Sybille Merceron

Prognostic value of electrographic postanoxic status epilepticus in comatose cardiac-arrest survivors in the therapeutic hypothermia era

BACKGROUND The independent prognostic significance of postanoxic status epilepticus (PSE) has not been evaluated prospectively since the introduction of therapeutic hypothermia. We studied 1-year functional outcomes and their determinants in comatose survivors of cardiac arrest (CA), with special attention to PSE. METHODS 106 comatose CA survivors admitted to the intensive care unit in 2005-2010 were included in a prospective observational study. The main outcome measure was a Cerebral Performance Category scale (CPC) of 1 or 2 (favorable outcome) 1 year after CA. RESULTS CA occurred out-of-hospital in 89 (84%) patients and was witnessed from onset in 94 (89%). Median times were 6 min (IQR, 0-11) from CA to first-responder arrival and 23 min (14-40) from collapse to return of spontaneous circulation. PSE was diagnosed in 33 (31%) patients at a median of 39 h (4-49) after CA. PSE was refractory in 24 (22%) cases and malignant in 19 (20%). After 1 year, 31 (29.3%) patients had favorable outcomes including 2 (6.44%) with PSE. Factors independently associated with poor outcome (CPC ≥ 3) were PSE (odds ratio [OR], 14.28; 95% confidence interval [95% CI], 2.77-50.0; P=0.001), time to restoration of spontaneous circulation (OR, 1.04/min; 95% CI, 1-1.07; P=0.035), and LOD score on day 1 (OR, 1.28/point; 95% CI, 1.08-1.54; P=0.003). CONCLUSION PSE strongly and independently predicts a poor outcome in comatose CA survivors receiving therapeutic hypothermia, but some patients with PSE survive with good functional outcomes. PSE alone is not sufficient to predict failure to awaken after CA in the era of therapeutic hypothermia.

What is the outcome of cancer patients admitted to the ICU after cardiac arrest? Results from a multicenter study

AIM Low survival rate was previously described after cardiac arrest in cancer patients and may challenge the appropriateness of intensive care unit (ICU) admission after return of spontaneous circulation (ROSC). Objectives of this study were to report outcome and characteristics of cancer patients admitted to the ICU after cardiac arrest. METHODS A retrospective chart review in seven medical ICUs in France, in 2002-2012. We studied consecutive patients with malignancies admitted after out-of-hospital cardiac arrest (OHCA) or in-hospital cardiac arrest (IHCA). RESULTS Of 133 included patients of whom 61% had solid tumors, 48 (36%) experienced OHCA and 85 (64%) IHCA. Cardiac arrest was related to the malignancy or its treatment in 47% of patients. Therapeutic hypothermia was used in 51 (41%) patients. The ICU mortality rate was 98/133 (74%). Main causes of ICU death were refractory shock or multiple organ failure (n = 64, 48%) and neurological injury (n = 27, 20%); 42 (32%) patients died in ICU after treatment-limitation decisions. Twenty-four (18%) patients were discharged alive from the hospital. Overall 6-month survival rate was 14% (18/133, 95% confidence interval, 8-21%). Survival rates at ICU discharge and after 6 months did not differ significantly across type of malignancy or between the OHCA and IHCA groups, and neither were they significantly different from those in matched controls who had cardiac arrest but no malignancy. CONCLUSIONS Even if low, the 6-month survival rate of 14% observed in cancer patients admitted to the ICU after cardiac arrest and ROSC may support the admission of these patients to the ICU and may warrant an initial full-code ICU management.

Influence of body mass index on the prognosis of patients successfully resuscitated from out-of-hospital cardiac arrest treated by therapeutic hypothermia☆☆☆

BACKGROUND Obesity prevalence has dramatically increased over recent years and is associated with cardiovascular diseases, but data are lacking on its prognostic impact in out-of-hospital cardiac arrest (OHCA) patients. METHODS Data of all consecutive OHCA patients admitted in two cardiac arrest centers from Paris and suburbs between 2005 and 2012 were prospectively collected. Patients treated by therapeutic hypothermia (TH) were included in the analysis. Logistic and Cox regression analyses were used to quantify the association between body mass index (BMI) at hospital admission and day-30 and 1-year mortality respectively. RESULTS 818 patients were included in the study (median age 60.9 [50.8-72.7] year, 70.2% male). Obese patients (BMI>30kgm-2) were older, more frequently male and evidenced more frequently cardiovascular risk factors than normally (18.5<BMI<25kgm-2) or overweight patients (25<BMI<30kgm-2). Post-resuscitation shock and therapeutic hypothermia failure were more frequent in obese patients. Overall mortality at day-30 and one-year was 63.8 and 67.2%, respectively. After multivariate adjustment, BMI>30kgm-2 was independently associated with day-30 mortality (Odds ratio [OR] in comparison with normally weight patients 2.45; 95% confidence interval [95%CI: 1.32-4.56; p<0.01]). Obesity was not associated with one-year mortality (Hazard ratio [HR] 0.99, 95%CI 0.21,4.67; p=0.99) while underweight was associated with one-year mortality in this subgroup of patients (Hazard ratio [HR] 3.94, 95%CI 1.11,14.01; p=0.03). CONCLUSION In the present study, obesity was independently associated with day-30 mortality in successfully resuscitated ICU TH OHCA patients. Further studies are needed to understand the mechanisms that underpin this finding.

Palliative vasoactive therapy in patients with septic shock.

We read with interest the article by Quill et al 1 in this issue of CHEST (see page 573 ) showing that the risk-adjusted propensity to withdraw life support in an ICU is directly associated with the standardized mortality ratio of the ICU. We believe that the reasons the end-of-life decision-making process is so variable deserve discussion. There may be two additional reasons to explain why so many discrepancies can be reported across centers and, in the same center, across apparently similar cases. First, most of the variables collected in databases are not able to capture each specific context (eg, the number of patients with do not resuscitate orders in the ICU, clinicians’ beliefs and burnout, as well as patients’ and relatives’ preferences and values). Second, in some groups of patients, the goals of care may be changing over time. Indeed, the literature is currently focused on guiding clinicians to provide patients with a full code management based on the best current evidence. However, an increasing number of patients are admitted to the ICU with treatment-limitation decisions but with curative intent. 2 , 3 These patients are receiving the least invasive management, with the hope that this will actually prolong their life. For instance, patients with acute respiratory failure who declined tracheal intubation may benefit from noninvasive mechanical ventilation, with good survival and preserved quality of life, without an increase of post-ICU burden. 4

A rare cause of status epilepticus

Dear Editor, Status epilepticus (SE) has a long list of potential causes. In about 15% of cases, no cause is identified [1]. We report on a patient who presented with convulsive SE due to concomitant reversible cerebral vasoconstriction syndrome (RCVS) and posterior reversible encephalopathy syndrome (PRES) in the early postpartal period. A 44-year-old nulliparous pregnant woman was admitted for labor induction at gestational week 41. Intravaginal prostaglandin gel was applied but emergency caesarean section was then performed because of recurrent fetal bradycardia. Her initial blood pressure was 110/70 mmHg. Spinal anesthesia was associated with maternal hypotension and bradycardia, which responded to ephedrine 60 mg and atropine 0.75 mg boluses followed by intravenous administration of 500 mL of crystalloids. Her blood pressure then reached up to 162/82 mmHg. She also received oxytocin 10 IU intravenously during caesarean section followed by a continuous infusion of 10 IU over the next 6 h. During the cesarean section, she experienced a thunderclap headache. Immediately after delivery, her blood pressure increased to 160/85 mmHg requiring nicardipine infusion. She experienced a first tonic–clonic seizure less than 3 h after the caesarean section, when her blood pressure was 110/60 mmHg. A second seizure occurred rapidly and stopped only after an intravenous bolus of 2 mg of midazolam and 2 g of magnesium over 30 min. A continuous 2 g/day magnesium infusion was started. A third seizure during transportation to the radiology suite required an additional intravenous bolus of 1 mg of midazolam. Figure 1a, d shows results of the first cerebral magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA). She was transferred to the ICU with a diagnosis of SE related to both RCVS and PRES. On ICU admission, blurred vision was the only abnormal clinical finding. Blood pressure was 120/62 mmHg. Routine electroencephalogram was normal. On day 2, her hemodynamic status was stable, her vision was normal, and her seizures were controlled. The continuous magnesium infusion was stopped. Intravenous administration of nimodipine (2 mg/h) was started to treat

Ongoing Abdominal Status Myoclonus in Postanoxic Coma

We present the video of a patient who presented massive and ongoing rhythmic abdominal myoclonus in postanoxic coma.

Duloxetine-related posterior reversible encephalopathy syndrome: A case report.

Background: Posterior reversible encephalopathy syndrome (PRES) has well-established links with several drugs. Whether a link also exists with serotonin–norepinephrine reuptake inhibitor such as duloxetine is unclear. Methods: We report on a patient who developed PRES with a coma and myoclonus related to hypertensive encephalopathy a few days after starting duloxetine treatment. Magnetic resonance imaging was performed and catecholamine metabolites assayed. Results: The patient achieved a full recovery after aggressive antihypertensive therapy and intravenous anticonvulsant therapy. Conclusions: The clinical history, blood and urinary catecholamine and serotonin levels, and response to treatment strongly suggest that PRES was induced by duloxetine. Duloxetine should be added to the list of causes of PRES.

The Clinical Picture of Severe Systemic Capillary-leak Syndrome Episodes Requiring Icu Admission

Objective: Systemic capillary-leak syndrome is a very rare cause of recurrent hypovolemic shock. Few data are available on its clinical manifestations, laboratory findings, and outcomes of those patients requiring ICU admission. This study was undertaken to describe the clinical pictures and ICU management of severe systemic capillary-leak syndrome episodes. Design, Setting, Patients: This multicenter retrospective analysis concerned patients entered in the European Clarkson’s disease (EurêClark) Registry and admitted to ICUs between May 1992 and February 2016. Measurements and Main Results: Fifty-nine attacks occurring in 37 patients (male-to-female sex ratio, 1.05; mean ± SD age, 51 ± 11.4 yr) were included. Among 34 patients (91.9%) with monoclonal immunoglobulin G gammopathy, 20 (58.8%) had kappa light chains. ICU-admission hemoglobin and proteinemia were respectively median (interquartile range) 20.2 g/dL (17.9–22 g/dL) and 50 g/L (36.5–58.5 g/L). IV immunoglobulins were infused (IV immunoglobulin) during 15 episodes (25.4%). A compartment syndrome developed during 12 episodes (20.3%). Eleven (18.6%) in-ICU deaths occurred. Bivariable analyses (the 37 patients’ last episodes) retained Sequential Organ-Failure Assessment score greater than 10 (odds ratio, 12.9 [95% CI, 1.2–140]; p = 0.04) and cumulated fluid-therapy volume greater than 10.7 L (odds ratio, 16.8 [1.6–180]; p = 0.02) as independent predictors of hospital mortality. Conclusions: We described the largest cohort of severe systemic capillary-leak syndrome flares requiring ICU admission. High-volume fluid therapy was independently associated with poorer outcomes. IV immunoglobulin use was not associated with improved survival; hence, their use should be considered prudently and needs further evaluation in future studies.

Assessment of cerebral blood flow changes in nonconvulsive status epilepticus in comatose patients: A pathophysiological transcranial Doppler study☆

PURPOSE We assessed the accuracy of transcranial Doppler (TCD) in helping to diagnose nonconvulsive status epilepticus (NCSE) in comatose patients admitted to the intensive care unit (ICU) for acute neurological disorders at high risk for NCSE. METHODS A 2-year prospective observational study in 38 consecutive patients requiring continuous electroencephalography (EEG) monitoring and intracranial pressure monitoring with TCD. RESULTS Of the 38 patients, 10 (26.3%) had NCSE by continuous EEG monitoring. Bilateral mean and maximal systolic and diastolic TCD velocities were significantly different between patients with and those without NCSE. Areas under the receiver-operating characteristic (ROC) curves of mean and maximal systolic velocities by TCD were 0.82 (95% CI, 0.64-1.00) and 0.79 (95% CI, 0.62-0.95) with cutoffs of 95 cm/s and 105 cm/s, respectively. Areas under the ROC curves of mean and maximal diastolic velocities were 0.76 (95% CI, 0.56-0.95) and 0.78 (95% CI, 0.60-0.96) with cutoffs of 31 cm/s and 40 cm/s, respectively. For none of the velocity parameters did the areas under the ROC curves differ significantly between the left and right sides. The best performance was obtained using mean systolic (SV) and a cutoff of 95 cm/s, which yielded a positive likelihood ratio of 3.8 and a negative likelihood ratio of 0.25. CONCLUSION Our preliminary results showed a significant association between increased TCD velocities and NCSE in comatose patients. However, the likelihood ratios suggested a limited role for TCD in helping to diagnose seizure activity. Further studies with larger samples of NCSE patients are warranted to determine the exact contribution of TCD for NCSE detection in comatose ICU patients.

Comparison of etomidate and sodium thiopental for induction during rapid sequence intubation in convulsive status epilepticus: A retrospective single-center study

PURPOSE Few outcome data are available about morbidity associated with endotracheal intubation modalities in critically ill patients with convulsive status epilepticus. We compared etomidate versus sodium thiopental for emergency rapid sequence intubation in patients with out-of-hospital convulsive status epilepticus. METHODS Patients admitted to our intensive care unit in 2006-2015 were studied retrospectively. The main outcome measure was seizure and/or status epilepticus recurrence within 12 h after rapid sequence intubation. RESULTS We included 97 patients (60% male; median age, 59 years [IQR, 48-70]). Median time from seizure onset to first antiepileptic drug was 60 min [IQR, 35-90]. Reasons for intubation were coma in 95 (98%), acute respiratory distress in 18 (19%), refractory convulsive status epilepticus in 9 (9%), and shock in 6 (6%) patients; 50 (52%) patients had more than one reason. The hypnotic drugs used were etomidate in 54 (56%) and sodium thiopental in 43 (44%) patients. Seizure and/or status epilepticus recurred in 13 (56%) patients in the etomidate group and 11 patients (44%) in the sodium thiopental group (adjusted common odds ratio [aOR], 0.98; 95%CI, 0.36-2.63; P = 0.97). The two groups were not significantly different for proportions of patients with hemodynamic instability after intubation (aOR, 0.60; 95%CI, 0.23-1.58; P = 0.30) or with difficult endotracheal intubation (OR, 1.28; 95% CI 0.23 to 7.21; P=0.77). CONCLUSIONS Our findings argue against a difference in seizure and/or status epilepticus recurrences rates between critically ill patients with convulsive status epilepticus given etomidate vs. sodium thiopental as the induction agent for emergency intubation.