Teresa May

Initial bispectral index may identify patients who will awaken during therapeutic hypothermia after cardiac arrest: A retrospective pilot study ☆

AIM Patients sustain a range of neurologic injuries after cardiac arrest, and determining which patients should be treated with therapeutic hypothermia (TH) is complex, often confounded by sedation and neuromuscular blockade (NMB). We evaluated bispectral index (BIS) monitoring as a tool to identify adult patients that awakened during therapeutic hypothermia. METHODS Review of prospectively collected registry data, with retrospective chart review of patient descriptions during hypothermia. Data are presented as median (interquartile range). RESULTS 7 of 309 patients (2.2%) treated with TH over 6 years awoke (followed commands) prior to completing hypothermia. Median age was 58 (54-66) years; 71% were male, cardiac arrest was witnessed in 6 (86%) and out-of-hospital in 6 (86%), and 4 patients (57%) were transferred from another hospital. 5 patients (71%) had an initial rhythm of ventricular tachycardia or fibrillation, time to return of spontaneous circulation was 17 (12-23)min. The BIS value after first NMB dose during TH was 63, 45, 43, 52, 62, 54, and 42 (median 52, IQR 44-58, 95% confidence interval 46-58). The median BIS value in the remaining data set (n=302) was 18 (6-36), p<0.001, and only 6% of BIS1 values were >46. CONCLUSION Patients who awakened early had higher BIS values after the first dose of NMB. Processed EEG values after cardiac arrest may provide additional information that could assist with determining best treatment.

Association of the Bedside Shivering Assessment Scale and derived EMG power during therapeutic hypothermia in survivors of cardiac arrest

INTRODUCTION Shivering during therapeutic hypothermia (TH) after cardiac arrest (CA) is common, but the optimal means of detection and appropriate threshold for treatment are not established. In an effort to develop a quantitative, continuous tool to measure shivering, we hypothesized that continuous derived electromyography (dEMG) power detected by the Aspect A2000 or VISTA monitor would correlate with the intermittent Bedside Shivering Assessment Scale (BSAS) performed by nurses. METHODS Among 38 patients treated with TH after CA, 853 hourly BSAS measurements were compared to dEMG power measured every minute by a frontal surface electrode. Patients received intermittent vecuronium by protocol to treat clinically recognized shivering (BSAS>0). Mean dEMG power in decibels (dB) was determined for the hour preceding each BSAS measurement. dEMG and BSAS were compared using ANOVA. RESULTS The median dEMG power for a BSAS score of 0 (no shivering) was 27 dB (IQR 26-31 dB), BSAS 1 was 30.5 dB (IQR 28-35 dB), BSAS 2 was 34 dB (IQR 30-38 dB), and BSAS 3 was 34.5 dB (IQR 32-44.25). The dEMG for BSAS≥1 (shivering) was statistically different from BSAS 0 (p<0.0001). dEMG and BSAS correlated moderately (r=0.66, p<0.001). CONCLUSION dEMG power measured from the forehead with the Aspect A2000 or VISTA monitor during therapeutic hypothermia correlated with the Bedside Shivering Assessment Scale. Given its continuous trending of dEMG power, the A2000 or VISTA may be a useful research and clinical tool for objectively monitoring shivering.

Feasibility of bispectral index monitoring to guide early post-resuscitation cardiac arrest triage ☆ ☆☆

INTRODUCTION Triage after resuscitation from cardiac arrest is hindered by reliable early estimation of brain injury. We evaluated the performance of a triage model based on early bispectral index (BIS) findings and cardiac risk classes. METHODS Retrospective evaluation of serial patients resuscitated from cardiac arrest, unable to follow commands, and undergoing hypothermia. Patients were assigned to a cardiac risk group: STEMI, VT/VF shock, VT/VF no shock, or PEA/asystole, and to a neurological dysfunction group, based on the BIS score following first neuromuscular blockade (BISi), and classified as BISi>20, BISi 10-20, or BISi<10. Cause of death was described as neurological or circulatory. RESULTS BISi in 171 patients was measured at 267(±177)min after resuscitation and 35(±1.7)°C. BISi<10 suffered 82% neurological-cause and 91% overall mortality, BISi 10-20 35% neurological and 55% overall mortality, and BISi>20 12% neurological and 36% overall mortality. 33 patients presented with STEMI, 15 VT/VF-shock, 41 VT/VF-no shock, and 80 PEA/asystole. Among BISi>20 patients, 75% with STEMI underwent urgent cardiac catheterization (cath) and 94% had good outcome. When BISi>20 with VT/VF and shock, urgent cath was infrequent (33%), and 4 deaths (44%) were uniformly of circulatory etiology. Of 56 VT/VF patients without STEMI, 24 were BISi>20 but did not undergo urgent cath - 5(20.8%) of these had circulatory-etiology death. Circulatory-etiology death also occurred in 26.5% BIS>20 patients with PEA/asystole. When BISi<10, a neurological etiology death dominated independent of cardiac risk group. CONCLUSIONS Neurocardiac triage based on very early processed EEG (BIS) is feasible, and may identify patients appropriate for individualized post-resuscitation care. This and other triage models warrant further study.

Correlation of bivalirudin dose with creatinine clearance during treatment of heparin-induced thrombocytopenia.

Study Objectives. To evaluate steady‐state bivalirudin dosing requirements in patients with a wide range of kidney function who were being treated for heparin‐induced thrombocytopenia (HIT)‐related disorders.

Analgesia, sedation, and neuromuscular blockade during targeted temperature management after cardiac arrest

The approach to sedation, analgesia, and neuromuscular blockade during targeted temperature management (TTM) remains largely unstudied, forcing clinicians to adapt previous research from other patient environments. During TTM, very little data guide drug selection, doses, and specific therapeutic goals. Sedation should be deep enough to prevent awareness during neuromuscular blockade, but titration is complex as metabolism and clearance are delayed for almost all drugs during hypothermia. Deeper sedation is associated with prolonged intensive care unit (ICU) and ventilator therapy, increased delirium and infection, and delayed wakening which can confound early critical neurological assessments, potentially resulting in erroneous prognostication and inappropriate withdrawal of life support. We review the potential therapeutic goals for sedation, analgesia, and neuromuscular blockade during TTM; the adverse events associated with that treatment; data suggesting that TTM and organ dysfunction impair drug metabolism; and controversies and potential benefits of specific monitoring. We also highlight the areas needing better research to guide our therapy.

Valproate Protein Binding Is Highly Variable in ICU Patients and Not Predicted by Total Serum Concentrations: A Case Series and Literature Review

The free fraction of valproate (the pharmacologically active moiety, normally 5–10%) may vary significantly in critically ill patients, but this topic is understudied, with only four prior intensive care unit (ICU) case reports. The objective of this study was to evaluate the range of valproate plasma protein binding in ICU patients.

The Implementation of Targeted Temperature Management: An Evidence-Based Guideline from the Neurocritical Care Society

BackgroundTargeted temperature management (TTM) is often used in neurocritical care to minimize secondary neurologic injury and improve outcomes. TTM encompasses therapeutic hypothermia, controlled normothermia, and treatment of fever. TTM is best supported by evidence from neonatal hypoxic-ischemic encephalopathy and out-of-hospital cardiac arrest, although it has also been explored in ischemic stroke, traumatic brain injury, and intracranial hemorrhage patients. Critical care clinicians using TTM must select appropriate cooling techniques, provide a reasonable rate of cooling, manage shivering, and ensure adequate patient monitoring among other challenges.MethodsThe Neurocritical Care Society recruited experts in neurocritical care, nursing, and pharmacotherapy to form a writing Committee in 2015. The group generated a set of 16 clinical questions relevant to TTM using the PICO format. With the assistance of a research librarian, the Committee undertook a comprehensive literature search with no back date through November 2016 with additional references up to March 2017.ResultsThe Committee utilized GRADE methodology to adjudicate the quality of evidence as high, moderate, low, or very low based on their confidence that the estimate of effect approximated the true effect. They generated recommendations regarding the implementation of TTM based on this systematic review only after considering the quality of evidence, relative risks and benefits, patient values and preferences, and resource allocation.ConclusionThis guideline is intended for neurocritical care clinicians who have chosen to use TTM in patient care; it is not meant to provide guidance regarding the clinical indications for TTM itself. While there are areas of TTM practice where clear evidence guides strong recommendations, many of the recommendations are conditional, and must be contextualized to individual patient and system needs.

Unexpected Rapid Improvement and Neurogenic Stunned Myocardium in a Patient With Acute Motor Axonal Neuropathy: A Case Report and Literature Review.

Acute Motor Axonal Neuropathy-type Guillain-Barré Syndrome (GBS) is a subset of GBS with either a rapidly improving or protracted course that was first described in China. We describe a 27-year-old previously healthy woman with weakness that progressed to complete tetraplegia and areflexia within 2 weeks after an upper respiratory illness. A lumbar puncture performed 4 days after onset of neurologic symptoms was inconclusive for GBS, and electromyography revealed complete motor axonal neuropathy. The patient had Mycoplasma pneumoniae in her nares and blood, and several antiganglioside antibodies in her blood. She was treated with plasmapheresis, antibiotics, and physical therapy. Her motor function and reflexes improved rapidly with treatment, and she was able to ambulate within 3 weeks. She also experienced cardiomyopathy, which improved with plasmapheresis. We report a rare case of Mycoplasma pneumonia-associated acute motor axonal neuropathy-type GBS presenting with complete tetraplegia, areflexia, and neurogenic stunned myocardium that rapidly improved with plasmapheresis.

Approaches to community consultation in exception from informed consent: Analysis of scope, efficiency, and cost at two centers

OBJECTIVES Community consultation (CC) is fundamental to the Exception from Informed Consent (EFIC) process for emergency research, designed to inform and receive feedback from the target study population about potential risks and benefits. To better understand the effectiveness of different techniques for CC, we evaluated EFIC processes at two centers participating in a trial of early cardiac catheterization following out-of-hospital cardiac arrest. METHODS We studied the Institutional Review Board-approved CC activities at Maine Medical Center (MMC) and University of Arizona (AZ) in support of NCT02387398. In Maine, the public was consulted by survey at a professional basketball game and in the emergency department waiting room (in-person group), by multimedia direction to an online website (online group), and by mail (mailing group). Arizona respondents were either approached at a county fair (in-person group) or were directed to an online survey (online group) via social media advertising. RESULTS Among 2185 survey respondents, approval rates were high for community involvement and personal participation without individual consent. Community consultation using in-person, online, and mailed surveys offered slightly different approval rates, and the rate of responses by modality differed by age and education level but not ethnicity. Print advertising was the least cost effective at

Long-term risk of seizures among cardiac arrest survivors

442 per completed survey. CONCLUSIONS Canvassing at public events was the most efficient mode of performing CC, with approval rates similar to mailings, online surveys, and canvassing in other locations. Print advertisements in local papers had a low yield and cost more than other approaches.