Background & Objectives: Bilateral absence of cortical response to somatosensory evoked potentials (SSEPs) after cardiac arrest (CA)is an established marker of poor neurological outcome. However, the presence of these responses (N20PRES) has failed to reliably predict good neurological outcome. In the setting of multimodal monitoring, few data are available on the clinical characteristics of N20PRES patients with poor neurological outcome. Materials & Methods: Retrospective analysis of an institutional database (January 2010 to January 2013) including all adult patients admitted to the Intensive Care Unit (ICU) after CA and undergoing SSEPs between 48 and 72 hours after cardiac arrest. All patients underwent targeted temperature management (TTM; 32–34°C) for 24 hours. We collected the absence of pupillary reflexes, absent or posturing motor response and status myoclonus on day 2–3 and electroencephalography (EEG) data (e.g. absence of reactivity to painful stimuli; presence of a malignant pattern, such as burst-suppression or flat tracings; electroencephalographic status epilepticus) after return to normothermia. Poor neurological outcome (PNO) was defined as a Cerebral Performance Categories of 3–5 at assessed at 3 months Results: We studied 126 patients, including 81 with N20PRES; 55 had PNO. Demographics, comorbidities and CA characteristics were similar between groups except for non-cardiac origin of arrest and non-shockable rhythm which were more frequent in patients with PNO than in the others. PNO Patients with N20PRES were more likely to have absent pupillary reflexes (31% vs. 0%; p=0.003), absent or posturing motor response (51% vs. 11%; p=0.001) on day 2–3 than the other patients. They were also more likely to have a malignant EEG pattern, particularly burst suppression (18% vs. 0%; p=0.02) and a non-reactive EEG (75% vs. 27%; p<0.001). All patients with absent pupillary reflexes on day 2–3 had a PNO (p=0.003). Conclusion: In patients with preserved cortical responses to painful stimuli prognostication may be reliably guided by clinical and EEG signs. The presence of early malignant EEG patterns and the absence of pupillary reflexes on day 2–3 are associated with poor neurological outcome The use of a multimodal assessment may be helpful to guide neuroprognostication in this setting. References: 1. Fugate JE, Wijdicks EF, Mandrekar J, et al. Predictors of neurologic outcome in hypothermia after cardiac arrest. Ann Neurol. 2010;68 (6): 907 - 914. 2. Sivaraju, A., Gilmore, E. J., Wira, C. R., Stevens, A., Rampal, N., Moeller, J. J.,Gaspard, N. (2015). Prognostication of post-cardiac arrest coma: early clinical and electroencephalographic predictors of outcome. Intensive Care Medicine, 41(7), 1264–1272 Disclosure of Interest: None declared
SCOPUS: ed.j
OBJECTIVE: Cancer patients frequently require admission to intensive care unit. However, there are a few data regarding predictive factors for mortality in this group of patients. The aim of this study was to evaluate whether arterial lactate or standard base deficit on admission and after 24 hours can predict mortality for patients with cancer. METHODS: We evaluated 1,129 patients with severe sepsis, septic shock, or postoperative after high-risk surgery. Lactate and standard base deficit collected at admission and after 24 hours were compared between survivors and non-survivors. We evaluated whether these perfusion markers are independent predictors of mortality. RESULTS: There were 854 hospital survivors (76.5%). 24 h lactate .1.9 mmol/L and standard base deficit , -2.3 were independent predictors of intensive care unit mortality. 24 h lactate .1.9 mmol/L and 24 h standard base deficit , -2.3 mmol/Lwere independent predictors of hospital death. CONCLUSION: Our findings suggest that lactate and standard base deficit measurement should be included in the routine assessment of patients with cancer admitted to the intensive care unit with sepsis, septic shock or after highrisk surgery. These markers may be useful in the adequate allocation of resources in this population.
info:eu-repo/semantics/published
Disturbed regional oxygenation is believed to contribute to organ dysfunction, organ failure, and death. Recent techniques such as orthogonal polarization spectral/sidestream darkfield imaging and near infrared spectroscopy have provided insight into the microcirculatory alterations present in critically ill patients. Using these techniques, persistent microcirculatory alterations have been shown to be associated with a worse prognosis, notably in patients with septic shock, irrespective of systemic hemodynamic variables. Data on the effects of therapeutic interventions on the microcirculation are also being gathered and may help in developing strategies that can influence regional oxygenation and cellular metabolism, and thereby prevent or reverse organ failure. Whether monitoring the microcirculation can be used to guide therapy remains unclear and requires further study, and this is an exciting field of ongoing research.
Severe sepsis is common and increasing in incidence. Mortality rates remain high. Discovery of the link between the coagulation system and the inflammatory response to sepsis led to the development of drotrecogin alpha (activated). This recombinant form of the natural anticoagulant, activated protein C, was shown to reduce 28-day mortality from severe sepsis in a large, randomised, placebo-controlled, multi-centre Phase III study. Although subsequent studies have demonstrated that drotrecogin alpha (activated) is not of benefit to all patients with severe sepsis, it does reduce mortality rates in patients at a high risk of death. Drotrecogin alpha (activated) is associated with an increased risk of bleeding. Recent studies have shed light on its mode of action, which is primarily attributed today to cytoprotective effects especially on the endothelium with improved microcirculation. Ongoing studies will help define which patients are most likely to benefit, perhaps with the help of biochemical markers.
