Precise And Quantitative Critical Condition Assessment Of Neurocritical Patients

Part 1 The application of APACHE? score for the assessment of critically ill patients in NICUBackground Acute physiology and chronic health evaluation II(APACHE?),as a widely used scoring index for patients' condition and outcomes,can be used to objectively assess the condition of critically ill patients and to predict their mortality.However,the application of APACHE? score specifically for critically ill patients with neural disease was limited.Researches concern the value of the APACHE? score in NICU(neurological intensive care unit)was rarely reported.Objective To investigate the application of APACHE? scoring in neurological critically ill patients,APACHE? score system was applied in NICU of Tongji Hospital of Tongji medical college of Huazhong University of Science and Technology(HUST)to assess patients' condition and predict their mortality risk.Methods This is a prospective observational study.242 critically ill patients admitted into NICU of Tongji Hospital of Tongji medical college of HUST were consecutively enrolled in this study.Demographic data,main diagnosis,complications,APACHE? score at ICU admission and discharge,length of NICU stay,mortality in NICU,mortality of 28 days were collected.For all enrolled patients,the worst parameters within the 24 hours of NICU admission was used for the NICU admission APACHE? scoring.With the same policy,NICU discharge APACHE? scoring was done.By this APACHE? score,the expected case fatality rate(R)was calculated by a given formula.Expected fatality rate of the study population was defined as the mean of the expected case fatality rate.Statistical analysis was performed using SPSS 19.0 software.Student t-test was used for the quantitative variables and either Pearsons' ?2 test,Continuity Correction test or Fisher's Exact test was used for qualitative variables.SPSS 19.0 software and Prisam Graphpad5.0 were used for statistical analysis and curve formation for the receiver operating characteristic curve(ROC curve).The area under the ROC curve(AU-ROC)was used to evaluated the diagnostic value of APACHE? score system.Results Intracerebral hemorrhage,cerebral infarction and intracranial infection ranked to the top-three of admission main diagnosis of enrolled patients.Those critically ill patients with high mortality risk received relatively good outcomes under intensive treatment in NICU,which delivered a message that those neurological critically ill patients may get profit from NICU.Expected fatality rate of the study population which calculated by APACHE? score was very close to the actual mortality of 28 days.With the increasing of APACHE? score,the expected fatality rate of the study population increased accordingly,while the actual mortality also increased.However,in patients with a relative low APACHE? score,the expected fatality rate usually higher than the actual fatality rate.By setting death during ICU stay as primary outcome,the APACHE? score at ICU admission,expected fatality rate and adjusted expected fatality rate of non-survival group were significantly higher than the survival group.By setting death at 28 days as secondary outcome,the APACHE? score at ICU admission,expected fatality rate and adjusted expected fatality rate of non-survival group were also significantly higher than the survival group.These results suggested that a high APACHE? score might indicate a poor prognosis of critically ill patient in NICU.Patients with APACHE? score equal to or higher than 10 had a significant higher expected fatality rate and mortality than those who had an APACHE? score lower than 10,which suggested that APACHE? score of 10 would be a reasonable indicator for deciding to enroll a patient into or discharge from ICU.Conclusion APACHE? score system showed signality in assessment of critically ill patients in NICU and value in predicting their prognosis.Part 2 Evaluation of nutrition risk assessment methods in neurological critically ill patients and predicting the prognosisBackground Critically ill patients in NICU are susceptible to nutrition risk.High nutrition risk is associated with poor prognosis by increasing patients' mortality,hospital infection rate,length of ICU stay,mechanical ventilation time and hospital costs.As a result,to assess neurological critically ill patients' nutrition risk is important.Nutrition risk assessment methods include nutrition risk screening tools,physical examinations and laboratory tests.Nutrition risk screening 2002(NRS 2002)and Nutrition Risk in Critically ill score(NUTRIC score),which can objectively assess patients' acute ill condition and nutrition status,can be applied easily and quickly in clinic.These two tools' assessments combined both nutrition status and ill condition simultaneously.However,NRS 2002 can not reveal the critical ill condition of those critically ill patients,while NUTRIC score system was not applied widely in clinic since its recent propose.As a result,the application of NUTRIC score system in critically ill patients in NICU need further inspections.Objective NRS 2002,NUTRIC and m NUTRIC score systems were applied to screen critically ill patients' nutrition risk and to investigate the relation between nutrition risk and critically ill patients' prognosis.The value of these screening systems in patients' nutrition risk assessment and prognosis prediction were investigated.Methods This is a prospective observational study.140 critically ill patients admitted into NICU of HUST were consecutively enrolled in this study.Demographic data,height,body weight,main diagnosis,complications,nutritional support form,initiate time of enteral nutrition(EN),way of EN,dosage of EN,complication of EN,hospital infection,vasopressor administration,renal replacement therapy,mechanical ventilation,length of NICU stay,length of hospital stay,mortality of NICU,mortality of 28 days were collected.NRS 2002,NUTRIC and m NUTRIC scoring were applied for enrolled patients at NICU admission.Laboratory test was performed at the NICU admission,the end of 1 week hospital stay and the end of 2 weeks hospital stay for serum albumin(ALB),pre-albumin(PA)and lymphocyte counting.Statistical analysis was performed using SPSS 19.0 software.Student t-test was used for the quantitative variables and either Pearsons' ?2 test,Continuity Correction test or Fisher's Exact test was used for qualitative variables in the univariate analysis of risk factors.The logistic regression backward method was used for multivariate analysis of the risk factors.Repeated measurement data was analyzed by Prisma Graph Pad 5.0 software using two-way ANOVA test followed by either Bonferroni post-test or Student t-test for comparing difference between groups at a certain time point.SPSS 19.0 software was used for statistical analysis and curve formation for the ROC curve.The AU-ROC was used to evaluated the diagnostic value of NRS2002?NUTRIC?m NUTRIC score system.Results Critically ill patients exhibited high nutrition risk.By NRS 2002 scoring,87.1% patients had nutrition risk while 12.9% patients did not have nutrition risk.By NUTRIC scoring,it revealed 84.3% patients with high nutrition risk while 15.7% patients without.By m NUTRIC scoring,it revealed 71.4% patients with high nutrition risk while 28.6% patients without.With the prolongation of hospital stay,both ALB and PA showed a trend of decreasing.At the end of 2 weeks hospital stay,the level of ALB and PA of non-survival group are significantly lower than survival group,which suggested dynamically monitoring of ALB as well as PA can reflect changes of patients' nutrition status.Relatively,NRS 2002 score system had a limited discrimination in assessing the extent of nutrition risk.While NUTRIC and m NUTRIC score system exhibited a satisfying discrimination in assessing the extent of nutrition risk,especially in patients with high nutrition risk.Neurological critically ill patients in our NICU received relatively normative nutrition support.The ratio of patients who received nutrition support was high(97.1%).The ratio of patients received EN was 82.1%.EN was delivered mainly from nasogastric tube(78.3%),while few patients from nasointestinal tube(3.5%).The initiate time of EN was relatively early since 76.5% patients who received EN was initiated EN within 24 hours after ICU admission.Patients exhibited good tolerance to EN support.Age more than 60 years old,hospital infection,mechanical ventilation,high nutrition risk(based on m NUTRIC scoring)were identified as independent risk factors for the mortality of 28 days.For the subgroup of patients who survived for more than 1 week,mechanical ventilation and high nutrition risk(based on m NUTRIC scoring)were identified as independent risk factors for the mortality of 28 days.For the subgroup of patients who survived for more than 2 weeks,only high nutrition risk(based on m NUTRIC scoring)remained significant as independent risk factors for the mortality of 28 days.Based on m NUTRIC scoring,high nutrition risk group had significant higher ratio of lung infection,hospital infection,organ dysfunction,vasopressor administration and mechanical ventilation and showed significantly increased mortality of NICU and mortality of 28 days.m NUTRIC score system exhibited predictive value for mortality of 28 days of patients in NICU.Furthermore,as the length of hospital stay increased,the predictive value of nutritional risk for outcomes was more meaningful than other measurements.Conclusion The m NUTRIC score system is not only a useful tool for assessing nutrition risk of neurological critically ill patients in NICU,but also a predictive tool for mortality of 28 days.It is therefore a valuable tool for assessing nutrition risk and prognosis of patients in NICU.Part 3 Assessment,prevention and treatment of venous thromboembolism in neurological critically ill patientsBackground Venous thromboembolism(VTE),including deep vein thrombosis(DVT)and pulmonary embolism(PE),severely affects the prognosis of patients.Although patients in NICU are supposed to have high risk of VTE,reliable VTE risk assessment based on large population are limited.Moreover,prevention of VTE based on evidence for neurological critically ill patients is also demanding.Objective To investigate the VTE events of patients in NICU,which include the incidence and clinic characteristics of DVT and PE.The VTE incidence and clinic characteristics of patients with intracerebral hemorrhage were specially focused on.By exploring the risk factors of VTE by both univariate and multivariate analysis in NICU patients,to investigate assessment of the VTE risk and provide evidence for VTE prevention.Methods This is a prospective observational study.126 critically ill patients admitted into NICU of HUST were consecutively enrolled in this study.Including criteria:(1)length of NICU?1 week;(2)with conscious disturbance or acroparalysis,and length of lying in bed?1 week.Excluding criteria:(1)unstable vital signs;(2)under mechanical ventilation and impossible wean off;(3)with renal dysfunction;(4)allergic to contrast medium;(5)patients or relatives refused to do pulmonary artery CTA scan;(6)other reasons cannot finish pulmonary artery CTA scan.All enrolled patients received intermittent pneumatic compression(IPC)and passive limbs movement for the prevention of DVT developing.Demographic data,main diagnosis,complications,chronic disease,paralyzed limbs,GCS score,Caprini score,HCY level,D-dimer level at admission and 1 week of hospital stay,all signs and symptoms of DVT and PE,treatment and prognosis were collected.Limb vein doppler ultrasonography and pulmonary artery CTA scan were performed for all enrolled patients between the 7th to 10 th day of NICU stay.Statistical analysis was performed using SPSS 19.0 software.Student t-test was used for the quantitative variables and either Pearsons' ?2 test,Continuity Correction test or Fisher's Exact test was used for qualitative variables in the univariate analysis of risk factors.The logistic regression enter method was used for multivariate analysis of the risk factors.Results Although positive action was applied for the prevention of DVT developing,patients in NICU still had a high incidence of VTE.At the end of first week of NICU stay,the incidence of DVT was 35.7% and the incidence of PE was 17.5%.Most patients who developed DVT and /or PE in NICU usually showed no specific clinic symptoms,which could easily lead to missed diagnosis.It had a high incidence of DVT in calf muscular vein(34/45,75.6%).Despite few patients' PE did involve main trunk of pulmonary artery(5/22,22.7%),most patients' PE only involved branches of pulmonary artery(17/22,77.3%).muscular calf vein thrombosis,MCVT.Only half of the patients with PE had DVT while the other half did no.This result suggested that if the PE screening was only done for patients with DVT,it would lead to lots of missed diagnosis of PE.For the intracerebral hemorrhage patients,the incidence of DVT was 31.6% and the incidence of PE was 12.3% at the end of first week of NICU stay.The incidence and characteristics of VTE was close to the whole population enrolled.Paralysis,elevated D-dimer level at admission and lung infection were identified as independent risk factors of DVT.Paralysis of both lower extremities,femoral vein thrombosis and lung infection were identified as independent risk factors of PE.Conclusion Patients in NICU had a very high incidence of VTE while most of them were asymptomatic,which could easily lead to missed diagnosis.Based on these findings,it is recommended to do limb vein doppler ultrasonography and pulmonary artery CTA scan as routine screening for the early diagnosis of VTE as well as early initiation of anticoagulant therapy,which might decrease mortality and improve prognosis of patients in NICU.