. Of these patients, 190 (2.8%) were diagnosed with anastomotic leakage. Finally, 143 (2.1%) patients with culture test results were included in this study. RESULTS: Of the 143 enrolled patients, 46 (32.2%) were classified in the MDR group. The use of antibiotics for more than 5 days before diagnosis of anastomosis site leakage (p = 0.016) and diabetes mellitus (p = 0.028) was identified as independent risk factors for MDR acquisition by multivariate analysis. The rate of adequate initial empirical antibiotic therapy in the MDR group was lower than in the non-MDR group (35 vs. 75%, p < 0.001). Furthermore, the duration of antibiotic administration after the leak was longer in the MDR group (p = 0.013). Patients in the MDR group also had a longer hospital stay (p = 0.012). CONCLUSIONS: The length of antibiotic administration before the diagnosis of anastomotic leakage and diabetes mellitus were risk factors associated with the acquisition of MDR bacteria in patients with anastomotic leakage after colorectal cancer surgery.

Predictors of neurological outcomes after successful extracorporeal cardiopulmonary resuscitation.

BACKGROUND: Extracorporeal cardiopulmonary resuscitation (ECPR) refers to use of extracorporeal membrane oxygenation (ECMO) in cardiopulmonary arrest. Although ECPR can increase survival rates after cardiac arrest, it can also result in poor post-resuscitation neurological status. Thus, we investigated predictors of good neurological outcomes after successful ECPR. METHODS: A total of 227 patients underwent ECPR from May 2004 to June 2013 at Samsung Medical Center. Successful ECPR was defined as survival more than 24 hours after ECPR. Neurological outcomes were assessed at discharge using the Glasgow-Pittsburgh Cerebral Performance Categories scale (CPC). CPC 1 and 2 were classified as good and CPC 3 to 5 were classified as poor neurological outcomes. Excluded were 22 patients who did not survive more than 24 hours after ECPR and 90 patients who died from unknown causes or causes other than brain death or whose neurological status could not be assessed at discharge. Multiple logistic regression analysis was used to identify independent predictors of neurological outcomes. RESULTS: Included were 115 patients with a mean age of 58 (range 45-66) years and 80 men (70%). Cardiopulmonary resuscitation (CPR) was performed at non-hospital sites for 19 (17%) patients and bystander CPR was performed in 9 of 19 cases (47%). Cardiac etiology was verified in 74 (64%) patients and therapeutic hypothermia was performed in 9 patients (8%); 68 (59%) had good neurological outcomes and 47 (41%) did not and 24 patients died from brain death. Neurological outcomes were affected by hemoglobin levels before ECMO (P = 0.02), serum lactic acid (P < 0.001) before ECMO insertion, and interval from cardiac arrest to ECMO (P = 0.04). CONCLUSIONS: Low hemoglobin or high serum lactic acid levels before ECMO, and prolonged interval from cardiac arrest to ECMO predicted poor neurological outcomes after successful ECPR. Early institution of ECMO and a low threshold for blood transfusion might improve neurological outcomes for patients who survive ECPR.

Clinical Outcomes Associated with Degree of Hypernatremia in Neurocritically Ill Patients.

OBJECTIVE: Hypernatremia is a common complication encountered during the treatment of neurocritically ill patients. However, it is unclear whether clinical outcomes correlate with the severity of hypernatremia in such patients. Therefore, we investigated the impact of hypernatremia on mortality of these patients, depending on the degree of hypernatremia. METHODS: Among neurosurgical patients admitted to the intensive care unit (ICU) in a tertiary hospital from January 2013 to December 2019, patients who were hospitalized in the ICU for more than 5 days and whose serum sodium levels were obtained during ICU admission were included. Hypernatremia was defined as the highest serum sodium level exceeding 150 mEq/L observed. We classified the patients into four subgroups according to the severity of hypernatremia and performed propensity score matching analysis. RESULTS: Among 1146 patients, 353 patients (30.8%) showed hypernatremia. Based on propensity score matching, 290 pairs were included in the analysis. The hypernatremia group had higher rates of in-hospital mortality and 28-day mortality in both overall and matched population (both p<0.001 and p=0.001, respectively). In multivariable analysis of propensity score-matched population, moderate and severe hypernatremia were significantly associated with in-hospital mortality (adjusted odds ratio [OR], 4.58; 95% confidence interval [CI], 2.15-9.75 and adjusted OR, 6.93; 95% CI, 3.46-13.90, respectively) and 28-day mortality (adjusted OR, 3.51; 95% CI, 1.54-7.98 and adjusted OR, 10.60; 95% CI, 5.10-21.90, respectively) compared with the absence of hypernatremia. However, clinical outcomes, including in-hospital mortality and 28-day mortality, were not significantly different between the group without hypernatremia and the group with mild hypernatremia (p=0.720 and p=0.690, respectively). The mortality rates of patients with moderate and severe hypernatremia were significantly higher in both overall and matched population. Interestingly, the mild hypernatremia group of matched population showed the best survival rate. CONCLUSION: Moderate and severe hypernatremia were associated with poor clinical outcomes in neurocritically ill patients. However, the prognosis of patients with mild hypernatremia was similar with that of patients without hypernatremia. Therefore, mild hypernatremia may be allowed during treatment of intracranial hypertension using hyperosmolar therapy.

Machine learning-based predictor for neurologic outcomes in patients undergoing extracorporeal cardiopulmonary resuscitation.

Background: We investigated the predictors of poor neurological outcomes in extracorporeal cardiopulmonary resuscitation (ECPR) patients using machine learning (ML) approaches. Methods: This study was a retrospective, single-center, observational study that included adult patients who underwent ECPR while hospitalized between January 2010 and December 2020. The primary outcome was neurologic status at hospital discharge as assessed by the Cerebral Performance Categories (CPC) score (scores range from 1 to 5). We trained and tested eight ML algorithms for a binary classification task involving the neurological outcomes of survivors after ECPR. Results: During the study period, 330 patients were finally enrolled in this analysis; 143 (43.3%) had favorable neurological outcomes (CPC score 1 and 2) but 187 (56.7%) did not. From the eight ML algorithms initially considered, we refined our analysis to focus on the three algorithms, eXtreme Gradient Boosting, random forest, and Stochastic Gradient Boosting, that exhibited the highest accuracy. eXtreme Gradient Boosting models exhibited the highest accuracy among all the machine learning algorithms (accuracy: 0.739, area under the curve: 0.837, Kappa: 0.450, sensitivity: 0.700, specificity: 0.740). Across all three ML models, mean blood pressure emerged as the most influential variable, followed by initial serum lactate, and arrest to extracorporeal membrane oxygenation (ECMO) pump-on-time as important predictors in machine learning models for poor neurological outcomes following successful ECPR. Conclusions: In conclusion, machine learning methods showcased outstanding predictive accuracy for poor neurological outcomes in patients who underwent ECPR.

Association between Fibrinogen-to-Albumin Ratio and Prognosis in Patients Admitted to an Intensive Care Unit.

The objective of this study was to investigate the usefulness of fibrinogen-to-albumin ratio (FAR) as a prognostic marker in patients admitted to an intensive care unit (ICU) compared with Sequential Organ Failure Assessment (SOFA) score, a widely used prognostic scoring system. An inverse probability weighting (IPW) was used to control for selection bias and confounding factors. After IPW adjustment, the high FAR group showed significantly higher risk of 1-year compared with low FAR group (36.4% vs. 12.4%, adjust hazard ratio = 1.72; 95% confidence interval (CI): 1.59-1.86; p < 0.001). In the receiver-operating characteristic curve analysis associated with the prediction of 1-year mortality, there was no significant difference between the area under the curve of FAR on ICU admission (C-statistic: 0.684, 95% CI: 0.673-0.694) and that of SOFA score on ICU admission (C-statistic: 0.679, 95% CI: 0.669-0.688) (p = 0.532). In this study, FAR and SOFA score at ICU admission were associated with 1-year mortality in patients admitted to an ICU. Especially, FAR was easier to obtain in critically ill patients than SOFA score. Therefore, FAR is feasible and might help predict long-term mortality in these patients.

Impact of early nutrition and feeding route on clinical outcomes of neurocritically ill patients.

Early proper nutritional support is important to critically ill patients. Nutritional support is also associated with clinical outcomes of neurocritically ill patients. We investigate whether early nutrition is associated with clinical outcomes in neurocritically ill patients. This was a retrospective, single-center, observational study including neurosurgical patients who were admitted to the intensive care unit (ICU) from January 2013 to December 2019. Patients who started enteral nutrition or parenteral nutrition within 72 hours after ICU admission were defined as the early nutrition group. The primary endpoint was in-hospital mortality. The secondary endpoint was an infectious complication. Propensity score matching (PSM) and propensity score weighting overlap weights (PSOW) were used to control selection bias and confounding factors. Among 1,353 patients, early nutrition was performed in 384 (28.4%) patients: 152 (11.2%) early enteral nutrition (EEN) and 232 (17.1%) early parenteral nutrition (EPN). In the overall study population, the rate of in-hospital mortality was higher in patients with late nutrition than in those with early nutrition (P<0.001). However, there was no significant difference in in-hospital mortality and infectious complications incidence between the late and the early nutrition groups in the PSM and PSOW adjusted population (all P>0.05). In the overall study population, EEN patients had a low rate of in-hospital mortality and infectious complications compared with those with EPN and late nutrition (P<0.001 and P = 0.001, respectively). In the multivariable analysis of the overall, PSM adjusted, and PSOW adjusted population, there was no significant association between early nutrition and in-hospital mortality and infectious complications (all P>0.05), but EEN was significantly associated with in-hospital mortality and infectious complications (all P<0.05). Eventually, early enteral nutrition may reduce the risk of in-hospital mortality and infectious complications in neurocritically ill patients.

Prognostic significance of respiratory quotient in patients undergoing extracorporeal cardiopulmonary resuscitation in Korea.

BACKGROUND: Respiratory quotient (RQ) may be used as a tissue hypoxia marker in various clinical settings but its prognostic significance in patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR) is not known. METHODS: Medical records of adult patients admitted to the intensive care units after ECPR in whom RQ could be calculated from May 2004 to April 2020 were retrospectively reviewed. Patients were divided into good neurologic outcome and poor neurologic outcome groups. Prognostic significance of RQ was compared to other clinical characteristics and markers of tissue hypoxia. RESULTS: During the study period, 155 patients were eligible for analysis. Of them, 90 (58.1%) had a poor neurologic outcome. The group with poor neurologic outcome had a higher incidence of out-of-hospital cardiac arrest (25.6% vs. 9.2%, P=0.010) and longer cardiopulmonary resuscitation to pump-on time (33.0 vs. 25.2 minutes, P=0.001) than the group with good neurologic outcome. For tissue hypoxia markers, the group with poor neurologic outcome had higher RQ (2.2 vs. 1.7, P=0.021) and lactate levels (8.2 vs. 5.4 mmol/L, P=0.004) than the group with good neurologic outcome. On multivariable analysis, age, cardiopulmonary resuscitation to pump-on time, and lactate levels above 7.1 mmol/L were significant predictors for a poor neurologic outcome but not RQ. CONCLUSIONS: In patients who received ECPR, RQ was not independently associated with poor neurologic outcome.

Prognostic Value of C-Reactive Protein and Albumin in Neurocritically Ill Patients with Acute Stroke.

We evaluated the prognostic value of C-reactive protein (CRP), albumin, CRP clearance (CRPc) and CRP/albumin ratio (CAR) in neurocritically ill patients with acute stroke. This is a retrospective, observational study. We included acute stroke patients who were hospitalized in the neurosurgical ICU from January 2013 to September 2019. The primary outcome was in-hospital mortality. A total of 307 patients were enrolled in the study. Among them, 267 (87.0%) survived until discharge from the hospital. CRP and CAR were significantly higher in non-survivors than in survivors (both p < 0.001). Serum albumin levels were significantly lower in the non-survivors than in the survivors (p < 0.001). In receiver operating characteristic curve analysis for prediction of in-hospital mortality, the area under the curve of CRP (C-statistic: 0.820) and CAR (C-statistic: 0.824) were greater than that of CRPc (C-statistic: 0.650) and albumin (C-statistic: 0.734) (all p < 0.005). However, there was no significant difference in the predictive performance between CRP and CAR (p = 0.287). In this study, CRP and CAR were more important than CRPc and albumin in predicting mortality of neurocritically ill patients with stroke. Early CRP level and CAR determination may help to predict the in-hospital mortality of these patients.

Association between High-Sensitivity Cardiac Troponin I and Clinical Prognosis of Neurosurgical and Neurocritically Ill Patients.

To investigate whether high-sensitivity troponin I (hs-TnI) elevation is associated with in-hospital mortality and major adverse cardiac events (MACEs) in neurosurgical and neurocritically ill patients. Among neurosurgical patients admitted to the intensive care unit (ICU) from January 2013 to December 2019, those whose serum hs-TnI levels were obtained within 7 days after ICU admission were included. Propensity score matching was used. Each patient with hs-TnI elevation was matched to a control patient. The primary endpoint was in-hospital mortality and the secondary outcome was MACEs. The hs-TnI elevation was shown in 848 (14.1%) of 6004 patients. After propensity score matching, 706 pairs of data were generated by 1:1 individual matching without replacement. In multivariable analysis of overall and propensity score-matched population, hs-TnI elevation was associated with in-hospital mortality (adjusted odds ratio (OR): 2.37, 95% confidence interval (CI): 1.68-3.33 and adjusted OR: 1.89, 95% CI: 1.28-2.81, respectively). In addition, hs-TnI elevation was associated with MACEs (adjusted OR: 2.73, 95% CI: 1.74-4.29 and adjusted OR: 2.64, 95% CI: 1.60-4.51, respectively). In this study, hs-TnI elevation was associated with in-hospital mortality and MACEs in neurosurgical and neurocritically ill patients.