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1 Neurologische Klinik und Poliklinik Prof. Dr. M. Dieterich Treatment of community acquired meningitis - ICU and neurologic perspective Izmir 2010
2 INFECTIOUS FOCI OF COMMUNITY ACQUIRED MENINGITIS
3 The cause matters Infectious focus: Ear 30% Lung 18% Sinus 8% Other 2% (e.g. endocarditis) no focus 42%
4 Sinusitis max. Infectious focus in bacterial meningitis ENT infection in 50/87 of patients with pneumococcal meningitis S. ethmoidalis S. sphenoidalis Mastoiditis (+ Sinusitis max.) Kastenbauer und Pfister, Brain 2003
5 Imagin for ENT focus post surgery CCT brain window CT skullbase bone window
6 41 yo male S. pneumoniae meningitis When to especially consider CSF leak?
7 63 yo female with H. influenzae meningitis Look at suspicious findings twice! Cholesteatoma mastoidectomy MRI T2 CT skull base
8 Beta2-Transferrin, a marker for the detection of CSF leaks post fluorescein application into CSF
9 Further infectious foci of bacterial meningitis Staphylococcus aureus 67 yo female post orthopaedic vertebral injections Staphylococcus aureus Spondylodiscitis paravertebral abscess
10 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
11 INTENSIVE CARE / ACUTE COMPLICATIONS
12 Acute complications
13 INTENSIVE CARE / ACUTE COMPLICATIONS INTRACRANIAL COMPLICATIONS (75%)
14 Acute complications ISCHEMIA VASCULOPATHY HYDROCEPHALUS OEDEMA V. THROMBOSIS VENTRICULITIS BLEEDING SEIZURES Kastenbauer et al, 2003
15 Arterial complications ISCHEMIA VASCULOPATHY HYDROCEPHALUS OEDEMA V. THROMBOSIS VENTRICULITIS BLEEDING SEIZURES
16 67yo female, S. pneumoniae meningitis Clinical Case
17 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 begun 80% had signs of arterial narrowing* * Klein et al., Neurology, 2010
18 Stroke in bacterial meningitis 6 patients with stroke Schut et al., 2009 Onset: 7-19 days after initiation of therapy Initially good clinical course with transfer to regular ward
19 Doppler in patients with bacterial meningitis 46 patients with increased cerebral blood flow (40%) (8±12 days after admission) Ischemic stroke in 16 patients 133 patients with bacterial meningitis 115 patients with transcranial doppler ultrasound 69 patients without increased cerebral blood flow Ischemic stroke in 2 patients
20 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) Hypervolämie Hämodilution
21 Increased intracranial pressure ISCHEMIA VASCULOPATHY HYDROCEPHALUS OEDEMA V. THROMBOSIS VENTRICULITIS BLEEDING SEIZURES
22 Conservative management of elevated ICP elevated positioning of the head 30 adequate analgesia and sedation fentanyl/sufentanyl, benzodiazepines, propofol, ketamine be careful with barbiturates! moderate hyperventilation (pco 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 recommended
23 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
24 17 yo patient Headache for 4 days CSF: meningitis Within 4h: GCS15 GCS3 Pupils asymetric, non-reactive to light Invasive management of increased ICP Streptococcus intermedius + Fusobacterium necrophorum Therapy: Meropenem, Rifampicin Good recovery
25 Invasive management of increased ICP Acta Neurochir 2008
26 Venous complications ISCHEMIA VASCULOPATHY HYDROCEPHALUS OEDEMA V. THROMBOSIS VENTRICULITIS BLEEDING SEIZURES
27 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
28 Ventriculitis ISCHEMIA VASCULOPATHY HYDROCEPHALUS OEDEMA V. THROMBOSIS VENTRICULITIS BLEEDING SEIZURES
29 Intracranial bleeding ISCHEMIA VASCULOPATHY HYDROCEPHALUS OEDEMA V. THROMBOSIS VENTRICULITIS BLEEDING SEIZURES
30 Seizures ISCHEMIA VASCULOPATHY HYDROCEPHALUS OEDEMA V. THROMBOSIS VENTRICULITIS BLEEDING SEIZURES
31 2008 Prehospital seizure 33/666 patients In-Hospital seizure 107/687 patients Seizures
32 2008 Seizures
33 Clinical case
34 2004 Seizures consider non-convulsive status epilepticus in patients with impaired comsciousness!
35 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 min, EKG, blood pressure monitoring!) - iv valproic acid 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
36 Systemic complications BMC Infect Dis, 2005 ISCHEMIA VASCULOPATHY HYDROCEPHALUS OEDEMA Systemic complications cause of death in 24% V. THROMBOSIS VENTRICULITIS BLEEDING SEIZURES
37 INTENSIVE CARE / ACUTE COMPLICATIONS SYSTEMIC COMPLICATIONS (30%)
38 Systemic complications: mechanical ventilation BMC Infect Dis, 2005 Mechanical ventilation in 86/128 patients (67%)!
39 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
40 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 ARDS
41 Systemic complications: Sepsis and Hemodynamic support Avoid hypovolemia and hypotension Use arterial line for continous blood pressure measurment Consider transpulmonary thermodilution/picco in unstable patients Pulmonary artery catheter questioned in sepsis questioned 1 First line vasopressors: norepinephrine, dopamine, dobutamine Effect of vasopressin (cerebral vasodilator) on ICP not studied in brain traum/cns infections Relative adrenal insufficiency: hydrocortisone ( 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
42 Systemic complications: DIC - ACTIVATE PROTEIN C -
43 Crit Care 2005 Systemic complications: DIC - ACTIVATE PROTEIN C - Do not use activated protein C in meningitis!
44 E R Summary I C U
45 Thank you.
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