Early Lymphopenia and Infections in Nontraumatic Subarachnoid Hemorrhage Patients.

INTRODUCTION: Subarachnoid hemorrhage (SAH) is associated with high morbidity and mortality. A certain degree of immunodepression has been reported during critical illness, and lymphopenia identified as an independent predictor of poor outcome; no data are available for critically ill SAH patients. We aimed to evaluate the prevalence of lymphopenia among SAH patients and its association with hospital-acquired infection. METHODS: Retrospective cohort study of adult patients admitted to an intensive care unit with nontraumatic SAH between January 2011 and May 2016. Lymphocyte count was obtained daily for the first 5 days; lymphopenia was defined as lymphocyte count <1000/mm3. The occurrence of infection during the first 21 days after hospital admission, hospital mortality, and unfavorable neurological outcome (Glasgow Outcome Scale score 1 to 3 at 3 mo) were recorded. RESULTS: Data from 270 patients were analyzed (median age 54 y; male 45%); 121 (45%) patients had lymphopenia and 62 (23%) patients developed infections. Median (25th to 75th percentiles) lymphocyte count at hospital admission was 1280 (890 to 1977)/mm3. Lymphopenia patients had more episodes of infection (38/121, 31% vs. 24/139, 17%; P=0.003) than nonlymphopenia patients, while mortality and unfavorable outcome were similar. Lymphopenia was not independently associated with the development of infection, unfavorable neurological outcome or with mortality. CONCLUSIONS: Early lymphopenia is common after SAH, but is not significantly associated with the development of infections or with poor outcome.

Multimodal Approach to Predict Neurological Outcome after Cardiac Arrest: A Single-Center Experience.

Introduction: The aims of this study were to assess the concordance of different tools and to describe the accuracy of a multimodal approach to predict unfavorable neurological outcome (UO) in cardiac arrest patients. Methods: Retrospective study of adult (>18 years) cardiac arrest patients who underwent multimodal monitoring; UO was defined as cerebral performance category 3-5 at 3 months. Predictors of UO were neurological pupillary index (NPi) ≤ 2 at 24 h; highly malignant patterns on EEG (HMp) within 48 h; bilateral absence of N20 waves on somato-sensory evoked potentials; and neuron-specific enolase (NSE) > 75 µg/L. Time-dependent decisional tree (i.e., NPi on day 1; HMp on day 1-2; absent N20 on day 2-3; highest NSE) and classification and regression tree (CART) analysis were used to assess the prediction of UO. Results: Of 137 patients, 104 (73%) had UO. Abnormal NPi, HMp on day 1 or 2, the bilateral absence of N20 or NSE >75 mcg/L had a specificity of 100% to predict UO. The presence of abnormal NPi was highly concordant with HMp and high NSE, and absence of N20 or high NSE with HMp. However, HMp had weak to moderate concordance with other predictors. The time-dependent decisional tree approach identified 73/103 patients (70%) with UO, showing a sensitivity of 71% and a specificity of 100%. Using the CART approach, HMp on EEG was the only variable significantly associated with UO. Conclusions: This study suggests that patients with UO had often at least two predictors of UO, except for HMp. A multimodal time-dependent approach may be helpful in the prediction of UO after CA. EEG should be included in all multimodal prognostic models.

Association of anemia and transfusions with outcome after subarachnoid hemorrhage.

INTRODUCTION: The benefits of correcting anemia using red blood cell transfusion (RBCT) after subarachnoid hemorrhage (SAH) are controversial. We aimed to evaluate the role of anemia and RBCT on neurological outcome after SAH using a restrictive transfusion policy. OBJECTIVE: We reviewed our institutional database of adult patients admitted to the Department of Intensive Care (ICU) after non-traumatic SAH over a 5-year period. We recorded hemoglobin (Hb) levels daily for a maximum of 20 days, as well as the use of RBCT. Unfavorable neurological outcome (UO) was defined as a Glasgow Outcome Score of 1-3 at 3 months. RESULTS: Among 270 eligible patients, UO was observed in 40% of them. Patients with UO had lower Hb over time and received RBCT more frequently than others (15/109, 14% vs. 6/161, 4% - p < 0.01). Pre-RBCT median Hb values were similar in UO and FO patients (6.9 [6.6-7.1] vs. 7.3 [6.3-8.1] g/dL - p = 0.21). The optimal discriminative Hb threshold for UO was 9 g/dL. In a multivariable analysis, neither anemia nor RBCT were independently associated with UO. CONCLUSION: In this retrospective single center study using a restrictive strategy of RBCT in SAH patients was not associated with worse outcome in 3 months.

The Impact of Extracerebral Infection After Subarachnoid Hemorrhage: A Single-Center Cohort Study.

BACKGROUND: Subarachnoid hemorrhage (SAH) is associated with high morbidity. Among all complications, infections, in particular if hospital acquired, could represent an important cause of death in patients with SAH. The aim of this study was to describe infectious complications in patients with SAH and to evaluate their impact on outcome. METHODS: A single-center cohort study included all patients with SAH admitted from January 2011 to December 2016, who stayed in the intensive care unit for at least 24 hours. Infection diagnosis was retrieved from medical files; central nervous system infections were not included. A multivariable analysis was performed to identify risk factors for development of infection. Logistic regression was performed to identify risks for unfavorable neurologic outcome at 3 months, defined as a Glasgow Outcome Scale score of 1-3. RESULTS: Of the 248 patients with SAH, 70 (28.2%) developed at least 1 infection; the most frequent site of infection was respiratory (57.1%), primary bloodstream (16%), and urinary tract infections (15.7%). Twenty-eight patients (11.3% of all patients) had at least 1 episode of septic shock. Infected patients had a higher unfavorable outcome rate (60.0% vs. 33.3%; P = 0.001). Diabetes mellitus (subdistribution hazard ratio, 1.79; 95% confidence interval [CI], 1.03-3.13) and intracranial hypertension (subdistribution hazard ratio, 1.92; 95% CI, 1.14-3.25) were independently associated with the occurrence of infections. Septic shock (odds ratio, 6.36; 95% CI, 1.24-32.51; P = 0.02) was independently associated with unfavorable outcome. CONCLUSIONS: Infections in patients with SAH are prevalent, especially pneumonia. Septic shock is associated with a poor neurologic outcome in this group of patients.