scholarly journals Proximity to the Treating Centre and Outcomes Following Subarachnoid Hemorrhage

2011 ◽  
Vol 38 (1) ◽  
pp. 36-40 ◽  
Author(s):  
Cian J. O'Kelly ◽  
Julian Spears ◽  
David Urbach ◽  
M. Christopher Wallace
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Survival Benefit ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Mortality Rates ◽  
Limited Resources ◽  
Early Complications ◽  
The Impact ◽  
The Relationship

Abstract:Background:In the management of subarachnoid hemorrhage (SAH), the potential for early complications and the centralization of limited resources often challenge the delivery of timely neurosurgical care. We sought to determine the impact of proximity to the accepting neurosurgical centre on outcomes following aneurysmal SAH.Methods:Using administrative data, we analyzed patients undergoing treatment for aneurysmal subarachnoid hemorrhage at neurosurgical centres in Ontario between 1995 and 2004. We compared mortality for patients receiving treatment at a centre in their county (in-county) versus those treated from outside counties (out-of-county). We also examined the impact of distance from the patient's residence to the treating centre.Results:The mortality rates were significantly lower for in-county versus out-of-county patients (23.5% vs. 27.6%, p=0.009). This advantage remained significant after adjusting for potential confounders (HR=0.84, p=0.01). The relationship between distance from the treating centre and mortality was biphasic. Under 300km, mortality increased with increasing distance. Over 300km, a survival benefit was observed.Conclusions:Proximity to the treating neurosurgical centre impacts survival after aneurysmal SAH. These results have significant implications for the triage of these critically ill patients.

scholarly journals Impact of Hyperoxia and Hypocapnia on Neurological Outcomes in Patients with Aneurysmal Subarachnoid Hemorrhage: A Retrospective Study

2019 ◽  
Vol 2019 ◽  
pp. 1-8
Author(s):  
Kin Chio Li ◽  
Catherine Wing Yan Tam ◽  
Hoi-Ping Shum ◽  
Wing Wa Yan
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Critically Ill ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Classification Tree ◽  
Tertiary Hospital ◽  
Classification Tree Analysis ◽  
Radiological Findings ◽  
Neurological Outcomes ◽  
Poor Outcomes ◽  
The Impact

In recent decades, there is increasing evidence suggesting that hyperoxia and hypocapnia are associated with poor outcomes in critically ill patients with cardiac arrest or traumatic brain injury. Yet, the impact of hyperoxia and hypocapnia on neurological outcome in patients with subarachnoid hemorrhage (SAH) has not been well studied. In the present study, we evaluated the impact of hyperoxia and hypocapnia on neurological outcomes in patients with aneurysmal SAH (aSAH). Patients with aSAH who were admitted to the intensive care unit (ICU) of a tertiary hospital in Hong Kong between January 2011 and December 2016 were retrospectively recruited. Patients’ demographics, comorbidities, radiological findings, clinical grades of SAH, PO2, and PCO2 within 24 hours of ICU admission, and Glasgow Outcome Scale (GOS) at 3 months after admission were recorded. Patients with a GOS score of 3 or less were considered having poor neurological outcomes. Among the 244 patients with aSAH, 122 of them (50%) had poor neurological outcomes at 3 months. Early hyperoxia (PO2 > 200 mmHg) and hypercapnia (PCO2 > 45 mmHg) were more common among patients with poor neurological outcomes. Logistic regression analysis indicated that hyperoxia independently predicted poor neurological outcomes (OR 3.788, 95% CI 1.131–12.690, P=0.031). Classification tree analysis revealed that hypocapnia was associated with poor neurological outcomes in patients who were less critically ill (APACHE < 50) and without concomitant intracranial hemorrhage (ICH) or intraventricular hemorrhage (IVH) (adjusted P=0.006, χ2 = 7.452). These findings suggested that hyperoxia and hypocapnia may be associated with poor neurological outcomes in patients with aSAH.

scholarly journals Deferred Consent in a Minimal-Risk Study Involving Critically Ill Subarachnoid Hemorrhage Patients

2014 ◽  
Vol 21 (5) ◽  
pp. 293-296 ◽  
Author(s):  
Jane Topolovec-Vranic ◽  
Marlene Santos ◽  
Andrew J Baker ◽  
Orla M Smith ◽  
Karen EA Burns
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Critically Ill ◽  
Decision Maker ◽  
Critically Ill Patients ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Minimal Risk ◽  
Surrogate Decision Maker ◽  
Sample Collection ◽  
Deferred Consent ◽  
Surrogate Decision

INTRODUCTION: Alterations from first-party and surrogate decision-maker consent can enhance the feasibility of research involving critically ill patients.OBJECTIVE: To describe the use of a deferred-consent model to enable participation of critically ill patients in a minimal-risk biomarker study.METHODS: A prospective observational study was conducted in which serum biomarker samples were collected three times daily over the first 14 days following aneurysmal subarachnoid hemorrhage. Sample collection was initiated on intensive care unit admission and consent was obtained when research personnel could approach the patient or the patient’s surrogate decision maker.RESULTS: Twenty-seven patients were eligible for the study, of whom only five were capable of providing informed consent. Full consent was obtained for 21 (78%) patients through self- (n=4) and surrogate (n=17) consent. Partial consent or refusal (only permitting the collection of blood samples as a part of routine care or use of data) occurred in three patients. Among the 22 consents sought from surrogates, three (11%) refused participation. The refusals included the sickest patients in the cohort. Once consent was provided, no patient or surrogate withdrew consent before study completion.DISCUSSION: Use of a deferred consent model enabled participation of critically ill patients in a minimal-risk biomarker study with no withdrawals.CONCLUSIONS: Further research and enhanced awareness of the potential utility of hybrid models, including deferred consent in addition to patient or surrogate consent, in the conduct of low-risk and minimally interventional time-sensitive studies of critically ill patients are required.

scholarly journals Survival Benefit of Corticosteroid Replacement in Critically Ill Patients: One Treatment Effect or Two?

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A96-A96
Author(s):  
Slavita M Laies ◽  
Clifford R Qualls ◽  
Richard I Dorin
Keyword(s):  
Placebo Group ◽  
Critically Ill ◽  
Treatment Effect ◽  
Critically Ill Patients ◽  
Diagnostic Tests ◽  
Survival Benefit ◽  
Treatment Effects ◽  
Severity Of Illness ◽  
Hyperbolic Function ◽  
The Relationship

Abstract Survival benefit of corticosteroid replacement in critically ill patients: one treatment effect or two? Background: In the comparison of placebo versus corticosteroid replacement therapy (CRT) among ill patients, the treatment effect (difference in 28-day mortality rate between placebo and CRT) tends to vary according to mortality in the placebo group. In this context, we treat 28-day mortality in the placebo group as a surrogate for severity of illness [1]. Hypothesis: In the present era of physiologic CRT, critical illness related corticosteroid insufficiency (CIRCI) may be defined operationally by the difference in clinical outcomes, such as 28-day mortality, between placebo and CRT treatment groups. In this simulation analysis, we examined the hypothesis that treatment effects of CRT observed in various randomized, placebo-controlled clinical trials may be explained by heterogeneous population consisting of two strata, S1 and S2, having discrete conditional probabilities of mortality when treated with CRT vs. placebo. Methods: Using published Randomized Controlled Trial (RCT) data, the relationship between treatment effect and severity of illness was analyzed using a least squares solution weighted by sample sizes. A probability model included likelihoods for outcomes (28-day mortality with placebo vs. CRT) in two population strata: (i) a minority stratum (S1) having treatment effect &gt; 0 and (ii) a majority stratum (S2) having a treatment effect ≤ 0. In a simple simulation scenario we varied the treatment effect in S1 as function of the placebo group mortality in S2 in order to fit the relationship obtained from published RCT data. The potential impact of sensitivity and specificity on diagnostic tests to identify S1 was also addressed. Results: A hyperbolic function (y = [Mx/(K+x)] - A) provided a good fit for published RCT trials of physiologic CRT (treatment effect [y] vs. placebo group mortality rate [x]). Pooling results for S1 and S2 having population frequencies of 0.2 and 0.8, respectively, approximated the observed hyperbolic function of treatment effects and severity of illness. A significant treatment effect was maintained when S1 was identified by diagnostic tests having 75% sensitivity-specificity. Conclusions: Population heterogeneity has not been excluded as an explanation for the relatively modest treatment effect of CRT in critically ill patients. Given the possibility of harm of CRT in the majority population (S2), our model further suggests that clinical or laboratory measures that would distinguish S1 and S2 with reasonable accuracy would significantly improve clinical outcomes and reduce numbers needed to treat. Our findings also support the more general hypothesis that the treatment effects of CRT vary according to severity of illness (1). References: 1.Briegel, J., V. Huge, and P. Mohnle, Hydrocortisone in septic shock: all the questions answered? J. Thorac. Dis, 2018. 10(Suppl 17): p. S1962-S1965.

Improved survival after aneurysmal subarachnoid hemorrhage: review of management during a 12-year period

1999 ◽  
Vol 90 (4) ◽  
pp. 664-672 ◽  
Author(s):  
Kristina G. Cesarini ◽  
Hans-Göran Hårdemark ◽  
Lennart Persson
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Mortality Rate ◽  
Clinical Outcomes ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Mortality Rates ◽  
Favorable Outcome ◽  
Monitoring Methods ◽  
Content Type ◽  
The Impact ◽  
Fine Print

Object. Based on the concept that unfavorable clinical outcome after aneurysmal subarachnoid hemorrhage (SAH), to a large extent, is a consequence of all ischemic insults sustained by the brain during the acute phase of the disease, management of patients with SAH changed at the authors' institution in the mid-1980s. The new management principles affected referral guidelines, diagnostic and monitoring methods, and pharmacological and surgical treatment in a neurointensive care setting. The impact of such changes on the outcome of aneurysmal SAH over a longer period of time has not previously been studied in detail. This was the present undertaking.Methods. The authors analyzed all patients with SAH admitted to the neurosurgery department between 1981 and 1992. This period was divided in two parts, Period A (1981–1986) and Period B (1987–1992), and different aspects of management and outcome were recorded for each period. In total, 1206 patients with SAH (mean age 52 years, 59% females) were admitted; an aneurysm presumably causing the SAH was found in 874 (72%).The 30-day mortality rate decreased from 29% during the first 2 years (1981–1982) to 9% during the last 2 years (1991–1992) (Period A 22%; Period B 10%; p < 0.0001) and the 6-month mortality rate decreased from 34 to 15% (Period A 26%; Period B 16%; p < 0.001). At follow-up review conducted 2 to 9 years (mean 5.2 years) after SAH occurred, patients were evaluated according to the Glasgow Outcome Scale. Subarachnoid hemorrhage—related poor outcome (vegetative or dead) was reduced (Period A 30%; Period B 18%; p < 0.001). There was an increase both in patients with favorable outcome (good recovery and moderate disability) (Period A 61%; Period B 66%) and in those with severe disability (Period A 9%; Period B 16%; p < 0.01).Conclusions. This study provides evidence that the prognosis for patients with aneurysmal SAH has improved during the last decades. The most striking results were a gradual reduction in mortality rates and improved clinical outcomes in patients with Hunt and Hess Grade I or II SAH and in those with intraventricular hemorrhage. The changes in mortality rates and the clinical outcomes of patients with Hunt and Hess Grades III to V SAH were less conspicuous, although reduced incidences of mortality were seen in some subgroups; however, few survivors subsequently appeared to attain a favorable outcome.

Effects of Smoking on Short-Term and Long-Term Mortality after Aneurysmal Subarachnoid Hemorrhage

2021 ◽  
pp. 1-11
Author(s):  
Xing Wang ◽  
Yu Zhang ◽  
Lu Jia ◽  
Tiangui Li ◽  
Chao You ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Smoking Status ◽  
Logistic Models ◽  
Multicenter Cohort Study ◽  
Current Smoking ◽  
Multivariate Relationships ◽  
The Impact ◽  
The Relationship

<b><i>Objective:</i></b> The relationship between smoking and clinical outcomes after aneurysmal subarachnoid hemorrhage (aSAH) is poorly clarified, and current pieces of evidence are inconsistent. The purpose of this multicenter cohort study is therefore to explore the relationship between smoking and mortality as well as several complications after aSAH. <b><i>Methods:</i></b> Databases of patient records were from 4 tertiary hospitals. We assessed the impact of tobacco use and tobacco dose (categorized based on smoking index [SI]) on several complication and overall outcome variables. The primary outcome was mortality within the longest follow-up. Logistic models were used to investigate univariate and multivariate relationships between predictors and outcomes. We also developed a propensity score matching for smoking status by using all known confounders. <b><i>Results:</i></b> A total of 6,578 patients with aSAH were analyzed. Current smoking and former smoking did not show association with mortality within the longest follow-up (odds ratio [OR], 0.95, 95% confidence interval [CI]: 0.69–1.30, <i>p</i> = 0.726; OR, 0.66, 95% CI: 0.38–1.15, <i>p</i> = 0.139, respectively). In addition, patients who were current smokers showed an independent association with the decreased occurrence of hydrocephalus (OR, 0.60; 95% CI: 0.41–0.88; <i>p</i> = 0.009) after matching all known confounders. We also found moderate smoking (SI between 384 and 625) was associated with reduced mortality in hospital. <b><i>Conclusions:</i></b> Our results indicated that in patients with aSAH, current smoking or former smoking was not associated with all-cause mortality up to 7-year follow-up.

Time to Lactate Measurement Affects Efficacy of Initial Lactate on Mortality in critically ill patients with sepsis.

2020 ◽  
Author(s):  
Xueying Luo ◽  
Xiaobo Zheng ◽  
Xi Rao ◽  
Ya Li ◽  
Sujing Zheng ◽  
...  
Keyword(s):  
Hospital Mortality ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Lactate Level ◽  
P Value ◽  
Detection Time ◽  
Lactate Measurement ◽  
Unit Increase ◽  
The Impact ◽  
The Relationship

Abstract Background: Evidence regarding the effect of time to lactate measurement on the relationship between the initial lactate level and mortality is limited. We aimed to investigate the relationships between time to lactate measurement, initial lactate level, and in-hospital mortality in critically ill patients with sepsis.Methods and Results: Of the 14339 eligible adult patients with recognized sepsis upon admission to the ICU based on the MIMIC-III database, the median value of initial lactate was 1.70 mmol/L (interquartile range [IQR] 1.20-2.80), and its detection time was 3.50 hours ([IQR] 1.31-10.24). The results of fully adjusted multivariate analyses demonstrated that lactate was positively associated with in-hospital mortality (odds ratio: 1.126, 95% confidence interval: 1.090 to 1.163, P<0.001), and there was an increase in the odds of death with hourly delays in lactate measurement (OR: 1.006, 95% CI: 1.004 to 1.008, P<0.001). In stratified analyses, delays in lactate measurement significantly interfered with the impact of increased lactate level on mortality (P-value for interaction<0.001). The hospital mortality rate substantially increased by 43.5% for each unit increase in lactate when measurement was delayed by 24 hours (OR: 1.435, 95% CI: 1.260 to 1.635, P<0.001).Discussion: The association of initial lactate with in-hospital mortality is likely to vary with delays in detection time (grouping based on the “1-hour bundle”) in critically ill patients with recognized sepsis upon admission to the ICU.

Terson sign:

2020 ◽  
Vol 2 (1) ◽  
pp. 38-43
Author(s):  
Luiz Severo Bem Junior ◽  
Gustavo De Souza Andrade ◽  
Joao Ribeiro Memória Júnior ◽  
Hildo Rocha Cirne de Azevedo Filho
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Early Recognition ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Case Reports ◽  
Clinical Status ◽  
Vitreous Hemorrhage ◽  
Anterior Communicating Artery ◽  
Inclusion Criteria ◽  
Relationship Of ◽  
The Relationship

Terson's sign (TS) is classically defined as vitreous hemorrhage associated with subarachnoid hemorrhage of aneurysmal origin, being an important predictor of severity, indicating greater morbidity and mortality when compared to patients without the sign. The objective of this study is to review the relationship of Terson syndrome/Terson sign with the prognosis of aneurysmal subarachnoid hemorrhage. A search for original articles, research and case reports was performed on the PubMed, Scielo, Cochrane and ScienceDirect platform, with the following descriptors: Terson sign and subarachnoid hemorrhage. Retrospective, prospective articles and case reports published in the last 5 years and which were in accordance with the established objective and inclusion criteria were selected. Ten (10) articles were selected, in which the available results show an unfavorable prognostic relationship of TS and subarachnoid hemorrhage, because these patients had a worse clinical status assessed on the Glasgow scales ≤ 8, Hunt & Hess > III, Fisher > 3, in addition to intracranial hypertension and location of the aneurysm in the anterior communicating artery complex. The early recognition of this condition described by Albert Terson in 1900 brought an important contribution to neurosurgery, being recognized until nowadays.

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