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Mogharari N, Wojtkiewicz S, Borycki D, Liebert A, Kacprzak M. Time-domain diffuse correlation spectroscopy at large source detector separation for cerebral blood flow recovery. BIOMEDICAL OPTICS EXPRESS 2024; 15:4330-4344. [PMID: 39022555 PMCID: PMC11249683 DOI: 10.1364/boe.523514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 05/29/2024] [Accepted: 05/31/2024] [Indexed: 07/20/2024]
Abstract
Time-domain diffuse correlation spectroscopy (td-DCS) enables the depth discrimination in tissue's blood flow recovery, considering the fraction of photons detected with higher time of flight (TOF) and longer pathlength through the tissue. However, the recovery result depends on factors such as the instrument response function (IRF), analyzed TOF gate start time, gate width and the source-detector separation (SDS). In this research we evaluate the performance of the td-DCS technique at three SDSs of 1.5, 2 and 2.5 cm to recover cerebral blood flow (CBF). To do that we presented comprehensive characterization of the td-DCS system through a series of phantom experiments. First by quality metrices such as coefficient of variation and contrast-to-noise ratios, we identified optimal time gate(s) of the TOF to extract dynamics of particles. Then using sensitivity metrices, each SDS ability to detect dynamics of particles in superficial and deeper layer was evaluated. Finally, td-DCS at each SDS was tested on healthy volunteers during cuff occlusion test and breathing tasks. According to phantom measurements, the sensitivity to estimate perfusion within the deep layer located at depth of 1.5 cm from the surface can be increased more than two times when the SDS increases from 1.5 cm to 2.5 cm.
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Affiliation(s)
- Neda Mogharari
- Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Poland
| | - Stanisław Wojtkiewicz
- Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Poland
| | - Dawid Borycki
- Institute of Physical Chemistry, Polish Academy of Sciences, Kasprzaka 44/52, Poland
| | - Adam Liebert
- Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Poland
| | - Michał Kacprzak
- Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Poland
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2
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Yin H, Yang R, Xin Y, Jiang T, Zhong D. In-hospital mortality and SpO2 incritical care patients with cerebral injury: data from the MIMIC‑IV Database. BMC Anesthesiol 2022; 22:386. [PMID: 36510130 PMCID: PMC9743499 DOI: 10.1186/s12871-022-01933-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 12/05/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Evidence regarding the relationship between in-hospital mortality and SpO2 was low oxygen saturations are often thought to be harmful, new research in patients with brain damage has found that high oxygen saturation actually enhances mortality. However, there is currently no clear study to point out the appropriate range for oxygen saturation in patients with craniocerebral diseases. METHODS: By screening all patients in the MIMIC IV database, 3823 patients with craniocerebral diseases (according to ICD-9 codes and ICD-10) were selected, and non-linear regression was used to analyze the relationship between in-hospital mortality and oxygen saturation. Covariates for all patients included age, weight, diagnosis, duration of ICU stay, duration of oxygen therapy, etc. RESULTS: In-hospital mortality in patients with TBI and SAH was kept to a minimum when oxygen saturation was in the 94-96 range. And in all patients, the relationship between oxygen saturation and in-hospital mortality was U-shaped. Subgroup analysis of the relationship between oxygen saturation and mortality in patients with metabolic encephalopathy and other encephalopathy also draws similar conclusions In-hospital mortality and oxygen saturation were all U-shaped in patients with subarachnoid hemorrhage, metabolic and toxic encephalopathy, cerebral infarction, and other encephalopathy, but the nonlinear regression was statistically significant only in patients with cerebral infarction (p for nonlinearity = 0.002). CONCLUSION Focusing too much on the lower limit of oxygen saturation and ignoring too high oxygen saturation can also lead to increase in-hospital mortality. For patients with TBI and SAH, maintaining oxygen saturation at 94-96% will minimize the in-hospital mortality of patients.
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Affiliation(s)
- Haoyang Yin
- grid.452206.70000 0004 1758 417XDepartment of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Rui Yang
- grid.452206.70000 0004 1758 417XDepartment of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yun Xin
- grid.452206.70000 0004 1758 417XDepartment of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Tao Jiang
- grid.452206.70000 0004 1758 417XDepartment of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Dong Zhong
- grid.452206.70000 0004 1758 417XDepartment of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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3
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Datzmann T, Messerer DAC, Münz F, Hoffmann A, Gröger M, Mathieu R, Mayer S, Gässler H, Zink F, McCook O, Merz T, Scheuerle A, Wolfschmitt EM, Thebrath T, Zuech S, Calzia E, Asfar P, Radermacher P, Kapapa T. The effect of targeted hyperoxemia in a randomized controlled trial employing a long-term resuscitated, model of combined acute subdural hematoma and hemorrhagic shock in swine with coronary artery disease: An exploratory, hypothesis-generating study. Front Med (Lausanne) 2022; 9:971882. [PMID: 36072939 PMCID: PMC9442904 DOI: 10.3389/fmed.2022.971882] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 08/04/2022] [Indexed: 11/24/2022] Open
Abstract
Controversial evidence is available regarding suitable targets for the arterial O2 tension (PaO2) after traumatic brain injury and/or hemorrhagic shock (HS). We previously demonstrated that hyperoxia during resuscitation from hemorrhagic shock attenuated cardiac injury and renal dysfunction in swine with coronary artery disease. Therefore, this study investigated the impact of targeted hyperoxemia in a long-term, resuscitated model of combined acute subdural hematoma (ASDH)-induced brain injury and HS. The prospective randomized, controlled, resuscitated animal investigation consisted of 15 adult pigs. Combined ASDH plus HS was induced by injection of 0.1 ml/kg autologous blood into the subdural space followed by controlled passive removal of blood. Two hours later, resuscitation was initiated comprising re-transfusion of shed blood, fluids, continuous i.v. noradrenaline, and either hyperoxemia (target PaO2 200 – 250 mmHg) or normoxemia (target PaO2 80 – 120 mmHg) during the first 24 h of the total of 54 h of intensive care. Systemic hemodynamics, intracranial and cerebral perfusion pressures, parameters of brain microdialysis and blood biomarkers of brain injury did not significantly differ between the two groups. According to the experimental protocol, PaO2 was significantly higher in the hyperoxemia group at the end of the intervention period, i.e., at 24 h of resuscitation, which coincided with a higher brain tissue PO2. The latter persisted until the end of observation period. While neurological function as assessed using the veterinary Modified Glasgow Coma Score progressively deteriorated in the control group, it remained unaffected in the hyperoxemia animals, however, without significant intergroup difference. Survival times did not significantly differ in the hyperoxemia and control groups either. Despite being associated with higher brain tissue PO2 levels, which were sustained beyond the intervention period, targeted hyperoxemia exerted neither significantly beneficial nor deleterious effects after combined ASDH and HS in swine with pre-existing coronary artery disease. The unavailability of a power calculation and, thus, the limited number of animals included, are the limitations of the study.
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Affiliation(s)
- Thomas Datzmann
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Ulm, Germany
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Ulm, Ulm, Germany
- *Correspondence: Thomas Datzmann,
| | - David Alexander Christian Messerer
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Ulm, Germany
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Ulm, Ulm, Germany
- Transfusionsmedizinische und Hämostaseologische Abteilung, Universitätsklinikum Erlangen und Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Franziska Münz
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Ulm, Germany
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Ulm, Ulm, Germany
| | - Andrea Hoffmann
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Ulm, Germany
| | - Michael Gröger
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Ulm, Germany
| | - René Mathieu
- Klinik fuür Neurochirurgie, Bundeswehrkrankenhaus Ulm, Ulm, Germany
| | - Simon Mayer
- Klinik fuür Neurochirurgie, Bundeswehrkrankenhaus Ulm, Ulm, Germany
| | - Holger Gässler
- Klinik fuür Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Bundeswehrkrankenhaus Ulm, Ulm, Germany
| | - Fabian Zink
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Ulm, Germany
| | - Oscar McCook
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Ulm, Germany
| | - Tamara Merz
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Ulm, Germany
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Ulm, Ulm, Germany
| | - Angelika Scheuerle
- Sektion Neuropathologie, Institut für Pathologie, Universitätsklinikum Ulm, Ulm, Germany
| | - Eva-Maria Wolfschmitt
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Ulm, Germany
| | - Timo Thebrath
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Ulm, Germany
| | - Stefan Zuech
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Ulm, Germany
| | - Enrico Calzia
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Ulm, Germany
| | - Pierre Asfar
- Département de Médecine Intensive – Réanimation et Médecine Hyperbare, Centre Hospitalier Universitaire, Angers, France
| | - Peter Radermacher
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Ulm, Germany
| | - Thomas Kapapa
- Klinik für Neurochirurgie, Universitätsklinikum Ulm, Ulm, Germany
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4
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The Impact of Short-Term Hyperoxia on Cerebral Metabolism: A Systematic Review and Meta-Analysis. Neurocrit Care 2022; 37:547-557. [PMID: 35641804 DOI: 10.1007/s12028-022-01529-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 04/26/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Cerebral ischemia due to hypoxia is a major cause of secondary brain injury and is associated with higher morbidity and mortality in patients with acute brain injury. Hyperoxia could improve energetic dysfunction in the brain in this setting. Our objectives were to perform a systematic review and meta-analysis of the current literature and to assess the impact of normobaric hyperoxia on brain metabolism by using cerebral microdialysis. METHODS We searched Medline and Scopus, following the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement; we searched for retrospective and prospective observational studies, interventional studies, and randomized clinical trials that performed a hyperoxia challenge in patients with acute brain injury who were concomitantly monitored with cerebral microdialysis. This study was registered in PROSPERO (CRD420211295223). RESULTS We included a total of 17 studies, with a total of 311 patients. A statistically significant reduction in cerebral lactate values (pooled standardized mean difference [SMD] - 0.38 [- 0.53 to - 0.23]) and lactate to pyruvate ratio values (pooled SMD - 0.20 [- 0.35 to - 0.05]) was observed after hyperoxia. However, glucose levels (pooled SMD - 0.08 [- 0.23 to 0.08]) remained unchanged after hyperoxia. CONCLUSIONS Normobaric hyperoxia may improve cerebral metabolic disturbances in patients with acute brain injury. The clinical impact of such effects needs to be further elucidated.
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5
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Navarro JC, Kofke WA. Perioperative Management of Acute Central Nervous System Injury. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00024-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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6
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Sorby-Adams AJ, Learoyd AE, Bath PM, Burrows F, Farr TD, Leonard AV, Schiessl I, Allan SM, Turner RJ, Trueman RC. Glyceryl trinitrate for the treatment of ischaemic stroke: Determining efficacy in rodent and ovine species for enhanced clinical translation. J Cereb Blood Flow Metab 2021; 41:3248-3259. [PMID: 34039053 PMCID: PMC8669202 DOI: 10.1177/0271678x211018901] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Hypertension is a leading risk factor for death and dependency after ischaemic stroke. However, administering anti-hypertensive medications post-stroke remains contentious with concerns regarding deleterious effects on cerebral blood flow and infarct expansion. This study sought to determine the effect of glyceryl trinitrate (GTN) treatment in both lissencephalic and gyrencephalic pre-clinical stroke models. Merino sheep underwent middle cerebral artery occlusion (MCAO) followed by GTN or control patch administration (0.2 mg/h). Monitoring of numerous physiologically relevant measures over 24 h showed that GTN administration was associated with decreased intracranial pressure, infarct volume, cerebral oedema and midline shift compared to vehicle treatment (p < 0.05). No significant changes in blood pressure or cerebral perfusion pressure were observed. Using optical imaging spectroscopy and laser speckle imaging, the effect of varying doses of GTN (0.69-50 µg/h) on cerebral blood flow and tissue oxygenation was examined in mice. No consistent effect was found. Additional mice undergoing MCAO followed by GTN administration (doses varying from 0-60 µg/h) also showed no improvement in infarct volume or neurological score within 24 h post-stroke. GTN administration significantly improved numerous stroke-related physiological outcomes in sheep but was ineffective in mice. This suggests that, whilst GTN administration could potentially benefit patients, further research into mechanisms of action are required.
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Affiliation(s)
- Annabel J Sorby-Adams
- Adelaide Medical School and Adelaide Centre for Neuroscience Research, The University of Adelaide, Adelaide, SA, Australia
| | - Annastazia E Learoyd
- School of Life Sciences, University of Nottingham Medical School, Nottingham, UK
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Fiona Burrows
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Tracy D Farr
- School of Life Sciences, University of Nottingham Medical School, Nottingham, UK
| | - Anna V Leonard
- Adelaide Medical School and Adelaide Centre for Neuroscience Research, The University of Adelaide, Adelaide, SA, Australia
| | - Ingo Schiessl
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK.,Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance NHS Group, University of Manchester, Manchester, UK
| | - Stuart M Allan
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK.,Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance NHS Group, University of Manchester, Manchester, UK
| | - Renée J Turner
- Adelaide Medical School and Adelaide Centre for Neuroscience Research, The University of Adelaide, Adelaide, SA, Australia
| | - Rebecca C Trueman
- School of Life Sciences, University of Nottingham Medical School, Nottingham, UK
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7
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Klinzing S, Stretti F, Pagnamenta A, Bèchir M, Brandi G. Transcranial color-coded duplex sonography assessment of cerebrovascular reactivity to carbon dioxide: an interventional study. BMC Neurol 2021; 21:305. [PMID: 34364365 PMCID: PMC8349098 DOI: 10.1186/s12883-021-02310-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 07/06/2021] [Indexed: 01/15/2023] Open
Abstract
Background The investigation of CO2 reactivity (CO2-CVR) is used in the setting of, e.g., traumatic brain injury (TBI). Transcranial color-coded duplex sonography (TCCD) is a promising bedside tool for monitoring cerebral hemodynamics. This study used TCCD to investigate CO2-CVR in volunteers, in sedated and mechanically ventilated patients without TBI and in sedated and mechanically ventilated patients in the acute phase after TBI. Methods This interventional investigation was performed between March 2013 and February 2016 at the surgical ICU of the University Hospital of Zurich. Ten volunteers (group 1), ten sedated and mechanically ventilated patients (group 2), and ten patients in the acute phase (12–36 h) after severe TBI (group 3) were included. CO2-CVR to moderate hyperventilation (∆ CO2 -5.5 mmHg) was assessed by TCCD. Results CO2-CVR was 2.14 (1.20–2.70) %/mmHg in group 1, 2.03 (0.15–3.98) %/mmHg in group 2, and 3.32 (1.18–4.48)%/mmHg in group 3, without significant differences among groups. Conclusion Our data did not yield evidence for altered CO2-CVR in the early phase after TBI examined by TCCD. Trial registration Part of this trial was performed as preparation for the interventional trial in TBI patients (clinicaltrials.gov NCT03822026, 30.01.2019, retrospectively registered).
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Affiliation(s)
- Stephanie Klinzing
- Institute for Intensive Medicine, University Hospital of Zurich, Raemistrasse 100, CH-8091, Zurich, Switzerland.
| | - Federica Stretti
- Intensive Care Unit, Westmead Hospital, Westmead, NSW, Australia
| | - Alberto Pagnamenta
- Intensive Care Unit, Regional Hospital of Mendrisio, Mendrisio, Switzerland.,Unit of Clinical Epidemiology, Ente Ospedaliero Cantonale, Bellinzona, Switzerland.,Division of Pneumology, University of Geneva, Geneva, Switzerland
| | - Markus Bèchir
- Institute for Intensive Medicine, University Hospital of Zurich, Raemistrasse 100, CH-8091, Zurich, Switzerland
| | - Giovanna Brandi
- Institute for Intensive Medicine, University Hospital of Zurich, Raemistrasse 100, CH-8091, Zurich, Switzerland
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8
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Takahashi CE, Virmani D, Chung DY, Ong C, Cervantes-Arslanian AM. Blunt and Penetrating Severe Traumatic Brain Injury. Neurol Clin 2021; 39:443-469. [PMID: 33896528 DOI: 10.1016/j.ncl.2021.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
Severe traumatic brain injury is a common problem. Current practices focus on the importance of early resuscitation, transfer to high-volume centers, and provider expertise across multiple specialties. In the emergency department, patients should receive urgent intracranial imaging and consideration for tranexamic acid. Close observation in the intensive care unit environment helps identify problems, such as seizure, intracranial pressure crisis, and injury progression. In addition to traditional neurologic examination, patients benefit from use of intracranial monitors. Monitors gather physiologic data on intracranial and cerebral perfusion pressures to help guide therapy. Brain tissue oxygenation monitoring and cerebromicrodialysis show promise in studies.
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Affiliation(s)
- Courtney E Takahashi
- Department of Neurology, Boston Medical Center, 72 East Concord Street, Collamore, C-3, Boston, MA 02118, USA.
| | - Deepti Virmani
- Department of Neurology, Boston University School of Medicine and Boston Medical Center, 72 East Concord Street, Collamore, C-3, Boston, MA 02118, USA
| | - David Y Chung
- Department of Neurology, Boston University School of Medicine and Boston Medical Center, 72 East Concord Street, Collamore, C-3, Boston, MA 02118, USA; Division of Neurocritical Care, Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA; Neurovascular Research Unit, Department of Radiology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Charlene Ong
- Department of Neurology, Boston University School of Medicine and Boston Medical Center, 72 East Concord Street, Collamore, C-3, Boston, MA 02118, USA
| | - Anna M Cervantes-Arslanian
- Boston University School of Medicine and Boston Medical Center, 72 East Concord Street, Collamore, C-3, Boston, MA 02118, USA
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9
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Ramineni A, Roberts EA, Vora M, Mahboobi SK, Nozari A. Anesthesia Considerations in Neurological Emergencies. Neurol Clin 2021; 39:319-332. [PMID: 33896521 DOI: 10.1016/j.ncl.2021.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Airway obstruction and respiratory failure are common complications of neurological emergencies. Anesthesia is often employed for airway management, surgical and endovascular interventions or in the intensive care units in patients with altered mental status or those requiring burst suppression. This article provides a summary of the unique airway management and anesthesia considerations and controversies for neurologic emergencies in general, as well as for specific commonly encountered conditions: elevated intracranial pressure, neuromuscular respiratory failure, acute ischemic stroke, and acute cervical spinal cord injury.
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Affiliation(s)
- Anil Ramineni
- Department of Neurology, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA 01805, USA
| | - Erik A Roberts
- Boston University School of Medicine, 72 East Concord Street, Boston, MA 02118, USA
| | - Molly Vora
- Boston University School of Medicine, 72 East Concord Street, Boston, MA 02118, USA
| | - Sohail K Mahboobi
- Department of Anesthesiology, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA 01805, USA; Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA 02111, USA
| | - Ala Nozari
- Boston University School of Medicine, 72 East Concord Street, Boston, MA 02118, USA; Department of Anesthesiology, Boston Medical Center, 750 Albany Street, Power Plant 2R, Boston, MA 02118, USA.
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10
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Godoy DA, Badenes R, Robba C, Murillo Cabezas F. Hyperventilation in Severe Traumatic Brain Injury Has Something Changed in the Last Decade or Uncertainty Continues? A Brief Review. Front Neurol 2021; 12:573237. [PMID: 33776876 PMCID: PMC7991081 DOI: 10.3389/fneur.2021.573237] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 01/28/2021] [Indexed: 11/16/2022] Open
Affiliation(s)
- Daniel Agustín Godoy
- Neurointensive Care Unit, Sanatorio Pasteur, Catamarca, Argentina.,Intensive Care Unit, Hospital San Juan Bautista, Catamarca, Argentina
| | - Rafael Badenes
- Department Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clinic Universitari de Valencia, Valencia, Spain.,Department of Surgery, University of Valencia, Valencia, Spain.,INCLIVA Research Medical Institute, Valencia, Spain
| | - Chiara Robba
- Department of Anaesthesia and Intensive Care, Policlinico San Martino Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) for Oncology and Neuroscience, Genoa, Italy.,School of Medicine and Surgery, University of Milano - Bicocca, Monza, Italy
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11
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Gouvea Bogossian E, Peluso L, Creteur J, Taccone FS. Hyperventilation in Adult TBI Patients: How to Approach It? Front Neurol 2021; 11:580859. [PMID: 33584492 PMCID: PMC7875871 DOI: 10.3389/fneur.2020.580859] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 12/21/2020] [Indexed: 11/13/2022] Open
Abstract
Hyperventilation is a commonly used therapy to treat intracranial hypertension (ICTH) in traumatic brain injury patients (TBI). Hyperventilation promotes hypocapnia, which causes vasoconstriction in the cerebral arterioles and thus reduces cerebral blood flow and, to a lesser extent, cerebral blood volume effectively, decreasing temporarily intracranial pressure. However, hyperventilation can have serious systemic and cerebral deleterious effects, such as ventilator-induced lung injury or cerebral ischemia. The routine use of this therapy is therefore not recommended. Conversely, in specific conditions, such as refractory ICHT and imminent brain herniation, it can be an effective life-saving rescue therapy. The aim of this review is to describe the impact of hyperventilation on extra-cerebral organs and cerebral hemodynamics or metabolism, as well as to discuss the side effects and how to implement it to manage TBI patients.
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Affiliation(s)
- Elisa Gouvea Bogossian
- Intensive Care Department, Erasmus Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Lorenzo Peluso
- Intensive Care Department, Erasmus Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jacques Creteur
- Intensive Care Department, Erasmus Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Fabio Silvio Taccone
- Intensive Care Department, Erasmus Hospital, Université Libre de Bruxelles, Brussels, Belgium
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12
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Ottolenghi S, Sabbatini G, Brizzolari A, Samaja M, Chiumello D. Hyperoxia and oxidative stress in anesthesia and critical care medicine. Minerva Anestesiol 2020; 86:64-75. [DOI: 10.23736/s0375-9393.19.13906-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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13
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Reid CH, Finnerty NJ. An electrochemical investigation into the effects of local and systemic administrations of sodium nitroprusside in brain extracellular fluid of mice. Bioelectrochemistry 2019; 132:107441. [PMID: 31869701 DOI: 10.1016/j.bioelechem.2019.107441] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 12/03/2019] [Accepted: 12/05/2019] [Indexed: 01/25/2023]
Abstract
Sodium nitroprusside (SNP) is a nitric oxide (NO)-donor drug used clinically to treat severe hypertension, however, there are limitations associated with its mechanism of action that prevent widespread adoption. In particular, its impact on cerebral hemodynamics is controversial and direct evidence on its effects are lacking. Electrochemical methods provide an attractive option to undertake real time neurochemical measurements in situ using selective microsensors. Herein, we report the novel application of an existing platinum (Pt)-Nafion® sensor to measure the release of NO from SNP under in vitro and in vivo conditions. Initially, the temporal release of NO was measured and the effect of the reducing agent, ascorbic acid (AA), was elucidated in vitro. A combined microdialysis/NO sensor construct was implanted into the striatum of anaesthetised mice and the local perfusion of 10 mM SNP with/without AA resulted in increased NO concentration detected using the Pt-Nafion® sensor. Subsequently, the NO sensor, coupled with carbon paste electrodes (CPEs) for the electrochemical measurement of O2, were applied to investigate SNP effects in freely moving mice. A complex mechanism of action was identified that infers NO inhibition and biphasic O2 dynamics. The preliminary findings within support a strong cerebrovascular effect of systemic SNP administration that warrants careful consideration for clinical use.
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Affiliation(s)
- Caroline H Reid
- Chemistry Department, Maynooth University, Co. Kildare, Ireland
| | - Niall J Finnerty
- Chemistry Department, Maynooth University, Co. Kildare, Ireland.
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Dellazizzo L, Demers SP, Charbonney E, Williams V, Serri K, Albert M, Giguère JF, Laroche M, Williamson D, Bernard F. Minimal PaO2 threshold after traumatic brain injury and clinical utility of a novel brain oxygenation ratio. J Neurosurg 2019; 131:1639-1647. [PMID: 30485198 DOI: 10.3171/2018.5.jns18651] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 05/16/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Avoiding decreases in brain tissue oxygenation (PbtO2) after traumatic brain injury (TBI) is important. How best to adjust PbtO2 remains unclear. The authors investigated the association between partial pressure of oxygen (PaO2) and PbtO2 to determine the minimal PaO2 required to maintain PbtO2 above the hypoxic threshold (> 20 mm Hg), accounting for other determinants of PbtO2 and repeated measurements in the same patient. They also explored the clinical utility of a novel concept, the brain oxygenation ratio (BOx ratio = PbtO2/PaO2) to detect overtreatment with the fraction of inspired oxygen (FiO2). METHODS A retrospective cohort study at an academic level 1 trauma center included 38 TBI patients who required the insertion of a monitor to measure PbtO2. Various determinants of PbtO2 were collected simultaneously whenever a routine arterial blood gas was drawn. A PbtO2/PaO2 ratio was calculated for each blood gas and plotted over time for each patient. All patients were managed according to a standardized clinical protocol. A mixed effects model was used to account for repeated measurements in the same patient. RESULTS A total of 1006 data points were collected. The lowest mean PaO2 observed to maintain PbtO2 above the ischemic threshold was 94 mm Hg. Only PaO2 and cerebral perfusion pressure were predictive of PbtO2 in multivariate analysis. The PbtO2/PaO2 ratio was below 0.15 in 41.7% of all measures and normal PbtO2 values present despite an abnormal ratio in 27.1% of measurements. CONCLUSIONS The authors' results suggest that the minimal PaO2 target to ensure adequate cerebral oxygenation during the first few days after TBI should be higher than that suggested in the Brain Trauma Foundation guidelines. The use of a PbtO2/PaO2 ratio (BOx ratio) may be clinically useful and identifies abnormal O2 delivery mechanisms (cerebral blood flow, diffusion, and cerebral metabolic rate of oxygen) despite normal PbtO2.
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Affiliation(s)
- Laura Dellazizzo
- Departments of1Neurosciences
- 5Department of Critical Care, Centre intégré universitaire de santé et de services sociaux (CIUSSS) du Nord-de-l'Ile-de-Montréal, Hôpital du Sacré-Cœur de Montréal, Québec, Canada
| | - Simon-Pierre Demers
- 2Medicine
- 5Department of Critical Care, Centre intégré universitaire de santé et de services sociaux (CIUSSS) du Nord-de-l'Ile-de-Montréal, Hôpital du Sacré-Cœur de Montréal, Québec, Canada
| | - Emmanuel Charbonney
- 2Medicine
- 5Department of Critical Care, Centre intégré universitaire de santé et de services sociaux (CIUSSS) du Nord-de-l'Ile-de-Montréal, Hôpital du Sacré-Cœur de Montréal, Québec, Canada
| | - Virginie Williams
- 5Department of Critical Care, Centre intégré universitaire de santé et de services sociaux (CIUSSS) du Nord-de-l'Ile-de-Montréal, Hôpital du Sacré-Cœur de Montréal, Québec, Canada
| | - Karim Serri
- 2Medicine
- 5Department of Critical Care, Centre intégré universitaire de santé et de services sociaux (CIUSSS) du Nord-de-l'Ile-de-Montréal, Hôpital du Sacré-Cœur de Montréal, Québec, Canada
| | - Martin Albert
- 2Medicine
- 3Neurosurgery, and
- 4Pharmacy, Université de Montréal; and
- 5Department of Critical Care, Centre intégré universitaire de santé et de services sociaux (CIUSSS) du Nord-de-l'Ile-de-Montréal, Hôpital du Sacré-Cœur de Montréal, Québec, Canada
| | - Jean-François Giguère
- 3Neurosurgery, and
- 5Department of Critical Care, Centre intégré universitaire de santé et de services sociaux (CIUSSS) du Nord-de-l'Ile-de-Montréal, Hôpital du Sacré-Cœur de Montréal, Québec, Canada
| | - Mathieu Laroche
- 3Neurosurgery, and
- 5Department of Critical Care, Centre intégré universitaire de santé et de services sociaux (CIUSSS) du Nord-de-l'Ile-de-Montréal, Hôpital du Sacré-Cœur de Montréal, Québec, Canada
| | - David Williamson
- 3Neurosurgery, and
- 5Department of Critical Care, Centre intégré universitaire de santé et de services sociaux (CIUSSS) du Nord-de-l'Ile-de-Montréal, Hôpital du Sacré-Cœur de Montréal, Québec, Canada
| | - Francis Bernard
- 2Medicine
- 5Department of Critical Care, Centre intégré universitaire de santé et de services sociaux (CIUSSS) du Nord-de-l'Ile-de-Montréal, Hôpital du Sacré-Cœur de Montréal, Québec, Canada
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15
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Gonschorek AS, Schaan M, Schwenkreis P, Wohlfarth K, Schmehl I. [Quality standards in treatment and rehabilitation of traumatic brain injuries]. Chirurg 2019; 89:1017-1032. [PMID: 30377703 DOI: 10.1007/s00104-018-0751-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The quality standards of the "Deutsche gesetzliche Unfallversicherung" (DGUV) on the treatment of traumatic brain injuries were first published in 2015. They describe the optimal conditions and requirements of acute treatment and in all phases of rehabilitation and aftercare, according to the current state of knowledge. The aim is to enable a life worth living in family, school, occupation and society for as many injuries as possible. The quality standards, as systematic orientation and decision-making aids, should promote the future development of the treatment and rehabilitation of traumatic brain injuries of all grades of severity and guarantee a uniformly high quality of treatment. A special and comprehensive rehabilitative alignment as well as a close networking of medical and occupation-promoting services will be of particular importance for the institutions participating in the rehabilitation of patients with traumatic brain injuries.
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Affiliation(s)
- A S Gonschorek
- Neurotraumatologisches Zentrum, BG Klinikum Hamburg, Bergedorfer Str. 10, 21033, Hamburg, Deutschland.
| | - M Schaan
- BG Unfallklinik Murnau, Murnau, Deutschland
| | - P Schwenkreis
- BG Universitätsklinikum Bergmannsheil Bochum, Bochum, Deutschland
| | - K Wohlfarth
- BG Klinikum Bergmannstrost Halle, Halle, Deutschland
| | - I Schmehl
- BG Klinikum Unfallkrankenhaus Berlin, Berlin, Deutschland
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16
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Stocker RA. Intensive Care in Traumatic Brain Injury Including Multi-Modal Monitoring and Neuroprotection. Med Sci (Basel) 2019; 7:medsci7030037. [PMID: 30813644 PMCID: PMC6473302 DOI: 10.3390/medsci7030037] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 02/01/2019] [Accepted: 02/14/2019] [Indexed: 12/20/2022] Open
Abstract
Moderate to severe traumatic brain injuries (TBI) require treatment in an intensive care unit (ICU) in close collaboration of a multidisciplinary team consisting of different medical specialists such as intensivists, neurosurgeons, neurologists, as well as ICU nurses, physiotherapists, and ergo-/logotherapists. Major goals include all measurements to prevent secondary brain injury due to secondary brain insults and to optimize frame conditions for recovery and early rehabilitation. The distinction between moderate and severe is frequently done based on the Glascow Coma Scale and therefore often is just a snapshot at the early time of assessment. Due to its pathophysiological pathways, an initially as moderate classified TBI may need the same sophisticated surveillance, monitoring, and treatment as a severe form or might even progress to a severe and difficult to treat affection. As traumatic brain injury is rather a syndrome comprising a range of different affections to the brain and as, e.g., age-related comorbidities and treatments additionally may have a great impact, individual and tailored treatment approaches based on monitoring and findings in imaging and respecting pre-injury comorbidities and their therapies are warranted.
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Affiliation(s)
- Reto A Stocker
- Institute for Anesthesiology and Intensive Care Medicine, Klinik Hirslanden, CH-8032 Zurich, Switzerland.
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17
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Abstract
Airway management and ventilation are central to the resuscitation of the neurologically ill. These patients often have evolving processes that threaten the airway and adequate ventilation. Furthermore, intubation, ventilation, and sedative choices directly affect brain perfusion. Therefore, Airway, Ventilation, and Sedation was chosen as an Emergency Neurological Life Support protocol. Topics include airway management, when and how to intubate with special attention to hemodynamics and preservation of cerebral blood flow, mechanical ventilation settings and the use of sedative agents based on the patient's neurological status.
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18
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Abstract
BACKGROUND Increased cerebral perfusion pressure (CPP)>70 mmHg has been associated with acute respiratory distress syndrome (ARDS) after traumatic brain injury (TBI). Since this reported association, significant changes in ventilation strategies and fluid management have been accepted as routine critical care. Recently, individualized perfusion targets using autoregulation monitoring suggest CPP titration>70 mmHg. Given these clinical advances, the association between ARDS and increased CPP requires further delineation. OBJECTIVE To determine the association between ARDS and increased CPP after TBI. METHODS We conducted a single-center historical cohort study investigating the association of increased CPP and ARDS after TBI. We collected demographic data and physiologic data for CPP, intracranial pressure, mechanical ventilation, cumulative fluid balance and delta/driving pressure (ΔP). We collected outcomes measures pertaining to duration of ventilation, intensive care unit admission length, hospitalization length and 6-month neurological outcome. RESULTS In total, 113 patients with severe TBI and multimodal neuromonitoring were included. In total, 16 patients (14%) developed ARDS according to the Berlin definition. There was no difference in the mean CPP during the first 7 days of admission between patients who developed ARDS (74 mmHg SD 18 vs. 73 mmHg SD 18, p=0.86) versus those who did not. Patients who developed ARDS had a higher ΔP (15 mmHg [5] vs. 12 mmHg [4], p=0.016) and lower lung compliance (35 ml/cmH2O [10] vs. 49 ml/cmH2O [18], p=0.024) versus those who did not. CONCLUSION We did not observe an association between increased CPP and ARDS. Patients with ARDS had higher ΔP and lower lung compliance.
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19
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Bundles of care for resuscitation from hemorrhagic shock and severe brain injury in trauma patients-Translating knowledge into practice. J Trauma Acute Care Surg 2018; 81:780-94. [PMID: 27389129 DOI: 10.1097/ta.0000000000001161] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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20
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Godoy DA, Seifi A, Garza D, Lubillo-Montenegro S, Murillo-Cabezas F. Hyperventilation Therapy for Control of Posttraumatic Intracranial Hypertension. Front Neurol 2017; 8:250. [PMID: 28769857 PMCID: PMC5511895 DOI: 10.3389/fneur.2017.00250] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 05/19/2017] [Indexed: 12/30/2022] Open
Abstract
During traumatic brain injury, intracranial hypertension (ICH) can become a life-threatening condition if it is not managed quickly and adequately. Physicians use therapeutic hyperventilation to reduce elevated intracranial pressure (ICP) by manipulating autoregulatory functions connected to cerebrovascular CO2 reactivity. Inducing hypocapnia via hyperventilation reduces the partial pressure of arterial carbon dioxide (PaCO2), which incites vasoconstriction in the cerebral resistance arterioles. This constriction decrease cerebral blood flow, which reduces cerebral blood volume and, ultimately, decreases the patient’s ICP. The effects of therapeutic hyperventilation (HV) are transient, but the risks accompanying these changes in cerebral and systemic physiology must be carefully considered before the treatment can be deemed advisable. The most prominent criticism of this approach is the cited possibility of developing cerebral ischemia and tissue hypoxia. While it is true that certain measures, such as cerebral oxygenation monitoring, are needed to mitigate these dangerous conditions, using available evidence of potential poor outcomes associated with HV as justification to dismiss the implementation of therapeutic HV is debatable and remains a controversial subject among physicians. This review highlights various issues surrounding the use of HV as a means of controlling posttraumatic ICH, including indications for treatment, potential risks, and benefits, and a discussion of what techniques can be implemented to avoid adverse complications.
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Affiliation(s)
- Daniel Agustín Godoy
- Neurointensive Care Unit, Sanatorio Pasteur, San Fernando del Valle de Catamarca, Argentina.,Intensive Care Unit, Hospital San Juan Bautista, Catamarca, Argentina
| | - Ali Seifi
- University of Texas Health Science Center San Antonio, San Antonio, TX, United States
| | - David Garza
- Department of Neurosurgery, University of Texas Health Science Center San Antonio, San Antonio, TX, United States
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21
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Adams H, Donnelly J, Czosnyka M, Kolias AG, Helmy A, Menon DK, Smielewski P, Hutchinson PJ. Temporal profile of intracranial pressure and cerebrovascular reactivity in severe traumatic brain injury and association with fatal outcome: An observational study. PLoS Med 2017; 14:e1002353. [PMID: 28742817 PMCID: PMC5526498 DOI: 10.1371/journal.pmed.1002353] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 06/12/2017] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Both intracranial pressure (ICP) and the cerebrovascular pressure reactivity represent the dysregulation of pathways directly involved in traumatic brain injury (TBI) pathogenesis and have been used to inform clinical management. However, how these parameters evolve over time following injury and whether this evolution has any prognostic importance have not been studied. METHODS AND FINDINGS We analysed the temporal profile of ICP and pressure reactivity index (PRx), examined their relation to TBI-specific mortality, and determined if the prognostic relevance of these parameters was affected by their temporal profile using mixed models for repeated measures of ICP and PRx for the first 240 hours from the time of injury. A total of 601 adults with TBI, admitted between September 2002 to January 2016, and with high-resolution continuous monitoring from a single centre, were studied. At 6 months postinjury, 133 (19%) patients had a fatal outcome; of those, 88 (78%) died from nonsurvivable TBI or brain death. The difference in mean ICP between those with a fatal outcome and functional survivors was only significant for the first 168 hours after injury (all p < 0.05). For PRx, those patients with a fatal outcome also had a higher (more impaired) PRx throughout the first 120 hours after injury (all p < 0.05). The separation of ICP and PRx was greatest in the first 72 hours after injury. Mixed models demonstrated that the explanatory power of the PRx decreases over time; therefore, the prognostic weight assigned to PRx should similarly decrease. However, the ability of ICP to predict a fatal outcome remained relatively stable over time. As control of ICP is the central purpose of TBI management, it is likely that some of the information that is reflected in the natural history of ICP changes is no longer apparent because of therapeutic intervention. CONCLUSIONS We demonstrated the temporal evolution of ICP and PRx and their relationship with fatal outcome, indicating a potential early prognostic and therapeutic window. The combination of dynamic monitoring variables and their time profile improved prediction of outcome. Therefore, time-driven dynamic modelling of outcome in patients with severe TBI may allow for more accurate and clinically useful prediction models. Further research is needed to confirm and expand on these findings.
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Affiliation(s)
- Hadie Adams
- Division of Neurosurgery, Department of Clinical Neuroscience, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Joseph Donnelly
- Division of Neurosurgery, Department of Clinical Neuroscience, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Marek Czosnyka
- Division of Neurosurgery, Department of Clinical Neuroscience, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom.,Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
| | - Angelos G Kolias
- Division of Neurosurgery, Department of Clinical Neuroscience, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neuroscience, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - David K Menon
- Department of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Peter Smielewski
- Division of Neurosurgery, Department of Clinical Neuroscience, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neuroscience, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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22
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Sahoo S, Sheshadri V, Sriganesh K, Madhsudana Reddy K, Radhakrishnan M, Umamaheswara Rao GS. Effect of Hyperoxia on Cerebral Blood Flow Velocity and Regional Oxygen Saturation in Patients Operated on for Severe Traumatic Brain Injury–The Influence of Cerebral Blood Flow Autoregulation. World Neurosurg 2017; 98:211-216. [DOI: 10.1016/j.wneu.2016.10.116] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 10/23/2016] [Accepted: 10/24/2016] [Indexed: 01/22/2023]
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Seder DB, Bösel J. Airway management and mechanical ventilation in acute brain injury. HANDBOOK OF CLINICAL NEUROLOGY 2017; 140:15-32. [PMID: 28187797 DOI: 10.1016/b978-0-444-63600-3.00002-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Patients with acute neurologic disease often develop respiratory failure, the management of which profoundly affects brain physiology and long-term functional outcomes. This chapter reviews airway management and mechanical ventilation of patients with acute brain injury, offering practical strategies to optimize treatment of respiratory failure and minimize secondary brain injury. Specific concerns that are addressed include physiologic changes during intubation and ventilation such as the effects on intracranial pressure and brain perfusion; cervical spine management during endotracheal intubation; the role of tracheostomy; and how ventilation and oxygenation are utilized to minimize ischemia-reperfusion injury and cerebral metabolic distress.
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Affiliation(s)
- D B Seder
- Department of Critical Care Services, Maine Medical Center, Portland, ME, USA; Tufts University School of Medicine, Boston, MA, USA.
| | - J Bösel
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
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24
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Abstract
Airway management and ventilation are central to the resuscitation of the neurologically ill. These patients often have evolving processes that threaten the airway and adequate ventilation. Furthermore, intubation, ventilation, and sedative choices directly affect brain perfusion. Therefore, airway, ventilation, and sedation was chosen as an emergency neurological life support protocol. Topics include airway management, when and how to intubate with special attention to hemodynamics and preservation of cerebral blood flow, mechanical ventilation settings, and the use of sedative agents based on the patient's neurological status.
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25
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Needham E, McFadyen C, Newcombe V, Synnot AJ, Czosnyka M, Menon D. Cerebral Perfusion Pressure Targets Individualized to Pressure-Reactivity Index in Moderate to Severe Traumatic Brain Injury: A Systematic Review. J Neurotrauma 2016; 34:963-970. [PMID: 27246184 DOI: 10.1089/neu.2016.4450] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Traumatic brain injury (TBI) frequently triggers a disruption of cerebral autoregulation. The cerebral perfusion pressure (CPP) at which autoregulation is optimal ("CPPopt") varies between individuals, and can be calculated based on fluctuations between arterial blood pressure and intracranial pressure. This review assesses the effect of individualizing CPP targets to pressure reactivity index (a measure of autoregulation) in patients with TBI. Cochrane Central Register of Controlled Trials, MEDLINE®, Embase, and Cumulative Index of Nursing and Allied Health Literature were searched in March 2015 for studies assessing the effect of targeting CPPopt in TBI. We included all studies that assessed the impact of targeting CPPopt on outcomes including mortality, neurological outcome, and physiological changes. Risk of bias was assessed using the RTI Item Bank and evidence quality was considered using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. Eight cohort studies (based on six distinct data sets) assessing the association between CPPopt and mortality, Glasgow Outcome Scale and physiological measures in TBI were included. The quality of evidence was deemed very low based on the GRADE criteria. Although the data suggest an association between variation from CPPopt and poor clinical outcome at 6 months, the quality of evidence prevents firm conclusions, particularly regarding causality, from being drawn. Available data suggest that targeting CPPopt might represent a technique to improve outcomes following TBI, but currently there is insufficient high-quality data to support a recommendation for use in clinical practice. Further prospective, randomized controlled studies should be undertaken to clarify its role in the acute management of TBI.
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Affiliation(s)
- Edward Needham
- 1 Department of Neurology, Addenbrookes Hospital, University of Cambridge , Cambridge, United Kingdom
| | - Charles McFadyen
- 2 Division of Anaesthesia, Addenbrookes Hospital, University of Cambridge , Cambridge, United Kingdom
| | - Virginia Newcombe
- 2 Division of Anaesthesia, Addenbrookes Hospital, University of Cambridge , Cambridge, United Kingdom
| | - Anneliese J Synnot
- 3 Australian & New Zealand Intensive Care Research Centre (ANZIC-RC) , School of Public Health and Preventive Medicine, Monash University, Melbourne Victoria, Australia; Cochrane Consumers and Communication Review Group, Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Melbourne, Australia; National Trauma Research Institute, Melborne, Australia
| | - Marek Czosnyka
- 4 Brain Physics Lab, Division of Neurosurgery, Addenbrookes Hospital, University of Cambridge , Cambridge, United Kingdom
| | - David Menon
- 2 Division of Anaesthesia, Addenbrookes Hospital, University of Cambridge , Cambridge, United Kingdom
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26
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Quintard H, Patet C, Suys T, Marques-Vidal P, Oddo M. Normobaric hyperoxia is associated with increased cerebral excitotoxicity after severe traumatic brain injury. Neurocrit Care 2016; 22:243-50. [PMID: 25168744 DOI: 10.1007/s12028-014-0062-0] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Normobaric oxygen therapy is frequently applied in neurocritical care, however, whether supplemental FiO2 has beneficial cerebral effects is still controversial. We examined in patients with severe traumatic brain injury (TBI) the effect of incremental FiO2 on cerebral excitotoxicity, quantified by cerebral microdialysis (CMD) glutamate. METHODS This was a retrospective analysis of a database of severe TBI patients monitored with CMD and brain tissue oxygen (PbtO2). The relationship of FiO2--categorized into four separate ranges (<40, 41-60, 61-80, and >80 %)--with CMD glutamate was examined using ANOVA with Tukey's post hoc test. RESULTS A total of 1,130 CMD samples from 36 patients--monitored for a median of 4 days--were examined. After adjusting for brain (PbtO2, intracranial pressure, cerebral perfusion pressure, lactate/pyruvate ratio, Marshall CT score) and systemic (PaCO2, PaO2, hemoglobin, APACHE score) covariates, high FiO2 was associated with a progressive increase in CMD glutamate [8.8 (95 % confidence interval 7.4-10.2) µmol/L at FiO2 < 40 % vs. 12.8 (10.9-14.7) µmol/L at 41-60 % FiO2, 19.3 (15.6-23) µmol/L at 61-80 % FiO2, and 22.6 (16.7-28.5) µmol/L at FiO2 > 80 %; multivariate-adjusted p < 0.05]. The threshold of FiO2-related increase in CMD glutamate was lower for samples with normal versus low PbtO2 < 20 mmHg (FiO2 > 40 % vs. FiO2 > 60 %). Hyperoxia (PaO2 > 150 mmHg) was also associated with increased CMD glutamate (adjusted p < 0.001). CONCLUSIONS Incremental normobaric FiO2 levels were associated with increased cerebral excitotoxicity in patients with severe TBI, independent from PbtO2 and other important cerebral and systemic determinants. These data suggest that supra-normal oxygen may aggravate secondary brain damage after severe TBI.
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Affiliation(s)
- Hervé Quintard
- Department of Intensive Care Medicine, Neuroscience Critical Care Research Group Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne University Hospital, Rue du Bugnon 46, BH 08.623, 1011, Lausanne, Switzerland
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27
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Moscote-Salazar LR, M. Rubiano A, Alvis-Miranda HR, Calderon-Miranda W, Alcala-Cerra G, Blancas Rivera MA, Agrawal A. Severe Cranioencephalic Trauma: Prehospital Care, Surgical Management and Multimodal Monitoring. Bull Emerg Trauma 2016; 4:8-23. [PMID: 27162922 PMCID: PMC4779465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2015] [Revised: 11/04/2015] [Accepted: 11/13/2015] [Indexed: 06/05/2023] Open
Abstract
Traumatic brain injury is a leading cause of death in developed countries. It is estimated that only in the United States about 100,000 people die annually in parallel among the survivors there is a significant number of people with disabilities with significant costs for the health system. It has been determined that after moderate and severe traumatic injury, brain parenchyma is affected by more than 55% of cases. Head trauma management is critical is the emergency services worldwide. We present a review of the literature regarding the prehospital care, surgical management and intensive care monitoring of the patients with severe cranioecephalic trauma.
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Affiliation(s)
| | | | | | | | | | | | - Amit Agrawal
- Department of Neurosurgery, MM Institute of Medical Sciences & Research, Maharishi Markandeshwar University, Mullana- Ambala, 133-207, Haryana, India
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28
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Abstract
Pressure autoregulation is an important hemodynamic mechanism that protects the brain against inappropriate fluctuations in cerebral blood flow in the face of changing cerebral perfusion pressure (CPP). Static autoregulation represents how far cerebrovascular resistance changes when CPP varies, and dynamic autoregulation represents how fast these changes happen. Both have been monitored in the setting of neurocritical care to aid prognostication and contribute to individualizing CPP targets in patients. Failure of autoregulation is associated with a worse outcome in various acute neurological diseases. Several studies have used transcranial Doppler ultrasound, intracranial pressure (ICP with vascular reactivity as surrogate measure of autoregulation), and near-infrared spectroscopy to continuously monitor the impact of spontaneous fluctuations in CPP on cerebrovascular physiology and to calculate derived variables of autoregulatory efficiency. Many patients who undergo such monitoring demonstrate a range of CPP in which autoregulatory efficiency is optimal. Management of patients at or near this optimal level of CPP is associated with better outcomes in traumatic brain injury. Many of these studies have utilized the concept of the pressure reactivity index, a correlation coefficient between ICP and mean arterial pressure. While further studies are needed, these data suggest that monitoring of autoregulation could aid prognostication and may help identify optimal CPP levels in individual patients.
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Affiliation(s)
- Marek Czosnyka
- Department of Clinical Neurosciences, Division of Neurosurgery, University of Cambridge, Addenbrooke's Hospital, Box 167, Cambridge, CB2 2QQ, UK,
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29
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Abstract
Maintenance of adequate oxygenation is a mainstay of intensive care, however, recommendations on the safety, accuracy, and the potential clinical utility of invasive and non-invasive tools to monitor brain and systemic oxygenation in neurocritical care are lacking. A literature search was conducted for English language articles describing bedside brain and systemic oxygen monitoring in neurocritical care patients from 1980 to August 2013. Imaging techniques e.g., PET are not considered. A total of 281 studies were included, the majority described patients with traumatic brain injury (TBI). All tools for oxygen monitoring are safe. Parenchymal brain oxygen (PbtO2) monitoring is accurate to detect brain hypoxia, and it is recommended to titrate individual targets of cerebral perfusion pressure (CPP), ventilator parameters (PaCO2, PaO2), and transfusion, and to manage intracranial hypertension, in combination with ICP monitoring. SjvO2 is less accurate than PbtO2. Given limited data, NIRS is not recommended at present for adult patients who require neurocritical care. Systemic monitoring of oxygen (PaO2, SaO2, SpO2) and CO2 (PaCO2, end-tidal CO2) is recommended in patients who require neurocritical care.
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30
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Furian M, Latshang TD, Aeschbacher SS, Ulrich S, Sooronbaev T, Mirrakhimov EM, Aldashev A, Bloch KE. Cerebral oxygenation in highlanders with and without high-altitude pulmonary hypertension. Exp Physiol 2015; 100:905-14. [DOI: 10.1113/ep085200] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 05/20/2015] [Indexed: 01/05/2023]
Affiliation(s)
- M. Furian
- Pulmonary Division and Sleep Disorders Center; University Hospital of Zurich; Zurich Switzerland
- Institute of Human Movement Sciences and Sport; Swiss Federal Institute of Technology; Zurich Switzerland
| | - T. D. Latshang
- Pulmonary Division and Sleep Disorders Center; University Hospital of Zurich; Zurich Switzerland
| | - S. S. Aeschbacher
- Pulmonary Division and Sleep Disorders Center; University Hospital of Zurich; Zurich Switzerland
| | - S. Ulrich
- Pulmonary Division and Sleep Disorders Center; University Hospital of Zurich; Zurich Switzerland
| | - T. Sooronbaev
- National Center for Cardiology and Internal Medicine; Bishkek Kyrgyzstan
| | - E. M. Mirrakhimov
- National Center for Cardiology and Internal Medicine; Bishkek Kyrgyzstan
| | - A. Aldashev
- Research Institute for Molecular Biology and Medicine; Bishkek Kyrgyzstan
| | - K. E. Bloch
- Pulmonary Division and Sleep Disorders Center; University Hospital of Zurich; Zurich Switzerland
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Roderique JD, Josef CS, Feldman MJ, Spiess BD. A modern literature review of carbon monoxide poisoning theories, therapies, and potential targets for therapy advancement. Toxicology 2015; 334:45-58. [PMID: 25997893 DOI: 10.1016/j.tox.2015.05.004] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2015] [Revised: 05/01/2015] [Accepted: 05/12/2015] [Indexed: 01/03/2023]
Abstract
The first descriptions of carbon monoxide (CO) and its toxic nature appeared in the literature over 100 years ago in separate publications by Drs. Douglas and Haldane. Both men ascribed the deleterious effects of this newly discovered gas to its strong interaction with hemoglobin. Since then the adverse sequelae of CO poisoning has been almost universally attributed to hypoxic injury secondary to CO occupation of oxygen binding sites on hemoglobin. Despite a mounting body of literature suggesting other mechanisms of injury, this pathophysiology and its associated oxygen centric therapies persists. This review attempts to elucidate the remarkably complex nature of CO as a gasotransmitter. While CO's affinity for hemoglobin remains undisputed, new research suggests that its role in nitric oxide release, reactive oxygen species formation, and its direct action on ion channels is much more significant. In the course of understanding the multifaceted character of this simple molecule it becomes apparent that current oxygen based therapies meant to displace CO from hemoglobin may be insufficient and possibly harmful. Approaching CO as a complex gasotransmitter will help guide understanding of the complex and poorly understood sequelae and illuminate potentials for new treatment modalities.
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Affiliation(s)
- Joseph D Roderique
- Department of Anesthesiology, VCU School of Medicine Sanger Hall, Rm B1-016, 1101 East Marshall Street, P.O. Box 980695, Richmond, VA 23298, United States
| | - Christopher S Josef
- Department of Anesthesiology, VCU School of Medicine Sanger Hall, Rm B1-016, 1101 East Marshall Street, P.O. Box 980695, Richmond, VA 23298, United States.
| | - Michael J Feldman
- Department of Plastic and Reconstructive Surgery, Critical Care Hospital 8th floor, 1213 East Clay St, Richmond, VA 23298, United States
| | - Bruce D Spiess
- Department of Anesthesiology, VCU School of Medicine Sanger Hall, Rm B1-016, 1101 East Marshall Street, P.O. Box 980695, Richmond, VA 23298, United States
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Roberts BW, Karagiannis P, Coletta M, Kilgannon JH, Chansky ME, Trzeciak S. Effects of PaCO2 derangements on clinical outcomes after cerebral injury: A systematic review. Resuscitation 2015; 91:32-41. [PMID: 25828950 DOI: 10.1016/j.resuscitation.2015.03.015] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Revised: 02/04/2015] [Accepted: 03/09/2015] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Partial pressure of arterial carbon dioxide (PaCO2) is a major regulator of cerebral blood flow (CBF). Derangements in PaCO2 have been thought to worsen clinical outcomes after many forms of cerebral injury by altering CBF. Our aim was to systematically analyze the biomedical literature to determine the effects of PaCO2 derangements on clinical outcomes after cerebral injury. METHODS We performed a search of Cochrane Library, PUBMED, CINHAL, conference proceedings, and other sources using a comprehensive strategy. Study inclusion criteria were (1) human subjects; (2) cerebral injury; (3) mechanical ventilation post-injury; (4) measurement of PaCO2; and (5) comparison of a clinical outcome measure (e.g. mortality) between different PaCO2 exposures. We performed a qualitative analysis to collate and summarize effects of PaCO2 derangements according to the recommended methodology from the Cochrane Handbook. RESULTS Seventeen studies involving different etiologies of cerebral injury (six traumatic brain injury, six post-cardiac arrest syndrome, two cerebral vascular accident, three neonatal ischemic encephalopathy) met all inclusion and no exclusion criteria. Three randomized control trials were identified and only one was considered a high quality study as per the Cochrane criteria for assessing risk of bias. In 13/17 (76%) studies examining hypocapnia, and 7/10 (70%) studies examining hypercapnia, the exposed group (hypercapnia or hypocapnia) was associated with poor clinical outcome. CONCLUSION The majority of studies in this report found exposure to hypocapnia and hypercapnia after cerebral injury to be associated with poor clinical outcome. However, the optimal PaCO2 range associated with good clinical outcome remains unclear.
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Affiliation(s)
- Brian W Roberts
- Department of Emergency Medicine, Cooper University Hospital and Cooper Medical School of Rowan University, Camden, NJ, USA.
| | - Paul Karagiannis
- Department of Emergency Medicine, Cooper University Hospital and Cooper Medical School of Rowan University, Camden, NJ, USA.
| | - Michael Coletta
- Department of Emergency Medicine, Cooper University Hospital and Cooper Medical School of Rowan University, Camden, NJ, USA.
| | - J Hope Kilgannon
- Department of Emergency Medicine, Cooper University Hospital and Cooper Medical School of Rowan University, Camden, NJ, USA.
| | - Michael E Chansky
- Department of Emergency Medicine, Cooper University Hospital and Cooper Medical School of Rowan University, Camden, NJ, USA.
| | - Stephen Trzeciak
- Department of Emergency Medicine, Cooper University Hospital and Cooper Medical School of Rowan University, Camden, NJ, USA; Department of Medicine, Division of Critical Care Medicine (ST), Cooper University Hospital and Cooper Medical School of Rowan University, Camden, NJ, USA.
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Cerebral blood flow and transcranial doppler sonography measurements of CO2-reactivity in acute traumatic brain injured patients. Neurocrit Care 2015; 20:54-9. [PMID: 22700360 DOI: 10.1007/s12028-012-9727-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Cerebral blood flow (CBF) measurements are helpful in managing patients with traumatic brain injury (TBI), and testing the cerebrovascular reactivity to CO(2) provides information about injury severity and outcome. The complexity and potential hazard of performing CBF measurements limits routine clinical use. An alternative approach is to measure the CBF velocity using bedside, non-invasive, and transcranial Doppler (TCD) sonography. This study was performed to investigate if TCD is a useful alternative to CBF in patients with severe TBI. METHOD CBF and TCD flow velocity measurements and cerebrovascular reactivity to hypocapnia were simultaneously evaluated in 27 patients with acute TBI. Measurements were performed preoperatively during controlled normocapnia and hypocapnia in patients scheduled for hematoma evacuation under general anesthesia. MAIN FINDING AND CONCLUSION Although the lack of statistical correlation between the calculated reactivity indices, there was a significant decrease in TCD-mean flow velocity and a decrease in CBF with hypocapnia. CBF and TCD do not seem to be directly interchangeable in determining CO(2)-reactivity in TBI, despite both methods demonstrating deviation in the same direction during hypocapnia. TCD and CBF measurements both provide useful information on cerebrovascular events which, although not interchangeable, may complement each other in clinical scenarios.
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Rangel-Castilla L, Spetzler RF, Nakaji P. Normal perfusion pressure breakthrough theory: a reappraisal after 35 years. Neurosurg Rev 2014; 38:399-404; discussion 404-5. [PMID: 25483235 DOI: 10.1007/s10143-014-0600-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Revised: 09/03/2014] [Accepted: 09/28/2014] [Indexed: 11/26/2022]
Abstract
The intrinsic ability of the brain to maintain constant cerebral blood flow (CBF) is known as cerebral pressure autoregulation. This ability protects the brain against cerebral ischemia and hyperemia within a certain range of blood pressures. The normal perfusion pressure breakthrough (NPPB) theory described by Spetzler in 1978 was adopted to explain the edema and hemorrhage that sometimes occur after resection of brain arteriovenous malformations (AVMs). The underlying pathophysiology of edema and hemorrhage after AVM resection still remains controversial. Over the last three decades, advances in neuroimaging, CBF, and cerebral perfusion pressure (CPP) measurement have both favored and contradicted the NBBP theory. At the same time, other theories have been proposed, including the occlusive hyperemia theory. We believe that both theories are related and complementary and that they both explain changes in hemodynamics after AVM resection. The purpose of this work is to review the current status of the NBBP theory 35 years after its original description.
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Affiliation(s)
- Leonardo Rangel-Castilla
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
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Prabhakar H, Sandhu K, Bhagat H, Durga P, Chawla R. Current concepts of optimal cerebral perfusion pressure in traumatic brain injury. J Anaesthesiol Clin Pharmacol 2014; 30:318-27. [PMID: 25190937 PMCID: PMC4152669 DOI: 10.4103/0970-9185.137260] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Traumatic brain injury (TBI) consists of varied pathophysiological consequences and alteration of intracranial dynamics, reduction of the cerebral blood flow and oxygenation. In the past decade more emphasis has been directed towards optimizing cerebral perfusion pressure (CPP) in patients who have suffered TBI. Injured brain may show signs of ischemia if CPP remains below 50 mmHg and raising the CPP above 60 mmHg may avoid cerebral oxygen desaturation. Though CPP above 70 mmHg is influential in achieving an improved patient outcome, maintenance of CPP higher than 70 mmHg was associated with greater risk of acute respiratory distress syndrome (ARDS). The target CPP has been laid within 50-70 mmHg. Cerebral blood flow and metabolism are heterogeneous after TBI and with regional temporal differences in the requirement for CPP. Brain monitoring techniques such as jugular venous oximetry, monitoring of brain tissue oxygen tension (PbrO2), and cerebral microdialysis provide complementary and specific information that permits the selection of the optimal CPP. This review highlights the rationale for use CPP directed therapies and neuromonitoring to identify optimal CPP of head injured patients. The article also reviews the evidence provided by various clinical trials regarding optimal CPP and their application in the management of head injured patients.
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Affiliation(s)
- Hemanshu Prabhakar
- Department of Neuroanaesthesiology, Neurosciences Centre, All India Institute of Medical Sciences, PGIMER, Chandigarh, India
| | - Kavita Sandhu
- Department of Neuroanaesthesiology and Critical Care, Max Superspeciality Hospital, PGIMER, Chandigarh, India
| | - Hemant Bhagat
- Department of Anaesthesia and Intensive Care, PGIMER, Chandigarh, India
| | - Padmaja Durga
- Department of Anesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, India
| | - Rajiv Chawla
- Department of Anaesthesiology and Intensive Care, G B Pant Hospital, New Delhi, India
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Pandin P, Renard M, Bianchini A, Desjardin P, Obbergh LV. Monitoring Brain and Spinal Cord Metabolism and Function. ACTA ACUST UNITED AC 2014. [DOI: 10.4236/ojanes.2014.46020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Czynski AJ, Terry MH, Deming DD, Power GG, Buchholz JN, Blood AB. Cerebral autoregulation is minimally influenced by the superior cervical ganglion in two- week-old lambs, and absent in preterm lambs immediately following delivery. PLoS One 2013; 8:e82326. [PMID: 24349256 PMCID: PMC3857252 DOI: 10.1371/journal.pone.0082326] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Accepted: 10/23/2013] [Indexed: 11/19/2022] Open
Abstract
Cerebral vessels in the premature newborn brain are well supplied with adrenergic nerves, stemming from the superior cervical ganglia (SCG), but their role in regulation of blood flow remains uncertain. To test this function twelve premature or two-week-old lambs were instrumented with laser Doppler flow probes in the parietal cortices to measure changes in blood flow during changes in systemic blood pressure and electrical stimulation of the SCG. In lambs delivered prematurely at ∼129 days gestation cerebral perfusion and driving pressure demonstrated a direct linear relationship throughout the physiologic range, indicating lack of autoregulation. In contrast, in lambs two-weeks of age, surgical removal of one SCG resulted in ipsilateral loss of autoregulation during pronounced hypertension. Electrical stimulation of one SCG elicited unilateral increases in cerebral resistance to blood flow in both pre-term and two-week-old lambs, indicating functioning neural pathways in the instrumented, anesthetized lambs. We conclude cerebral autoregulation is non-functional in preterm lambs following cesarean delivery. Adrenergic control of cerebral vascular resistance becomes effective in newborn lambs within two-weeks after birth but SCG-dependent autoregulation is essential only during pronounced hypertension, well above the normal range of blood pressure.
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Affiliation(s)
- Adam J. Czynski
- Department of Pediatrics, Division of Neonatology, Loma Linda University School of Medicine, Loma Linda, California, United States of America
| | - Michael H. Terry
- Department of Respiratory Care, Pulmonary Physiology Laboratories, Loma Linda University Medical Center, Loma Linda, California, United States of America
| | - Douglas D. Deming
- Department of Pediatrics, Division of Neonatology, Loma Linda University School of Medicine, Loma Linda, California, United States of America
| | - Gordon G. Power
- Center for Perinatal Biology, Loma Linda University School of Medicine, Loma Linda, California, United States of America
| | - John N. Buchholz
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, California, United States of America
| | - Arlin B. Blood
- Department of Pediatrics, Division of Neonatology, Loma Linda University School of Medicine, Loma Linda, California, United States of America
- Center for Perinatal Biology, Loma Linda University School of Medicine, Loma Linda, California, United States of America
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Bouzat P, Sala N, Payen JF, Oddo M. Beyond intracranial pressure: optimization of cerebral blood flow, oxygen, and substrate delivery after traumatic brain injury. Ann Intensive Care 2013; 3:23. [PMID: 23837598 PMCID: PMC3716965 DOI: 10.1186/2110-5820-3-23] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Accepted: 06/25/2013] [Indexed: 02/17/2023] Open
Abstract
Monitoring and management of intracranial pressure (ICP) and cerebral perfusion pressure (CPP) is a standard of care after traumatic brain injury (TBI). However, the pathophysiology of so-called secondary brain injury, i.e., the cascade of potentially deleterious events that occur in the early phase following initial cerebral insult—after TBI, is complex, involving a subtle interplay between cerebral blood flow (CBF), oxygen delivery and utilization, and supply of main cerebral energy substrates (glucose) to the injured brain. Regulation of this interplay depends on the type of injury and may vary individually and over time. In this setting, patient management can be a challenging task, where standard ICP/CPP monitoring may become insufficient to prevent secondary brain injury. Growing clinical evidence demonstrates that so-called multimodal brain monitoring, including brain tissue oxygen (PbtO2), cerebral microdialysis and transcranial Doppler among others, might help to optimize CBF and the delivery of oxygen/energy substrate at the bedside, thereby improving the management of secondary brain injury. Looking beyond ICP and CPP, and applying a multimodal therapeutic approach for the optimization of CBF, oxygen delivery, and brain energy supply may eventually improve overall care of patients with head injury. This review summarizes some of the important pathophysiological determinants of secondary cerebral damage after TBI and discusses novel approaches to optimize CBF and provide adequate oxygen and energy supply to the injured brain using multimodal brain monitoring.
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Affiliation(s)
- Pierre Bouzat
- Department of Intensive Care Medicine, CHUV-University Hospital, Rue du Bugnon 46, BH 08,623, CH-1011 Lausanne, Switzerland.
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Mesquita RC, Schenkel SS, Minkoff DL, Lu X, Favilla CG, Vora PM, Busch DR, Chandra M, Greenberg JH, Detre JA, Yodh AG. Influence of probe pressure on the diffuse correlation spectroscopy blood flow signal: extra-cerebral contributions. BIOMEDICAL OPTICS EXPRESS 2013; 4:978-94. [PMID: 23847725 PMCID: PMC3704102 DOI: 10.1364/boe.4.000978] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Revised: 05/13/2013] [Accepted: 05/14/2013] [Indexed: 05/03/2023]
Abstract
A pilot study explores relative contributions of extra-cerebral (scalp/skull) versus brain (cerebral) tissues to the blood flow index determined by diffuse correlation spectroscopy (DCS). Microvascular DCS flow measurements were made on the head during baseline and breath-holding/hyperventilation tasks, both with and without pressure. Baseline (resting) data enabled estimation of extra-cerebral flow signals and their pressure dependencies. A simple two-component model was used to derive baseline and activated cerebral blood flow (CBF) signals, and the DCS flow indices were also cross-correlated with concurrent Transcranial Doppler Ultrasound (TCD) blood velocity measurements. The study suggests new pressure-dependent experimental paradigms for elucidation of blood flow contributions from extra-cerebral and cerebral tissues.
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Affiliation(s)
- Rickson C. Mesquita
- Department of Physics & Astronomy, University of Pennsylvania, 3231 Walnut St., Philadelphia, PA 19104, USA
- Institute of Physics, University of Campinas, 777 Sergio Buarque de Holanda St., Campinas, SP 13083-859, Brazil
| | - Steven S. Schenkel
- Department of Physics & Astronomy, University of Pennsylvania, 3231 Walnut St., Philadelphia, PA 19104, USA
| | - David L. Minkoff
- Department of Physics & Astronomy, University of Pennsylvania, 3231 Walnut St., Philadelphia, PA 19104, USA
| | - Xiangping Lu
- Department of Neurology, University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104, USA
| | - Christopher G. Favilla
- Department of Neurology, University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104, USA
| | - Patrick M. Vora
- Department of Physics & Astronomy, University of Pennsylvania, 3231 Walnut St., Philadelphia, PA 19104, USA
| | - David R. Busch
- Department of Physics & Astronomy, University of Pennsylvania, 3231 Walnut St., Philadelphia, PA 19104, USA
- Department of Pediatrics, Division of Neurology, Children’s Hospital of Philadelphia, 34th St. & Civic Center Blvd., Philadelphia, PA 19104, USA
| | - Malavika Chandra
- Department of Physics & Astronomy, University of Pennsylvania, 3231 Walnut St., Philadelphia, PA 19104, USA
| | - Joel H. Greenberg
- Department of Neurology, University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104, USA
| | - John A. Detre
- Department of Neurology, University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104, USA
- Department of Radiology, University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104, USA
| | - A. G. Yodh
- Department of Physics & Astronomy, University of Pennsylvania, 3231 Walnut St., Philadelphia, PA 19104, USA
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Arbour RB. Traumatic brain injury: pathophysiology, monitoring, and mechanism-based care. Crit Care Nurs Clin North Am 2013; 25:297-319. [PMID: 23692946 DOI: 10.1016/j.ccell.2013.02.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Traumatic brain injury, which may be blunt or penetrating, begins altering intracranial physiology at the moment of impact as primary brain trauma. This article differentiates blunt versus penetrating brain trauma, primary versus secondary brain injury, and subsequent intracranial pathophysiology. Discussion and case study correlate intracranial pathophysiology and multisystem influences on evolving brain injury with mechanism-based interventions to modulate brain components (brain, blood, and cerebrospinal fluid volumes). The discussion also explores the effects of controlled ventilation, cardiopulmonary physiology, and global physiologic state on secondary injury, control of intracranial pressure, and recovery.
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Prehospital management of severe traumatic brain injury: concepts and ongoing controversies. Curr Opin Anaesthesiol 2013; 25:556-62. [PMID: 22821147 DOI: 10.1097/aco.0b013e328357225c] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW Prehospital management affects long-term outcome of patients with severe traumatic brain injury (TBI). This article reviews the current concepts and ongoing controversies of prehospital treatment of severe TBI. RECENT FINDINGS Prehospital management focuses on the prevention of secondary brain injury and rapid transport to a neurotrauma center for definitive diagnosis and life- as well as brain-saving emergency treatment such as decompressive craniotomy. There is a broad consensus that adequate airway management, prevention of hypoxia, hypocapnia or hypercapnia, prevention of hypotension and control of hemorrhage represent preclinical therapeutic modalities that may contribute to improved survival in severe TBI. The precise role of prehospital endotracheal intubation, osmotic agents and early therapeutic hypothermia needs to be clarified in the context of time required for transportation, local infrastructure, geographical factors and availability of experienced emergency teams. SUMMARY Prehospital management of TBI remains challenging. There are no universal objectives suitable to all patients. Randomized, controlled clinical trials are necessary for developing optimal protocols for paramedic and physician emergency medical teams.
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Abstract
OBJECTIVE Type 1 diabetes mellitus is the most common chronic disease of childhood. Diabetic ketoacidosis is a well-known complication of diabetes mellitus and can be associated with devastating cerebral edema resulting in severe long-term neurologic disability. Despite the significant morbidity and mortality associated with this condition, relatively few treatments are recommended for these patients. The authors present two patients in which they used both intracranial pressure and brain tissue oxygenation monitoring to manage diabetic ketoacidosis-associated cerebral edema with favorable neurologic outcomes. SETTING Pediatric intensive care unit in a tertiary care teaching hospital. INTERVENTIONS Two children presented to the emergency room with vague complaints and were found to have diabetic ketoacidosis. During treatment, both patients became comatose with head computed tomography scans revealing diffuse cerebral edema and herniation syndrome. Intracranial pressure and brain tissue oxygenation monitors were placed to guide therapy. RESULTS Multiple episodes of brain tissue hypoxia were noted in both patients. Intracranial pressure control with intubation, sedation, and hyperosmolar therapy improved episodes of decreased brain tissue oxygenation associated with intracranial hypertension. Brain tissue oxygenation was also noted to be significantly less than the target value on several occasions even when intracranial pressure was controlled and an age-appropriate cerebral perfusion pressure goal was met. Augmentation of cerebral perfusion pressure above age-appropriate goal with fluid boluses and inotropic agents increased brain tissue oxygenation in these instances. Both children had very low Glasgow Coma Scale scores at admission, but ultimately had favorable neurologic outcomes. CONCLUSIONS Multimodal neuromonitoring of both intracranial pressure and brain tissue oxygenation during episodes of clinically apparent diabetic ketoacidosis-associated cerebral edema allows for the detection and treatment of episodes of elevated intracranial pressure and/or brain tissue hypoxia that may be of clinical significance.
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Beynon C, Kiening KL, Orakcioglu B, Unterberg AW, Sakowitz OW. Brain tissue oxygen monitoring and hyperoxic treatment in patients with traumatic brain injury. J Neurotrauma 2012; 29:2109-23. [PMID: 22616852 DOI: 10.1089/neu.2012.2365] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Cerebral ischemia is a well-recognized contributor to high morbidity and mortality after traumatic brain injury (TBI). Standard of care treatment aims to maintain a sufficient oxygen supply to the brain by avoiding increased intracranial pressure (ICP) and ensuring a sufficient cerebral perfusion pressure (CPP). Devices allowing direct assessment of brain tissue oxygenation have showed promising results in clinical studies, and their use was implemented in the Brain Trauma Foundation Guidelines for the treatment of TBI patients in 2007. Results of several studies suggest that a brain tissue oxygen-directed therapy guided by these monitors may contribute to reduced mortality and improved outcome of TBI patients. Whether increasing the oxygen supply to supraphysiological levels has beneficial or detrimental effects on TBI patients has been a matter of debate for decades. The results of trials of hyperbaric oxygenation (HBO) have failed to show a benefit, but renewed interest in normobaric hyperoxia (NBO) in the treatment of TBI patients has emerged in recent years. With the increased availability of advanced neuromonitoring devices such as brain tissue oxygen monitors, it was shown that some patients might benefit from this therapeutic approach. In this article, we review the pathophysiological rationale and technical modalities of brain tissue oxygen monitors, as well as its use in studies of brain tissue oxygen-directed therapy. Furthermore, we analyze hyperoxia as a treatment option in TBI patients, summarize the results of clinical trials, and give insights into the recent findings of hyperoxic effects on cerebral metabolism after TBI.
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Affiliation(s)
- Christopher Beynon
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany.
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Continuous brain tissue oxygenation monitoring in the management of pediatric stroke. Neurocrit Care 2012; 15:529-36. [PMID: 21416310 DOI: 10.1007/s12028-011-9531-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Direct invasive monitoring of brain tissue oxygenation (PbtO(2)) has been routinely utilized to predict cerebral ischemia and to prevent secondary injury in patients with traumatic brain injury (TBI) and vasospasm secondary to subarachnoid hemorrhage (SAH). The safety and utility of these devices in the pediatric population have been examined in a few small studies. No studies, however, have examined the use of PbtO(2) monitoring in stroke patients. METHODS Retrospective chart review of the first two consecutive, critically ill pediatric patients in the pediatric intensive care unit requiring brain tissue oxygen monitoring for newly diagnosed cerebral ischemia. ICP, CPP, PbtO(2), SaO(2), BP, and RR were all continually monitored during their care and were retrospectively collected and reviewed. RESULTS We present two pediatric stroke patients managed in a critical care setting with PbtO(2) monitoring in addition to ICP, MAP, CPP, and SaO(2). Both patients had multiple events of low brain tissue oxygen (PbtO(2) <20 torr), independent of abnormal values in other monitoring parameters, which required physician intervention. No new ischemic damage occurred after PbtO(2) monitoring began in either patient. CONCLUSIONS There is currently inadequate data to support the application of PbtO(2) monitoring in children with stroke to prevent progressive ischemia and to improve outcome. However, the positive results for these two patients support the need for further study in this area.
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46
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Kan EM, Ling EA, Lu J. Microenvironment changes in mild traumatic brain injury. Brain Res Bull 2012; 87:359-72. [PMID: 22289840 DOI: 10.1016/j.brainresbull.2012.01.007] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2011] [Revised: 01/10/2012] [Accepted: 01/12/2012] [Indexed: 02/08/2023]
Abstract
Traumatic brain injury (TBI) is a major public-health problem for which mild TBI (MTBI) makes up majority of the cases. MTBI is a poorly-understood health problem and can persist for years manifesting into neurological and non-neurological problems that can affect functional outcome. Presently, diagnosis of MTBI is based on symptoms reporting with poor understanding of ongoing pathophysiology, hence precluding prognosis and intervention. Other than rehabilitation, there is still no pharmacological treatment for the treatment of secondary injury and prevention of the development of cognitive and behavioural problems. The lack of external injuries and absence of detectable brain abnormalities lend support to MTBI developing at the cellular and biochemical level. However, the paucity of suitable and validated non-invasive methods for accurate diagnosis of MTBI poses as a substantial challenge. Hence, it is crucial that a clinically useful evaluation and management procedure be instituted for MTBI that encompasses both molecular pathophysiology and functional outcome. The acute microenvironment changes post-MTBI presents an attractive target for modulation of MTBI symptoms and the development of cognitive changes later in life.
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Affiliation(s)
- Enci Mary Kan
- Combat Care Laboratory, Defence Medical and Environmental Research Institute, DSO National Laboratories, 27 Medical Drive, Singapore 117510, Singapore
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Comment gérer l’hypertension intracrânienne réfractaire ? MEDECINE INTENSIVE REANIMATION 2012. [DOI: 10.1007/s13546-011-0419-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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Abstract
PURPOSE OF REVIEW The developing brain is particularly vulnerable to traumatic brain injury (TBI), leading to frequent disability or death. This article is an update of the pediatric specificities of TBI management. RECENT FINDINGS We review the evidences with regards to general management and therapeutic goals to prevent secondary injuries in pediatric TBI patients. Recent controversies in neurocritical care, such as multimodal neuromonitoring, hyperventilation, barbiturate coma, hypothermia, and decompressive surgery, are also highlighted. SUMMARY Many therapeutic modalities in pediatric TBI have a low level of evidence. Further research is needed to establish clear resuscitation goals. Universal objectives may not be suitable for all patients; intensive neuromonitoring may help in identifying individual therapeutic goals and guiding the selection of treatments.
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Current world literature. Curr Opin Anaesthesiol 2011; 24:224-33. [PMID: 21386670 DOI: 10.1097/aco.0b013e32834585d6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
PURPOSE OF REVIEW This review focuses on the role of various intracranial monitoring technologies in the diagnosis and therapy of traumatic brain injury injury. RECENT FINDINGS There exist many controversial points as to the utility of different intracranial monitoring with regard to improvement of outcomes from severe traumatic brain injury. Most recent studies are confirming that the use of multiple modalities in the neurological ICU setting may offer promising results. SUMMARY Increased adherence to guideline-based and protocol-driven neurointensive care utilizing multimodality in monitoring technology for patients with severe traumatic brain injury is likely to give clinicians increased insight into the elusive mechanisms underlying the complex pathophysiology of this disease process and may further improve outcomes in this patient population.
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