Increased variability of mean arterial pressure is associated with increased risk of short-term mortality in intensive care unit: A retrospective study

For stroke patients, what is the protocol that will prevent this increased mortality? Your hospital probably should have been working on solving this problem for decades.

Increased variability of mean arterial pressure is associated with increased risk of short-term mortality in intensive care unit: A retrospective study

Jia Yao^1†, Dandan Liu^1†, Weifeng Huang², Yuexin Fang¹, Yifan Yang¹, Yingchuan Li², Pengyuan Liu^3* and Xiaoqing Pan^1*

• ¹Department of Mathematics, Shanghai Normal University, Shanghai, China
• ²Department of Critical Care Medicine, Shanghai Sixth People's Hospital, Shanghai Jiaotong University, Shanghai, China
• ³Department of Respiratory Medicine, Sir Run Run Shaw Hospital and Institute of Translational Medicine, Zhejiang University School of Medicine, Hangzhou, China

Background: In intensive care unit (ICU), what thresholds of MAP variability are effective in distinguishing low- and high-risk patients for short-term mortality (in-hospital and 28-day) remains unclear.

Methods: Fifteen thousand five hundred sixty adult subjects admitted to ICU at Beth Israel Deaconess Medical Center (Boston, USA) between 2001 and 2012 were included in this retrospective study from MIMIC-III database. MAP within the first 24 h after admission were collected. Quantiles of MAP variability from 10% to 90% with 10% increasement each were considered to divide study participants into two groups, either having coefficients of variation of MAP greater or less than the given threshold. The threshold of MAP variability was identified by maximizing the odds ratio associated with increased risk of short-term mortality (in-hospital and 28-day). Logistic regression and Cox regression models were further applied to evaluate the association between increased variability of MAP and short-term mortality (in-hospital and 28-day).

Results: 90% quantile of MAP variability was determined as the threshold generating the largest odds ratio associated with the increased risk of short-term mortality. Increased MAP variability, especially over 90% of MAP variability, was associated with increased risk of in-hospital mortality (odds ratio: 2.351, 95% CI: 2.064–2.673), and 28-day mortality (hazard ratio: 2.064, 95% CI: 1.820–2.337).

Conclusion: Increased MAP variability, especially over 90% of MAP variability, is associated with short-term mortality. Our proposed threshold of MAP variability may aid in the early identification of critically ill patients with a high risk of mortality.

Introduction

Blood pressure (BP) is a fundamental physiological variable monitored in intensive care medicine. The variation of BP arises naturally because BP is influenced by biological, behavioral, emotional, and environmental factors and their complex interactions (1–5). The increased variation of BP has been reported to be associated with various organ injuries, high risks of cardiovascular and cerebrovascular events, and mortality, as it reflects sympathetic activation and impairment of baroceptive reflexes (6–9).

BP variation is a continuous phenotype, mainly divided into short-term (minutes to hours) and long-term (days and months) variation. Both short- and long-term blood pressure variability independently increased the risk of death in hypertensive patients as well as in patients with diabetes and chronic kidney disease (10–12). Critically ill patients are often accompanied by high incidence of anxiety, delirium, sleep deprivation, central, and autonomic dysregulation during intensive care unit (ICU) (13), which may contribute to increased BP variation, especially short-term BP variation. Increased short-term BP variability is known to adversely affect patients with chronic diseases, however the extent to which increased short-term BP variability increases the risk of in-hospital mortality in critically ill patients in the ICU remains to be further investigated.

Circadian rhythm of mean arterial pressure (MAP) is recommended for assessing the prognosis of patients admitted to ICU in the clinical setting (14, 15). Although accumulating evidence also indicated that increased BP variability was independently associated with higher risk of target-organ damage, cardiovascular event, and mortality (11, 13, 16–18), little was known about the threshold at which MAP variability is high enough to have clinical significance in critically ill patients. In this study, we hypothesized that increased MAP variability is associated with short-term mortality and further proposed a threshold of MAP variability to aid early identification of critically ill patients at a high risk of mortality.

More at link.

Immersive Brain Puzzle: a virtual reality application aimed at the rehabilitation of post-stroke patients

I think this is way overly optimistic that this can be used in the ICU. 

 Immersive Brain Puzzle: a virtual reality application aimed at the rehabilitation of post-stroke patients

Juliana de Fátima Ovídio Araújo1, Elvis Hernandes Ribeiro1
, Marcelo de Paiva Guimarães3,4, José Remo Ferreira
Brega2
, Alexandre Fonseca Brandão3
, Diego Roberto Colombo Dias1,3
1Computer Science Department
Federal University of São João del-Rei
São João del-Rei-MG, Brazil
2Computer Department
Paulista State University
Bauru-SP, Brazil
3Brazilian Institute on Neuroscience and Neurotechnology – CEPID BRAINN
4Rectorate/ Federal University of São Paulo - Computer Science Master Program (Unifaccamp)
São Paulo-SP, Brazil
julianadft@gmail.com, elvishribeiro@aluno.ufsj.edu.br, marcelo.paiva@unifesp.br, remo.brega@unesp.br, brandao@gmail.com,
diegodias@ufsj.edu.br

Abstract — 

Stroke is the disease that most causes disability in the world due to the many recurrences that can affect the individuals. In this context, this study addresses the proposal and implementation of the Immersive Brain Puzzle that aims to assist >the rehabilitation of post-stroke patients and stimulate motor and cognitive activities (dual task) by presenting a virtual reality puzzle. It is assumed that treatment in the first hours after a stroke event can significantly contribute to the patient’s progress and recovery; thus, our application was developed to be used in the intensive care unit (ICU). The next stage of this research consists of its validation within the hospital environment to be carried out at the Brazilian Institute of Neuroscience and Neurotechnology (CEPID BRAINN) - Unicamp.

Keywords - virtual reality; rehabilitation; stroke.

I. INTRODUCTION 

A stroke occurs when the blood supply to the brain is interrupted or drastically reduced, depriving the cells of oxygen and nutrients. It can also occur when a blood vessel ruptures, causing cerebral hemorrhage. Stroke is a cerebrovascular disease that is more prevalent in the elderly population, although it affects all age groups. Furthermore, it is the third leading cause of death in developed countries, surpassed only by coronary heart disease and cancer. The sequelae of stroke, as well as its severity, depend on the site affected and the time of response to the event. Motor sequelae are the most frequent and are usually characterized by paralysis on one side of the body. As for neurological sequelae, the main ones are memory loss, difficulty expressing oneself, difficulty speaking, eating, facial paralysis, imbalance, and difficulty in spatial location. Considering that stroke is a disease with a great impact on global public health, with a high mortality rate and sequelae for the affected population, new rehabilitation methods have been proposed to minimize the functional deficiencies of post-stroke patients. Thus, several therapeutic modalities are available, such as induced restraint therapy and task-oriented therapy, helping to restore the affected functions [1]. However, such intervention methods can become demotivating and monotonous for the patient because of intensive repetition. In this context, therapy using virtual reality (VR) emerges, comprising exercises based on games, contributing playfulness in facilitating normal movement and functional training [2].We define VR as an interface between the user and the computer system, provided with three-dimensional (3D) graphic >resources, which aims to provide the sensation of presence in a simulated virtual environment. The creation of fully virtual worlds has been revolutionizing several industries worldwide, and as this technology advances, the possibilities of using VR in other areas, such as health, have emerged. Literature studies on VR and health have concluded that the use of VR applications is effective in treating stroke patients; however, the studies emphasize that since the development is recent, a larger number of case studies are necessary [3]. The Immersive Brain Puzzle application (Figure 1) allows patients to play a VR puzzle game in which the healthcare professional in charge can follow the patient’s progress through an independent device (e.g., a TV), viewing the application in real-time. With this, we hope to contribute to the verification of the hypothesis that the use of a VR application in the first hours of rehabilitation can promote significant improvements in motor and cognitive activities of post-stroke patients. This research is based on studies conducted within the scope of the Brazilian Institute of Neuroscience and Neurotechnology (BRAINN), an interdisciplinary research group aimed at understanding the human brain, exploring areas such as genetics, neurobiology, pharmacology, neuroimaging, computer science, robotics, physics, and engineering. The group is composed of more than 60 researchers and has its headquarters in Campinas, São Paulo. Its mission is to propose new solutions to the most urgent neuroscientific needs of society [4]. 

 

More at link, including the VR used.

Intracranial pressure monitoring in patients with acute brain injury in the intensive care unit (SYNAPSE-ICU): an international, prospective observational cohort study

 Well then write this up as a proposed protocol and deliver it to all emergency rooms and intensive care centers all over the word. JUST WRITING THIS ARTICLE DOES NOTHING! Action is required and it is up to you to accomplish that action. You'd be fired in my laboratory if you didn't do that followup.

Intracranial pressure monitoring in patients with acute brain injury in the intensive care unit (SYNAPSE-ICU): an international, prospective observational cohort study

• Chiara Robba, MD *
• Francesca Graziano, PhD *
• Paola Rebora, PhD *
• Francesca Elli, PhD
• Prof Carlo Giussani, MD
• Prof Mauro Oddo, MD
• et al.
• Show all authors
• Show footnotes

Published:July, 2021DOI:https://doi.org/10.1016/S1474-4422(21)00138-1

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Summary

Background

The indications for intracranial pressure (ICP) monitoring in patients with acute brain injury and the effects of ICP on patients’ outcomes are uncertain. The aims of this study were to describe current ICP monitoring practises for patients with acute brain injury at centres around the world and to assess variations in indications for ICP monitoring and interventions, and their association with long-term patient outcomes.

Methods

We did a prospective, observational cohort study at 146 intensive care units (ICUs) in 42 countries. We assessed for eligibility all patients aged 18 years or older who were admitted to the ICU with either acute brain injury due to primary haemorrhagic stroke (including intracranial haemorrhage or subarachnoid haemorrhage) or traumatic brain injury. We included patients with altered levels of consciousness at ICU admission or within the first 48 h after the brain injury, as defined by the Glasgow Coma Scale (GCS) eye response score of 1 (no eye opening) and a GCS motor response score of at least 5 (not obeying commands). Patients not admitted to the ICU or with other forms of acute brain injury were excluded from the study. Between-centre differences in use of ICP monitoring were quantified by using the median odds ratio (MOR). We used the therapy intensity level (TIL) to quantify practice variations in ICP interventions. Primary endpoints were 6 month mortality and 6 month Glasgow Outcome Scale Extended (GOSE) score. A propensity score method with inverse probability of treatment weighting was used to estimate the association between use of ICP monitoring and these 6 month outcomes, independently of measured baseline covariates. This study is registered with ClinicalTrial.gov, NCT03257904.

Findings

Between March 15, 2018, and April 30, 2019, 4776 patients were assessed for eligibility and 2395 patients were included in the study, including 1287 (54%) with traumatic brain injury, 587 (25%) with intracranial haemorrhage, and 521 (22%) with subarachnoid haemorrhage. The median age of patients was 55 years (IQR 39–69) and 1567 (65%) patients were male. Considerable variability was recorded in the use of ICP monitoring across centres (MOR 4·5, 95% CI 3·8–4·9 between two randomly selected centres for patients with similar covariates). 6 month mortality was lower in patients who had ICP monitoring (441/1318 [34%]) than in those who were not monitored (517/1049 [49%]; p<0·0001). ICP monitoring was associated with significantly lower 6 month mortality in patients with at least one unreactive pupil (hazard ratio [HR] 0·35, 95% CI 0·26–0·47; p<0·0001), and better neurological outcome at 6 months (odds ratio 0·38, 95% CI 0·26–0·56; p=0·0025). Median TIL was higher in patients with ICP monitoring (9 [IQR 7–12]) than in those who were not monitored (5 [3–8]; p<0·0001) and an increment of one point in TIL was associated with a reduction in mortality (HR 0·94, 95% CI 0·91–0·98; p=0·0011).

Interpretation

The use of ICP monitoring and ICP management varies greatly across centres and countries. The use of ICP monitoring might be associated with a more intensive therapeutic approach and with lower 6-month mortality in more severe cases. Intracranial hypertension treatment guided by monitoring might be considered in severe cases due to the potential associated improvement in long-term clinical results.

Funding

University of Milano-Bicocca and the European Society of Intensive Care Medicine.

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Admitting Low-Risk Patients With Intracerebral Hemorrhage to a Neurological Step-Down Unit Is Safe, Results in Shorter Length of Stay, and Reduces Intensive Care Utilization: A Retrospective Controlled Cohort Study

Safety is not the question to be asking. What is the best procedure that gets these patients 100% recovered? At least try to ask the correct question. THIS IS WHY SURVIVORS NEED TO BE IN CHARGE. They won't lose sight of the only goal in stroke. 100% recovery.  

Admitting Low-Risk Patients With Intracerebral Hemorrhage to a Neurological Step-Down Unit Is Safe, Results in Shorter Length of Stay, and Reduces Intensive Care Utilization: A Retrospective Controlled Cohort Study 

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Lindsay Laws, MD, Flavia Lee, DO, Abhay Kumar, MD, ...

First Published May 20, 2020 Research Article

https://doi.org/10.1177/1941874420926760

Article information

Abstract

Background and Purpose:

Patients suffering intracerebral hemorrhage (ICH) are at risk for early neurologic deterioration and are often admitted to intensive care units (ICU) for observation. There is limited data on the safety of admitting low-risk patients with ICH to a non-ICU setting. We hypothesized that admitting such patients to a neurologic step-down unit (SDU) is safe(For whom?) and less resource-intensive.

Methods:

We performed a retrospective analysis of patients with primary ICH admitted to our SDU. We compared this cohort to a control group of ICH patients admitted to a neurologic-ICU (NICU) at a partner institution. We analyzed patients with supratentorial ICH ≤15 cc, Glasgow Coma Scale ≥ 13, National Institutes of Health Stroke Scale ≤ 10, and no to minimal intraventricular hemorrhage. Primary end points were (re-)admission to an NICU and rates of hematoma expansion (HE). We also compared total NICU days and hospital length of stay (LOS).

Results:

Eighty patients with ICH were admitted to the SDU. Only 2 required transfer to the NICU for complications related to ICH, including 1 for HE.(Have you identified the reasons so you can change the inclusion criteria?) Seventy-four SDU patients met inclusion criteria and were compared to 58 patients admitted to an NICU. There was no difference in rates of NICU (re-)admission (7 vs 2, P = .17) or rates of HE (3 vs 5, P = .28). Median NICU days were 0 versus 1 (P < .001). Step-down unit admission was associated with shorter LOS (3 vs 4 days, P = .05).

Conclusions:

Select patients with ICH can be safely admitted to an SDU. This may reduce LOS and ICU utilization. We also propose criteria for admitting patients with ICH to an SDU.

Keywords intracerebral hemorrhage, step-down unit, transitional care unit, neurologic intensive care unit, intensive care unit utilization

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A Standardized Checklist Improves the Transfer of Stroke Patients from the Neurocritical Care Unit to Hospital Ward

You will notice that I'm sure it is missing the most important question? 

Did you stop the 5 causes of the neuronal cascade of death in the first week?  Accomplished? Not accomplished? Did you calculate how many neurons you allowed to die? My calculation is that my doctors let 

5.4 billion neurons die. 

21,600 miles dead myelinated fibers 

2.8 trillion dead synapses 

Damn hard to recover from all that with no stroke protocols.  

A Standardized Checklist Improves the Transfer of Stroke Patients from the Neurocritical Care Unit to Hospital Ward

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Nick M. Murray, MD, Aditya N. Joshi, MD, Kassi Kronfeld, MD, ...

First Published September 10, 2019 Research Article

https://doi.org/10.1177/1941874419873810

Article information

Abstract

Background and Purpose:

The transfer of patients with ischemic stroke from the intensive care unit (ICU) to noncritical care inpatient wards involves detailed information sharing between care teams. Our local transfer process was not standardized, leading to potential patient risk. We developed and evaluated an “ICU Transfer Checklist” to standardize communication between the neurocritical care team and the stroke ward team.

Methods:

Retrospective review of consecutive patients with ischemic stroke admitted to the neurocritical care unit who were transferred to the stroke ward was used to characterize transfer documentation. A multidisciplinary team developed and implemented an ICU Transfer Checklist that contained a synthesis of the patient’s clinical course, immediate “to-do” action items, and a system-based review of active medical problems. Postintervention checklist utilization was recorded for 8 months, and quality metrics for the postintervention cohort were compared to the preintervention cohort. Providers were surveyed pre- and postintervention to characterize perceived workflow and quality of care.

Results:

Patients before (n = 52) and after (n = 81) ICU Transfer Checklist implementation had similar demographic and clinical characteristics. In the postchecklist implementation period, the ICU Transfer Checklist was used in over 85% of patients and median hospital length of stay (LOS) decreased (8.6 days vs 5.4 days, P = .003), while ICU readmission rate remained low. The checklist was associated with improved perceptions of safety and decreased time needed to transfer patients.

Conclusions:

Use of the standardized ICU Transfer Checklist was associated with decreased hospital LOS and with improvements in providers’ perceptions of patient safety.

Keywords quality improvement, patient handoff, checklist, critical care, stroke, patient safety

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Safety and Costs of Stroke Unit Admission for Select Acute Intracerebral Hemorrhage Patients

Notice the word; 'SELECT'.  Once again you have to have the correct stroke. Rather than figuring out how ALL stroke survivors can get fully recovered our fucking lazy researchers take the easy route.  

Safety and Costs of Stroke Unit Admission for Select Acute Intracerebral Hemorrhage Patients

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Corey R. Fehnel, MD, MPH, Kimberly M. Glerum, BA, Linda C. Wendell, MD, ...

First Published June 2, 2017 Research Article

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Abstract

Background and Purpose:

There are limited data to guide intensive care unit (ICU) versus dedicated stroke unit (SU) admission for intracerebral hemorrhage (ICH) patients. We hypothesized select patients can be safely cared for in SU versus ICU at lower costs.

Methods:

We conducted a retrospective cohort study of consecutive patients with predefined minor ICH (≤20 cm³, supratentorial, no coagulopathy) receiving care in either an ICU or an SU. Multiple linear regression and inverse probability weighting were used to adjust for differences in patient characteristics and nonrandom ICU versus SU assignment. The primary outcome was poor functional status at discharge (modified Rankin score [mRS] ≥3). Secondary outcomes included complications, discharge disposition, hospital length of stay, and direct inpatient costs.

Results:

The study population included 104 patients (41 admitted to the ICU and 63 admitted to the SU). After controlling for differences in baseline characteristics, there were no differences in poor functional outcome at discharge (93% vs 85%, P = .26) or in mean mRS (2.9 vs 3.0, P = .73). Similarly, there were no differences in the rates of complications (6% vs 10%, P = .44), discharged dead or to a skilled nursing facility (8% vs 13%, P = .59), or direct patient costs (US$7100 vs US$6200, P = .33). Median length of stay was significantly longer in the ICU group (5 vs 4 days, P = .01).

Conclusions:

This study revealed a shorter length of stay but no large differences in functional outcome, safety, or cost among patients with minor ICH admitted to a dedicated SU compared to an ICU.

Patients at high risk for psychiatric symptoms after a stay in the intensive care unit

How was your stay in the intensive care unit? Mine was listening to a family screaming at doctors to help the husband/father who had some heart condition. My three days there were marked by zero sleep. I don't recall any psychiatric symptoms. What is your doctor doing to treat this? ANYTHING AT ALL?

http://www.mdlinx.com/internal-medicine/medical-news-article/2016/04/22/6638062/?

Johns Hopkins Medicine, 04/22/2016

Results of a multi–institutional national study of nearly 700 people who survived life–threatening illness with a stay in an intensive care unit (ICU) suggest that a substantial majority of them are at high risk for persistent depression, anxiety and post–traumatic stress disorder – especially if they are female, young and unemployed. The study, led by Johns Hopkins University researchers, found that two–thirds of study participants who survived a condition called acute respiratory distress syndrome (ARDS) and spent time in the ICU self–reported symptoms of at least one of these psychiatric disorders, and one–third of those patients with at least one psychiatric symptom said they experienced all three at the same time. Contrary to the common risk factors associated with post–ARDS physical impairments and mortality, such as severity of illness and length of ICU stay, this study demonstrated that none of these risk factors had positive association with psychiatric symptoms. In a report on the study, published in the May issue of the journal Critical Care Medicine, the investigators point out that women, younger people, and those who were unemployed or who misused alcohol prior to hospitalization and survived ARDS were at increased risk for psychiatric symptoms. Based on their self–reporting at six months, 36 percent of participants showed signs of depression, 42 percent showed signs of anxiety and 24 percent showed signs of PTSD. At 12 months, prevalence of these symptoms was nearly the same — 36, 42 and 23 percent, respectively. Of the patients who experienced symptoms of depression, anxiety or PTSD at six months, more than one–half — 57 to 66 percent — still had the same symptoms at 12 months, indicating the persistence of the symptoms. Of the patients at six months without substantial symptoms of depression, anxiety or PTSD, less than 15 percent later developed symptoms by the one–year mark. Most important, the researchers say, the majority of survivors — 63 percent — with any psychiatric illness experienced two or more symptoms at the same time at both six and 12 months. Needham and Huang say they plan to investigate preventive and therapeutic measures that might help such patients. They also plan to look further into the complex role of in–ICU opioid administration and dosages.