Morrow, Lee E.

Introduction: Intracranial hemorrhage (ICH) is associated with high mortality rate of 30-52% despite current advances in management. New cardiovascular abnormalities (CA), such as EKG or cardiac biomarker abnormalities ensue in ICH and are postulated to be due to hypothalamic injury and catecholamine surge. These CA are thought to portend a poor prognosis. Methods: We evaluated clinical studies reporting CA in ICH and assessing their effect on mortality. Studies without a control group, pediatric, and non-English literature were excluded. We extracted data on demographics, comorbidities and mortality [in-hospital (IHM), 30 day (30M) and 90 day (90M)]. CA data included EKG changes (bradycardia, atrial fibrillation, bundle branch blocks, QTc prolongation, ST-segment depression, and ST-segment elevation), biomarker elevation (troponin-T (TnT), CK-MB and BNP), and wall motion abnormalities (WMA). Unadjusted and adjusted rates for CA and pooled risk ratio (RR) with 95% CI were calculated using Mantel-Haenszel random effects model for mortality. Results: We reviewed 453 studies, of which 26 met our inclusion criteria. Heterogeneity varied from moderate to severe depending on the outcome chosen. Of a total 5580 patients, 2796 (50.1%) had sub-arachnoid hemorrhage (SAH), 1633 ICH (29.3%) and 1151 (20.6%) both. The incidence of CA is presented in Table 1. Of these 26 studies, 19 evaluated the influence of new CA on mortality. IHM was noted in 175/566 (30.9%) and 491/2496 (19.7%) patients with and without CA, respectively. In addition, 30M and 90M were noted in 18/38 (47.4%) vs. 14/136 (10.3%) and 90/175 (51.4%) vs. 247/1139 (21.7%) patients with and without CA, respectively. CA was associated with worse IHM (RR 2.03, 95% CI 1.58-2.62, p<0.001), 30M (RR 3.18, 95% CI 1.86-5.42, p<0.001) and 90M (RR 2.11, 95% CI 1.44-3.08, p<0.001) in patients with ICH compared to those who did not have CA. Conclusion: CA are common in patients with ICH and are associated with worse IHM, 30M and 90M.

Background: Little is known about hypoxemia surrounding endotracheal intubation in the critically ill. Thus, we sought to identify risk factors associated with peri-intubation hypoxemia and its effects’ on the critically ill. Methods: Data from a multicenter, prospective, cohort study enrolling 1,033 critically ill adults who underwent endotracheal intubation across 16 medical/surgical ICUs in the United States from July 2015-January 2017 were used to identify risk factors associated with peri-intubation hypoxemia and its effects on patient outcomes. We defined hypoxemia as any pulse oximetry ≤ 88% during and up to 30 minutes following endotracheal intubation. Results: In the full analysis (n = 1,033), 123 (11.9%) patients experienced the primary outcome. Five risk factors independently associated with our outcome were identified on multiple logistic regression: cardiac related reason for endotracheal intubation (OR 1.67, [95% CI 1.04, 2.69]); pre-intubation noninvasive ventilation (OR 1.66, [95% CI 1.09, 2.54]); emergency intubation (OR 1.65, [95% CI 1.06, 2.55]); moderate-severe difficult bag-mask ventilation (OR 2.68, [95% CI 1.72, 4.19]); and crystalloid administration within the preceding 24 hours (OR 1.24, [95% CI 1.07, 1.45]; per liter up to 4 liters). Higher baseline S p O 2 was found to be protective (OR 0.93, [95% CI 0.91, 0.96]; per percent up to 97%). Consistent results were seen in a separate analysis on only stable patients (n = 921, 93 [10.1%]) (those without baseline hypoxemia ≤ 88%). Peri-intubation hypoxemia was associated with in-hospital mortality (OR 2.40, [95% CI 1.33, 4.31]; stable patients: OR 2.67, [95% CI 1.38, 5.17]) but not ICU length of stay (point estimate 0.9 days, [95% CI −1.0, 2.8 days]; stable patients: point estimate 1.5 days, [95% CI −0.4, 3.4 days]) after adjusting for age, body mass index, illness severity, airway related reason for intubation (i.e., acute respiratory failure), and baseline S P O 2 . Conclusions: Patients with pre-existing noninvasive ventilation and volume loading who were intubated emergently in the setting of hemodynamic compromise with bag-mask ventilation described as moderate-severe were at increased risk for peri-intubation hypoxemia. Higher baseline oxygenation was found to be protective against peri-intubation hypoxemia. Peri-intubation hypoxemia was associated with in-hospital mortality but not ICU length of stay. Trial registration: Clinicaltrials.gov identifier: NCT02508948 and Registered Report Identifier: RR2-10.2196/11101.

Background: The role of B-type natriuretic peptide (BNP) is less understood in the risk stratification of patients with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD), especially in patients with normal left ventricular ejection fraction (LVEF). Methods: This retrospective study from 2008 to 2012 evaluated all adult patients with AECOPD having BNP levels and available echocardiographic data demonstrating LVEF ≥40%. The patients were divided into groups 1, 2, and 3 with BNP ≤ 100, 101 to 500, and ≥501 pg/mL, respectively. A subgroup analysis was performed for patients without renal dysfunction. Outcomes included need for and duration of noninvasive ventilation (NIV) and mechanical ventilation (MV), NIV failure, reintubation at 48 hours, intensive care unit (ICU) and total length of stay (LOS), and in-hospital mortality. Two-tailed P < .05 was considered statistically significant. Results: Of the total 1145 patients, 550 (48.0%) met our inclusion criteria (age 65.1 ± 12.2 years; 271 [49.3%] males). Groups 1, 2, and 3 had 214, 216, and 120 patients each, respectively, with higher comorbidities and worse biventricular function in higher categories. Higher BNP values were associated with higher MV use, NIV failure, MV duration, and ICU and total LOS. On multivariate analysis, BNP was an independent predictor of higher NIV and MV use, NIV failure, NIV and MV duration, and total LOS in groups 2 and 3 compared to group 1. B-type natriuretic peptide continued to demonstrate positive correlation with NIV and MV duration and ICU and total LOS independent of renal function in a subgroup analysis. Conclusion: Elevated admission BNP in patients with AECOPD and normal LVEF is associated with worse in-hospital outcomes and can be used to risk-stratify these patients.