Movement-induced heart rate changes in epileptic and non-epileptic seizures Alterações da frequência cardíaca induzidas pelo movimento em crises epilépticas e não-epilépticas

Heart rate changes are common in epileptic and non-epileptic seizures. Previous studies have not adequately assessed the contribution of motor activity on these changes nor have evaluated them during prolonged monitoring. We retrospectively evaluated 143 seizures and auras from 76 patients admitted for video EEG monitoring. The events were classified according to the degree of ictal motor activity (severe, moderate and mild/absent) in: severe epileptic (SE, N=17), severe non-epileptic (SNE, N=6), moderate epileptic (ME, N=28), moderate non-epileptic (MNE, N=11), mild epileptic (mE, N=35), mild non-epileptic (mNE, N=33) and mild aura (aura, N=13). Heart rate increased in the ictal period in severe epileptic, severe non-epileptic, moderate epileptic and mild epileptic events (pAlterações da frequência cardíaca são comuns em crises epilépticas e não-epilépticas. Estudos prévios não avaliaram adequadamente a contribuição da atividade motora nas alterações da frequência cardíaca, e as crises não foram estudadas durante monitoração prolongada. No presente estudo avaliamos retrospectivamente 143 crises de 76 pacientes admitidos para monitoração com vídeo-EEG no Hospital da Universidade de Saint Louis. As crises foram classificadas de acordo com o grau de atividade motora (severa, moderada e leve/ausente) em: epiléptica grave (EG, N=17), não-epiléptica grave (NEG, N=6), epiléptica moderada (EM, N=28), não epiléptica moderada (NEM, N=11), epiléptica leve (EL, N=35), não-epiléptica leve (NEL, N=33), e aura, N=13. A frequência cardíaca aumentou no período ictal nas crises epilépticas graves, não epilépticas graves, epilépticas moderadas, epilépticas leves (p<0,05). A frequência cardíaca apresentou tendência a retornar aos níveis basais durante o período pós ictal nas crises não epilépticas graves, mas não nas crises epilépticas graves. As auras apresentaram frequência cardíaca basal aumentada. Um limiar de 20% no aumento da frequência cardíaca pode diferenciar eventos epilépticos moderados de eventos epilépticos leves com duração maior que 30 segundos. Em crises epilépticas com atividade motora leve ou ausente, a magnitude do aumento da frequência cardíaca é proporcional à duração do evento. A análise da frequência cardíaca em crises com diferentes quantidades de movimento na fase ictal podem ajudar na diferenciação de crises epilépticas de não epilépticas

Weaning from mechanical ventilation in intensive care units across 50 countries (WEAN SAFE): a multicentre, prospective, observational cohort study

International audienceBackground: Current management practices and outcomes in weaning from invasive mechanical ventilation are poorly understood. We aimed to describe the epidemiology, management, timings, risk for failure, and outcomes of weaning in patients requiring at least 2 days of invasive mechanical ventilation. Methods: WEAN SAFE was an international, multicentre, prospective, observational cohort study done in 481 intensive care units in 50 countries. Eligible participants were older than 16 years, admitted to a participating intensive care unit, and receiving mechanical ventilation for 2 calendar days or longer. We defined weaning initiation as the first attempt to separate a patient from the ventilator, successful weaning as no reintubation or death within 7 days of extubation, and weaning eligibility criteria based on positive end-expiratory pressure, fractional concentration of oxygen in inspired air, and vasopressors. The primary outcome was the proportion of patients successfully weaned at 90 days. Key secondary outcomes included weaning duration, timing of weaning events, factors associated with weaning delay and weaning failure, and hospital outcomes. This study is registered with ClinicalTrials.gov, NCT03255109. Findings: Between Oct 4, 2017, and June 25, 2018, 10 232 patients were screened for eligibility, of whom 5869 were enrolled. 4523 (77·1%) patients underwent at least one separation attempt and 3817 (65·0%) patients were successfully weaned from ventilation at day 90. 237 (4·0%) patients were transferred before any separation attempt, 153 (2·6%) were transferred after at least one separation attempt and not successfully weaned, and 1662 (28·3%) died while invasively ventilated. The median time from fulfilling weaning eligibility criteria to first separation attempt was 1 day (IQR 0–4), and 1013 (22·4%) patients had a delay in initiating first separation of 5 or more days. Of the 4523 (77·1%) patients with separation attempts, 2927 (64·7%) had a short wean (≤1 day), 457 (10·1%) had intermediate weaning (2–6 days), 433 (9·6%) required prolonged weaning (≥7 days), and 706 (15·6%) had weaning failure. Higher sedation scores were independently associated with delayed initiation of weaning. Delayed initiation of weaning and higher sedation scores were independently associated with weaning failure. 1742 (31·8%) of 5479 patients died in the intensive care unit and 2095 (38·3%) of 5465 patients died in hospital. Interpretation: In critically ill patients receiving at least 2 days of invasive mechanical ventilation, only 65% were weaned at 90 days. A better understanding of factors that delay the weaning process, such as delays in weaning initiation or excessive sedation levels, might improve weaning success rates. Funding: European Society of Intensive Care Medicine, European Respiratory Society