Publications by authors named "Fabio S Taccone"

131 Publications

Higher levels of IgA and IgG at sepsis onset are associated with higher mortality: results from the Albumin Italian Outcome Sepsis (ALBIOS) trial.

Ann Intensive Care 2021 Nov 26;11(1):161. Epub 2021 Nov 26.

Department of Cardiovascular Medicine, Institute for Pharmacological Research Mario Negri IRCCS, Via Mario Negri 2, 20156, Milan, Italy.

Background: The role of intravenous immunoglobulins (IVIG) during sepsis is controversial, as different trials on IVIG have observed inconsistent survival benefits. We aimed to elucidate the possible association and clinical significance between circulating levels of immunoglobulins.

Methods: In a subset of 956 patients with severe sepsis and septic shock of the multicentre, open-label RCT ALBIOS, venous blood samples were serially collected 1, 2, and 7 days after enrolment (or at ICU discharge, whichever came first). IgA, IgG and IgM concentrations were assayed in all patients on day 1 and in a subgroup of 150 patients on days 2 and 7. Ig concentrations were measured employing a turbidimetric assay, OSR61171 system.

Results: IgA on day 1 had a significant predictive value for both 28-day and 90-day mortality (28-day mortality, HR: 1.50 (95% CI 1.18-1.92); 90-day mortality, HR: 1.54 (95% CI 1.25-1.91)). IgG, but not IgM, on day 1 showed similar results for 28-day (HR 1.83 (95% CI 1.33-2.51) and 90-day mortality HR: 1.66 (95% CI 1.23-2.25)). In addition, lower levels of IgG but not of IgA and IgM, at day 1 were associated with significantly higher risk of secondary infections (533 [406-772] vs 600 [452-842] mg/dL, median [Q1-Q3], p = 0.007).

Conclusions: In the largest cohort study of patients with severe sepsis or septic shock, we found that high levels of IgA and IgG on the first day of diagnosis were associated with a decreased 90-day survival. No association was found between IgM levels and survival. As such, the assessment of endogenous immunoglobulins could be a useful tool to identify septic patients at high risk of mortality. Trial registration #NCT00707122, Clinicaltrial.gov, registered 30 June 2008.
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http://dx.doi.org/10.1186/s13613-021-00952-zDOI Listing
November 2021

Basic ultrasound head-to-toe skills for intensivists in the general and neuro intensive care unit population: consensus and expert recommendations of the European Society of Intensive Care Medicine.

Intensive Care Med 2021 Dec 5;47(12):1347-1367. Epub 2021 Oct 5.

Intensive Care Medicine Unit, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Paré, Billancourt, 92100, Boulogne, France.

Purpose: To provide consensus, and a list of experts' recommendations regarding the basic skills for head-to-toe ultrasonography in the intensive care setting.

Methods: The Executive Committee of the European Society of Intensive Care (ESICM) commissioned the project and supervised the methodology and structure of the consensus. We selected an international panel of 19 expert clinicians-researchers in intensive care unit (ICU) with expertise in critical care ultrasonography (US), plus a non-voting methodologist. The panel was divided into five subgroups (brain, lung, heart, abdomen and vascular ultrasound) which identified the domains and generated a list of questions to be addressed by the panel. A Delphi process based on an iterative approach was used to obtain the final consensus statements. Statements were classified as a strong recommendation (84% of agreement), weak recommendation (74% of agreement), and no recommendation (less than 74%), in favor or against.

Results: This consensus produced a total of 74 statements (7 for brain, 20 for lung, 20 for heart, 20 for abdomen, 7 for vascular Ultrasound). We obtained strong agreement in favor for 49 statements (66.2%), 8 weak in favor (10.8%), 3 weak against (4.1%), and no consensus in 14 cases (19.9%). In most cases when consensus was not obtained, it was felt that the skills were considered as too advanced. A research agenda and discussion on training programs were implemented from the results of the consensus.

Conclusions: This consensus provides guidance for the basic use of critical care US and paves the way for the development of training and research projects.
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http://dx.doi.org/10.1007/s00134-021-06486-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8596353PMC
December 2021

Perioperative management of severe brain injured patients.

Minerva Anestesiol 2021 Oct 12. Epub 2021 Oct 12.

Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium.

Traumatic brain injury (TBI) is a leading cause of mortality and disability worldwide. Head injured patients may frequently require emergency neurosurgery. The perioperative TBI period is very important as many interventions done in this stage can have a profound effect on the long-term neurological outcome. This practical concise narrative review focused mainly on: 1) the management of severe TBI patients with neurosurgical lesions admitted to a spoke center (i.e. hospital without neurosurgery) and therefore needing a transfer to the hub center (i.e. hospital with neurosurgery); 2) the management of severe TBI patients with intracranial hypertension/brain herniation awaiting for neurosurgery and 3) the neuromonitoring-oriented management in the immediate post-operative period. The proposals presented in this review mainly apply to severe TBI patients admitted to high-income countries.
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http://dx.doi.org/10.23736/S0375-9393.21.15927-9DOI Listing
October 2021

Creatinine correction to account for fluid overload in children with acute respiratory distress syndrome treated with extracorporeal membrane oxygenation: an initial exploratory report.

Pediatr Nephrol 2021 Sep 20. Epub 2021 Sep 20.

Department of Intensive Care, Hôpital Universitaire Des Enfants (HUDERF), Université Libre de Bruxelles (ULB), Brussels, Belgium.

Background: Creatinine is distributed between the intracellular and extracellular compartments, and as a result, the measurement of its concentration is strongly related to the fluid status of the patient. An interest has been shown in correcting measured serum creatinine levels according to the fluid balance in order to better specify the degree of acute kidney injury (AKI).

Methods: We conducted a retrospective observational study of 33 children, aged 0 to 5 years, admitted to the pediatric intensive care unit for acute respiratory distress syndrome treated by extracorporeal membrane oxygenation. We compared measured and corrected creatinine and assessed the degree of agreement between these values using both Cohen's kappa and Krippendorff's alpha coefficient.

Results: In our cohort, 37% of the classifications made according to measured creatinine levels were erroneous and, in the majority of cases, the degree of AKI was underestimated.

Conclusion: Correction of the measured creatinine value according to the degree of fluid overload may result in more accurate diagnosis of AKI. Graphical abstract A higher resolution version of the Graphical abstract is available as Supplementary information.
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http://dx.doi.org/10.1007/s00467-021-05257-8DOI Listing
September 2021

Extracorporeal cardiopulmonary resuscitation in adults: evidence and implications.

Intensive Care Med 2021 Sep 10. Epub 2021 Sep 10.

Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, 622 W168th St., PH 8E, Room 101, New York, NY, 10032, USA.

Rates of survival with functional recovery for both in-hospital and out-of-hospital cardiac arrest are notably low. Extracorporeal cardiopulmonary resuscitation (ECPR) is emerging as a modality to improve prognosis by augmenting perfusion to vital end-organs by utilizing extracorporeal membrane oxygenation (ECMO) during conventional CPR and stabilizing the patient for interventions aimed at reversing the aetiology of the arrest. Implementing this emergent procedure requires a substantial investment in resources, and even the most successful ECPR programs may nonetheless burden healthcare systems, clinicians, patients, and their families with unsalvageable patients supported by extracorporeal devices. Non-randomized and observational studies have repeatedly shown an association between ECPR and improved survival, versus conventional CPR, for in-hospital cardiac arrest in select patient populations. Recently, randomized controlled trials suggest benefit for ECPR over standard resuscitation, as well as the feasibility of performing such trials, in out-of-hospital cardiac arrest within highly coordinated healthcare delivery systems. Application of these data to clinical practice should be done cautiously, with outcomes likely to vary by the setting and system within which ECPR is initiated. ECPR introduces important ethical challenges, including whether it should be considered an extension of CPR, at what point it becomes sustained organ replacement therapy, and how to approach patients unable to recover or be bridged to heart replacement therapy. The economic impact of ECPR varies by health system, and has the potential to outstrip resources if used indiscriminately. Ideally, studies should include economic evaluations to inform health care systems about the cost-benefits of this therapy.
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http://dx.doi.org/10.1007/s00134-021-06514-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8429884PMC
September 2021

Do ventilatory parameters influence outcome in patients with severe acute respiratory infection? Secondary analysis of an international, multicentre14-day inception cohort study.

J Crit Care 2021 12 27;66:78-85. Epub 2021 Aug 27.

Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada; Keenan Research Centre, Li KaShing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.

Purpose: To investigate the possible association between ventilatory settings on the first day of invasive mechanical ventilation (IMV) and mortality in patients admitted to the intensive care unit (ICU) with severe acute respiratory infection (SARI).

Materials And Methods: In this pre-planned sub-study of a prospective, multicentre observational study, 441 patients with SARI who received controlled IMV during the ICU stay were included in the analysis.

Results: ICU and hospital mortality rates were 23.1 and 28.1%, respectively. In multivariable analysis, tidal volume and respiratory rate on the first day of IMV were not associated with an increased risk of death; however, higher driving pressure (DP: odds ratio (OR) 1.05; 95% confidence interval (CI): 1.01-1.1, p = 0.011), plateau pressure (Pplat) (OR 1.08; 95% CI: 1.04-1.13, p < 0.001) and positive end-expiratory pressure (PEEP) (OR 1.13; 95% CI: 1.03-1.24, p = 0.006) were independently associated with in-hospital mortality. In subgroup analysis, in hypoxemic patients and in patients with acute respiratory distress syndrome (ARDS), higher DP, Pplat, and PEEP were associated with increased risk of in-hospital death.

Conclusions: In patients with SARI receiving IMV, higher DP, Pplat and PEEP, and not tidal volume, were associated with a higher risk of in-hospital death, especially in those with hypoxemia or ARDS.
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http://dx.doi.org/10.1016/j.jcrc.2021.08.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8394083PMC
December 2021

Multicentre observational study on practice of ventilation in brain injured patients: the VENTIBRAIN study protocol.

BMJ Open 2021 08 11;11(8):e047100. Epub 2021 Aug 11.

Anesthesia and Intensive Care, Policlinico San Martino, IRCCS for Oncology and Neuroscience, Genova, Italy.

Introduction: Mechanical ventilatory is a crucial element of acute brain injured patients' management. The ventilatory goals to ensure lung protection during acute respiratory failure may not be adequate in case of concomitant brain injury. Therefore, there are limited data from which physicians can draw conclusions regarding optimal ventilator management in this setting.

Methods And Analysis: This is an international multicentre prospective observational cohort study. The aim of the 'multicentre observational study on practice of ventilation in brain injured patients'-the VENTIBRAIN study-is to describe the current practice of ventilator settings and mechanical ventilation in acute brain injured patients. Secondary objectives include the description of ventilator settings among different countries, and their association with outcomes. Inclusion criteria will be adult patients admitted to the intensive care unit (ICU) with a diagnosis of traumatic brain injury or cerebrovascular diseases (intracranial haemorrhage, subarachnoid haemorrhage, ischaemic stroke), requiring intubation and mechanical ventilation and admission to the ICU. Exclusion criteria will be the following: patients aged <18 years; pregnant patients; patients not intubated or not mechanically ventilated or receiving only non-invasive ventilation. Data related to clinical examination, neuromonitoring if available, ventilator settings and arterial blood gases will be recorded at admission and daily for the first 7 days and then at day 10 and 14. The Glasgow Outcome Scale Extended on mortality and neurological outcome will be collected at discharge from ICU, hospital and at 6 months follow-up.

Ethics And Dissemination: The study has been approved by the Ethic committee of Brianza at the Azienda Socio Sanitaria Territoriale-Monza. Data will be disseminated to the scientific community by abstracts submitted to the European Society of Intensive Care Medicine annual conference and by original articles submitted to peer-reviewed journals.

Trial Registration Number: NCT04459884.
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http://dx.doi.org/10.1136/bmjopen-2020-047100DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8359464PMC
August 2021

Association of cerebrospinal fluid protein biomarkers with outcomes in patients with traumatic and non-traumatic acute brain injury: systematic review of the literature.

Crit Care 2021 08 5;25(1):278. Epub 2021 Aug 5.

Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route De Lennik 808, 1070, Brussels, Belgium.

Background: Acute brain injuries are associated with high mortality rates and poor long-term functional outcomes. Measurement of cerebrospinal fluid (CSF) biomarkers in patients with acute brain injuries may help elucidate some of the pathophysiological pathways involved in the prognosis of these patients.

Methods: We performed a systematic search and descriptive review using the MEDLINE database and the PubMed interface from inception up to June 29, 2021, to retrieve observational studies in which the relationship between CSF concentrations of protein biomarkers and neurological outcomes was reported in patients with acute brain injury [traumatic brain injury, subarachnoid hemorrhage, acute ischemic stroke, status epilepticus or post-cardiac arrest]. We classified the studies according to whether or not biomarker concentrations were associated with neurological outcomes. The methodological quality of the studies was evaluated using the Newcastle-Ottawa quality assessment scale.

Results: Of the 39 studies that met our criteria, 30 reported that the biomarker concentration was associated with neurological outcome and 9 reported no association. In TBI, increased extracellular concentrations of biomarkers related to neuronal cytoskeletal disruption, apoptosis and inflammation were associated with the severity of acute brain injury, early mortality and worse long-term functional outcome. Reduced concentrations of protein biomarkers related to impaired redox function were associated with increased risk of neurological deficit. In non-traumatic acute brain injury, concentrations of CSF protein biomarkers related to dysregulated inflammation and apoptosis were associated with a greater risk of vasospasm and a larger volume of brain ischemia. There was a high risk of bias across the studies.

Conclusion: In patients with acute brain injury, altered CSF concentrations of protein biomarkers related to cytoskeletal damage, inflammation, apoptosis and oxidative stress may be predictive of worse neurological outcomes.
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http://dx.doi.org/10.1186/s13054-021-03698-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8340466PMC
August 2021

Tier-three therapies for refractory intracranial hypertension in adult head trauma.

Minerva Anestesiol 2021 Aug 2. Epub 2021 Aug 2.

Department of Intensive Care Medicine, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium.

Refractory intracranial hypertension after traumatic brain injury (TBI) is defined as recurrent increase of intracranial pressure (ICP) above 20-22 mmHg for sustained period of time (10-15 min), despite conventional therapies, such as osmotic therapy, cerebral spinal fluid drainage and mild hyperventilation. As such, more aggressive treatments should be taken into consideration. In particular, therapeutic hypothermia, barbiturates administration and decompressive craniectomy are considered as tier-three or "salvage" interventions, as they have shown to be able to control refractory hypertension, but are also associated with an increased risk of significant side effects. The aim of this review is therefore to describe the evidence supporting the use of these tier-three therapies in the management of refractory intracranial hypertension in TBI patients.
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http://dx.doi.org/10.23736/S0375-9393.21.15827-4DOI Listing
August 2021

Fever management in critically ill COVID-19 patients: a retrospective analysis.

Minerva Anestesiol 2021 11 2;87(11):1217-1225. Epub 2021 Aug 2.

Department of Intensive Care Medicine, Erasme University Hospital, Brussels, Belgium.

Background: Fever has been reported as a common symptom in COVID-19 patients. The aim of the study was to describe the characteristics of COVID-19 critically ill patients with fever and to assess if fever management had an impact on some physiologic variables.

Methods: This is a retrospective monocentric cohort analysis of critically ill COVID-19 patients admitted to the Department of Intensive Care Unit (ICU) of Erasme Hospital, Brussels, Belgium, between March 2020 and May 2020. Fever was defined as body temperature ≥38 °C during the ICU stay. We assessed the independent predictors of fever during ICU stay. We reported the clinical and physiological variables before and after the first treated episode of fever during the ICU stay.

Results: A total of 72 critically ill COVID-19 patients were admitted to the ICU over the study period and were all eligible for the final analysis; 53 (74%) of them developed fever, after a median of 4 [0-13] hours since ICU admission. In the multivariable analysis, male gender (OR 5.41 [C.I. 95% 1.34-21.92]; P=0.02) and low PaO2/FiO2 ratio (OR 0.99 [C.I. 95% 0.99-1.00]; P=0.04) were independently associated with fever. After the treatment of the first febrile episode, heart rate and respiratory rate significantly decreased together with an increase in PaO2 and SaO2.

Conclusions: In our study, male gender and severe impairment of oxygenation were independently associated with fever in critically ill COVID-19 patients. Fever treatment reduced heart rate and respiratory rate and improved systemic oxygenation.
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http://dx.doi.org/10.23736/S0375-9393.21.15711-6DOI Listing
November 2021

Intracranial pressure monitoring in patients with acute brain injury in the intensive care unit (SYNAPSE-ICU): an international, prospective observational cohort study.

Lancet Neurol 2021 07;20(7):548-558

School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Neurointensive Care Unit, Ospedale San Gerardo, Azienda Socio-Sanitaria Territoriale di Monza, Monza, Italy. Electronic address:

Background: The indications for intracranial pressure (ICP) monitoring in patients with acute brain injury and the effects of ICP on patients' outcomes are uncertain. The aims of this study were to describe current ICP monitoring practises for patients with acute brain injury at centres around the world and to assess variations in indications for ICP monitoring and interventions, and their association with long-term patient outcomes.

Methods: We did a prospective, observational cohort study at 146 intensive care units (ICUs) in 42 countries. We assessed for eligibility all patients aged 18 years or older who were admitted to the ICU with either acute brain injury due to primary haemorrhagic stroke (including intracranial haemorrhage or subarachnoid haemorrhage) or traumatic brain injury. We included patients with altered levels of consciousness at ICU admission or within the first 48 h after the brain injury, as defined by the Glasgow Coma Scale (GCS) eye response score of 1 (no eye opening) and a GCS motor response score of at least 5 (not obeying commands). Patients not admitted to the ICU or with other forms of acute brain injury were excluded from the study. Between-centre differences in use of ICP monitoring were quantified by using the median odds ratio (MOR). We used the therapy intensity level (TIL) to quantify practice variations in ICP interventions. Primary endpoints were 6 month mortality and 6 month Glasgow Outcome Scale Extended (GOSE) score. A propensity score method with inverse probability of treatment weighting was used to estimate the association between use of ICP monitoring and these 6 month outcomes, independently of measured baseline covariates. This study is registered with ClinicalTrial.gov, NCT03257904.

Findings: Between March 15, 2018, and April 30, 2019, 4776 patients were assessed for eligibility and 2395 patients were included in the study, including 1287 (54%) with traumatic brain injury, 587 (25%) with intracranial haemorrhage, and 521 (22%) with subarachnoid haemorrhage. The median age of patients was 55 years (IQR 39-69) and 1567 (65%) patients were male. Considerable variability was recorded in the use of ICP monitoring across centres (MOR 4·5, 95% CI 3·8-4·9 between two randomly selected centres for patients with similar covariates). 6 month mortality was lower in patients who had ICP monitoring (441/1318 [34%]) than in those who were not monitored (517/1049 [49%]; p<0·0001). ICP monitoring was associated with significantly lower 6 month mortality in patients with at least one unreactive pupil (hazard ratio [HR] 0·35, 95% CI 0·26-0·47; p<0·0001), and better neurological outcome at 6 months (odds ratio 0·38, 95% CI 0·26-0·56; p=0·0025). Median TIL was higher in patients with ICP monitoring (9 [IQR 7-12]) than in those who were not monitored (5 [3-8]; p<0·0001) and an increment of one point in TIL was associated with a reduction in mortality (HR 0·94, 95% CI 0·91-0·98; p=0·0011).

Interpretation: The use of ICP monitoring and ICP management varies greatly across centres and countries. The use of ICP monitoring might be associated with a more intensive therapeutic approach and with lower 6-month mortality in more severe cases. Intracranial hypertension treatment guided by monitoring might be considered in severe cases due to the potential associated improvement in long-term clinical results.

Funding: University of Milano-Bicocca and the European Society of Intensive Care Medicine.
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http://dx.doi.org/10.1016/S1474-4422(21)00138-1DOI Listing
July 2021

Hypothermia versus Normothermia after Out-of-Hospital Cardiac Arrest.

N Engl J Med 2021 06;384(24):2283-2294

From the Department of Clinical Sciences Lund, Sections of Cardiology (J. Dankiewicz, D.E.), Neurology (T. Cronberg, G.L.), and Anesthesiology and Intensive Care (H. Levin, O.B.), Skåne University Hospital Lund, Lund University and Clinical Studies Sweden - Forum South, Skåne University Hospital (S.U.), Lund; the Department of Clinical Sciences Lund, Section of Anesthesia and Intensive Care, Skåne University Hospital Malmö, Malmö, (J. Düring, S.S., H.F.); the Department of Clinical Sciences Lund, Sections of Anesthesiology and Intensive Care (M.A., N.N.) and Clinical Sciences Helsingborg (N.N.), Helsingborg Hospital, Helsingborg; the Department of Clinical Sciences Lund, Section of Anesthesiology and Intensive Care Lund, Hallands Hospital, Halmstad (J.U.); the Department of Anesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg (C.R., A. Lundin); the Department of Clinical Science and Education, Center for Resuscitation Science, Karolinska Institutet, Södersjukhuset, Stockholm (P.N., J. Hollenberg, A.A.); and the Department of Anesthesiology, Intensive Care, and Acute Medicine, Linköping University, Linköping (M.S.C.) - all in Sweden; Copenhagen Trial Unit, Center for Clinical Intervention Research, Copenhagen University Hospital (J.C.J.), and the Section of Biostatistics, Faculty of Health and Medical Sciences (T.L.), University of Copenhagen, Copenhagen, the Department of Regional Health Research, the Faculty of Health Sciences, University of Southern Denmark, Odense (J.C.J.), the Research Center for Emergency Medicine, the Department of Clinical Medicine (H.K.), and the Department of Intensive Care (A.M.G., S.C.), Aarhus University Hospital, Aarhus - all in Denmark; Adult Critical Care, University Hospital of Wales, Cardiff (M.P.W., M.P.G.M., J.M.C.), the Department of Intensive Care, Bristol Royal Infirmary, Bristol (M.T., J. Bewley, K.S.), Essex Cardiothoracic Centre, Basildon (T.R.K., G.V.K.), Anglia Ruskin University School of Medicine, Chelmsford, Essex (T.R.K., G.V.K.), and the Department of Anesthesiology and Intensive Care, Royal Victoria Hospital, Belfast (P.M.) - all in the United Kingdom; Neuroscience Critical Care Research Group and Adult Intensive Care Medicine Service, Centre Hospitalier Universitaire Vaudois-Lausanne University Hospital and University of Lausanne, Lausanne (M. Oddo, S.A.-M.), the Departments of Intensive Care Medicine (M.H.) and Anesthesiology and Pain Medicine, Inselspital (A. Levis), Bern University Hospital, University of Bern, Bern, the Intensive Care Department, Kantonsspital St. Gallen, St. Gallen (C. Schrag, E.F.), the Institute of Intensive Care Medicine, University Hospital Zurich, Zurich (M.M., P.D.W.G.), and the Cardiac Anesthesia and Intensive Care Department, Instituto Cardiocentro Ticino, Lugano (T. Cassina) - all in Switzerland; Descartes University of Paris and Cochin University Hospital, Paris (A.C., P.J.), Medical-Surgical Intensive Care Unit, Dupuytren Teaching Hospital, Limoges (P.V.) - all in France; the 2nd Department of Medicine (J. Bělohlávek, O.S.), and the Department of Anesthesiology and Intensive Care Medicine (M. Otáhal), General University Hospital and First Faculty of Medicine, Charles University, Prague, the 1st Department of Internal Medicine-Cardioangiology, University Hospital Hradec Králové, and Faculty of Medicine, Charles University, Hradec Králové (M. Solar) - all in the Czech Republic; the Department of Anesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, Rikshospitalet, Oslo (J. Hovdenes), the Department of Anesthesiology, Sørlandet Hospital, Arendal (R.B.O.), the Department of Anesthesiology and Intensive Care Medicine, St. Olav's University Hospital, and the Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim (H. Langeland) - all in Norway; the Division of Critical Care and Trauma, George Institute for Global Health, and Bankstown-Lidcombe Hospital, South Western Sydney Local Health District, Sydney (M. Saxena), and the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine (G.M.E., A.D.N.), and the Department of Intensive Care, Alfred Health (A.D.N.), Monash University, Melbourne - all in Australia; the Medical Research Institute of New Zealand, Intensive Care Unit, Wellington Hospital, Wellington (P.J.Y., L.N.); the Departments of Surgical Sciences and Integrated Diagnostics (P.P.) and Anesthesiology and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience (P.P., I.B.), University of Genoa, Genoa, Italy; the Department of Nephrology and Medical Intensive Care (C. Storm), and Klinik und Hochschulambulanz für Neurologie (C.L.), Charité Universitätzmedizin, Berlin, Germany; the Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels (F.S.T.); the Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria (M.J.); the Department of Emergency Medicine, University of Pittsburgh, Pittsburgh (C.C.); and University College Dublin Clinical Research Centre at St. Vincent's University Hospital, Dublin, Ireland (A.D.N.).

Background: Targeted temperature management is recommended for patients after cardiac arrest, but the supporting evidence is of low certainty.

Methods: In an open-label trial with blinded assessment of outcomes, we randomly assigned 1900 adults with coma who had had an out-of-hospital cardiac arrest of presumed cardiac or unknown cause to undergo targeted hypothermia at 33°C, followed by controlled rewarming, or targeted normothermia with early treatment of fever (body temperature, ≥37.8°C). The primary outcome was death from any cause at 6 months. Secondary outcomes included functional outcome at 6 months as assessed with the modified Rankin scale. Prespecified subgroups were defined according to sex, age, initial cardiac rhythm, time to return of spontaneous circulation, and presence or absence of shock on admission. Prespecified adverse events were pneumonia, sepsis, bleeding, arrhythmia resulting in hemodynamic compromise, and skin complications related to the temperature management device.

Results: A total of 1850 patients were evaluated for the primary outcome. At 6 months, 465 of 925 patients (50%) in the hypothermia group had died, as compared with 446 of 925 (48%) in the normothermia group (relative risk with hypothermia, 1.04; 95% confidence interval [CI], 0.94 to 1.14; P = 0.37). Of the 1747 patients in whom the functional outcome was assessed, 488 of 881 (55%) in the hypothermia group had moderately severe disability or worse (modified Rankin scale score ≥4), as compared with 479 of 866 (55%) in the normothermia group (relative risk with hypothermia, 1.00; 95% CI, 0.92 to 1.09). Outcomes were consistent in the prespecified subgroups. Arrhythmia resulting in hemodynamic compromise was more common in the hypothermia group than in the normothermia group (24% vs. 17%, P<0.001). The incidence of other adverse events did not differ significantly between the two groups.

Conclusions: In patients with coma after out-of-hospital cardiac arrest, targeted hypothermia did not lead to a lower incidence of death by 6 months than targeted normothermia. (Funded by the Swedish Research Council and others; TTM2 ClinicalTrials.gov number, NCT02908308.).
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http://dx.doi.org/10.1056/NEJMoa2100591DOI Listing
June 2021

The role of noninvasive brain oximetry in adult critically ill patients without primary non-anoxic brain injury.

Minerva Anestesiol 2021 11 3;87(11):1226-1238. Epub 2021 May 3.

Unit of Trauma and Neurocritical Care, Cambridge University Hospital, Cambridge, UK.

A primary objective in intensive care and perioperative settings is to promote an adequate supply and delivery of oxygen to tissues and organs, particularly to the brain. Cerebral near infrared spectroscopy (NIRS) is a noninvasive, continuous monitoring technique, that can be used to assess cerebral oxygenation. Using NIRS to monitor cerebral oximetry is not new and has been in widespread use in neonates and cardiac surgery for decades. In addition, it has become common to see NIRS being used in adult and pediatric cardiac surgery, acute neurological diseases, neurosurgical procedures, vascular surgery, severe trauma and other acute medical diseases. Furthermore, recent evidence suggests a role for NIRS in the perioperative settings; detecting and preventing episodes of cerebral desaturation aiming to reduce the development of postoperative delirium. NIRS is not without its limitations; these include the risk of extra-cranial contamination, spatial limitations and skin blood flow/volume changes, as well being a measure of localized blood oxygenation underneath the sensor. However, NIRS is a noninvasive technique and can be used in those patients without indications or justification for invasive brain monitoring; non-neurosurgical procedures such as liver transplantation, major orthopedic surgery and critically illness where the brain is at risk. The aim of this manuscript was to discuss the physical principles of NIRS and to report the current evidence regarding its use in critically ill patients without primary non-anoxic brain injury.
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http://dx.doi.org/10.23736/S0375-9393.21.15333-7DOI Listing
November 2021

The Prognostic Value of Brain Dysfunction in Critically Ill Patients with and without Sepsis: A Analysis of the ICON Audit.

Brain Sci 2021 Apr 23;11(5). Epub 2021 Apr 23.

Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, 1070 Brussels, Belgium.

Brain dysfunction is associated with poor outcome in critically ill patients. In a post hoc analysis of the Intensive Care over Nations (ICON) database, we investigated the effect of brain dysfunction on hospital mortality in critically ill patients. Brain failure was defined as a neurological sequential organ failure assessment (nSOFA) score of 3-4, based on the assumed Glasgow Coma Scale (GCS) score. Multivariable analyses were performed to assess the independent roles of nSOFA and change in nSOFA from admission to day 3 (ΔnSOFA) for predicting hospital mortality. Data from 7192 (2096 septic and 5096 non-septic) patients were analyzed. Septic patients were more likely than non-septic patients to have brain failure on admission (434/2095 (21%) vs. 617/4665 (13%), < 0.001) and during the ICU stay (625/2063 (30%) vs. 736/4665 (16%), < 0.001). The presence of sepsis (RR 1.66 (1.31-2.09)), brain failure (RR 4.85 (3.33-7.07)), and both together (RR 5.61 (3.93-8.00)) were associated with an increased risk of in-hospital death, but nSOFA was not. In the 3280 (46%) patients in whom ΔnSOFA was available, sepsis (RR 2.42 (1.62-3.60)), brain function deterioration (RR 6.97 (3.71-13.08)), and the two together (RR 10.24 (5.93-17.67)) were associated with an increased risk of in-hospital death, whereas improvement in brain function was not.
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http://dx.doi.org/10.3390/brainsci11050530DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8146463PMC
April 2021

Transpulmonary thermodilution during extracorporeal organ support (ECOS): is it worth it?A brief commentary on the effects of the extracorporeal circuit on TPTD-derived parameters.

J Clin Monit Comput 2021 08 23;35(4):681-687. Epub 2021 Apr 23.

Faculty of Engineering, Vrije Universiteit Brussel (VUB), Pleinlaan 2, 1050, Elsene, Belgium.

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http://dx.doi.org/10.1007/s10877-021-00699-9DOI Listing
August 2021

Early β-lactam concentrations and infectious complications after lung transplantation.

Am J Transplant 2021 07 25;21(7):2489-2497. Epub 2020 Dec 25.

Department of Intensive Care. Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium.

Antibiotic underdosing in prophylactic antibiotic regimes after lung transplantation (LTx) can increase the risk of infection. We aimed to study whether β-lactam concentrations achieved desirable pharmacodynamic targets in the early phase after LTx and the association between drug concentrations and the development of early infections or the acquisition of multidrug-resistant (MDR) strains. We reviewed patients in whom broad-spectrum β-lactam levels were measured after LTx during antibiotic prophylaxis. β-Lactam concentrations were considered "insufficient" if drug levels remained below four times the clinical breakpoint of the minimal inhibitory concentration for Pseudomonas aeruginosa. The primary outcome was the occurrence of an infection and/or acquisition of MDR pathogens in the first 14 days after transplantation. A total of 70 patients were included. "Insufficient" drug concentrations were found in 40% of patients. In 27% of patients, an early MDR pathogen was identified and 49% patients were diagnosed with an early posttransplant infection. Patients with "insufficient" drug concentrations acquired more frequently MDR bacteria and/or developed an infection than others (22/28, 79% vs. 20/42, 48% - p = .01). β-Lactam levels were often found to be below the desired drug targets in the early phase after transplantation and may be associated with the occurrence of early infectious complications.
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http://dx.doi.org/10.1111/ajt.16432DOI Listing
July 2021

Extracorporeal Membrane Oxygenation in Patients With COVID-19: An International Multicenter Cohort Study.

J Intensive Care Med 2021 Aug 7;36(8):910-917. Epub 2021 Apr 7.

Department of Intensive Care, Amsterdam University Medical Centers, Location Academic Medical Center (26066AMC), Amsterdam, the Netherlands.

Background: To report and compare the characteristics and outcomes of COVID-19 patients on extracorporeal membrane oxygenation (ECMO) to non-COVID-19 acute respiratory distress syndrome (ARDS) patients on ECMO.

Methods: We performed an international retrospective study of COVID-19 patients on ECMO from 13 intensive care units from March 1 to April 30, 2020. Demographic data, ECMO characteristics and clinical outcomes were collected. The primary outcome was to assess the complication rate and 28-day mortality; the secondary outcome was to compare patient and ECMO characteristics between COVID-19 patients on ECMO and non-COVID-19 related ARDS patients on ECMO (non-COVID-19; January 1, 2018 until July 31, 2019).

Results: During the study period 71 COVID-19 patients received ECMO, mostly veno-venous, for a median duration of 13 days (IQR 7-20). ECMO was initiated at 5 days (IQR 3-10) following invasive mechanical ventilation. Median PaO/FiO ratio prior to initiation of ECMO was similar in COVID-19 patients (58 mmHg [IQR 46-76]) and non-COVID-19 patients (53 mmHg [IQR 44-66]), the latter consisting of 48 patients. 28-day mortality was 37% in COVID-19 patients and 27% in non-COVID-19 patients. However, Kaplan-Meier curves showed that after a 100-day follow-up this non-significant difference resolves. Non-surviving COVID-19 patients were more acidotic prior to initiation ECMO, had a shorter ECMO run and fewer received muscle paralysis compared to survivors.

Conclusions: No significant differences in outcomes were found between COVID-19 patients on ECMO and non-COVID-19 ARDS patients on ECMO. This suggests that ECMO could be considered as a supportive therapy in case of refractory respiratory failure in COVID-19.
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http://dx.doi.org/10.1177/08850666211007063DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8267077PMC
August 2021

Impact of CRRT in Patients with PARDS Treated with VV-ECMO.

Membranes (Basel) 2021 Mar 11;11(3). Epub 2021 Mar 11.

Departments of Intensive Care, Hospital Universitaire des Enfants Reine Fabiola (HUDERF), 1020 Brussels, Belgium.

The high mortality of pediatric acute respiratory distress syndrome (PARDS) is partly related to fluid overload. Extracorporeal membrane oxygenation (ECMO) is used to treat pediatric patients with severe PARDS, but can result in acute kidney injury (AKI) and worsening fluid overload. The objective of this study was to determine whether the addition of CRRT to ECMO in patients with PARDS is associated with increased mortality.

Methods: We conducted a retrospective 7-year study of patients with PARDS requiring ECMO and divided them into those requiring CRRT and those not requiring CRRT. We calculated severity of illness scores, the amount of blood products administered to both groups, and determined the impact of CRRT on mortality and morbidity.

Results: We found no significant difference in severity of illness scores except the vasoactive inotropic score (VIS, 45 ± 71 vs. 139 ± 251, = 0.042), which was significantly elevated during the initiation and the first three days of ECMO. CRRT was associated with an increase in the use of blood products and noradrenaline ( < 0.01) without changing ECMO duration, length of PICU stay or mortality.

Conclusion: The addition of CRRT to ECMO is associated with a greater consumption of blood products but no increase in mortality.
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http://dx.doi.org/10.3390/membranes11030195DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7999958PMC
March 2021

A year in review in Minerva Anestesiologica 2020: critical care.

Minerva Anestesiol 2021 01;87(1):124-133

Division of Anesthesia and General Intensive Care, Department of Medical, Surgical and Experimental Sciences, University Hospital of Sassari, University of Sassari, Sassari, Italy.

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http://dx.doi.org/10.23736/S0375-9393.20.15495-6DOI Listing
January 2021

Brain ultrasonography to assess midline shift in neurocritical patients: good, but not good enough.

Minerva Anestesiol 2021 04 17;87(4):400-402. Epub 2020 Dec 17.

Department of Integrated Surgical and Diagnostic Science, IRCCS San Martino - IST National Cancer Research Institute, University of Genoa, Genoa, Italy.

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http://dx.doi.org/10.23736/S0375-9393.20.15310-0DOI Listing
April 2021

Neuron-specific enolase levels are not related to cerebral autoregulation in septic patients.

Minerva Anestesiol 2021 02 16;87(2):238-239. Epub 2020 Dec 16.

Department of Intensive Care, Erasme University Hospital, Brussels, Belgium.

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http://dx.doi.org/10.23736/S0375-9393.20.14941-1DOI Listing
February 2021

Fever management in COVID-19 patients.

Minerva Anestesiol 2021 01 24;87(1):1-3. Epub 2020 Nov 24.

Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium.

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http://dx.doi.org/10.23736/S0375-9393.20.15195-2DOI Listing
January 2021

The Acquisition of Multidrug-Resistant Bacteria in Patients Admitted to COVID-19 Intensive Care Units: A Monocentric Retrospective Case Control Study.

Microorganisms 2020 Nov 19;8(11). Epub 2020 Nov 19.

Department of Intensive Care, CUB-Hôpital Erasme, Université Libre de Bruxelles, 1070 Brussels, Belgium.

Whether the risk of multidrug-resistant bacteria (MDRB) acquisition in the intensive care unit (ICU) is modified by the COVID-19 crisis is unknown. In this single center case control study, we measured the rate of MDRB acquisition in patients admitted in COVID-19 ICU and compared it with patients admitted in the same ICU for subarachnoid hemorrhage (controls) matched 1:1 on length of ICU stay and mechanical ventilation. All patients were systematically and repeatedly screened for MDRB carriage. We compared the rate of MDRB acquisition in COVID-19 patients and in control using a competing risk analysis. Of note, although we tried to match COVID-19 patients with septic shock patients, we were unable due to the longer stay of COVID-19 patients. Among 72 patients admitted to the COVID-19 ICUs, 33% acquired 31 MDRB during ICU stay. The incidence density of MDRB acquisition was 30/1000 patient days. Antimicrobial therapy and exposure time were associated with higher rate of MDRB acquisition. Among the 72 SAH patients, 21% acquired MDRB, with an incidence density was 18/1000 patient days. The septic patients had more comorbidities and a greater number of previous hospitalizations than the COVID-19 patients. The incidence density of MDRB acquisition was 30/1000 patient days. The association between COVID-19 and MDRB acquisition (compared to control) risk did not reach statistical significance in the multivariable competing risk analysis (sHR 1.71 (CI 95% 0.93-3.21)). Thus, we conclude that, despite strong physical isolation, acquisition rate of MDRB in ICU patients was at least similar during the COVID-19 first wave compared to previous period.
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http://dx.doi.org/10.3390/microorganisms8111821DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7699265PMC
November 2020

Early Lymphopenia and Infections in Nontraumatic Subarachnoid Hemorrhage Patients.

J Neurosurg Anesthesiol 2020 Nov 17. Epub 2020 Nov 17.

Departments of Intensive Care.

Introduction: Subarachnoid hemorrhage (SAH) is associated with high morbidity and mortality. A certain degree of immunodepression has been reported during critical illness, and lymphopenia identified as an independent predictor of poor outcome; no data are available for critically ill SAH patients. We aimed to evaluate the prevalence of lymphopenia among SAH patients and its association with hospital-acquired infection.

Methods: Retrospective cohort study of adult patients admitted to an intensive care unit with nontraumatic SAH between January 2011 and May 2016. Lymphocyte count was obtained daily for the first 5 days; lymphopenia was defined as lymphocyte count <1000/mm. The occurrence of infection during the first 21 days after hospital admission, hospital mortality, and unfavorable neurological outcome (Glasgow Outcome Scale score 1 to 3 at 3 mo) were recorded.

Results: Data from 270 patients were analyzed (median age 54 y; male 45%); 121 (45%) patients had lymphopenia and 62 (23%) patients developed infections. Median (25th to 75th percentiles) lymphocyte count at hospital admission was 1280 (890 to 1977)/mm. Lymphopenia patients had more episodes of infection (38/121, 31% vs. 24/139, 17%; P=0.003) than nonlymphopenia patients, while mortality and unfavorable outcome were similar. Lymphopenia was not independently associated with the development of infection, unfavorable neurological outcome or with mortality.

Conclusions: Early lymphopenia is common after SAH, but is not significantly associated with the development of infections or with poor outcome.
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http://dx.doi.org/10.1097/ANA.0000000000000744DOI Listing
November 2020

Neurofilament to predict post-anoxic neurological outcome: are we ready for the prime time?

Intensive Care Med 2021 01 9;47(1):77-79. Epub 2020 Nov 9.

Department of Intensive Care, Radboud University Nijmegen Hospital, Nijmegen, The Netherlands.

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http://dx.doi.org/10.1007/s00134-020-06309-7DOI Listing
January 2021

Antihistamines-refractory chronic pruritus in psoriatic patients undergoing biologics: aprepitant vs antihistamine double dosage, a real-world data.

J Dermatolog Treat 2020 Oct 28:1-4. Epub 2020 Oct 28.

Young Dermatologists Italian Network, Bergamo, Italy.

Background: Psoriasis-related pruritus (PRP) in patients under systemic treatment is challenging. The risk to switch anti-psoriatic drugs and to lose response to previous therapy is high, thus dermatologists prefer to add an anti-pruritic agent.

Objectives: To evaluate the effect of anti-histamines and aprepitant in treating PPR of psoriatic patients undergoing systemic anti-psoriatic therapies.

Methods: A pilot observational open-label study was performed on responsive psoriatic patients with PPR under treatment. Initial therapy included oral rupatadine (10 mg/day for 30 days). In case of the Epworth Sleepiness Scale (ESS) was above 14, patients were switched to aprepitant (80 mg/day for 7 days), otherwise, rupatadine dosage was increased (20 mg/day for 7 days). Clinical evaluation was performed at the baseline (T0) and after 7 days (T7).

Results: We enrolled 40 patients with PPR, 20 in each group. Age, gender, Psoriatic arthritis (PsA) and the itch - VAS, were matched. At T7, aprepitant displayed higher improvements than rupatadine (itch - VAS = 4 [3-5] vs 8.5 [8-9],  < .01, DLQI = 14 [13-16] vs. 18 [16-21],  < .01 and ESS = 5 [4-7] vs 15 [14-16],  < .01). Doubling the rupatadine dosage from 10 mg to 20 mg/day only slightly improve itch (itch - VAS = 9 [8-10] vs 9 [8-9],  = .03), conversely no modifications in the quality of life (DLQI = 18 [17-20] vs 18 [17-21],  = .73) and increased sleepiness (ESS = 10 [9-11] vs 15 [14-16], < .01).

Conclusions: Aprepitant may be a valid alternative in PPR patients with ESS >14 under antihistamines.
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http://dx.doi.org/10.1080/09546634.2020.1840502DOI Listing
October 2020

Carbon Dioxide Elimination During Veno-Venous Extracorporeal Membrane Oxygenation Weaning: A Pilot Study.

ASAIO J 2021 06;67(6):700-708

Department of Cardio-Thoracic Surgery, Heart & Vascular Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Hospital, Maastricht, The Netherlands.

Veno-venous extracorporeal membrane oxygenation (V-V ECMO) represents a component of the treatment strategy for severe respiratory failure. Clinical evidence on the management of the lung during V-V ECMO are limited just as the consensus regarding timing of weaning. The monitoring of the carbon dioxide (CO2) removal (V'CO2TOT) is subdivided into two components: the membrane lung (ML) and the native lung (NL) are both taken into consideration to evaluate the improvement of the function of the lung and to predict the time to wean off ECMO. We enrolled patients with acute respiratory distress syndrome (ARDS). The V'CO2NL ratio (V'CO2NL/V'CO2TOT) value was calculated based on the distribution of CO2 between the NL and the ML. Of 18 patients, 15 were successfully weaned off of V-V ECMO. In this subgroup, we observed a significant increase in the V'CO2NL ratio comparing the median values of the first and last quartiles (0.32 vs. 0.53, p = 0.0045), without observing any modifications in the ventilation parameters. An increase in the V'CO2NL ratio, independently from any change in ventilation could, despite the limitations of the study, indicate an improvement in pulmonary function and may be used as a weaning index for ECMO.
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http://dx.doi.org/10.1097/MAT.0000000000001282DOI Listing
June 2021

Variability in Serum Sodium Concentration and Prognostic Significance in Severe Traumatic Brain Injury: A Multicenter Observational Study.

Neurocrit Care 2021 06 2;34(3):899-907. Epub 2020 Oct 2.

Intensive Care Unit, Royal Melbourne Hospital, Level 5, B Block, Parkville, VIC, 3050, Australia.

Background/objective: Dysnatremia is common in severe traumatic brain injury (TBI) patients and may contribute to mortality. However, serum sodium variability has not been studied in TBI patients. We hypothesized that such variability would be independently associated with mortality.

Methods: We collected 6-hourly serum sodium levels for the first 7 days of ICU admission from 240 severe TBI patients in 14 neurotrauma ICUs in Europe and Australia. We evaluated the association between daily serum sodium standard deviation (dNa), an index of variability, and 28-day mortality.

Results: Patients were 46 ± 19 years of age with a median initial GCS of 6 [4-8]. Overall hospital mortality was 28%. Hypernatremia and hyponatremia occurred in 64% and 24% of patients, respectively. Over the first 7 days in ICU, serum sodium standard deviation was 2.8 [2.0-3.9] mmol/L. Maximum daily serum sodium standard deviation (dNa) occurred at a median of 2 [1-4] days after admission. There was a significant progressive decrease in dNa over the first 7 days (coefficient - 0.15 95% CI [- 0.18 to - 0.12], p < 0.001). After adjusting for baseline TBI severity, diabetes insipidus, the use of osmotherapy, the occurrence of hypernatremia, and hyponatremia and center, dNa was significantly independently associated with 28-day mortality (HR 1.27 95% CI (1.01-1.61), p = 0.048).

Conclusions: Our study demonstrates that daily serum sodium variability is an independent predictor of 28-day mortality in severe TBI patients. Further prospective investigations are necessary to confirm the significance of sodium variability in larger cohorts of TBI patients and test whether attenuating such variability confers outcome benefits to such patients.
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http://dx.doi.org/10.1007/s12028-020-01118-8DOI Listing
June 2021

The Impact of Extracerebral Infection After Subarachnoid Hemorrhage: A Single-Center Cohort Study.

World Neurosurg 2020 12 28;144:e883-e897. Epub 2020 Sep 28.

Department of Intensive Care, Erasmus Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium.

Background: Subarachnoid hemorrhage (SAH) is associated with high morbidity. Among all complications, infections, in particular if hospital acquired, could represent an important cause of death in patients with SAH. The aim of this study was to describe infectious complications in patients with SAH and to evaluate their impact on outcome.

Methods: A single-center cohort study included all patients with SAH admitted from January 2011 to December 2016, who stayed in the intensive care unit for at least 24 hours. Infection diagnosis was retrieved from medical files; central nervous system infections were not included. A multivariable analysis was performed to identify risk factors for development of infection. Logistic regression was performed to identify risks for unfavorable neurologic outcome at 3 months, defined as a Glasgow Outcome Scale score of 1-3.

Results: Of the 248 patients with SAH, 70 (28.2%) developed at least 1 infection; the most frequent site of infection was respiratory (57.1%), primary bloodstream (16%), and urinary tract infections (15.7%). Twenty-eight patients (11.3% of all patients) had at least 1 episode of septic shock. Infected patients had a higher unfavorable outcome rate (60.0% vs. 33.3%; P = 0.001). Diabetes mellitus (subdistribution hazard ratio, 1.79; 95% confidence interval [CI], 1.03-3.13) and intracranial hypertension (subdistribution hazard ratio, 1.92; 95% CI, 1.14-3.25) were independently associated with the occurrence of infections. Septic shock (odds ratio, 6.36; 95% CI, 1.24-32.51; P = 0.02) was independently associated with unfavorable outcome.

Conclusions: Infections in patients with SAH are prevalent, especially pneumonia. Septic shock is associated with a poor neurologic outcome in this group of patients.
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http://dx.doi.org/10.1016/j.wneu.2020.09.102DOI Listing
December 2020

Platelet morphological indices on Intensive Care Unit admission predict mortality in septic but not in non-septic patients.

Minerva Anestesiol 2021 02 22;87(2):184-192. Epub 2020 Sep 22.

Unit of Anesthesia and Intensive Care, Department of Morphology, Surgery and Experimental Medicine, Sant'Anna University Hospital, University of Ferrara, Ferrara, Italy.

Background: Thrombocytopenia is associated with worse outcomes in critically ill patients. The clinical relevance of other platelets indices is less studied. We investigated the ability of the platelets distribution width (PDW) and the mean platelet volume (MPV) to predict mortality in critically ill patients. We hypothesized that the prognostic values of PDW and MPV could be different in septic and non-septic patients.

Methods: We prospectively analyzed patients with an expected ICU length of stay ≥48 hours. Repeated measurements of PDW and MPV were considered (on ICU admission and up to day 5 thereafter). The primary outcome was to investigate the ability of PDW and MPV to predict 90-day mortality in septic and non-septic patients.

Results: We included in the study 234 patients of which 31% patients were septic. 90-day mortality was 39% in septic and 27% non-septic patients. PDW and MPV values on admission were 12.5±2.5% and 10.7±1.1 fL, respectively. The AUROC of PDW values on admission to predict 90-day mortality in septic patients was 0.813, being higher than those in non-septic patients (0.550, P<0.001). Similarly, the AUROC for MPV in septic patients was higher than non-septic patients (0.55, P<0.001). The combined analysis of platelets morphological indices and lactate improved the predictive accuracy (PDW and lactate AUROC=0.870; MPV and lactate AUROC=0.867).

Conclusions: Platelet morphological indices are independent predictor of 90-day mortality in septic patients but not in non-septic patients. A combined analysis of platelets morphological indices and lactate in septic patients resulted in improved prediction of mortality.
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http://dx.doi.org/10.23736/S0375-9393.20.14528-0DOI Listing
February 2021
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