Effects of PEEP on intracranial pressure in patients with acute brain injury: An observational, prospective and multicenter study.

OBJECTIVE: To analyze the impact of positive end-expiratory pressure (PEEP) changes on intracranial pressure (ICP) dynamics in patients with acute brain injury (ABI). DESIGN: Observational, prospective and multicenter study (PEEP-PIC study). SETTING: Seventeen intensive care units in Spain. PATIENTS: Neurocritically ill patients who underwent invasive neuromonitorization from November 2017 to June 2018. INTERVENTIONS: Baseline ventilatory, hemodynamic and neuromonitoring variables were collected immediately before PEEP changes and during the following 30 min. MAIN VARIABLES OF INTEREST: PEEP and ICP changes. RESULTS: One-hundred and nine patients were included. Mean age was 52.68 (15.34) years, male 71 (65.13%). Traumatic brain injury was the cause of ABI in 54 (49.54%) patients. Length of mechanical ventilation was 16.52 (9.23) days. In-hospital mortality was 21.1%. PEEP increases (mean 6.24-9.10 cmH2O) resulted in ICP increase from 10.4 to 11.39 mmHg, P < .001, without changes in cerebral perfusion pressure (CPP) (P = .548). PEEP decreases (mean 8.96 to 6.53 cmH2O) resulted in ICP decrease from 10.5 to 9.62 mmHg (P = .052), without changes in CPP (P = .762). Significant correlations were established between the increase of ICP and the delta PEEP (R = 0.28, P < .001), delta driving pressure (R = 0.15, P = .038) and delta compliance (R = -0.14, P = .052). ICP increment was higher in patients with lower baseline ICP. CONCLUSIONS: PEEP changes were not associated with clinically relevant modifications in ICP values in ABI patients. The magnitude of the change in ICP after PEEP increase was correlated with the delta of PEEP, the delta driving pressure and the delta compliance.

[Limiting ICU admission from emergency services and wards]. / Limitación del ingreso en unidades de cuidados intensivos desde los servicios de urgencias y las plantas de hospitalización.

INTRODUCTION: Decisions not to admit a patient to intensive care units (ICU) as a way of limiting life support treatment (LLST) is a practice that can affect the operation of the emergency services and the way in which patients die. METHODS: Post hoc analysis of the ADENI-UCI study. The main variable analysed was the reason for refusal of admission to the ICU as a measure of LLST. For the present post hoc analysis, the registered patients were divided into 2 groups: the patients assessed in the intensive medicine services from the emergency department and the patients assessed from the conventional hospitalization areas. Student t was used in the comparative statistics when the mean values of the patient sub-cohorts were compared. Categorical variables were compared with the χ2 tests. RESULTS: The ADENI-ICU study included 2,284 decisions not to admit to the ICU as a measure of LLST. Estimated poor quality of life (p=.0158), the presence of severe chronic disease (P=.0169) and futility of treatment (P=.0006) were percentage decisions with greater weight within the population of hospitalized patients. The percentage of disagreement between the consulting physician and the intensivist was significantly lower in patients assessed from the emergency services (P=.0021). CONCLUSIONS: There are appreciable differences in the reasons for consultation, as well as in those for refusal of admission to an ICU between the consultations made from an emergency department and a conventional hospitalization facility.

Mechanical thrombectomy: an alternative for treating cerebral venous sinus thrombosis. / Trombectomía mecánica como alternativa de tratamiento en la trombosis venosa cerebral.

EN: We report the use of mechanical venous thrombectomy in 2 cases of cerebral venous sinus thrombosis in which the usual first-choice treatment with systemic anticoagulants was contraindicated. Our aim is to present this treatment as an alternative to consider when anticoagulants therapy is too risky or is contraindicated in critically ill patients.

ES: Se presentan 2 casos de trombosis venosa cerebral (TVC) aguda tratados mediante trombectomía mecánica venosa (TMV) en los que la anticoagulación sistémica, considerada como la primera línea terapéutica, estaba contraindicada. El objetivo de la presente nota clínica es mostrar esta técnica como tratamiento alternativo en pacientes críticos en los que la anticoagulación supone un riesgo excesivamente elevado o está contraindicada.