Page 20

241300_NCS Currents_March2016_23

JOURNAL WATCH Journal Watch By Chitra Venkatasubramanian MBBS, MSc and Aimee Aysenne MD, MPH After five dedicated years, Chad Miller This study demonstrates that early subjective clinical judgment of and Susanne Muehlschlegel, creators physicians and nurses correlates more closely with actual three- and co-editors of the NEWS (NEW month functional outcomes of ICH patients compared to the ICH Science in neurocritical care) have or FUNC scores. The accuracy of the attendings’ predictions was stepped down. We are excited to step strong even in ambiguous clinical situations, i.e., moderately into the roles of co-editors starting large ICH and middle range GCS. The analysis using the cohort January 2016. We are committed to without CC orders is another strength of the study, eliminating bring top quality reviews of clinically bias due to limiting aggressive measures. The errors for both relevant articles in neurocritical care. In physicians and nurses tended to be more optimistic and both addition, as an acknowledgement to groups underestimated the actual death rate. Finally, it should Chitra the diverse membership of our society, be noted that these formal scales are based on population data Venkatasubramanian we will expand the scope of our reviews and were not designed for individual patient prognostication. MBBS, MSc to include outstanding publications Comparing their performance against clinical judgment for a in medical critical care and pediatric patient’s outcome may not be a robust comparison. neurocritical care. We are very thankful for the precedent set by Drs. Miller and Bradycardia is associated with lower mortality after cardiac Muehlschlegel, their many years of arrest with TTM at 33o C service, and their guidance throughout Thomsen JH, Nielsen N, Hassager C, et al. Critical Care Medicine the transition. 2016;44:308-318. Here we highlight two recent This is a post hoc analysis of the landmark paper that compared commentaries. The first one is a all cause mortality and functional neurological outcomes after pragmatic study in spontaneous ICH targeted temperature management (TTM) at 33o C versus 36o C. Aimee Aysenne The current study evaluates the association of bradycardia withpatients, comparing physician and MD, MPH nursing prognostication in the first 180-day unfavorable neurologic outcome (cerebral performance 24 hours based on clinical judgment versus formal severity category 3-5) and mortality. In the maintenance phase of TTM, scales for predicting actual three-month functional outcome. heart rates were measured at three predefined time points: 12, 20, The second study is a post hoc analysis from the landmark and 28 hours after randomization. targeted temperature management (TTM) trial comparing 33o C versus 36o C in cardiac arrest. The authors evaluated Patients (n=447) assigned to the 33o C group were divided based whether bradycardia during TTM is independently associated on lowest heart rate recorded: bradycardia (HR <50), HR 50-59, with 6-month functional outcomes. and no bradycardia. Mortality increased with increasing heart rate (32% versus 43% versus 60%, p=<0.0001). Even after adjusting Clinical judgment of physicians correlates more closely with for confounding factors that are surrogate markers of prolonged 3-month outcome after ICH than formal prognostic scales resuscitation and hemodynamic variables including vasopressor Hwang DY, Dell CA, Sparks MJ, et al. Neurology 2016;86:126-133. need, bradycardia remained independently associated with a lower 180-day mortality with adjusted HR 0.50 0.34–0.74; p This is a prospective observational study of adults with and lower odds of unfavorable outcome (OR = 0.38 0.21– spontaneous ICH, comparing formal ICH prognostic scales 0.68; p < 0.01). In a multivariate analysis, when heart rate wasadjusted (ICH score and FUNC score) with subjective clinical judgment evaluated as a continuous variable, for every increase of heart rate of physicians and nurses in the Neuro ICU. Exclusion criteria by 5, there was up to an 8% increase in mortality and up to a 12% were screening beyond 24 hours of onset, inability to obtain increase in poor outcome. predictions within 24 hours, comfort care (CC) orders or death before predictions were obtained, and missing three-month o C group, only 8%Of the patients (n=429) assigned to the 36 modified Rankin Scale (mRS). One physician and one nurse experienced HR <50. Due to the low incidence of bradycardia, the from the treating team predicted the three-month mRS using all o C group was divided into quartiles. Those inheart rate in the 36 available information and were asked if they would recommend the lowest quartile had the lowest mortality and lowest odds of CC. Blinded personnel collected the actual three-month mRS by unfavorable neurologic outcome. telephone. mRS scores were compared to the outcome predictions from the ICH and FUNC scores and to that of attending physicians (n=36), physicians in training (n=17), and nurses (n=76) This study demonstrates the association of bradycardia separately. All analyses were also done for the three-month- during the maintenance phase of TTM with lower survivor-only cohort and in those without CC recommendations. mortality and lower odds of poor neurologic outcome at 180 days in comatose cardiac arrest patients. Bradycardia Out of 763 eligible patients, 121 made up the final cohort. is a normal physiologic response of hypothermia and Attending physicians and nurses had more optimistic errors in occurs at temperatures below 35.5o C. Patients who have their predictions compared to actual outcomes. Each group severe anoxic injury may lack an optimally functioning predicted only 17 of 43 deaths at 3 months. Compared to the autonomic nervous system and, therefore, not have a ICH score (r=0.62) or FUNC score (r=-0.56), attending (r=0.78) normal physiologic bradycardic response to temperature and nursing predictions (r=0.72) were closer to the actual three- lowering. Lack of information on medications that affect month mRS. Trainees’ prediction (r=0.64) was comparable to heart rate may add bias to the study. Future research is that of ICH and FUNC scores. Attending predictions continued to needed to validate the hypothesis that bradycardia during perform better even when the analysis was done in the survivor- TTM is indeed an early favorable marker for neurologic only cohort, in those without CC orders, and in those with GCS outcome after cardiac arrest. 5-12 or ICH volume 30-60 cc. 20


241300_NCS Currents_March2016_23
To see the actual publication please follow the link above