External ventricular drainage complications

External ventricular drainage complications

Acutely increased intracranial pressure (ICP) is frequently managed by external ventricular drainage (EVD). This procedure is life-saving but marred by a high incidence of complications. It has recently been indicated that bolt-connected external ventricular drainage (BC-EVD) compared to the standard technique of tunnelled EVD (T-EVD) may result in less complications 1).

Intracranial hemorrhage

Infection

Misplacement

Obstruction

Ventricular catheter obstruction.


The purpose of this study was to investigate whether a surgeon’s experience affects the associated complication rate. Methods This retrospective study included all adult patients undergoing EVD insertion at a single centre between July 2013 and June 2015. Medical records were retrieved to obtain details on patient demographics, surgical indication, risk factors for infection and use of anticoagulants or antiplatelets. Surgeon experience, operative time, intraoperative antibiotic prophylaxis, need for revision surgery and EVD associated infection were examined. Information on catheter tip position and radiological evidence of intracranial haemorrhage was obtained from postoperative imaging. Results A total of 89 patients were included in the study. The overall infection, haemorrhage and revision rates were 4.8%, 7.8% and 13.0% respectively, with no significant difference among surgeons of different experience. The mean operating time for patients who developed an infection was 22 minutes while for those without an infection, it was 33 minutes (p=0.474). Anticoagulation/antiplatelet use did not appear to increase the rate of haemorrhage. The infection rate did not correlate with known risk factors (eg diabetes and steroids), operation start time (daytime vs out of hours) or duration of surgery although intraoperative (single dose) antibiotic prophylaxis seemed to reduce the infection rate. There was also a correlation between longer duration of catheterisation and increased risk of infection. Conclusions This is the first study demonstrating there is no significant difference in complication rates between surgeons of different experience. EVD insertion is a core neurosurgical skill and junior trainees should be trained to perform it 2).


Patients were prospectively enrolled in the CLEAR III trial after placement of an EVD for obstructive intraventricular hemorrhage and randomized to receive recombinant tissue-type plasminogen activator or placebo. We counted any detected new hemorrhage (catheter tract hemorrhage or any other distant hemorrhage) on computed tomography scan within 30 days from the randomization. Meta-analysis of published series of EVD placement was compiled with STATA software.

Growing or unstable hemorrhage was reported as a cause of exclusion from the trial in 74 of 5707 cases (1.3%) screened for CLEAR III. The first 250 patients enrolled have completed adjudication of adverse events. Forty-two subjects (16.8%) experienced ≥1 new bleeds or expansions, and 6 of 250 subjects (2.4%) suffered symptomatic hemorrhages. Eleven cases (4.4%) had culture-proven bacterial meningitis or ventriculitis.

Risks of bleeding and infection in the ongoing CLEAR III trial are comparable to those previously reported in EVD case series. In the present study, rates of new bleeds and bacterial meningitis/ventriculitis are very low despite multiple daily injections, blood in the ventricles, the use of thrombolysis in half the cases, and generalization to >60 trial sites 3).

References

1)

Jensen TS, Carlsen JG, Sørensen JC, Poulsen FR. Fewer complications with bolt-connected than tunneled external ventricular drainage. Acta Neurochir (Wien). 2016 Aug;158(8):1491-4. doi: 10.1007/s00701-016-2863-8. Epub 2016 Jun 21. PubMed PMID: 27324657.
2)

Yuen J, Selbi W, Muquit S, Berei T. Complication rates of external ventricular drain insertion by surgeons of different experience. Ann R Coll Surg Engl. 2018 Mar;100(3):221-225. doi: 10.1308/rcsann.2017.0221. Epub 2018 Jan 24. PubMed PMID: 29364007; PubMed Central PMCID: PMC5930101.
3)

Dey M, Stadnik A, Riad F, Zhang L, McBee N, Kase C, Carhuapoma JR, Ram M, Lane K, Ostapkovich N, Aldrich F, Aldrich C, Jallo J, Butcher K, Snider R, Hanley D, Ziai W, Awad IA; CLEAR III Trial Investigators. Bleeding and Infection With External Ventricular Drainage: A Systematic Review in Comparison With Adjudicated Adverse Events in the Ongoing Clot Lysis Evaluating Accelerated Resolution of Intraventricular Hemorrhage Phase III (CLEAR-III IHV) Trial. Neurosurgery. 2015 Mar;76(3):291-301. doi: 10.1227/NEU.0000000000000624. PubMed PMID: 25635887; PubMed Central PMCID: PMC4333009.

Hypernatremia

Hypernatremia

Hypernatremia, is a high concentration of sodium in the blood. Normal serum sodium levels are 135 – 145 mmol/L (135 – 145 mEq/L). Hypernatremia is generally defined as a serum sodium level of more than 145 mmol/L.

Hypernatremia is one of the most common electrolyte disturbances following aneurysmal subarachnoid hemorrhage (aSAH) and has been correlated with increased mortality in single institution studies. Both hyponatremia and hypernatremia during ICU management were significantly associated with unfavorable neurologic outcomes 1).

In neurosurgical patients, this is most often seen in the setting of diabetes insipidus (DI). Since normal total body water (TBW) is ≈ 60% of the patient’s normal body weight, the patient’s current TBW may be estimated by Eq.

Mild and moderate hypernatremia were significantly associated with increased early mortality in patients with severe TBI 2). Hypernatremia was associated also with poorer outcomes in patients with severe TBI. This finding warrants further investigation in a prospective, randomized study 3).

Electrolyte imbalances are common in traumatic brain injury. In a study Hypokalemia was the most common electrolyte imbalance at 65.5%. The results of the use of a multivariable logistic regression model showed that the odds of postoperative death in TBI patients were increased with high levels of blood glucose, hypernatremia, and acidosis.Hypokalemia was the most common electrolyte imbalance in TBI patients. Hypernatremia, acidosis, and hyperglycemia significantly increased the odds ratio of death in the first 24  hours post TBI 4).

Clinical features

Early symptoms may include a strong feeling of thirstweaknessnausea, and loss of appetite.

Severe symptoms include confusion, muscle twitching, and bleeding in or around the brain.

Severe symptoms typically only occur when levels are above 160 mmol/L.

Treatment

The free water deficit to be replaced is given by a Eq. Correction must be made slowly to avoid exacerbating cerebral edema. One half the water deficit is replaced over 24 hours, and the remainder is given over 1–2 additional days. Judicious replacement of deficient ADH in cases of true DI must also be made.


The aim of a work of Vassilyev was to evaluate the effectiveness of Sterofundin in the framework of complex therapy of hypernatremia in neurosurgical patients after removal of brain tumors. They analyzed the dynamics of the concentrations of sodium, potassium, chorus of the plasma, anion gap and buffer bases in the postoperative period of these patients. For obtaining reliable results, the patients were divided into groups according to the nature of the treatment: Sterofundin and symptomatic correction of hypotonic solution of sodium chloride, saluretic and Spironolactone respectively. In a comparison between the groups, a distinct difference in the speed of regression of hypernatremia and durability of the achieved effect was observed. In case of treatment with Sterofundin there was a significant decrease of hypernatremia by the end of the second day of the postoperative period without tendency to re-raise. The prevalence of hypotonic solutions of sodium chloride and potassium-sparing saluretics in intensive care allowed reducing the sodium concentration non-persistently to the fourth day on the background of significant fluctuations in its concentration. The use of Sterofundin in complex therapy of electrolyte disturbances, particularly of hypernatremia in neurosurgical patients after removal of brain tumors, is reflected in the form of significant regression of increased sodium concentration in plasmacompared with the method of use “hypotonic” hemodilution, saluretics and potassium-sparing diuretics 5).

Complications

Coma.

Pulmonary complications and acute kidney injury were more common in hypernatremia 6).


Hoffman et al., from the Upstate Medical University performed a retrospective analysis of adults between 2002 and 2011 with a primary diagnosis of aneurysmal subarachnoid hemorrhage (aSAH) using the Nationwide Inpatient Sample (NIS). Patients were grouped according to whether or not an inpatient diagnosis of hypernatremia was present. The primary outcome was the NIS-SAH outcome measure. Secondary outcomes included in-hospital mortalitylength of stay (LOS), and non-routine hospital discharge. Outcomes analyses adjusted for SAH severity using the NIS-SAH Severity Score, Charlson Comorbidity Index, and the presence of cerebral edema.

A total of 18,377 patients were included in the study. The incidence of a poor outcome as defined by the NIS-SAH outcome measure was 65.9% in the hypernatremia group and 33.4% in the normonatremia group (OR 1.96, 95% CI 1.68 – 2.27). There was higher mortality in the hypernatremia group (OR 1.60, 95% CI 1.37 – 1.87). Patients with hypernatremia had a significantly higher rate of non-routine hospital discharge and gastrostomy. The incidences of poor outcome, in-hospital mortality, and non-routine disposition were higher in the hypernatremia group regardless of treatment type (clipping vs. endovascular embolization). Pulmonary complications and acute kidney injury were more common in the hypernatremia group as well.

In patients with aSAH, hypernatremia is associated with poorer functional outcomes regardless of SAH severity 7).

References

1)

Okazaki T, Hifumi T, Kawakita K, Shishido H, Ogawa D, Okauchi M, Shindo A, Kawanishi M, Tamiya T, Kuroda Y. Target Serum Sodium Levels During Intensive Care Unit Management of Aneurysmal Subarachnoid Hemorrhage. Shock. 2017 Nov;48(5):558-563. doi: 10.1097/SHK.0000000000000897. PubMed PMID: 28498294.
2)

Vedantam A, Robertson CS, Gopinath SP. Morbidity and mortality associated with hypernatremia in patients with severe traumatic brain injury. Neurosurg Focus. 2017 Nov;43(5):E2. doi: 10.3171/2017.7.FOCUS17418. PubMed PMID: 29088954.
3)

Hoffman H, Jalal MS, Chin LS. Effect of Hypernatremia on Outcomes After severe Traumatic Brain Injury: A Nationwide Inpatient Sample analysis. World Neurosurg. 2018 Oct;118:e880-e886. doi: 10.1016/j.wneu.2018.07.089. Epub 2018 Jul 18. PubMed PMID: 30031178.
4)

Pin-On P, Saringkarinkul A, Punjasawadwong Y, Kacha S, Wilairat D. Serum electrolyte imbalance and prognostic factors of postoperative death in adult traumatic brain injury patients: A prospective cohort study. Medicine (Baltimore). 2018 Nov;97(45):e13081. doi: 10.1097/MD.0000000000013081. PubMed PMID: 30407307; PubMed Central PMCID: PMC6250545.
5)

Vassilyev D. [MODERN APPROACHES TO CORRECTION OF HYPERNATREMIA IN NEUROSURGICAL PATIENTS]. Georgian Med News. 2016 Nov;(Issue):12-16. Russian. PubMed PMID: 28009309.
6) , 7)

Hoffman H, Verhave B, Chin LS. Hypernatremia is associated with poorer outcomes following aneurysmal subarachnoid hemorrhage: a nationwide inpatient sample analysis. J Neurosurg Sci. 2018 Dec 5. doi: 10.23736/S0390-5616.18.04611-8. [Epub ahead of print] PubMed PMID: 30514071.

Update: Antiepileptic drug treatment outcome

Antiepileptic drug treatment outcome

Careful antiepileptic drug selection for epileptic patients must be highlighted in order to improve outcome, reduce adverse drug reactions (ADRs) and improve patient compliance 1).
The goal in treating patients with epilepsy is a cost-effective approach to the elimination of seizures or a reduction in their number and frequency while avoiding drug interactions and side effects, so as to achieve the best possible quality of life. Among the desirable outcomes are an enhanced understanding of epilepsy by patients, caregivers, and society, and a lessening of the psychosocial risks of this disease. Patients fail to achieve their goals and outcomes when they fail to adhere to the drug regimen or when a less-than-adequate drug regimen is prescribed. To help improve adherence, once- or twice-daily formulations should be used. Working together, patients and clinicians can maximize the effectiveness of AED therapy and the potential for achieving desired goals and outcomes 2).
Despite the availability of many new AEDs with differing mechanisms of action, overall outcomes in newly diagnosed epilepsy have not improved. Most patients who attain control do so with the first or second AED. The probability of achieving seizure freedom diminishes substantially with each subsequent AED regimen tried. More than one-third of patients experience epilepsy that remains uncontrolled.
This was the conclusion of a longitudinal observational cohort study that was conducted at the Epilepsy Unit of the Western Infirmary in GlasgowScotland. A total of 1795 individuals who were newly treated for epilepsy with AEDs between July 1, 1982, and October 31, 2012, were included in this analysis. All patients were followed up for a minimum of 2 years (until October 31, 2014) or until death, whichever came sooner. Data analysis was completed between March 2015 and May 2016.
Seizure control was assessed at the end of the study period. Probability of achieving 1-year seizure freedom was estimated for each AED regimen prescribed. Multivariable models assessed the associations between risk factors and AED treatment outcome after adjustments were made for demographic and clinical characteristics.
Of the 1795 included patients, 964 (53.7%) were male; the median age was 33 years (range, 9-93 years). At the end of the study period, 1144 patients (63.7%) had been seizure free for the previous year or longer. Among those achieving 1-year seizure freedom, 993 (86.8%) were taking monotherapy and 1028 (89.9%) had achieved seizure control with the first or second AED regimens. Of the total patient pool, 906 (50.5%) remained seizure free for 1 year or longer with the initial AED. If this AED failed, the second and third regimens provided an additional 11.6% and 4.4% likelihoods of seizure freedom, respectively. Only 2.12% of patients attained optimal seizure control with subsequent AEDs. Epilepsy that was not successfully controlled with the first AED had 1.73 times greater odds of not responding to treatment for each subsequent medication regimen (odds ratio, 1.73; 95% CI, 1.56-1.91; P < .001). 3).


Machine learning approaches yielded predictions of successful drug treatment outcomes which in turn could reduce the burdens of drug trials and lead to substantial improvements in patient quality of life 4).
1)

Horváth L, Fekete K, Márton S, Fekete I. Outcome of antiepileptic drug treatment of 1282 patients with epilepsy, their pharmacovigilance reports and concomitant medication on CNS in an East-Hungarian adult database. J Neurol Sci. 2016 Oct 15;369:220-226. doi: 10.1016/j.jns.2016.08.039. Epub 2016 Aug 17. PubMed PMID: 27653893.
2)

Garnett WR. Antiepileptic drug treatment: outcomes and adherence. Pharmacotherapy. 2000 Aug;20(8 Pt 2):191S-199S. Review. PubMed PMID: 10937819.
3)

Chen Z, Brodie MJ, Liew D, Kwan P. Treatment Outcomes in Patients With Newly Diagnosed Epilepsy Treated With Established and New Antiepileptic Drugs: A 30-Year Longitudinal Cohort Study. JAMA Neurol. 2018 Mar 1;75(3):279-286. doi: 10.1001/jamaneurol.2017.3949. PubMed PMID: 29279892; PubMed Central PMCID: PMC5885858.
4)

Colic S, Wither RG, Lang M, Zhang L, Eubanks JH, Bardakjian BL. Prediction of antiepileptic drug treatment outcomes using machine learning. J Neural Eng. 2017 Feb;14(1):016002. doi: 10.1088/1741-2560/14/1/016002. Epub 2016 Nov 30. PubMed PMID: 27900948.
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