Nutritional support and brain tissue glucose metabolism in poor-grade SAH: a retrospective observational study

INTRODUCTION: We sought to determine the effect of nutritional support and insulin infusion therapy on serum and brain glucose levels and cerebral metabolic crisis after aneurysmal subarachnoid hemorrhage (SAH). METHODS: We used a retrospective observational cohort study of 50 mechanically ventilated poor-grade (Hunt-Hess 4 or 5) aneurysmal SAH patients who underwent brain microdialysis monitoring for an average of 109 hours. Enteral nutrition was started within 72 hours of admission whenever feasible. Intensive insulin therapy was used to maintain serum glucose levels between 5.5 and 7.8 mmol/l. Serum glucose, insulin and caloric intake from enteral tube feeds, dextrose and propofol were recorded hourly. Cerebral metabolic distress was defined as a lactate to pyruvate ratio (LPR) > 40. Time-series data were analyzed using a general linear model extended by generalized estimation equations (GEE). RESULTS: Daily mean caloric intake received was 13.8 ± 6.9 cal/kg and mean serum glucose was 7.9 ± 1 mmol/l. A total of 32% of hourly recordings indicated a state of metabolic distress and < 1% indicated a state of critical brain hypoglycemia (< 0.2 mmol/l). Calories received from enteral tube feeds were associated with higher serum glucose concentrations (Wald = 6.07, P = 0.048), more insulin administered (Wald = 108, P < 0.001), higher body mass index (Wald = 213.47, P < 0.001), and lower body temperature (Wald = 4.1, P = 0.043). Enteral feeding (Wald = 1.743, P = 0.418) was not related to brain glucose concentrations after accounting for serum glucose concentrations (Wald = 67.41, P < 0.001). In the presence of metabolic distress, increased insulin administration was associated with a relative reduction of interstitial brain glucose concentrations (Wald = 8.26, P = 0.017), independent of serum glucose levels. CONCLUSIONS: In the presence of metabolic distress, insulin administration is associated with reductions in brain glucose concentration that are independent of serum glucose levels. Further study is needed to understand how nutritional support and insulin administration can be optimized to minimize secondary injury after subarachnoid hemorrhage

Systemic glucose variability predicts cerebral metabolic distress and mortality after subarachnoid hemorrhage: a retrospective observational study

Introduction: Cerebral glucose metabolism and energy production are affected by serum glucose levels. Systemic glucose variability has been shown to be associated with poor outcome in critically ill patients. The objective of this study was to assess whether glucose variability is associated with cerebral metabolic distress and outcome after subarachnoid hemorrhage. Methods: A total of 28 consecutive comatose patients with subarachnoid hemorrhage, who underwent cerebral microdialysis and intracranial pressure monitoring, were studied. Metabolic distress was defined as lactate/pyruvate ratio (LPR) >40. The relationship between daily glucose variability, the development of cerebral metabolic distress and hospital outcome was analyzed using a multivariable general linear model with a logistic link function for dichotomized outcomes. Results: Daily serum glucose variability was expressed as the standard deviation (SD) of all serum glucose measurements. General linear models were used to relate this predictor variable to cerebral metabolic distress and mortality at hospital discharge. A total of 3,139 neuromonitoring hours and 181 days were analyzed. After adjustment for Glasgow Coma Scale (GCS) scores and brain glucose, SD was independently associated with higher risk of cerebral metabolic distress (adjusted odds ratio = 1.5 (1.1 to 2.1), P = 0.02). Increased variability was also independently associated with in hospital mortality after adjusting for age, Hunt Hess, daily GCS and symptomatic vasospasm (P = 0.03). Conclusions: Increased systemic glucose variability is associated with cerebral metabolic distress and increased hospital mortality. Therapeutic approaches that reduce glucose variability may impact on brain metabolism and outcome after subarachnoid hemorrhage

Qualitative Study of Long‐Term Cardiac Arrest Survivors’ Challenges and Recommendations for Improving Survivorship

Background Cardiac arrest survivorship refers to the lived experience of long‐term survivors of cardiac arrest and the many postdischarge challenges they experience. We aimed to gather a nuanced understanding of these challenges and of survivors' perceptions of ways to improve the recovery process. Methods and Results We conducted 15 semistructured, one‐on‐one interviews with cardiac arrest survivor members of the Sudden Cardiac Arrest Foundation; the interviews were conducted by telephone and recorded and transcribed verbatim. We used thematic analysis, informed by the Framework Method, to identify underlying themes regarding cardiac arrest survivorship challenges and recommendations to improve cardiac arrest survivorship. Regarding challenges, the overarching theme was a feeling of unpreparedness to confront postarrest challenges because of lack of resources, education, and appropriate expectations for recovery. Regarding recommendations, we uncovered 3 overarching themes including systemic recommendations (eg, providing appropriate resources and expectations, educating providers about survivorship, following up with survivors, including caregivers in treatment planning), social recommendations (eg, attending peer support groups, spending time with loved ones, providing support resources for family members), and individual coping recommendations (eg, acceptance, resilience, regaining control, seeking treatment, focusing on meaning and purpose). Conclusions We described common challenges that survivors of cardiac arrest face, such as lacking resources, education, and appropriate expectations for recovery. Additionally, we identified promising pathways that may improve cardiac arrest survivorship at systemic, social, and individual coping levels. Future studies could use our findings as targets for interventions to support and improve survivorship

Anemia is associated with metabolic distress and brain tissue hypoxia after subarachnoid hemorrhage

Anemia is frequently encountered in critically ill patients and adversely affects cerebral oxygen delivery and brain tissue oxygen (PbtO2). The objective of this study is to assess whether there is an association between anemia and metabolic distress or brain tissue hypoxia in patients with subarachnoid hemorrhage