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Zhang Y, Sun K, Wang Y, Qin Y, Li H. Early vs late fracture fixation in severe head and orthopedic injuries. Am J Emerg Med 2018; 36:1410-1417. [DOI: 10.1016/j.ajem.2017.12.067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 12/27/2017] [Accepted: 12/28/2017] [Indexed: 10/18/2022] Open
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Abstract
Neuromonitoring plays an important role in the management of traumatic brain injury. Simultaneous assessment of cerebral hemodynamics, oxygenation, and metabolism allows an individualized approach to patient management in which therapeutic interventions intended to prevent or minimize secondary brain injury are guided by monitored changes in physiologic variables rather than generic thresholds. This narrative review describes various neuromonitoring techniques that can be used to guide the management of patients with traumatic brain injury and examines the latest evidence and expert consensus guidelines for neuromonitoring.
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Dash HH, Chavali S. Management of traumatic brain injury patients. Korean J Anesthesiol 2018; 71:12-21. [PMID: 29441170 PMCID: PMC5809702 DOI: 10.4097/kjae.2018.71.1.12] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 01/24/2018] [Accepted: 01/24/2018] [Indexed: 01/07/2023] Open
Abstract
Traumatic brain injury (TBI) has been called the ‘silent epidemic’ of modern times, and is the leading cause of mortality and morbidity in children and young adults in both developed and developing nations worldwide. In recent years, the treatment of TBI has undergone a paradigm shift. The management of severe TBI is ideally based on protocol-based guidelines provided by the Brain Trauma Foundation. The aims and objectives of its management are prophylaxis and prompt management of intracranial hypertension and secondary brain injury, maintenance of cerebral perfusion pressure, and ensuring adequate oxygen delivery to injured brain tissue. In this review, the authors discuss protocol-based approaches to the management of severe TBI as per recent guidelines.
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Affiliation(s)
- Hari Hara Dash
- Department of Anesthesiology and Pain Medicine, Fortis Memorial Research Institute, Gurgaon, India
| | - Siddharth Chavali
- Department of Neuroanesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
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Braun M, Khan ZT, Khan MB, Kumar M, Ward A, Achyut BR, Arbab AS, Hess DC, Hoda MN, Baban B, Dhandapani KM, Vaibhav K. Selective activation of cannabinoid receptor-2 reduces neuroinflammation after traumatic brain injury via alternative macrophage polarization. Brain Behav Immun 2018; 68:224-237. [PMID: 29079445 PMCID: PMC5767553 DOI: 10.1016/j.bbi.2017.10.021] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Revised: 10/14/2017] [Accepted: 10/23/2017] [Indexed: 02/07/2023] Open
Abstract
Inflammation is an important mediator of secondary neurological injury after traumatic brain injury (TBI). Endocannabinoids, endogenously produced arachidonate based lipids, have recently emerged as powerful anti-inflammatory compounds, yet the molecular and cellular mechanisms underlying these effects are poorly defined. Endocannabinoids are physiological ligands for two known cannabinoid receptors, CB1R and CB2R. In the present study, we hypothesized that selective activation of CB2R attenuates neuroinflammation and reduces neurovascular injury after TBI. Using a murine controlled cortical impact (CCI) model of TBI, we observed a dramatic upregulation of CB2R within infiltrating myeloid cells beginning at 72 h. Administration of the selective CB2R agonist, GP1a (1-5 mg/kg), attenuated pro-inflammatory M1 macrophage polarization, increased anti-inflammatory M2 polarization, reduced edema development, enhanced cerebral blood flow, and improved neurobehavioral outcomes after TBI. In contrast, the CB2R antagonist, AM630, worsened outcomes. Taken together, our findings support the development of selective CB2R agonists as a therapeutic strategy to improve TBI outcomes while avoiding the psychoactive effects of CB1R activation.
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Affiliation(s)
- Molly Braun
- Department of Neurosurgery, Medical College of Georgia, Augusta University
| | - Zenab T. Khan
- Department of Neurosurgery, Medical College of Georgia, Augusta University,Center for Nursing Research, Augusta University
| | - Mohammad B. Khan
- Department of Neurology, Medical College of Georgia, Augusta University
| | - Manish Kumar
- European Molecular Biology Laboratory (EMBL), Monterontondo, Italy
| | - Ayobami Ward
- Department of Neurosurgery, Medical College of Georgia, Augusta University
| | | | | | - David C. Hess
- Department of Neurology, Medical College of Georgia, Augusta University
| | - Md. Nasrul Hoda
- Department of Neurology, Medical College of Georgia, Augusta University,Department of Medical Laboratory, Imaging, and Radiological Sciences, College of Allied Health Sciences, Augusta University
| | - Babak Baban
- Department of Neurology, Medical College of Georgia, Augusta University,Department of Oral Biology, Dental College of Georgia, Augusta University,Department of Surgery, Medical College of Georgia, Augusta University
| | | | - Kumar Vaibhav
- Department of Neurosurgery, Medical College of Georgia, Augusta University, United States; Department of Medical Laboratory, Imaging, and Radiological Sciences, College of Allied Health Sciences, Augusta University, United States.
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Geeraerts T, Velly L, Abdennour L, Asehnoune K, Audibert G, Bouzat P, Bruder N, Carrillon R, Cottenceau V, Cotton F, Courtil-Teyssedre S, Dahyot-Fizelier C, Dailler F, David JS, Engrand N, Fletcher D, Francony G, Gergelé L, Ichai C, Javouhey É, Leblanc PE, Lieutaud T, Meyer P, Mirek S, Orliaguet G, Proust F, Quintard H, Ract C, Srairi M, Tazarourte K, Vigué B, Payen JF. Management of severe traumatic brain injury (first 24hours). Anaesth Crit Care Pain Med 2017; 37:171-186. [PMID: 29288841 DOI: 10.1016/j.accpm.2017.12.001] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The latest French Guidelines for the management in the first 24hours of patients with severe traumatic brain injury (TBI) were published in 1998. Due to recent changes (intracerebral monitoring, cerebral perfusion pressure management, treatment of raised intracranial pressure), an update was required. Our objective has been to specify the significant developments since 1998. These guidelines were conducted by a group of experts for the French Society of Anesthesia and Intensive Care Medicine (Société francaise d'anesthésie et de réanimation [SFAR]) in partnership with the Association de neuro-anesthésie-réanimation de langue française (ANARLF), The French Society of Emergency Medicine (Société française de médecine d'urgence (SFMU), the Société française de neurochirurgie (SFN), the Groupe francophone de réanimation et d'urgences pédiatriques (GFRUP) and the Association des anesthésistes-réanimateurs pédiatriques d'expression française (ADARPEF). The method used to elaborate these guidelines was the Grade® method. After two Delphi rounds, 32 recommendations were formally developed by the experts focusing on the evaluation the initial severity of traumatic brain injury, the modalities of prehospital management, imaging strategies, indications for neurosurgical interventions, sedation and analgesia, indications and modalities of cerebral monitoring, medical management of raised intracranial pressure, management of multiple trauma with severe traumatic brain injury, detection and prevention of post-traumatic epilepsia, biological homeostasis (osmolarity, glycaemia, adrenal axis) and paediatric specificities.
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Affiliation(s)
- Thomas Geeraerts
- Pôle anesthésie-réanimation, Inserm, UMR 1214, Toulouse neuroimaging center, ToNIC, université Toulouse 3-Paul Sabatier, CHU de Toulouse, 31059 Toulouse, France.
| | - Lionel Velly
- Service d'anesthésie-réanimation, Aix-Marseille université, CHU Timone, Assistance publique-Hôpitaux de Marseille, 13005 Marseille, France
| | - Lamine Abdennour
- Département d'anesthésie-réanimation, groupe hospitalier Pitié-Salpêtrière, AP-HP, 75013 Paris, France
| | - Karim Asehnoune
- Service d'anesthésie et de réanimation chirurgicale, Hôtel-Dieu, CHU de Nantes, 44093 Nantes cedex 1, France
| | - Gérard Audibert
- Département d'anesthésie-réanimation, hôpital Central, CHU de Nancy, 54000 Nancy, France
| | - Pierre Bouzat
- Pôle anesthésie-réanimation, CHU Grenoble-Alpes, 38043 Grenoble cedex 9, France
| | - Nicolas Bruder
- Service d'anesthésie-réanimation, Aix-Marseille université, CHU Timone, Assistance publique-Hôpitaux de Marseille, 13005 Marseille, France
| | - Romain Carrillon
- Service d'anesthésie-réanimation, hôpital neurologique Pierre-Wertheimer, groupement hospitalier Est, hospices civils de Lyon, 69677 Bron, France
| | - Vincent Cottenceau
- Service de réanimation chirurgicale et traumatologique, SAR 1, hôpital Pellegrin, CHU de Bordeaux, Bordeaux, France
| | - François Cotton
- Service d'imagerie, centre hospitalier Lyon Sud, hospices civils de Lyon, 69495 Pierre-Bénite cedex, France
| | - Sonia Courtil-Teyssedre
- Service de réanimation pédiatrique, hôpital Femme-Mère-Enfant, hospices civils de Lyon, 69677 Bron, France
| | | | - Frédéric Dailler
- Service d'anesthésie-réanimation, hôpital neurologique Pierre-Wertheimer, groupement hospitalier Est, hospices civils de Lyon, 69677 Bron, France
| | - Jean-Stéphane David
- Service d'anesthésie réanimation, centre hospitalier Lyon Sud, hospices civils de Lyon, 69495 Pierre-Bénite, France
| | - Nicolas Engrand
- Service d'anesthésie-réanimation, Fondation ophtalmologique Adolphe de Rothschild, 75940 Paris cedex 19, France
| | - Dominique Fletcher
- Service d'anesthésie réanimation chirurgicale, hôpital Raymond-Poincaré, université de Versailles Saint-Quentin, AP-HP, Garches, France
| | - Gilles Francony
- Pôle anesthésie-réanimation, CHU Grenoble-Alpes, 38043 Grenoble cedex 9, France
| | - Laurent Gergelé
- Département d'anesthésie-réanimation, CHU de Saint-Étienne, 42055 Saint-Étienne, France
| | - Carole Ichai
- Service de réanimation médicochirurgicale, UMR 7275, CNRS, Sophia Antipolis, hôpital Pasteur, CHU de Nice, 06000 Nice, France
| | - Étienne Javouhey
- Service de réanimation pédiatrique, hôpital Femme-Mère-Enfant, hospices civils de Lyon, 69677 Bron, France
| | - Pierre-Etienne Leblanc
- Département d'anesthésie-réanimation, hôpital de Bicêtre, hôpitaux universitaires Paris-Sud, AP-HP, Le Kremlin-Bicêtre, France; Équipe TIGER, CNRS 1072-Inserm 5288, service d'anesthésie, centre hospitalier de Bourg en Bresse, centre de recherche en neurosciences, Lyon, France
| | - Thomas Lieutaud
- UMRESTTE, UMR-T9405, IFSTTAR, université Claude-Bernard de Lyon, Lyon, France; Service d'anesthésie-réanimation, hôpital universitaire Necker-Enfants-Malades, université Paris Descartes, AP-HP, Paris, France
| | - Philippe Meyer
- EA 08 Paris-Descartes, service de pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte, 75743 Paris cedex 15, France
| | - Sébastien Mirek
- Service d'anesthésie-réanimation, CHU de Dijon, Dijon, France
| | - Gilles Orliaguet
- EA 08 Paris-Descartes, service de pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte, 75743 Paris cedex 15, France
| | - François Proust
- Service de neurochirurgie, hôpital Hautepierre, CHU de Strasbourg, 67098 Strasbourg, France
| | - Hervé Quintard
- Service de réanimation médicochirurgicale, UMR 7275, CNRS, Sophia Antipolis, hôpital Pasteur, CHU de Nice, 06000 Nice, France
| | - Catherine Ract
- Département d'anesthésie-réanimation, hôpital de Bicêtre, hôpitaux universitaires Paris-Sud, AP-HP, Le Kremlin-Bicêtre, France; Équipe TIGER, CNRS 1072-Inserm 5288, service d'anesthésie, centre hospitalier de Bourg en Bresse, centre de recherche en neurosciences, Lyon, France
| | - Mohamed Srairi
- Pôle anesthésie-réanimation, Inserm, UMR 1214, Toulouse neuroimaging center, ToNIC, université Toulouse 3-Paul Sabatier, CHU de Toulouse, 31059 Toulouse, France
| | - Karim Tazarourte
- SAMU/SMUR, service des urgences, hospices civils de Lyon, hôpital Édouard-Herriot, 69437 Lyon cedex 03, France
| | - Bernard Vigué
- Département d'anesthésie-réanimation, hôpital de Bicêtre, hôpitaux universitaires Paris-Sud, AP-HP, Le Kremlin-Bicêtre, France; Équipe TIGER, CNRS 1072-Inserm 5288, service d'anesthésie, centre hospitalier de Bourg en Bresse, centre de recherche en neurosciences, Lyon, France
| | - Jean-François Payen
- Pôle anesthésie-réanimation, CHU Grenoble-Alpes, 38043 Grenoble cedex 9, France
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Della Torre V, Badenes R, Corradi F, Racca F, Lavinio A, Matta B, Bilotta F, Robba C. Acute respiratory distress syndrome in traumatic brain injury: how do we manage it? J Thorac Dis 2017; 9:5368-5381. [PMID: 29312748 PMCID: PMC5756968 DOI: 10.21037/jtd.2017.11.03] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 10/31/2017] [Indexed: 12/24/2022]
Abstract
Traumatic brain injury (TBI) is an important cause of morbidity and mortality worldwide. TBI patients frequently suffer from lung complications and acute respiratory distress syndrome (ARDS), which is associated with poor clinical outcomes. Moreover, the association between TBI and ARDS in trauma patients is well recognized. Mechanical ventilation of patients with a concomitance of acute brain injury and lung injury can present significant challenges. Frequently, guidelines recommending management strategies for patients with traumatic brain injuries come into conflict with what is now considered best ventilator practice. In this review, we will explore the strategies of the best practice in the ventilatory management of patients with ARDS and TBI, concentrating on those areas in which a conflict exists. We will discuss the use of ventilator strategies such as protective ventilation, high positive end expiratory pressure (PEEP), prone position, recruitment maneuvers (RMs), as well as techniques which at present are used for 'rescue' in ARDS (including extracorporeal membrane oxygenation) in patients with TBI. Furthermore, general principles of fluid, haemodynamic and hemoglobin management will be discussed. Currently, there are inadequate data addressing the safety or efficacy of ventilator strategies used in ARDS in adult patients with TBI. At present, choice of ventilator rescue strategies is best decided on a case-by-case basis in conjunction with local expertise.
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Affiliation(s)
- Valentina Della Torre
- Neurocritical Care Unit, Addenbrooke’s Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Rafael Badenes
- Department of Anesthesiology and Surgical Trauma Intensive Care, Hospital Clinic Universitari Valencia, University of Valencia, Valencia, Spain
| | | | - Fabrizio Racca
- Department of Anesthesiology and Intensive Care Unit, SS Antonio Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Andrea Lavinio
- Neurocritical Care Unit, Addenbrooke’s Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Basil Matta
- Neurocritical Care Unit, Addenbrooke’s Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Federico Bilotta
- Department of Anaesthesia and Intensive Care, La Sapienza University, Rome, Italy
| | - Chiara Robba
- Neurocritical Care Unit, Addenbrooke’s Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
- Department of Neuroscience, University of Genova, Italy
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Mateo J, Payen D, Ghout I, Vallée F, Lescot T, Welschbillig S, Tazarourte K, Azouvi P, Weiss JJ, Aegerter P, Vigué B. Impact of extended monitoring-guided intensive care on outcome after severe traumatic brain injury: A prospective multicentre cohort study (PariS-TBI study). Brain Inj 2017; 31:1642-1650. [PMID: 28925746 DOI: 10.1080/02699052.2017.1370554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE We evaluated whether an integrated monitoring with systemic and specific monitoring affect mortality and disability in adults with severe traumatic brain injury (sTBI). METHODS Adults with severeTBI (Glasgow Coma Scale [GCS] ≤ 8) admitted alive in intensive care units (ICUs) were prospectively included. Primary endpoints were in-hospital 30-day mortality and extended Glasgow outcome score (GOSE) at 3 years. Association with the intensity of monitoring and outcome was studied by comparing a high level of monitoring (HLM) (systemic and ≥3 specific monitoring) and low level of monitoring (LLM) (systemic and 0-2 specific monitoring) and using inverse probability weighting procedure. RESULTS 476 patients were included and IPW was used to improve the balance between the two groups of treatments (HLM/LMM). Overall hospital mortality (at 30 days) was 43%, being significantly lower in HLM than LLM group (27% vs. 53%: RR, 1.63: 95% CI: 1.23-2.15). The 14-day hospital mortality was also lower in the HLM group than expected, based upon the CRASH prediction model (35%). At 3 years, disability was not significantly different between the monitoring groups. CONCLUSIONS After adjustment, HLM group improved short-term mortality but did not show any improvement in the 3-year outcome compared with LLM.
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Affiliation(s)
- Joaquim Mateo
- a Department of Anesthesiology and Critical Care , Lariboisière University Hospital, Assistance Publique-Hôpitaux de Paris, University Paris 7 Diderot , Paris , France
| | - Didier Payen
- a Department of Anesthesiology and Critical Care , Lariboisière University Hospital, Assistance Publique-Hôpitaux de Paris, University Paris 7 Diderot , Paris , France
| | - Idir Ghout
- b Unité de Recherche Clinique Paris-Ouest , Hôpital Ambroise Paré, AP-HP , Boulogne , France
| | - Fabrice Vallée
- a Department of Anesthesiology and Critical Care , Lariboisière University Hospital, Assistance Publique-Hôpitaux de Paris, University Paris 7 Diderot , Paris , France
| | - Thomas Lescot
- c Department of Anesthesiology and Critical Care , Pitié-Salpêtrière University Hospital, APHP, University Paris 6 , Paris , France
| | - Stephane Welschbillig
- a Department of Anesthesiology and Critical Care , Lariboisière University Hospital, Assistance Publique-Hôpitaux de Paris, University Paris 7 Diderot , Paris , France
| | - Karim Tazarourte
- d SAMU 77, Mobile Care Unit , Marc Jacquet Hospital , Melun , France
| | - Philippe Azouvi
- e Department of Physical Medicine and Rehabilitation , Raymond Poincaré Hospital, Assistance Publique-Hôpitaux de Paris , Garches , France
| | - Jean-Jacques Weiss
- f Department of Public Health , Centre Ressources Francilien du Traumatisme Crânien , Paris , France
| | - Philippe Aegerter
- g UMR-S 1168, INSERM , Université Versailles St-Quentin , Paris , France
| | - Bernard Vigué
- h Department of Anesthesiology and Intensive Care , Bicêtre University Hospital, Assistance Publique-Hôpitaux de Paris, University Paris Sud , Le Kremlin Bicêtre , France
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Akbik OS, Krasberg M, Nemoto EM, Yonas H. Effect of Cerebrospinal Fluid Drainage on Brain Tissue Oxygenation in Traumatic Brain Injury. J Neurotrauma 2017; 34:3153-3157. [PMID: 28614970 DOI: 10.1089/neu.2016.4912] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The effectiveness of cerebrospinal fluid (CSF) drainage in lowering high intracranial pressure (ICP) is well established in severe traumatic brain injury (TBI). Recently, however, the use of external ventricular drains (EVDs) and ICP monitors in TBI has come under question. The aim of this retrospective study was to investigate the effect of CSF drainage on brain tissue oxygenation (PbtO2). Using a multi-modality monitoring system, we continuously monitored PbtO2 and parenchymal ICP during CSF drainage events via a ventriculostomy in 40 patients with severe TBI. Measurements were time-locked continuous recordings on a Component Neuromonitoring System in a neuroscience intensive care unit. We further selected for therapeutic CSF drainage events initiated at ICP values above 25 mm Hg and analyzed the 4-min periods before and after drainage for the physiologic variables ICP, cerebral perfusion pressure (CPP), and PbtO2. We retrospectively identified 204 CSF drainage events for ICP EVD-opening values greater than 25 mm Hg in 23 patients. During the 4 min of opened EVD, ICP decreased by 5.7 ± 0.6 mm Hg, CPP increased by 4.1 ± 1.2 mm Hg, and PbtO2 increased by 1.15 ± 0.26 mm Hg. ICP, CPP, and PbtO2 all improved with CSF drainage at ICP EVD-opening values above 25 mm Hg. Although the average PbtO2 changes were small, a clinically significant change in PbtO2 of 5 mm Hg or greater occurred in 12% of CSF drainage events, which was correlated with larger decreases in ICP, displaying a complex relationship between ICP and PbtO2 that warrants further studies.
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Affiliation(s)
- Omar S Akbik
- Department of Neurosurgery, University of New Mexico , Albuquerque, New Mexico
| | - Mark Krasberg
- Department of Neurosurgery, University of New Mexico , Albuquerque, New Mexico
| | - Edwin M Nemoto
- Department of Neurosurgery, University of New Mexico , Albuquerque, New Mexico
| | - Howard Yonas
- Department of Neurosurgery, University of New Mexico , Albuquerque, New Mexico
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Nordström CH, Koskinen LO, Olivecrona M. Aspects on the Physiological and Biochemical Foundations of Neurocritical Care. Front Neurol 2017; 8:274. [PMID: 28674514 PMCID: PMC5474476 DOI: 10.3389/fneur.2017.00274] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 05/29/2017] [Indexed: 12/25/2022] Open
Abstract
Neurocritical care (NCC) is a branch of intensive care medicine characterized by specific physiological and biochemical monitoring techniques necessary for identifying cerebral adverse events and for evaluating specific therapies. Information is primarily obtained from physiological variables related to intracranial pressure (ICP) and cerebral blood flow (CBF) and from physiological and biochemical variables related to cerebral energy metabolism. Non-surgical therapies developed for treating increased ICP are based on knowledge regarding transport of water across the intact and injured blood-brain barrier (BBB) and the regulation of CBF. Brain volume is strictly controlled as the BBB permeability to crystalloids is very low restricting net transport of water across the capillary wall. Cerebral pressure autoregulation prevents changes in intracranial blood volume and intracapillary hydrostatic pressure at variations in arterial blood pressure. Information regarding cerebral oxidative metabolism is obtained from measurements of brain tissue oxygen tension (PbtO2) and biochemical data obtained from intracerebral microdialysis. As interstitial lactate/pyruvate (LP) ratio instantaneously reflects shifts in intracellular cytoplasmatic redox state, it is an important indicator of compromised cerebral oxidative metabolism. The combined information obtained from PbtO2, LP ratio, and the pattern of biochemical variables reveals whether impaired oxidative metabolism is due to insufficient perfusion (ischemia) or mitochondrial dysfunction. Intracerebral microdialysis and PbtO2 give information from a very small volume of tissue. Accordingly, clinical interpretation of the data must be based on information of the probe location in relation to focal brain damage. Attempts to evaluate global cerebral energy state from microdialysis of intraventricular fluid and from the LP ratio of the draining venous blood have recently been presented. To be of clinical relevance, the information from all monitoring techniques should be presented bedside online. Accordingly, in the future, the chemical variables obtained from microdialysis will probably be analyzed by biochemical sensors.
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Affiliation(s)
| | - Lars-Owe Koskinen
- Department of Clinical Neuroscience, Division of Neurosurgery, Umeå University, Umeå, Sweden
| | - Magnus Olivecrona
- Faculty of Health and Medicine, Department of Anesthesia and Intensive Care, Section for Neurosurgery Örebro University Hospital, Örebro University, Örebro, Sweden
- Department for Medical Sciences, Örebro University, Örebro, Sweden
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Vidal-Jorge M, Sánchez-Guerrero A, Mur-Bonet G, Castro L, Rădoi A, Riveiro M, Fernández-Prado N, Baena J, Poca MA, Sahuquillo J. Does Normobaric Hyperoxia Cause Oxidative Stress in the Injured Brain? A Microdialysis Study Using 8-Iso-Prostaglandin F2α as a Biomarker. J Neurotrauma 2017; 34:2731-2742. [PMID: 28323516 DOI: 10.1089/neu.2017.4992] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Significant controversy exists regarding the potential clinical benefit of normobaric hyperoxia (NBO) in patients with traumatic brain injury (TBI). This study consisted of two aims: 1) to assess whether NBO improves brain oxygenation and metabolism and 2) to determine whether this therapy may increase the risk of oxidative stress (OxS), using 8-iso-Prostaglandin F2α (PGF2α) as a biomarker. Thirty-one patients with a median admission Glasgow Coma Scale score of 4 (min: 3, max: 12) were monitored with cerebral microdialysis and brain tissue oxygen sensors and treated with fraction of inspired oxygen (FiO2) of 1.0 for 4 h. Patients were divided into two groups according to the area monitored by the probes: normal injured brain and traumatic penumbra/traumatic core. NBO maintained for 4 h did not induce OxS in patients without preOxS at baseline, except in one case. However, for patients in whom OxS was detected at baseline, NBO induced a significant increase in 8-iso-PGF2α. The results of our study showed that NBO did not change energy metabolism in the whole group of patients. In the five patients with brain lactate concentration ([Lac]brain) > 3.5 mmol/L at baseline, NBO induced a marked reduction in both [Lac]brain and lactate-to-pyruvate ratio. Although these differences were not statistically significant, together with the results of our previous study, they suggest that TBI patients would benefit from receiving NBO when they show indications of disturbed brain metabolism. These findings, in combination with increasing evidence that TBI metabolic crises are common without brain ischemia, open new possibilities for the use of this accessible therapeutic strategy in TBI patients.
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Affiliation(s)
- Marian Vidal-Jorge
- 1 Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR) , Barcelona, Spain
| | - Angela Sánchez-Guerrero
- 1 Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR) , Barcelona, Spain
| | - Gemma Mur-Bonet
- 1 Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR) , Barcelona, Spain
| | - Lidia Castro
- 1 Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR) , Barcelona, Spain
| | - Andreea Rădoi
- 1 Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR) , Barcelona, Spain
| | - Marilyn Riveiro
- 2 Neurotraumatology Intensive Care Unit, Vall d'Hebron University Hospital , Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Natalia Fernández-Prado
- 2 Neurotraumatology Intensive Care Unit, Vall d'Hebron University Hospital , Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jacinto Baena
- 2 Neurotraumatology Intensive Care Unit, Vall d'Hebron University Hospital , Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Maria-Antonia Poca
- 1 Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR) , Barcelona, Spain .,3 Department of Neurosurgery, Vall d'Hebron University Hospital , Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Juan Sahuquillo
- 1 Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR) , Barcelona, Spain .,3 Department of Neurosurgery, Vall d'Hebron University Hospital , Universitat Autònoma de Barcelona, Barcelona, Spain
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Mortality and Outcome Comparison Between Brain Tissue Oxygen Combined with Intracranial Pressure/Cerebral Perfusion Pressure–Guided Therapy and Intracranial Pressure/Cerebral Perfusion Pressure–Guided Therapy in Traumatic Brain Injury: A Meta-Analysis. World Neurosurg 2017; 100:118-127. [DOI: 10.1016/j.wneu.2016.12.097] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 12/21/2016] [Accepted: 12/23/2016] [Indexed: 11/21/2022]
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Sone JY, Kondziolka D, Huang JH, Samadani U. Helmet efficacy against concussion and traumatic brain injury: a review. J Neurosurg 2017; 126:768-781. [DOI: 10.3171/2016.2.jns151972] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Helmets are one of the earliest and most enduring methods of personal protection in human civilization. Although primarily developed for combat purposes in ancient times, modern helmets have become highly diversified to sports, recreation, and transportation. History and the scientific literature exhibit that helmets continue to be the primary and most effective prevention method against traumatic brain injury (TBI), which presents high mortality and morbidity rates in the US. The neurosurgical and neurotrauma literature on helmets and TBI indicate that helmets provide effectual protection against moderate to severe head trauma resulting in severe disability or death. However, there is a dearth of scientific data on helmet efficacy against concussion in both civilian and military aspects. The objective of this literature review was to explore the historical evolution of helmets, consider the effectiveness of helmets in protecting against severe intracranial injuries, and examine recent evidence on helmet efficacy against concussion. It was also the goal of this report to emphasize the need for more research on helmet efficacy with improved experimental design and quantitative standardization of assessments for concussion and TBI, and to promote expanded involvement of neurosurgery in studying the quantitative diagnostics of concussion and TBI. Recent evidence summarized by this literature review suggests that helmeted patients do not have better relative clinical outcome and protection against concussion than unhelmeted patients.
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Affiliation(s)
- Je Yeong Sone
- 1Department of Neurosurgery, New York University School of Medicine, New York, New York
| | - Douglas Kondziolka
- 1Department of Neurosurgery, New York University School of Medicine, New York, New York
| | - Jason H. Huang
- 2Department of Neurosurgery, Baylor Scott & White Central Division, Temple, Texas; and
| | - Uzma Samadani
- 3Department of Neurosurgery, Hennepin County Medical Center, University of Minnesota, Minneapolis, Minnesota
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Russell DW, Janz DR, Emerson WL, May AK, Bernard GR, Zhao Z, Koyama T, Ware LB. Early exposure to hyperoxia and mortality in critically ill patients with severe traumatic injuries. BMC Pulm Med 2017; 17:29. [PMID: 28158980 PMCID: PMC5291954 DOI: 10.1186/s12890-017-0370-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 01/18/2017] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND Hyperoxia is common early in the course of resuscitation of critically ill patients. It has been associated with mortality in some, but not all, studies of cardiac arrest patients and other critically ill cohorts. Reasons for the inconsistency are unclear and may depend on unmeasured patient confounders, the timing and duration of hyperoxia, population characteristics, or the way that hyperoxia is defined and measured. We sought to determine whether, in a prospectively collected cohort of mechanically ventilated patients with traumatic injuries with and without head trauma, higher maximum partial pressure of arterial oxygen (PaO2) within 24 hours of admission would be associated with increased risk of in-hospital mortality. METHODS Critically ill patients with traumatic injuries undergoing invasive mechanical ventilation enrolled in the Validating Acute Lung Injury biomarkers for Diagnosis (VALID) study were included in this study. All arterial blood gases (ABGs) from the first 24 hours of admission were recorded. Primary analysis was comparison of the highest PaO2 between hospital survivors and non-survivors. RESULTS A total of 653 patients were evaluated for inclusion. Of these, 182 were not mechanically ventilated or did not have an ABG measured in the first 24 hours, leaving 471 patients in the primary analysis. In survivors, the maximum PaO2 was 141 mmHg (median, interquartile range 103 - 212) compared to 148 mmHg (IQR 105 - 209) in non-survivors (p = 0.82). In the subgroup with head trauma (n = 266), the maximum PaO2 was 133 mmHg (IQR 97 - 187) among survivors and 152 mmHg (108 - 229) among nonsurvivors (p = 0.19). After controlling for age, injury severity score, number of arterial blood gases, and fraction of inspired oxygen, maximum PaO2 was not associated with increased mortality (OR 1.27 for every fold increase of PaO2 (95% CI 0.72 - 2.25). CONCLUSIONS In mechanically ventilated patients with severe traumatic injuries, hyperoxia in the first 24 hours of admission was not associated with increased risk of death or worsened neurological outcomes in a setting without brain tissue oxygenation monitoring.
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Affiliation(s)
- Derek W Russell
- Lung Health Center, Division of Pulmonary and Critical Care Medicine, University of Alabama at Birmingham, 1900 University Blvd., THT 423, Birmingham, AL, 35233, USA.
| | - David R Janz
- Section of Pulmonary and Critical Care Medicine, Louisiana State University School of Medicine New Orleans, New Orleans, LA, USA
| | - William L Emerson
- Departments of Medicine and Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN, USA
| | - Addison K May
- Departments of Medicine and Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN, USA
| | - Gordon R Bernard
- Departments of Medicine and Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN, USA
| | - Zhiguo Zhao
- Departments of Medicine and Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN, USA
| | - Tatsuki Koyama
- Departments of Medicine and Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN, USA
| | - Lorraine B Ware
- Departments of Medicine and Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN, USA
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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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Foley LM, Clark RS, Vazquez AL, Hitchens TK, Alexander H, Ho C, Kochanek PM, Manole MD. Enduring disturbances in regional cerebral blood flow and brain oxygenation at 24 h after asphyxial cardiac arrest in developing rats. Pediatr Res 2017; 81:94-98. [PMID: 27636898 PMCID: PMC5287715 DOI: 10.1038/pr.2016.175] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2016] [Accepted: 07/25/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND Disturbances in cerebral blood flow (CBF) and brain oxygenation (PbO2) are present early after pediatric cardiac arrest (CA). CBF-targeted therapies improved neurological outcome in our CA model. To assess the therapeutic window for CBF- and PbO2-targeted therapies, we propose to determine if CBF and PbO2 disturbances persist at 24 h after experimental pediatric CA. METHODS Regional CBF and PbO2 were measured at 24 h after asphyxial CA in immature rats (n = 26, 6-8/group) using arterial spin label MRI and tissue electrodes, respectively. RESULTS In all regions but the thalamus, CBF recovered to sham values by 24 h; thalamic CBF was >32% higher after CA vs. sham. PbO2 values at 24 h after CA in the cortex and thalamus were similar to shams in rats who received supplemental oxygen, however, on room air, cortical PbO2 was lower after CA vs. shams. CONCLUSION CBF remains increased in the thalamus at 24 h after CA and PbO2 is decreased to hypoxic levels in cortex at 24 h after CA in rats who do not receive supplemental oxygen. Given the enduring disturbances in this model and the lack of routine CBF or PbO2 monitoring in patients, our data suggest the need for clinical correlation.
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Affiliation(s)
- Lesley M. Foley
- Animal Imaging Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Robert S.B. Clark
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, Pittsburgh, PA, USA
| | - Alberto L. Vazquez
- Animal Imaging Center, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Radiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - T. Kevin Hitchens
- Animal Imaging Center, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Neurobiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Henry Alexander
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, Pittsburgh, PA, USA
| | - Chien Ho
- Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Patrick M. Kochanek
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, Pittsburgh, PA, USA
- Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Bioengineering, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Mioara D. Manole
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, Pittsburgh, PA, USA
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Abstract
Neurocritical care has two main objectives. Initially, the emphasis is on treatment of patients with acute damage to the central nervous system whether through infection, trauma, or hemorrhagic or ischemic stroke. Thereafter, attention shifts to the identification of secondary processes that may lead to further brain injury, including fever, seizures, and ischemia, among others. Multimodal monitoring is the concept of using various tools and data integration to understand brain physiology and guide therapeutic interventions to prevent secondary brain injury. This chapter will review the use of electroencephalography, intracranial pressure monitoring, brain tissue oxygenation, cerebral microdialysis and neurochemistry, near-infrared spectroscopy, and transcranial Doppler sonography as they relate to neuromonitoring in the critically ill. The concepts and design of each monitor, in addition to the patient population that may most benefit from each modality, will be discussed, along with the various tools that can be used together to guide individualized patient treatment options. Major clinical trials, observational studies, and their effect on clinical outcomes will be reviewed. The future of multimodal monitoring in the field of bioinformatics, clinical research, and device development will conclude the chapter.
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Affiliation(s)
- G Korbakis
- Department of Neurosurgery, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - P M Vespa
- Department of Neurosurgery, UCLA David Geffen School of Medicine, Los Angeles, CA, USA; Department of Neurology, UCLA David Geffen School of Medicine, Los Angeles, CA, USA.
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Jones S, Schwartzbauer G, Jia X. Brain Monitoring in Critically Neurologically Impaired Patients. Int J Mol Sci 2016; 18:E43. [PMID: 28035993 PMCID: PMC5297678 DOI: 10.3390/ijms18010043] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 12/10/2016] [Accepted: 12/21/2016] [Indexed: 02/07/2023] Open
Abstract
Assessment of neurologic injury and the evolution of severe neurologic injury is limited in comatose or critically ill patients that lack a reliable neurologic examination. For common yet severe pathologies such as the comatose state after cardiac arrest, aneurysmal subarachnoid hemorrhage (aSAH), and severe traumatic brain injury (TBI), critical medical decisions are made on the basis of the neurologic injury. Decisions regarding active intensive care management, need for neurosurgical intervention, and withdrawal of care, depend on a reliable, high-quality assessment of the true state of neurologic injury, and have traditionally relied on limited assessments such as intracranial pressure monitoring and electroencephalogram. However, even within TBI there exists a spectrum of disease that is likely not captured by such limited monitoring and thus a more directed effort towards obtaining a more robust biophysical signature of the individual patient must be undertaken. In this review, multimodal monitoring including the most promising serum markers of neuronal injury, cerebral microdialysis, brain tissue oxygenation, and pressure reactivity index to access brain microenvironment will be discussed with their utility among specific pathologies that may help determine a more complete picture of the neurologic injury state for active intensive care management and long-term outcomes. Goal-directed therapy guided by a multi-modality approach appears to be superior to standard intracranial pressure (ICP) guided therapy and should be explored further across multiple pathologies. Future directions including the application of optogenetics to evaluate brain injury and recovery and even as an adjunct monitoring modality will also be discussed.
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Affiliation(s)
- Salazar Jones
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
| | - Gary Schwartzbauer
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
- Institute for Global Health, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
| | - Xiaofeng Jia
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
- Department of Anatomy and Neurobiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
- Department of Biomedical Engineering, The Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
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Subdural Empyema in the Setting of Multimodal Intracranial Monitoring. World Neurosurg 2016; 97:749.e1-749.e6. [PMID: 27826090 DOI: 10.1016/j.wneu.2016.10.133] [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: 10/12/2016] [Revised: 10/26/2016] [Accepted: 10/28/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND Multimodal intracranial monitoring is becoming an increasingly common tool in the management of patients with traumatic brain injury. Although numerous reports detailing the benefits of such advanced monitoring exist in the literature, there is minimal discussion of the possible complications that may arise in this patient population. CASE DESCRIPTION We report the case of a 32-year-old patient who had been assaulted and presented initially at an outside facility with a Glasgow Coma Scale score of 8. After transfer to our hospital, his Glasgow Coma Scale score was noted at 7T and multimodal monitoring with the Integra Licox brain tissue oxygen monitor and the Hemedex Bowman perfusion monitor was implemented, along with an external ventricular drain when a standard intracranial pressure monitor indicated increasing intracranial pressure. The patient's intracranial pressure normalized but he did require a course of antibiotics during this time for a fever and methicillin-resistant Staphylococcus aureus. The patient subsequently developed multifocal subdural empyemas requiring surgical evacuation. Postoperatively, the patient's intraoperative cultures remained without bacterial growth, likely related to the 2-week broad-spectrum antibiotic use. CONCLUSIONS To our knowledge, this is the first reported incidence of a subdural empyema developing in this setting. Although the safety profile of multimodal intracranial modeling is excellent, with increasing numbers of invasive bedside procedures, neurosurgeons must remain acutely vigilant for the development of infectious complications.
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69
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Abstract
Traumatic brain injury (TBI) represents a wide spectrum of disease and disease severity. Because the primary brain injury occurs before the patient enters the health care system, medical interventions seek principally to prevent secondary injury. Anesthesia teams that provide care for patients with TBI both in and out of the operating room should be aware of the specific therapies and needs of this unique and complex patient population.
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70
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Abstract
A mismatch between cerebral oxygen supply and demand can lead to cerebral hypoxia/ischemia and deleterious outcomes. Cerebral oxygenation monitoring is an important aspect of multimodality neuromonitoring. It is increasingly deployed whenever intracranial pressure monitoring is indicated. Although there is a large body of evidence demonstrating an association between cerebral hypoxia/ischemia and poor outcomes, it remains to be determined whether restoring cerebral oxygenation leads to improved outcomes. Randomized prospective studies are required to address uncertainties about cerebral oxygenation monitoring and management. This article describes the different methods of monitoring cerebral oxygenation, their indications, evidence base, limitations, and future perspectives.
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Affiliation(s)
- Matthew A Kirkman
- Neurocritical Care Unit, The National Hospital for Neurology and Neurosurgery, University College London Hospitals, Queen Square, London WC1N 3BG, UK
| | - Martin Smith
- Neurocritical Care Unit, The National Hospital for Neurology and Neurosurgery, University College London Hospitals, Queen Square, London WC1N 3BG, UK.
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71
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Algarra NN, Sharma D. Perioperative Management of Traumatic Brain Injury. CURRENT ANESTHESIOLOGY REPORTS 2016. [DOI: 10.1007/s40140-016-0170-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Evaluating the Role of Reduced Oxygen Saturation and Vascular Damage in Traumatic Brain Injury Using Magnetic Resonance Perfusion-Weighted Imaging and Susceptibility-Weighted Imaging and Mapping. Top Magn Reson Imaging 2016; 24:253-65. [PMID: 26502307 DOI: 10.1097/rmr.0000000000000064] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The cerebral vasculature, along with neurons and axons, is vulnerable to biomechanical insult during traumatic brain injury (TBI). Trauma-induced vascular injury is still an underinvestigated area in TBI research. Cerebral blood flow and metabolism could be important future treatment targets in neural critical care. Magnetic resonance imaging offers a number of key methods to probe vascular injury and its relationship with traumatic hemorrhage, perfusion deficits, venous blood oxygen saturation changes, and resultant tissue damage. They make it possible to image the hemodynamics of the brain, monitor regional damage, and potentially show changes induced in the brain's function not only acutely but also longitudinally following treatment. These methods have recently been used to show that even mild TBI (mTBI) subjects can have vascular abnormalities, and thus they provide a major step forward in better diagnosing mTBI patients.
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74
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Mullah SH, Abutarboush R, Moon-Massat PF, Saha BK, Haque A, Walker PB, Auker CR, Arnaud FG, McCarron RM, Scultetus AH. Sanguinate's effect on pial arterioles in healthy rats and cerebral oxygen tension after controlled cortical impact. Microvasc Res 2016; 107:83-90. [PMID: 27287870 DOI: 10.1016/j.mvr.2016.06.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 05/23/2016] [Accepted: 06/06/2016] [Indexed: 01/18/2023]
Abstract
Sanguinate, a polyethylene glycol-conjugated carboxyhemoglobin, was investigated for cerebral vasoactivity in healthy male Sprague-Dawley rats (Study 1) and for its ability to increase brain tissue oxygen pressure (PbtO2) after controlled cortical impact (CCI) - traumatic brain injury (TBI) (Study 2). In both studies ketamine-acepromazine anesthetized rats were ventilated with 40% O2. In Study 1, a cranial window was used to measure the diameters of medium - (50-100μm) and small-sized (<50μm) pial arterioles before and after four serial infusions of Sanguinate (8mL/kg/h, cumulative 16mL/kg IV), volume-matched Hextend, or normal saline. In Study 2, PbtO2 was measured using a phosphorescence quenching method before TBI, 15min after TBI (T15) and then every 10min thereafter for 155min. At T15, rats received either 8mL/kg IV Sanguinate (40mL/kg/h) or no treatment (saline, 4mL/kg/h). Results showed: 1) in healthy rats, percentage changes in pial arteriole diameter were the same among the groups, 2) in TBI rats, PbtO2 decreased from 36.5±3.9mmHg to 19.8±3.0mmHg at T15 in both groups after TBI and did not recover in either group for the rest of the study, and 3) MAP increased 16±4mmHg and 36±5mmHg after Sanguinate in healthy and TBI rats, respectively, while MAP was unchanged in control groups. In conclusion, Sanguinate did not cause vasoconstriction in the cerebral pial arterioles of healthy rats but it also did not acutely increase PbtO2 when administered after TBI. Sanguinate was associated with an increase in MAP in both studies.
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Affiliation(s)
- Saad H Mullah
- Naval Medical Research Center, NeuroTrauma Department, 503 Robert Grant Avenue Silver Spring, MD 20910, USA.
| | - Rania Abutarboush
- Naval Medical Research Center, NeuroTrauma Department, 503 Robert Grant Avenue Silver Spring, MD 20910, USA.
| | - Paula F Moon-Massat
- Naval Medical Research Center, NeuroTrauma Department, 503 Robert Grant Avenue Silver Spring, MD 20910, USA.
| | - Biswajit K Saha
- Naval Medical Research Center, NeuroTrauma Department, 503 Robert Grant Avenue Silver Spring, MD 20910, USA.
| | - Ashraful Haque
- Naval Medical Research Center, NeuroTrauma Department, 503 Robert Grant Avenue Silver Spring, MD 20910, USA.
| | - Peter B Walker
- Naval Medical Research Center, NeuroTrauma Department, 503 Robert Grant Avenue Silver Spring, MD 20910, USA.
| | - Charles R Auker
- Naval Medical Research Center, NeuroTrauma Department, 503 Robert Grant Avenue Silver Spring, MD 20910, USA.
| | - Francoise G Arnaud
- Naval Medical Research Center, NeuroTrauma Department, 503 Robert Grant Avenue Silver Spring, MD 20910, USA; Uniformed Services University of the Health Sciences, Department of Surgery, Bethesda, MD 20814, USA.
| | - Richard M McCarron
- Naval Medical Research Center, NeuroTrauma Department, 503 Robert Grant Avenue Silver Spring, MD 20910, USA; Uniformed Services University of the Health Sciences, Department of Surgery, Bethesda, MD 20814, USA.
| | - Anke H Scultetus
- Naval Medical Research Center, NeuroTrauma Department, 503 Robert Grant Avenue Silver Spring, MD 20910, USA; Uniformed Services University of the Health Sciences, Department of Surgery, Bethesda, MD 20814, USA.
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Kessel B, Alfici R, Korin A, Olsha O, Dudkiewicz M, Oren M. Real time cerebral perfusion monitoring in acute trauma patients: a preliminary study. ANZ J Surg 2016; 86:598-601. [PMID: 26924545 DOI: 10.1111/ans.13461] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2015] [Indexed: 01/07/2023]
Affiliation(s)
- Boris Kessel
- Trauma Unit; Hillel Yaffe Medical Center; Hadera Israel
| | - Ricardo Alfici
- Surgical Division; Hillel Yaffe Medical Center; Hadera Israel
| | | | - Oded Olsha
- Surgery Department; Shaare Zedek Medical Center; Jerusalem Israel
| | | | - Meir Oren
- Hospital Administration; Hillel Yaffe Medical Center; Hadera Israel
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Taher A, Pilehvari Z, Poorolajal J, Aghajanloo M. Effects of Normobaric Hyperoxia in Traumatic Brain Injury: A Randomized Controlled Clinical Trial. Trauma Mon 2016; 21:e26772. [PMID: 27218057 PMCID: PMC4869427 DOI: 10.5812/traumamon.26772] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 11/21/2015] [Indexed: 01/22/2023] Open
Abstract
Background Traumatic brain injury (TBI) is one of the important causes of morbidity and mortality throughout the world, especially in young people. In recent years normobaric hyperoxia has become an important and useful step for recovery and improvement of outcome in TBI. Objectives The purpose of this study was to evaluate the effects of normobaric hyperoxia on clinical neurological outcomes of patients with severe traumatic brain injuries. We used the Glasgow outcome scale (GOS), barthel index, and modified rankin scale (mRS) to measure the outcomes of patients with TBI. Patients and Methods Sixty-eight consecutive patients with severe TBI (mean Glasgow coma scale [GCS] score: 7.4) who met the inclusion criteria were entered in this randomized controlled clinical trial. The patients were randomized into two groups, as follows: 1) experimental: received 80% oxygen via mechanical ventilator in the first 6 hours of admission, 2) control: received 50% oxygen by mechanical ventilator in the first 6 hours of admission and then standard medical care. We measured the GOS, Barthel Index, and mRS at the time of discharge from hospital and reassessed these measurements at the 6-month follow-up after injury. Results According to our study, there were no significant sex or age differences between the two groups (P = 0.595 and 0.074). The number of days in the intensive care unit (ICU) in the control group and experimental group were 11.4 and 9.4 days, respectively (P = 0.28), while the numbers of days of general ward admission were 13.9 and 11.4 days (P = 0.137) respectively. The status of GOS at time of discharge were severe = 13 and 10, moderate = 16 and 19, and low = 5 and 5 in the control and experimental groups, respectively (P = 0.723); 6 months after injury, the scores were as follows: moderate = 16 and 9, low = 15 and 25, and severe = 3 and 0 (P = 0.024). The Barthel index scores in the control and experimental groups were 59.7 and 63.9 at time of discharge (P = 0.369) and 82.7 and 91.3 at 6 months after injury (P = 0.018), respectively. The mRS results were 2.6 and 2.3 at time of discharge (P = 0.320) and 1.6 and 0.7 at 6 months after injury (P = 0.006) for the control and experimental groups, respectively. Conclusions According to the results of this study, oxygen therapy by mechanical ventilator in the first 6 hours after injury in patients with severe TBI can improve the final GOS, Barthel index, and mRS scores. It could also improve long-term outcomes and enhance rehabilitation and the quality of life.
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Affiliation(s)
- Abbas Taher
- Department of Anesthesiology and Critical Care, Hamadan University of Medical Sciences, Hamadan, IR Iran
| | - Zahra Pilehvari
- Department of Anesthesiology and Critical Care, Hamadan University of Medical Sciences, Hamadan, IR Iran
- Corresponding author: Zahra Pilehvari, Department of Anesthesiology and Critical Care, Besat Hospital, Hamadan University of Medical Sciences, Hamadan, IR Iran. Tel: +98-9123878776, Fax: +98-2177053308, E-mail:
| | - Jalal Poorolajal
- Department of Epidemiology, Modeling of Noncommunicable Diseases Research Center, School of Public Health, Hamadan University of Medical Sciences, Hamadan, IR Iran
| | - Mashhood Aghajanloo
- Department of Neurosurgery, Hamadan University of Medical Sciences, Hamadan, IR Iran
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77
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Bellapart J, Cuthbertson K, Dunster K, Diab S, Platts DG, Raffel OC, Gabrielian L, Barnett A, Paratz J, Boots R, Fraser JF. Cerebral Microcirculation during Experimental Normovolaemic Anemia. Front Neurol 2016; 7:6. [PMID: 26869986 PMCID: PMC4735869 DOI: 10.3389/fneur.2016.00006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 01/14/2016] [Indexed: 11/13/2022] Open
Abstract
Anemia is accepted among critically ill patients as an alternative to elective blood transfusion. This practice has been extrapolated to head injury patients with only one study comparing the effects of mild anemia on neurological outcome. There are no studies quantifying microcirculation during anemia. Experimental studies suggest that anemia leads to cerebral hypoxia and increased rates of infarction, but the lack of clinical equipoise, when testing the cerebral effects of transfusion among critically injured patients, supports the need of experimental studies. The aim of this study was to quantify cerebral microcirculation and the potential presence of axonal damage in an experimental model exposed to normovolaemic anemia, with the intention of describing possible limitations within management practices in critically ill patients. Under non-recovered anesthesia, six Merino sheep were instrumented using an intracardiac transeptal catheter to inject coded microspheres into the left atrium to ensure systemic and non-chaotic distribution. Cytometric analyses quantified cerebral microcirculation at specific regions of the brain. Amyloid precursor protein staining was used as an indicator of axonal damage. Animals were exposed to normovolaemic anemia by blood extractions from the indwelling arterial catheter with simultaneous fluid replacement through a venous central catheter. Simultaneous data recording from cerebral tissue oxygenation, intracranial pressure, and cardiac output was monitored. A regression model was used to examine the effects of anemia on microcirculation with a mixed model to control for repeated measures. Homogeneous and normal cerebral microcirculation with no evidence of axonal damage was present in all cerebral regions, with no temporal variability, concluding that acute normovolaemic anemia does not result in short-term effects on cerebral microcirculation in the ovine brain.
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Affiliation(s)
- Judith Bellapart
- Department of Intensive Care, Royal Brisbane and Women's Hospital , Herston, QLD , Australia
| | - Kylie Cuthbertson
- Department of Intensive Care, Royal Brisbane and Women's Hospital , Herston, QLD , Australia
| | - Kimble Dunster
- Critical Care Research Group, University of Queensland, St Lucia, QLD, Australia; Medical Engineering Research Facility, Queensland University of Technology, Brisbane, QLD, Australia
| | - Sara Diab
- Critical Care Research Group, University of Queensland, St Lucia, QLD, Australia; Medical Engineering Research Facility, Queensland University of Technology, Brisbane, QLD, Australia
| | - David G Platts
- Medical Engineering Research Facility, Queensland University of Technology, Brisbane, QLD, Australia; Department of Cardiology, The Prince Charles Hospital, Chermside, QLD, Australia
| | - O Christopher Raffel
- Medical Engineering Research Facility, Queensland University of Technology, Brisbane, QLD, Australia; Department of Cardiology, The Prince Charles Hospital, Chermside, QLD, Australia
| | - Levon Gabrielian
- Medical Research Centre, Medical School, University of South Australia , Adelaide, SA , Australia
| | - Adrian Barnett
- Medical Engineering Research Facility, Queensland University of Technology, Brisbane, QLD, Australia; School of Public Health and Social Work, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia
| | - Jenifer Paratz
- Department of Intensive Care, Royal Brisbane and Women's Hospital , Herston, QLD , Australia
| | - Rob Boots
- Department of Intensive Care, Royal Brisbane and Women's Hospital , Herston, QLD , Australia
| | - John F Fraser
- Critical Care Research Group, University of Queensland, St Lucia, QLD, Australia; Medical Engineering Research Facility, Queensland University of Technology, Brisbane, QLD, Australia; School of Public Health and Social Work, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia; Department of Intensive Care, The Prince Charles Hospital, Chermside, QLD, Australia
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Perfluorocarbon NVX-108 increased cerebral oxygen tension after traumatic brain injury in rats. Brain Res 2016; 1634:132-139. [PMID: 26794250 DOI: 10.1016/j.brainres.2016.01.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Revised: 12/23/2015] [Accepted: 01/08/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND Hypoxia is a critical secondary injury mechanism in traumatic brain injury (TBI), and early intervention to alleviate post-TBI hypoxia may be beneficial. NVX-108, a dodecafluoropentane perfluorocarbon, was screened for its ability to increase brain tissue oxygen tension (PbtO2) when administered soon after TBI. METHODS Ketamine-acepromazine anesthetized rats ventilated with 40% oxygen underwent moderate controlled cortical impact (CCI)-TBI at time 0 (T0). Rats received either no treatment (NON, n=8) or 0.5 ml/kg intravenous (IV) NVX-108 (NVX, n=9) at T15 (15 min after TBI) and T75. RESULTS Baseline cortical PbtO2 was 28±3 mm Hg and CCI-TBI resulted in a 46±6% reduction in PbtO2 at T15 (P<0.001). Significant differences in time-group interactions (P=0.013) were found when comparing either absolute or percentage change of PbtO2 to post-injury (mixed-model ANOVA) suggesting that administration of NVX-108 increased PbtO2 above injury levels while it remained depressed in the NON group. Specifically in the NVX group, PbtO2 increased to a peak 143% of T15 (P=0.02) 60 min after completion of NVX-108 injection (T135). Systemic blood pressure was not different between the groups. CONCLUSION NVX-108 caused an increase in PbtO2 following CCI-TBI in rats and should be evaluated further as a possible immediate treatment for TBI.
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79
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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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80
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Wang F, Wang Y, Sun T, Yu HL. Hyperbaric oxygen therapy for the treatment of traumatic brain injury: a meta-analysis. Neurol Sci 2016; 37:693-701. [PMID: 26746238 DOI: 10.1007/s10072-015-2460-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Accepted: 12/21/2015] [Indexed: 10/22/2022]
Abstract
Compelling evidence suggests the advantage of hyperbaric oxygen therapy (HBOT) in traumatic brain injury. The present meta-analysis evaluated the outcomes of HBOT in patients with traumatic brain injury (TBI). Prospective studies comparing hyperbaric oxygen therapy vs. control in patients with mild (GCS 13-15) to severe (GCS 3-8) TBI were hand-searched from medical databases using the terms "hyperbaric oxygen therapy, traumatic brain injury, and post-concussion syndrome". Glasgow coma scale (GCS) was the primary outcome, while Glasgow outcome score (GOS), overall mortality, and changes in post-traumatic stress disorder (PTSD) score, constituted the secondary outcomes. The results of eight studies (average age of patients, 23-41 years) reveal a higher post-treatment GCS score in the HBOT group (pooled difference in means = 3.13, 95 % CI 2.34-3.92, P < 0.001), in addition to greater improvement in GOS and lower mortality, as compared to the control group. However, no significant change in the PTSD score was observed. Patients undergoing hyperbaric therapy achieved significant improvement in the GCS and GOS with a lower overall mortality, suggesting its utility as a standard intensive care regimen in traumatic brain injury.
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Affiliation(s)
- Fei Wang
- The Second Department of Neurosurgery, First Affiliated Hospital of Kunming Medical University, 295 Xichang Rd, Kunming, Yunnan, 650032, China
| | - Yong Wang
- The Second Department of Neurosurgery, First Affiliated Hospital of Kunming Medical University, 295 Xichang Rd, Kunming, Yunnan, 650032, China
| | - Tao Sun
- The Second Department of Neurosurgery, First Affiliated Hospital of Kunming Medical University, 295 Xichang Rd, Kunming, Yunnan, 650032, China
| | - Hua-Lin Yu
- The Second Department of Neurosurgery, First Affiliated Hospital of Kunming Medical University, 295 Xichang Rd, Kunming, Yunnan, 650032, China.
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Makarenko S, Griesdale DE, Gooderham P, Sekhon MS. Multimodal neuromonitoring for traumatic brain injury: A shift towards individualized therapy. J Clin Neurosci 2016; 26:8-13. [PMID: 26755455 DOI: 10.1016/j.jocn.2015.05.065] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Accepted: 05/30/2015] [Indexed: 01/08/2023]
Abstract
Multimodal neuromonitoring in the management of traumatic brain injury (TBI) enables clinicians to make individualized management decisions to prevent secondary ischemic brain injury. Traditionally, neuromonitoring in TBI patients has consisted of a combination of clinical examination, neuroimaging and intracranial pressure monitoring. Unfortunately, each of these modalities has its limitations and although pragmatic, this simplistic approach has failed to demonstrate improved outcomes, likely owing to an inability to consider the underlying heterogeneity of various injury patterns. As neurocritical care has evolved, so has our understanding of underlying disease pathophysiology and patient specific considerations. Recent additions to the multimodal neuromonitoring platform include measures of cerebrovascular autoregulation, brain tissue oxygenation, microdialysis and continuous electroencephalography. The implementation of neurocritical care teams to manage patients with advanced brain injury has led to improved outcomes. Herein, we present a narrative review of the recent advances in multimodal neuromonitoring and highlight the utility of dedicated neurocritical care.
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Affiliation(s)
- Serge Makarenko
- Division of Neurosurgery, Department of Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Donald E Griesdale
- Department of Anaesthesiology, Pharmacology and Therapeutics, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada; Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada; Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, Room 2438, Jim Pattison Pavilion, 2nd Floor, 899 West 12th Avenue, University of British Columbia, Vancouver, BC V5Z 1M9, Canada
| | - Peter Gooderham
- Division of Neurosurgery, Department of Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, Room 2438, Jim Pattison Pavilion, 2nd Floor, 899 West 12th Avenue, University of British Columbia, Vancouver, BC V5Z 1M9, Canada.
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82
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Schrieff-Elson LE, Thomas KGF, Rohlwink UK, Figaji AA. Low brain oxygenation and differences in neuropsychological outcomes following severe pediatric TBI. Childs Nerv Syst 2015; 31:2257-68. [PMID: 26337700 DOI: 10.1007/s00381-015-2892-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 08/24/2015] [Indexed: 11/27/2022]
Abstract
PURPOSE Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in children. Preventing secondary injury by controlling physiological parameters (e.g. intracranial pressure [ICP], cerebral perfusion pressure [CPP] and brain tissue oxygen [PbtO2]) has a potential to improve outcome. Low PbtO2 is independently associated with poor clinical outcomes in both adults and children. However, no studies have investigated associations between low PbtO2 and neuropsychological and behavioural outcomes following severe pediatric TBI (pTBI). METHODS We used a quasi-experimental case-control design to investigate these relationships. A sample of 11 TBI patients with a Glasgow Coma Scale score ≤8 who had PbtO2 and ICP monitoring at the Red Cross War Memorial Children's Hospital underwent neuropsychological evaluation ≥1 year post-injury. Their performance was compared to that of 11 demographically matched healthy controls. We then assigned each TBI participant into one of two subgroups, (1) children who had experienced at least one episode of PbtO2 ≤ 10 mmHg or (2) children for whom PbtO2 > 10 mmHg throughout the monitoring period, and compared their results on neuropsychological evaluation. RESULTS TBI participants performed significantly more poorly than controls in several cognitive domains (IQ, attention, visual memory, executive functions and expressive language) and behavioural (e.g. externalizing behaviour) domains. The PbtO2 ≤ 10 mmHg group performed significantly worse than the PbtO2 > 10 mmHg group in several cognitive domains (IQ, attention, verbal memory, executive functions and expressive language), but not on behavioural measures. CONCLUSION Results demonstrate that low PbtO2 may be prognostic of not only mortality but also neuropsychological outcomes.
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Affiliation(s)
- L E Schrieff-Elson
- ACSENT Laboratory, Department of Psychology, University of Cape Town, Cape Town, South Africa.
| | - K G F Thomas
- ACSENT Laboratory, Department of Psychology, University of Cape Town, Cape Town, South Africa
| | - U K Rohlwink
- Division of Neurosurgery, Department of Surgery, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - A A Figaji
- Division of Neurosurgery, Department of Surgery, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
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83
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Galgano MA, Tovar-Spinoza Z. Multimodality Neuromonitoring in Pediatric Neurocritical Care: Review of the Current Resources. Cureus 2015; 7:e385. [PMID: 26719828 PMCID: PMC4689558 DOI: 10.7759/cureus.385] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Brain insults in children represent a daily challenge in neurocritical care. Having a constant grasp on various parameters in the pediatric injured brain may affect the patient's outcome. Currently, new advances provide clinicians with the ability to utilize several modalities to monitor brain function. This multi-modal approach allows real-time information, leading to faster responses in management and furthermore avoiding secondary insults in the injured brain.
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84
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Monitoring of hematological and hemostatic parameters in neurocritical care patients. Neurocrit Care 2015; 21 Suppl 2:S168-76. [PMID: 25208669 DOI: 10.1007/s12028-014-0023-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Anemia and bleeding are paramount concerns in neurocritical care and often relate to the severity of intracranial hemorrhage. Anemia is generally associated with worse outcomes, and efforts to minimize anemia through reduced volume of blood sampled are encouraged. Point-of-care-testing reliably detects the use of non-steroidal anti-inflammatory drugs that may worsen bleeding and reduce platelet activity, particularly in patients with intracerebral hemorrhage. How best to monitor the effect of platelet transfusion or platelet-activating therapy is not well studied. For patients known to take novel oral anticoagulants, drug-specific coagulation tests before neurosurgical intervention are prudent.
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85
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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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87
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Kerz T, Beyer C, Huthmann A, Kalasauskas D, Amr AN, Boor S, Welschehold S. Continuous-wave near-infrared spectroscopy is not related to brain tissue oxygen tension. J Clin Monit Comput 2015; 30:641-7. [DOI: 10.1007/s10877-015-9755-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Accepted: 08/17/2015] [Indexed: 01/21/2023]
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De Santis V, Singer M. Tissue oxygen tension monitoring of organ perfusion: rationale, methodologies, and literature review. Br J Anaesth 2015. [PMID: 26198717 DOI: 10.1093/bja/aev162] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Tissue oxygen tension is the partial pressure of oxygen within the interstitial space of an organ bed. As it represents the balance between local oxygen delivery and consumption at any given time, it offers a ready monitoring capability to assess the adequacy of tissue perfusion relative to local demands. This review covers the various methodologies used to measure tissue oxygen tension, describes the underlying physiological and pathophysiological principles, and summarizes human and laboratory data published to date.
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Affiliation(s)
- V De Santis
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, Cruciform Building, Gower Street, London WC1E 6BT, UK
| | - M Singer
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, Cruciform Building, Gower Street, London WC1E 6BT, UK
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89
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Skendelas JP, Muccigrosso M, Eiferman DS, Godbout JP. Chronic Inflammation After TBI and Associated Behavioral Sequelae. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2015. [DOI: 10.1007/s40141-015-0091-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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90
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Caldwell M, Hapuarachchi T, Highton D, Elwell C, Smith M, Tachtsidis I. BrainSignals Revisited: Simplifying a Computational Model of Cerebral Physiology. PLoS One 2015; 10:e0126695. [PMID: 25961297 PMCID: PMC4427507 DOI: 10.1371/journal.pone.0126695] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Accepted: 04/07/2015] [Indexed: 02/06/2023] Open
Abstract
Multimodal monitoring of brain state is important both for the investigation of healthy cerebral physiology and to inform clinical decision making in conditions of injury and disease. Near-infrared spectroscopy is an instrument modality that allows non-invasive measurement of several physiological variables of clinical interest, notably haemoglobin oxygenation and the redox state of the metabolic enzyme cytochrome c oxidase. Interpreting such measurements requires the integration of multiple signals from different sources to try to understand the physiological states giving rise to them. We have previously published several computational models to assist with such interpretation. Like many models in the realm of Systems Biology, these are complex and dependent on many parameters that can be difficult or impossible to measure precisely. Taking one such model, BrainSignals, as a starting point, we have developed several variant models in which specific regions of complexity are substituted with much simpler linear approximations. We demonstrate that model behaviour can be maintained whilst achieving a significant reduction in complexity, provided that the linearity assumptions hold. The simplified models have been tested for applicability with simulated data and experimental data from healthy adults undergoing a hypercapnia challenge, but relevance to different physiological and pathophysiological conditions will require specific testing. In conditions where the simplified models are applicable, their greater efficiency has potential to allow their use at the bedside to help interpret clinical data in near real-time.
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Affiliation(s)
- Matthew Caldwell
- Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Tharindi Hapuarachchi
- Department of Medical Physics and Biomedical Engineering, University College London, London, UK
- Centre for Mathematics and Physics in the Life Sciences and Experimental Biology, University College London, London, UK
| | - David Highton
- Neurocritical Care Unit, University College Hospitals, London, UK
| | - Clare Elwell
- Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Martin Smith
- Neurocritical Care Unit, University College Hospitals, London, UK
| | - Ilias Tachtsidis
- Department of Medical Physics and Biomedical Engineering, University College London, London, UK
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91
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Neuroprotection in acute brain injury: an up-to-date review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:186. [PMID: 25896893 PMCID: PMC4404577 DOI: 10.1186/s13054-015-0887-8] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Neuroprotective strategies that limit secondary tissue loss and/or improve functional outcomes have been identified in multiple animal models of ischemic, hemorrhagic, traumatic and nontraumatic cerebral lesions. However, use of these potential interventions in human randomized controlled studies has generally given disappointing results. In this paper, we summarize the current status in terms of neuroprotective strategies, both in the immediate and later stages of acute brain injury in adults. We also review potential new strategies and highlight areas for future research.
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Abstract
Neuromonitoring aims to detect harmful physiologic events, early enough to guide the treatment instituted. Evidences encourage us to implement multimodal monitoring, as no single monitor is capable of providing a complete picture of dynamic cerebral state. This review highlights the role of intracranial pressure monitoring, cerebral oxygenation (jugular venous oximetry, brain tissue oxygenation, near infrared oximetry, cerebral microdialysis) and cerebral blood flow monitoring (direct and indirect methods) in the management of neurologically injured patients. In this context, the recent developments of these monitors along with the relevant clinical implications have been discussed. Nevertheless, the diverse range of data obtained from these monitors needs to be integrated and simplified for the clinician. Hence, the future research should focus on identification of a most useful monitor for integration into multimodal system.
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Affiliation(s)
- Charu Mahajan
- Department of Neuroanaesthesiology, All India Institute of Medical Sciences, New Delhi, India
| | - Girija Prasad Rath
- Department of Neuroanaesthesiology, All India Institute of Medical Sciences, New Delhi, India
| | - Parmod Kumar Bithal
- Department of Neuroanaesthesiology, All India Institute of Medical Sciences, New Delhi, India
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Davies DJ, Su Z, Clancy MT, Lucas SJE, Dehghani H, Logan A, Belli A. Near-Infrared Spectroscopy in the Monitoring of Adult Traumatic Brain Injury: A Review. J Neurotrauma 2015; 32:933-41. [PMID: 25603012 DOI: 10.1089/neu.2014.3748] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Cerebral near-infrared spectroscopy (NIRS) has long represented an exciting prospect for the noninvasive monitoring of cerebral tissue oxygenation and perfusion in the context of traumatic brain injury (TBI), although uncertainty still exists regarding the reliability of this technology specifically within this field. We have undertaken a review of the existing literature relating to the application of NIRS within TBI. We discuss current "state-of-the-art" NIRS monitoring, provide a brief background of the technology, and discuss the evidence regarding the ability of NIRS to substitute for established invasive monitoring in TBI.
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Affiliation(s)
- David J Davies
- 1 Department of Neurosurgery Clinical Research, Queen Elizabeth Hospital , Edgbaston, Birmingham, United Kingdom
| | - Zhangjie Su
- 1 Department of Neurosurgery Clinical Research, Queen Elizabeth Hospital , Edgbaston, Birmingham, United Kingdom
| | - Michael T Clancy
- 2 School of Computational Science Medical Imaging Group, University of Birmingham , Edgbaston, Birmingham, United Kingdom
| | - Samuel J E Lucas
- 3 Department of Exercise Physiology, School of Sport, Exercise, and Rehabilitation Sciences, University of Birmingham , Edgbaston, Birmingham, United Kingdom
| | - Hamid Dehghani
- 4 Department of Medical Imaging, School of Computer Science, University of Birmingham , Edgbaston, Birmingham, United Kingdom
| | - Ann Logan
- 5 Department of Molecular Neuroscience, School of Clinical and Experimental Medicine, University of Birmingham , Edgbaston, Birmingham, United Kingdom
| | - Antonio Belli
- 6 Department of Surgical Neurology, National Institute for Health Research, Queen Elizabeth Hospital , Edgbaston, Birmingham, United Kingdom
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94
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Propagation of damage in brain tissue: coupling the mechanics of oedema and oxygen delivery. Biomech Model Mechanobiol 2015; 14:1197-216. [DOI: 10.1007/s10237-015-0665-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 03/05/2015] [Indexed: 11/26/2022]
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95
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Windowed multitaper correlation analysis of multimodal brain monitoring parameters. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2015; 2015:124325. [PMID: 25821507 PMCID: PMC4363616 DOI: 10.1155/2015/124325] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 02/16/2015] [Indexed: 11/18/2022]
Abstract
Although multimodal monitoring sets the standard in daily practice of neurocritical care, problem-oriented analysis tools to interpret the huge amount of data are lacking. Recently a mathematical model was presented that simulates the cerebral perfusion and oxygen supply in case of a severe head trauma, predicting the appearance of distinct correlations between arterial blood pressure and intracranial pressure. In this study we present a set of mathematical tools that reliably detect the predicted correlations in data recorded at a neurocritical care unit. The time resolved correlations will be identified by a windowing technique combined with Fourier-based coherence calculations. The phasing of the data is detected by means of Hilbert phase difference within the above mentioned windows. A statistical testing method is introduced that allows tuning the parameters of the windowing method in such a way that a predefined accuracy is reached. With this method the data of fifteen patients were examined in which we found the predicted correlation in each patient. Additionally it could be shown that the occurrence of a distinct correlation parameter, called scp, represents a predictive value of high quality for the patients outcome.
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96
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Preservation of the blood brain barrier and cortical neuronal tissue by liraglutide, a long acting glucagon-like-1 analogue, after experimental traumatic brain injury. PLoS One 2015; 10:e0120074. [PMID: 25822252 PMCID: PMC4379006 DOI: 10.1371/journal.pone.0120074] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 02/02/2015] [Indexed: 01/04/2023] Open
Abstract
Cerebral edema is a common complication following moderate and severe traumatic brain injury (TBI), and a significant risk factor for development of neuronal death and deterioration of neurological outcome. To this date, medical approaches that effectively alleviate cerebral edema and neuronal death after TBI are not available. Glucagon-like peptide-1 (GLP-1) has anti-inflammatory properties on cerebral endothelium and exerts neuroprotective effects. Here, we investigated the effects of GLP-1 on secondary injury after moderate and severe TBI. Male Sprague Dawley rats were subjected either to TBI by Controlled Cortical Impact (CCI) or sham surgery. After surgery, vehicle or a GLP-1 analogue, Liraglutide, were administered subcutaneously twice daily for two days. Treatment with Liraglutide (200 μg/kg) significantly reduced cerebral edema in pericontusional regions and improved sensorimotor function 48 hours after CCI. The integrity of the blood-brain barrier was markedly preserved in Liraglutide treated animals, as determined by cerebral extravasation of Evans blue conjugated albumin. Furthermore, Liraglutide reduced cortical tissue loss, but did not affect tissue loss and delayed neuronal death in the thalamus on day 7 post injury. Together, our data suggest that the GLP-1 pathway might be a promising target in the therapy of cerebral edema and cortical neuronal injury after moderate and severe TBI.
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97
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Sheriff FG, Hinson HE. Pathophysiology and clinical management of moderate and severe traumatic brain injury in the ICU. Semin Neurol 2015; 35:42-9. [PMID: 25714866 DOI: 10.1055/s-0035-1544238] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Moderate and severe traumatic brain injury (TBI) is the leading cause of morbidity and mortality among young individuals in high-income countries. Its pathophysiology is divided into two major phases: the initial neuronal injury (or primary injury) followed by secondary insults (secondary injury). Multimodality monitoring now offers neurointensivists the ability to monitor multiple physiologic parameters that act as surrogates of brain ischemia and hypoxia, the major driving forces behind secondary brain injury. The heterogeneity of the pathophysiology of TBI makes it necessary to take into consideration these interacting physiologic factors when recommending for or against any therapies; it may also account for the failure of all the neuroprotective therapies studied so far. In this review, the authors focus on neuroclinicians and neurointensivists, and discuss the developments in therapeutic strategies aimed at optimizing intracranial pressure and cerebral perfusion pressure, and minimizing cerebral hypoxia. The management of moderate to severe TBI in the intensive care unit is moving away from a pure "threshold-based" treatment approach toward consideration of patient-specific characteristics, including the state of cerebral autoregulation. The authors also include a concise discussion on the management of medical and neurologic complications peculiar to TBI as well as an overview of prognostication.
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Affiliation(s)
- Faheem G Sheriff
- Department of Neurology, Oregon Health Science University, Portland, Oregon
| | - Holly E Hinson
- Department of Neurology, Oregon Health Science University, Portland, Oregon
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Kowoll CM, Dohmen C, Kahmann J, Dziewas R, Schirotzek I, Sakowitz OW, Bösel J. Standards of scoring, monitoring, and parameter targeting in German neurocritical care units: a national survey. Neurocrit Care 2014; 20:176-86. [PMID: 23979795 DOI: 10.1007/s12028-013-9893-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Optimal management of physiological parameters in neurological/neurosurgical intensive care units (NICUs) is largely unclear as high-quality evidence is lacking. The aim of this survey was to investigate if standards exist in the use of clinical scores, systemic and cerebral monitoring and the targeting of physiology values and in what way this affects clinical management in German NICUs. METHODS National survey, on-line anonymized questionnaire. German departments stating to run a neurological, neurosurgical or interdisciplinary neurological/neurosurgical intensive care unit were identified by a web-based search of all German hospitals and contacted via email. RESULTS Responses from 78 German NICUs were obtained. Of 19 proposed clinical/laboratory/radiological scores only 5 were used regularly by >60 %. Bedside neuromonitoring (NM) predominantly consisted of transcranial Doppler sonography (94 %), electroencephalography (92 %) and measurement of intracranial pressure (ICP) (90 %), and was installed if patients had or were threatened by elevated ICP (86 %), had specific diseases like subarachnoid hemorrhage (51 %) or were comatose (35 %). Although mean trigger values for interventions complied with guidelines or wide-spread customs, individual trigger values varied widely, e.g., for hyperglycemia (maximum blood glucose between 120 and 250 mg/dl) or for anemia (minimum hemoglobin values between 5 and 10 g/dl). CONCLUSIONS Although apparently aiming for standardization in neurocritical care, German NICUs show substantial differences in NM and monitoring-associated interventions. In terms of scoring and monitoring methods, German NICUs seem to be quite conservative. These survey results suggest a need of prospective and randomized interventional trials in neurocritical care to help define standards and target values.
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Affiliation(s)
- C M Kowoll
- Department of Neurology, University Hospital of Köln, Cologne, Germany
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Abstract
PURPOSE OF REVIEW Increased intracranial pressure (ICP) is associated with worse outcome after traumatic brain injury (TBI), but whether its management improves the outcome is unclear. In this review, we will examine the implications of the Benchmark Evidence from South American Trials: Treatment of Intracranial Pressure (BEST TRIP) trial, evidence for an influence of ICP care on outcome, and a need for greater understanding of the pathophysiology than just ICP through multimodal monitoring (MMM) to enhance the outcome. RECENT FINDINGS The primary impact of the BEST TRIP trial, a randomized clinical trial that examined two TBI management strategies, one that used an ICP monitor, is in research and should not alter clinical practice. Analyses of large databases suggest TBI care based on the Brain Trauma Foundation guidelines and management of intracranial hypertension can improve patient outcome. However, accumulating evidence demonstrates there are several mechanisms of secondary brain injury (SBI), for example, microvascular dysfunction or alterations in glucose utilization that cannot be detected using an ICP monitor. In these patients, growing clinical evidence suggests that MMM can help manage SBI and improve TBI outcome. SUMMARY ICP-based monitoring and treatment alone may not be enough to enhance TBI outcome, but ICP and cerebral perfusion pressure therapy remain important in TBI care. Although high-quality evidence for MMM is limited, it should be more widely adapted to better understand the complex pathophysiology after TBI, better target care, and identify new therapeutic opportunities.
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Narotam PK, Morrison JF, Schmidt MD, Nathoo N. Physiological complexity of acute traumatic brain injury in patients treated with a brain oxygen protocol: utility of symbolic regression in predictive modeling of a dynamical system. J Neurotrauma 2014; 31:630-41. [PMID: 24195645 DOI: 10.1089/neu.2013.3104] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Predictive modeling of emergent behavior, inherent to complex physiological systems, requires the analysis of large complex clinical data streams currently being generated in the intensive care unit. Brain tissue oxygen protocols have yielded outcome benefits in traumatic brain injury (TBI), but the critical physiological thresholds for low brain oxygen have not been established for a dynamical patho-physiological system. High frequency, multi-modal clinical data sets from 29 patients with severe TBI who underwent multi-modality neuro-clinical care monitoring and treatment with a brain oxygen protocol were analyzed. The inter-relationship between acute physiological parameters was determined using symbolic regression (SR) as the computational framework. The mean patient age was 44.4±15 with a mean admission GCS of 6.6±3.9. Sixty-three percent sustained motor vehicle accidents and the most common pathology was intra-cerebral hemorrhage (50%). Hospital discharge mortality was 21%, poor outcome occurred in 24% of patients, and good outcome occurred in 56% of patients. Criticality for low brain oxygen was intracranial pressure (ICP) ≥22.8 mm Hg, for mortality at ICP≥37.1 mm Hg. The upper therapeutic threshold for cerebral perfusion pressure (CPP) was 75 mm Hg. Eubaric hyperoxia significantly impacted partial pressure of oxygen in brain tissue (PbtO2) at all ICP levels. Optimal brain temperature (Tbr) was 34-35°C, with an adverse effect when Tbr≥38°C. Survivors clustered at [Formula: see text] Hg vs. non-survivors [Formula: see text] 18 mm Hg. There were two mortality clusters for ICP: High ICP/low PbtO2 and low ICP/low PbtO2. Survivors maintained PbtO2 at all ranges of mean arterial pressure in contrast to non-survivors. The final SR equation for cerebral oxygenation is: [Formula: see text]. The SR-model of acute TBI advances new physiological thresholds or boundary conditions for acute TBI management: PbtO2≥25 mmHg; ICP≤22 mmHg; CPP≈60-75 mmHg; and Tbr≈34-37°C. SR is congruous with the emerging field of complexity science in the modeling of dynamical physiological systems, especially during pathophysiological states. The SR model of TBI is generalizable to known physical laws. This increase in entropy reduces uncertainty and improves predictive capacity. SR is an appropriate computational framework to enable future smart monitoring devices.
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