Out-of-hospital cardiac arrest (OHCA) due to aneurysmal subarachnoid hemorrhage (aSAH) is rare but associated with extremely poor prognosis. Data on neurological outcomes and prognostic factors are limited. We conducted a retrospective multicenter cohort study across 12 French neuro-ICUs including all adult patients admitted alive after OHCA-aSAH between 2014 and 2024. Demographics, cardiac arrest characteristics, aSAH severity, ICU management, and 6-month neurological outcomes (modified Rankin Scale, mRS) were collected. Firth penalized logistic regression was applied to explore predictors of favorable outcome. Among 15,907 SAH admissions, 164 patients had OHCA-aSAH. Median age was 54 [43–62] years; 47.5

High-dose continuous infusion of cefepime is frequently employed in ICU patients with a creatinine clearance above 60 mL/min. The CEFTOX study aimed to investigate whether this regimen could lead to cefepime overexposure and cefepime-induced neurotoxicity (CIN) in a cohort of severe trauma and brain-injured patients. This retrospective cohort study included patients from a Level 1 Trauma Center who received a continuous infusion of 6 g/day of cefepime and had a therapeutic drug monitoring (TDM) within 24-48 h of treatment initiation. They were divided into three groups based on creatinine clearance: mild renal impairment (60-90 mL/min), normal clearance (90-150 mL/min), and augmented renal clearance (ARC) (>150 mL/min). The primary outcome was cefepime overexposure. A key secondary outcome was CIN. One hundred and sixty-two critically ill patients were included: 84 with ARC, 62 with normal renal clearance, and 16 with mild renal impairment. Cefepime overexposure occurred in 72 (44.4%) patients. While 50% of patients with normal renal clearance experienced overexposure, the rate was higher in those with mild renal impairment (87.5%) and lower in those with ARC (32.1%; P < 0.0001). In the ARC group, age > 33 years was a risk factor for overexposure (odds ratio [OR] 3.76; 95% CI [1.30-10.95]; P = 0.01), while sepsis was a protective factor (OR 0.30; 95% CI [0.11-0.83]; P = 0.02). CIN was observed in 24% of overexposed patients when TDM results were obtained ≤48 h compared to 57.4% when results were delayed >48 h (P = 0.006). These results highlight the need for early TDM and individualized dose adjustment to avoid CIN.

BACKGROUND:Blunt trauma is the main trauma mechanism leading to severe trauma, mortality and disability. Improving data on early death would help in improving current trauma management. METHODS:This retrospective observational multicentric study was conducted using data from a prospective French national registry (TraumaBase) from January 2017 to December 2022. Inclusion criteria were: blunt trauma who died within the first 24 h in Level 1 Trauma Centers. RESULTS:Seven hundred twenty-two patients were included. The mean age was 51 (SD 23) years with a male predominance (72.7 %). Mechanisms involved were: road traffic accidents (n = 404, 56.0 %), falls (n = 293, 40.6 %), blunt object traumas (n = 23, 3.2 %), and other mechanisms (n = 2, 0.3 %). Median Injury Severity Score (ISS) was 30 (22-45). The anatomical regions affected were: head/neck (n = 590, 81.7 %), thorax (n = 426, 59.0 %), extremities (n = 339, 47.0 %), abdomen (n = 251, 34.8 %), face (n = 184, 25.5 %), and skin (n = 86, 4.7 %). Two-thirds (n = 508, 70.4 %) of patients presented hemorrhagic shock (HS), with the origin being abdominal (35.0 %), pelvic (25.8 %), or thoracic (15.2 %). Hemostasis was achieved through open surgery (n = 77/126, 61.1 %) or interventional radiology (n = 49/126, 38.9 %). The three main causes of mortality at 24 h were: central nervous system (CNS) injury (n = 310, 42.9 %), hemorrhage (n = 169, 23.4 %), multi-organ failure (MOF) (n = 156, 21.6 %). Potentially Preventable Death (PPD) accounted for 353 patients (48.9 %). CONCLUSIONS:Early mortality causes after severe blunt trauma in France were neurological (42.9 %), hemorrhagic (23.4 %), and MOF (21.6 %). Among patients with traumatic brain injury (TBI), 65.2 % presented concomitant HS. Hemorrhage remained the second presumed cause of death among PDD, with pelvic origin being the most frequent. Victims of severe blunt trauma should be considered as having isolated or concomitant life-threatening traumatic brain injury and non-compressible extra cranial hemorrhage. Every effort must be made to stabilize these patients, at least temporarily, to obtain rapid injury assessment to identify the "first lethal injury" to treat.

BACKGROUND AND OBJECTIVES:Clinical outcome assessment (COA), particularly health-related quality of life (HRQoL) is an important component of patient-centered outcome assessment. Few studies have evaluated this in the context of the status epilepticus (SE). The objective of the current study was to describe COAs in patients who had been critically ill with SE. METHODS:We conducted a cross-sectional study in patients previously included in the ICTAL Status Epilepticus Registry between February 2018 and February 2022 in 15 French intensive care units. Eligible patients were invited to complete COA questionnaires covering the following domains: HRQoL, dependency, mental health, cognitive status, and social support. These were performed up to 5 years after the SE episode. RESULTS:The median [IQR] age of the 66 responders was 58 [47, 68] years and 43 patients (65.2 %) were male. A total of 15 patients (22.7 %) had a previous history of epilepsy. Overall, 48 patients (70.7 %) in our cohort presented with worse HRQoL than the general population. Physical and mental composite scores showed similar alterations, with mean (SD) values of 42.1 (11.1) and 42.3 (12.5), respectively. A strong and significant correlation was identified between the 36-item Short-Form (SF-36) total score and domains of dependency and mental health. The search for an association between predictors of poor outcome after SE and HRQoL findings at the time of the cross-sectional assessment in patients with a worse SF-36 score than the reference population was negative for all variables tested. DISCUSSION:We report poorer HRQoL among patients treated for SE. Longitudinal studies are needed to corroborate these findings.

Background:Machine learning could improve the timely identification of trauma patients in need of hemorrhage control resuscitation (HCR), but the real-life performance remains unknown. The ShockMatrix study aimed to compare the predictive performance of a machine learning algorithm with that of clinicians in identifying the need for HCR. Methods:Prospective, observational study in eight level-1 trauma centers. Upon receiving a prealert call, trauma clinicians in the resuscitation room entered nine predictor variables into a dedicated smartphone app and provided a subjective prediction of the need for HCR. These predictors matched those used in the machine learning model. The primary outcome, need for HCR, was defined as: transfusion in the resuscitation room, transfusion of more than four red blood cell units in 6 h of admission, any hemorrhage control procedure within 6 h, or death from hemorrhage within 24 h. The human and machine learning performances were assessed by sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and net clinical benefit. Human and machine learning agreement was assessed with Cohen's kappa coefficient. Findings:Between August 2022 and June 2024, out of 5550 potential eligible patients, 1292 were ultimately included in the analyses. The need for HCR occurred in 170/1292 patients (13%). The results showed a positive likelihood ratio of 3.74 (95% confidence interval [CI]: 3.20-4.36) and a negative likelihood ratio of 0.36 (95% CI: 0.29-0.46) for the human prediction and a positive likelihood ratio of 4.01 (95% CI: 3.43-4.70) and negative likelihood ratio of 0.35 (95% CI: 0.38-0.44) for the machine learning prediction. The combined use of human and machine learning prediction yielded a sensitivity of 83% (95% CI: 77-88%) and a specificity of 73% (95% CI: 70-75%). The Cohen's kappa coefficient showed an agreement of 0.51 (95% CI: 0.48-0.55). Interpretation:The prospective ShockMatrix temporal validation study suggests a comparable human and machine learning performance to predict the need for HCR using real-life and real-time information with a moderate level of agreement between the two. Machine learning enhanced decision awareness could potentially improve the detection of patients in need of HCR if used by clinicians. Funding:The study received no funding.

To reduce the number of deaths caused by exsanguination, the initial management of severe trauma aims to prevent, if not limit, the lethal triad, which consists of acidosis, coagulopathy, and hypothermia. Recently, several studies have suggested adding hypocalcemia to the lethal triad to form the lethal diamond, but the evidence supporting this change is limited. Therefore, the aim of this study was to compare the lethal triad and lethal diamond for their respective associations with 24-h mortality in severe trauma patients receiving transfusion. We performed a multicenter retrospective analysis of patients in TraumaBase®, a French database (2011–2023). The patients included in this study were all trauma patients who had received transfusions of at least 1 unit of red blood cells (RBCs) within the first 6 h of hospital admission and for whom ionized calcium measurements were available. Hypocalcemia was defined as an ionized calcium level < 1.1 mmol/L. A total of 2141 severe trauma patients were included (median age: 39, interquartile range [IQR]: 26–57; median injury severity score: 27, IQR: 17–41). Patients primarily presented with blunt trauma (81.7

Background To reduce the number of deaths caused by exsanguination, the initial management of severe trauma aims to prevent, if not limit, the lethal triad, which consists of acidosis, coagulopathy, and hypothermia. Recently, several studies have suggested adding hypocalcemia to the lethal triad to form the lethal diamond, but the evidence supporting this change is limited. Therefore, the aim of this study was to compare the lethal triad and lethal diamond for their respective associations with 24-hour mortality in transfused severe trauma patients. Methods We performed a multicenter retrospective analysis of patients in TraumaBase®, a French database (2011–2023). The patients included in this study were all trauma patients who had received transfusions of at least 1 unit of packed red blood cells (RBCs) within the first 6 hours of hospital admission and for whom ionized calcium measurements were available. Hypocalcemia was defined as an ionized calcium level < 1.1 mmol/L. Results A total of 2141 severe trauma patients were included (median age: 39, interquartile range [IQR]: 26–57; median injury severity score [ISS]: 27, IQR: 17–41). Patients primarily presented with blunt trauma (81.7%), and a 24-hour mortality rate of 16.1% was observed. Receiver operating characteristic (ROC) curve analysis revealed no significant difference in the association with 24-hour mortality between the lethal diamond (area under the curve [AUC]: 0.71) and the lethal triad (AUC: 0.72) (p = 0.26). The strength of the association with 24-hour mortality was similar between the lethal triad and the lethal diamond, with Cramer’s V values of 0.29 and 0.28, respectively. Conclusions This study revealed no significant difference between the lethal triad and the lethal diamond in terms of their respective associations with 24-hour mortality in severe trauma patients requiring transfusion. These results raise questions about the independent role of hypocalcemia in early mortality.

Background and ObjectivesTo report the prevalence of acute encephalopathy and outcomes in patients with severe coronavirus disease 2019 (COVID-19) and to identify determinants of 90-day outcomes.MethodsData from adults with severe COVID-19 and acute encephalopathy were prospectively collected for patients requiring intensive care unit management in 31 university or university-affiliated intensive care units in 6 countries (France, United States, Colombia, Spain, Mexico, and Brazil) between March and September of 2020. Acute encephalopathy was defined, as recently recommended, as subsyndromal delirium or delirium or as a comatose state in case of severely decreased level of consciousness. Logistic multivariable regression was performed to identify factors associated with 90-day outcomes. A Glasgow Outcome Scale-Extended (GOS-E) score of 1-4 was considered a poor outcome (indicating death, vegetative state, or severe disability).ResultsOf 4,060 patients admitted with COVID-19, 374 (9.2%) experienced acute encephalopathy at or before the intensive care unit (ICU) admission. A total of 199/345 (57.7%) patients had a poor outcome at 90-day follow-up as evaluated by the GOS-E (29 patients were lost to follow-up). On multivariable analysis, age older than 70 years (odds ratio [OR] 4.01, 95% CI 2.25-7.15), presumed fatal comorbidity (OR 3.98, 95% CI 1.68-9.44), Glasgow coma scale score <9 before/at ICU admission (OR 2.20, 95% CI 1.22-3.98), vasopressor/inotrope support during ICU stay (OR 3.91, 95% CI 1.97-7.76), renal replacement therapy during ICU stay (OR 2.31, 95% CI 1.21-4.50), and CNS ischemic or hemorrhagic complications as acute encephalopathy etiology (OR 3.22, 95% CI 1.41-7.82) were independently associated with higher odds of poor 90-day outcome. Status epilepticus, posterior reversible encephalopathy syndrome, and reversible cerebral vasoconstriction syndrome were associated with lower odds of poor 90-day outcome (OR 0.15, 95% CI 0.03-0.83).DiscussionIn this observational study, we found a low prevalence of acute encephalopathy at ICU admission in patients with COVID-19. More than half of patients with COVID-19 presenting with acute encephalopathy had poor outcomes as evaluated by GOS-E. Determinants of poor 90-day outcome were dominated by older age, comorbidities, degree of impairment of consciousness before/at ICU admission, association with other organ failures, and acute encephalopathy etiology.

Objectives: To describe early electrocardiogram (ECG) abnormalities after status epilepticus (SE) and evaluate their association with 90-day neurological outcomes. Design: Retrospective analysis of a multicenter, national prospective registry between February 2018 and June 2020. Setting: Sixteen ICUs in France, IctalGroup Research Network. Patients: Adults with available ECG performed less than or equal to 24 hours after the onset of SE and less than or equal to 12 hours after its resolution. Intervention: Double-blinded review of all ECGs was performed by two independent cardiologists. ECGs were categorized as normal/abnormal and then with minor/major early ECG abnormalities according to the Novacode ECG Classification system. Measurements and Main Results: Among 155 critically ill patients with SE, early ECG abnormalities were encountered in 145 (93.5%), categorized as major in 91 of 145 (62.8%). In addition to sinus tachycardia, the main abnormalities were in the ST segment (elevation [16.6%] or depression [17.9%]) or negative T waves (42.1%). Major early ECG abnormalities were significantly associated with respiratory distress and sinus tachycardia at the scene and hyperlactatemia at ICU admission. By multivariable analysis, three variables were significantly associated with 90-day poor outcome: age, preexisting ultimately fatal comorbidity, and cerebral insult as the cause of SE. Early major ECG abnormalities were not independently associated with 90-day functional outcome. Conclusions: In our study, early ECG abnormalities in the acute phase of SE were frequent, often unrecognized and were associated with clinical and biological stigma of hypoxemia. Although they were not independently associated with 90-day functional outcome, ECG changes at the early stage of SE should be systematically evaluated. TRIAL REGISTRATION: https://clinicaltrials.gov/ct2/show/NCT03457831.

IntroductionStatus epilepticus (SE) is a common life-threatening neurological emergency that can cause long-term impairments. Overall outcomes remain poor. Major efforts are required to clarify the epidemiology of SE and the determinants of outcomes, thereby identifying targets for improved management.Methods and analysisICTAL Registry is a multicentre open cohort of critically ill patients with convulsive, non-convulsive or psychogenic non-epileptic SE. Observational methods are applied to collect uniform data. The goal of the ICTAL Registry is to collect high-quality information on a large number of patients, thereby allowing elucidation of the pathophysiological mechanisms involved in mortality and morbidity. The registry structure is modular, with a large core data set and the opportunity for research teams to create satellite data sets for observational or interventional studies (eg, cohort multiple randomised controlled trials, cross-sectional studies and short-term and long-term longitudinal outcome studies). The availability of core data will hasten patient recruitment to studies, while also decreasing costs. Importantly, the vast amount of data from a large number of patients will allow valid subgroup analyses, which are expected to identify patient populations requiring specific treatment strategies. The results of the studies will have a broad spectrum of application, particularly given the multidisciplinary approach used by the IctalGroup research network.Ethics and disseminationThe ICTAL Registry protocol was approved by the ethics committee of the French Intensive Care Society (#CE_SRLF 19-68 and 19-68a). Patients or their relatives/proxies received written information to the use of the retrospectively collected and pseudonymised data, in compliance with French law. Prospectively included patients receive written consent form as soon as they recover decision-making competency; if they refuse consent, they are excluded from the registry. Data from the registry will be disseminated via conference presentations and peer-reviewed publications.Trial registration numberNCT03457831.

BACKGROUND This study aimed to determine the prevalence of withholding or withdrawal of life-sustaining therapy (WLST) decisions in trauma ICU patients, using a large registry. We hypothesised that this prevalence is similar to that of the general population admitted to an ICU. As secondary aims, it sought to describe the trauma patients for whom the decision was made for WLST and the factors associated with this decision. DESIGN This observational study assessed data from 14 French centres listed in the TraumaBase(TM) registry. All trauma patients hospitalised for more than 48 h were pro-spectively included. RESULTS Data from 8569 trauma patients, obtained from January 2016 to December 2018, were included in this study. A WLST decision was made in 6% of all cases. In the WLST group, 67% of the patients were older men (age: 62 versus 36, P < 0.001); more often they had a prior medical history and higher median severity scores than the patients in the no WLST decision group; SAPS II 58 (46 to 69) versus 21 (13 to 35) and ISS 26 (22 to 24) versus 12 (5 to 22), P < 0.001. Neurological status was strongly associated with WLST decisions. The geographic area of the ICUs affected the rate of the WLST decisions. The ICU mortality was 11% (n = 907) of which 47% (n = 422) were preceded by WLST decisions. Fourteen percent of WLST orders were not associated to the death. CONCLUSION Among 8569 patients, medical history, trauma severity criteria, notably neurological status and geographical areas were associated with WLST. These regional differences deserve to be investigated in future studies.

Purpose The aim of this work is to study a cohort of patients of ISS < 15 admitted to a TC, and to determine the number of patients that ultimately benefited from the skills and resources specific of a level 1 trauma center. Methods Retrospective study from a prospective cohort of patients admitted to TC (Beaujon Hospital, APHP) for suspected severe trauma from January 2011 to December 2017. The main outcome criterion was the use of surgery or interventional radiology within the first 24 h after admission of patients with ISS < 15. The secondary outcomes were stratified into severe (mortality, resuscitation care, length of stay in intensive care units) and non-severe criteria (mild head injury, hospital discharge or transfer within 24 h). Results Of 3035 patients admitted during the study period, 1409 with an ISS < 15 were included, corresponding to a theoretical overtriage rate of 46.4%. Among these, 611 patients (43.4%) underwent emergency intervention within the first 24 h (586 surgical interventions, 19 direct transfers to the operating theater and 6 acts of interventional radiology), 238 (16.9%) of patients presented with severe and 531 (38%) with non-severe outcome criteria. Conclusion This work demonstrates that in a cohort of patients classified as ISS < 15 admitted to a TC, a considerable amount of TC-specific resources are required, and patients present with severe outcome criteria despite being classified as overtriaged. These results suggest that triage of trauma patients should be based on resource use and clinical outcome rather than anatomic criteria.

(1) Background: Little is known about the impact of pathophysiological mechanisms that underlie the enhancement of excitotoxicity and the neuronal consequences of status epilepticus (SE), as well as the clinical consequences of secondary brain insults (SBI) in patients with SE on outcome; (2) Methods: Electronic searches were conducted in May 2020 using Medline via PubMed, Embase, and Google Scholar (#CRD42019139092). Experimental studies of animals or randomized, observational, controlled trials of patients with SE in indexed journals were included. There were no language or date restrictions for the published literature included in this review. Information was extracted on study design, sample size, SBI characteristics, and primary and secondary outcomes, including the timing of evaluation; (3) Results: Among the 2209 articles responding to our inclusion criteria, 56 were included in this systematic review. There are numerous experimental data reporting the deleterious effects associated with each of the SBI in animals exposed to SE. In humans, only the effect of target temperature management in hypothermia (32–34 °C) has been explored. (4) Conclusions: There is little experimental evidence that favors the control of secondary brain insult after SE. Further studies are required to assess the neuroprotective interest of secondary brain insult control after SE in humans.

Epileptic seizures in critically ill patients represent a major source of concern, because they are associated with significant mortality and morbidity rates. Despite recent advances that have enabled a better understanding of the global epidemiology of this entity, epileptic seizures in critically ill patients remain associated with a high degree of uncertainty and numerous questions remain unanswered. The present Special Issue aims to invite authors to contribute original research articles as well as review articles related to all aspects of epileptic seizures in critically ill patients, diagnosis, management, and outcomes.

Massive transfusion remains an essential element in the therapeutic arsenal for the management of major trauma patients with acute haemorrhage. Massive transfusion can be defined as the administration of an important volume of blood products in a given time unit to reflect the dynamic and nature of the haemorrhage and its management. The use of higher red blood to fresh frozen plasma ratios, early administration of platelets, administration of tranexamic acid and smaller amounts of crystalloid fluid resuscitation has changed the practice of massive transfusion. Three strategies can be distinguished: (1) empiric or probabilistic; (2) individuali-sed/targeted by objective criteria; (3) hybrid. Massive transfusion needs to be integrated into a comprehensive clinical pathway. The perspective of prehospital use of fresh frozen plasma or administration of whole blood hold the potential to change considerably transfusion strategies in trauma.

Background. We determined whether an audit on the adherence to guidelines for hospital-acquired pneumonia (HAP) can improve the outcomes of patients in intensive care units (ICUs). Methods. This study was conducted at 35 ICUs in 30 hospitals. We included consecutive, adult patients hospitalized in ICUs for 3 days or more. After a 3-month baseline period followed by the dissemination of recommendations, an audit on the compliance to recommendations (audit period) was followed by a 3-month cluster-randomized trial. We randomly assigned ICUs to either receive audit and feedback (intervention group) or participate in a national registry (control group). The primary outcome was the duration of ICU stay. Results. Among 1856 patients enrolled, 602, 669, and 585 were recruited in the baseline, audit, and intervention periods, respectively. The composite measures of compliance were 47% (interquartile range [IQR], 38-56%) in the intervention group and 42% (IQR, 25-53%) in the control group (P=.001). As compared to the baseline period, the ICU lengths of stay were reduced by 3.2 days in the intervention period (P=.07) and by 2.8 days in the control period (P=.02). The durations of ICU stay were 7 days (IQR, 5-14 days) in the control group and 9 days (IQR, 5-20 days) in the intervention group (P=.10). After adjustment for unbalanced baseline characteristics, the hazard ratio for being discharged alive from the ICU in the control group was 1.17 (95% confidence interval,.69-2.01; P=.10). Conclusions. The publication of French guidelines for HAP was associated with a reduction of the ICU length of stay. However, the realization of an audit to improve their application did not further improve outcomes.