Impact of frailty, biomarkers and basic biochemical parameters on outcomes of comatose patients in status epilepticus: a single-center prospective pilot study.

BACKGROUND: Status epilepticus (SE) is a severe acute condition in neurocritical care with high mortality. Searching for risk factors affecting the prognosis in SE remains a significant issue. The primary study's aim was to test the predictive values of the Clinical Frailty Scale (CFS) and the Modified 11-item Frailty Index (mFI-11), the biomarkers and basic biochemical parameters collected at ICU on the Glasgow Outcome Scale (GOS) assessed at hospital discharge (hosp), and three months later (3 M), in comatose patients with SE. The secondary aim was to focus on the association between the patient's state at admission and the duration of mechanical ventilation, the ICU, and hospital stay. METHODS: In two years single-centre prospective pilot study enrolling 30 adult neurocritical care patients with SE classified as Convulsive SE, A.1 category according to the International League Against Epilepsy (ILAE) Task Force without an-/hypoxic encephalopathy, we evaluated predictive powers of CFS, mFI-11, admission Status Epilepticus Severity Score (STESS), serum protein S100, serum Troponin T and basic biochemical parameters on prognosticating GOS using univariate linear regression, logistic regression and Receiver Operating Characteristic (ROC) analysis. RESULTS: Our study included 60% males, with a mean age of 57 ± 16 years (44-68) and a mean BMI of 27 ± 5.6. We found CFS, mFI-11, STESS, and age statistically associated with GOS at hospital discharge and three months later. Among the biomarkers, serum troponin T level affected GOS hosp (p = 0.027). Serum C-reactive protein significance in prognosticating GOS was found by logistic regression (hosp p = 0.008; 3 M p = 0.004), and serum calcium by linear regression (hosp p = 0.028; 3 M p = 0.015). In relation to secondary outcomes, we found associations between the length of hospital stay and each of the following: age (p = 0.03), STESS (p = 0.009), and serum troponin T (p = 0.029) parameters. CONCLUSIONS: This pilot study found promising predictive powers of two frailty scores, namely CFS and mFI-11, which were comparable to age and STESS predictors regarding the GOS at hospital discharge and three months later in ICU patients with SE. Among biomarkers and biochemical parameters, only serum troponin T level affected GOS at hospital discharge.

Yoga Breathing (Maheshwarananda's Modified Bhujangini Pranayama): A Randomized Study in Hypobaric Hypoxemia at 3,650 m Elevation.

Hypobaric hypoxemia represents a risk factor for body integrity and challenges its homeostasis. We examined whether practicing Maheshwarananda's modified bhujangini pranayama yoga breathing technique would influence hypobaric hypoxemia at an altitude of 3,650 m. An international randomized two-period, two-sequence crossover intervention study was conducted in September 2019 in the Himalayas. We compared 5-minute testing periods of pranayama breathing with normal resting breathing in 20 subjects divided randomly into two groups of 10 individuals; all had a daily practice of Maheshwarananda's modified bhujangini pranayama and were nonsmokers, lacto vegetarians, and alcohol abstainers. We measured the arterial saturation by pulse oximetry (SpO2; our primary outcome variable), end-tidal carbon dioxide partial pressure (EtCO2), respiratory rate, and heart rate at two altitudes: (1) 378 m (T0); and (2) 3,650 m (T1 = 2nd day, T2 = 4th day at the camp) immediately after finishing each testing period. We also monitored the presence of acute mountain sickness using the Lake Louise Scoring System. Mean SpO2 at 3,650 m increased right after the yoga breathing exercise from 88.60% to 90.35% at T1, and from 88.35% to 90.60% at T2 (T1 p = 0.007, T2 p = 0.004). No significant changes were observed in heart rate or EtCO2. The mean rate of normal control resting breathing was 13/min; the mean rate was 7/min during the yoga breathing. Right after Maheshwarananda's modified bhujangini pranayama hypobaric hypoxemia decreased as measured by SpO2, whereas EtCO2 and heart rate stayed comparable with the control resting breathing.

Comparison of nursing students' performance of cardiopulmonary resuscitation between 1 semester and 3 semesters of manikin simulations in the Czech Republic: a non-randomized controlled study

PURPOSE: This study aimed to assess the effect of simulation teaching in critical care courses in a nursing study program on the quality of chest compressions of cardiopulmonary resuscitation (CPR). METHODS: An observational cross-sectional study was conducted at the Faculty of Health Studies at the Technical University of Liberec. The success rate of CPR was tested in exams comparing 2 groups of students, totaling 66 different individuals, who completed half a year (group 1: intermediate exam with model simulation) or 1.5 years (group 2: final theoretical critical care exam with model simulation) of undergraduate nursing critical care education taught completely with a Laerdal SimMan 3G simulator. The quality of CPR was evaluated according to 4 components: compression depth, compression rate, time of correct frequency, and time of correct chest release. RESULTS: Compression depth was significantly higher in group 2 than in group 1 (P=0.016). There were no significant differences in the compression rate (P=0.210), time of correct frequency (P=0.586), or time of correct chest release (P=0.514). CONCLUSION: Nursing students who completed the final critical care exam showed an improvement in compression depth during CPR after 2 additional semesters of critical care teaching compared to those who completed the intermediate exam. The above results indicate that regularly scheduled CPR training is necessary during critical care education for nursing students.

Incidence of surgical site infections after cervical spine surgery: results of a single-center cohort study adhering to multimodal preventive wound control protocol.

PURPOSE: The incidence of surgical site infections is considered a relevant indicator of perioperative and postoperative care quality. The aim of this study is to analyze and evaluate SSIs after elective cervical spine surgery under the guidance of our preventive multimodal wound protocol. METHODS: A monocentric observational cohort study analyzed 797 patients who underwent cervical spine surgery from 2005 to 2010 (mean age 51.58 ± 11.74 year, male 56.09%, mean BMI 26.87 ± 4.41, ASA score 1-2 in 81.68% of patients), fulfilling the entry criteria: (1) cervical spine surgery performed by neurosurgeons (degenerative disease 85.19%, trauma 11.04%, tumor 3.76%), (2) elective surgery, (3) postoperative care in our neurointensive care unit. Our preventive wound control protocol management focused mainly on antibiotic prophylaxis, wound hygiene regime, and drainage equipment. All wound complications and surgical site infections were monitored up for 1 year after surgery. RESULTS: We had only 2 (0.25%) patients with SSI after cervical spine surgery-one organ/space infection (osteomyelitis, primary due to liquorrhea) after anterior surgical approach, and one deep surgical site infection (due to dehiscence) after posterior approach. We had 17 (2.13%) patients with some wound complications (secretion 7, dehiscence 4, hematoma 1, edema 3, and liquorrhea 2) that were not classified as SSI according to the CDC guidelines. CONCLUSION: Concerning our study population of patients undergoing elective cervical surgery, with ASA scores 1-2 in 81.68% of our patients, the incidence of SSI was 0.14% after anterior surgical approach, 1.4% after posterior surgical approach, and 0.25% altogether in the referred cohort.

Individualized perioperative management in transoral spine surgery: a single-center cohort study evaluating surgical wound complications and wound infections.

BACKGROUND: Transoral spine surgery is specific due to both its surgical approach and the spectrum of diseases it targets. Patients with high age and elevated clinical frailty scores are often involved, and there are reports of increased risks of surgical site infection (SSI) due to extended exposures requiring maxilotomy or mandibulotomy. Our case series describes surgical wound complications under the meticulous application of individualized perioperative multimodal management. METHODS: Our primary outcome was the occurrence of SSI and the secondary outcome was the occurrence of other noninfectious wound complications evaluated in 22 adult patients who consecutively underwent the transoral spine surgery from 2001 to 2018 (trauma - C2, cervical nonunion: 6 patients, 27%; tumor: 4 patients, 18%; osteomyelitis: 6 patients, 27%; other non-traumatic cases: 6 patients, 27%). Structuralized data comprising parameters related to nosocomial infections after spine surgery were continuously processed and put into specialized database of preventive multimodal nosocomial infection control protocol that was used as a main source of analyzed parameters. The mean age of studied cohort was 54.9 [Formula: see text] 15.5 years, with 68% males, mean body mass index (BMI) 24.9 [Formula: see text] 5.22, and the mean clinical frailty score was 2.59 [Formula: see text] 1.07. There were 7 patients (32%) who only had the transoral approach and 15 patients (68%) having this approach followed by additional posterior approach. We observed SSI from all wound complications for up to one year after surgery. RESULTS: There were 4 (18%) superficial wound complications from transoral approach, but none of them were infected. We had 2 patients (13%) with deep wound infections after subsequent posterior approach, but only one (4.5%) was classified as SSI. CONCLUSIONS: We describe the wound complications and the incidence of SSI in a series of 22 patients after the transoral surgery. Considering the average values of the clinical frailty score reaching 2.59, American Society of Anesthesiologists score of 2.73, and the BMI of 26.87, the transoral spine surgery did not seem to be a considerable risk for SSI in the analyzed cohort, provided preventive perioperative multimodal management is properly individualized and followed.

Yogic breathing in hypobaric environment: breathing exercising and its effect on hypobaric hypoxemia and heart rate at 3,650-m elevation.

High altitude sojourn is a risk factor for hypobaric hypoxemia and subsequent altitude sickness. The aim of this study was to analyze the effect of new type of yogic breathing-Maheshwarananda's new Modified Bhujangini Pranayama performed by active yoga practitioners-on the arterial haemoglobin saturation of oxygen (measured by the pulse oximetry - SpO2) and the heart rate compared to normal spontaneous resting breathing. A pilot prospective study was conducted in the Himalayas at an altitude of 3,650 m. We monitored SpO2 and pulse rate in 34 experienced yoga practitioners. Within the 3 measurement days at the altitude of 3,650 m, the mean value of SpO2 increased from 89.11± 4.78 to 93.26±4.44 (P<0.001) after the yogic breathing exercise. No significant changes were observed in pulse rate (P<0.230) measured before and after yogic breathing. The new Yogic breathing-Maheshwarananda's Modified Bhujangini Pranayama-is increasing the arterial haemoglobin saturation compared to normal resting spontaneous breathing. The heart rate was not affected by this type of yogic breathing.

Risk factors associated with surgical site infections after thoracic or lumbar surgery: a 6-year single centre prospective cohort study.

BACKGROUND: Surgical site infection (SSI) is a risk in every operation. Infections negatively impact patient morbidity and mortality and increase financial demands. The aim of this study was to analyse SSI and its risk factors in patients after thoracic or lumbar spine surgery. METHODS: A six-year single-centre prospective observational cohort study monitored the incidence of SSI in 274 patients who received planned thoracic or lumbar spinal surgery for degenerative disease, trauma, or tumour. They were monitored for up to 30 days postoperatively and again after 1 year. All patients received short antibiotic prophylaxis and stayed in the eight-bed neurointensive care unit (NICU) during the immediate postoperative period. Risk factors for SSI were sought using multivariate logistic regression analysis. RESULTS: We recorded 22 incidences of SSI (8.03%; superficial 5.84%, deep 1.82%, and organ 0.36%). Comparing patients with and without SSI, there were no differences in age (p=0.374), gender (p=0.545), body mass index (p=0.878), spine diagnosis (p=0.745), number of vertebrae (p=0.786), spine localization (p=0.808), implant use (p=0.428), American Society of Anesthesiologists (ASA) Score (p=0.752), urine catheterization (p=0.423), drainage (p=0.498), corticosteroid use (p=0.409), transfusion (p=0.262), ulcer prophylaxis (p=0.409) and diabetes mellitus (p=0.811). The SSI group had longer NICU stays (p=0.043) and more non-infectious hospital wound complications (p<0.001). SSI risk factors according to our multivariate logistic regression analysis were hospital wound complications (OR 20.40, 95% CI 7.32-56.85, p<0.001) and warm season (OR 2.92, 95% CI 1.03-8.27, p=0.044). CONCLUSIONS: Contrary to the prevailing literature, our study did not identify corticosteroids, diabetes mellitus, or transfusions as risk factors for the development of SSI. Only wound complications and warm seasons were significantly associated with SSI development according to our multivariate regression analysis.

Evaluation of regional ventilation by electric impedance tomography during percutaneous dilatational tracheostomy in neurocritical care: a pilot study.

BACKGROUND: Percutaneous dilatational tracheostomy (PDT) has become a widely performed technique in neurocritical care, which is however known to be accompanied by some risks to the patient. The aim of this pilot study was to assess the derecruitment effects of PDT with the electric impedance tomography (EIT) during the PDT procedure in neurocritical care. METHODS: The prospective observational pilot study investigated 11 adult, intubated, mechanically ventilated patients with acute brain disease. We recorded EIT data to determine regional ventilation delay standard deviation (RVD SD), compliance win (CW) and loss (CL), end-expiratory lung impedance (EELI), with the EIT belt placed at the level of Th 4 before, during and after the PDT, performed in the standard PDT position ensuring hyperextension of the neck. RESULTS: From 11 patients, we finally analyzed EIT data in 6 patients - EIT data of 5 patients have been excluded due to the insufficient EIT recordings. The mean RVD SD post-PDT decreased to 7.00 ± 1.29% from 7.33 ± 1.89%. The mean post-PDT CW was 27.33 ± 15.81 and PDT CL 6.33 ± 6.55. Only in one patient, where the trachea was open for 170 s, was a massive dorsal collapse (∆EELI - 25%) detected. In other patients, the trachea was open from 15 to 50 s. CONCLUSIONS: This pilot study demonstrated the feasibility of EIT to detect early lung derecruitment occurring due to the PDT procedure. The ability to detect regional changes in ventilation could be helpful in predicting further progression of ventilation impairment and subsequent hypoxemia, to consider optimal ventilation regimes or time-schedule and type of recruitment maneuvres required after the PDT.

Potential brain dead organ donation in neurocritical care mortality.

BACKGROUND: Mortality is a marker of quality in neurocritical care, but it also provides potential for donors after brain death (DBD) following irreversible acute brain damage. The aim of this study was to analyze the neurointensive care unit (NICU) mortality rate and recovery of potential DBD. METHODS: We performed a 10-year prospective observational cohort computer database analysis of 6138 acute neurological and neurosurgical patients (pts, 58.2% male, mean: age 55.9±14.7 years, body weight 78.3±15.6 kg, body mass index 26.9±4.7, NICU stay 3.8±5.3 days): 3462 (56.4%) pts with brain disease (mostly stroke 43.2%, tumor 31.1%, trauma 13.6%); 10.3% pts with internal carotid artery (ICA) stenosis; 32.6% pts with spine diseases, and others. Mean Acute Physiology and Chronic Health Evaluation (APACHE) II score on admission was 10.63±5.2 and Glasgow Coma Scale on admission was 13.79±2.51. RESULTS: There were 159 (2.6%) cases of mortality with a significantly higher mortality rate in pts with brain diseases (95.6% of deceased pts, P<0.001) than in ICA stenosis (0.6%), spine (1.9%) and from others (1.9%). There were 23 (14.5%) pts with clinical signs of brain death, of whom 13 (56.5%) became donors. The main reasons for non-recovery of potential donors were hemodynamic instability (16.7%) and family reluctance (12.5%). CONCLUSIONS: The study showed that our NICU mortality was 2.6%. There were relatively few clinical signs of brain death and not all potential donors were recovered.

Pre-stroke undiagnosed dysphagia lusoria as a rare cause of aspiration pneumonia with respiratory failure in a stroke patient.

INTRODUCTION: Dysphagia is a risk factor for aspiration pneumonia and acute respiratory failure in acute stroke patients. Dysphagia lusoria is caused by compression on the esophagus from artery lusoria, when the aberrant right subclavian artery arises from the descending aortic arch. We present a rare case report of pre-stroke undiagnosed dysphagia lusoria as a cause of aspiration pneumonia with acute respiratory failure in a 67-year-old female patient admitted with a minor left intracerebral hemorrhage in the left basal ganglia. On admission to the stroke unit, she had Glasgow Coma Scale of 15, National Institutes of Health Stroke Scale of 8, and a negative screening test for dysphagia, dysphasia, and right-sided hemiparesis. After 16 h of admission, dyspnea suddenly occurred with a decrease in SpO2 (72%). X-ray of the lungs showed less ventilated areas of the lung due to aspiration pneumonia and a broad disfigured shadow of the anterior mediastinum on the base of the lusoria artery. Dysphagia lusoria was confirmed by spiral computed tomography angiography. CONCLUSION: One aim of neurocritical care is the prevention of pneumonia from dysphagia due to risk of acute respiratory failure and secondary brain damage. Pre-stroke undiagnosed dysphagia lusoria could be one very rare cause. A broad disfigured shadow of the anterior mediastinum in X-ray of the lungs gives rise to the first suspicion of the possibility of dysphagia lusoria.

Low incidence of multidrug-resistant bacteria and nosocomial infection due to a preventive multimodal nosocomial infection control: a 10-year single centre prospective cohort study in neurocritical care.

BACKGROUND: Nosocomial infection (NI) control is an important issue in neurocritical care due to secondary brain damage and the increased morbidity and mortality of primary acute neurocritical care patients. The primary aim of this study was to determine incidence of nosocomial infections and multidrug-resistant bacteria and seek predictors of nosocomial infections in a preventive multimodal nosocomial infection protocol in the neurointensive care unit (NICU). The secondary aim focused on their impact on stay, mortality and cost in the NICU. METHODS: A10-year, single-centre prospective observational cohort study was conducted on 3464 acute brain disease patients. There were 198 (5.7%) patients with nosocomial infection (wound 2.1%, respiratory 1.8%, urinary 1.0%, bloodstream 0.7% and other 0.1%); 67 (1.9%) with Extended spectrum beta-lactamase (ESBL); 52 (1.5%) with Methicillin-resistant Staphylococcus aureus (MRSA), nobody with Vancomycin-resistant enterococcus (VRE). The protocol included hygienic, epidemiological status and antibiotic policy. Univariate and multivarite logistic regression analysis was used for identifying predictors of nosocomial infection. RESULTS: From 198 NI patients, 153 had onset of NI during their NICU stay (4.4%; wound 1.0%, respiratory 1.7%, urinary 0.9%, bloodstream 0.6%, other 0.1%); ESBL in 31 (0.9%) patients, MRSA in 30 (0.9%) patients. Antibiotics in prophylaxis was given to 63.0% patients (59.2 % for operations), in therapy to 9.7% patients. Predictors of NI in multivariate logistic regression analysis were airways (OR 2.69, 95% CI 1.81-3.99, p<0.001), urine catheters (OR 2.77, 95% CI 1.00-7.70, p=0.050), NICU stay (OR 1.14, 95% CI 1.12-1.16, p<0.001), transfusions (OR 1.79, 95% CI 1.07-2.97, p=0.025) antibiotic prophylaxis (OR 0.50, 95% CI 0.34-0.74, p<0.001), wound complications (OR 2.30, 95% CI 1.33-3.97, p=0.003). NI patients had longer stay (p<0.001), higher mortality (p<0.001) and higher TISS sums (p<0.001) in the NICU. CONCLUSIONS: The presented preventive multimodal nosocomial infection control management was efficient; it gave low rates of nosocomial infections (4.2%) and multidrug-resistant bacteria (ESBL 0.9%, MRSA 0.9% and no VRE). Strong predictors for onset of nosocomial infection were accesses such as airways and urine catheters, NICU stay, antibiotic prophylaxis, wound complications and transfusion. This study confirmed nosocomial infection is associated with worse outcome, higher cost and longer NICU stay.

N-terminal pro-B-type Natriuretic Peptide in three different mechanisms of dysnatremia onset after a child's craniopharyngioma surgery.

Craniopharyngioma, due to its sellar location, can be perioperatively complicated by different types of dysnatremia. We present a rare postoperative onset of a combination of three different mechanisms of dysnatremia with N-terminal pro-B-type Natriuretic Peptide (NT-proBNP) and renal function parameters in a boy with a good outcome after craniopharyngioma surgery: 1/ Central diabetes insipidus (CDI) onset immediately after the operation, hypernatremia with peak serum sodium (SNa) 158 mmol/l) caused by free water polyuria (electrolyte-free water clearance, EWC 0.104 ml/s), NT-proBNP 350 pg/ml; 2/ cerebral salt wasting (CSW) onset on day 7, hyponatremia (SNa 128 mmol/l) with hypoosmolality (measured serum osmolality, SOsm 265 mmol/kg) caused by natriuresis (sodium - daily output 605 mmol/day, fractional excretion 0.035), NT-proBNP 191 pg/ml; 3/ Polydypsia onset on day 11 caused hyponatremia (SNa 132 mmol/l), EWC 0.015, NT-proBNP 68 pg/ml.

Five-Year Follow-Up on Transplanted Organs From Donors After Brain Death After Acute Stroke.

OBJECTIVES: Efficient intensive care donor management can help alleviate the shortage of organs for transplant. The aim of this study was to investigate the efficiency of management of donors after brain death from our neurointensive care unit. MATERIALS AND METHODS: We conducted a prospective observational 5-year follow-up on 29 transplanted organs from 14 brain-dead donors after acute stroke (7 subarachnoid and 4 intracerebral hemorrhages, 3 ischemic strokes). Mean age of donors was 56.2 ± 8.70 years, and mean number of days of artificial ventilation was 5.0 ± 3.84. We transplanted 27 kidneys and 2 livers to 29 patients with mean age of 55.3 ± 9.76 years. No hearts or lungs were transplanted from these donors. RESULTS: Of the 27 patients who underwent kidney transplant, 21 patients (78%) lived 5 years; of those, 17 patients (63%) had functional grafts. One patient (4%) had a primary afunctional graft, and 3 patients (11%) had graft rejection (at 3, 15, and 41 mo). Six patients (22%) died after kidney transplant, with 1 patient in this group having a functional graft, 1 patient having a primary afunctional graft, and 4 patients (15%) having graft rejection (at 1, 12, 44, and 56 mo). The 2 patients with liver transplants lived 5 years with functional grafts. CONCLUSIONS: The 5-year follow-up showed that organs from 14 brain-dead donors improved and saved 19 lives, with 17 patients receiving kidney transplants and 2 patients receiving liver transplants. Another 7 patients had only partially improved quality of life.

Dysnatremia as a poor prognostic indicator in patients with acute subarachnoid hemorrhage.

BACKGROUND: Dysnatremias are common and carry a risk of poor prognosis in acute subarachnoid hemorrhage (SAH) patients. The aim of this study was to determine the frequency and outcome of dysnatremias in 344 SAH patients treated by a targeted sodium management regimen. METHODS: We performed a 10-year observational dysnatremia study. Hyponatremia was defined as serum sodium (SNa) below 135 mmol/L, hypernatremia SNa above 150 mmol/L. RESULTS: Dysnatremia occurred in 35.8% patients; this was more frequently hyponatremia (19.8%) with a mean SNa 132.23±2.09 mmol/L, (16.0% mild, 3.2% moderate, 0.6% severe). Hypernatremia occurred less commonly in 11.9%, P<0.001 with a mean SNa 154.21±3.72 mmol/L, (6.1% mild, 2.9% moderate, 2.9% severe). In 4.8% of patients there were episodes of both dysnatremias. The incidence of hypo-osmolar hyponatremia was 6.4%, Cerebral salt wasting (CSW) 3.5%, syndrome of inappropriate secretion of antidiuretic hormone (SIADH) 0.3% and Central diabetes insipidus 1.7%. The hypernatremic patients had a higher inpatient mortality rate (P=0.001) and a worse overall outcome (P<0.001) than those hyponatremic or normotremic patients. Multivariate logistic regression showed that hypernatremia was an independent risk factor for increased inpatient mortality and poor outcome in patients with SAH. CONCLUSIONS: Our 10-year targeted sodium management regimen in acute SAH patients showed that dysnatremias were frequent, predominantly hyponatremia of which the more usual causes were CSW and not SIADH. Hypernatremia was shown to be an independent risk factor for inpatient mortality and poor outcome.

Polyuria in relation to dysnatraemias in neurocritical care.

INTRODUCTION: Polyuria has the potential to cause severe water and sodium imbalance. We studied the epidemiology of polyuria in association with dysnatraemias and whether polyuria is an independent risk factor for higher mortality and poorer outcome in neurocritical care. METHODS: We performed an analysis of a 3-year prospective database containing 902 neurocritical care patients. Polyuria was defined as diuresis above 4000 ml/day, hyponatraemia as a serum sodium (SeNa) < 135 mmol/l and hypernatraemia as SeNa > 150 mmol/l. RESULTS: We identified polyuria in 236 (26.2%) patients (639 days). Polyuric patients stayed in the neurointensive care unit (NICU) longer than those without polyuria (mean: 10.7 vs. 3.5 days, p < 0.001). These patients also had more frequent cerebral complications (p < 0.001) and a poorer outcome upon discharge from the NICU (p = 0.032). NICU mortality had borderline significance in relation to whether the patients were polyuric (p = 0.055). There were only 49 (20.8%) patients with dysnatraemia who were shown to have a significantly higher NICU mortality (p = 0.006). There were no differences in frequency between hyponatraemic and hypernatraemic polyuric patients (p = 0.127). Polyuric patients with hypernatraemia suffered poorer outcomes (p = 0.009) and higher NICU mortality (p < 0.001), but they had a lower Glasgow Coma Scale or GCS recorded at the onset of polyuria (p < 0.001). Cerebral salt wasting (CSW) was thought to be the cause of polyuria in 7 (3.0%) patients and central diabetes insipidus (CDI) in another 5 (2.1%) patients. Univariate models showed polyuria to be a risk factor for poor outcome (odds ratio [OR] = 1.39, p = 0.032) and had a borderline significance for mortality during their NICU stay (OR = 1.83, p = 0.055). These factors did not appear as significant following multivariate logistic regression analysis. CONCLUSION: Polyuria often occurred in neurocritical care patients, but was not usually associated with sodium imbalance, CSW or CDI. We did not find that polyuria was a significant predictor of increased mortality or poorer outcome in NICU patients.

The Impact of a Standardized Sodium Protocol on Incidence and Outcome of Dysnatremias in Neurocritical Care.

BACKGROUND: Dysnatremias are common and prognostically serious in neurocritical care. We studied whether a standardized sodium protocol would improve our neurocritical care of dysnatremias. METHODS: A 5-year prospective study of a standardized sodium protocol for 1,560 patients admitted with various brain diseases in an adult neurologic-neurosurgical intensive care unit (NNICU) was compared with a 5-year retrospective analysis of 1,440 patients without the sodium protocol. Hyponatremia was defined as serum sodium (SNa(+)) < 135 mmol/L and hypernatremia SNa(+ )> 150 mmol/L. The sodium protocol involved measuring SNa(+), serum, and urine osmolality, measured and calculated renal function parameters, fluid intake 40 mL/kg weight/day without hypotonic saline, thiazide, and desmopressin acetate in all normonatremic NNICU patients. RESULTS: In the protocol study, hyponatremia occurred slightly less often (15.7 versus 16.3% of patients; p = 0.684), hypernatremia was significantly higher (respectively 8.5% versus 5.2% of patients; p < 0.001), and no differences were noted in hypo/hypernatremia (p = 0.483). There were no differences in the incidence of hypo-osmolal hyponatremia (respectively 3.5% versus 3.5% of patients; p = 0.987), cerebral salt wasting (CSW; respectively 1.7% versus 1.7% of patients; p = 0.883), syndrome of inappropriate secretion of antidiuretic hormone (SIADH; respectively 0.1% versus 0.3% of patients; p = 0.152), central diabetes insipidus (CDI; respectively 1.0% versus 0.6% of patients; p = 0.149). In hyponatremia there were no differences in the Glasgow Coma Scale (GCS) score upon onset of hyponatremia (p = 0.294), NNICU mortality (respectively 1.0% versus 0.4% patients; p = 0.074), and bad outcome upon discharge from NNICU (respectively 5.1% versus 6.5% of patients; p = 0.101), but in hypernatremia GCS score upon onset (p < 0.001), mortality (respectively 2.8% versus 1.0%; p < 0.001), and bad outcome from NNICU (respectively 6.7% versus 2.7% patients; p < 0.001) were significantly higher. Multivariate logistic regression analysis showed that hypernatremia, compared with hyponatremia, was a significant predictor of mortality during NNICU stay (respectively odds ratio [OR]: 1.14; p = 0.003 versus OR; 5.3; p = 0.002). CONCLUSIONS: The standard sodium protocol lowered the frequency of SIADH, which was encountered in only one patient over 5 years. However, it did not significantly reduce the incidence and improve the outcome of hyponatremia. Hypernatremia occurred more often and had a higher mortality and worse outcome than hyponatremia, but these patients were neurologically worse upon its onset. The prospective study confirmed that CSW, SIADH, and CDI were not common in our neurocritical care.

Outcome and frequency of sodium disturbances in neurocritically ill patients.

Sodium disturbances are frequent and serious complications in neurocritically ill patients. Hyponatremia is more common than hypernatremia, which is, however, prognostically worse. The aim of this study was to analyse outcome and frequency of sodium disturbances in relation to measured serum osmolality in neurologic-neurosurgical critically ill patients. A 5-year retrospective collection of patients (pts) and laboratory data were made from the Laboratory Information System database in the Clinical Biochemistry Department. The criteria for patients' inclusion was acute brain disease and serum sodium (SNa(+)) <135 mmol/l (hyponatremia) or SNa(+) >150 mmol/l (hypernatremia). Hypoosmolality was defined as measured serum osmolality (SOsm) <275 mmol/kg, hyperosmolality as SOsm >295 mmol/kg. We performed analysis of differences between hyponatremia and hypernatremia and subanalysis of differences between hypoosmolal hyponatremia and hypernatremia. From 1,440 pts with acute brain diseases there were 251 (17 %) pts with hyponatremia (mean SNa(+) 131.78 ± 2.89 mmol/l, SOsm 279.46 ± 11.84 mmol/kg) and 75 (5 %) pts with hypernatremia (mean SNa(+) 154.38 ± 3.76 mmol/l, SOsm 326.07 ± 15.93 mmol/kg). Hypoosmolal hyponatremia occurred in 50 (20 % of hyponatremic patients) pts (mean SNa(+) 129.62 ± 4.15 mmol/l; mean SOsm 267.35 ± 6.28 mmol/kg). Multiple logistic regression analysis showed that hypernatremia is a significant predictor of mortality during neurologic-neurosurgical intensive care unit (NNICU) stay (OR 5.3, p = 0.002) but not a predictor of bad outcome upon discharge from NNICU, defined as Glasgow Coma Scale 1-3. These results showed that hypernatremia occurred less frequently than all hyponatremias, but more often than hypoosmolal hyponatremia. Hypernatremia was shown to be a significant predictor of NNICU mortality compared to hyponatremia.

Central diabetes insipidus is not a common and prognostically worse type of hypernatremia in neurointensive care.

BACKGROUND: Hypernatremia is a common sodium dysbalance in neurointensive care which is associated with worse outcome. It can be caused by central diabetes insipidus (cDI) or by other mechanisms, more often from osmotherapy and furosemide. The aim of this study was to determine the incidence of cDI and to analyse outcome as compared with other causes of hypernatremias found in neurointesive care. METHODS: We analysed 75 hypernatremic (serum sodium, SNa+ >150 mmol/l) patients (pts) with brain diseases admitted over a period of five years to Neurologic-Neurosurgical Intensive Care Unit (NNICU). Firstly we diagnosed cDI according to measured serum and urine osmolality, eletrolyte free water clearance (EWC) and response to desmopressin acetate. The remaining hypernatremias were categorised as "non cDI". We observed Glasgow Coma Scale (GCS) on onset of hypernatremia, incidence of cerebral complications, Glasgow Outcome Scale (GOS) upon discharge from NNICU and mortality in NNICU. RESULTS: We found cDI in 8 pts (mean SNa+ 154.8 ± 5.4 mmol/l). Most pts (67) were classified as "non cDI" hypernatremias (mean SNa+ 154.3 ± 3.6 mmol/l). There were no differences in serum sodium (p=0.682), serum osmolality (p=0.476) between the two groups, however patients with cDI indicated low urine osmolality (p=0.001) and positive EWC (p=0.049). We did not find any differences in GCS score on onset of hypernatremia (p=0.395), incidence of cerebral complications (p=0.705), GOS score upon discharge from NNICU (p=0.61) and mortality in NNICU (p=0.638). More patients in the "non cDI" group received antiedematic therapy (p=0.028) and diuretic furosemide (p=0.026). Multivariate logistic regression analysis showed that independent predictors of NNICU mortality was the highest level of serum sodium (Odds ratio, OR 1.13, per 1 mmol/l increase in maximal hypernatremia during NNICU stay, 95% confidence interval, CI 1.01-1.26, p=0.027), and GCS on admission of less than 9 (OR 2.61, 95% CI 1.41-5.44, p=0.003). CONCLUSIONS: Central diabetes insipidus is not a frequent type of hypernatremia in neurointensive care. Prognosis is connected with serum sodium level, not with type of hypernatremia.

N-terminal pro-B-type natriuretic peptide with fractional excretion and clearance of sodium in relation to cardiovascular events after elective cervical spine surgery.

OBJECTIVES: N-terminal pro-B-type natriuretic peptide (NT-proBNP) is increasingly being used as a biomarker of cardiovascular risk. To date neither its cut-off for postoperative period in noncardiac surgery nor whether the cardiovascular risk has any relation to natriuresis has been assessed. DESIGN: The prospective observational study evaluated postoperative serum levels of NT-proBNP with fractional excretion of sodium (FENa+) and sodium clearance (CNa+) in relation to the occurrence of cardiovascular events in patients after elective cervical spine surgery. METHODS: In 27 otherwise healthy patients after elective cervical spine surgery we prospectively measured serum NT-proBNP and serum sodium immediately after the operation (day 1) and on day two. We correlated both NT-proBNP with FENa+, CNa+, diuresis and intake of fluids and sodium, which were assessed from the beginning of the operation until day two. We followed the incidence of myocardial infarction, heart failure and cardiac death postoperatively to 1 year. RESULTS: Immediate postoperative NT-proBNP values were within the reference range (mean 4.53 ± 2.48 pmol/l), but they increased significantly on the second day (mean 23.57 ± 12.27 pmol/l, p<0.001). Significantly elevated CNa+ (0.033 ± 0.014 ml/s, p<0.001), FENa+ (0.018 ± 0.008, p<0.001) and fUNa+ (mean 326.9 ± 125.2 mmol, p<0.01) were found. There was a significant positive correlation between the two values of NT-proBNP (r=0.47, p=0.014), but we did not find any correlation between NT-proBNP and the further measured parameters. None of the patients had any cardiovascular events from operation until 1 year. CONCLUSIONS: The significant postoperative elevation of NT-proBNP had no relationship with the rise in FENa+, CNa+ or fUNa+ and was not connected with any occurrence of cardiovascular events in patients after elective cervical spine surgery.