Update in Neurocritical Care: a summary of the 2018 Paris international conference of the French Society of Intensive Care

Oddo, Mauro; Bracard, Serge; Cariou, Alain; Chanques, Gérald; Citerio, Giuseppe; Clerckx, Béatrix; Godeau, Bertrand; Godiér, Anne; Horn, Janneke; Jaber, Samir; Jung, Boris; Kuteifan, Khaldoun; Léone, Marc; Mailles, Alexandra; Mazighi, Mikaël; Mégarbane, Bruno; Outin, Hervé; Puybasset, Louis; Sharshar, Tarek; Sandroni, Claudio; Sonneville, Romain; Weiss, Nicolas; Taccone, Fabio Silvio

doi:10.1186/s13613-019-0523-x

Cited by 16 publications

(10 citation statements)

References 113 publications

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“…Targeted temperature management (TTM) is currently recommended in patients after OHCA with initial shockable rhythm who remain comatose after ROSC and is suggested in patients after OHCA with non-shockable rhythm or after in-hospital CA with any initial rhythm who remain comatose after ROSC, for at least 24 h [ 47 , 60 , 61 ]. TTM should be started immediately at ICU admission [ 62 ]. However, the optimal target temperature [ 63 , 64 ], the optimal duration [ 65 ] of TTM as well as the cooling procedures [ 66 – 68 ] are still matter of debate.…”

Section: Management Of Post-resuscitation Shockmentioning

confidence: 99%

Post-resuscitation shock: recent advances in pathophysiology and treatment

Jozwiak

Bougouin

Géri

et al. 2020

Ann. Intensive Care

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A post-resuscitation shock occurs in 50–70% of patients who had a cardiac arrest. It is an early and transient complication of the post-resuscitation phase, which frequently leads to multiple-organ failure and high mortality. The pathophysiology of post-resuscitation shock is complex and results from the whole-body ischemia–reperfusion process provoked by the sequence of circulatory arrest, resuscitation manoeuvers and return of spontaneous circulation, combining a myocardial dysfunction and sepsis features, such as vasoplegia, hypovolemia and endothelial dysfunction. Similarly to septic shock, the hemodynamic management of post-resuscitation shock is based on an early and aggressive hemodynamic management, including fluid administration, vasopressors and/or inotropes. Norepinephrine should be considered as the first-line vasopressor in order to avoid arrhythmogenic effects of other catecholamines and dobutamine is the most established inotrope in this situation. Importantly, the optimal mean arterial pressure target during the post-resuscitation shock still remains unknown and may probably vary according to patients. Mechanical circulatory support by extracorporeal membrane oxygenation can be necessary in the most severe patients, when the neurological prognosis is assumed to be favourable. Other symptomatic treatments include protective lung ventilation with a target of normoxia and normocapnia and targeted temperature management by avoiding the lowest temperature targets. Early coronary angiogram and coronary reperfusion must be considered in ST-elevation myocardial infarction (STEMI) patients with preserved neurological prognosis although the timing of coronary angiogram in non-STEMI patients is still a matter of debate. Further clinical research is needed in order to explore new therapeutic opportunities regarding inflammatory, hormonal and vascular dysfunction.

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Section: Management Of Post-resuscitation Shockmentioning

confidence: 99%

Post-resuscitation shock: recent advances in pathophysiology and treatment

Jozwiak

Bougouin

Géri

et al. 2020

Ann. Intensive Care

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“…Robust and straight-forward prediction scores used as a practical decision tool to support clinical assessments would probably improve the overall cardiac arrest care by directing very advanced and potentially high-risk invasive treatment to those patients who may benefit from it. Such scores would hopefully also increase the ability to provide reliable prognostic information to next-ofkin, earlier than the observation time of at least 72 h, which is the current recommendation for neurological prognostication after cardiac arrest [17,18,47,48].…”

Section: Discussionmentioning

confidence: 99%

Artificial neural networks improve early outcome prediction and risk classification in out-of-hospital cardiac arrest patients admitted to intensive care

et al. 2020

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Background: Pre-hospital circumstances, cardiac arrest characteristics, comorbidities and clinical status on admission are strongly associated with outcome after out-of-hospital cardiac arrest (OHCA). Early prediction of outcome may inform prognosis, tailor therapy and help in interpreting the intervention effect in heterogenous clinical trials. This study aimed to create a model for early prediction of outcome by artificial neural networks (ANN) and use this model to investigate intervention effects on classes of illness severity in cardiac arrest patients treated with targeted temperature management (TTM). Methods: Using the cohort of the TTM trial, we performed a post hoc analysis of 932 unconscious patients from 36 centres with OHCA of a presumed cardiac cause. The patient outcome was the functional outcome, including survival at 180 days follow-up using a dichotomised Cerebral Performance Category (CPC) scale with good functional outcome defined as CPC 1-2 and poor functional outcome defined as CPC 3-5. Outcome prediction and severity class assignment were performed using a supervised machine learning model based on ANN. Results: The outcome was predicted with an area under the receiver operating characteristic curve (AUC) of 0.891 using 54 clinical variables available on admission to hospital, categorised as background, pre-hospital and admission data. Corresponding models using background, pre-hospital or admission variables separately had inferior prediction performance. When comparing the ANN model with a logistic regression-based model on the same cohort, the ANN model performed significantly better (p = 0.029). A simplified ANN model showed promising performance with an AUC above 0.852 when using three variables only: age, time to ROSC and first monitored rhythm. The ANN-stratified analyses showed similar intervention effect of TTM to 33°C or 36°C in predefined classes with different risk of a poor outcome.

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“…Neither neuroimaging, nor multimodality monitoring can replace the neurologic examination ( 75 ), and it remains the most valuable tool for the assessment of brain injured patients, from stroke ( 74 ), to SAH ( 76 , 77 ), and TBI ( 14 , 24 , 72 ). A recent intensive care symposium in Paris aiming to update neurocritical care recommendations states that the neurologic examination is indispensable for the accurate assessment of comatose patients, along with the simultaneous use of neuroimaging and multimodality monitoring ( 78 ). The SIBICC panel recommend a sedation holiday (an NWT) in TBI patients with ongoing ICP monitoring to facilitate an accurate neurologic exam ( 79 ).…”

Section: The Nwtmentioning

confidence: 99%

Neurologic Assessment of the Neurocritical Care Patient

Musick

Alberico

2021

Front. Neurol.

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Sedation is a ubiquitous practice in ICUs and NCCUs. It has the benefit of reducing cerebral energy demands, but also precludes an accurate neurologic assessment. Because of this, sedation is intermittently stopped for the purposes of a neurologic assessment, which is termed a neurologic wake-up test (NWT). NWTs are considered to be the gold-standard in continued assessment of brain-injured patients under sedation. NWTs also produce an acute stress response that is accompanied by elevations in blood pressure, respiratory rate, heart rate, and ICP. Utilization of cerebral microdialysis and brain tissue oxygen monitoring in small cohorts of brain-injured patients suggests that this is not mirrored by alterations in cerebral metabolism, and seldom affects oxygenation. The hard contraindications for the NWT are preexisting intracranial hypertension, barbiturate treatment, status epilepticus, and hyperthermia. However, hemodynamic instability, sedative use for primary ICP control, and sedative use for severe agitation or respiratory distress are considered significant safety concerns. Despite ubiquitous recommendation, it is not clear if additional clinically relevant information is gleaned through its use, especially with the contemporaneous utilization of multimodality monitoring. Various monitoring modalities provide unique and pertinent information about neurologic function, however, their role in improving patient outcomes and guiding treatment plans has not been fully elucidated. There is a paucity of information pertaining to the optimal frequency of NWTs, and if it differs based on type of injury. Only one concrete recommendation was found in the literature, exemplifying the uncertainty surrounding its utility. The most common sedative used and recommended is propofol because of its rapid onset, short duration, and reduction of cerebral energy requirements. Dexmedetomidine may be employed to facilitate serial NWTs, and should always be used in the non-intubated patient or if propofol infusion syndrome (PRIS) develops. Midazolam is not recommended due to tissue accumulation and residual sedation confounding a reliable NWT. Thus, NWTs are well-tolerated in selected patients and remain recommended as the gold-standard for continued neuromonitoring. Predicated upon one expert panel, they should be performed at least one time per day. Propofol or dexmedetomidine are the main sedative choices, both enabling a rapid awakening and consistent NWT.

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Update in Neurocritical Care: a summary of the 2018 Paris international conference of the French Society of Intensive Care

Cited by 16 publications

References 113 publications

Post-resuscitation shock: recent advances in pathophysiology and treatment

Post-resuscitation shock: recent advances in pathophysiology and treatment

Artificial neural networks improve early outcome prediction and risk classification in out-of-hospital cardiac arrest patients admitted to intensive care

Neurologic Assessment of the Neurocritical Care Patient

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