Effects of Early Bedside Cycle Exercise on Intracranial Pressure and Systemic Hemodynamics in Critically Ill Patients in a Neurointensive Care Unit

Treatment with osmoactive agents such as mannitol or hypertonic saline (HTS) solutions is widely used to manage or prevent the increase of intracranial pressure (ICP) in central nervous system (CNS) disorders. We sought to evaluate the variability and mean plasma concentrations of the water and electrolyte balance parameters in critically ill patients treated with osmotic therapy and their influence on mortality. This cohort study covered patients hospitalized in an intensive care unit (ICU) from January 2017 to June 2019 with presumed increased ICP or considered to be at risk of it, treated with 15% mannitol (G1, n = 27), a combination of 15% mannitol and 10% hypertonic saline (HTS) (G2, n = 33) or 10% HTS only (G3, n = 13). Coefficients of variation (Cv) and arithmetic means (mean) were calculated for the parameters reflecting the water and electrolyte balance, i.e., sodium (NaCv/NaMean), chloride (ClCv/ClMean) and osmolality (mOsmCv/mOsmMean). In-hospital mortality was also analyzed. The study group comprised 73 individuals (36 men, 49%). Mortality was 67% (n = 49). Median NaCv (G1: p = 0.002, G3: p = 0.03), ClCv (G1: p = 0.02, G3: p = 0.04) and mOsmCv (G1: p = 0.001, G3: p = 0.02) were higher in deceased patients. NaMean (p = 0.004), ClMean (p = 0.04), mOsmMean (p = 0.003) were higher in deceased patients in G3. In G1: NaCv (AUC = 0.929, p < 0.0001), ClCv (AUC = 0.817, p = 0.0005), mOsmCv (AUC = 0.937, p < 0.0001) and in G3: NaMean (AUC = 0.976, p < 0.001), mOsmCv (AUC = 0.881, p = 0.002), mOsmMean (AUC = 1.00, p < 0.001) were the best predictors of mortality. The overall mortality prediction for combined G1+G2+G3 was very good, with AUC = 0.886 (p = 0.0002). The mortality of critically ill patients treated with osmotic agents is high. Electrolyte disequilibrium is the independent predictor of mortality regardless of the treatment method used. Variations of plasma sodium, chloride and osmolality are the most deleterious factors regardless of the absolute values of these parameters

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Diagnosis of elevated intracranial pressure in critically ill adults: systematic review and meta-analysis

BMJ ◽

10.1136/bmj.l4225 ◽

2019 ◽

pp. l4225 ◽

Cited By ~ 15

Author(s):

Shannon M Fernando ◽

Alexandre Tran ◽

Wei Cheng ◽

Bram Rochwerg ◽

Monica Taljaard ◽

...

Keyword(s):

Systematic Review ◽

Intracranial Pressure ◽

Physical Examination ◽

Critically Ill ◽

Sensitivity And Specificity ◽

Critically Ill Patients ◽

Meta Analysis ◽

Elevated Intracranial Pressure ◽

Midline Shift ◽

Non Invasive

Abstract Objectives To summarise and compare the accuracy of physical examination, computed tomography (CT), sonography of the optic nerve sheath diameter (ONSD), and transcranial Doppler pulsatility index (TCD-PI) for the diagnosis of elevated intracranial pressure (ICP) in critically ill patients. Design Systematic review and meta-analysis. Data sources Six databases, including Medline, EMBASE, and PubMed, from inception to 1 September 2018. Study selection criteria English language studies investigating accuracy of physical examination, imaging, or non-invasive tests among critically ill patients. The reference standard was ICP of 20 mm Hg or more using invasive ICP monitoring, or intraoperative diagnosis of raised ICP. Data extraction Two reviewers independently extracted data and assessed study quality using the quality assessment of diagnostic accuracy studies tool. Summary estimates were generated using a hierarchical summary receiver operating characteristic (ROC) model. Results 40 studies (n=5123) were included. Of physical examination signs, pooled sensitivity and specificity for increased ICP were 28.2% (95% confidence interval 16.0% to 44.8%) and 85.9% (74.9% to 92.5%) for pupillary dilation, respectively; 54.3% (36.6% to 71.0%) and 63.6% (46.5% to 77.8%) for posturing; and 75.8% (62.4% to 85.5%) and 39.9% (26.9% to 54.5%) for Glasgow coma scale of 8 or less. Among CT findings, sensitivity and specificity were 85.9% (58.0% to 96.4%) and 61.0% (29.1% to 85.6%) for compression of basal cisterns, respectively; 80.9% (64.3% to 90.9%) and 42.7% (24.0% to 63.7%) for any midline shift; and 20.7% (13.0% to 31.3%) and 89.2% (77.5% to 95.2%) for midline shift of at least 10 mm. The pooled area under the ROC (AUROC) curve for ONSD sonography was 0.94 (0.91 to 0.96). Patient level data from studies using TCD-PI showed poor performance for detecting raised ICP (AUROC for individual studies ranging from 0.55 to 0.72). Conclusions Absence of any one physical examination feature is not sufficient to rule out elevated ICP. Substantial midline shift could suggest elevated ICP, but the absence of shift cannot rule it out. ONSD sonography might have use, but further studies are needed. Suspicion of elevated ICP could necessitate treatment and transfer, regardless of individual non-invasive tests. Registration PROSPERO CRD42018105642.

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Chest physiotherapy on intracranial pressure of critically ill patients admitted to the intensive care unit: a systematic review

Revista Brasileira de Terapia Intensiva ◽

10.5935/0103-507x.20130055 ◽

2013 ◽

Vol 25 (4) ◽

Cited By ~ 5

Author(s):

Lucas Lima Ferreira ◽

Vitor Engrácia Valenti ◽

Luiz Carlos Marques Vanderlei

Keyword(s):

Systematic Review ◽

Intensive Care Unit ◽

Intensive Care ◽

Intracranial Pressure ◽

Critically Ill ◽

Critically Ill Patients ◽

Chest Physiotherapy

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Electrostatic discharges and their effect on the validity of registered values in intracranial pressure monitors

Journal of Neurosurgery ◽

10.3171/2013.7.jns13506 ◽

2013 ◽

Vol 119 (5) ◽

pp. 1119-1124 ◽

Cited By ~ 7

Author(s):

Morten Andresen ◽

Marianne Juhler ◽

Ole Cornelius Thomsen

Keyword(s):

Intracranial Pressure ◽

Isotonic Saline ◽

Neurointensive Care ◽

Pressure Monitor ◽

Electrostatic Discharges ◽

Neurointensive Care Unit ◽

Clinical Observations ◽

Clinically Significant ◽

Large Container ◽

Different Levels

Object Intracranial pressure (ICP) monitoring is used extensively in clinical practice, and as such, the accuracy of registered ICP values is paramount. Clinical observations of nonphysiological changes in ICP have called into question the accuracy of registered ICP values. Subsequently, the authors have tried to determine if the ICP monitors from major manufacturers were affected by electrostatic discharges (ESDs), if the changes were permanent or transient in nature, and if the changes were modified by the addition of different electrical appliances normally used in the neurointensive care unit environment. Methods The authors established a test setup in the neurointensive care unit using a large container filled with isotonic saline, creating a phantom patient. Intracranial pressure monitors were sequentially lowered into the container and subjected to a predefined test battery of ESDs. Results Five pressure monitors from 4 manufacturers were evaluated. Three monitors containing electrical circuitry at the tip of the transducer were all affected by ESDs. Clinically significant permanent changes in the reported ICP values for 1 pressure monitor were observed, as well as temporary deflections for 2 other monitors. The monitors had different levels of sensitivity to discharges at low voltages. Conclusions These results explain some of the sudden shifts in ICP noted in the clinical setting. However, a clear deflection pattern related to the addition of electrical appliances was not found. The authors recommend instituting policies for reducing the risk of subjecting patients to ESDs in the neurointensive care unit setting.

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