The neuro-ICU patient and electroencephalography paroxysms: if and when to treat.

PURPOSE OF REVIEW: To review recent clinical data and summarize actual recommendations for the management of electrographic seizures and status epilepticus in neuro-ICU patients. RECENT FINDINGS: Electrographic, 'nonconvulsive', seizures are frequent in neuro-ICU patients including traumatic brain injury, subarachnoid hemorrhage, intracerebral hemorrhage and hypoxic-ischemic encephalopathy. Continuous electroencephalography monitoring is thus of great potential utility. The impact of electrographic seizures on outcome however is not entirely established and it is also unclear what type of electroencephalography paroxysms require treatment and when and how exactly to treat them. Evidence from randomized studies is lacking and will not be available in the near future. Given robust animal and human evidence showing the potential negative impact of seizures on secondary cerebral damage and outcome, treatment of seizures appears reasonable, particularly if related to status epilepticus. On the contrary, over-aggressive antiepileptic therapy entails risks. The management of seizures should therefore be guided individually, based on the underlying cause, the severity of illness and patient comorbidities. SUMMARY: We provide a pragmatic approach for the management of electrographic seizures in neuro-ICU patients. International consensus guidelines on continuous electroencephalography monitoring and seizure therapy are needed and would represent the rationale for a future multicenter randomized trial.

ESPEN Guidelines on Enteral Nutrition: Intensive care.

Enteral nutrition (EN) via tube feeding is, today, the preferred way of feeding the critically ill patient and an important means of counteracting for the catabolic state induced by severe diseases. These guidelines are intended to give evidence-based recommendations for the use of EN in patients who have a complicated course during their ICU stay, focusing particularly on those who develop a severe inflammatory response, i.e. patients who have failure of at least one organ during their ICU stay. These guidelines were developed by an interdisciplinary expert group in accordance with officially accepted standards and are based on all relevant publications since 1985. They were discussed and accepted in a consensus conference. EN should be given to all ICU patients who are not expected to be taking a full oral diet within three days. It should have begun during the first 24h using a standard high-protein formula. During the acute and initial phases of critical illness an exogenous energy supply in excess of 20-25 kcal/kg BW/day should be avoided, whereas, during recovery, the aim should be to provide values of 25-30 total kcal/kg BW/day. Supplementary parenteral nutrition remains a reserve tool and should be given only to those patients who do not reach their target nutrient intake on EN alone. There is no general indication for immune-modulating formulae in patients with severe illness or sepsis and an APACHE II Score >15. Glutamine should be supplemented in patients suffering from burns or trauma.

Molecular epidemiology of Pseudomonas aeruginosa in intensive care units over a 10-year period (1998-2007).

Pseudomonas aeruginosa is one of the leading nosocomial pathogens in intensive care units (ICUs). The source of this microorganism can be either endogenous or exogenous. The proportion of cases as a result of transmission is still debated, and its elucidation is important for implementing appropriate control measures. To understand the relative importance of exogenous vs. endogenous sources of P. aeruginosa, molecular typing was performed on all available P. aeruginosa isolated from ICU clinical and environmental specimens in 1998, 2000, 2003, 2004 and 2007. Patient samples were classified according to their P. aeruginosa genotypes into three categories: (A) identical to isolate from faucet; (B) identical to at least one other patient sample and not found in faucet; and (C) unique genotype. Cases in categories A and B were considered as possibly exogenous, and cases in category C as possibly endogenous. A mean of 34 cases per 1000 admissions per year were found to be colonized or infected by P. aeruginosa. Higher levels of faucet contamination were correlated with a higher number of cases in category A. The number of cases in category B varied from 1.9 to 20 cases per 1000 admissions. This number exceeded 10/1000 admissions on three occasions and was correlated with an outbreak on one occasion. The number of cases considered as endogenous (category C) was stable and independent of the number of cases in categories A and B. The present study shows that repeated molecular typing can help identify variations in the epidemiology of P. aeruginosa in ICU patients and guide infection control measures.

Performance of noninvasive ventilation algorithms on ICU ventilators during pressure support: a clinical study.

To evaluate the impact of noninvasive ventilation (NIV) algorithms available on intensive care unit ventilators on the incidence of patient-ventilator asynchrony in patients receiving NIV for acute respiratory failure. Prospective multicenter randomized cross-over study. Intensive care units in three university hospitals. Patients consecutively admitted to the ICU and treated by NIV with an ICU ventilator were included. Airway pressure, flow and surface diaphragmatic electromyography were recorded continuously during two 30-min periods, with the NIV (NIV+) or without the NIV algorithm (NIV0). Asynchrony events, the asynchrony index (AI) and a specific asynchrony index influenced by leaks (AIleaks) were determined from tracing analysis. Sixty-five patients were included. With and without the NIV algorithm, respectively, auto-triggering was present in 14 (22%) and 10 (15%) patients, ineffective breaths in 15 (23%) and 5 (8%) (p = 0.004), late cycling in 11 (17%) and 5 (8%) (p = 0.003), premature cycling in 22 (34%) and 21 (32%), and double triggering in 3 (5%) and 6 (9%). The mean number of asynchronies influenced by leaks was significantly reduced by the NIV algorithm (p < 0.05). A significant correlation was found between the magnitude of leaks and AIleaks when the NIV algorithm was not activated (p = 0.03). The global AI remained unchanged, mainly because on some ventilators with the NIV algorithm premature cycling occurs. In acute respiratory failure, NIV algorithms provided by ICU ventilators can reduce the incidence of asynchronies because of leaks, thus confirming bench test results, but some of these algorithms can generate premature cycling.

Clinical Use of EEG in the ICU: Technical Setting.

Neurophysiology is an essential tool for clinicians dealing with patients in the intensive care unit. Because of consciousness disorders, clinical examination is frequently limited. In this setting, neurophysiological examination provides valuable information about seizure detection, treatment guidance, and neurological outcome. However, to acquire reliable signals, some technical precautions need to be known. EEG is prone to artifacts, and the intensive care unit environment is rich in artifact sources (electrical devices including mechanical ventilation, dialysis, and sedative medications, and frequent noise, etc.). This review will discuss and summarize the current technical guidelines for EEG acquisition and also some practical pitfalls specific for the intensive care unit.

Clinical neurophysiology in disorders of consciousness: brain function monitoring in the ICU and beyond.

Over the past two decades, electrophysiology has undergone unprecedented changes thanks to technical improvements, which simplify measurement and analysis and allow more compact data storage. This book covers in detail the spectrum of electrophysiology applications in patients with disorders of consciousness. Its content spans from clinical aspects of the management of subjects in the intensive care unit, including EEG, evoked potentials and related implications in terms of prognosis and patient management to research applications in subjects with ongoing consciousness impairment. While the first section provides up-to-date information for the interested clinician, the second part highlights the latest developments in this exciting field. The book comprehensively combines clinical and research information related to neurophysiology in disorder-of- consciousness patients, making it an easily accessible reference for neuro-ICU specialists, epileptologists and clinical neurophysiologists as well as researchers utilizing EEG and event-related potentials.

Perinatal care at the limit of viability between 22 and 26 completed weeks of gestation in Switzerland.

Perinatal care of pregnant women at high risk for preterm delivery and of preterm infants born at the limit of viability (22-26 completed weeks of gestation) requires a multidisciplinary approach by an experienced perinatal team. Limited precision in the determination of both gestational age and foetal weight, as well as biological variability may significantly affect the course of action chosen in individual cases. The decisions that must be taken with the pregnant women and on behalf of the preterm infant in this context are complex and have far-reaching consequences. When counselling pregnant women and their partners, neonatologists and obstetricians should provide them with comprehensive information in a sensitive and supportive way to build a basis of trust. The decisions are developed in a continuing dialogue between all parties involved (physicians, midwives, nursing staff and parents) with the principal aim to find solutions that are in the infant's and pregnant woman's best interest. Knowledge of current gestational age-specific mortality and morbidity rates and how they are modified by prenatally known prognostic factors (estimated foetal weight, sex, exposure or nonexposure to antenatal corticosteroids, single or multiple births) as well as the application of accepted ethical principles form the basis for responsible decision-making. Communication between all parties involved plays a central role. The members of the interdisciplinary working group suggest that the care of preterm infants with a gestational age between 22 0/7 and 23 6/7 weeks should generally be limited to palliative care. Obstetric interventions for foetal indications such as Caesarean section delivery are usually not indicated. In selected cases, for example, after 23 weeks of pregnancy have been completed and several of the above mentioned prenatally known prognostic factors are favourable or well informed parents insist on the initiation of life-sustaining therapies, active obstetric interventions for foetal indications and provisional intensive care of the neonate may be reasonable. In preterm infants with a gestational age between 24 0/7 and 24 6/7 weeks, it can be difficult to determine whether the burden of obstetric interventions and neonatal intensive care is justified given the limited chances of success of such a therapy. In such cases, the individual constellation of prenatally known factors which impact on prognosis can be helpful in the decision making process with the parents. In preterm infants with a gestational age between 25 0/7 and 25 6/7 weeks, foetal surveillance, obstetric interventions for foetal indications and neonatal intensive care measures are generally indicated. However, if several prenatally known prognostic factors are unfavourable and the parents agree, primary non-intervention and neonatal palliative care can be considered. All pregnant women with threatening preterm delivery or premature rupture of membranes at the limit of viability must be transferred to a perinatal centre with a level III neonatal intensive care unit no later than 23 0/7 weeks of gestation, unless emergency delivery is indicated. An experienced neonatology team should be involved in all deliveries that take place after 23 0/7 weeks of gestation to help to decide together with the parents if the initiation of intensive care measures appears to be appropriate or if preference should be given to palliative care (i.e., primary non-intervention). In doubtful situations, it can be reasonable to initiate intensive care and to admit the preterm infant to a neonatal intensive care unit (i.e., provisional intensive care). The infant's clinical evolution and additional discussions with the parents will help to clarify whether the life-sustaining therapies should be continued or withdrawn. Life support is continued as long as there is reasonable hope for survival and the infant's burden of intensive care is acceptable. If, on the other hand, the health care team and the parents have to recognise that in the light of a very poor prognosis the burden of the currently used therapies has become disproportionate, intensive care measures are no longer justified and other aspects of care (e.g., relief of pain and suffering) are the new priorities (i.e., redirection of care). If a decision is made to withhold or withdraw life-sustaining therapies, the health care team should focus on comfort care for the dying infant and support for the parents.

Pulse oximetry in pediatric intensive care: comparison with measured saturations and transcutaneous oxygen tension.

We evaluated a new pulse oximeter designed to monitor beat-to-beat arterial oxygen saturation (SaO2) and compared the monitored SaO2 with arterial samples measured by co-oximetry. In 40 critically ill children (112 data sets) with a mean age of 3.9 years (range 1 day to 19 years), SaO2 ranged from 57% to 100%, and PaO2 from 27 to 128 mm Hg, heart rates from 85 to 210 beats per minute, hematocrit from 20% to 67%, and fetal hemoglobin levels from 1.3% to 60%; peripheral temperatures varied between 26.5 degrees and 36.5 degrees C. Linear correlation analysis revealed a good agreement between simultaneous pulse oximeter values and both directly measured SaO2 (r = 0.95) and that calculated from measured arterial PaO2 (r = 0.95). The device detected several otherwise unrecognized drops in SaO2 but failed to function in four patients with poor peripheral perfusion secondary to low cardiac output. Simultaneous measurements with a tcPO2 electrode showed a similarly good correlation with PaO22 (r = 0.91), but the differences between the two measurements were much wider (mean 7.1 +/- 10.3 mm Hg, range -14 to +49 mm Hg) than the differences between pulse oximeter SaO2 and measured SaO2 (1.5% +/- 3.5%, range -7.5% to -9%) and were not predictable. We conclude that pulse oximetry is a reliable and accurate noninvasive device for measuring saturation, which because of its rapid response time may be an important advance in monitoring changes in oxygenation and guiding oxygen therapy.

Consensus summary statement of the International Multidisciplinary Consensus Conference on Multimodality Monitoring in Neurocritical Care : A statement for healthcare professionals from the Neurocritical Care Society and the European Society of Intensive Care Medicine.

Neurocritical care depends, in part, on careful patient monitoring but as yet there are little data on what processes are the most important to monitor, how these should be monitored, and whether monitoring these processes is cost-effective and impacts outcome. At the same time, bioinformatics is a rapidly emerging field in critical care but as yet there is little agreement or standardization on what information is important and how it should be displayed and analyzed. The Neurocritical Care Society in collaboration with the European Society of Intensive Care Medicine, the Society for Critical Care Medicine, and the Latin America Brain Injury Consortium organized an international, multidisciplinary consensus conference to begin to address these needs. International experts from neurosurgery, neurocritical care, neurology, critical care, neuroanesthesiology, nursing, pharmacy, and informatics were recruited on the basis of their research, publication record, and expertise. They undertook a systematic literature review to develop recommendations about specific topics on physiologic processes important to the care of patients with disorders that require neurocritical care. This review does not make recommendations about treatment, imaging, and intraoperative monitoring. A multidisciplinary jury, selected for their expertise in clinical investigation and development of practice guidelines, guided this process. The GRADE system was used to develop recommendations based on literature review, discussion, integrating the literature with the participants' collective experience, and critical review by an impartial jury. Emphasis was placed on the principle that recommendations should be based on both data quality and on trade-offs and translation into clinical practice. Strong consideration was given to providing pragmatic guidance and recommendations for bedside neuromonitoring, even in the absence of high quality data.

Zerebrale Probleme in der pädiatrischen Intensivmedizin [Cerebral problems in pediatric intensive care]

This paper presents a review of different methods enabling the monitoring of cerebral function in neonatal and paediatric intensive care. EEG, evoked potentials, conventional radiological studies, computerized tomography, ultrasound, intracranial pressure measurements, nuclear magnetic resonance, Doppler ultrasound, radioisotope studies, angiography, infra-red spectral analysis and last, but not least, clinical examination produce information regarding the neurological state of the patient which must be critically analysed in order to ensure optimal management of the case. Unfortunately, and in spite of impressive progress in non-invasive monitoring of the cerebral function, we are still forced to make important medical and ethical decisions without precise information about the neurological state of our patients.

Revue critique d'instruments pour evaluer la douleur chez les personnes cérébrolésées non communicantes aux soins intensifs [Critical review of instruments to assess pain in the non communicative brain injured persons in intensive care].

The purpose of this review is to critically appraise the pain assessment tools for non communicative persons in intensive care available in the literature and to determine their relevance for those with brain injury. Nursing and medical electronic databases were searched to identify pain tools, with a description of psychometric proprieties, in English and French. Seven of the ten tools were considered relevant and systematically evaluated according to the criteria and the indicators in the following five areas: conceptualisation, target population, feasibility and clinical utility, reliability and validity. Results indicate a number of well designed pain tools, but additional work is necessary to establish their accuracy and adequacy for the brain injured non communicative person in intensive care. Recommendations are made to choose the best tool for clinical practice and for research.

Analyse des épisodes de bactériémies chez les patients nécessitant une prise en charge aux soins intensifs

Introduction : Bacteremia are among the leading forms of severe infections requiring ICU management, and have been reported to be associated with important morbidity and mortality. Bloodstream infection (BSI) can be classified as hospital-acquired (HA), healthcare-associated (HCA) and community-acquired (CA). Each type has its own characteristics and outcome. Methods : We analyzed all consecutive episodes of bacteremia occurring in patients hospitalized in our mixed 32-bed ICU over a 12 month period (01.10.2009-30.09.2010). HA BSI were prospectively included in a multicenter study (EUROBACT). We adapted the case report form to analyze retrospectively all other cases of BSI. Chi-square tests were used for the categorical variables and ANOVA tests for the continuous variables. Results : Bacteremia occurred in 103 patients (120 bacteria) for an incidence-density of 49.3 episodes/1000 admissions. Among HA episodes, about one quarter of episodes was related to vascular accesses, including two thirds acquired outside of the ICU. Concerning HCA BSI, two-thirds originated from the urinary tract. In contrast, a respiratory origin was found in one third of CA episodes. Multiresistant microorganisms were more frequent in HA and HCA BSI. The overall mortality was 32%, as compared to 7.9% and 13.6% for the overall ICU and hospital mortality of other ICU patients over the same period, respectively. In a multivariate model, age (1.06 [1.02-1.11]), septic shock (3.11 [1.16-8.33]) and renal remplacement (7.81 [1.50, 14.93]) were significantly associated with a fatal outcome. Conclusion : Two-thirds of bacteremia documented among ICU patients were nosocomial and in contrast to those community-acquired, Gram-negatives represented the majority of them. However, CA bacteremia were associated with a higher rate of septic shock and death. The microbiological characteristics of HCA episodes were more similar to those HA, that is why it is important to individualize this category in order to adapt the antibiotics.