scholarly journals The Association Between Arterial Oxygen Level and Outcome in Neurocritically Ill Patients is not Affected by Blood Pressure

2021 ◽  
Author(s):  
Jaana Humaloja ◽  
Markus B. Skrifvars ◽  
Rahul Raj ◽  
Erika Wilkman ◽  
Pirkka T. Pekkarinen ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Intensive Care ◽  
Brain Injury ◽  
Hemodynamic Instability ◽  
Arterial Oxygen ◽  
Admission Diagnosis ◽  
Secondary Brain Injury ◽  
Multivariable Logistic Regression Model ◽  
Mechanically Ventilated ◽  
The Relationship

Abstract Background In neurocritically ill patients, one early mechanism behind secondary brain injury is low systemic blood pressure resulting in inadequate cerebral perfusion and consequent hypoxia. Intuitively, higher partial pressures of arterial oxygen (PaO2) could be protective in case of inadequate cerebral circulation related to hemodynamic instability. Study purpose We examined whether the association between PaO2 and mortality is different in patients with low compared to normal and high mean arterial pressure (MAP) in patients after various types of brain injury. Methods We screened the Finnish Intensive Care Consortium database for mechanically ventilated adult (≥ 18) brain injury patients treated in several tertiary intensive care units (ICUs) between 2003 and 2013. Admission diagnoses included traumatic brain injury, cardiac arrest, subarachnoid and intracranial hemorrhage, and acute ischemic stroke. The primary exposures of interest were PaO2 (recorded in connection with the lowest measured PaO2/fraction of inspired oxygen ratio) and the lowest MAP, recorded during the first 24 h in the ICU. PaO2 was grouped as follows: hypoxemia (< 8.2 kPa, the lowest 10th percentile), normoxemia (8.2–18.3 kPa), and hyperoxemia (> 18.3 kPa, the highest 10th percentile), and MAP was divided into equally sized tertiles (< 60, 60–68, and > 68 mmHg). The primary outcome was 1-year mortality. We tested the association between hyperoxemia, MAP, and mortality with a multivariable logistic regression model, including the PaO2, MAP, and interaction of PaO2*MAP, adjusting for age, admission diagnosis, premorbid physical performance, vasoactive use, intracranial pressure monitoring use, and disease severity. The relationship between predicted 1-year mortality and PaO2 was visualized with locally weighted scatterplot smoothing curves (Loess) for different MAP levels. Results From a total of 8290 patients, 3912 (47%) were dead at 1 year. PaO2 was not an independent predictor of mortality: the odds ratio (OR) for hyperoxemia was 1.16 (95% CI 0.85–1.59) and for hypoxemia 1.24 (95% CI 0.96–1.61) compared to normoxemia. Higher MAP predicted lower mortality: OR for MAP 60–68 mmHg was 0.73 (95% CI 0.64–0.84) and for MAP > 68 mmHg 0.80 (95% CI 0.69–0.92) compared to MAP < 60 mmHg. The interaction term PaO2*MAP was nonsignificant. In Loess visualization, the relationship between PaO2 and predicted mortality appeared similar in all MAP tertiles. Conclusions During the first 24 h of ICU treatment in mechanically ventilated brain injured patients, the association between PaO2 and mortality was not different in patients with low compared to normal MAP.

Traditional systolic blood pressure targets underestimate hypotension-induced secondary brain injury

2012 ◽  
Vol 72 (5) ◽  
pp. 1135-1139 ◽  
Author(s):  
Megan Brenner ◽  
Deborah M. Stein ◽  
Peter F. Hu ◽  
Bizhan Aarabi ◽  
Kevin Sheth ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Brain Injury ◽  
Systolic Blood Pressure ◽  
Secondary Brain Injury ◽  
Blood Pressure Targets

Five-Year Outcomes After Implementing a Pain, Agitation, and Delirium Protocol in a Mixed Intensive Care Unit

2021 ◽  
pp. 088506662110634
Author(s):  
Jeffrey T. Fish ◽  
Jared T. Baxa ◽  
Ryan R. Draheim ◽  
Matthew J. Willenborg ◽  
Jared C. Mills ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Academic Medical Center ◽  
Admission Diagnosis ◽  
Surgical Intensive Care Unit ◽  
Standardized Mortality Ratio ◽  
Surgical Intensive Care ◽  
Mechanically Ventilated ◽  
Mortality Ratio ◽  
Apache Iv

Objective: Assess for continued improvements in patient outcomes after updating our institutional sedation and analgesia protocol to include recommendations from the 2013 Society of Critical Care Medicine (SCCM) Pain, Agitation, and Delirium (PAD) guidelines. Methods: Retrospective before-and-after study in a mixed medical/surgical intensive care unit (ICU) at an academic medical center. Mechanically ventilated adults admitted from September 1, 2011 through August 31, 2012 (pre-implementation) and October 1, 2012 through September 30, 2017 (post-implementation) were included. Measurements included number of mechanically ventilated patients, APACHE IV scores, age, type of patient (medical or surgical), admission diagnosis, ICU length of stay (LOS), hospital LOS, ventilator days, number of self-extubations, ICU mortality, ICU standardized mortality ratio, hospital mortality, hospital standardized mortality ratio, medication data including as needed (PRN) analgesic and sedative use, and analgesic and sedative infusions, and institutional savings. Results: Ventilator days (Pre-PAD = 4.0 vs. Year 5 post = 3.2, P < .0001), ICU LOS (Pre-PAD = 4.8 days vs. Year 5 post = 4.1 days, P = .0004) and hospital LOS (Pre-PAD = 14 days vs. Year 5 post = 12 days, P < .0001) decreased after protocol implementation. Hospital standardized mortality ratio (Pre-PAD = 0.69 vs. Year 5 post = 0.66) remained constant; while, APACHE IV scores (Pre-PAD = 77 vs. Year 5 post = 89, P < .0001) and number of intubated patients (Pre-PAD = 1146 vs. Year 5 post = 1468) increased over the study period. Using the decreased ICU and hospital LOS estimates, it is projected the institution saved $4.3 million over the 5 years since implementation. Conclusions: Implementation of an updated PAD protocol in a mixed medical/surgical ICU was associated with a significant decrease in ventilator time, ICU LOS, and hospital LOS without a change in the standardized mortality ratio over a five-year period. These favorable outcomes are associated with a significant cost savings for the institution.

Mobile computerized tomography scanning in the neurosurgery intensive care unit: increase in patient safety and reduction of staff workload

2000 ◽  
Vol 93 (3) ◽  
pp. 432-436 ◽  
Author(s):  
Thorsteinn Gunnarsson ◽  
Annette Theodorsson ◽  
Per Karlsson ◽  
Steen Fridriksson ◽  
Sverre Boström ◽  
...  
Keyword(s):  
Intensive Care ◽  
Brain Injury ◽  
Risk Group ◽  
Ct Scanning ◽  
Secondary Brain Injury ◽  
Content Type ◽  
Medium Risk ◽  
Mobile Ct ◽  
Staff Workload ◽  
Fine Print

Object. Transportation of unstable neurosurgical patients involves risks that may lead to further deterioration and secondary brain injury from perturbations in physiological parameters. Mobile computerized tomography (CT) head scanning in the neurosurgery intensive care (NICU) is a new technique that minimizes the need to transport unstable patients. The authors have been using this device since June 1997 and have developed their own method of scanning such patients.Methods. The scanning procedure and radiation safety measures are described. The complications that occurred in 89 patients during transportation and conventional head CT scanning at the Department of Radiology were studied prospectively. These complications were compared with the ones that occurred during mobile CT scanning in 50 patients in the NICU. The duration of the procedures was recorded, and an estimation of the staff workload was made. Two patient groups, defined as high- and medium-risk cases, were studied. Medical and/or technical complications occurred during conventional CT scanning in 25% and 20% of the patients in the high- and medium-risk groups, respectively. During mobile CT scanning complications occurred in 4.3% of the high-risk group and 0% of the medium-risk group. Mobile CT scanning also took significantly less time, and the estimated personnel cost was reduced.Conclusions. Mobile CT scanning in the NICU is safe. It minimizes the risk of physiological deterioration and technical mishaps linked to intrahospital transport, which may aggravate secondary brain injury. The time that patients have to remain outside the controlled environment of the NICU is minimized, and the staff's workload is decreased.

Traditional systolic blood pressure targets underestimate hypotension-induced secondary brain injury

2012 ◽  
Vol 72 (5) ◽  
pp. 1456-1457
Author(s):  
Megan Brenner ◽  
Deborah M. Stein ◽  
Peter F. Hu ◽  
Bizhan Aarabi ◽  
Kevin Sheth ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Brain Injury ◽  
Systolic Blood Pressure ◽  
Secondary Brain Injury ◽  
Blood Pressure Targets

Cerebral Autoregulation and Outcome in Acute Brain Injury

2001 ◽  
Vol 2 (3) ◽  
pp. 175-185 ◽  
Author(s):  
Catherine J. Kirkness ◽  
Pamela H. Mitchell ◽  
Robert L. Burr ◽  
David W. Newell
Keyword(s):  
Blood Pressure ◽  
Brain Injury ◽  
Cerebral Autoregulation ◽  
Acute Brain Injury ◽  
Reactivity Index ◽  
Cerebrovascular Pathology ◽  
Arterial Blood ◽  
Score Analysis ◽  
Pressure Changes ◽  
The Relationship

The purpose of this study was to examine the relationship between Czosnyka and others’ Pressure Reactivity Index (PRx) and neurologic outcome in patients with acute brain injury, including traumatic brain injury (TBI) and cerebrovascular pathology. PRx measures the correlation between arterial blood pressure and intracranial pressure waves and may reflect cerebral autoregulation in response to blood pressure changes. A negative PRx reflects intact cerebrovascular response, whereas a positive PRx reflects impaired response. Positive PRx has been shown to correlate with poorer outcome in individuals with TBI, but these findings have not been confirmed by replication in other studies, nor have PRx values been reported for individuals with cerebrovascular pathology. In this study, PRx was determined in 52 patients with TBI (n = 27) or cerebrovascular pathology (n = 25). Hierarchical linear regression was used to evaluate the contribution of PRx to outcome, controlling for age and Glasgow Coma Scale score. Analysis of all subjects together did not support the previously reported relationship between PRx and outcome. However, for those with TBI, positive PRx was a significant predictor of negative outcome (P = 0.03). For those with cerebrovascular pathology, the effect was not significant (P = 0.10) and was in the opposite direction. For individuals with TBI, PRx may provide useful information related to cerebral autoregulation that is predictive of outcome. The meaning of PRx in individuals with cerebrovascular pathology is unclear, and further study is needed to examine the paradoxical findings observed.

scholarly journals Digital signatures for early traumatic brain injury outcome prediction in the intensive care unit

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Anil K. Palepu ◽  
Aditya Murali ◽  
Jenna L. Ballard ◽  
Robert Li ◽  
Samiksha Ramesh ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Traumatic Brain Injury ◽  
Intensive Care ◽  
Brain Injury ◽  
Neurological Function ◽  
Series Data ◽  
Admission Diagnosis ◽  
Electronic Health Record Data ◽  
Prediction Of Mortality ◽  
Icu Discharge

AbstractTraumatic brain injury (TBI) is a leading neurological cause of death and disability across the world. Early characterization of TBI severity could provide a window for therapeutic intervention and contribute to improved outcome. We hypothesized that granular electronic health record data available in the first 24 h following admission to the intensive care unit (ICU) can be used to differentiate outcomes at discharge. Working from two ICU datasets we focused on patients with a primary admission diagnosis of TBI whose length of stay in ICU was ≥ 24 h (N = 1689 and 127). Features derived from clinical, laboratory, medication, and physiological time series data in the first 24 h after ICU admission were used to train elastic-net regularized Generalized Linear Models for the prediction of mortality and neurological function at ICU discharge. Model discrimination, determined by area under the receiver operating characteristic curve (AUC) analysis, was 0.903 and 0.874 for mortality and neurological function, respectively. Model performance was successfully validated in an external dataset (AUC 0.958 and 0.878 for mortality and neurological function, respectively). These results demonstrate that computational analysis of data routinely collected in the first 24 h after admission accurately and reliably predict discharge outcomes in ICU stratum TBI patients.

scholarly journals The Relationship Between PaO2/FiO2 and Delirium in Intensive Care: A Cross-Sectional Study

2020 ◽  
Author(s):  
Fang Gong ◽  
Yuhang Ai ◽  
Lina Zhang ◽  
Qianyi Peng ◽  
Quan Zhou ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Intensive Care ◽  
Cross Sectional Study ◽  
Assessment Method ◽  
Arterial Oxygen ◽  
Apache Ii Score ◽  
Sectional Study ◽  
Cross Sectional ◽  
Non Linear ◽  
The Relationship

Abstract Background: Studies investigating the association of delirium with ratio of partial pressure of arterial oxygen to fraction of inspired oxygen (PaO2/FiO2) have been limited. The main purpose of the our study was to explore the relationship between PaO2/FiO2 and the risk of delirium in intensive care units (ICUs). Methods: This was a cross-sectional study that involved the collection of data from patients admitted to the Xiang Ya Hospital Cardiothoracic Surgical Care Unit and Comprehensive Intensive Care Unit from September 1st, 2016, to December 10th, 2016. Delirium was diagnosed by the simplified version of the Chinese Confusion Assessment Method for the ICU (CAM-ICU). The PaO2/FiO2 of each patient was recorded at the first 24 h after admission to the ICU. Results: There was a non-linear relationship between the PaO2/FiO2 and delirium, after adjusting for the following potential confounders: gender, age, hypertension, heart disease, history of a cerebral vascular accident, diabetes, smoking habits, drinking habits, chronic pulmonary dysfunction, blood pressure at admission, postoperative surgery, mechanical ventilation, mechanical ventilation time, PaCO2, sedation, APACHE II score, and SOFA score. We used a two-piecewise linear regression model to calculate the threshold of 247 mmHg. On the left side of the threshold, the odds ratio (OR) was 0.91 (95% CI [0.84, 0.98]), while the OR on the right side was 1.03 (95% CI [1.00, 1.06]).Conclusions: The relationship between PaO2/FiO2 and risk of delirium was non-linear. The PaO2/FiO2 was negatively associated with the risk of delirium when the PaO2/FiO2 was less than 247 mmHg. As a readily available laboratory indicator, PaO2/FiO2 has potential value in the clinical evaluation risk of delirium in ICU patients. Of course, our conclusions need further confirmation from other studies, especially large prospective studies.

Serum Biomarkers for Risk Assessment of Intrahospital Transports in Mechanically Ventilated Neurosurgical Intensive Care Unit Patients

2019 ◽  
pp. 088506661989106
Author(s):  
Michael Bender ◽  
Marco Stein ◽  
Seong Woong Kim ◽  
Eberhard Uhl ◽  
Karsten Schöller
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Intracranial Pressure ◽  
Demographic Data ◽  
Simplified Acute Physiology Score ◽  
Serum Biomarkers ◽  
Secondary Brain Injury ◽  
Mechanically Ventilated ◽  
Neurosurgical Intensive Care ◽  
Neurosurgical Intensive Care Unit

Objective: Intrahospital transports (IHTs) of neurosurgical intensive care unit (NICU) patients can be hazardous. Increasing intracranial pressure (ICP) and/or decreasing cerebral perfusion pressure (CPP) as well as cardiopulmonary alterations are common complications of an IHTs, which can lead to secondary brain injury. This study was performed to assess several serum biomarkers concerning their potential to improve safety of IHTs in mechanically ventilated NICU patients. Methods: All IHTs of mechanically ventilated and sedated NICU patients from 03/2017 to 01/2018 were retrospectively analyzed. Intracranial pressure and CPP measurements were performed in all patients. Serum hemoglobin, hematocrit, and serum sodium were defined as serum biomarkers. Demographic data, computed tomography scan on admission, Simplified Acute Physiology Score and Acute Physiology and Chronic Health Evaluation II, modified Rankin Scale, indication and consequence of IHTs were analyzed. Alteration of ICP/CPP, hemodynamic and pulmonary events were defined as complications. The study population was stratified into patients with the occurrence of a complication and absence of a complication. Results: We analyzed a total number of 184 IHTs in 70 NICU patients with an overall complication rate of 57.6%. Of all, 32.1% IHTs had no direct therapeutic consequence. In patients with higher hemoglobin values prior to IHT less complications occurred, concerning ICP ( P = .001), CPP ( P = .001), hemodynamic ( P = .005), and pulmonary ( P < .0001) events. In addition, complications concerning ICP ( P = .001), CPP ( P = .001), hemodynamic ( P = .005), and pulmonary problems ( P = .002) were significantly lower in patients with higher hematocrit values before IHT. Conclusion: Intrahospital transports of mechanically ventilated NICU patients carry a high risk of increased ICP and hemodynamic complications and should be performed restrictively. Higher values of hemoglobin and hematocrit prior to IHT were associated with less complications with regard to ICP, CPP as well as hemodynamic and pulmonary events and could be helpful to assess the potential risk of complications prior to IHTs.

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