ESICM LIVES 2016: part two

Introduction In addition to systemic hemodynamics, the management of neurocritically ill patients is often informed by neuromonitoring. In the absence of high-level evidence clinicians are often guided by personal and local expertise. Little is known about practices as they pertain to the use of such monitoring in patients with acute brain injury (ABI). Objectives To investigate practices in bedside monitoring for ABI patients. Particularly interested in differences among “neurointensivists” (NIs; defined here as intensivists whose clinical practice is comprised > 1/3 by neurocritical care) and other intensivists (OIs). Also, to explore patterns specific to traumatic brain injury (TBI) and subarachnoid hemorrhage (SAH), as well as preferences and availability of particular technologies/devices. Methods Electronic survey of 22 items including two case-based scenarios; endorsed by SCCM (9,000 recipients) and ESICM (on-line newsletter) in 2013. A sample size of 370 was calculated based on a population of 10,000 physician members, a 5 % margin error, and 95 % confidence interval. We summarized results using descriptive statistics (proportions with 95 % confidence intervals). A chi-square test was used to compare proportions of responses between NIs and OIs with a significance p < 0.05. Results There were 655 responders (66 % completion rate); 422(65 %) were classified as OIs and 226(35 %) as NIs. More NIs follow hemodynamic protocols for neurocritically-ill patients (56 % vs. 43 %, p 0.001), in TBI (44.5 % vs. 33.3 %, p 0.007), and in SAH (38.1 % vs. 21.3 %, p < 000.1). For delayed cerebral ischemia (DCI), more NIs target cardiac index (CI) (35 % vs. 21 %, p 0.0001), and fluid responsiveness (62 % vs. 53 %, p 0.03), use more bedside ultrasound (BUS) (42 % vs. 29 %, p 0.005) and arterial waveform analysis (40 % vs. 29 %, p 0.02). For DCI neuromonitoring, NIs use more angiography (57 % vs. 43 %, p 0.004), TCD (46 % vs. 38 %, p 0.0001), and CTP (32 % vs.16 %, p 0.0001). For CPP optimization in TBI, NIs use more arterial waveform analysis (45 % vs. 35 %, p 0.019), and BUS (37 % vs. 27.7 %, p 0.023), while more OIs monitor mixed venous oxygen saturation (54.1 % vs. 45 %, p 0.045). For TBI neuromonitoring, NIs use more PbtO2 (28 % vs. 10 %, p 0.0001). In the case scenario of raised ICP/low PbtO2, most employ analgosedation (47 %) and osmotherapy (38 %). Fewer make use of preserved pressure reactivity, particularly OIs (vasopressor use 23 % vs. 34 %, p 0.014). Conclusions There is large heterogeneity in the use of monitoring protocols, variables, and technologies/devices. “Neurointensivists” not only employ more neuromonitoring but also more hemodynamic monitoring in patients with acute brain injury. ICP/CPP remain the most commonly followed neuro-variables in TBI patients, with low use of other brain-physiology parameters, sugg