Association of Neurocritical Care Services With Mortality and Functional Outcomes for Adults With Brain Injury

Pham, Xiuxian; Ray, Jason C; Neto, Ary Serpa; Laing, Joshua; Perucca, Piero; Kwan, Patrick; O’Brien, Terence J.; Udy, Andrew

doi:10.1001/jamaneurol.2022.2456

Cited by 22 publications

(19 citation statements)

References 47 publications

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“…A recent meta-analysis suggested improved survival and better functional outcomes in brain-injured patients treated in specialized neurocritical care units. 26 In our study, most of the patients were treated in general ICUs, and it is not known to what extent outcomes would have differed if all of them had been treated in neuro-ICUs.…”

Section: Discussionmentioning

confidence: 84%

One-Year Outcomes in Patients With Acute Stroke Requiring Mechanical Ventilation

Sonneville,

Mazighi,

Collet

et al. 2023

Stroke

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Background: Long-term outcomes of patients with severe stroke remain poorly documented. We aimed to characterize one-year outcomes of patients with stroke requiring mechanical ventilation in the intensive care unit (ICU). Methods: We conducted a prospective multicenter cohort study in 33 ICUs in France (2017–2019) on patients with consecutive strokes requiring mechanical ventilation for at least 24 hours. Outcomes were collected via telephone interviews by an independent research assistant. The primary end point was poor functional outcome, defined by a modified Rankin Scale score of 4 to 6 at 1 year. Multivariable mixed models investigated variables associated with the primary end point. Secondary end points included quality of life, activities of daily living, and anxiety and depression in 1-year survivors. Results: Among the 364 patients included, 244 patients (66.5% [95% CI, 61.7%–71.3%]) had a poor functional outcome, including 190 deaths (52.2%). After adjustment for non-neurological organ failure, age ≥70 years (odds ratio [OR], 2.38 [95% CI, 1.26–4.49]), Charlson comorbidity index ≥2 (OR, 2.01 [95% CI, 1.16–3.49]), a score on the Glasgow Coma Scale <8 at ICU admission (OR, 3.43 [95% CI, 1.98–5.96]), stroke subtype (intracerebral hemorrhage: OR, 2.44 [95% CI, 1.29–4.63] versus ischemic stroke: OR, 2.06 [95% CI, 1.06–4.00] versus subarachnoid hemorrhage: reference) remained independently associated with poor functional outcome. In contrast, a time between stroke diagnosis and initiation of mechanical ventilation >1 day was protective (OR, 0.56 [95% CI, 0.33–0.94]). A sensitivity analysis conducted after exclusion of patients with early decisions of withholding/withdrawal of care yielded similar results. We observed persistent physical and psychological problems at 1 year in >50% of survivors. Conclusions: In patients with severe stroke requiring mechanical ventilation, several ICU admission variables may inform caregivers, patients, and their families on post-ICU trajectories and functional outcomes. The burden of persistent sequelae at 1 year reinforces the need for a personalized, multi-disciplinary, prolonged follow-up of these patients after ICU discharge. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03335995

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Section: Discussionmentioning

confidence: 84%

One-Year Outcomes in Patients With Acute Stroke Requiring Mechanical Ventilation

Sonneville,

Mazighi,

Collet

et al. 2023

Stroke

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“…This is important not only for the surgical aspect but also to facilitate appropriate care in a specialized environment [1,3,[6][7][8]. Moreover, a recent systematic review and meta-analysis showed that neurocritical care services are associated with improved survival and functional outcomes in critically ill adults with brain injury [20].…”

Section: Transfer To the Hub Centermentioning

confidence: 99%

“…venous drainage in the spoke center and during transfer to the hub center Strong recommendation20 We recommend that in severe TBI patients, the head should be maintained in the midline avoiding compression of the neck veins in the spoke center and during transfer to the hub center Strong recommendation21 We recommend avoiding core body temperature > 37.5 °C and to aim for normothermia in severe TBI patients Strong recommendation22 We recommend maintaining Hb level > 7 g/dl in severe TBI patients28 We recommend an increase in sedation, while maintaining an acceptable ABP, as a therapeutic maneuver that should be utilized in the management of patients with signs of brain herniation awaiting emergent neurosurgeryStrong recommendation TBI, traumatic brain injury; ICP, intracranial pressure; ICU, intensive care unit; OR, operating room; CT, computed tomography; GCS, Glasgow coma scale; ABP, arterial blood pressure; ECG, electrocardiogram; HR, heart rate; SpO 2 , peripheral oxygen saturation; ETCO 2 , end-tidal carbon dioxide; MAP, mean arterial pressure; SAP, systolic arterial pressure; PLT, platelet; PT, prothrombin time; aPTT, activated partial thromboplastin time; POC, point-of-care; TEG, thromboelastography; ROTEM, rotational thromboelastometry; EEG, electroencephalogram; Hb, hemoglobin; PaCO 2 , arterial partial pressure of carbon dioxide; Na, sodium Page 5 of 12 Picetti et al World Journal of Emergency Surgery (2023) 18:5…”

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confidence: 99%

Early management of isolated severe traumatic brain injury patients in a hospital without neurosurgical capabilities: a consensus and clinical recommendations of the World Society of Emergency Surgery (WSES)

et al. 2023

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Background Severe traumatic brain-injured (TBI) patients should be primarily admitted to a hub trauma center (hospital with neurosurgical capabilities) to allow immediate delivery of appropriate care in a specialized environment. Sometimes, severe TBI patients are admitted to a spoke hospital (hospital without neurosurgical capabilities), and scarce data are available regarding the optimal management of severe isolated TBI patients who do not have immediate access to neurosurgical care. Methods A multidisciplinary consensus panel composed of 41 physicians selected for their established clinical and scientific expertise in the acute management of TBI patients with different specializations (anesthesia/intensive care, neurocritical care, acute care surgery, neurosurgery and neuroradiology) was established. The consensus was endorsed by the World Society of Emergency Surgery, and a modified Delphi approach was adopted. Results A total of 28 statements were proposed and discussed. Consensus was reached on 22 strong recommendations and 3 weak recommendations. In three cases, where consensus was not reached, no recommendation was provided. Conclusions This consensus provides practical recommendations to support clinician’s decision making in the management of isolated severe TBI patients in centers without neurosurgical capabilities and during transfer to a hub center.

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“…Moreover, the need for intensive care for AIS has increased due to the aging population and innovative reperfusion therapy (including intravenous thrombolysis and mechanical thrombectomy). Meanwhile, subspecialized neurocritical care (NCC) delivery was linked with lower mortality and better functional results in patients with acute brain injury [ 4 ]. Hence, identifying the risk factors for poor results early on should be considered to determine the appropriate population for advanced therapy and specific NCC services.…”

Section: Introductionmentioning

confidence: 99%

Is Thrombocytopenia an In-Hospital Mortality Risk Factor among Patients with Acute Ischemic Stroke? A Propensity Score-Matched Analysis from the MIMIC-IV Database

Wang

Yang

Lee

et al. 2023

JCM

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(1) Background: We aimed to evaluate the aspect of thrombocytopenia in patients with acute ischemic stroke (AIS); (2) Methods: Patients with AIS were recruited in the Medical Information Mart for Intensive Care IV database from 2008 to 2019. The thrombocytopenia was defined as a platelet blood count of less than 150 K/µL. We compared the patient characteristics and clinical outcomes using propensity score matching (PSM); (3) Results: Thrombocytopenia affected 151 out of the 1236 patients (12.2%). Patients with thrombocytopenia were older (70.5 ± 12.8 vs. 68.4 ± 14.4; SMD = 0.154) and had a higher Charlson comorbidity index (7.3 ± 2.5 vs. 6.7 ± 2.7; SMD = 0.228) and acute physiology score III (44.8 ± 21.0 vs. 38.2 ± 19.1; SMD = 0.328) than those without thrombocytopenia. The risk of in-hospital mortality did not increase linearly or nonlinearly with a lower platelet count (overall p value = 0.794; nonlinear p value = 0.646). After PSM, 147 pairs remained. Thrombocytopenia was not linked with in-hospital mortality (HR: 1.06, 95% CIs: 0.60–1.88); (4) Conclusions: We described the clinical characteristics of patients admitted for thrombocytopenia and AIS who did not receive reperfusion therapy; additionally, we found that thrombocytopenia was not an independent short-term risk factor of in-hospital mortality.

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Association of Neurocritical Care Services With Mortality and Functional Outcomes for Adults With Brain Injury

Cited by 22 publications

References 47 publications

One-Year Outcomes in Patients With Acute Stroke Requiring Mechanical Ventilation

One-Year Outcomes in Patients With Acute Stroke Requiring Mechanical Ventilation

Early management of isolated severe traumatic brain injury patients in a hospital without neurosurgical capabilities: a consensus and clinical recommendations of the World Society of Emergency Surgery (WSES)

Is Thrombocytopenia an In-Hospital Mortality Risk Factor among Patients with Acute Ischemic Stroke? A Propensity Score-Matched Analysis from the MIMIC-IV Database

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