Status epilepticus: impact of therapeutic coma on outcome.

OBJECTIVES: Therapeutic coma is advocated in guidelines for management of refractory status epilepticus; this is, however, based on weak evidence. We here address the specific impact of therapeutic coma on status epilepticus outcome. DESIGN: Retrospective assessment of a prospectively collected cohort. SETTING: Academic hospital. PATIENTS: Consecutive adults with incident status epilepticus lasting greater than or equal to 30 minutes, admitted between 2006 and 2013. MEASUREMENTS AND MAIN RESULTS: We recorded prospectively demographics, clinical status epilepticus features, treatment, and outcome at discharge and retrospectively medical comorbidities, hospital stay, and infectious complications. Associations between potential predictors and clinical outcome were analyzed using multinomial logistic regressions. Of 467 patients with incident status epilepticus, 238 returned to baseline (51.1%), 162 had new disability (34.6%), and 67 died (14.3%); 50 subjects (10.7%) were managed with therapeutic coma. Therapeutic coma was associated with poorer outcome in the whole cohort (relative risk ratio for new disability, 6.86; 95% CI, 2.84-16.56; for mortality, 9.10; 95% CI, 3.17-26.16); the effect was more important in patients with complex partial compared with generalized convulsive or nonconvulsive status epilepticus in coma. Prevalence of infections was higher (odds ratio, 3.81; 95% CI, 1.66-8.75), and median hospital stay in patients discharged alive was longer (16 d [range, 2-240 d] vs 9 d [range, 1-57 d]; p < 0.001) in subjects managed with therapeutic coma. CONCLUSIONS: This study provides class III evidence that therapeutic coma is associated with poorer outcome after status epilepticus; furthermore, it portends higher infection rates and longer hospitalizations. These data suggest caution in the straightforward use of this approach, especially in patients with complex partial status epilepticus.

Glutamine and antioxidants in the critically ill patient: a post hoc analysis of a large-scale randomized trial.

BACKGROUND: The recent large randomized controlled trial of glutamine and antioxidant supplementation suggested that high-dose glutamine is associated with increased mortality in critically ill patients with multiorgan failure. The objectives of the present analyses were to reevaluate the effect of supplementation after controlling for baseline covariates and to identify potentially important subgroup effects. MATERIALS AND METHODS: This study was a post hoc analysis of a prospective factorial 2 × 2 randomized trial conducted in 40 intensive care units in North America and Europe. In total, 1223 mechanically ventilated adult patients with multiorgan failure were randomized to receive glutamine, antioxidants, both glutamine and antioxidants, or placebo administered separate from artificial nutrition. We compared each of the 3 active treatment arms (glutamine alone, antioxidants alone, and glutamine + antioxidants) with placebo on 28-day mortality. Post hoc, treatment effects were examined within subgroups defined by baseline patient characteristics. Logistic regression was used to estimate treatment effects within subgroups after adjustment for baseline covariates and to identify treatment-by-subgroup interactions (effect modification). RESULTS: The 28-day mortality rates in the placebo, glutamine, antioxidant, and combination arms were 25%, 32%, 29%, and 33%, respectively. After adjusting for prespecified baseline covariates, the adjusted odds ratio of 28-day mortality vs placebo was 1.5 (95% confidence interval, 1.0-2.1, P = .05), 1.2 (0.8-1.8, P = .40), and 1.4 (0.9-2.0, P = .09) for glutamine, antioxidant, and glutamine plus antioxidant arms, respectively. In the post hoc subgroup analysis, both glutamine and antioxidants appeared most harmful in patients with baseline renal dysfunction. No subgroups suggested reduced mortality with supplements. CONCLUSIONS: After adjustment for baseline covariates, early provision of high-dose glutamine administered separately from artificial nutrition was not beneficial and may be associated with increased mortality in critically ill patients with multiorgan failure. For both glutamine and antioxidants, the greatest potential for harm was observed in patients with multiorgan failure that included renal dysfunction upon study enrollment.

Updates in the perioperative and emergency management of non-vitamin K antagonist oral anticoagulants.

Perioperative management of patients treated with the non-vitamin K antagonist oral anticoagulants is an ongoing challenge. Due to the lack of good clinical studies involving adequate monitoring and reversal therapies, management requires knowledge and understanding of pharmacokinetics, renal function, drug interactions, and evaluation of the surgical bleeding risk. Consideration of the benefit of reversal of anticoagulation is important and, for some low risk bleeding procedures, it may be in the patient's interest to continue anticoagulation. In case of major intra-operative bleeding in patients likely to have therapeutic or supra-therapeutic levels of anticoagulation, specific reversal agents/antidotes would be of value but are currently lacking. As a consequence, a multimodal approach should be taken which includes the administration of 25 to 50 U/kg 4-factor prothrombin complex concentrates or 30 to 50 U/kg activated prothrombin complex concentrate (FEIBA®) in some life-threatening situations. Finally, further studies are needed to clarify the ideal therapeutic intervention.

New-onset refractory status epilepticus: Etiology, clinical features, and outcome.

OBJECTIVES: The aims of this study were to determine the etiology, clinical features, and predictors of outcome of new-onset refractory status epilepticus. METHODS: Retrospective review of patients with refractory status epilepticus without etiology identified within 48 hours of admission between January 1, 2008, and December 31, 2013, in 13 academic medical centers. The primary outcome measure was poor functional outcome at discharge (defined as a score >3 on the modified Rankin Scale). RESULTS: Of 130 cases, 67 (52%) remained cryptogenic. The most common identified etiologies were autoimmune (19%) and paraneoplastic (18%) encephalitis. Full data were available in 125 cases (62 cryptogenic). Poor outcome occurred in 77 of 125 cases (62%), and 28 (22%) died. Predictors of poor outcome included duration of status epilepticus, use of anesthetics, and medical complications. Among the 63 patients with available follow-up data (median 9 months), functional status improved in 36 (57%); 79% had good or fair outcome at last follow-up, but epilepsy developed in 37% with most survivors (92%) remaining on antiseizure medications. Immune therapies were used less frequently in cryptogenic cases, despite a comparable prevalence of inflammatory CSF changes. CONCLUSIONS: Autoimmune encephalitis is the most commonly identified cause of new-onset refractory status epilepticus, but half remain cryptogenic. Outcome at discharge is poor but improves during follow-up. Epilepsy develops in most cases. The role of anesthetics and immune therapies warrants further investigation.

EEG as an Indicator of Cerebral Functioning in Postanoxic Coma.

Postanoxic coma after cardiac arrest is one of the most serious acute cerebral conditions and a frequent cause of admission to critical care units. Given substantial improvement of outcome over the recent years, a reliable and timely assessment of clinical evolution and prognosis is essential in this context, but may be challenging. In addition to the classic neurologic examination, EEG is increasingly emerging as an important tool to assess cerebral functions noninvasively. Although targeted temperature management and related sedation may delay clinical assessment, EEG provides accurate prognostic information in the early phase of coma. Here, the most frequently encountered EEG patterns in postanoxic coma are summarized and their relations with outcome prediction are discussed. This article also addresses the influence of targeted temperature management on brain signals and the implication of the evolution of EEG patterns over time. Finally, the article ends with a view of the future prospects for EEG in postanoxic management and prognostication.

Le point sur la pratique infirmière avancée [Update on advanced practice nursing].

NlmCategory="UNASSIGNED">We report outcomes of a clinical audit examining criteria used in clinical practice to rationalize endotracheal tube (ETT) suction, and the extent these matched criteria in the Endotracheal Suction Assessment Tool(ESAT)©. A retrospective audit of patient notes (N = 292) and analyses of criteria documented by pediatric intensive care nurses to rationalize ETT suction were undertaken. The median number of documented respiratory and ventilation status criteria per ETT suction event that matched the ESAT© criteria was 2 [Interquartile Range (IQR) 1-6]. All criteria listed within the ESAT© were documented within the reviewed notes. A direct link was established between criteria used for current clinical practice of ETT suction and the ESAT©. The ESAT©, therefore, reflects documented clinical decision making and could be used as both a clinical and educational guide for inexperienced pediatric critical care nurses. Modification to the ESAT© requires "preparation for extubation" to be added.

Metabolic and nutritional support of critically ill patients: consensus and controversies.

The results of recent large-scale clinical trials have led us to review our understanding of the metabolic response to stress and the most appropriate means of managing nutrition in critically ill patients. This review presents an update in this field, identifying and discussing a number of areas for which consensus has been reached and others where controversy remains and presenting areas for future research. We discuss optimal calorie and protein intake, the incidence and management of re-feeding syndrome, the role of gastric residual volume monitoring, the place of supplemental parenteral nutrition when enteral feeding is deemed insufficient, the role of indirect calorimetry, and potential indications for several pharmaconutrients.

Effect of hyperoxia on the intestinal IgA secretory component in neonatal rats and on intestinal epithelial cells in vitro

Oxygen therapy is essential for the treatment of some neonatal critical care conditions but its extrapulmonary effects have not been adequately investigated. We therefore studied the effects of various oxygen concentrations on intestinal epithelial cell function. In order to assess the effects of hyperoxia on the intestinal immunological barrier, we studied two physiological changes in neonatal rats exposed to hyperoxia: the change in intestinal IgA secretory component (SC, an important component of SIgA) and changes in intestinal epithelial cells. Immunohistochemistry and Western blot were used to detect changes in the intestinal tissue SC of neonatal rats. To detect intestinal epithelial cell growth, cells were counted, and 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) and Giemsa staining were used to assess cell survival. Immunohistochemistry was used to determine SC expression. The expression of intestinal SC in neonatal rats under hyperoxic conditions was notably increased compared with rats inhaling room air (P < 0.01). In vitro, 40% O2 was beneficial for cell growth. However, 60% O2 and 90% O2 induced rapid cell death. Also, 40% O2 induced expression of SC by intestinal epithelial cells, whereas 60% O2did not; however, 90% O2 limited the ability of intestinal epithelial cells to express SC. In vivo and in vitro, moderate hyperoxia brought about increases in intestinal SC. This would be expected to bring about an increase in intestinal SIgA. High levels of SC and SIgA would serve to benefit hyperoxia-exposed individuals by helping to maintain optimal conditions in the intestinal tract.

Detection of acute cerebral hemorrhage in rabbits by magnetic induction

Acute cerebral hemorrhage (ACH) is an important clinical problem that is often monitored and studied with expensive devices such as computed tomography, magnetic resonance imaging, and positron emission tomography. These devices are not readily available in economically underdeveloped regions of the world, emergency departments, and emergency zones. We have developed a less expensive tool for non-contact monitoring of ACH. The system measures the magnetic induction phase shift (MIPS) between the electromagnetic signals on two coils. ACH was induced in 6 experimental rabbits and edema was induced in 4 control rabbits by stereotactic methods, and their intracranial pressure and heart rate were monitored for 1 h. Signals were continuously monitored for up to 1 h at an exciting frequency of 10.7 MHz. Autologous blood was administered to the experimental group, and saline to the control group (1 to 3 mL) by injection of 1-mL every 5 min. The results showed a significant increase in MIPS as a function of the injection volume, but the heart rate was stable. In the experimental (ACH) group, there was a statistically significant positive correlation of the intracranial pressure and MIPS. The change of MIPS was greater in the ACH group than in the control group. This high-sensitivity system could detect a 1-mL change in blood volume. The MIPS was significantly related to the intracranial pressure. This observation suggests that the method could be valuable for detecting early warning signs in emergency medicine and critical care units.

Potential virulence of Klebsiella sp. isolates from enteral diets

We aimed to evaluate the potential virulence of Klebsiellaisolates from enteral diets in hospitals, to support nosocomial infection control measures, especially among critical-care patients. Phenotypic determination of virulence factors, such as capsular expression on the external membrane, production of aerobactin siderophore, synthesis of capsular polysaccharide, hemolytic and phospholipase activity, and resistance to antibiotics, which are used therapeutically, were investigated in strains ofKlebsiella pneumoniae and K. oxytoca. Modular industrialized enteral diets (30 samples) as used in two public hospitals were analyzed, and Klebsiella isolates were obtained from six (20%) of them. The hypermucoviscous phenotype was observed in one of the K. pneumoniae isolates (6.7%). Capsular serotypes K1 to K6 were present, namely K5 and K4. Under the conditions of this study, no aerobactin production, hemolytic activity or lecithinase activity was observed in the isolates. All isolates were resistant to amoxicillin and ampicillin and sensitive to cefetamet, imipenem, chloramphenicol, gentamicin and sulfamethoxazole-trimethoprim. Most K. pneumoniae isolates (6/7, 85.7%) from hospital B presented with a higher frequency of resistance to the antibiotics tested in this study, and multiple resistance to at least four antibiotics (3/8; 37.5%) compared with isolates from Hospital A. The variations observed in the antibiotic resistance profiles allowed us to classify theKlebsiella isolates as eight antibiotypes. No production of broad-spectrum β-lactamases was observed among the isolates. Our data favor the hypothesis that Klebsiella isolates from enteral diets are potential pathogens for nosocomial infections.

TEHOHOITAJIEN KIVUN ARVIOINNIN OSAAMINEN – Tehohoitopotilaille kehitetyn kivunarviointimittarin käytön oppiminen video-opetuksen avulla.

Tehohoitopotilaan kivun arvioiminen on usein haastavaa, johtuen potilaan kyvyttömyydestä kommunikoida. Kivun arvioinnin avuksi onkin tästä syystä kehitetty käyttäytymiseen perustuvia kipumittareita. Tehohoitajilla on keskeinen asema kivun arvioinnissa, mutta tutkimusten perusteella tehohoitajien kivun arvioinnin osaaminen on puutteellista niin tietojen kuin taitojen osalta ja heillä on ennakkoasenteita kivun arviointiin liittyen. Tehohoitajien kouluttaminen kivun arviointiin liittyen on tärkeä keino tehohoitopotilaan kivun arvioinnin edistämisessä. Koulutuksen tulee kuitenkin olla helposti saatavilla, ottaen huomioon hoitotodellisuuden siihen tuomat haasteet. Tutkimuksen tarkoituksena oli arvioida video-opetuksen vaikutusta tehohoitajien tietoihin ja taitoihin tehohoitopotilaalle kehitetyn Critical-Care Pain Observation Tool (CPOT)-kipumittarin käyttöön liittyen, sekä kuvailla tehohoitajien kokemuksia video-opetuksesta oppimismenetelmänä. Yhdeltä teho-osastolta 48 tehohoitajaa katsoi tutkimusta varten kehitetyn CPOT-opetusvideon, jonka jälkeen he arvioivat kahden potilaan kipua CPOT-kipumittarilla, tutkijan tehdessä samanaikaisesti rinnakkaisarvioinnit potilaista. Arviointien jälkeen tehohoitajat tekivät tietotestin ja täyttivät CPOT-arviointilomakkeen. Tehohoitajien CPOT-kipumittarin käyttötaitoja arvioitiin tarkastelemalla tehohoitajien ja tutkijan tekemien kivunarviointien yhdenmukaisuutta interrater reliabiliteettilaskelmin. Kaksikymmentä tehohoitajaa haastateltiin heidän kokemuksista oppimismenetelmään liittyen. Haastattelut analysoitiin deduktiivisella temaattisella analyysillä. Tehohoitajat oppivat CPOT-kipumittarin käytön periaatteet ja kokivat oppineensa mittarin käytön, mutta interrater reliabiliteetti suhteessa tutkijan tekemiin kivun arviointeihin oli keskinkertainen. Video-opetus koettiin positiivisena, vaikkakin vuorovaikutuksellisuutta kaivattiin. Tutkimus osoitti video-opetuksen olevan käyttökelpoinen oppimismenetelmä CPOT-kipumittarin käytön periaatteiden oppimiseen, mutta parempien käyttötaitojen saavuttaminen vaatii lisäharjoittelua. Koska tehohoitajien subjektiivinen arvio käyttötaidoista ei välttämättä vastaa todellisia käyttötaitoja, oleellista olisi varmistaa myös objektiivisesti mittarin käyttötaidot koulutuksen jälkeen. Jatkossa tulisi tutkia käytäntöön soveltuvia keinoja varmistaa mittarin käyttötaidot, sekä teho-osastojen oppimiskulttuuria ja tehohoitajien motivaatiota ja asenteita työhön liittyvään oppimiseen.

Pantoprazole intraveineux aux soins intensifs pédiatriques: un modèle de pharmacocinétique de population

Objectifs : Définir les paramètres pharmacocinétiques du pantoprazole intraveineux en soins intensifs pédiatriques et déterminer l’influence qu’exercent sur ceux-ci les facteurs démographiques, le syndrome de réponse inflammatoire systémique (SRIS), la dysfonction hépatique et l’administration d’un inhibiteur du cytochrome (CYP) 2C19. Méthode : Cent cinquante-six concentrations plasmatiques de pantoprazole provenant d’une population de 20 patients (âgés de 10 jours à 16.4 ans) à risque ou atteints d’une hémorragie gastroduodénale de stress, ayant reçu des doses quotidiennes de pantoprazole de 19.9 à 140.6 mg/1.73m2, ont été analysées selon les méthodes non compartimentale et de modélisation non linéaire à effets mixtes. Résultats : Une clairance médiane (CL) de 0.14 L/h/kg, un volume apparent de distribution de 0.20 L/kg et une demi-vie d’élimination de 1.7 h ont été déterminés via l’approche non compartimentale. Le modèle populationnel à deux compartiments avec une infusion d’ordre zéro et une élimination d’ordre un représentait fidèlement la cinétique du pantoprazole. Le poids, le SRIS, la dysfonction hépatique et l’administration d’un inhibiteur du CYP2C19 constituaient les covariables significatives rendant compte de 75 % de la variabilité interindividuelle observée pour la CL. Seul le poids influençait significativement le volume central de distribution (Vc). Selon les estimations du modèle final, un enfant de cinq ans pesant 20 kg avait une CL de 5.28 L/h et un Vc de 2.22 L. La CL du pantoprazole augmentait selon l’âge et le poids tandis qu’elle diminuait respectivement de 62.3%, 65.8% et 50.5% en présence d’un SRIS, d’un inhibiteur du CYP2C19 ou d’une dysfonction hépatique. Conclusion : Ces résultats permettront de guider les cliniciens dans le choix d’une dose de charge et dans l’ajustement des posologies du pantoprazole en soins intensifs pédiatriques dépendamment de facteurs fréquemment rencontrés dans cette population.