Outcome Prognostication of Acute Brain Injury using the Neurological Pupil Index (ORANGE) study: protocol for a prospective, observational, multicentre, international cohort study.

The pupillary examination is an important part of the neurological assessment, especially in the setting of acutely brain-injured patients, and pupillary abnormalities are associated with poor outcomes. Currently, the pupillary examination is based on a visual, subjective and frequently inaccurate estimation. The use of automated infrared pupillometry to measure the pupillary light reflex can precisely quantify subtle changes in pupillary functions. The study aimed to evaluate the association between abnormal pupillary function, assessed by the Neurological Pupil Index (NPi), and long-term outcomes in patients with acute brain injury (ABI). The Outcome Prognostication of Acute Brain Injury using the Neurological Pupil Index study is a prospective, observational study including adult patients with ABI requiring admission at the intensive care unit. We aimed to recruit at least 420 patients including those suffering from traumatic brain injury or haemorrhagic strokes, over 12 months. The primary aim was to assess the relationship between NPi and 6-month mortality or poor neurological outcome, measured by the Extended Glasgow Outcome Score (GOS-E, poor outcome=GOS-E 1-4). Supervised and unsupervised methods and latent class mixed models will be used to identify patterns of NPi trajectories and Cox and logistic model to evaluate their association with outcome. The study has been approved by the institutional review board (Comitato Etico Brianza) on 16 July 2020. Approved protocol V.4.0 dated 10 March 2020. The results of this study will be published in peer-reviewed journals and presented at conferences. NCT04490005

Patient controlled pressure support ventilation

Introduction Pressure support ventilation is mostly used in weaning from mechanical ventilaton in acute respiratory failure. There are no data regarding the optimal level of assistance for each patient in different clinical conditions. We approach a new method that allows patients to set their own PSV level by a remote control connected to the ventilator. Materials and methods In 9 awake intubated patients (age 57 \ub1 17 years, BMI 24 \ub1 3 kg/m2, PaO2/FiO2 283 \ub1 51, Ramsey 1.9 \ub1 0.4) we measured the breathing pattern (VT, RR), the work of breathing (WOB J/min, estimated from a modified Campbell diagram [1]) and the dyspnea sensation using the Borg visual scale [2]. Patients were studied at three fixed levels of PSV (5-15-25 cmH2O). At the end of each step we gave the patient the possibility to change the level of PSV using the remote control. Patients were previously instructed by attendant physician about the use of the remote control. Results See Table and Figure. It appears that increasing the pressure support level, the patient work of breathing decreases while the Borg dyspnea scale shows no significant differences. Figure. The dyspnea sensation when patient is allowed to set the pressure support level. Conclusions Patient controlled PSV could be a useful technique in ventilatory management of critically ill awake patients

ASSESSMENT OF CHLORIDE LEVELS ON RENAL FUNCTION AFTER CARDIAC ARREST

SCOPUS: no.jinfo:eu-repo/semantics/publishe

Echocardiography and pulse contour analysis to assess cardiac output in trauma patients.

Echocardiography is a valuable technique to assess cardiac output (CO) in trauma patients, but it does not allow a continuous bedside monitoring. Beat-to-beat CO assessment can be obtained by other techniques, including the pulse contour method MostCare. The aim of our study was to compare CO obtained with MostCare (MC-CO) with CO estimated by transthoracic echocardiography (TTE-CO) in trauma patients. METHODS: Forty-nine patients with blunt trauma admitted to an intensive care unit and requiring hemodynamic optimization within 24 hours from admission were studied. TTE-CO and MC-CO were estimated simultaneously at baseline, after a fluid challenge and after the start of vasoactive drug therapy. RESULTS: One hundred sixteen paired CO values were obtained. TTE-CO values ranged from 2.9 to 7.6 L·min-1, and MC-CO ranged from 2.8 to 8.2 L·min-1. The correlation between the two methods was 0.94 (95% confidence interval [CI] = 0.89 to 0.97; p<0.001). The mean bias was -0.06 L·min-1 with limits of agreements (LoA) of -0.94 to 0.82 L·min-1 (lower 95% CI, -1.16 to -0.72; upper 95% CI, 0.60 to 1.04) and a percentage error of 18%. Changes in CO showed a correlation of 0.91 (95% CI = 0.87 to 0.95; p<0.001), a mean bias of - 0.01 L·min-1 with LoA of -0.67 to 0.65 L·min-1 (lower 95% CI, -0.83 to -0.51; upper 95% CI, 0.48 to 0.81). CONCLUSION: CO measured by MostCare showed good agreement with CO obtained by transthoracic echocardiography. Pulse contour analysis can complement echocardiography in evaluating hemodynamics in trauma patients

Incidence and prognosis of dysnatraemia in critically ill patients: Analysis of a large prevalence study

Background: The objective of this study is to assess the impact of dysnatraemia on mortality among intensive care unit (ICU) patients in a large, international cohort. Material and methods: Analysis of the Extended Prevalence of Infection in Intensive Care (EPIC II) study, a 1-day (8 May 2007) worldwide multicenter, prospective point prevalence study. Hyponatraemia was categorized as mild (130-134 mM/L), moderate (125-129 mM/L) or severe ( 155 mM/L). Patients with normal serum sodium (135-145 mM/L) constituted the reference group. The main outcome was hospital mortality. Analysis was conducted separately for patients admitted on the study day (25·8%) and those already present on the ICU (74·2%). Results: Serum sodium was measured in 13 276 of the 13 796 patients (96·2%). A total of 3815 patients (28·7%) had dysnatraemia: 12·9% with hyponatraemia and 15·8% with hypernatraemia. The prevalence of dysnatraemia was significantly greater in patients already present on the ICU prior to the study day than for those just admitted (13·1% vs. 12·3% for hyponatraemia and 17·1% vs. 12·1% for hypernatraemia, both P < 0·001). Hospital mortality rates were higher in patients with dysnatraemia than in those with normal sodium levels and were directly related to the severity of hypo- and hypernatraemia. This association between dysnatraemia and mortality was similar in infected and noninfected patients (P = 0·061). Conclusions: Dysnatraemia is more frequent during the ICU stay than on the day of admission. Dysnatraemia in the ICU - even mild - is an independent predictor of increased hospital mortality

Strain threshold for ventilator-induced lung injury

Introduction Unphysiological lung strain (tidal volume/functional residual capacity, TV/FRC) may cause ventilator-induced lung injury (VILI) [1]. Whether VILI develops proportionally to the applied strain or only above a critical threshold remains unknown. Methods In 20 healthy, mechanically ventilated pigs, FRC and lung weight were measured by computed tomography. Animals were then ventilated for up to 54 hours with a TV set to produce a predetermined strain. At the end, lung weight was measured with a balance. VILI was defi ned as fi nal lung weight exceeding the initial one. Results Lung weight either did not increase at all (no-VILI group; lung weight change \u201373 \ub1 42 g, n = 9) or markedly augmented (VILI group; 264 \ub1 80 g, n = 11). In the two groups, strain was 1.38 \ub1 0.68 and 2.16 \ub1 0.50 (P <0.01), respectively. VILI occurred only when lung strain reached or exceeded a critical threshold, between 1.5 and 2.1 (Figure 1). Conclusions In animals with healthy lungs VILI only occurs when lung strain exceeds a critical threshold. Reference 1. Gattinoni L, Carlesso E, Cadringher P, et al.: Physical and biological triggers of ventilator-induced lung injury and its prevention [review]. Eur Respir J 2003, 22(Suppl 47):15s-25s