John J. Lewin

Guideline for Reversal of Antithrombotics in Intracranial Hemorrhage : A Statement for Healthcare Professionals from the Neurocritical Care Society and Society of Critical Care Medicine.

BackgroundThe use of antithrombotic agents, including anticoagulants, antiplatelet agents, and thrombolytics has increased over the last decade and is expected to continue to rise. Although antithrombotic-associated intracranial hemorrhage can be devastating, rapid reversal of coagulopathy may help limit hematoma expansion and improve outcomes.MethodsThe Neurocritical Care Society, in conjunction with the Society of Critical Care Medicine, organized an international, multi-institutional committee with expertise in neurocritical care, neurology, neurosurgery, stroke, hematology, hemato-pathology, emergency medicine, pharmacy, nursing, and guideline development to evaluate the literature and develop an evidence-based practice guideline. Formalized literature searches were conducted, and studies meeting the criteria established by the committee were evaluated.ResultsUtilizing the GRADE methodology, the committee developed recommendations for reversal of vitamin K antagonists, direct factor Xa antagonists, direct thrombin inhibitors, unfractionated heparin, low-molecular weight heparin, heparinoids, pentasaccharides, thrombolytics, and antiplatelet agents in the setting of intracranial hemorrhage.ConclusionsThis guideline provides timely, evidence-based reversal strategies to assist practitioners in the care of patients with antithrombotic-associated intracranial hemorrhage.

Glucocorticoid therapy in neurologic critical care

Background:The pivotal role of inflammation and edema across the spectrum of central nervous system injury has driven extensive investigation into the therapeutic potential of glucocorticoids. Objective:To review the experimental and clinical data relating to the efficacy and adverse effects of glucocorticoids in conditions encountered in critical neurologic and neurosurgical illness. Data Source:Search of MEDLINE and Cochrane databases, manual review of article bibliographies. Data Synthesis and Conclusions:The efficacy of glucocorticoids is well established in ameliorating edema associated with brain tumors and in improving outcome in subsets of patients with bacterial meningitis. Despite frequently encouraging experimental results, clinical trials of glucocorticoids in ischemic stroke, intracerebral hemorrhage, aneurysmal subarachnoid hemorrhage, and traumatic brain injury have not shown a definite therapeutic effect. The evidence supporting glucocorticoid therapy for spinal cord injury is controversial; however methylprednisolone continues to be widely employed in this setting.

Update in the Diagnosis and Management of Central Nervous System Infections

Central nervous system (CNS) infections presenting to the emergency room include meningitis, encephalitis, brain and spinal epidural abscess, subdural empyema, and ventriculitis. These conditions often require admission to an intensive care unit (ICU) and are complications of ICU patients with neurologic injury, contributing significantly to morbidity and mortality. Reducing morbidity and mortality is critically dependent on rapid diagnosis and, perhaps more importantly, on the timely initiation of appropriate antimicrobial therapy. New insights into the role of inflammation and the immune response in CNS infections have contributed to development of new diagnostic strategies using markers of inflammation, and to the study of agents with focused immunomodulatory activity, which may lead to further adjunctive therapy in human disease.

Management of bleeding and reversal strategies for oral anticoagulants: Clinical practice considerations

PURPOSE Currently available clinical data and optimal strategies for reversing oral anticoagulants in patients who are bleeding or need an urgent invasive procedure or operation are reviewed. SUMMARY Bleeding from oral anticoagulants, including new target-specific oral agents (TSOAs), is a common cause of morbidity and mortality, especially in elderly patients. Limited clinical data are available to guide the reversal of warfarin or TSOAs in patients who are bleeding or need an urgent invasive procedure or operation. A panel of five experts with diverse backgrounds in anticoagulation therapy, cardiology, critical care, and emergency medicine and with experience in managing complications of anticoagulation therapy was convened to develop practical strategies for managing patients receiving oral anticoagulants who are bleeding or have an urgent need for an invasive procedure. The strategies were designed to guide clinicians in the acute care setting by providing efficient and potentially effective management concepts to avoid delays in initiating treatment that could adversely affect patient outcomes. The consensus of this expert panel is summarized herein. Recommendations are based on currently available evidence from a comprehensive review of the literature and other pertinent data, along with the experience and expert opinion of the panelists. CONCLUSION Bleeding is a serious complication of the use of oral anticoagulants, and limited information is available to guide the reversal of warfarin or TSOAs in patients who are bleeding or are in need of an urgent invasive procedure. Use of a systematic approach to assessing and treating these patients based on available evidence and expert opinion can help avoid delays that could adversely affect patient outcomes.

Improving the role of intraventricular antimicrobial agents in the management of meningitis.

Purpose of reviewThe aim is to review the role of intraventricular administration of antimicrobial agents in the treatment of patients with bacterial and fungal meningitis. Recent findingsThis article discusses indications for intraventricular antimicrobial agents, choice of antibiotics, strategies to monitor pharmacokinetics of central nervous system compartments and unanswered issues for this management approach. SummaryIntraventricular administration of antimicrobials may be necessary in certain difficult- to-eradicate central nervous system infections. There is a significant need for clinical trials and management guidelines in this area.

Improving Door-to-Antibiotic Time in Severely Septic Emergency Department Patients

BACKGROUND The Surviving Sepsis Campaign (SSC) guidelines recommend that broad-spectrum antibiotics be administered to severely septic patients within 3 h of emergency department (ED) admission. Despite the well-established evidence regarding the benefit of timely antibiotics, adoption of the SSC recommendation into daily clinical practice has been slow and sporadic. STUDY OBJECTIVE To study the impact of storing broad-spectrum antibiotics in an ED automated dispensing cabinet (ADC) on the timeliness of antibiotic administration in severely septic patients presenting to the ED. METHODS Retrospective observational study of timeliness of antibiotic administration in severely septic patients presenting to a community ED before and after adding broad-spectrum antibiotics to the ED ADC. Data on 56 patients before and 54 patients after the intervention were analyzed. The primary outcome measure was mean order-to-antibiotic time. Secondary outcome measures included mean door-to-antibiotic time and percentage of patients receiving antibiotics within 3 h. RESULTS The final analysis was on 110 patients. Order-to-antibiotic administration time was reduced by 29 min post-intervention (55 min vs. 26 min, 95% confidence interval [CI] 12.5-45.19). Mean door-to-antibiotic time was also reduced by 70 min (167 min vs. 97 min, 95% CI 37.53-102.29). The percentage of severely septic patients receiving antibiotics within 3h of arrival to the ED increased from 65% pre-intervention to 93% post-intervention (95% CI 0.12-0.42). CONCLUSION Storing key antibiotics in an institutions severe sepsis antibiogram in the ED ADC can significantly reduce order-to-antibiotic times and increase the percentage of patients receiving antibiotics within the recommended 3 h of ED arrival.

‘Cooperative Sedation’: Optimizing Comfort while Maximizing Systemic and Neurological Function

Common indications for sedation in the intensive care unit (ICU) include patient comfort, management of agitation, pain, ventilator dysynchrony, and intracranial hypertension. Current trends in ICU care, however, have shifted towards sedation strategies that provide the minimally effective amount of sedation, to improve patient autonomy and preserve both the neurological exam and neurocognitive function.

Dexmedetomidine preserves attention/calculation when used for cooperative and short-term intensive care unit sedation

PURPOSE Differential effects on cognition were recently demonstrated between dexmedetomidine (DEX) and propofol (PRO) when used for cooperative sedation. Propofol was found to reduce cognition, whereas DEX improved cognition. To further discriminate these effects, we evaluated the effect of PRO vs DEX in selected areas of cognition. METHODS This is a post hoc analysis of the Acute Neurologic Intensive Care Unit Sedation Trial and an investigator-initiated, prospective, randomized, double-blinded, crossover study, comparing the effect of PRO and DEX on cognition measure by the Johns Hopkins Adapted Cognitive Exam (ACE). A linear model analysis accounting for within-patient correlation of measures was used to estimate differences in ACE subscales between drugs. RESULTS Propofol diminished adjusted scores on all ACE subscales (P < .05), whereas DEX improved adjusted scores selectively for attention/calculation (3.55; 95% confidence interval, 1.49-5.61; P < .01). The positive and significant difference in ACE scores between agents was present across subscales. CONCLUSIONS Our findings indicate that DEX improved ACE attention/calculation subscale in awake patients receiving cooperative sedation. This is in contrast to the deterioration in all mean ACE subscale scores observed using PRO, suggesting DEX preserved cognitive function with specific preservation of focus and attention and allows for greater cognition compared with PRO across all cognitive domains.

Guideline for Reversal of Antithrombotics in Intracranial Hemorrhage: Executive Summary. A Statement for Healthcare Professionals from the Neurocritical Care Society and the Society of Critical Care Medicine

PRELIMINARY REMARKSGuideline LimitationsPractice guidelines should be used in the context of individual patient characteristics and may be superseded by clinical judgment or patient preference. The use of practice guidelines does not guarantee specific outcome benefit but rather should serve as an e

Sedation and analgesia in critically ill neurologic patients.

Critically ill neurologic patients can pose a challenge when it comes to providing sedation and analgesia, primarily with the balance of maintaining sedation to provide patient comfort while still allowing a neurological examination. Determination of the optimal agent requires assessment and understanding of the underlying requirement for sedation: provision of analgesia, anxiolysis, or treatment of delirium. Pharmacological options exist that can affect individual or multiple underlying sedation requirements. Numerous evaluation tools exist to monitor the efficacy of sedation as well as help clinicians titrate agents to predefined goals; these tools allow the safe administration of drugs that can otherwise have serious adverse effects. Sedation regimens must ultimately be individualized to each patient to account for differences in pharmacokinetics and dynamics of the various agents, and this is particularly true in sedating neurologically injured patients. The agents frequently used to provide sedation and analgesia in the critically ill neurologic patient will be reviewed.