Jessalyn K. Holodinsky

Risk factors for intra-abdominal hypertension and abdominal compartment syndrome among adult intensive care unit patients: a systematic review and meta-analysis

IntroductionAlthough intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are associated with substantial morbidity and mortality among critically ill adults, it remains unknown if prevention or treatment of these conditions improves patient outcomes. We sought to identify evidence-based risk factors for IAH and ACS in order to guide identification of the source population for future IAH/ACS treatment trials and to stratify patients into risk groups based on prognosis.MethodsWe searched electronic bibliographic databases (MEDLINE, EMBASE, PubMed, and the Cochrane Database from 1950 until January 21, 2013) and reference lists of included articles for observational studies reporting risk factors for IAH or ACS among adult ICU patients. Identified risk factors were summarized using formal narrative synthesis techniques alongside a random effects meta-analysis.ResultsAmong 1,224 citations identified, 14 studies enrolling 2,500 patients were included. The 38 identified risk factors for IAH and 24 for ACS could be clustered into three themes and eight subthemes. Large volume crystalloid resuscitation, the respiratory status of the patient, and shock/hypotension were common risk factors for IAH and ACS that transcended across presenting patient populations. Risk factors with pooled evidence supporting an increased risk for IAH among mixed ICU patients included obesity (four studies; odds ratio (OR) 5.10; 95% confidence interval (CI), 1.92 to 13.58), sepsis (two studies; OR 2.38; 95% CI, 1.34 to 4.23), abdominal surgery (four studies; OR 1.93; 95% CI, 1.30 to 2.85), ileus (two studies; OR 2.05; 95% CI, 1.40 to 2.98), and large volume fluid resuscitation (two studies; OR 2.17; 95% CI, 1.30 to 3.63). Among trauma and surgical patients, large volume crystalloid resuscitation and markers of shock/hypotension and metabolic derangement/organ failure were risk factors for IAH and ACS while increased disease severity scores and elevated creatinine were risk factors for ACS in severe acute pancreatitis patients.ConclusionsAlthough several IAH/ACS risk factors transcend across presenting patient diagnoses, some appear specific to the population under study. As our findings were somewhat limited by included study methodology, the risk factors reported in this study should be considered candidate risk factors until confirmed by a large prospective multi-centre observational study.

Active Negative Pressure Peritoneal Therapy After Abbreviated Laparotomy The Intraperitoneal Vacuum Randomized Controlled Trial

Supplemental Digital Content is Available in the Text. This randomized trial observed a survival difference between patients randomized to the ABThera versus Barkers vacuum pack after abbreviated laparotomy. As this difference did not seem to be mediated by improved peritoneal fluid drainage, fascial closure rates, or markers of systemic inflammation, it should be confirmed by a multicenter trial.

Drip ‘n Ship Versus Mothership for Endovascular Treatment: Modeling the Best Transportation Options for Optimal Outcomes

Background and Purpose— There is uncertainty regarding the best way for patients outside of endovascular-capable or Comprehensive Stroke Centers (CSC) to access endovascular treatment for acute ischemic stroke. The role of the nonendovascular-capable Primary Stroke Centers (PSC) that can offer thrombolysis with alteplase but not endovascular treatment is unclear. A key question is whether average benefit is greater with early thrombolysis at the closest PSC before transportation to the CSC (Drip ‘n Ship) or with PSC bypass and direct transport to the CSC (Mothership). Ideal transportation options were mapped based on the location of their endovascular-capable CSCs and nonendovascular-capable PSCs. Methods— Probability models for endovascular treatment were developed from the ESCAPE trial’s (Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis on Minimizing CT to Recanalization Times) decay curves and for alteplase treatment were extracted from the Get With The Guidelines decay curve. The time on-scene, needle-to-door-out time at the PSC, door-to-needle time at the CSC, and door-to-reperfusion time were assumed constant at 25, 20, 30, and 115 minutes, respectively. Emergency medical services transportation times were calculated using Google’s Distance Matrix Application Programming Interface interfaced with MATLAB’s Mapping Toolbox to create map visualizations. Results— Maps were generated for multiple onset-to-first medical response times and door-to-needle times at the PSCs of 30, 60, and 90. These figures demonstrate the transportation option that yields the better modeled outcome in specific regions. The probability of good outcome is shown. Conclusions— Drip ‘n Ship demonstrates that a PSC that is in close proximity to a CSC remains significant only when the PSC is able to achieve a door-to-needle time of ⩽30 minutes when the CSC is also efficient.

Drip and Ship Versus Direct to Comprehensive Stroke Center: Conditional Probability Modeling

The outcome of ischemic stroke is related to the volume of brain that is infarcted, and the volume of infarction is directly related to the time to reperfusion.1 In an anterior circulation, large-vessel ischemic stroke 1.9 million neurons are lost every minute.2 Treatment efficacy is dependent on time to treatment initiation. Acute ischemic stroke is treated medically with the administration of intravenous alteplase. Recent results of several randomized trials established the efficacy of endovascular treatment in ischemic stroke.3–8 The facilities and expertise needed for endovascular procedures are only available at endovascular capable centers (ECCs), which are typically tertiary care hospitals. Medical treatment with alteplase is more widely available. This creates 2 options for prehospital destination decision-making for suspected stroke: (1) transport the patient directly to the nearest ECC to receive alteplase and, if appropriate, immediate endovascular therapy even though this might mean bypassing a closer non-ECC (nECC; mothership model); or (2) transport the patient to the nearest nECC to receive alteplase and then transfer the patient to the nearest ECC for endovascular therapy (drip and ship model). There are advantages and disadvantages to each of these options, and it is currently unknown which of these options will lead to the highest probability of good outcome for the patient. The RACECAT trial in Barcelona, Spain, is planned to directly address this question (NCT02795962). Herein, we propose a methodology for addressing this problem using statistical probability modeling and suggest a candidate model for evaluation. ### Assumptions We make several assumptions in the development of the prediction models (Table I in the online-only Data Supplement). First, these models apply when there is uncertainty on which transport and treatment decision to choose. Second, the nECC is the closest treatment center to the location of stroke occurrence. If an ECC is the …

Multiphase CT angiography increases detection of anterior circulation intracranial occlusion

Objective: To evaluate whether the use of multiphase CT angiography (CTA) improves interrater agreement for intracranial occlusion detection between stroke neurology trainees and an expert neuroradiologist. Methods: A neuroradiologist and 2 stroke neurology fellows independently reviewed 100 prospectively collected single-phase and multiphase CTA scans from acute ischemic stroke patients with mild symptoms (NIH Stroke Scale score ≤5). The presence and location of a vascular occlusion(s) were documented. Interrater agreement single- and multiphase CTA was quantified using unweighted κ statistics. We assessed for any occlusions, anterior vs posterior occlusions, and pial vessel asymmetry. Results: Using multiphase CTA, the neuroradiologist detected 50 scans with anterior circulation occlusions and 15 scans with posterior circulation occlusions. Median reading time was 2 minutes per scan. Median reading time for the neurologists was 3 minutes per multiphase CTA scan. Interrater agreement was fair between the 2 neurologists and neuroradiologist when using single-phase CTA (κ = 0.45 and 0.32). Agreement improved minimally when stratified by anterior vs posterior circulation. When using multiphase CTA, agreement was high for detection of occlusion or asymmetry of pial vessels in the anterior circulation (κ = 0.80 and 0.84). Conclusions: Multiphase CTA improves diagnostic accuracy in minor ischemic stroke for detection of anterior circulation intracranial occlusion. Classification of evidence: This study provides Class II evidence that multiphase CTA, compared to single-phase CTA, improves the interrater agreement between stroke neurology trainees and an expert neuroradiologist for detecting anterior circulation intracranial vascular occlusion in patients with minor acute ischemic strokes.

Use and Utility of Administrative Health Data for Stroke Research and Surveillance

Despite declining age-standardized stroke incidence in high-income countries, stroke incidence is rising in low- and middle-income countries.1 Globally, the absolute burden of stroke was high in 2010 with 16.9 million first-ever strokes, 5.9 million stroke-related deaths, and 102 million disability-adjusted life-years lost.1 These numbers are projected to increase. Surveillance provides an understanding of stroke frequency, burden, distribution, and determinants. These data are essential for monitoring trends over time, guiding judicious resource allocation, and for the design, implementation, and evaluation of interventions aimed at stroke prevention, treatment, and rehabilitation.2 Collecting data specifically for research purposes can be costly and time-consuming, limiting the sample size, period of follow-up, and geographical distribution of subjects. Surveillance requires continuous data collection in large geographic areas over years; therefore, attention has been paid to secondary use data. Health services utilization data, or administrative health data, provide a wealth of information for health services researchers and for stroke surveillance. However, the information collected and ascertainment methods are heterogeneous between countries and even between jurisdictions within a country, making the data vulnerable to selection and measurement bias. Comparing international data is also challenging.3 In this review, we discuss the strengths and weaknesses of administrative health data for stroke surveillance. Administrative health data are routinely generated through interactions with healthcare systems. They are collected for payment, monitoring, planning, priority setting, and evaluation of health services provision. Sources include, but are not limited to, hospitalizations, emergency department and ambulatory care visits, and physician billings. Unlike prospective clinical research data collection, administrative health data are accumulated in a distributed manner over a prolonged period of time. As a result, these data capture a large number of individuals and a wide range of demographic information, including race/ethnicities, geographical areas (eg, rural versus urban), and institutions (eg, community versus …

Intraventricular Fibrinolysis with Tissue Plasminogen Activator is Associated with Transient Cerebrospinal Fluid Inflammation: A Randomized Controlled Trial:

Locally administered tissue plasminogen activator (TPA) accelerates clearance of intraventricular hemorrhage (IVH), but its impact on neurologic outcomes remains unclear and preclinical research suggests it may have pro-inflammatory effects. We randomly allocated patients with ruptured cerebral aneurysms and IVH, treated with endovascular coiling and ventricular drainage, to receive either 2-mg intraventricular TPA or placebo every 12 hours. Cerebrospinal fluid (CSF) and serum cytokine and white blood cell (WBC) concentrations were measured before drug administration and daily for 72 hours. Cerebrospinal fluid D-dimer levels were assessed 6 and 12 hours after administration to quantify fibrinolysis. Six patients were randomized to each group. Patients treated with TPA developed higher CSF cytokine concentrations compared with placebo-treated patients (P < 0.05 for tumor necrosis factor-α, interferon-γ, interleukin (IL)-1α, IL-1β, IL-2, IL-4, and IL-6), as well as higher CSF WBC counts (P = 0.03). Differences were greatest after 24 hours and decreased over 48 to 72 hours. The magnitude of the inflammatory response was significantly associated with peak CSF D-dimer concentration and extent of IVH clearance. We conclude that intraventricular TPA administration produces a transient local inflammatory response, the severity of which is strongly associated with the degree of fibrinolysis, suggesting it may be induced by release of hematoma breakdown products, rather than the drug itself.

Improving Door-to-Needle Times for Acute Ischemic Stroke: Effect of Rapid Patient Registration, Moving Directly to Computed Tomography, and Giving Alteplase at the Computed Tomography Scanner

Background— The effectiveness of specific systems changes to reduce DTN (door-to-needle) time has not been fully evaluated. We analyzed the impact of 4 specific DTN time reduction strategies implemented prospectively in a staggered fashion. Methods and Results— The HASTE (Hurry Acute Stroke Treatment and Evaluation) project was implemented in 3 phases at a single academic medical center. In HASTE I (June 6, 2012 to June 5, 2013), baseline performance was analyzed. In HASTE II (June 6, 2013 to January 24, 2015), 3 changes were implemented: (1) a STAT stroke protocol to prenotify the stroke team about incoming stroke patients; (2) administering alteplase at the computed tomography (CT) scanner; and (3) registering the patient as unknown to allow immediate order entry. In HASTE III (January 25, 2015 to June 29, 2015), we implemented a process to bring the patient directly to CT on the emergency medical services stretcher. Log-transformed DTN time was modeled. Data from 350 consecutive alteplase-treated patients were analyzed. Multivariable regression showed the following factors to be significant: giving alteplase in the CT (32% decrease in DTN time, 95% confidence interval [CI] 38%–55%), stretcher to CT (30% decrease in DTN time, 95% CI 16%–42%), patient registered as unknown (12% decrease in DTN time, 95% CI 3%–20%), STAT stroke protocol (11% decrease in DTN time, 95% CI 1%–20%), and stroke severity (National Institutes of Health Stroke Scale score 6–8: 19% decrease in DTN time, 95% CI 6%–31%; National Institutes of Health Stroke Scale score >8: 27% decrease in DTN time, 95% CI 17%–37%). Conclusions— Taking the patient to CT on the emergency medical services stretcher, registering the patient as unknown, STAT stroke protocol, and administering alteplase in CT are associated with lower DTN time.

History, Evolution, and Importance of Emergency Endovascular Treatment of Acute Ischemic Stroke

More than 800,000 people in North America suffer a stroke each year, with ischemic stroke making up the majority of these cases. The outcomes of ischemic stroke range from complete functional and cognitive recovery to severe disability and death; outcome is strongly associated with timely reperfusion treatment. Historically, ischemic stroke has been treated with intravenous thrombolytic agents with moderate success. However, five recently published positive trials have established the efficacy of endovascular treatment in acute ischemic stroke. In this review, we will discuss the history of stroke treatments moving from various intravenous thrombolytic drugs to intra-arterial thrombolysis, early mechanical thrombectomy devices, and finally modern endovascular devices. Early endovascular therapy failures, recent successes, and implications for current ischemic stroke management and future research directions are discussed.

A Survey of Rounding Practices in Canadian Adult Intensive Care Units

Objective To describe rounding practices in Canadian adult Intensive Care Units (ICU) and identify opportunities for improvement. Design Mixed methods design. Cross sectional survey of Canadian Adult ICUs (n = 180) with purposefully sampled follow-up interviews (n = 7). Measurements and Main Results Medical directors representing 111 ICUs (62%) participated in the survey. Rounding practices varied across ICUs with the majority reporting the use of interprofessional rounds (81%) that employed an open (94%) and collaborative (86%) approach, occurred at the patient’s bedside (82%), and started at a standard time (79%) and standard location (56%). Most participants reported that patients (83%) and family members (67%) were welcome to attend rounds. Approximately half of ICUs (48%) used tools to facilitate rounds. Interruptions during rounds were reported to be common (i.e., ≥1 interruption for ≥50% of patients) in 46% of ICUs. Four themes were identified from qualitative analysis of participant responses to open-ended survey questions and interviews: multidisciplinarity, patient and family involvement, factors influencing productivity, and teaching and learning. Conclusions There is considerable variation in current rounding practices in Canadian medical/surgical ICUs. Opportunities exist to improve ICU rounds including ensuring the engagement of essential participants, clearly defining participant roles, establishing a standardized approach to the rounding process, minimizing interruptions, modifying the role of teaching, utilizing a structured rounding tool, and developing a metric for measuring rounding quality.