icu and neurologic perspective by escmid
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Treatment of community acquired meningitis-
ICU and neurologic perspective
Izmir 2010
Neurologische Klinik und PoliklinikProf. Dr. M. Dieterich
Dr. Matthias Klein, Munich, Germany
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INFECTIOUS FOCI OF
COMMUNITY ACQUIRED MENINGITIS
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The cause matters
Infectious focus:
Ear 30%Lung 18%Sinus 8%Other 2%(e.g. endocarditis)
no focus 42%
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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
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Imagin for ENT focus
CCT brain window CT skullbase bone window
post surgery
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When to especially consider CSF leak?
41 yo maleS. pneumoniae meningitis
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Beta2-Transferrin, a marker for the detection of CSF leaks
post fluorescein application into CSF
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Further infectious foci of bacterial meningitis
Staphylococcus aureus
Spondylodiscitis
67 yo femalepost orthopaedic vertebral injectionsStaphylococcus aureus
paravertebral abscessESCMID O
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• 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
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INTENSIVE CARE / ACUTE COMPLICATIONS
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Acute complications
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INTENSIVE CARE / ACUTE COMPLICATIONS
INTRACRANIAL COMPLICATIONS (75%)
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Acute complications
Kastenbauer et al, 2003
ISCHEMIA VASCULOPATHY HYDROCEPHALUS OEDEMA
V. THROMBOSIS VENTRICULITIS BLEEDING SEIZURESESCMID O
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Arterial complications
ISCHEMIA VASCULOPATHY HYDROCEPHALUS OEDEMA
V. THROMBOSIS VENTRICULITIS BLEEDING SEIZURESESCMID O
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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
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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
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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
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Increased intracranial pressure
ISCHEMIA VASCULOPATHY HYDROCEPHALUS OEDEMA
V. THROMBOSIS VENTRICULITIS BLEEDING SEIZURESESCMID O
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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
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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
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Invasive management of increased ICP
Acta Neurochir 2008
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Venous complications
ISCHEMIA VASCULOPATHY HYDROCEPHALUS OEDEMA
V. THROMBOSIS VENTRICULITIS BLEEDING SEIZURESESCMID O
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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
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Ventriculitis
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Intracranial bleeding
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Seizures
ISCHEMIA VASCULOPATHY HYDROCEPHALUS OEDEMA
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Seizures
2008
Prehospital seizure
33/666 patients
In-Hospital seizure
107/687 patients
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Seizures
2008
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Clinical case
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Seizures
consider non-convulsive status epilepticus
in patients with impaired comsciousness!
2004
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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
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ISCHEMIA VASCULOPATHY HYDROCEPHALUS OEDEMA
V. THROMBOSIS VENTRICULITIS BLEEDING SEIZURES
Systemic complications cause of death in 24%
BMC Infect Dis, 2005
Systemic complications
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INTENSIVE CARE / ACUTE COMPLICATIONS
SYSTEMIC COMPLICATIONS (30%)
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Systemic complications: mechanical ventilation
BMC Infect Dis, 2005
Mechanical ventilation in 86/128 patients (67%)!
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Systemic complications: mechanical ventilation
INDICATIONS FOR INTUBATION
• Risk of aspiration
• Severe hypoxemia
• Impaired ventilation (CO2, O2)
• Increased work of breathing
• ICP management
• Need to safely complete diagnostic tests
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Systemic complications: mechanical ventilation
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
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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
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Systemic complications: DIC- ACTIVATE PROTEIN C -
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Crit Care 2005
Do not use activated protein C in meningitis!
Systemic complications: DIC- ACTIVATE PROTEIN C -
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Summary
E R I C U
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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
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THANK YOU FOR YOUR ATTENTION
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