Brainstem dysfunction in critically ill patients

The brainstem conveys sensory and motor inputs between the spinal cord and the brain, and contains nuclei of the cranial nerves. It controls the sleep-wake cycle and vital functions via the ascending reticular activating system and the autonomic nuclei, respectively. Brainstem dysfunction may lead to sensory and motor deficits, cranial nerve palsies, impairment of consciousness, dysautonomia, and respiratory failure. The brainstem is prone to various primary and secondary insults, resulting in acute or chronic dysfunction. Of particular importance for characterizing brainstem dysfunction and identifying the underlying etiology are a detailed clinical examination, MRI, neurophysiologic tests such as brainstem auditory evoked potentials, and an analysis of the cerebrospinal fluid. Detection of brainstem dysfunction is challenging but of utmost importance in comatose and deeply sedated patients both to guide therapy and to support outcome prediction. In the present review, we summarize the neuroanatomy, clinical syndromes, and diagnostic techniques of critical illness-associated brainstem dysfunction for the critical care setting

The positive impact of COVID-19 on critical care: from unprecedented challenges to transformative changes, from the perspective of young intensivists

International audienceOver the past 2 years, SARS-CoV-2 infection has resulted in numerous hospitalizations and deaths worldwide. As young intensivists, we have been at the forefront of the fight against the COVID-19 pandemic and it has been an intense learning experience affecting all aspects of our specialty. Critical care was put forward as a priority and managed to adapt to the influx of patients and the growing demand for beds, financial and material resources, thereby highlighting its flexibility and central role in the healthcare system. Intensivists assumed an essential and unprecedented role in public life, which was important when claiming for indispensable material and human investments. Physicians and researchers around the world worked hand-in-hand to advance research and better manage this disease by integrating a rapidly growing body of evidence into guidelines. Our daily ethical practices and communication with families were challenged by the massive influx of patients and restricted visitation policies, forcing us to improve our collaboration with other specialties and innovate with new communication channels. However, the picture was not all bright, and some of these achievements are already fading over time despite the ongoing pandemic and hospital crisis. In addition, the pandemic has demonstrated the need to improve the working conditions and well-being of critical care workers to cope with the current shortage of human resources. Despite the gloomy atmosphere, we remain optimistic. In this ten-key points review, we outline our vision on how to capitalize on the lasting impact of the pandemic to face future challenges and foster transformative changes of critical care for the better

Meningitis in critically ill patients admitted to intensive care unit for severe community-acquired pneumococcal pneumonia

Abstract Background Although it has been reported that patients with pneumococcal pneumonia may develop meningitis, lumbar puncture is not systematically recommended in these patients, even in patients with associated bacteremia or invasive pneumococcal disease. The aim of this study was to determine the characteristics and outcomes of patients admitted to intensive care unit (ICU) for pneumococcal community-acquired pneumonia who developed meningitis. Methods We retrospectively included all consecutive patients admitted to our ICU from January 2006 to December 2020 for severe pneumococcal community-acquired pneumonia according to American Thoracic Society criteria. Meningitis was defined as pleocytosis > 5 cells/mm3 or a positive culture of cerebrospinal fluid for Streptococcus pneumoniae in lumbar puncture. The primary endpoint was the proportion of patients with meningitis during their ICU stay. Results Overall, 262 patients [64(52–75) years old] were included: 154(59%) were male, 80(30%) had chronic respiratory disease, 105(39%) were immunocompromised and 6(2%) were vaccinated against S. pneumoniae. A lumbar puncture was performed in 88(34%) patients with a delay from ICU admission to puncture lumbar of 10.5 (2.8–24.1) h and after the initiation of pneumococcal antibiotherapy in 81(92%) patients. Meningitis was diagnosed in 14 patients: 16% of patients with lumbar puncture and 5% of patients in the whole population. Patients with meningitis had more frequently human immunodeficiency virus positive status (29 vs. 5%, p = 0.02), neurological deficits on ICU admission (43 vs. 16%, p = 0.03) and pneumococcal bacteremia (71 vs. 30%, p < 0.01) than those without. The ICU mortality rate (14 vs. 13%, p = 0.73) and the mortality rate at Day-90 (21 vs. 15%, p = 0.83) did not differ between patients with and without meningitis. The proportion of patients with neurological disorders at ICU discharge was higher in patients with meningitis (64 vs. 23%, p < 0.001) than in those without. The other outcomes did not differ at ICU discharge, Day-30 and Day-90 between the two groups of patients. Conclusion Meningitis was diagnosed in 16% of patients with severe pneumococcal community-acquired pneumonia in whom a lumbar puncture was performed, was more frequent in patients with pneumococcal bacteremia and was associated with more frequent neurological disorders at ICU discharge. Further studies are needed to confirm these results

Aberrant brain–heart coupling is associated with the severity of post cardiac arrest brain injury

Abstract Objective To investigate autonomic nervous system activity measured by brain–heart interactions in comatose patients after cardiac arrest in relation to the severity and prognosis of hypoxic–ischemic brain injury. Methods Strength and complexity of bidirectional interactions between EEG frequency bands (delta, theta, and alpha) and ECG heart rate variability frequency bands (low frequency, LF and high frequency, HF) were computed using a synthetic data generation model. Primary outcome was the severity of brain injury, assessed by (i) standardized qualitative EEG classification, (ii) somatosensory evoked potentials (N20), and (iii) neuron‐specific enolase levels. Secondary outcome was the 3‐month neurological status, assessed by the Cerebral Performance Category score [good (1–2) vs. poor outcome (3–4–5)]. Results Between January 2007 and July 2021, 181 patients were admitted to ICU for a resuscitated cardiac arrest. Poor neurological outcome was observed in 134 patients (74%). Qualitative EEG patterns suggesting high severity were associated with decreased LF/HF. Severity of EEG changes were proportional to higher absolute values of brain‐to‐heart coupling strength (p < 0.02 for all brain‐to‐heart frequencies) and lower values of alpha‐to‐HF complexity (p = 0.049). Brain‐to‐heart coupling strength was significantly higher in patients with bilateral absent N20 and correlated with neuron‐specific enolase levels at Day 3. This aberrant brain‐to‐heart coupling (increased strength and decreased complexity) was also associated with 3‐month poor neurological outcome. Interpretation Our results suggest that autonomic dysfunctions may well represent hypoxic–ischemic brain injury post cardiac arrest pathophysiology. These results open avenues for integrative monitoring of autonomic functioning in critical care patients

Aphasia outcome: the interactions between initial severity, lesion size and location

International audienceThe outcome of aphasia at 3 months is variable in patients with moderate/severe stroke. The aim was to predict 3-month aphasia outcome using prediction models including initial severity in addition to the interaction between lesion size and location at the acute phase

Brainstem dysfunction in critically ill patients

International audienceThe brainstem conveys sensory and motor inputs between the spinal cord and the brain, and contains nuclei of the cranial nerves. It controls the sleep-wake cycle and vital functions via the ascending reticular activating system and the autonomic nuclei, respectively. Brainstem dysfunction may lead to sensory and motor deficits, cranial nerve palsies, impairment of consciousness, dysautonomia, and respiratory failure. The brainstem is prone to various primary and secondary insults, resulting in acute or chronic dysfunction. Of particular importance for characterizing brainstem dysfunction and identifying the underlying etiology are a detailed clinical examination, MRI, neurophysiologic tests such as brainstem auditory evoked potentials, and an analysis of the cerebrospinal fluid. Detection of brainstem dysfunction is challenging but of utmost importance in comatose and deeply sedated patients both to guide therapy and to support outcome prediction. In the present review, we summarize the neuroanatomy, clinical syndromes, and diagnostic techniques of critical illness-associated brainstem dysfunction for the critical care setting

Association between the Cardiac Arrest Hospital Prognosis (CAHP) score and reason for death after successfully resuscitated cardiac arrest

International audienceIndividualize treatment after cardiac arrest could potentiate future clinical trials selecting patients most likely to benefit from interventions. We assessed the Cardiac Arrest Hospital Prognosis (CAHP) score for predicting reason for death to improve patient selection. Consecutive patients in two cardiac arrest databases were studied between 2007 and 2017. Reasons for death were categorised as refractory post-resuscitation shock (RPRS), hypoxic-ischaemic brain injury (HIBI) and other. We computed the CAHP score, which relies on age, location at OHCA, initial cardiac rhythm, no-flow and low-flow times, arterial pH, and epinephrine dose. We performed survival analyses using the Kaplan–Meier failure function and competing-risks regression. Of 1543 included patients, 987 (64%) died in the ICU, 447 (45%) from HIBI, 291 (30%) from RPRS, and 247 (25%) from other reasons. The proportion of deaths from RPRS increased with CAHP score deciles; the sub-hazard ratio for the tenth decile was 30.8 (9.8–96.5; p < 0.0001). The sub-hazard ratio of the CAHP score for predicting death from HIBI was below 5. Higher CAHP score values were associated with a higher proportion of deaths due to RPRS. This score may help to constitute uniform patient populations likely to benefit from interventions assessed in future randomised controlled trials