Inadvertent hypothermia after endovascular therapy is not associated with improved outcome in stroke due to anterior circulation large vessel occlusion.

BACKGROUND AND PURPOSE: Hypothermia may be neuroprotective in acute ischemic stroke. Patients with anterior circulation large vessel occlusion (acLVO) are frequently hypothermic after endovascular therapy (EVT). We sought to determine whether this inadvertent hypothermia is associated with improved outcome. METHODS: We extracted data of consecutive patients (January 2016 to May 2019) who received EVT for acLVO from our prospective EVT register of all patients screened for EVT at our tertiary stroke center. We assessed functional outcome at 3 months and performed multivariate analysis to calculate adjusted risk ratios (aRRs) for favorable outcome (modified Rankin Scale scores = 0-2) and mortality across patients who were hypothermic (<36°C) and patients who were normothermic (≥36°C to <37.6°C) after EVT. Moreover, we compared the frequency of complications between these groups. RESULTS: Among 837 patients screened, 416 patients received EVT for acLVO and fulfilled inclusion criteria (200 [48.1%] male, mean age = 76 ± 16 years, median National Institutes of Health Stroke Scale score = 16, interquartile range [IQR] = 12-20). Of these, 209 patients (50.2%) were hypothermic (median temperature = 35.2°C, IQR = 34.7-35.7) and 207 patients were normothermic (median temperature = 36.4°C, IQR = 36.1-36.7) after EVT. In multivariate analysis, hypothermia was not associated with favorable outcome (aRR = 0.99, 95% confidence interval [CI] = 0.75-1.31) and mortality (aRR = 1.18, 95% CI = 0.84-1.66). More hypothermic patients suffered from pneumonia (36.4% vs. 25.6%, p = 0.02) and bradyarrhythmia (52.6% vs. 16.4%, p < 0.001), whereas thromboembolic events were distributed evenly (5.7% vs. 6.8%, not significant). CONCLUSIONS: Inadvertent hypothermia after EVT for acLVO is not associated with improved functional outcome or reduced mortality but is associated with an increased rate of pneumonia and bradyarrhythmia in patients with acute ischemic stroke.

Team Prenotification Reduces Procedure Times for Patients With Acute Ischemic Stroke Due to Large Vessel Occlusion Who Are Transferred for Endovascular Therapy.

Background: The clinical benefit from endovascular therapy (EVT) for patients with acute ischemic stroke is time-dependent. We tested the hypothesis that team prenotification results in faster procedure times prior to initiation of EVT. Methods: We analyzed data from our prospective database (01/2016-02/2018) including all patients with acute ischemic stroke who were evaluated for EVT at our comprehensive stroke center. We established a standardized algorithm (EVT-Call) in 06/2017 to prenotify team members (interventional neuroradiologist, neurologist, anesthesiologist, CT and angiography technicians) about patient transfer from remote hospitals for evaluation of EVT, and team members were present in the emergency department at the expected patient arrival time. We calculated door-to-image, image-to-groin and door-to-groin times for patients who were transferred to our center for evaluation of EVT, and analyzed changes before (-EVT-Call) and after (+EVT-Call) implementation of the EVT-Call. Results: Among 494 patients in our database, 328 patients were transferred from remote hospitals for evaluation of EVT (208 -EVT-Call and 120 +EVT-Call, median [IQR] age 75 years [65-81], NIHSS score 17 [12-22], 49.1% female). Of these, 177 patients (54%) underwent EVT after repeated imaging at our center (111/208 [53%) -EVT-Call, 66/120 [55%] +EVT-Call). Median (IQR) door-to-image time (18 min [14-22] vs. 10 min [7-13]; p < 0.001), image-to-groin time (54 min [43.5-69.25] vs. 47 min [38.3-58.75]; p = 0.042) and door-to-groin time (74 min [58-86.5] vs. 60 min [49.3-71]; p < 0.001) were reduced after implementation of the EVT-Call. Conclusions: Team prenotification results in faster patient assessment and initiation of EVT in patients with acute ischemic stroke. Its impact on functional outcome needs to be determined.

Association of Anesthetic Exposure Time With Clinical Outcomes After Endovascular Therapy for Acute Ischemic Stroke.

Background: The optimal sedative regimen with general anesthesia (GA) or conscious sedation for patients undergoing endovascular therapy (EVT) remains controversial. Apart from sedative regimen, the duration of anesthetic exposure may affect clinical outcomes. We aimed to determine whether there is an association between anesthetic exposure time and clinical outcomes in mechanically ventilated stroke patients undergoing EVT for large vessel occlusion. Methods: This was an observational study of consecutive ischemic stroke patients who underwent EVT for anterior circulation large vessel occlusion under GA from January 2016 to March 2018. To minimize confounding by indication, we restricted our analysis to patients whose anesthetic exposure lasted <72 h. Multivariable logistic regression modeling adjusted for covariates was employed to evaluate whether 90-days independent functional outcome (defined as modified Rankin Scale scores 0-2) and 90-days survival could be predicted by anesthetic exposure time. Results: During the study period, 138 patients with ischemic stroke who underwent EVT received GA and fulfilled our study criteria: median age was 77 years (interquartile range, 65-82); 46.4% were men; median NIHSS score was 18 (15-21), median ASPECT score was 7 (6-8). Median duration of GA was 5.4 (2.5-19.7) h. Logistic regression modeling revealed an independent association between duration of anesthetic exposure and both 90-days independent functional outcome (p = 0.034) and 90-days survival (p = 0.011). Each additional 15-min of anesthetic exposure decreased the likelihood of achieving an independent functional outcome at 90 days by 1.5% and of being alive at 90 days by 1.0%. Conclusion: Our data promotes the notion that ischemic stroke patients who require peri-interventional GA for EVT should be extubated as soon as possible after the procedure.

Fish or chips?

Cell membranes are not simply barriers separating intracellular from extracellular space. Rather, they represent a dynamic high-turnover system that adapts to current demands. During inflammation, prostaglandins and leukotrienes are formed from membrane-derived phospholipids. Encouraging improvements in critically ill patients were observed after nutritional replacement of long-chain omega-6 fatty acids with long-chain omega-3-fatty acids, contained in fish oil.

Propofol in a medium- and long-chain triglyceride emulsion: pharmacological characteristics and potential beneficial effects.

UNLABELLED: Hypertriglyceridemia is a possible unwanted effect during long-term propofol sedation while using a formulation containing long-chain triglycerides (LCT) from soybean oil. The use of propofol formulated in a solvent consisting of medium-chain triglycerides (MCT) and LCT might reduce the risk. Because a new solvent may affect the pharmacological profile of propofol, in this prospective, randomized, controlled, and double-blinded study we compared the pharmacodynamic and kinetic characteristics of propofol diluted in MCT/LCT fat solution with those of propofol formulated in LCT fat emulsion. In addition, serum triglyceride levels were measured during and after the administration of both drugs. Thirty patients likely to require mechanical ventilation over at least 48 h were randomized to receive either propofol 2% MCT/LCT (Group 1) or propofol 2% LCT (Group 2). Infusion rates of propofol (2.34 +/- 0.83 mg. kg(-1). h(-1) in Group 1 versus 2.31 +/- 0.6 mg. kg(-1). h(-1) in Group 2), the plasma propofol concentrations during infusion (0.95 +/- 0.53 versus 0.98 +/- 0.32 micro g/mL), and the concentrations and arousal behavior after discontinuation of the drug did not show significant differences. Plasma triglyceride concentrations during sedation did not differ between the groups, whereas there was a tendency toward a more rapid triglyceride elimination in Group 1 after termination of the propofol administration. IMPLICATIONS: Propofol diluted in an emulsion of medium- and long chain-triglycerides shows equivalent pharmacological properties during long-term sedation compared with its hitherto well known formulation containing long-chain triglycerides only. In addition, potential favorable effects on the plasma triglyceride profile could be found.

Progressive electroencephalogram frequency deceleration despite constant depth of propofol-induced sedation.

OBJECTIVE: To investigate a possible time-dependent effect of propofol sedation on electroencephalographic activity, we analyzed the electroencephalogram frequency behavior while keeping patients at a constant level of sedation. DESIGN: Prospective, controlled trial. SETTING: Intensive care unit of a university hospital. PATIENTS: Twenty patients without neurologic or metabolic disorders. MEASUREMENTS AND MAIN RESULTS: During sedation with propofol (1-4 mg x kg(-1) x hr(-1)), a bifrontally recorded processed electroencephalogram was obtained. For 48 hrs, sedation was kept constant at a level according to Ramsay Scale 3 while we adjusted the dosage of propofol given per hour. At hours 6, 18, 30, and 42, blood samples were taken to assess the plasma concentration of propofol. The electroencephalogram values of 60 mins obtained during 1 hr before blood sampling were taken for further calculation. From the data, relative band power of the beta-, alpha-, theta, and delta-bands, spectral median frequency, and spectral edge frequency 90 and 95 were computed. For statistical analysis, a polynomial three-factorial repeated-measures analysis of variance with covariates was performed. Relative power of beta- and alpha-wavebands showed a constant and significant decrease over time (beta, 15.5%, 10.3%, 10.3%, 7.6%; alpha, 14.8%, 13.4%, 10.0%, 8.3%), whereas relative delta power increased (delta, 56.4%, 63.4%, 70.7%, 72.3%). The theta-waveband remained unchanged. Accordingly, spectral edge frequency 90 and 95 and spectral median frequency decreased significantly. From hours 6 to 18, a significant increase of the plasma propofol concentration was found. Subsequently, the level remained constant. CONCLUSION: Despite constant sedation, a longer period of propofol application induces a time-dependent electroencephalogram frequency deceleration. The use of electroencephalogram derivatives to monitor depth of sedation in the intensive care unit thus should be regarded cautiously.