Thank you. To begin with, I just want to say Happy Lunar New Year to everyone who satisfies it. Today is the first year of Revit. Very happy to be here. So again, my name is Fajun. I fortunately just graduated last year and transitioned to my first job six months in. I have nothing to disclose. We're going to try to focus on three topics today and two of the papers were already mentioned by Rhonda, but I kind of want to take a deeper dive and to discuss from as a recent trainee perspective that what I have learned. The first thing is timing of tracheostomy in patients with severe stroke. Then we want to look at the strategy of epileptic form discharges in cardiac arrest survivors. And then the last thing is our day-to-day practice. What kind of fluids do I choose in the neuro ICU patient? So the first trial was done, the treatment trial, in a mixed medical and surgical ICU population. They look at the early tracheostomy and standardized tracheostomy to see whether it will change patients' mortality outcome or functional outcome. And the result was negative. So doing an early trach did not change anything. And also tells us that physicians are really bad at predicting who's going to need a trach down the line. About 50% of patients in the control group did not end up requiring a trach. And we thought with neuro patients, maybe we're better, right? Because of the extent of the brain injury, we kind of know they're not able to protect their airway. So a group of people in Europe did this pilot study, the SEP point trial, which is a small study looking at the early tracheostomy in the severe stroke patients. So they recruited 60 patients with severe stroke. And they used to cut off of the SEP score more than eight, which it has a sensitivity of 64% and a specificity of 86%, which is pretty good at predicting the requirement of tracheostomy and prolonged mechanical ventilation. Their result was somewhat encouraging, even though they showed same ICU length of stay, similar ICU courses, but was safe and feasible to do early tracheostomy. And patients who received early trach had less sedatives, they have less controlled ventilation, and they even had lower mortality in the early tracheostomy group. So this led to the large SEP point two trial that was published last year. It was a multi-center international randomized control trial. Again, they compared early tracheostomy to a standard timing tracheostomy. Mechanically ventilated patients with severe stroke. They look at six months functional outcome. The inclusion criteria was pretty simple. Basically anyone who meets the SEP score more than 10 or the intensivist thinks the patient needs a trach can be included in any type of the stroke. And they excluded those who are expected to die pretty soon or the family who's unwilling to undergo aggressive critical care. And as you can expect it, the age was pretty much like on the around 60s, and they're very sick. The median age is 20, the GCS score is 7, and the ICH score is 3, and the WFNS score for subarachnoid hemorrhage is 5, which is essentially a comatose patient. What's interesting is still only about 67% of patients in the standard group received tracheostomy. That's because 11% of those patients died before day 11, and the rest 22% who was successfully went from ventilator and did not require trach. So as you can see from almost every single outcome, they look at the functional outcome, the mortality outcome, the length of stay, or even the use of sedatives. There's no difference when comparing early tracheostomy or standard tracheostomy timing. What's interesting is this, the winning attempt. So in the standard tracheostomy group, more patients had winning extubation attempt, and more patients were successfully extubated. So my take-home message when I read this paper was early tracheostomy does not improve, even though we thought it made six months mortality or functional outcome in patients with severe stroke. Early tracheostomy does not minimize ICU length of stay or the use of sedatives. Early tracheostomy in severe stroke seems to be safe regarding whenever you do it, but if you do it on a standard timing around day 10, day 11, there are about 20% of patients who you can, you know, avoid doing invasive procedures, or less patiently require those procedures unnecessarily. So now I'm going to shift gears and looking at the epileptic form discharges in cardiac arrest survivors. As a practicing neurointensivist, I get phone call almost every week from my MECU colleagues and ask me to look at this patient and say what should we do, and how do we guide family conversation. And it's extremely hard when patients don't wake up, and they're on 5 AEDs and 3 DRIP, and you're asking yourself, well, are they not waking up because their brain is burned? Or are they just over sedated from all the medications and the sedatives? So a group of smart people, again from Europe, did this Telstar study. It's a multi-center randomized open labels trial. They enrolled all cardiac survivors who had continuous EEG started within 24 hours of ROSC, who had had rhythmic discharges on EEG and according to that definition. And I just want to show the patterns, the examples they included into the study. So on the panel A, it basically shows an electrographic seizure pattern and status pattern. And panel B is an evolving pattern that shows you the evolution of the seizure. And panel C is probably the most common pattern we're going to see, and panel D is the C is generalized periodic discharges, and D is rhythmic delta activity. As you can see, it almost looks like a wavy ocean. So they divided the patients into two groups. The treatment group, they use a stepwise treatment strategy with adding more and more AEDs with the goal to completely suppress EEG discharges. And in the standard group, physicians are allowed to use sedatives to prevent vent desynchrony or use it as hemodynamic stabilization. As you can see from the outcome, whatever they measured had no difference. I do want to point out the limitation of this study. So about two-thirds of the patients they enrolled in the trial actually had generalized myoclonic status, which will potentially skew the trial results towards negative, because we know it's kind of the ominous sign when you have generalized myoclonic status after cardiac arrest. And most deaths in both groups actually happened within 24 hours after randomization. They didn't specify how many percent of those were from withdrawal of care, but there are definitely a certain amount of numbers are from withdrawal of life support, and that also will lead to fewer patients you can have to judge the long-term functional outcome. And they also only reported very limited data on neurological examination or neuroimaging, which might potentially tell you the prognostic data on those patient population. So given all this, I think it's still pragmatic when you have an arrest patient using sedatives in the beginning to try to prevent desynchrony and stabilize the patient, and try to expedite the tests that can provide more prognostic values, and which may help guide you when you're involved, and maybe involve palliative care if that's the case, and guide family discussion and decision-making. And the other thing is that it's probably true that if patient has generalized myoclonic status, if you're using multiple, multiple AEDs trying to suppress the EEG discharges, you may not be able to reverse the trajectory because that's from the severity of brain injury after the cessation of cerebral perfusion. The last topic that I want to bring your attention to is really important in our day-to-day practice in the neuro ICU is what kind of fluids do I use when I have a neurological critically ill patient? The SMART trial that came out many, many years ago kind of like shipped the landscape of how we think about fluid resuscitation. So the group used balanced fluids, mostly lactate wringer, and I think a small portion of plasmolyte to resuscitate mixed medical-surgical ICU population. They were able to show improved 30-day composite outcome in a balanced fluid group. And then in 2021, the basic trial came out. It's a group of Brazilian physicians. They designed this study to use plasmolyte compared to normal saline in the same setting, mixed medical-surgical ICU population, and looking at the 30-day mortality outcome and the new incidence of acute kidney injury or new initiation of renal replacement therapy, and they were unable to show any benefit in the plasmolyte group. Earlier 2022, the PLOS group out of Australia and New Zealand was basically using the same approach, plasmolyte versus normal saline in a mixed medical ICU population, and looking at the same outcome, 30-day mortality and new AKI or RRT, and they had the same result. There is no benefit in the plasmolyte group. So the study I want to bring your attention to is this meta-analysis published on New England Journal Evidence after the PLOS trial was published. The authors did a very rigorous literature research. They only included randomized control studies. It's important to note that about more than 50% of patients actually stemmed from the BASIC and PLOS trial, because those two are the ones have most patients enrolled. And this is kind of the list of the oldest studies they enrolled. It's a busy table, but you can kind of see most patients are kind of in the mixed medical ICU, surgical ICU patient population, with sepsis. So this first plot you can see is a 90-day mortality comparing the group of using balanced crystalloids versus normal saline, and there's a clear trend, even though it didn't reach statistical significance, that favors balanced crystalloids in the mixed medical ICU and surgical ICU population. And this also holds true when you look at the acute kidney injury, the new incidence of AKI, there is a clear trend, but again, there is no statistical significance. And same thing for new initiation of renal replacement therapy. There is a trend, but there is no statistical significance. When you look at the ventilation-free days and the vasopressor-free days, only high quality low-bias trials reported these two data points, so you see less studies being included, but there's quite even distribution across the non-significance line. So the balanced crystalloids doesn't really make a difference when you're talking about vent-free day or vasopressor-free days. However, when you look at patients with sepsis only, this is almost, almost statistical significant. It's only crossing the line 1.01. So there is a clear benefit trend towards using balanced crystalloids to resuscitate patients with sepsis. And as a neurointensivist, I care much more about brain injured patients. Unfortunately, most of the studies exclude anyone with acute brain injuries. They do have some small population that were included for whatever reason that has traumatic brain injury, and you can see a clear trend towards harm when you use balanced fluids in the patient with traumatic brain injury, and I think that's most likely from the hypotonicity of the balanced fluids compared to the plasma. So my take-home message for this paper is I think in a mixed medical surgical ICU population, using a balanced crystalloids is probably reasonable. You have a trend towards mortality benefit and AKI benefit and RRT benefit, especially in those patients with sepsis. However, in the neural ICU, you have to be really careful in patients with brain injuries, especially in TBI population, because there is a clear trend towards harm. So the bottom line that I can think of is really important to select your choice of fluids based on your in the patient patient condition. We shouldn't really use a one-size-fits-all approach when treating patients. Precision medicine should be the future, now and the future. Thank you.

neurocritical care

tracheostomy timing

epileptiform discharges

fluid resuscitation

balanced crystalloids