ICU and neurologic perspective by ESCMID

Treatment of community acquired meningitis-

ICU and neurologic perspective

Izmir 2010

Neurologische Klinik und PoliklinikProf. Dr. M. Dieterich

Dr. Matthias Klein, Munich, Germany

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

INFECTIOUS FOCI OF

COMMUNITY ACQUIRED MENINGITIS

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

The cause matters

Infectious focus:

Ear 30%Lung 18%Sinus 8%Other 2%(e.g. endocarditis)

no focus 42%

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Infectious focus in bacterial meningitis

Sinusitis max.Mastoiditis

(+ Sinusitis max.)S. sphenoidalisS. ethmoidalis

ENT infection in 50/87 of patients with pneumococcal meningitis

Kastenbauer und Pfister, Brain 2003

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Imagin for ENT focus

CCT brain window CT skullbase bone window

post surgery

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

When to especially consider CSF leak?

41 yo maleS. pneumoniae meningitis

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Beta2-Transferrin, a marker for the detection of CSF leaks

post fluorescein application into CSF

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Further infectious foci of bacterial meningitis

Staphylococcus aureus

Spondylodiscitis

67 yo femalepost orthopaedic vertebral injectionsStaphylococcus aureus

paravertebral abscessESCMID O

nline

Lectu

re Lib

rary

© by au

thor

• check for foci early (on admission day)CT skull base, ENT, chest X-ray, (spine imaging, echocardiography, CT whole body)

• take adequate measures, if possible on admission day

• transfer patient to ICU

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

INTENSIVE CARE / ACUTE COMPLICATIONS

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Acute complications

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor


INTRACRANIAL COMPLICATIONS (75%)

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Acute complications

Kastenbauer et al, 2003

ISCHEMIA VASCULOPATHY HYDROCEPHALUS OEDEMA

V. THROMBOSIS VENTRICULITIS BLEEDING SEIZURESESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Arterial complications



nline

Lectu

re Lib

rary

© by au

thor

Stroke in bacterial meningitis

12/17 patients with stroke had alterations of cerebral arteries

STROKE CAN OCCUR LATE!In 10/17 cases onset > 5 days after therapy begun80% had signs of arterial narrowing*

* Klein et al., Neurology, 2010

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Stroke in bacterial meningitis

Schut et al., 2009

6 patients with stroke

Onset: 7-19 days after initiation of therapyInitially good clinical course with transfer to regular ward

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Treatment options of arterial complications

Diagnostic measures:

• transcranial doppler ultrasound+ bedside test, non-invasive, no contrast (kidney!), cheap• CT Angiography/Perfusion+ good quality, - might be risk for patient (transport, contrast)• conventional angiography+ gold standard, - risk for patient (transport, contrast, dissection)

Therapy: NO STUDIES AVAILABLE!

• Nimodipin po/iv- Induces hypotension, only use with arterial line• Triple H: Hypertension (CAVE cerebral perfusion pressure) HypervolämieHämodilution

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Increased intracranial pressure



nline

Lectu

re Lib

rary

© by au

thor

Conservative management of elevated ICP

• elevated positioning of the head 30°

• adequate analgesia and sedationfentanyl/sufentanyl, benzodiazepines, propofol, ketaminebe careful with barbiturates!

• moderate hyperventilation (pCO2 32-34 mmHg) aggressive hyperventilation lowers ICP at risk of perfusion!

• osmotic therapy with mannitol in uncontrollable CNS oedema(serum osmolality < 320 mOsm/l)

• hypertonic saline ?be careful with rate of elevation of sodium

• avoid hypo- and hypernatremia

• treat fever (paracetamol, novalgine, systemic cooling devices)data for hypothermia not available, currently not recommendedESCMID

Onli

ne Le

cture

Librar

y

© by au

thor

Invasive management of increased ICP

External Ventricular Drain

• insert preferrably from frontal right side• crucial in occluding hydrocephalus• allows ICP monitoring (important in anesthetized patients)• allows sophisticated control of cerebral perfusion pressure

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Invasive management of increased ICP

Acta Neurochir 2008

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Venous complications



nline

Lectu

re Lib

rary

© by au

thor

Venous complications in bacterial meningitis

NO STUDIES AVAILABLE

Retrospective analysis of data* suggests heparine iv (goal 2-3xPTT).

Do not use heparine in sinus transversus is affected (bleeding!).

* Southwick et al., 1995

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Ventriculitis



nline

Lectu

re Lib

rary

© by au

thor

Intracranial bleeding



nline

Lectu

re Lib

rary

© by au

thor

Seizures



nline

Lectu

re Lib

rary

© by au

thor

Seizures

2008

Prehospital seizure

33/666 patients

In-Hospital seizure

107/687 patients

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Seizures

2008

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Clinical case

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Seizures

consider non-convulsive status epilepticus

in patients with impaired comsciousness!

2004

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Seizures

Seizure or history of seizure:

- start antiepileptic therapy

Epileptic status*:

- iv benzodiazepines, e.g. lorazepam(0.1 mg/kg, 2mg/min, max. 10mg)

- iv phenytoin(15-20 mg/kg, 50mg/min for 5 minutes, rest in 20-30 min, EKG, blood pressure monitoring!)

- iv valproic acid20-30 mg/kg bolus

- (i.v. levetiracetam, barbiturates)

- if not effective:24h EEG guided burst suppression (midazolam, propofol)

Prophylactic treatment not indicated (NO DATA)

* Guidelines for therapy of status epilepticus of DGN 2008

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor


V. THROMBOSIS VENTRICULITIS BLEEDING SEIZURES

Systemic complications cause of death in 24%

BMC Infect Dis, 2005

Systemic complications

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Systemic complications: mechanical ventilation

BMC Infect Dis, 2005

Mechanical ventilation in 86/128 patients (67%)!

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor


INDICATIONS FOR INTUBATION

• Risk of aspiration

• Severe hypoxemia

• Impaired ventilation (CO2, O2)

• Increased work of breathing

• ICP management

• Need to safely complete diagnostic tests

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor


ARDS-protective ventilation:

limit tidal volumes (6ml/kg)- but avoid permissive hypercapnia

and respiratory acidosis (ICP) limit PEEP

Consider early tracheostomy if prolonged ventilation time considered

Time of extubation: level of consciousness vs. prolonged ventilation

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Systemic complications: Sepsis and Hemodynamic support

Avoid hypovolemia and hypotension

Use arterial line for continous blood pressure measurment

Consider transpulmonary thermodilution/PiCCO in unstable patientsPulmonary artery catheter questioned in sepsis questioned1

First line vasopressors: norepinephrine, dopamine, dobutamineEffect of vasopressin (cerebral vasodilator) on ICP not studied in brain traum/CNS infections

Relative adrenal insufficiency: hydrocortisone (200-300 mg/d)2

(if serum cortisol low or response to adrenocorticotropic hormone inadequate)

1 Richard et al., JAMA 2003, 2 Annane et al. JAMA 2002

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Crit Care 2005

Do not use activated protein C in meningitis!

Systemic complications: DIC- ACTIVATE PROTEIN C -

ESCMID O

nline

Lectu

re Lib

rary

© by au

thor

Department of Neurology

B Angele C HöhneC Demel U KoedelC Haubner N TremelT Högen HW Pfister

Institute of Neuropathology

A Giese

Institute of Microbiology

J Heesemann

Institutes of Immunology,

Microbiology and Hygiene

G Häcker C KirschningS Kirschnek H Wagner

Department of Microbiology

S Barnum

Dept. Med Biochem & Immunol Health

BP Morgan T Hughes

Dept. Genetics of Microorganisms

S Hammerschmidt T Härtel

Department of Biochemistry

J TschoppESCMID O

nline

Lectu

re Lib

rary

© by au

thor

http://www.unil.ch/central

ICU and neurologic perspective by ESCMID

Documents

Transcript of ICU and neurologic perspective by ESCMID