Predictive value of neurological examination for early cortical responses to somatosensory evoked potentials in patients with postanoxic coma

Bilateral absence of cortical N20 responses of median nerve somatosensory evoked potentials (SEP) predicts poor neurological outcome in postanoxic coma after cardiopulmonary resuscitation (CPR). Although SEP is easy to perform and available in most hospitals, it is worthwhile to know how neurological signs are associated with SEP results. The aim of this study was to investigate whether specific clinical neurological signs are associated with either an absent or a present median nerve SEP in patients after CPR. Data from the previously published multicenter prospective cohort study PROPAC (prognosis in postanoxic coma, 2000–2003) were used. Neurological examination, consisting of Glasgow Coma Score (GCS) and brain stem reflexes, and SEP were performed 24, 48, and 72 h after CPR. Positive predictive values for predicting absent and present SEP, as well as diagnostic accuracy were calculated. Data of 407 patients were included. Of the 781 SEPs performed, N20 s were present in 401, bilaterally absent in 299, and 81 SEPs were technically undeterminable. The highest positive predictive values (0.63–0.91) for an absent SEP were found for absent pupillary light responses. The highest positive predictive values (0.71–0.83) for a present SEP were found for motor scores of withdrawal to painful stimuli or better. Multivariate analyses showed a fair diagnostic accuracy (0.78) for neurological examination in predicting an absent or present SEP at 48 or 72 h after CPR. This study shows that neurological examination cannot reliably predict absent or present cortical N20 responses in median nerve SEPs in patients after CPR

Acute posthypoxic myoclonus after cardiopulmonary resuscitation

<p>Abstract</p> <p>Background</p> <p>Acute posthypoxic myoclonus (PHM) can occur in patients admitted after cardiopulmonary resuscitation (CPR) and is considered to have a poor prognosis. The origin can be cortical and/or subcortical and this might be an important determinant for treatment options and prognosis. The aim of the study was to investigate whether acute PHM originates from cortical or subcortical structures, using somatosensory evoked potential (SEP) and electroencephalogram (EEG).</p> <p>Methods</p> <p>Patients with acute PHM (focal myoclonus or status myoclonus) within 72 hours after CPR were retrospectively selected from a multicenter cohort study. All patients were treated with hypothermia. Criteria for cortical origin of the myoclonus were: giant SEP potentials; or epileptic activity, status epilepticus, or generalized periodic discharges on the EEG (no back-averaging was used). Good outcome was defined as good recovery or moderate disability after 6 months.</p> <p>Results</p> <p>Acute PHM was reported in 79/391 patients (20%). SEPs were available in 51/79 patients and in 27 of them (53%) N20 potentials were present. Giant potentials were seen in 3 patients. EEGs were available in 36/79 patients with 23/36 (64%) patients fulfilling criteria for a cortical origin. Nine patients (12%) had a good outcome. A broad variety of drugs was used for treatment.</p> <p>Conclusions</p> <p>The results of this study show that acute PHM originates from subcortical, as well as cortical structures. Outcome of patients admitted after CPR who develop acute PHM in this cohort was better than previously reported in literature. The broad variety of drugs used for treatment shows the existing uncertainty about optimal treatment.</p

Potential Clinical Consequences of Medication Process Problems in Older Home Care Patients

Background: Home care professionals regularly observe drug-related problems during home care provision. Problems related to the process of the medication therapy could involve discrepancies in medication prescriptions between the hospital discharge letter and the medication administration record lists (MARL) or insufficient drug delivery. The objective of this study is to determine the potential clinical consequences of medication process problems observed by home care professionals, since those consequences have not been assessed before. Methods: A retrospective descriptive study design was performed. An expert panel performed an assessment procedure on the clinical consequences of medication process problems. Such problems were reported by home care professionals during routine care (May 2016 until May 2017) using the eHOME system, which is a digital system developed to assist in the reporting and monitoring of drug-related problems. Using a three-point scale, an expert panel assessed the potential clinical consequences of those medication process problems among older home care patients (aged 65 years and over). Results: 309 medication process problems in 120 out of 451 patients were assessed for potential discomfort or clinical deterioration. The problems involved the following: medication discrepancies (new prescription not listed on the MARL [n = 69, 36.7%]; medication stopped by the prescriber but still listed on the MARL [n = 43, 22.9%]; discrepant time of intake [n = 25, 13.3%]; frequency [n = 24, 12.8%]; and dose [n = 21, 11.2%], therapeutic duplication listed on the MARL [n = 5, 2.6%]; and discrepant information on route of administration [n = 1, 0.5%]); an undelivered MARL [n = 103, 33.3%]; undelivered medication [n = 16, 5.2%]; and excessive medication delivery [n = 2, 0.7%]. Furthermore, 180 (58.2%) out of 309 medication process problems were assessed as having the potential for moderate or severe discomfort or clinical deterioration in patients. Conclusions: The majority of medication process problems may result in patient discomfort or clinical deterioration

Feasibility and diagnostic accuracy of early electrophysiological recordings for ICU-acquired weakness: an observational cohort study

An early diagnosis of ICU-acquired weakness (ICU-AW) is difficult because disorders of consciousness frequently preclude muscle strength assessment. In this study, we investigated feasibility and accuracy of electrophysiological recordings to diagnose ICU-AW early in non-awake critically ill patients. Newly admitted patients, mechanically ventilated ≥2 days and unreactive to verbal stimuli, were included in this study. Electrophysiological recordings comprised nerve conduction studies (NCS) of three nerves and, if coagulation was normal, myography in three muscles. Upon awakening, strength was assessed (ICU-AW: average Medical Research Council score 75 %) recordings was analyzed based on cut-off values from healthy controls and from critically ill patients with and without ICU-AW. Thirty-five patients were included (17 with ICU-AW). Recordings were obtained on day 4 (IQR: 3-6). Feasibility was acceptable for ulnar and peroneal nerve recordings, and low for sural recordings and myography. Diagnostic accuracy based on cut-off values from healthy controls was low. When using cut-off values from critically ill patients with and without ICU-AW, the peroneal compound muscle action potential amplitude and ulnar sensory nerve action potential amplitude had good diagnostic accuracy. Nerve conduction studies of the ulnar and peroneal nerve are feasible in critically ill patients. The diagnostic accuracy is low using cut-off values from healthy controls. Cut-off values validated specifically for discrimination between critically ill patients with and without ICU-AW may improve diagnostic accurac

Hypothermia after CPR prolongs conduction times of somatosensory evoked potentials

To investigate the effect of mild hypothermia on conduction times and amplitudes of median nerve somatosensory evoked potentials (SEP) in patients after cardiopulmonary resuscitation (CPR). Patients treated with hypothermia after CPR who underwent SEP recording during hypothermia and after rewarming were selected from a prospectively collected database. Latencies and amplitudes of N9 (peripheral conduction time, PCT), N13, and N20 were measured. The central conduction time (CCT) was defined as peak-peak latency N13-N20. Recordings of 25 patients were assessed by a second observer to determine the intraclass correlation coefficient (ICC). A total of 115 patients were included. The mean body temperature at SEP during hypothermia was 33.1 °C (SD 0.8) and after rewarming 37.1 °C (SD 0.8). Mean latencies of N9, N13, and N20 and mean CCT were longer during hypothermia. There were no consistent differences in amplitudes. There was an almost perfect ICC for assessment of latencies and amplitudes. This study showed that PCT and CCT of median nerve SEP were prolonged during treatment with hypothermia after CPR compared with after rewarming. Amplitudes did not differ consistentl