Jennifer A. Frontera

Impact of medical complications on outcome after subarachnoid hemorrhage.

Objective:Medical complications occur frequently after subarachnoid hemorrhage (SAH). Their impact on outcome remains poorly defined. Design:Inception cohort study. Patients:Five-hundred eighty patients enrolled in the Columbia University SAH Outcomes Project between July 1996 and May 2002. Setting:Neurologic intensive care unit. Interventions:Patients were treated according to standard management protocols. Measurements and Main Results:Poor outcome was defined as death or severe disability (modified Rankin score, 4–6) at 3 months. We calculated the frequency of medical complications according to prespecified criteria and evaluated their impact on outcome, using forward stepwise multiple logistic regression after adjusting for known predictors of poor outcome. Thirty-eight% had a poor outcome; mortality was 21%. The most frequent complications were temperature >38.3°C (54%), followed by anemia treated with transfusion (36%), hyperglycemia >11.1 mmol/L (30%), treated hypertension (>160 mm Hg systolic; 27%), hypernatremia >150 mmol/L (22%), pneumonia (20%), hypotension (<90 mm Hg systolic) treated with vasopressors (18%), pulmonary edema (14%), and hyponatremia <130 mmol/L (14%). Fever (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.1–3.4; p = .02), anemia (OR, 1.8; 95% CI, 1.1–2.9; p = .02), and hyperglycemia (OR, 1.8; 95% CI, 1.1–3.0; p = .02) significantly predicted poor outcome after adjustment for age, Hunt-Hess grade, aneurysm size, rebleeding, and cerebral infarction due to vasospasm. Conclusions:Fever, anemia, and hyperglycemia affect 30% to 54% of patients with SAH and are significantly associated with mortality and poor functional outcome. Critical care strategies directed at maintaining normothermia, normoglycemia, and prevention of anemia may improve outcome after SAH. LEARNING OBJECTIVESOn completion of this article, the reader should be able to: Identify common medical complications after subarachnoid hemorrhage. Describe complications that influence outcome. Use this inofrmation in a clinical setting. Dr. Connolly has disclosed that he is/was the recipient of direct grant/research funds from the National Institutes of Health. The remaining authors have disclosed that they have no financial relationships with or interests in any commercial companies pertaining to the educational activity. Wolters Kluwer has identified and resolved all faculty conflicts of interest regarding the educational activity. Visit the Critical Care Medicine Web site (www.ccmjournal.org) for information on obtaining continuing medical education credit.

Prediction of symptomatic vasospasm after subarachnoid hemorrhage: the modified fisher scale.

OBJECTIVE We developed a modification of the Fisher computed tomographic rating scale and compared it with the original Fisher scale to determine which scale best predicts symptomatic vasospasm after subarachnoid hemorrhage. METHODS We analyzed data from 1355 subarachnoid hemorrhage patients in the placebo arm of four randomized, double-blind, placebo-controlled studies of tirilazad. Modified Fisher computed tomographic grades were calculated on the basis of the presence of cisternal blood and intraventricular hemorrhage. Crude odds ratios (OR) reflecting the risk of developing symptomatic vasospasm were calculated for each scale level, and adjusted ORs expressing the incremental risk were calculated after controlling for known predictors of vasospasm. RESULTS Of 1355 patients, 451 (33%) developed symptomatic vasospasm. For the modified Fisher scale, compared with Grade 0 to 1 patients, the crude OR for vasospasm was 1.6 (95% confidence interval [CI], 1.0-2.5) for Grade 2, 1.6 (95% CI, 1.1-2.2) for Grade 3, and 2.2 (95% CI, 1.6-3.1) for Grade 4. For the original Fisher scale, referenced to Grade 1, the OR for vasospasm was 1.3 (95% CI, 0.7-2.2) for Grade 2, 2.2 (95% CI, 1.4-3.5) for Grade 3, and 1.7 (95% CI, 1.0-3.0) for Grade 4. Early angiographic vasospasm, history of hypertension, neurological grade, and elevated admission mean arterial pressure were identified as risk factors for symptomatic vasospasm. After adjusting for these variables, the modified Fisher scale remained a significant predictor of vasospasm (adjusted OR, 1.28; 95% CI, 1.06-1.54), whereas the original Fisher scale was not. CONCLUSION The modified Fisher scale, which accounts for thick cisternal and ventricular blood, predicts symptomatic vasospasm after subarachnoid hemorrhage more accurately than original Fisher scale.

ELECTROGRAPHIC SEIZURES AND PERIODIC DISCHARGES AFTER INTRACEREBRAL HEMORRHAGE

Objective: To determine the frequency and significance of electrographic seizures and other EEG findings in patients with intracerebral hemorrhage (ICH). Methods: We reviewed 102 consecutive patients with ICH who underwent continuous electroencephalographic monitoring (cEEG). Demographic, clinical, radiographic, and cEEG findings were recorded. Using multivariate logistic regression analysis, we determined factors associated with 1) electrographic seizures, 2) periodic epileptiform discharges (PEDs), and 3) poor outcome (death, vegetative or minimally conscious state) at hospital discharge. Results: Seizures occurred in 31% (n = 32) of patients with ICH, prior to cEEG in 19 patients. Eighteen percent (n = 18) of patients had electrographic seizures; only one of these patients also had clinical seizures while on cEEG. After controlling for demographic and clinical predictors, only an increase in ICH volume of 30% or more between admission and 24-hour follow-up CT scan was associated with electrographic seizures (33% vs 15%; OR 9.5, 95% CI 1.7 to 53.8). PEDs were less frequently seen in those with hemorrhages located at least 1 mm from the cortex (8% vs 29%; OR 0.2, 95% CI 0.1 to 0.7). PEDs were independently associated with poor outcome (65% vs 17%; OR 7.6, 95% CI 2.1 to 27.3). In patients with electrographic seizures, the first seizure was detected within the first hour of cEEG monitoring in 56% and within 48 hours in 94%. Conclusions: Seizures occurred in one third of patients with intracerebral hemorrhage (ICH) and over half were purely electrographic. Electrographic seizures were associated with expanding hemorrhages, and periodic discharges with cortical ICH and poor outcome. Further research is needed to determine if treating or preventing seizures or PEDs might lead to improved outcome after ICH. GLOSSARY: BIPLEDs = bilateral independent PLEDs; cEEG = continuous EEG monitoring; CLUES = clinically unrecognized electrographic seizures; EVD = external ventricular drain; IRDA = frontal intermittent rhythmic delta activity; GCS = Glasgow Coma Score; GOS = Glasgow Outcome Scale; GPDs = generalized periodic discharges; ICH = intracerebral hemorrhage; ICP = intracranial pressure; ICU = intensive care unit; IVH = intraventricular hemorrhage; NICU = neuroICU; PEDs = periodic epileptiform discharges; PLEDs = periodic lateralized epileptiform discharges; SAH = subarachnoid hemorrhage; SDH = subdural hematomas; SE = status epilepticus; SIRPIDS = stimulus-induced rhythmic, periodic, or ictal discharges.

Defining Vasospasm After Subarachnoid Hemorrhage. What Is the Most Clinically Relevant Definition

Background and Purpose— Vasospasm is an important complication of subarachnoid hemorrhage, but is variably defined in the literature. Methods— We studied 580 patients with subarachnoid hemorrhage and identified those with: (1) symptomatic vasospasm, defined as clinical deterioration deemed secondary to vasospasm after other causes were eliminated; (2) delayed cerebral ischemia (DCI), defined as symptomatic vasospasm, or infarction on CT attributable to vasospasm; (3) angiographic spasm, as seen on digital subtraction angiography; and (4) transcranial Doppler (TCD) spasm, defined as any mean flow velocity >120 cm/sec. Logistic regression analysis was performed to test the association of each definition of vasospasm with various hospital complications, and 3-month quality of life (sickness impact profile), cognitive status (telephone interview of cognitive status), instrumental activities of daily living (Lawton score), and death or severe disability at 3 months (modified Rankin scale score 4–6), after adjustment for covariates. Results— Symptomatic vasospasm occurred in 16%, DCI in 21%, angiographic vasospasm in 31%, and TCD spasm in 45% of patients. DCI was statistically associated with more hospital complications (N=7; all P<0.05) than symptomatic spasm (N=4), angiographic spasm (N=1), or TCD vasospasm (N=1). Angiographic and TCD vasospasm were not related to any aspect of clinical outcome. Both symptomatic vasospasm and DCI were related to reduced instrumental activities of daily living, cognitive impairment, and poor quality of life (all P<0.05). However, only DCI was associated with death or severe disability at 3 months (adjusted OR, 2.2; 95% CI, 1.2–3.9; P=0.007). Conclusions— DCI is a more clinically meaningful definition than either symptomatic deterioration alone or the presence of arterial spasm by angiography or TCD.

Prognostic Significance of Continuous EEG Monitoring in Patients With Poor-Grade Subarachnoid Hemorrhage

IntroductionPredicting outcome in patients with poor-grade subarachnoid hemorrhage (SAH) may help guide therapy and assist in family discussions. The objective of this study was to determine if continuous electroencephalogram (cEEG) monitoring results are predictive of 3-month outcome in critically ill patients with SAH.MethodsWe prospectively studied 756 patients with SAH over a 7-year period. Functional outcome was assessed at 3 months with the modified Rankin Scale (mRS). Patients that underwent cEEG monitoring were retrospectively identified and EEG findings were collected. Multivariate logistic regression analysis was performed to identify EEG findings associated with poor outcome, defined as mRS 4 to 6 (dead or moderately to severely disabled).ResultsIn 116 patients with SAH, cEEG monitoring and 3-month mRS were available. Of these patients, 88% had a Hunt & Hess grade of 3 or worse on admission. After controlling for age, Hunt & Hess grade, and presence of intraventricular hemorrhage on admission CT scan, poor outcome was associated with the absence of sleep architecture (80 versus 47%; odds ratio [OR] 4.3, 95%-confidence interval [CI] 1.1–17.2) and the presence of periodic lateralized epileptiform discharges (PLEDS) (91 versus 66% OR 18.8, 95%-CI 1.6–214.6). In addition, outcome was poor in all patients with absent EEG reactivity (n=8), generalized periodic epileptiform discharges (n=12), or bilateral independent PLEDs (n=5, and in 92% (11 of 12) of patients with nonconvulsive status epilepticus.ConclusionscEEG monitoring provides independent prognostic information in patients with poor-grade SAH, even after controlling for clinical and radiological findings. Unfavorable findings include periodic epileptiform discharges, electrographic status epilepticus, and the absence of sleep architecture.

Hyperglycemia After SAH: Predictors, Associated Complications, and Impact on Outcome

Background and Purpose— Hyperglycemia is common after subarachnoid hemorrhage (SAH). The extent to which prolonged hyperglycemia contributes to in-hospital complications and poor outcome after SAH is unknown. Methods— We studied an inception cohort of 281 SAH patients with an initial serum glucose level obtained within 3 days of SAH onset and who had at least 7 daily glucose measurements between SAH days 0 and 10. We defined mean glucose burden (GB) as the average peak daily glucose level >5.8 mmol/L (105 mg/dL). Hospital complications were recorded prospectively, and 3-month outcome was assessed with the modified Rankin scale. Results— The median GB was 1.8 mmol/L (33 mg/dL). Predictors of high-GB included age ≥54 years, Hunt and Hess grade III–V, poor Acute Physiology and Chronic Health Evaluation (APACHE)-2 physiological subscores, and a history of diabetes mellitus (all P≤0.001). In a multivariate analysis, GB was associated with increased intensive care unit length of stay (P=0.003) and the following complications: congestive heart failure, respiratory failure, pneumonia, and brain stem compression from herniation (all P<0.05). After adjusting for Hunt-Hess grade, aneurysm size, and age, GB was an independent predictor of death (odds ratio, 1.10 per mmol/L; 95% CI, 1.01 to 1.21; P=0.027) and death or severe disability (modified Rankin scale score of 4 to 6; odds ratio, 1.17 per mmol/L; 95% CI 1.07 to 1.28, P<0.001). Conclusions— Hyperglycemia after SAH is associated with serious hospital complications, increased intensive care unit length of stay, and an increased risk of death or severe disability.

Impact of nosocomial infectious complications after subarachnoid hemorrhage

OBJECTIVECritically ill neurological patients are susceptible to infections that may be distinct from other intensive care patients. The aim of this study is to quantify the prevalence, risk factors, and effect on the outcome of nosocomial infectious complications in patients with subarachnoid hemorrhage (SAH). METHODSWe studied 573 consecutive patients with SAH, identified the most prevalent infectious complications, and performed univariate analyses to determine risk factors for each complication. Multiple logistic regression models were constructed to calculate adjusted odds ratios for associated risk factors and to assess the impact of infectious complications on 3-month outcome as evaluated with the modified Rankin Scale. RESULTSThe most prevalent nosocomial infections were pneumonia (n = 114, 20%), urinary tract infection (n = 77, 13%), bloodstream infection (BSI) (n = 48, 8%), and meningitis/ventriculitis (n = 28, 5%). Significant independent associations with pneumonia included older age, poor Hunt and Hess grade, intubation/mechanical ventilation, and loss of consciousness at ictus. Urinary tract infection was associated with female sex and central line use. BSI was also associated with central line use, and meningitis/ventriculitis was associated with the presence of intraventricular hemorrhage and external ventricular drainage (all P < 0.05). After adjustment for Hunt and Hess grade, aneurysm size, and age, pneumonia (adjusted odds ratio, 2.04; 95% confidence interval, 1.12–3.71; P = 0.020) and BSI (adjusted odds ratio, 2.51; 95% confidence interval, 1.14–5.56; P = 0.023) independently predicted death or severe disability at 3 months. Prolonged length of stay was significantly associated with all infection types (P < 0.001). CONCLUSIONPneumonia and BSI are common infectious complications of SAH and independently predict poor outcome. The implementation of infection-control measures may be needed to improve outcome after SAH.

Choosing and using screening criteria for palliative care consultation in the ICU: A report from the improving palliative care in the ICU (IPAL-ICU) advisory board

Objective:To review the use of screening criteria (also known as “triggers”) as a mechanism for engaging palliative care consultants to assist with care of critically ill patients and their families in the ICU. Data Sources:We searched the MEDLINE database from inception to December 2012 for all English-language articles using the terms “trigger,” “screen,” “referral,” “tool,” “triage,” “case-finding,” “assessment,” “checklist,” “proactive,” or “consultation,” together with “intensive care” or “critical care” and “palliative care,” “supportive care,” “end-of-life care,” or “ethics.” We also hand-searched reference lists and author files and relevant tools on the Center to Advance Palliative Care website. Study SelectionTwo members (a physician and a nurse with expertise in clinical research, intensive care, and palliative care) of the interdisciplinary Improving Palliative Care in the ICU Project Advisory Board presented studies and tools to the full Board, which made final selections by consensus. Data ExtractionWe critically reviewed the existing data and tools to identify screening criteria for palliative care consultation, to describe methods for selecting, implementing, and evaluating such criteria, and to consider alternative strategies for increasing access of ICU patients and families to high-quality palliative care. Data SynthesisThe Improving Palliative Care in the ICU Advisory Board used data and experience to address key questions relating to: existing screening criteria; optimal methods for selection, implementation, and evaluation of such criteria; and appropriateness of the screening approach for a particular ICU. Conclusions:Use of specific criteria to prompt proactive referral for palliative care consultation seems to help reduce utilization of ICU resources without changing mortality, while increasing involvement of palliative care specialists for critically ill patients and families in need. Existing data and resources can be used in developing such criteria, which should be tailored for a specific ICU, implemented through an organized process involving key stakeholders, and evaluated by appropriate measures. In some settings, other strategies for increasing access to palliative care may be more appropriate.

Predictors of long-term shunt-dependent hydrocephalus after aneurysmal subarachnoid hemorrhage. Clinical article.

OBJECT The purpose of this study was to identify predictors of shunt-dependent hydrocephalus after aneurysmal subarachnoid hemorrhage (SAH). METHODS The authors evaluated the incidence of shunt-dependent hydrocephalus in a consecutive cohort of 580 patients with SAH who were admitted to the Neurological Intensive Care Unit of Columbia University Medical Center between July 1996 and September 2002. Patient demographics, 24-hour admission variables, initial CT scan characteristics, daily transcranial Doppler variables, and development of in-hospital complications were analyzed. Odds ratios and 95% CIs for candidate predictors were calculated using multivariate nominal logistic regression. RESULTS Admission glucose of at least 126 mg/dl (adjusted OR 1.6; 95% CI 1.0-2.6), admission brain CT scan with a bicaudate index of at least 0.20 (adjusted OR 1.43; 95% CI 1.0-2.0), Fisher Grade 4 (adjusted OR 2.71; 95% CI 1.2-5.7), fourth ventricle hemorrhage (adjusted OR 1.78; 95% CI 1.1-2.7), and development of nosocomial meningitis (adjusted OR 2.2; 95% CI 1.4-3.7) were independently associated with shunt dependency. CONCLUSIONS These data suggest that permanent CSF diversion after aneurysmal SAH may be independently predicted by hyperglycemia at admission, findings on the admission CT scan (Fisher Grade 4, fourth ventricle intraventricular hemorrhage, and bicaudate index ≥ 0.20), and development of nosocomial meningitis. Future research is needed to assess if tight glycemic control, reduction of fourth ventricle clot burden, and prevention of nosocomial meningitis may reduce the need for permanent CSF diversion after aneurysmal SAH.

Predictors of global cognitive impairment 1 year after subarachnoid hemorrhage.

OBJECTIVEWe sought to determine the frequency, risk factors, and impact on functional outcome and quality of life (QOL) of global cognitive impairment 1 year after subarachnoid hemorrhage. METHODSWe prospectively evaluated global cognitive status 3 and 12 months after hospitalization with the Telephone Interview for Cognitive Status in 232 subarachnoid hemorrhage survivors. Cognitive impairment was defined as a score of 30 or less (scaled 0 = worst, 51 = best). Logistic regression was performed to calculate adjusted odds ratios (AORs) for impairment at 1 year. Basic activities of daily living were evaluated with the Barthel Index, instrumental activities of daily living were assessed with the Lawton scale, and QOL was evaluated with the Sickness Impact Profile. RESULTSThe frequency of cognitive impairment was 27% at 3 months and 21% at 12 months. After the effects of age, education, and race/ethnicity were controlled for, risk factors for cognitive impairment at 12 months included anemia treated with transfusion (AOR, 3.4; P = 0.006), any temperature level higher than 38.6°C (AOR, 2.7; P = 0.016), and delayed cerebral ischemia (AOR, 3.6; P = 0.01). Among cognitively impaired patients at 3 months, improvement at 1 year occurred in 34% and was associated with more than 12 years of education and the absence of fever higher than 38.6°C during hospitalization (P = 0.015). Patients with cognitive impairment at 1 year had worse concurrent QOL and less ability to perform instrumental and basic activities of daily living (all P < 0.001). CONCLUSIONGlobal cognitive impairment affects more than 20% of subarachnoid hemorrhage survivors at 1 year, is predicted by fever, anemia treated with transfusion, and delayed cerebral ischemia, and adversely affects functional recovery and QOL.