Citations

Purpose: The purpose of this study was to evaluate rates of delirium or coma-free days between continuous infusion sedative-dose ketamine and continuous infusion benzodiazepines in critically ill patients. Materials and Methods: In this single-center, retrospective cohort adult patients were screened for inclusion if they received continuous infusions of either sedative-dose ketamine or benzodiazepines (lorazepam or midazolam) for at least 24 h, were mechanically ventilated for at least 48 h and admitted to the intensive care unit of a large quaternary academic center between 5/5/2018 and 12/1/2021. Results: A total of 165 patients were included with 64 patients in the ketamine group and 101 patients in the benzodiazepine group (lorazepam n = 35, midazolam n = 78). The primary outcome of median (IQR) delirium or coma-free days within the first 28 days of hospitalization was 1.2 (0.0, 3.7) for ketamine and 1.8 (0.7, 4.6) for benzodiazepines (p = 0.13). Patients in the ketamine arm spent a significantly lower proportion of time with RASS −3 to +4, received significantly higher doses and longer durations of propofol and fentanyl infusions, and had a significantly longer intensive care unit length of stay. Conclusions: The use of sedative-dose ketamine had no difference in delirium or coma-free days compared to benzodiazepines.

Objective: Stress cardiomyopathy(SCM) occurs between 4-15% in aneurysmal sub-arachnoid hemorrhage(aSAH). Predictors and prognostic implications of SCM in aSAH remains incompletely known. Methods: Adult patients between January 2006-December 2019 with diagnosis of aSAH and echocardiogram during same admission were identified from a prospectively maintained aSAH registry. Presence of SCM was confirmed using the echocardiographic criteria. Severity of aSAH was categorized using the modified Fisher(mFisher) and the World Federation of Neurological Scale(WFNS). Results: Among 570 aSAH patients during study period, 194 aSAH cases had echocardiography and 37(19%) of them had SCM. In comparison to aSAH without SCM, aSAH with SCM were mainly females(76% vs 62%; p= 0.12) and postmenopausal(57±12 vs 59±13 years; p= 0.39). Echocardiographic findings in Table . aSAH with SCM was associated with WFNS grade>3(68% vs 42%; p= 0.005) and mFisher grade>2(87% vs 81%; p= 0.39), intraventricular hemorrhage(IVH)(81% vs 64%; p= 0.04) and larger size of the ruptured aneurysm(8±5 vs 6±4; p= 0.04). Medical management, microsurgical clipping and endovascular coil embolization rates were similar in patients with and without SCM, yet patients with SCM had lower rates of disposition to home(8% vs 27%; p =0.02) and higher in-hospital mortality(41% vs 25%, p= 0.05). On multivariate analysis, ruptured ophthalmic artery aneurysms had 13-times higher odds for formation of SCM(OR 13.43 [1.22-147.8]; p= 0.02). Conclusion: aSAH with SCM predominantly occurred in postmenopausal females with larger aneurysms, and higher severity of bleeds. Ophthalmic artery aneurysms were associated with substantially increased risk of SCM after adjustment for aSAH severity. Despite similar treatment rates, SCM was associated with higher in-hospital mortality. These findings will require further confirmation in a larger subset of aSAH with SCM patients.

Moderate traumatic brain injury (TBI) is a diagnosis that describes diverse patients with heterogeneity of primary injuries. Defined by a Glasgow Coma Scale between 9 and 12, this category includes patients who may neurologically worsen and require increasing intensive care resources and/or emergency neurosurgery. Despite the unique characteristics of these patients, there have not been specific guidelines published before this effort to support decision-making in these patients. A Delphi consensus group from the Latin American Brain Injury Consortium was established to generate recommendations related to the definition and categorization of moderate TBI. Before an in-person meeting, a systematic review of the literature was performed identifying evidence relevant to planned topics. Blinded voting assessed support for each recommendation. A priori the threshold for consensus was set at 80% agreement. Nine PICOT questions were generated by the panel, including definition, categorization, grouping, and diagnosis of moderate TBI. Here, we report the results of our work including relevant consensus statements and discussion for each question. Moderate TBI is an entity for which there is little published evidence available supporting definition, diagnosis, and management. Recommendations based on experts' opinion were informed by available evidence and aim to refine the definition and categorization of moderate TBI. Further studies evaluating the impact of these recommendations will be required.

Background Mechanical thrombectomy (MT) is a safe and effective treatment option for acute ischemic stroke due to large vessel occlusion. To investigate differences in outcomes between patients receiving left-sided and right-sided MT, we performed a systematic review and meta-analysis. Methods A systematic literature review was performed using Embase, PubMed, Scopus, and Web of Science databases. Additional literature was searched for manually. Studies reporting safety and efficacy metrics for MT were included. Data regarding the modified Rankin scale (mRS), thrombolysis in cerebral infarction (TICI), symptomatic intracranial hemorrhage (sICH), and 90-day mortality were included. A random-effects model was used to calculate pooled odds ratios (ORs), mean differences (MDs), and 95% confidence intervals (CIs). Results The literature search yielded 13 reports consisting of 19 studies ranging from 98 to 5590 patients. Patients presenting with left-sided stroke had a National Institutes of health stroke scale score 2.89 greater than patients presenting with right-sided stroke (MD = 2.89; 95% CI = 2.09–3.68; P -value < 0.001). There were no differences between left-sided and right-sided MT patients for mRS 0–2 (OR = 0.94; 95% CI = 0.85–1.04; P -value = 0.224), TICI 2b–3 (OR = 1.05; 95% CI = 0.88–1.25; P -value = 0.598), sICH (OR = 0.83; 95% CI = 0.61–1.14; P -value = 0.255), or 90-day mortality (OR = 1.06; 95% CI = 0.84–1.33; P -value = 0.610). Conclusions There does not appear to be a difference in outcomes for patients undergoing left-sided or right-sided thrombectomy.