Matthew Vibbert

Association between hyperoxia and mortality after stroke: a multicenter cohort study.

Objective:To test the hypothesis that hyperoxia was associated with higher in-hospital mortality in ventilated stroke patients admitted to the ICU. Design:Retrospective multicenter cohort study. Setting:Primary admissions of ventilated stroke patients with acute ischemic stroke, subarachnoid hemorrhage, and intracerebral hemorrhage who had arterial blood gases within 24 hours of admission to the ICU at 84 U.S. ICUs between 2003 and 2008. Patients were divided into three exposure groups: hyperoxia was defined as PaO2 ≥300 mm Hg (39.99 kPa), hypoxia as any PaO2<60 mm Hg (7.99 kPa) or PaO2/FiO2 ratio ⩽300, and normoxia, not defined as hyperoxia or hypoxia. The primary outcome was in-hospital mortality. Participants:Two thousand eight hundred ninety-four patients. Methods:Patients were divided into three exposure groups: hyperoxia was defined as PaO2 more than or equal to 300 mm Hg (39.99 kPa), hypoxia as any PaO2 less than 60 mm Hg (7.99 kPa) or PaO2/FIO2 ratio less than or equal to 300, and normoxia, not defined as hyperoxia or hypoxia. The primary outcome was in-hospital mortality. Interventions:Exposure to hyperoxia. Results:Over the 5-year period, we identified 554 ventilated patients with acute ischemic stroke (19%), 936 ventilated patients with subarachnoid hemorrhage (32%), and 1,404 ventilated patients with intracerebral hemorrhage (49%) of whom 1,084 (38%) were normoxic, 1,316 (46%) were hypoxic, and 450 (16%) were hyperoxic. Mortality was higher in the hyperoxia group as compared with normoxia (crude odds ratio 1.7 [95% CI 1.3-2.1]; p < 0.0001) and hypoxia groups (crude odds ratio, 1.3 [95% CI, 1.1–1.7]; p < 0.01). In a multivariable analysis adjusted for admission diagnosis, other potential confounders, the probability of being exposed to hyperoxia, and hospital-specific effects, exposure to hyperoxia was independently associated with in-hospital mortality (adjusted odds ratio, 1.2 [95% CI, 1.04–1.5]). Conclusion:In ventilated stroke patients admitted to the ICU, arterial hyperoxia was independently associated with in-hospital death as compared with either normoxia or hypoxia. These data underscore the need for studies of controlled reoxygenation in ventilated critically ill stroke populations. In the absence of results from clinical trials, unnecessary oxygen delivery should be avoided in ventilated stroke patients.

Significance of arterial hyperoxia and relationship with case fatality in traumatic brain injury: a multicentre cohort study

Objective In this retrospective multi-centre cohort study, we tested the hypothesis that hyperoxia was not associated with higher in-hospital case fatality in ventilated traumatic brain injury (TBI) patients admitted to the intensive care unit (ICU). Methods Admissions of ventilated TBI patients who had arterial blood gases within 24 h of admission to the ICU at 61 US hospitals between 2003 and 2008 were identified. Hyperoxia was defined as PaO2 ≥300 mm Hg (39.99 kPa), hypoxia as any PaO2 <60 mm Hg (7.99 kPa) or PaO2/FiO2 ratio ≤300 and normoxia, not defined as hyperoxia or hypoxia. The primary outcome was in-hospital case fatality. Results Over the 5-year period, we identified 1212 ventilated TBI patients, of whom 403 (33%) were normoxic, 553 (46%) were hypoxic and 256 (21%) were hyperoxic. The case-fatality was higher in the hypoxia group (224/553 [41%], crude OR 2.3, 95% CI 1.7-3.0, p<.0001) followed by hyperoxia (80/256 [32%], crude OR 1.5, 95% CI 1.1-2.5, p=.01) as compared to normoxia (87/403 [23%]). In a multivariate analysis adjusted for other potential confounders, the probability of being exposed to hyperoxia and hospital-specific characteristics, exposure to hyperoxia was independently associated with higher in-hospital case fatality adjusted OR 1.5, 95% CI 1.02-2.4, p=0.04. Conclusions In ventilated TBI patients admitted to the ICU, arterial hyperoxia was independently associated with higher in-hospital case fatality. In the absence of results from clinical trials, unnecessary oxygen delivery should be avoided in critically ill ventilated TBI patients.

Early neurological deterioration after subarachnoid haemorrhage: risk factors and impact on outcome

Background Early neurological deterioration occurs frequently after subarachnoid haemorrhage (SAH). The impact on hospital course and outcome remains poorly defined. Methods We identified risk factors for worsening on the Hunt–Hess grading scale within the first 24 h after admission in 609 consecutively admitted aneurysmal SAH patients. Admission risk factors and the impact of early worsening on outcome was evaluated using multivariable analysis adjusting for age, gender, admission clinical grade, admission year and procedure type. Outcome was evaluated at 12 months using the modified Rankin Scale (mRS). Results 211 patients worsened within the first 24 h of admission (35%). In a multivariate adjusted model, early worsening was associated with older age (OR 1.02, 95% CI 1.001 to 1.03; p=0.04), the presence of intracerebral haematoma on initial CT scan (OR 2.0, 95% CI 1.2 to 3.5; p=0.01) and higher SAH and intraventricular haemorrhage sum scores (OR 1.05, 95% CI 1.03 to 1.08 and 1.1, 95% CI 1.01 to 1.2; p<0.001 and 0.03, respectively). Early worsening was associated with more hospital complications and prolonged length of hospital stay and was an independent predictor of death (OR 12.1, 95% CI 5.7 to 26.1; p<0.001) and death or moderate to severe disability (mRS 4–6, OR 8.4, 95% CI 4.9 to 14.5; p=0.01) at 1 year. Conclusions Early worsening after SAH occurs in 35% of patients, is predicted by clot burden and is associated with mortality and poor functional outcome at 1 year.

Tight glycemic control reduces infection and improves neurological outcome in critically ill neurosurgical and neurological patients.

BACKGROUND Tight glycemic control (TGC) may improve outcomes in hyperglycemic neurosurgical patients. The adoption of TGC has been limited by a lack of adequate data on optimal insulin delivery protocols and serum glucose concentration and by concerns about the risks of hypoglycemia. OBJECTIVE This study was designed as a meta-analysis of outcomes to compare intensive insulin therapy and TGC with conventional insulin therapy and conventional glucose control. The secondary objective was to determine retrospectively whether a particular glucose range correlates with better outcomes. METHODS Using electronic databases, we retrieved all English language studies published between January 1997 and December 2010 reporting outcomes in neurological and neurosurgical patients as a function of glucose levels and insulin protocols. We conducted a meta-analysis around 4 outcome measures: infection, neurological outcome, hypoglycemia, and mortality. Effect sizes in each study were individually correlated with target intensive insulin therapy glucose levels. Individual studies were assessed for quality by use of the Jadad scale. RESULTS Nine studies reporting on 1459 patients met the inclusion criteria. Five were restricted to neurosurgical patients. Four included neurological patients. Compared with conventional glucose control, TGC lowered infection rates (odds ratio, 0.59; 95% confidence interval, 0.47-0.76; P < .001) and yielded better neurological outcomes (odds ratio, 1.72; 95% confidence interval, 1.36-2.16; P < .001). Beneficial effects increased as glucose limits tightened and study quality improved (R > 0.9 for both). TGC resulted in a higher rate of hypoglycemic events (odds ratio, 8.04; 95% confidence interval, 4.85-13.31; P < .001). Mortality was not affected. CONCLUSION TGC reduced infection risk and improved neurological outcome despite increased rates of hypoglycemic events. An optimal target for serum glucose concentrations could not be determined.

Hospital mortality in primary admissions of septic patients with status epilepticus in the United States

Objective:To determine the prevalence of status epilepticus, associated factors, and relationship with in-hospital mortality in primary admissions of septic patients in the United States. Design:Cross-sectional study. Setting:Primary admissions of adult patients more than 18 years old with a diagnosis of sepsis and status epilepticus from 1988 to 2008 identified through the Nationwide Inpatient Sample. Participants:A total of 7,669,125 primary admissions of patients with sepsis. Interventions:None. Results:During the 21-year study period, the prevalence of status epilepticus in primary admissions of septic patients increased from 0.1% in 1988 to 0.2% in 2008 (p < 0.001). Status epilepticus was also more common among later years, younger admissions, female gender, Black race, rural hospital admissions, and in those patients with organ dysfunctions. Mortality of primary sepsis admissions decreased from 20% in 1988 to 18% in 2008 (p < 0.001). Mortality in status epilepticus during sepsis decreased from 43% in 1988 to 28% in 2008. In-hospital mortality after admissions for sepsis was associated with status epilepticus, older age, and Black and Native American/Eskimo race; patients admitted to a rural or urban private hospitals; and patients with organ dysfunctions. Conclusion:Our analysis demonstrates that status epilepticus after admission for sepsis in the United States was rare. Despite an overall significant reduction in mortality after admission for sepsis, status epilepticus carried a higher risk of death. More aggressive electrophysiological monitoring and a high level of suspicion for the diagnosis of status epilepticus may be indicated in those patients with central nervous system organ dysfunction after sepsis.

The Prevalence and Impact of Mortality of the Acute Respiratory Distress Syndrome on Admissions of Patients With Ischemic Stroke in the United States

Purpose: To determine the epidemiology of the acute respiratory distress syndrome (ARDS) and impact on in-hospital mortality in admissions of patients with acute ischemic stroke (AIS) in the United States. Methods: Retrospective cohort study of admissions with a diagnosis of AIS and ARDS from 1994 to 2008 identified through the Nationwide Inpatient Sample. Results: During the 15-year study period, we found 55 58 091 admissions of patients with AIS. The prevalence of ARDS in admissions of patients with AIS increased from 3% in 1994 to 4% in 2008 (P < .001). The ARDS was more common among younger men, nonwhites, and associated with history of congestive heart failure, hypertension, chronic obstructive pulmonary disease, renal failure, chronic liver disease, systemic tissue plasminogen activator, craniotomy, angioplasty or stent, sepsis, and multiorgan failures. Mortality due to AIS and ARDS decreased from 8% in 1994 to 6% in 2008 (P < .001) and 55% in 1994 to 45% in 2008 (P < .001), respectively. The ARDS in AIS increased in-hospital mortality (odds ratio, 14; 95% confidence interval, 13.5-14.3). A significantly higher length of stay was seen in admissions of patients with AIS having ARDS. Conclusion: Our analysis demonstrates that ARDS is rare after AIS. Despite an overall significant reduction in mortality after AIS, ARDS carries a higher risk of death in this patient population.

Neurological Critical Care Services’ Influence Following Large Hemispheric Infarction and Their Impact on Resource Utilization

Introduction: Acute ischemic stroke (AIS) is the fourth leading cause of death in the US. Numerous studies have demonstrated the use of comprehensive stroke units and neurological intensive care units (NICU) in improving outcomes after stroke. We hypothesized that an expanded neurocritical care (NCC) service would decrease resource utilization in patients with LHI. Methods: Retrospective data from consecutive admissions of large hemispheric infarction (LHI) patients requiring mechanical ventilation were acquired from the hospital medical records. Between 2011-2013, there were 187 consecutive patients admitted to the Jefferson Hospital for Neuroscience (Philadelphia, USA) with AIS and acute respiratory failure. Our intention was to determine the number of tracheostomies done over time. The primary outcome measure was the number of tracheostomies over time. Secondary outcomes were, ventilator-free days (Vfd), total hospital charges, intensive care unit length of stay (ICU-LOS), and total hospital length of stay (hospital-LOS), including ICU LOS. Hospital charges were log-transformed to meet assumptions of normality and homoscedasticity of residual variance terms. Generalized Linear Models were used and ORs and 95% CIs calculated. The significance level was set at α = 0.05. Results: Of the 73 patients included in this analysis, 33% required a tracheostomy. There was a decrease in the number of tracheostomies undertaken since 2011. (OR 0.8; 95% CI 0.6-0.9: p=0.02). Lower Vfd were seen in tracheostomized patients (OR 0.11; 95%CI 0.1-0.26: p<0.0001). The log-hospital charges decreased over time but not significantly (OR 0.9; 95%CI 0.78-1.07: p=0.2) and (OR 0.99; 95%CI 0.85-1.16: p=0.8) from 2012 to 2013 respectively. The ICU-LOS at 23 days vs 10 days (p=0.01) and hospital-LOS at 33 days vs 11 days (p=0.008) were higher in tracheostomized patients. Conclusion: The data suggest that in LHI-patients requiring mechanical ventilation, a dedicated NCC service reduces the overall need for tracheostomy, increases Vfd, and decreases ICU and hospital-LOS. Keywors: neurocritical care, neurological critical care, large hemispheric infarct, malignant stroke, extubation, tracheostomy, resource utilization Received: 18 June 2017 / Accepted: 12 December 2017 * Correspondence to: Syed Omar Shah, Department of Neurological Surgery, Thomas Jefferson University and Jefferson College of Medicine. 909 Walnut Street, 3rd Floor, Philadelphia, PA 19107. E-Mail:syed.o.shah@jefferson.edu DOI: 10.2478/jccm-2018-0001 6 • The Journal of Critical Care Medicine 2018;4(1) Available online at: www.jccm.ro

758: CAN PROCALCITONIN DIFFERENTIATE BETWEEN CENTRAL AND INFECTIOUS FEVER IN PATIENTS WITH ICH

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) median dose of 4FPCC in the SD and HD groups was 25 units/kg and 50 units/ kg, respectively. The repeat INR post 4FPCC in the SD was 1.2 [1.2–1.3] and 1.1 [1.1–1.2] in the HD 4FPCC group (p=0.19). No difference was observed in achieving an INR of 1.3 or less when comparing the HD and SD 4FPCC groups (77 vs 82%, p=0.72). Hematoma expansion occurred equally in both groups at 13% (p=0.96). Lastly, in the HD group, there was one thrombotic event reported vs none in the SD group. Conclusions: Administering SD or HD 4FPCC to patients with WICH effectively lowered the INR to 1.3 or less in most patients. HD 4FPCC was not associated with a significant increase in thrombotic events. Further studies are warranted to evaluate the impact of HD 4FPCC on functional outcomes and mortality.

445: SAFETY AND EFFICACY OF A SHORTENED FASTING TIME FOR MECHANICALLY VENTILATED PATIENTS

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) in 2015. Results: The study population included 55 patients (83% new onset) with a median age of 55 months (105-188) and weight of 44.5 kg (22.5-56). On admission, patients had a median venous pH of 7.06 (6.96-7.15), mean bicarbonate of 5 mmol/L (±2.1), anion gap (AG) of 25 (±5.7), and hemoglobin A1c of 12.7 % (±2.1). During DKA management, patients received a median chloride load (CL) of 606.8 mEq (357.8-767.7). It took a median of 8 hours (4-8) for the AG to normalize and an additional 8 hours (3-14) for overall acidosis to resolve. There was a significant positive correlation between CL from IVF and duration of overall acidosis (rs = 0.391, p<0.01) and CL and duration of acidosis after the AG normalized (rs=0.318, p=0.01). After adjusting for age, initial pH and hemoglobin A1c, the chloride load from 1L of 0.9% normal saline was associated with an increased duration of acidosis of 4.6 hours (95%CI 2.5-6.5; p<0.01). After adjusting for age and initial pH, having a serum chloride level over 120 mEq/dL increased the hospital length of stay by 0.33 days (95%CI 0.14-1.54; p=0.02). Conclusions: The iatrogenic chloride load from DKA management is associated with prolongation of acidosis well after the anion gap normalizes and elevated serum chloride prolongs length of stay. Further research to evaluate the potential for shortening of the duration of acidosis and overall length of stay in children with DKA by changing the chloride content of IV fluids administered needed.