Multimodal non-invasive assessment of intracranial hypertension: an observational study

Abstract Background Although placement of an intra-cerebral catheter remains the gold standard method for measuring intracranial pressure (ICP), several non-invasive techniques can provide useful estimates. The aim of this study was to compare the accuracy of four non-invasive methods to assess intracranial hypertension. Methods We reviewed prospectively collected data on adult intensive care unit (ICU) patients with traumatic brain injury (TBI), subarachnoid hemorrhage (SAH), or intracerebral hemorrhage (ICH) in whom invasive ICP monitoring had been initiated and estimates had been simultaneously collected from the following non-invasive indices: optic nerve sheath diameter (ONSD), pulsatility index (PI), estimated ICP (eICP) using transcranial Doppler, and the neurological pupil index (NPI) measured using automated pupillometry. Intracranial hypertension was defined as an invasively measured ICP &gt; 20 mmHg. Results We studied 100 patients (TBI = 30; SAH = 47; ICH = 23) with a median age of 52 years. The median invasively measured ICP was 17 [12–25] mmHg and intracranial hypertension was present in 37 patients. Median values from the non-invasive techniques were ONSD 5.2 [4.8–5.8] mm, PI 1.1 [0.9–1.4], eICP 21 [14–29] mmHg, and NPI 4.2 [3.8–4.6]. There was a significant correlation between all the non-invasive techniques and invasive ICP (ONSD, r = 0.54; PI, r = 0.50; eICP, r = 0.61; NPI, r = − 0.41—p &lt; 0.001 for all). The area under the curve (AUC) to estimate intracranial hypertension was 0.78 [CIs = 0.68–0.88] for ONSD, 0.85 [95% CIs 0.77–0.93] for PI, 0.86 [95% CIs 0.77–0.93] for eICP, and 0.71 [95% CIs 0.60–0.82] for NPI. When the various techniques were combined, the highest AUC (0.91 [0.84–0.97]) was obtained with the combination of ONSD with eICP. Conclusions Non-invasive techniques are correlated with ICP and have an acceptable accuracy to estimate intracranial hypertension. The multimodal combination of ONSD and eICP may increase the accuracy to estimate the occurrence of intracranial hypertension. </jats:sec

Multimodal non-invasive assessment of intracranial hypertension: an observational study.

BACKGROUND: Although placement of an intra-cerebral catheter remains the gold standard method for measuring intracranial pressure (ICP), several non-invasive techniques can provide useful estimates. The aim of this study was to compare the accuracy of four non-invasive methods to assess intracranial hypertension. METHODS: We reviewed prospectively collected data on adult intensive care unit (ICU) patients with traumatic brain injury (TBI), subarachnoid hemorrhage (SAH), or intracerebral hemorrhage (ICH) in whom invasive ICP monitoring had been initiated and estimates had been simultaneously collected from the following non-invasive indices: optic nerve sheath diameter (ONSD), pulsatility index (PI), estimated ICP (eICP) using transcranial Doppler, and the neurological pupil index (NPI) measured using automated pupillometry. Intracranial hypertension was defined as an invasively measured ICP > 20 mmHg. RESULTS: We studied 100 patients (TBI = 30; SAH = 47; ICH = 23) with a median age of 52 years. The median invasively measured ICP was 17 [12-25] mmHg and intracranial hypertension was present in 37 patients. Median values from the non-invasive techniques were ONSD 5.2 [4.8-5.8] mm, PI 1.1 [0.9-1.4], eICP 21 [14-29] mmHg, and NPI 4.2 [3.8-4.6]. There was a significant correlation between all the non-invasive techniques and invasive ICP (ONSD, r = 0.54; PI, r = 0.50; eICP, r = 0.61; NPI, r = - 0.41-p < 0.001 for all). The area under the curve (AUC) to estimate intracranial hypertension was 0.78 [CIs = 0.68-0.88] for ONSD, 0.85 [95% CIs 0.77-0.93] for PI, 0.86 [95% CIs 0.77-0.93] for eICP, and 0.71 [95% CIs 0.60-0.82] for NPI. When the various techniques were combined, the highest AUC (0.91 [0.84-0.97]) was obtained with the combination of ONSD with eICP. CONCLUSIONS: Non-invasive techniques are correlated with ICP and have an acceptable accuracy to estimate intracranial hypertension. The multimodal combination of ONSD and eICP may increase the accuracy to estimate the occurrence of intracranial hypertension

Comparison of estimation of cardiac output using an uncalibrated pulse contour method and echocardiography during veno-venous extracorporeal membrane oxygenation

Introduction: During veno-venous extracorporeal membrane oxygenation, cardiac output monitoring is essential to assess tissue oxygen delivery. Adequate arterial oxygenation depends on the ratio between the extracorporeal pump blood flow and the cardiac output. The aim of this study was to compare estimates of cardiac output and blood flow/cardiac output ratios made using an uncalibrated pulse contour method with those made using echocardiography in patients treated with veno-venous extracorporeal membrane oxygenation. Methods: Cardiac output was estimated simultaneously using a pulse contour method (MostCareUp; Vygon, Encouen, France) and echocardiography in 17 hemodynamically stable patients treated with veno-venous extracorporeal membrane oxygenation. Comparisons were made using Bland–Altman and linear regression analysis. Results: There were significant correlations between cardiac output estimated using pulse contour method and echocardiography and between blood flow/cardiac output estimated using pulse contour method and blood flow/cardiac output estimated using echocardiography (r = 0.84, p &lt; 0.001 and r = 0.87, p &lt; 0.001, respectively). Bland–Altman analysis showed a good agreement (bias −0.20 ± 0.50 L/min) and a low percentage of error (25%) for the cardiac output values estimated by the two methods. The bias between the blood flow/cardiac output ratios obtained with the two methods was 5.19% ± 12.3% (percentage of error = 28.1%). Conclusions: The pulse contour method is a valuable alternative to echocardiography for the assessment of cardiac output and the blood flow/cardiac output ratio in patients treated with veno-venous extracorporeal membrane oxygenation. </jats:sec

Altered liver function in patients undergoing veno-arterial extracorporeal membrane oxygenation therapy

BACKGROUND: Multiple organ dysfunction can occur in patients undergoing veno-arterial extra corporal membrane oxygenation (VA-ECMO); however, liver function has not been well studied in this setting. METHODS: In a review of our institutional ECMO database (N.=162), we collected aspartate (AST) and alanine (ALT ) transaminases, total bilirubin and international normalized ratio (INR) at time of ECMO initiation (baseline) and once daily during therapy in patients who survived for at least 24 hours. Elevated liver enzymes (ELE) were defined if AST and/or ALT were >200 UI/L, and acute liver failure (ALF) as the presence of an INR 1.5, new onset encephalopathy and an elevated total bilirubin concentrations. RESULTS :On a total of 80 patients undergoing VA-ECMO, 69 patients met the inclusion criteria (cardiogenic shock, N.=52; refractory cardiac arrest, N.=15; cardiac failure following severe ARDS, N.=2). Of them, 45 (65%) had early ELE after ECMO initiation (median highest AST and ALT were 528 [251-2606] UI/L and 513 [130-1031] UI/L, respectively). Two thirds of patients with ELE (N.=30) had a progressive reduction in AST and ALT ,but the levels were normalized only after 5 (5-6) days. Among patients with ELE, 21/45 (47%) had AST and/or ALT levels above >1000 UI/L. A total of 14/69 (20%) patients developed ALF. However, mortality rate was not significantly higher in patients with ELE or ALF when compared to others. CONCLUSIONS: A substantial proportion of patients needing VA-ECMO have early ELE, which usually improves over days. The prognostic implications are not evident.SCOPUS: ar.jinfo:eu-repo/semantics/publishe

COMPARISON OF CARDIAC CYCLE EFFICIENCY AND PARAMETERS OF GLOBAL OXYGENATION AND FLOW IN ICU PATIENTS

8siConference: 46th Critical Care Congress of the Society-of-Critical-Care-Medicine. - Location: Honolulu, HI. - Date: JAN 21-25, 2017. - Sponsor(s):Soc Crit Care Med.nonenoneCavicchi, Federica Zama; Pozzebon, Selene; Bond, Ottavia; Scolletta, Sabino; Franchi, Federico; Creteur, Jacques; Vincent, Jean-Louis; Taccone, Fabio SilvioCavicchi, Federica Zama; Pozzebon, Selene; Bond, Ottavia; Scolletta, Sabino; Franchi, Federico; Creteur, Jacques; Vincent, Jean Louis; Taccone, Fabio Silvi

COMPARISON BETWEEN ECHOCARDIOGRAPHY AND UNCALIBRATED PULSE CONTOUR METHOD CO MEASUREMENT IN VV ECMO

8siConference: 46th Critical Care Congress of the Society-of-Critical-Care-Medicine. - Location: Honolulu, HI. - Date: JAN 21-25, 2017. - Sponsor(s):Soc Crit Care Med. -nonenoneBond, Ottavia; Pozzebon, Selene; Scolletta, Sabino; Franchi, Federico; Cavicchi, Federica Zama; Creteur, Jacques; Vincent, Jean-Louis; Taccone, Fabio SilvioBond, Ottavia; Pozzebon, Selene; Scolletta, Sabino; Franchi, Federico; Cavicchi, Federica Zama; Creteur, Jacques; Vincent, Jean Louis; Taccone, Fabio Silvi