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Kommentar zu: Erythropoetingabe und Transfusionsregime nach Schädel-Hirn-Trauma. Anaesthesist 2014; 63:793-4. [DOI: 10.1007/s00101-014-2367-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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102
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Role of microvascular shunts in the loss of cerebral blood flow autoregulation. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2014. [PMID: 24729213 DOI: 10.1007/978-1-4939-0620-8_6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register]
Abstract
Historically, determination of the critical cerebral perfusion pressure (CPP) was done in animals by a progressive lowering of arterial pressure yielding a nominal critical CPP of 60 mmHg. Subsequently, it was shown that if the CPP was decreased by increasing intracranial pressure (ICP), critical CPP fell to 30 mmHg. This discrepancy was unexplained. We recently provided evidence that the decrease in critical CPP was due to microvascular shunting resulting in maintained cerebral blood flow (CBF) at a lower CPP. We demonstrated by a progressive increase in ICP in rats using two-photon laser scanning microscopy (2PLSM) that the transition from capillary to microvascular shunt flow is a pathological process. We surmise that the loss of CBF autoregulation revealed by decreasing arterial pressure occurs by dilation of normal cerebral blood vessels whereas that which occurs by increasing ICP is due to microvascular shunting. Our observations indicate that the loss of CBF autoregulation we observed in brain injured patients that changes on an hourly or daily basis reflects an important pathophysiological process impacting on outcome that remains to be determined.
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103
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Nature has no principle-inflammation following brain injury is neither good nor evil*. Crit Care Med 2014; 42:1958-9. [PMID: 25029142 DOI: 10.1097/ccm.0000000000000479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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104
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Lee JH, Wei L, Gu X, Wei Z, Dix TA, Yu SP. Therapeutic effects of pharmacologically induced hypothermia against traumatic brain injury in mice. J Neurotrauma 2014; 31:1417-30. [PMID: 24731132 DOI: 10.1089/neu.2013.3251] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Preclinical and clinical studies have shown therapeutic potential of mild-to-moderate hypothermia for treatments of stroke and traumatic brain injury (TBI). Physical cooling in humans, however, is usually slow, cumbersome, and necessitates sedation that prevents early application in clinical settings and causes several side effects. Our recent study showed that pharmacologically induced hypothermia (PIH) using a novel neurotensin receptor 1 (NTR1) agonist, HPI-201 (also known as ABS-201), is efficient and effective in inducing therapeutic hypothermia and protecting the brain from ischemic and hemorrhagic stroke in mice. The present investigation tested another second-generation NTR1 agonist, HPI-363, for its hypothermic and protective effect against TBI. Adult male mice were subjected to controlled cortical impact (CCI) (velocity=3 m/sec, depth=1.0 mm, contact time=150 msec) to the exposed cortex. Intraperitoneal administration of HPI-363 (0.3 mg/kg) reduced body temperature by 3-5°C within 30-60 min without triggering a shivering defensive reaction. An additional two injections sustained the hypothermic effect in conscious mice for up to 6 h. This PIH treatment was initiated 15, 60, or 120 min after the onset of TBI, and significantly reduced the contusion volume measured 3 days after TBI. HPI-363 attenuated caspase-3 activation, Bax expression, and TUNEL-positive cells in the pericontusion region. In blood-brain barrier assessments, HPI-363 ameliorated extravasation of Evans blue dye and immunoglobulin G, attenuated the MMP-9 expression, and decreased the number of microglia cells in the post-TBI brain. HPI-363 decreased the mRNA expression of tumor necrosis factor-α and interleukin-1β (IL-1β), but increased IL-6 and IL-10 levels. Compared with TBI control mice, HPI-363 treatments improved sensorimotor functional recovery after TBI. These findings suggest that the second generation NTR-1 agonists, such as HPI-363, are efficient hypothermic-inducing compounds that have a strong potential in the management of TBI.
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Affiliation(s)
- Jin Hwan Lee
- 1 Department of Anesthesiology, Emory University School of Medicine , Atlanta, Georgia
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Fujita Y, Algarra NN, Vavilala MS, Prathep S, Prapruettham S, Sharma D. Intraoperative secondary insults during extracranial surgery in children with traumatic brain injury. Childs Nerv Syst 2014; 30:1201-8. [PMID: 24429505 DOI: 10.1007/s00381-014-2353-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2013] [Accepted: 01/02/2014] [Indexed: 11/28/2022]
Abstract
PURPOSE Data on intraoperative secondary insults in pediatric traumatic brain injury (TBI) are limited. METHODS We examined intraoperative secondary insults during extracranial surgery in children with moderate-severe TBI and polytrauma and their association with postoperative head computed tomography (CT) scans, intracranial pressure (ICP), and therapeutic intensity level (TIL) scores 24 h after surgery. After IRB approval, we reviewed the records of children <18 years with a Glasgow Coma Scale score <13 who underwent extracranial surgery within 72 h of TBI. Definitions of secondary insults were as follows: systemic hypotension (SBP <70 + 2 × age or 90 mmHg), cerebral hypotension (cerebral perfusion pressure <40 mmHg), intracranial hypertension (ICP >20 mmHg), hypoxia (oxygen saturation <90 %), hypercarbia (end-tidal CO2 >45 mmHg), hypocarbia (end-tidal CO2 <30 mmHg without hypotension and in the absence of intracranial hypertension), hyperglycemia (blood glucose >200 mg/dL), hyperthermia (temperature >38 °C), and hypothermia (temperature <35 °C). RESULTS Data from 50 surgeries in 42 patients (median age 15.5 years, 25 males) revealed systemic hypotension during 78 %, hypocarbia during 46 %, and hypercarbia during 25 % surgeries. Intracranial hypertension occurred in 64 % and cerebral hypotension in 18 % surgeries with ICP monitoring (11/50). Hyperglycemia occurred during 17 % of the 29 surgeries with glucose monitoring. Cerebral hypotension and hypoxia were associated with postoperative intracranial hypertension (p = 0.02 and 0.03, respectively). We did not observe an association between intraoperative secondary insults and postoperative worsening of head CT scan or TIL score. CONCLUSIONS Intraoperative secondary insults were common during extracranial surgery in pediatric TBI. Intraoperative cerebral hypotension and hypoxia were associated with postoperative intracranial hypertension. Strategies to prevent secondary insults during extracranial surgery in TBI are needed.
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Affiliation(s)
- Yasuki Fujita
- Departments of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
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Boutin A, Chassé M, Shemilt M, Lauzier F, Moore L, Zarychanski R, Lacroix J, Fergusson DA, Desjardins P, Turgeon AF. Red blood cell transfusion in patients with traumatic brain injury: a systematic review protocol. Syst Rev 2014; 3:66. [PMID: 24943006 PMCID: PMC4090399 DOI: 10.1186/2046-4053-3-66] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Accepted: 05/19/2014] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Anemia is a prevalent condition in critically ill patients and red blood cell transfusions are frequent. Although transfusions at low hemoglobin levels have been shown to be associated with equivalent or better outcomes than higher hemoglobin thresholds, clinical equipoise persists in patients with traumatic brain injury considering their susceptibility to secondary cerebral insults such as those from hypoxemia. METHODS Our objectives are to estimate the frequency of red blood cell transfusion in patients with traumatic brain injury and to evaluate transfusion thresholds, determinants and outcomes associated with transfusion strategies.We will conduct a systematic review of cohort studies and randomized controlled trials of patients with traumatic brain injury. We will search MEDLINE, Embase, BIOSIS and the Cochrane Library for eligible studies. Two independent reviewers will screen all identified references. Studies including adult patients with traumatic brain injury reporting data on red blood cell transfusions will be eligible. We will collect data on baseline demographics, trauma characteristics, hemoglobin thresholds, blood transfusions and clinical outcomes (mortality, length of stay, complications, and so on). Two independent reviewers will extract data using a standardized form. We will pool cumulative incidences using DerSimonian and Lair random-effect models after a Freeman-Tukey transformation to stabilize variances. We will pool risk ratios or mean differences with random-effect models and Mantel-Haenszel or inverse variance methods in order to evaluate the association between red blood cell transfusion and potential determinants or outcomes. Sensitivity and subgroup analysis according to timing of red blood cell transfusion, traumatic brain injury severity, year of conduction of the study, risk of bias, notably, are planned. DISCUSSION We expect to observe high heterogeneity in the proportion of transfused patients across studies and that the global proportion will be similar to the frequency observed in the general medical critically ill population. Our systematic review will allow us to better describe and understand current transfusion practices in patients with traumatic brain injury, a clinical population in which liberal transfusions are still advocated in the absence of evidence-based data. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42014007402.
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Affiliation(s)
- Amélie Boutin
- Department of Social and Preventive Medicine, Université Laval, Québec, QC, Canada
- Centre Hospitalier Universitaire (CHU) de Québec Research Center, Population Health and Optimal Health Practices Research Unit, Traumatology-Emergency-Critical Care Medicine, Université Laval, Québec, QC, Canada
| | - Michaël Chassé
- Centre Hospitalier Universitaire (CHU) de Québec Research Center, Population Health and Optimal Health Practices Research Unit, Traumatology-Emergency-Critical Care Medicine, Université Laval, Québec, QC, Canada
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec, QC, Canada
- Department of Medicine, Université Laval, Québec, QC, Canada
| | - Michèle Shemilt
- Centre Hospitalier Universitaire (CHU) de Québec Research Center, Population Health and Optimal Health Practices Research Unit, Traumatology-Emergency-Critical Care Medicine, Université Laval, Québec, QC, Canada
| | - François Lauzier
- Centre Hospitalier Universitaire (CHU) de Québec Research Center, Population Health and Optimal Health Practices Research Unit, Traumatology-Emergency-Critical Care Medicine, Université Laval, Québec, QC, Canada
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec, QC, Canada
- Department of Medicine, Université Laval, Québec, QC, Canada
| | - Lynne Moore
- Department of Social and Preventive Medicine, Université Laval, Québec, QC, Canada
- Centre Hospitalier Universitaire (CHU) de Québec Research Center, Population Health and Optimal Health Practices Research Unit, Traumatology-Emergency-Critical Care Medicine, Université Laval, Québec, QC, Canada
| | - Ryan Zarychanski
- Department of Internal Medicine, Sections of Critical Care Medicine of Hematology and of Medical Oncology, University of Manitoba, Winnipeg, MB, Canada
| | - Jacques Lacroix
- Department of Pediatrics, Critical Care Medicine, Université de Montréal, Montréal, QC, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Unit, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Philippe Desjardins
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec, QC, Canada
| | - Alexis F Turgeon
- Centre Hospitalier Universitaire (CHU) de Québec Research Center, Population Health and Optimal Health Practices Research Unit, Traumatology-Emergency-Critical Care Medicine, Université Laval, Québec, QC, Canada
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec, QC, Canada
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Koukiasa P, Bitzani M, Papaioannou V, Pnevmatikos I. Resting Energy Expenditure in Critically Ill Patients With Spontaneous Intracranial Hemorrhage. JPEN J Parenter Enteral Nutr 2014; 39:917-21. [PMID: 24928226 DOI: 10.1177/0148607114539352] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 05/18/2014] [Indexed: 01/06/2023]
Abstract
BACKGROUND Data on energy requirements of patients with spontaneous intracranial hemorrhage (SICH) are scarce. The objective of this study was to determine the resting energy expenditure (REE) in critically ill patients with SICH and to compare it with the predicted basal metabolic rate (BMR). METHODS In 30 nonseptic patients with SICH, the REE was measured during the 10 first posthemorrhage days with the use of indirect calorimetry (IC). Predicted BMR was also evaluated by the Harris-Benedict (HB) equation. Bland-Altman analysis was used to evaluate the agreement between measured and predicted values. The possible effect of confounding factors (demographics, disease, and severity of illness score) on the evolution of continuous variables was also tested. RESULTS mean predicted BMR, calculated by the HB equation, was 1580.3 ± 262 kcal/d, while measured REE was 1878.9 ± 478 kcal/d (117.5% BMR). Compared with BMR, measured REE values showed a statistically significant increase at all studied points (P < .005). Measured and predicted values showed a good correlation (r = 0.73, P < .001), but the test of agreement between the 2 methods with the Bland-Altman analysis showed a mean bias (294.6 ± 265.6 kcal/d) and limits of agreement (-226 to 815.29 kcal/d) that were beyond the clinically acceptable range. REE values presented a trend toward increase over time (P = .077), reaching significance (P < .005) after the seventh day. Significant correlation was found between REE and temperature (P = .002, r = 0.63), as well as between REE and cortisol level (P = .017, r = 0.62) on the 10th day. No correlation was identified between REE and depth of sedation, as well as Acute Physiology and Chronic Health Evaluation II, Glasgow Coma Scale, and Hunt and Hess scores. CONCLUSIONS During the early posthemorrhagic stage, energy requirements of critically ill patients with SICH are increased, presenting a trend toward increase over time. Compared with IC, the HB equation underestimates energy requirements and is inefficient in detecting individual variability of REE in this group of patients.
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Affiliation(s)
- Pagona Koukiasa
- ICU Department, G. Papanikolaou Hospital, Thessaloniki, Greece
| | - Militsa Bitzani
- ICU Department, G. Papanikolaou Hospital, Thessaloniki, Greece
| | - Vasileios Papaioannou
- ICU Department, University Hospital, Democritus University of Trace, Alexandroupolis, Greece
| | - Ioannis Pnevmatikos
- ICU Department, University Hospital, Democritus University of Trace, Alexandroupolis, Greece
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Depreitere B, Güiza F, Van den Berghe G, Schuhmann MU, Maier G, Piper I, Meyfroidt G. Pressure autoregulation monitoring and cerebral perfusion pressure target recommendation in patients with severe traumatic brain injury based on minute-by-minute monitoring data. J Neurosurg 2014; 120:1451-7. [PMID: 24745709 DOI: 10.3171/2014.3.jns131500] [Citation(s) in RCA: 104] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECT In severe traumatic brain injury, a universal target for cerebral perfusion pressure (CPP) has been abandoned. Attempts to identify a dynamic CPP target based on the patient's cerebrovascular autoregulatory capacity have been promising so far. Bedside monitoring of pressure autoregulatory capacity has become possible by a number of methods, Czosnyka's pressure reactivity index (PRx) being the most frequently used. The PRx is calculated as the moving correlation coefficient between 40 consecutive 5-second averages of intracranial pressure (ICP) and mean arterial blood pressure (MABP) values. Plotting PRx against CPP produces a U-shaped curve in roughly two-thirds of monitoring time, with the bottom of this curve representing a CPP range corresponding with optimal autoregulatory capacity (CPPopt). In retrospective series, keeping CPP close to CPPopt corresponded with better outcomes. Monitoring of PRx requires high-frequency signal processing. The aim of the present study is to investigate how the processing of the information on cerebrovascular pressure reactivity that can be obtained from routine minute-by-minute ICP and MABP data can be enhanced to enable CPPopt recommendations that do not differ from those obtained by the PRx method, show the same associations with outcome, and can be generated in more than two-thirds of monitoring time. METHODS The low-frequency autoregulation index (LAx) was defined as the moving minute-by-minute ICP/MABP correlation coefficient calculated over time intervals varying from 3 to 120 minutes. The CPPopt calculation was based on LAx-CPP plots and done for time windows between 1 and 24 hours and for each LAx type. The resulting matrix of CPPopts were then averaged in a weighted manner, with the weight based on the goodness of fit of a U-shape and the lower value of the LAx corresponding to the U-bottom, to result in a final CPPopt recommendation. The association between actual CPP/CPPopt and outcome was assessed in the multicenter Brain Monitoring with Information Technology Research Group (BrainIT) database (n = 180). In the Leuven-Tübingen database (60-Hz waveform data, n = 21), LAx- and PRx-based CPPopts were compared. RESULTS In the BrainIT database, CPPopt recommendations were generated in 95% of monitoring time. Actual CPP being close to LAx-based CPPopt was associated with increased survival. In a multivariate model using the Corticosteroid Randomization After Significant Head Injury (CRASH) model as covariates, the average absolute difference between actual CPP and CPPopt was independently associated with increased mortality. In the high-frequency data set no significant difference was observed between PRx-based and LAx-based CPPopts. The new method issued a CPPopt recommendation in 97% of monitoring time, as opposed to 44% for PRx-based CPPopt. CONCLUSIONS Minute-by-minute ICP/MABP data contain relevant information for autoregulation monitoring. In this study, the authors' new method based on minute-by-minute data resolution allowed for CPPopt calculation in nearly the entire monitoring time. This will facilitate the use of pressure reactivity monitoring in all ICUs.
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109
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Crossley S, Reid J, McLatchie R, Hayton J, Clark C, MacDougall M, Andrews PJD. A systematic review of therapeutic hypothermia for adult patients following traumatic brain injury. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:R75. [PMID: 24742169 PMCID: PMC4056614 DOI: 10.1186/cc13835] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Accepted: 04/03/2014] [Indexed: 12/16/2022]
Abstract
Introduction Research into therapeutic hypothermia following traumatic brain injury has been characterised by small trials of poor methodological quality, producing variable results. The Cochrane review, published in 2009, now requires updating. The aim of this systematic review is to assess the effectiveness of the application of therapeutic hypothermia to reduce death and disability when administered to adult patients who have been admitted to hospital following traumatic brain injury. Methods Two authors extracted data from each trial. Unless stated in the trial report, relative risks and 95% confidence intervals (CIs) were calculated for each trial. We considered P < 0 · 05 to be statistically significant. We combined data from all trials to estimate the pooled risk ratio (RR) with 95% confidence intervals for death, unfavourable outcome, and pneumonia. All statistical analyses were performed using RevMan 5.1 (Cochrane IMS, Oxford, UK) and Stata (Intercooled Version 12.0, StataCorp LP). Pooled RRs were calculated using the Mantel-Haenszel estimator. The random effects model of DerSimonian and Laird was used to estimate variances for the Mantel-Haenszel and inverse variance estimators. Results Twenty studies are included in the review, while 18 provided mortality data. When the results of 18 trials that evaluated mortality as one of the outcomes were statistically aggregated, therapeutic hypothermia was associated with a significant reduction in mortality and a significant reduction in poor outcome. There was a lack of statistical evidence for an association between use of therapeutic hypothermia and increased onset of new pneumonia. Conclusions In contrast to previous reviews, this systematic review found some evidence to suggest that therapeutic hypothermia may be of benefit in the treatment of traumatic brain injury. The majority of trials were of low quality, with unclear allocation concealment. Low quality trials may overestimate the effectiveness of hypothermia treatment versus standard care. There remains a need for more, high quality, randomised control trials of therapeutic hypothermia after traumatic brain injury. PROSPERO Systematic Review Registration Number 2012:
CRD42012002449.
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Santarsieri M, Niyonkuru C, McCullough EH, Dobos JA, Dixon CE, Berga SL, Wagner AK. Cerebrospinal fluid cortisol and progesterone profiles and outcomes prognostication after severe traumatic brain injury. J Neurotrauma 2014; 31:699-712. [PMID: 24354775 PMCID: PMC3967414 DOI: 10.1089/neu.2013.3177] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Despite significant advances in the management of head trauma, there remains a lack of pharmacological treatment options for traumatic brain injury (TBI). While progesterone clinical trials have shown promise, corticosteroid trials have failed. The purpose of this study was to (1) characterize endogenous cerebrospinal fluid (CSF) progesterone and cortisol levels after TBI, (2) determine relationships between CSF and serum profiles, and (3) assess the utility of these hormones as predictors of long-term outcomes. We evaluated 130 adults with severe TBI. Serum samples (n=538) and CSF samples (n=746) were collected for 6 days post-injury, analyzed for cortisol and progesterone, and compared with healthy controls (n=13). Hormone data were linked with clinical data, including Glasgow Outcome Scale (GOS) scores at 6 and 12 months. Group based trajectory (TRAJ) analysis was used to develop temporal hormone profiles delineating distinct subpopulations. Compared with controls, CSF cortisol levels were significantly and persistently elevated during the first week after TBI, and high CSF cortisol levels were associated with poor outcome. As a precursor to cortisol, progesterone mediated these effects. Serum and CSF levels for both cortisol and progesterone were strongly correlated after TBI relative to controls, possibly because of blood-brain barrier disruption. Also, differentially impaired hormone transport and metabolism mechanisms after TBI, potential de novo synthesis of steroids within the brain, and the complex interplay of cortisol and pro-inflammatory cytokines may explain these acute hormone profiles and, when taken together, may help shed light on why corticosteroid trials have previously failed and why progesterone treatment after TBI may be beneficial.
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Affiliation(s)
- Martina Santarsieri
- University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Christian Niyonkuru
- University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Emily H. McCullough
- University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Julie A. Dobos
- University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania
| | - C. Edward Dixon
- University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania
- Safar Center for Resuscitation Research, Universitry of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sarah L. Berga
- Department of Obstetrics/Gynecology, Wake Forest University, Winston-Salem, North Carolina
| | - Amy K. Wagner
- University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania
- Safar Center for Resuscitation Research, Universitry of Pittsburgh, Pittsburgh, Pennsylvania
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Abstract
Neurocritical care is a pioneering subspecialty dedicated to the treatment of patients with life-threatening neurological illnesses, postoperative neurosurgical complications, and neurological manifestations of systemic disease. The care of these patients requires specialized neurological monitoring and specific clinical expertise and has generated a body of literature commensurate with the expansion of the field. This article reviews landmark studies over the last 10 years in the management and treatment of common acute neurological illnesses including massive cerebral infarction, intracerebral hemorrhage, subarachnoid hemorrhage, traumatic brain injury, and status epilepticus.
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Affiliation(s)
- Diana J Goodman
- Department of Neurology, Medical University of South Carolina Charleston, SC, Charleston, SC, USA
| | - Monisha A Kumar
- Department of Neurology, Hospital of the University of Pennsylvania Philadelphia, Philadelphia, PA, USA ; Department of Neurosurgery, Hospital of the University of Pennsylvania Philadelphia, Philadelphia, PA, USA ; Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania Philadelphia, Philadelphia, PA, USA
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Study of the long-term results of decompressive craniectomy after severe traumatic brain injury based on a series of 60 consecutive cases. ScientificWorldJournal 2014; 2014:207585. [PMID: 24719566 PMCID: PMC3956416 DOI: 10.1155/2014/207585] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 01/16/2014] [Indexed: 11/19/2022] Open
Abstract
Background. Decompressive craniectomy can be proposed in the management of severe traumatic brain injury. Current studies report mixed results, preventing any clear conclusions on the place of decompressive craniectomy in traumatology. Methods. The objective of this retrospective study was to evaluate the results of all decompressive craniectomies performed between 2005 and 2011 for refractory intracranial hypertension after severe traumatic brain injury. Sixty patients were included. Clinical parameters (Glasgow scale, pupillary examination) and radiological findings (Marshall CT scale) were analysed. Complications, clinical outcome, and early and long-term Glasgow Outcome Scale (GOS) were evaluated after surgery. Finally, the predictive value of preoperative parameters to guide the clinician's decision to perform craniectomy was studied. Results. Craniectomy was unilateral in 58 cases and the mean bone flap area was 100 cm2. Surgical complications were observed in 6.7% of cases. Mean followup was 30 months and a favourable outcome was obtained in 50% of cases. The initial Glasgow Scale was the only statistically significant predictive factor for long-term outcome. Conclusion. Despite the discordant results in the literature, this study demonstrates that decompressive craniectomy is useful for the management of refractory intracranial hypertension after severe traumatic brain injury.
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Raychaudhuri R, Litofsky NS. Which traumatic brain injury patients should be treated with anticoagulants and when? Expert Rev Neurother 2014; 14:237-9. [DOI: 10.1586/14737175.2014.888652] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Melhem S, Shutter L, Kaynar AM. A trial of intracranial pressure monitoring in traumatic brain injury. Crit Care 2014; 18:302. [PMID: 24485039 PMCID: PMC4056074 DOI: 10.1186/cc13713] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Intracranial pressure (ICP) monitoring is considered the standard of care for severe traumatic brain injury (TBI) and is used frequently, but the efficacy of treatment based on monitoring in improving the outcome has not been rigorously assessed. METHODS OBJECTIVE The objective was to compare efficacy of guideline-based management in which a protocol for monitoring intraparenchymal ICP was used (ICP group) or a protocol in which treatment was based on imaging and clinical examination (exam group). DESIGN A multicenter randomized controlled trial was conducted. SETTING The trial was set in ICUs in Bolivia or Ecuador. SUBJECTS Patients had severe TBI (n = 324) and were 13 years of age or older. INTERVENTIONS Patients were randomly allocated to ICP monitoring or clinical exam-based monitoring. OUTCOMES The primary outcome was a composite of survival time, impaired consciousness, functional status at 3 and 6 months, and neuropsychological status at 6 months; neuropsychological status was assessed by an examiner who was unaware of the protocol assignment. This composite measure was based on performance across 21 measures of functional and cognitive status and was calculated as a percentile (with 0 indicating the worst performance, and 100 the best performance). RESULTS There was no significant between-group difference in the primary outcome, a composite measure based on percentile performance across 21 measures of functional and cognitive status (score 56 in the pressure-monitoring group versus 53 in the imaging-clinical examination group; P = 0.49). Six-month mortality rates were 39% in the pressure-monitoring group and 41% in the imaging-clinical examination group (P = 0.60). The median lengths of stay in the ICU were similar in the two groups (12 days in the pressure-monitoring group and 9 days in the imaging-clinical examination group; P = 0.25), although the number of days of brain-specific treatments (for example, administration of hyperosmolar fluids and the use of hyperventilation) in the ICU was higher in the imaging-clinical examination group than in the pressure-monitoring group (4.8 versus 3.4, P = 0.002). The distributions of serious adverse events were similar in the two groups. CONCLUSIONS For patients with severe TBI, care focused on maintaining monitored ICP at 20 mmHg or less was not shown to be superior to care based on imaging and clinical examination.
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Affiliation(s)
- Samer Melhem
- Department of Anesthesiology, NYU Langone Medical Center, 550 1st Avenue, New York, NY 10016, USA
| | - Lori Shutter
- Department of Critical Care Medicine, University of Pittsburgh, 3550 Terrace Street, Pittsburgh, PA 15261, USA
| | - A Murat Kaynar
- Department of Critical Care Medicine, University of Pittsburgh, 3550 Terrace Street, Pittsburgh, PA 15261, USA
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Sadek AR, Eynon CA. The role of neurosciences intensive care in trauma and neurosurgical conditions. Br J Hosp Med (Lond) 2014; 74:552-7. [PMID: 24105307 DOI: 10.12968/hmed.2013.74.10.552] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The creation of neurosciences intensive care units was born out of the awareness that a group of neurological and neurosurgical patients required specialized intensive medical and nursing care. This first of two articles describes the role of neurosciences intensive care in the management of trauma and neurosurgical conditions.
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Affiliation(s)
- Ahmed-Ramadan Sadek
- Walport Academic Clinical Fellow in Neurosurgery and Jason Brice Fellow in Neurosurgical Research
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116
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Dams-O'Connor K, Cuthbert JP, Whyte J, Corrigan JD, Faul M, Harrison-Felix C. Traumatic brain injury among older adults at level I and II trauma centers. J Neurotrauma 2013; 30:2001-13. [PMID: 23962046 DOI: 10.1089/neu.2013.3047] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Individuals 65 years of age and over have the highest rates of traumatic brain injury (TBI)-related hospitalizations and deaths, and older adults (defined variably across studies) have particularly poor outcomes after TBI. The factors predicting these outcomes remain poorly understood, and age-specific care guidelines for TBI do not exist. This study provides an overview of TBI in older adults using data from the National Trauma Data Bank (NTDB) gathered between 2007 and 2010, evaluates age group-specific trends in rates of TBI over time using U.S. Census data, and examines whether routinely collected information is able to predict hospital discharge status among older adults with TBI in the NTDB. Results showed a 20-25% increase in trauma center admissions for TBI among the oldest age groups (those >=75 years), relative to the general population, between 2007 and 2010. Older adults (>=65 years) with TBI tended to be white females who have incurred an injury from a fall resulting in a "severe" Abbreviated Injury Scale (AIS) score of the head. Older adults had more in-hospital procedures, such as neuroimaging and neurosurgery, tended to experience longer hospital stays, and were more likely to require continued medical care than younger adults. Older age, injury severity, and hypotension increased the odds of in-hospital death. The public health burden of TBI among older adults will likely increase as the Baby Boom generation ages. Improved primary and secondary prevention of TBI in this cohort is needed.
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Affiliation(s)
- Kristen Dams-O'Connor
- 1 Department of Rehabilitation Medicine, Icahn School of Medicine at Mount Sinai , New York, New York
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117
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Phipps HW, Longo LM, Blaber SI, Blaber M, VanLandingham JW. Kallikrein-related peptidase 6: A biomarker for traumatic brain injury in the rat. Brain Inj 2013; 27:1698-706. [DOI: 10.3109/02699052.2013.823563] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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118
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Reljic T, Mahony H, Djulbegovic B, Etchason J, Paxton H, Flores M, Kumar A. Value of repeat head computed tomography after traumatic brain injury: systematic review and meta-analysis. J Neurotrauma 2013; 31:78-98. [PMID: 23914924 DOI: 10.1089/neu.2013.2873] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Diagnosis and management of traumatic brain injury (TBI) is crucial to improve patient outcomes. While initial head computed tomography (CT) scan is the optimum tool for quick and accurate detection of intracranial hemorrhage, the guidelines on use of repeat CT differ among institutions. Three systematic reviews have been conducted on a similar topic; none have performed a comprehensive meta-analysis of all studies. Search of Medline, the Cochrane Library database, and Clinicaltrials.gov , and a hand search of conference abstracts and references for all completed studies reporting data on change in management following repeat CT was conducted. Two authors reviewed all studies and extracted data using a standardized form. A proportional meta-analysis was conducted using the random-effects model for outcomes related to any change in management following repeat CT. Any change in management included intracranial intervention, change in intracranial pressure monitoring, and/or administration of drug therapy. Search results yielded 6982 references. In all, 41 studies enrolling 10,501 patients were included. Change in management following repeat CT was reported in 13 prospective and 28 retrospective studies and yielded a pooled proportion of 11.4% (95% confidence interval [CI] 5.9-18.4) and 9.6% (95% CI 6.5-13.2), respectively. In a subgroup analysis of mild TBI patients (Glasgow Coma Scale score 13 to 15), five prospective and nine retrospective studies reported on change in management following repeat CT with the pooled proportion across prospective studies at 2.3% (95% CI 0.3-6.3) and across retrospective studies at 3.9% (95% CI 2.3-5.7), respectively. The evidence suggests that repeat CT in patients with TBI results in a change in management for only a minority of patients. Better designed studies are needed to address the issue of the value of repeat CT in the management of TBI.
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Affiliation(s)
- Tea Reljic
- 1 Center for Evidence Based Medicine and Health Outcomes Research, University of South Florida , Tampa, Florida
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119
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Kolmodin L, Sekhon MS, Henderson WR, Turgeon AF, Griesdale DEG. Hypernatremia in patients with severe traumatic brain injury: a systematic review. Ann Intensive Care 2013; 3:35. [PMID: 24196399 PMCID: PMC3826846 DOI: 10.1186/2110-5820-3-35] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Accepted: 10/21/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hypernatremia is common following traumatic brain injury (TBI) and occurs from a variety of mechanisms, including hyperosmotic fluids, limitation of free water, or diabetes insipidus. The purpose of this systematic review was to assess the relationship between hypernatremia and mortality in patients with TBI. METHODS We searched the following databases up to November 2012: MEDLINE, EMBASE, and CENTRAL. Using a combination of MeSH and text terms, we developed search filters for the concepts of hypernatremia and TBI and included studies that met the following criteria: (1) compared hypernatremia to normonatremia, (2) adult patients with TBI, (3) presented adjusted outcomes for mortality or complications. RESULTS Bibliographic and conference search yielded 1,152 citations and 11 abstracts, respectively. Sixty-five articles were selected for full-text review with 5 being included in our study. All were retrospective cohort studies totaling 5,594 (range 100-4,296) patients. There was marked between-study heterogeneity. The incidence of hypernatremia ranged between 16% and 40%. Use of hyperosmolar therapy was presented in three studies (range 14-85% of patients). Hypernatremia was associated with increased mortality across all four studies that presented this outcome. Only one study considered diabetes insipidus (DI) in their analysis where hypernatremia was associated with increased mortality in patients who did not receive DDAVP. CONCLUSIONS Although hypernatremia was associated with increased mortality in the included studies, there was marked between-study heterogeneity. DI was a potential confounder in several studies. Considering these limitations, the clinical significance of hypernatremia in TBI is difficult to establish at this stage.
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Affiliation(s)
- Leif Kolmodin
- Department of Medicine, Division of Critical Care Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Mypinder S Sekhon
- Department of Medicine, Division of Critical Care Medicine, University of British Columbia, Vancouver, BC, Canada
- Critical Care Medicine, Vancouver General Hospital, Room 2438, Jim Pattison Pavilion, 2nd Floor, 855 West 12th Avenue, Vancouver, BC V5Z 1 M9, Canada
| | - William R Henderson
- Department of Medicine, Division of Critical Care Medicine, University of British Columbia, Vancouver, BC, Canada
- Critical Care Medicine, Vancouver General Hospital, Room 2438, Jim Pattison Pavilion, 2nd Floor, 855 West 12th Avenue, Vancouver, BC V5Z 1 M9, Canada
| | - Alexis F Turgeon
- Department of anesthesiology, Division of Critical Care, Université Laval, Québec City, QC, Canada
| | - Donald EG Griesdale
- Department of Medicine, Division of Critical Care Medicine, University of British Columbia, Vancouver, BC, Canada
- Department of Anesthesia, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
- Critical Care Medicine, Vancouver General Hospital, Room 2438, Jim Pattison Pavilion, 2nd Floor, 855 West 12th Avenue, Vancouver, BC V5Z 1 M9, Canada
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120
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Rincon F, Patel U, Schorr C, Lee E, Ross S, Dellinger RP, Zanotti-Cavazzoni S. Brain Injury as a Risk Factor for Fever Upon Admission to the Intensive Care Unit and Association With In-Hospital Case Fatality. J Intensive Care Med 2013; 30:107-14. [DOI: 10.1177/0885066613508266] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Purpose: To test the hypothesis that fever was more frequent in critically ill patients with brain injury when compared to nonneurological patients and to study its effect on in-hospital case fatality. Methods: Retrospective matched cohort study utilizing a single-center prospectively compiled registry. Critically ill neurological patients ≥18 years and consecutively admitted to the intensive care unit (ICU) with acute ischemic stroke (AIS), intracerebral hemorrhage (ICH), and traumatic brain injury (TBI) were selected. Patients were matched by sex, age, and Acute Physiology and Chronic Health Evaluation II (APACHE-II) to a cohort of nonneurological patients. Fever was defined as any temperature ≥37.5°C within the first 24 hours upon admission to the ICU. The primary outcome measure was in-hospital case fatality. Results: Mean age among neurological patients was 65.6 ± 15 years, 46% were men, and median APACHE-II was 15 (interquartile range 11-20). There were 18% AIS, 27% ICH, and 6% TBI. More neurological patients experienced fever than nonneurological patients (59% vs 47%, P = .007). The mean hospital length of stay was higher for nonneurological patients (18 ± 20 vs 14 ± 15 days, P = .007), and more neurological patients were dead at hospital discharge (29% vs 20%, P < .0001). After risk factor adjustment, diagnosis (neurological vs nonneurological), and the probability of being exposed to fever (propensity score), the following variables were associated with higher in-hospital case fatality: APACHE-II, neurological diagnosis, mean arterial pressure, cardiovascular and respiratory dysfunction in ICU, and fever (odds ratio 1.9, 95% confidence interval 1.04-3.6, P = .04). Conclusion: These data suggest that fever is a frequent occurrence after brain injury, and that it is independently associated with in-hospital case fatality.
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Affiliation(s)
- Fred Rincon
- Department of Medicine, Division of Critical Care and Cardiovascular Medicine, Robert Wood Johnson Medical School, Cooper University Hospital, UMDNJ, Camden, NJ, USA
| | - Utkal Patel
- Department of Medicine, Division of Critical Care and Cardiovascular Medicine, Robert Wood Johnson Medical School, Cooper University Hospital, UMDNJ, Camden, NJ, USA
| | - Christa Schorr
- Department of Medicine, Division of Critical Care and Cardiovascular Medicine, Robert Wood Johnson Medical School, Cooper University Hospital, UMDNJ, Camden, NJ, USA
| | - Elizabeth Lee
- Department of Medicine, Division of Critical Care and Cardiovascular Medicine, Robert Wood Johnson Medical School, Cooper University Hospital, UMDNJ, Camden, NJ, USA
| | - Steven Ross
- Department of Surgery, Division of Trauma and Critical Care, Robert Wood Johnson Medical School, Cooper University Hospital, UMDNJ, Camden, NJ, USA
| | - R. Phillip Dellinger
- Department of Medicine, Division of Critical Care and Cardiovascular Medicine, Robert Wood Johnson Medical School, Cooper University Hospital, UMDNJ, Camden, NJ, USA
| | - Sergio Zanotti-Cavazzoni
- Department of Medicine, Division of Critical Care and Cardiovascular Medicine, Robert Wood Johnson Medical School, Cooper University Hospital, UMDNJ, Camden, NJ, USA
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121
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Egea-Guerrero JJ, Murillo-Cabezas F, Gordillo-Escobar E, Rodríguez-Rodríguez A, Enamorado-Enamorado J, Revuelto-Rey J, Pacheco-Sánchez M, León-Justel A, Domínguez-Roldán JM, Vilches-Arenas A. S100B protein may detect brain death development after severe traumatic brain injury. J Neurotrauma 2013; 30:1762-9. [PMID: 23710646 PMCID: PMC3796324 DOI: 10.1089/neu.2012.2606] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Despite improvements in the process of organ donation and transplants, the number of organ donors is progressively declining in developed countries. Therefore, the early detection of patients at risk for brain death (BD) is a priority for transplant teams seeking more efficient identification of potential donors. In the extensive literature on S100B as a biomarker for traumatic brain injury (TBI), no evidence appears to exist on its prognostic capacity as a predictor of BD after severe TBI. The objective of this study is to assess the value of including acute S100B levels in standard clinical data as an early screening tool for BD after severe TBI. This prospective study included patients with severe TBI (Glasgow Coma Scale score [GCS] ≤ 8) admitted to our Neurocritical Care Unit over a 30 month period. We collected the following clinical variables: age, gender, GCS score, pupillary alterations at admission, hypotension and pre-hospital desaturation, CT scan results, isolated TBI or other related injuries, Injury Severity Score (ISS), serum S100B levels at admission and 24 h post-admission, and a final diagnosis regarding BD. Of the 140 patients studied, 11.4% developed BD and showed significantly higher S100B concentrations (p<0.001). Multivariate analysis showed that bilateral unresponsive mydriasis at admission and serum S100B at 24 h post-admission had odds ratios (ORs) of 21.35 (p=0.005) and 4.9 (p=0.010), respectively. The same analysis on patients with photomotor reflex in one pupil at admission left only the 24 h S100B sample in the model (OR=15.5; p=0.009). Receiver operating characteristics (ROC) curve analysis on this group showed the highest area under the curve (AUC) (0.86; p=0.001) for 24 h S100B determinations. The cut off was set at 0.372 μg/L (85.7% sensitivity, 79.3% specificity, positive predictive value [PPV]=18.7% and negative predictive value [NPV]=98.9%). This study shows that pupillary responsiveness at admission, as well as 24 h serum S100B levels, could serve as screening tools for the early detection of patients at risk for BD after severe TBI.
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Affiliation(s)
- Juan J. Egea-Guerrero
- NeuroCritical Care Unit, Virgen del Rocío University Hospital, IBIS/CSIC/University of Seville, Seville, Spain
| | - Francisco Murillo-Cabezas
- NeuroCritical Care Unit, Virgen del Rocío University Hospital, IBIS/CSIC/University of Seville, Seville, Spain
| | - Elena Gordillo-Escobar
- NeuroCritical Care Unit, Virgen del Rocío University Hospital, IBIS/CSIC/University of Seville, Seville, Spain
| | - Ana Rodríguez-Rodríguez
- Department of Clinical Biochemistry, Virgen del Rocío University Hospital, IBIS/CSIC/University of Seville, Seville, Spain
| | - Judy Enamorado-Enamorado
- NeuroCritical Care Unit, Virgen del Rocío University Hospital, IBIS/CSIC/University of Seville, Seville, Spain
| | - Jaume Revuelto-Rey
- NeuroCritical Care Unit, Virgen del Rocío University Hospital, IBIS/CSIC/University of Seville, Seville, Spain
| | - María Pacheco-Sánchez
- NeuroCritical Care Unit, Virgen del Rocío University Hospital, IBIS/CSIC/University of Seville, Seville, Spain
| | - Antonio León-Justel
- Department of Clinical Biochemistry, Virgen del Rocío University Hospital, IBIS/CSIC/University of Seville, Seville, Spain
| | - Jose M. Domínguez-Roldán
- NeuroCritical Care Unit, Virgen del Rocío University Hospital, IBIS/CSIC/University of Seville, Seville, Spain
| | - Angel Vilches-Arenas
- Department of Preventive Medicine and Public Health, IBIS/CSIC/University of Seville, Seville, Spain
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122
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Roberts DJ, Jenne CN, Léger C, Kramer AH, Gallagher CN, Todd S, Parney IF, Doig CJ, Yong VW, Kubes P, Zygun DA. Association between the Cerebral Inflammatory and Matrix Metalloproteinase Responses after Severe Traumatic Brain Injury in Humans. J Neurotrauma 2013; 30:1727-36. [DOI: 10.1089/neu.2012.2842] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Affiliation(s)
- Derek J. Roberts
- Department of Surgery, University of Calgary and the Foothills Medical Centre, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary and the Foothills Medical Centre, Calgary, Alberta, Canada
- Department of Critical Care Medicine, University of Calgary and the Foothills Medical Centre, Calgary, Alberta, Canada
| | - Craig N. Jenne
- Department of Critical Care Medicine, University of Calgary and the Foothills Medical Centre, Calgary, Alberta, Canada
- Department of Calvin, Phoebe and Joan Snyder Institute for Chronic Diseases, University of Calgary and the Foothills Medical Centre, Calgary, Alberta, Canada
| | - Caroline Léger
- Department of Critical Care Medicine, University of Calgary and the Foothills Medical Centre, Calgary, Alberta, Canada
- Department of Calvin, Phoebe and Joan Snyder Institute for Chronic Diseases, University of Calgary and the Foothills Medical Centre, Calgary, Alberta, Canada
| | - Andreas H. Kramer
- Department of Critical Care Medicine, University of Calgary and the Foothills Medical Centre, Calgary, Alberta, Canada
- Department of Clinical Neurosciences, University of Calgary and the Foothills Medical Centre, Calgary, Alberta, Canada
- Department of Hotchkiss Brain Institute, University of Calgary and the Foothills Medical Centre, Calgary, Alberta, Canada
| | - Clare N. Gallagher
- Department of Clinical Neurosciences, University of Calgary and the Foothills Medical Centre, Calgary, Alberta, Canada
- Department of Hotchkiss Brain Institute, University of Calgary and the Foothills Medical Centre, Calgary, Alberta, Canada
| | - Stephanie Todd
- Department of Critical Care Medicine, University of Calgary and the Foothills Medical Centre, Calgary, Alberta, Canada
| | - Ian F. Parney
- Department of Neurological Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota, University of Alberta, Edmonton, Alberta, Canada
| | - Christopher J. Doig
- Department of Community Health Sciences, University of Calgary and the Foothills Medical Centre, Calgary, Alberta, Canada
- Department of Critical Care Medicine, University of Calgary and the Foothills Medical Centre, Calgary, Alberta, Canada
| | - V. Wee Yong
- Department of Clinical Neurosciences, University of Calgary and the Foothills Medical Centre, Calgary, Alberta, Canada
- Department of Oncology, University of Calgary and the Foothills Medical Centre, Calgary, Alberta, Canada
- Department of Hotchkiss Brain Institute, University of Calgary and the Foothills Medical Centre, Calgary, Alberta, Canada
| | - Paul Kubes
- Department of Critical Care Medicine, University of Calgary and the Foothills Medical Centre, Calgary, Alberta, Canada
- Department of Physiology and Pharmacology, University of Calgary and the Foothills Medical Centre, Calgary, Alberta, Canada
- Department of Hotchkiss Brain Institute, University of Calgary and the Foothills Medical Centre, Calgary, Alberta, Canada
- Department of Calvin, Phoebe and Joan Snyder Institute for Chronic Diseases, University of Calgary and the Foothills Medical Centre, Calgary, Alberta, Canada
| | - David A. Zygun
- Department of Community Health Sciences, University of Calgary and the Foothills Medical Centre, Calgary, Alberta, Canada
- Division of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada
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123
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Roberts DJ, Jenne CN, Léger C, Kramer AH, Gallagher CN, Todd S, Parney IF, Doig CJ, Yong VW, Kubes P, Zygun DA. A prospective evaluation of the temporal matrix metalloproteinase response after severe traumatic brain injury in humans. J Neurotrauma 2013; 30:1717-26. [PMID: 23725031 DOI: 10.1089/neu.2012.2841] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract Accumulating pre-clinical data suggests that matrix metalloproteinase (MMP) expression plays a critical role in the pathophysiology of secondary brain injury. We conducted a prospective multimodal monitoring study in order to characterize the temporal MMP response after severe traumatic brain injury (TBI) in eight critically ill humans and its relationship with outcomes. High-cutoff, cerebral microdialysis (n=8); external ventricular drainage (n=3); and arterial and jugular venous bulb catheters were used to collect microdialysate, cerebrospinal fluid, and arterial and jugular bulb blood over 6 days. Levels of MMP-8 and -9 were initially high in microdialysate and then gradually declined over time. After these MMPs decreased, a spike in the microdialysate levels of MMP-2 and -3 occurred, followed by a gradual rise in the microdialysate concentration of MMP-7. Use of generalized estimating equations suggested that MMP-8 concentration in microdialysate was associated with mortality (p=0.019) and neurological outcome at hospital discharge (p=0.013). Moreover, the mean microdialysate concentration of MMP-8 was 2.4-fold higher among those who died after severe TBI than in those who survived. Mean microdialysate levels of MMP-8 also rose with increasing intracranial pressure (ICP), whereas those of MMP-7 decreased with increasing cerebral perfusion pressure (CPP). Significant changes in the mean microdialysate concentrations of MMP-1, -2, -3, and -9 and MMP-1, -2, -3, -7, and -9 also occurred with increases in microdialysate glucose and the lactate/pyruvate ratio, respectively. These results imply that monitoring of MMPs following severe TBI in humans is feasible, and that their expression may be associated with clinical outcomes, ICP, CPP, and cerebral metabolism.
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Affiliation(s)
- Derek J Roberts
- 1 Department of Surgery, University of Calgary and the Foothills Medical Center , Calgary, Alberta, Canada
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124
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Andrews PJD, Sinclair LH, Harris B, Baldwin MJ, Battison CG, Rhodes JKJ, Murray G, De Backer D. Study of therapeutic hypothermia (32 to 35°C) for intracranial pressure reduction after traumatic brain injury (the Eurotherm3235Trial): outcome of the pilot phase of the trial. Trials 2013; 14:277. [PMID: 24004918 PMCID: PMC3766230 DOI: 10.1186/1745-6215-14-277] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Accepted: 08/22/2013] [Indexed: 12/14/2022] Open
Abstract
Background Clinical trials in traumatic brain injury (TBI) are challenging. Previous trials of complex interventions were conducted in high-income countries, reported long lead times for site setup and low screened-to-recruitment rates. In this report we evaluate the internal pilot phase of an international, multicentre TBI trial of a complex intervention to assess: design and implementation of an online case report form; feasibility of recruitment (sites and patients); feasibility and effectiveness of delivery of the protocol. Methods All aspects of the pilot phase of the trial were conducted as for the main trial. The pilot phase had oversight by independent Steering and Data Monitoring committees. Results Forty sites across 12 countries gained ethical approval. Thirty seven of 40 sites were initiated for recruitment. Of these, 29 had screened patients and 21 randomized at least one patient. Lead times to ethics approval (6.8 weeks), hospital approval (18 weeks), interest to set up (61 weeks), set up to screening (11 weeks), and set up to randomization (31.6 weeks) are comparable with other international trials. Sixteen per cent of screened patients were eligible. We found 88% compliance rate with trial protocol. Conclusion The pilot data demonstrated good feasibility for this large international multicentre randomized controlled trial of hypothermia to control intracranial pressure. The sample size was reduced to 600 patients because of homogeneity of the patient group and we showed an optimized cooling intervention could be delivered. Trial registration Current Controlled Trials: ISRCTN34555414.
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Affiliation(s)
- Peter J D Andrews
- Department of Anaesthesia and Pain Management, University of Edinburgh, Edinburgh, UK.
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125
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Park K, Biederer T. Neuronal adhesion and synapse organization in recovery after brain injury. FUTURE NEUROLOGY 2013; 8:555-567. [PMID: 24489481 DOI: 10.2217/fnl.13.35] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Few specific therapeutic targets exist to manage brain injury, despite the prevalence of stroke or traumatic brain injury. With traumatic brain injury, characteristic neuronal changes include axonal swelling and degeneration, and the loss of synapses, the sites of communication between neurons. This is followed by axonal sprouting and alterations in synaptic markers in recovery. The resulting changes in neuronal connectivity are likely to contribute to the effects of traumatic brain injury on cognitive functions and the underlying mechanisms may represent points of therapeutic intervention. In agreement, animal studies implicate adhesion and signaling molecules that organize synapses as molecular players in neuronal recovery. In this article, the authors focus on the role of cell surface interactions in the recovery after brain injury in humans and animals. The authors review cellular and synaptic alterations that occur with injury and how changes in cell adhesion, protein expression and modification may be involved in recovery. The changes in neuronal surface interactions as potential targets and their possible value for the development of therapeutics are also discussed.
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Affiliation(s)
- Kellie Park
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA
| | - Thomas Biederer
- Department of Molecular Biophysics & Biochemistry, Yale University School of Medicine, New Haven, CT, USA ; Program in Cellular Neuroscience, Neurodegeneration & Repair, Yale University School of Medicine, New Haven, CT, USA
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126
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Cheng SX, Zhang S, Sun HT, Tu Y. Effects of Mild Hypothermia Treatment on Rat Hippocampal β-Amyloid Expression Following Traumatic Brain Injury. Ther Hypothermia Temp Manag 2013; 3:132-139. [PMID: 24066267 DOI: 10.1089/ther.2013.0005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Previous studies have reported that mild induced hypothermia (MIH) treatment has positive effects on traumatic brain injury (TBI) outcomes, which have recently been linked to β-amyloid (Aβ)-induced secondary brain injury (SBI) extent in hippocampal tissues. We therefore investigate the relationship between MIH treatment and expression of Aβ and related proteins following TBI. Adult Sprague-Dawley rats were randomly divided into three equal groups (S: sham-operated, N: normothermia, and H: mild hypothermia). After TBI induced by fluid percussion, group N remained at normal temperature, and group H underwent MIH (32°C) for 6 hours. Behavioral scale scores were then assessed. All rats were sacrificed 24 hours and hippocampal tissues were harvested, stained with hematoxylin and eosin. mRNA and protein expressions of Aβ, β-amyloid protein precursor (APP), and β-secretase (BACE) were analyzed. Our results revealed significantly improved behavioral scale scores and the surviving neuron numbers were observed in group H compared to group N (p<0.05). Additionally, group N increased APP, Aβ, and BACE levels compared to group S (all p<0.05). Reduced expression of APP-, Aβ-, and BACE were apparent in group H compared to group N (all p<0.05). However, no statistically significant difference was observed between groups H and S in behavioral scale scores and the expression of APP-, Aβ-, and BACE (p>0.05). In conclusion, MIH treatment significantly improves the survival of neuron and reduced Aβ, BACE, and APP upregulation after TBI, which may provide a better understanding of the mechanisms by which hypothermia reduces SBI in TBI patients.
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Affiliation(s)
- Shi-Xiang Cheng
- Institute of Traumatic Brain Injury and Neuroscience, Center for Neurology and Neurosurgery, Pingjin Hospital , Logistics College of the Chinese People's Armed Police Forces, Tianjin, China
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127
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Pelosi P, Sutherasan Y. High-frequency oscillatory ventilation with tracheal gas insufflation: the rescue strategy for brain-lung interaction. Crit Care 2013; 17:R179. [PMID: 23981807 PMCID: PMC4057213 DOI: 10.1186/cc12862] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
The occurrence of moderate to severe acute respiratory distress syndrome due to traumatic brain injury is not uncommon and is associated with an extremely high incidence of morbidity and mortality. Owing to the complex interaction between the lung and brain, protective ventilation for the lung with lower tidal volume and higher positive end-expiratory pressure with or without mild hypercapnia might be harmful for the brain, and maintaining normocapnia or mild hypocapnia by increasing tidal volume or respiratory rate (or both) with lower positive end-expiratory pressure levels for protecting the brain might lead to ventilator-induced lung injury. Balancing the end-point between lungs and brain becomes a challenging issue, and non-conventional modes of mechanical ventilation might play a role in the more difficult clinical cases. In this commentary, the authors discuss the rationale, based on the physiologic principle of targeting both vital organs, of applying high-frequency oscillation and tracheal gas insufflation in acute respiratory distress syndrome patients with traumatic brain injury.
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Affiliation(s)
- Paolo Pelosi
- IRCCS AOU San Martino-IST, Department of Surgical Sciences and Integrated
Diagnostics, University of Genoa, Largo Rosanna Benzi 8, 16132, Genova,
Italy
| | - Yuda Sutherasan
- Ramathibodi Hospital, Rama 6 Road, Mahidol University, 10400, Bangkok,
Thailand
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128
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Raj R, Bendel S, Reinikainen M, Kivisaari R, Siironen J, Lång M, Skrifvars M. Hyperoxemia and long-term outcome after traumatic brain injury. Crit Care 2013; 17:R177. [PMID: 23958227 PMCID: PMC4056982 DOI: 10.1186/cc12856] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Accepted: 08/06/2013] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION The relationship between hyperoxemia and outcome in patients with traumatic brain injury (TBI) is controversial. We sought to investigate the independent relationship between hyperoxemia and long-term mortality in patients with moderate-to-severe traumatic brain injury. METHODS The Finnish Intensive Care Consortium database was screened for mechanically ventilated patients with a moderate-to-severe TBI. Patients were categorized, according to the highest measured alveolar-arterial O₂ gradient or the lowest measured PaO₂ value during the first 24 hours of ICU admission, to hypoxemia (<10.0 kPa), normoxemia (10.0 to 13.3 kPa) and hyperoxemia (>13.3 kPa). We adjusted for markers of illness severity to evaluate the independent relationship between hyperoxemia and 6-month mortality. RESULTS A total of 1,116 patients were included in the study, of which 16% (n = 174) were hypoxemic, 51% (n = 567) normoxemic and 33% (n = 375) hyperoxemic. The total 6-month mortality was 39% (n = 435). A significant association between hyperoxemia and a decreased risk of mortality was found in univariate analysis (P = 0.012). However, after adjusting for markers of illness severity in a multivariate logistic regression model hyperoxemia showed no independent relationship with 6-month mortality (hyperoxemia vs. normoxemia OR 0.88, 95% CI 0. 63 to 1.22, P = 0.43; hyperoxemia vs. hypoxemia OR 0.97, 95% CI 0.63 to 1.50, P = 0.90). CONCLUSION Hyperoxemia in the first 24 hours of ICU admission after a moderate-to-severe TBI is not predictive of 6-month mortality.
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Affiliation(s)
- Rahul Raj
- Department of Neurosurgery, Helsinki University Central Hospital, Topeliuksenkatu 5 FI-00029 HUS Helsinki,Finland
| | - Stepani Bendel
- Department of Intensive Care Medicine, Kuopio University Hospital and Kuopio University, Puijonlaaksontie 2, 70211 Kuopio, Finland
| | - Matti Reinikainen
- Department of Intensive Care Medicine, North Karelia Central Hospital, Tikkamäentie 16, 80210 Joensuu, Finland
| | - Riku Kivisaari
- Department of Neurosurgery, Helsinki University Central Hospital, Topeliuksenkatu 5 FI-00029 HUS Helsinki,Finland
| | - Jari Siironen
- Department of Neurosurgery, Helsinki University Central Hospital, Topeliuksenkatu 5 FI-00029 HUS Helsinki,Finland
| | - Maarit Lång
- Department of Intensive Care Medicine, Kuopio University Hospital and Kuopio University, Puijonlaaksontie 2, 70211 Kuopio, Finland
| | - Markus Skrifvars
- Department of Neurosurgery, Helsinki University Central Hospital, Topeliuksenkatu 5 FI-00029 HUS Helsinki,Finland
- Department of Anesthesiology and Intensive Care Medicine, Helsinki University Central Hospital, Helsinki, Finland
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Cook AM, Arora S, Davis J, Pittman T. Augmented Renal Clearance of Vancomycin and Levetiracetam in a Traumatic Brain Injury Patient. Neurocrit Care 2013; 19:210-4. [DOI: 10.1007/s12028-013-9837-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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130
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Graetz D, Nagel A, Schlenk F, Sakowitz O, Vajkoczy P, Sarrafzadeh A. High ICP as trigger of proinflammatory IL-6 cytokine activation in aneurysmal subarachnoid hemorrhage. Neurol Res 2013; 32:728-35. [DOI: 10.1179/016164109x12464612122650] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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131
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Brandner S, Thaler C, Buchfelder M, Kleindienst A. Brain-derived protein concentrations in the cerebrospinal fluid: contribution of trauma resulting from ventricular drain insertion. J Neurotrauma 2013; 30:1205-10. [PMID: 23390981 DOI: 10.1089/neu.2012.2621] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
In recent years, the measurement of biomarkers following neurotrauma assisted in improving outcome prediction and guiding therapy. The use of neuroproteins as diagnostic parameters requires a detailed knowledge of their dynamics in biological fluids for an appropriate interpretation. S100B is the most widely studied neuromarker, and its concentration in serum and cerebrospinal fluid (CSF) reflects the extent of brain damage. Neuron-specific enolase (NSE) is considered reflecting neuronal damage, while Beta-Trace is a lepto-meningeal protein used to diagnose CSF leakage. In five patients treated with an external ventricular drain (EVD) because of aneurysmal subarachnoid hemorrhage (SAH, n=3) or postinfectious hydrocephalus (n=2), an EVD exchange was performed 8 to 12 days after initial insertion. S100B and NSE were measured with the Cobas e411(®) electrochemiluminescence assay (Roche Diagnostics, Mannheim, Germany) and Beta-Trace with the BN Pro Spec(®) nephelometer (Dade Behring/Siemens, Germany) 1 h before EVD exchange, upon the insertion of the new drain, and 1, 3, 6, 12, 18, 24 and 48 h after EVD exchange. Before EVD exchange, S100B CSF concentrations were within the normal range in all patients (1.48 ± 0.37 μg/L), while NSE CSF concentrations were normal in four of five patients (6.51 ± 2.98 μg/L). Following EVD exchange, S100B and NSE CSF levels peaked significantly at 3 h after insertion of the new drain (S100B 39.02 ± 9.17 μg/L; NSE 54.80 ± 43.34 μg/L). S100B serum levels were slightly increased 6 to 24 h after EVD exchange. Beta-Trace concentrations in the CSF were not altered by EVD insertion. Our data demonstrate that EVD insertion results in a distinct increase of S100B and NSE concentrations in the CSF. Thus, the tampering of brain-derived protein concentrations in the CSF by diagnostic or therapeutic procedures has to be considered in the interpretation of neuromarker levels.
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Abstract
The choice of fluid for resuscitation of the brain-injured patient remains controversial, and the 'ideal' resuscitation fluid has yet to be identified. Large volumes of hypotonic solutions must be avoided because of the risk of cerebral swelling and intracranial hypertension. Traditionally, 0.9% sodium chloride has been used in patients at risk of intracranial hypertension, but there is increasing recognition that 0.9% saline is not without its problems. Roquilly and colleagues show a reduction in the development of hyperchloremic acidosis in brain-injured patients given 'balanced' solutions for maintenance and resuscitation compared with 0.9% sodium chloride. In this commentary, we explore the idea that we should move away from 0.9% sodium chloride in favor of a more 'physiological' solution.
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Affiliation(s)
- Euan McIntosh
- Department of Anaesthesia & Critical Care, Royal Infirmary of Edinburgh, NHS Lothian, 51 Little France Crescent, Edinburgh EH16 4SA, UK
- The Army Medical Corps, Dreghorn Barracks, Redford Road, The City of Edinburgh Bypass, Edinburgh EH13 9QW, UK
| | - Peter J Andrews
- Centre for Clinical Brain Sciences, The University of Edinburgh, Chancellor's Building, Edinburgh EH16 4SB, UK
- NHS Lothian, Western General Hospital, Edinburgh EH12 6ER, UK
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Goyal A, Failla MD, Niyonkuru C, Amin K, Fabio A, Berger RP, Wagner AK. S100b as a prognostic biomarker in outcome prediction for patients with severe traumatic brain injury. J Neurotrauma 2013; 30:946-57. [PMID: 23190274 PMCID: PMC3684103 DOI: 10.1089/neu.2012.2579] [Citation(s) in RCA: 116] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
As an astrocytic protein specific to the central nervous system, S100b is a potentially useful marker in outcome prediction after traumatic brain injury (TBI). Some studies have questioned the validity of S100b, citing the extracerebral origins of the protein as reducing the specificity of the marker. This study evaluated S100b as a prognostic biomarker in adult subjects with severe TBI (sTBI) by comparing outcomes with S100b temporal profiles generated from both cerebrospinal fluid (CSF) (n = 138 subjects) and serum (n = 80 subjects) samples across a 6-day time course. Long-bone fracture, Injury Severity Score (ISS), and isolated head injury status were variables used to assess extracerebral sources of S100b in serum. After TBI, CSF and serum S100b levels were increased over healthy controls across the first 6 days post-TBI (p ≤ 0.005 and p ≤ 0.031). Though CSF and serum levels were highly correlated during early time points post-TBI, this association diminished over time. Bivariate analysis showed that subjects who had temporal CSF profiles with higher S100b concentrations had higher acute mortality (p < 0.001) and worse Glasgow Outcome Scale (GOS; p = 0.002) and Disability Rating Scale (DRS) scores (p = 0.039) 6 months post-injury. Possibly as a result of extracerebral sources of S100b in serum, as represented by high ISS scores (p = 0.032), temporal serum profiles were associated with acute mortality (p = 0.015). High CSF S100b levels were observed in women (p = 0.022) and older subjects (p = 0.004). Multivariate logistic regression confirmed CSF S100b profiles in predicting GOS and DRS and showed mean and peak serum S100b as acute mortality predictors after sTBI.
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Affiliation(s)
- Akash Goyal
- Department Of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Michelle D. Failla
- Department Of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania
- Center for Neuroscience, University of Pittsburgh, Pittsburgh, Pennsylvania
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Christian Niyonkuru
- Department Of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Krutika Amin
- Department Of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Anthony Fabio
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Rachel P. Berger
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Amy K. Wagner
- Department Of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania
- Center for Neuroscience, University of Pittsburgh, Pittsburgh, Pennsylvania
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania
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Abstract
Comparative effectiveness research (CER) is emerging as a commonly applied technique to determine the usefulness of medical interventions. Such research aims to compare various treatments for specific disease entities for overall effectiveness and potential for harm. According to the Centers for Disease Control, an estimated 1.7 million patients sustain a traumatic brain injury (TBI) annually in the US. In this review the authors examine the existence of CER reports in the area of neurotrauma to date and consider the context in which clinical research and evidence-based guidelines have and will continue to inform such analyses, with special attention to TBI.
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Affiliation(s)
- Shelly D Timmons
- Department of Neurosurgery, Geisinger Health System, 100 Academy Avenue North, Danville, PA 17822, USA.
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136
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Rockswold SB, Rockswold GL, Zaun DA, Liu J. A prospective, randomized Phase II clinical trial to evaluate the effect of combined hyperbaric and normobaric hyperoxia on cerebral metabolism, intracranial pressure, oxygen toxicity, and clinical outcome in severe traumatic brain injury. J Neurosurg 2013; 118:1317-28. [PMID: 23510092 DOI: 10.3171/2013.2.jns121468] [Citation(s) in RCA: 101] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECT Preclinical and clinical investigations indicate that the positive effect of hyperbaric oxygen (HBO2) for severe traumatic brain injury (TBI) occurs after rather than during treatment. The brain appears better able to use baseline O2 levels following HBO2 treatments. In this study, the authors evaluate the combination of HBO2 and normobaric hyperoxia (NBH) as a single treatment. METHODS Forty-two patients who sustained severe TBI (mean Glasgow Coma Scale [GCS] score 5.7) were prospectively randomized within 24 hours of injury to either: 1) combined HBO2/NBH (60 minutes of HBO2 at 1.5 atmospheres absolute [ATA] followed by NBH, 3 hours of 100% fraction of inspired oxygen [FiO2] at 1.0 ATA) or 2) control, standard care. Treatments occurred once every 24 hours for 3 consecutive days. Intracranial pressure, surrogate markers for cerebral metabolism, and O2 toxicity were monitored. Clinical outcome was assessed at 6 months using the sliding dichotomized Glasgow Outcome Scale (GOS) score. Mixed-effects linear modeling was used to statistically test differences between the treatment and control groups. Functional outcome and mortality rates were compared using chi-square tests. RESULTS There were no significant differences in demographic characteristics between the 2 groups. In comparison with values in the control group, brain tissue partial pressure of O2 (PO2) levels were significantly increased during and following combined HBO2/NBH treatments in both the noninjured and pericontusional brain (p < 0.0001). Microdialysate lactate/pyruvate ratios were significantly decreased in the noninjured brain in the combined HBO2/NBH group as compared with controls (p < 0.0078). The combined HBO2/NBH group's intracranial pressure values were significantly lower than those of the control group during treatment, and the improvement continued until the next treatment session (p < 0.0006). The combined HBO2/NBH group's levels of microdialysate glycerol were significantly lower than those of the control group in both noninjured and pericontusional brain (p < 0.001). The combined HBO2/NBH group's level of CSF F2-isoprostane was decreased at 6 hours after treatment as compared with that of controls, but the difference did not quite reach statistical significance (p = 0.0692). There was an absolute 26% reduction in mortality for the combined HBO2/NBH group (p = 0.048) and an absolute 36% improvement in favorable outcome using the sliding dichotomized GOS (p = 0.024) as compared with the control group. CONCLUSIONS In this Phase II clinical trial, in comparison with standard care (control treatment) combined HBO2/NBH treatments significantly improved markers of oxidative metabolism in relatively uninjured brain as well as pericontusional tissue, reduced intracranial hypertension, and demonstrated improvement in markers of cerebral toxicity. There was significant reduction in mortality and improved favorable outcome as measured by GOS. The combination of HBO2 and NBH therapy appears to have potential therapeutic efficacy as compared with the 2 treatments in isolation. CLINICAL TRIAL REGISTRATION NO.: NCT00170352 (ClinicalTrials.gov).
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Affiliation(s)
- Sarah B Rockswold
- Department of Physical Medicine and Rehabilitation, University of Minnesota, Minneapolis, Minnesota, USA
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137
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High-dose barbiturates for refractory intracranial hypertension in children with severe traumatic brain injury. Pediatr Crit Care Med 2013; 14:239-47. [PMID: 23392360 DOI: 10.1097/pcc.0b013e318271c3b2] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To evaluate high-dose barbiturates as a second-tier therapy for pediatric refractory intracranial hypertension complicating severe traumatic brain injury. DESIGN This is a retrospective cohort study of children with refractory intracranial hypertension treated with high-dose barbiturates. SETTING A single center level I pediatric trauma from 2001 to 2010. PATIENTS Thirty-six children with refractory intracranial hypertension defined as intracranial pressure greater than 20 mm Hg despite standard management treated with high-dose barbiturates after severe traumatic brain injury. INTERVENTIONS High-dose barbiturates were administered for refractory intracranial hypertension for a minimum duration of 6 hours and monitored by continuous electroencephalography. MEASUREMENTS AND MAIN RESULTS Exposure was control of refractory intracranial hypertension defined as > 20 mm Hg within 6 hours after starting barbiturates. Pediatric cerebral performance category scores at hospital discharge and at 3 months (or longer) follow-up were the primary outcomes. Ten of 36 patients (28%) had control of refractory intracranial hypertension. Neither demographic nor injury characteristics were associated with refractory intracranial hypertension control. Children who responded received barbiturates significantly later after injury (76 vs. 29 median hours). Overall, 14 children died, 13 without control of intracranial pressure. Survival was more common in those who responded compared with those who did not respond to high-dose barbiturates, although this did not reach statistical significance (relative risk of death 0.2; 95% confidence interval; [0.03-1.3]). Of the 22 survivors, 19 had an acceptable survival (pediatric cerebral performance category less than 3) at 3 months or longer after injury; however, only three returned to normal function. Among survivors, control of refractory intracranial hypertension was associated with significantly better pediatric cerebral performance category scores and over two-fold likelihood of acceptable long-term outcome (relative risk 2.3; 95% confidence interval [1.4-4.0]) compared with uncontrolled refractory intracranial hypertension despite high-dose barbiturates. CONCLUSIONS Addition of high-dose barbiturates achieved control of refractory intracranial hypertension in almost 30% of treated children. Control of refractory intracranial hypertension was associated with increased likelihood of an acceptable long-term outcome.
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138
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Clinical predictors of outcome following inflicted traumatic brain injury in children. J Trauma Acute Care Surg 2013; 73:S248-53. [PMID: 23026962 DOI: 10.1097/ta.0b013e31826b0062] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The study aimed to determine which acute injury variables were predictors of long-term functional outcome following inflicted traumatic brain injury (iTBI). METHODS A retrospective case review of 35 children with iTBI was performed. After controlling for age at injury and time since injury, the generalized estimation equations method was used to identify acute injury variables that were significantly related to the Glasgow Outcome Scale scores at the initial follow-up assessments. When available, functional sequelae at these and longer-term follow-ups were also examined. RESULTS In bivariate generalized estimation equations analyses, a low Glasgow Coma Scale (GCS) eye component score, a low GCS motor component score, a low GCS verbal component score, need for neurosurgical intervention, seizures in the first week after injury, need for mechanical ventilation for more than 10 days, length of intensive care unit stay of more than 10 days, initial hyperglycemia, and neuroimaging findings of cerebral edema or loss of gray-white matter differentiation were significantly (p ≤ 0.05) related to having a poor outcome, as defined by their Glasgow Outcome Scale score at the initial follow-up. In multivariable analyses, considering the significant predictors while controlling for age at injury and time since injury, the presence of cerebral edema on neuroimaging (odds ratio, 27.21; 95% confidence interval, 4.40-168.22), and length of intensive care unit stay of more than 10 days (odds ratio, 21.57; 95% confidence interval, 3.09-150.48) were significantly related to having a poor outcome. CONCLUSION Early clinical data following iTBI help predict long-term functional outcome. Further research to support these findings may help delineate acutely after injury which children with iTBI are at risk for a poor prognosis and should be more closely followed up over time. LEVEL OF EVIDENCE Prognostic study, level IV.
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139
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Chesnut RM, Temkin N, Carney N, Dikmen S, Rondina C, Videtta W, Petroni G, Lujan S, Pridgeon J, Barber J, Machamer J, Chaddock K, Celix JM, Cherner M, Hendrix T. A trial of intracranial-pressure monitoring in traumatic brain injury. N Engl J Med 2012; 367:2471-81. [PMID: 23234472 PMCID: PMC3565432 DOI: 10.1056/nejmoa1207363] [Citation(s) in RCA: 800] [Impact Index Per Article: 66.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Intracranial-pressure monitoring is considered the standard of care for severe traumatic brain injury and is used frequently, but the efficacy of treatment based on monitoring in improving the outcome has not been rigorously assessed. METHODS We conducted a multicenter, controlled trial in which 324 patients 13 years of age or older who had severe traumatic brain injury and were being treated in intensive care units (ICUs) in Bolivia or Ecuador were randomly assigned to one of two specific protocols: guidelines-based management in which a protocol for monitoring intraparenchymal intracranial pressure was used (pressure-monitoring group) or a protocol in which treatment was based on imaging and clinical examination (imaging-clinical examination group). The primary outcome was a composite of survival time, impaired consciousness, and functional status at 3 months and 6 months and neuropsychological status at 6 months; neuropsychological status was assessed by an examiner who was unaware of protocol assignment. This composite measure was based on performance across 21 measures of functional and cognitive status and calculated as a percentile (with 0 indicating the worst performance, and 100 the best performance). RESULTS There was no significant between-group difference in the primary outcome, a composite measure based on percentile performance across 21 measures of functional and cognitive status (score, 56 in the pressure-monitoring group vs. 53 in the imaging-clinical examination group; P=0.49). Six-month mortality was 39% in the pressure-monitoring group and 41% in the imaging-clinical examination group (P=0.60). The median length of stay in the ICU was similar in the two groups (12 days in the pressure-monitoring group and 9 days in the imaging-clinical examination group; P=0.25), although the number of days of brain-specific treatments (e.g., administration of hyperosmolar fluids and the use of hyperventilation) in the ICU was higher in the imaging-clinical examination group than in the pressure-monitoring group (4.8 vs. 3.4, P=0.002). The distribution of serious adverse events was similar in the two groups. CONCLUSIONS For patients with severe traumatic brain injury, care focused on maintaining monitored intracranial pressure at 20 mm Hg or less was not shown to be superior to care based on imaging and clinical examination. (Funded by the National Institutes of Health and others; ClinicalTrials.gov number, NCT01068522.).
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Affiliation(s)
- Randall M Chesnut
- Department of Neurological Surgery, University of Washington, Harborview Medical Center, Seattle, WA 98104, USA.
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Chen H, Guo Y, Chen SW, Wang G, Cao HL, Chen J, Gu Y, Tian HL. Progressive epidural hematoma in patients with head trauma: incidence, outcome, and risk factors. Emerg Med Int 2012; 2012:134905. [PMID: 23320175 PMCID: PMC3536037 DOI: 10.1155/2012/134905] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2012] [Revised: 11/15/2012] [Accepted: 11/15/2012] [Indexed: 12/25/2022] Open
Abstract
Progressive epidural hematoma (PEDH) after head injury is often observed on serial computerized tomography (CT) scans. Recent advances in imaging modalities and treatment might affect its incidence and outcome. In this study, PEDH was observed in 9.2% of 412 head trauma patients in whom two CT scans were obtained within 24 hours of injury, and in a majority of cases, it developed within 3 days after injury. In multivariate logistic regression, patient gender, age, Glasgow Coma Scale (GCS) score at admission, and skull fracture were not associated with PEDH, whereas hypotension (odds ratio (OR) 0.38, 95% confidence interval (CI) 0.17-0.84), time interval of the first CT scanning (OR 0.42, 95% CI 0.19-0.83), coagulopathy (OR 0.36, 95% CI 0.15-0.85), or decompressive craniectomy (DC) (OR 0.46, 95% CI 0.21-0.97) was independently associated with an increased risk of PEDH. The 3-month postinjury outcome was similar in patients with PEDH and patients without PEDH (χ(2) = 0.07, P = 0.86). In conclusion, epidural hematoma has a greater tendency to progress early after injury, often in dramatic and rapid fashion. Recognition of this important treatable cause of secondary brain injury and the associated risk factors may help identify the group at risk and tailor management of patients with TBI.
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Affiliation(s)
- Hao Chen
- Department of Neurosurgery, Shanghai sixth People Hospital, Shanghai Jiaotong University, Shanghai 200233, China
| | - Yan Guo
- Department of Neurosurgery, Shanghai sixth People Hospital, Shanghai Jiaotong University, Shanghai 200233, China
| | - Shi-Wen Chen
- Department of Neurosurgery, Shanghai sixth People Hospital, Shanghai Jiaotong University, Shanghai 200233, China
| | - Gan Wang
- Department of Neurosurgery, Shanghai sixth People Hospital, Shanghai Jiaotong University, Shanghai 200233, China
| | - He-Li Cao
- Department of Neurosurgery, Shanghai sixth People Hospital, Shanghai Jiaotong University, Shanghai 200233, China
| | - Jiong Chen
- Department of Neurosurgery, Shanghai sixth People Hospital, Shanghai Jiaotong University, Shanghai 200233, China
| | - Yi Gu
- Department of Neurosurgery, Shanghai sixth People Hospital, Shanghai Jiaotong University, Shanghai 200233, China
| | - Heng-Li Tian
- Department of Neurosurgery, Shanghai sixth People Hospital, Shanghai Jiaotong University, Shanghai 200233, China
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Sheridan RL, Schaefer PW, Whalen M, Fagan S, Stoddard FJ, Schneider JC, McConkey B, Cancio LC. Case records of the Massachusetts General Hospital. Case 36-2012. Recovery of a 16-year-old girl from trauma and burns after a car accident. N Engl J Med 2012; 367:2027-37. [PMID: 23171100 DOI: 10.1056/nejmcpc1200088] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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142
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Cooper DJ, Rosenfeld JV, Wolfe R. DECRA investigators' response to "The future of decompressive craniectomy for diffuse traumatic brain injury" by Honeybul et al. J Neurotrauma 2012; 29:2595-6. [PMID: 22853315 DOI: 10.1089/neu.2011.2279] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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143
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Flower O, Hellings S. Sedation in traumatic brain injury. Emerg Med Int 2012; 2012:637171. [PMID: 23050154 PMCID: PMC3461283 DOI: 10.1155/2012/637171] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Revised: 05/16/2012] [Accepted: 06/22/2012] [Indexed: 02/08/2023] Open
Abstract
Several different classes of sedative agents are used in the management of patients with traumatic brain injury (TBI). These agents are used at induction of anaesthesia, to maintain sedation, to reduce elevated intracranial pressure, to terminate seizure activity and facilitate ventilation. The intent of their use is to prevent secondary brain injury by facilitating and optimising ventilation, reducing cerebral metabolic rate and reducing intracranial pressure. There is limited evidence available as to the best choice of sedative agents in TBI, with each agent having specific advantages and disadvantages. This review discusses these agents and offers evidence-based guidance as to the appropriate context in which each agent may be used. Propofol, benzodiazepines, narcotics, barbiturates, etomidate, ketamine, and dexmedetomidine are reviewed and compared.
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Affiliation(s)
- Oliver Flower
- University of Sydney, Sydney, NSW, Australia
- Department of Intensive Care, Royal North Shore Hospital, Sydney, NSW 2065, Australia
| | - Simon Hellings
- Department of Intensive Care, Royal North Shore Hospital, Sydney, NSW 2065, Australia
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Controversies in the management of adults with severe traumatic brain injury. AACN Adv Crit Care 2012; 23:188-203. [PMID: 22543492 DOI: 10.1097/nci.0b013e31824db4f3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Despite progress in the management of adults with severe traumatic brain injury, several controversies persist. Among the unresolved issues of greatest concern to neurocritical care clinicians and scientists are the following: (1) the best use of technological advances and the data obtained from multimodality monitoring; (2) the use of mannitol and hypertonic saline in the management of increased intracranial pressure; (3) the use of decompressive craniectomy and barbiturate coma in refractory increased intracranial pressure; (4) therapeutic hypothermia as a neuroprotectant; (5) anemia and the role of blood transfusion; and (6) venous thromboembolism prophylaxis in severe traumatic brain injury. Each of these strategies for managing severe traumatic brain injury, including the postulated mechanism(s) of action and beneficial effects of each intervention, adverse effects, the state of the science, and critical care nursing implications, is discussed.
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Cianchi G, Bonizzoli M, Zagli G, di Valvasone S, Biondi S, Ciapetti M, Perretta L, Mariotti F, Peris A. Late decompressive craniectomyafter traumatic brain injury: neurological outcome at 6 months after ICU discharge. J Trauma Manag Outcomes 2012; 6:8. [PMID: 22867014 PMCID: PMC3489798 DOI: 10.1186/1752-2897-6-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Accepted: 07/23/2012] [Indexed: 11/18/2022]
Abstract
INTRODUCTION The choice of optimal treatment in traumatic brain injured (TBI) patients is a challenge. The aim of this study was to verify the neurological outcome of severe TBI patients treated with decompressive craniectomy (early < 24 h, late > 24 h), compared to conservative treatment, in hospital and after 6-months. METHODS A total of 186 TBI patients admitted to the ICU of the Emergency Department of a tertiary referral center (Careggi Teaching Hospital, Florence, Italy) from 2005 through 2009 were retrospectively studied. Patients treated with decompressive craniectomy were divided into 2 groups: "early craniectomy group" (patients who underwent to craniectomy within the first 24 hours); and "late craniectomy group" (patients who underwent to craniectomy later than the first 24 hours). As a control group, patients whose intracranial hypertension was successfully controlled by medical treatment were included in the "no craniectomy group". RESULTS Groups included 41 patients who required early decompressive craniectomy, 21 patients treated with late craniectomy (7.7 days after trauma, on average), and 124 patients for whom intracranial hypertension was successfully controlled through conservative treatment. Groups were comparable in age and trauma/critical illness scores, except for a significantly higher Marshall score in early craniectomized patients. The Glasgow Outcome Scale was comparable between groups at ICU, at the time of hospital discharge and at 6 months. CONCLUSIONS In our sample, a late craniectomy in patients with refractory intracranial hypertension produced a comparable 6-months neurological outcome if compared to patients responder to standard treatment. This data must be reproduced and confirmed before considering as goal-treatment in refractory intracranial hypertension.
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Affiliation(s)
- Giovanni Cianchi
- Anesthesia and Intensive Care Unit of Emergency Department, Careggi Teaching Hospital, Largo Brambilla 3, 50139 Florence, Italy
| | - Manuela Bonizzoli
- Anesthesia and Intensive Care Unit of Emergency Department, Careggi Teaching Hospital, Largo Brambilla 3, 50139 Florence, Italy
| | - Giovanni Zagli
- Anesthesia and Intensive Care Unit of Emergency Department, Careggi Teaching Hospital, Largo Brambilla 3, 50139 Florence, Italy
| | - Simona di Valvasone
- Postgraduate School of Anesthesia and Intensive Care, Careggi Teaching Hospital, Largo Brambilla 3, 50139, Florence, Italy
| | - Simona Biondi
- Postgraduate School of Anesthesia and Intensive Care, Careggi Teaching Hospital, Largo Brambilla 3, 50139, Florence, Italy
| | - Marco Ciapetti
- Anesthesia and Intensive Care Unit of Emergency Department, Careggi Teaching Hospital, Largo Brambilla 3, 50139 Florence, Italy
| | - Lucia Perretta
- Anesthesia and Intensive Care Unit of Emergency Department, Careggi Teaching Hospital, Largo Brambilla 3, 50139 Florence, Italy
| | - Furio Mariotti
- Department of Neurosurgery, Careggi Teaching Hospital, Largo Brambilla 3, 50139, Florence, Italy
| | - Adriano Peris
- Anesthesia and Intensive Care Unit of Emergency Department, Careggi Teaching Hospital, Largo Brambilla 3, 50139 Florence, Italy
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146
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Sekhon MS, McLean N, Henderson WR, Chittock DR, Griesdale DEG. Association of hemoglobin concentration and mortality in critically ill patients with severe traumatic brain injury. Crit Care 2012; 16:R128. [PMID: 22817913 PMCID: PMC3580711 DOI: 10.1186/cc11431] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Accepted: 07/20/2012] [Indexed: 11/23/2022] Open
Abstract
Introduction The critical care management of traumatic brain injury focuses on preventing secondary ischemic injury. Cerebral oxygen delivery is dependent upon the cerebral perfusion pressure and the oxygen content of blood, which is principally determined by hemoglobin. Despite its importance to the cerebral oxygen delivery, the precise hemoglobin concentration to provide adequate oxygen delivery to injured neuronal tissue in TBI patients is controversial with limited evidence to provide transfusion thresholds. Methods We conducted a retrospective cohort study of severe TBI patients, investigating the association between mean 7-day hemoglobin concentration and hospital mortality. Demographic, physiologic, intensive care interventions, clinical outcomes and daily hemoglobin concentrations were recorded for all patients. Patients were all cared for at a tertiary, level 1 trauma center in a mixed medical and surgical intensive unit. Patients were divided into quartiles based on their mean 7-day hemoglobin concentration: < 90 g/L, 90 - 99 g/L, 100 - 109 g/L and > 110 g/L. Multivariable log-binomial regression was used to model the association between mean daily hemoglobin concentration and hospital mortality. Results Two hundred seventy-three patients with traumatic brain injury were identified and 169 were included in the analysis based on inclusion/exclusion criteria. Of these, 77% of the patients were male, with a mean age of 38 (SD 17) years and a median best GCS of 6 (IQR 5 - 7). One hundred fifteen patients (68%) received a red blood cell (RBC) transfusion. In RBCs administered in the ICU, the median pre-transfusion hemoglobin was 79 g/L (IQR 73 - 85). Thirty-seven patients (22%) died in hospital. Multivariable analysis revealed that mean 7-day hemoglobin concentration < 90 g/L was independently associated with an increased risk of hospital mortality (RR 3.1, 95% CI 1.5 - 6.3, p = 0.03). Other variables associated with increased mortality on multivariable regression were insertion of external ventricular drain, age and decreased GCS. Red blood cell transfusion was not associated with mortality following multivariable adjustment. Conclusions A mean 7-day hemoglobin concentration of < 90g/L is associated with increased hospital mortality in patients with severe traumatic brain injury.
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147
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Mondello S, Gabrielli A, Catani S, D'Ippolito M, Jeromin A, Ciaramella A, Bossù P, Schmid K, Tortella F, Wang KKW, Hayes RL, Formisano R. Increased levels of serum MAP-2 at 6-months correlate with improved outcome in survivors of severe traumatic brain injury. Brain Inj 2012; 26:1629-35. [PMID: 22794497 DOI: 10.3109/02699052.2012.700083] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To evaluate microtubule-associated proteins (MAP-2), a dendritic marker of both acute damage and chronic neuronal regeneration after injury, in serum of survivors after severe TBI and examine the association with long-term outcome. METHODS Serum concentrations of MAP-2 were evaluated in 16 patients with severe TBI (Glasgow Coma Scale score [GCS] ≤ 8) 6 months post-injury and in 16 controls. Physical and cognitive outcomes were assessed, using the Glasgow Outcome Scale Extended (GOSE) and Levels of Cognitive Functioning Scale (LCFS), respectively. RESULTS Severe TBI patients had significantly higher serum MAP-2 concentrations than normal controls with no history of TBI (p = 0.008) at 6 months post-injury. MAP-2 levels correlated with the GOSE (r = 0.58, p = 0.02) and LCFS (r = 0.65, p = 0.007) at month 6. Significantly lower serum levels of MAP-2 were observed in patients in a vegetative state (VS) compared to non-VS patients (p < 0.05). A trend tracking the level of consciousness was observed. CONCLUSIONS Severe TBI results in a chronic release of MAP-2 into the peripheral circulation in patients with higher levels of consciousness, suggesting that remodelling of synaptic junctions and neuroplasticity processes occur several months after injury. The data indicate MAP-2 as a potential marker for emergence to higher levels of cognitive function.
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Affiliation(s)
- Stefania Mondello
- University of Florida, Department of Anesthesiology, Gainesville, FL, USA.
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Pearson WS, Ovalle F, Faul M, Sasser SM. A review of traumatic brain injury trauma center visits meeting physiologic criteria from The American College of Surgeons Committee on Trauma/Centers for Disease Control and Prevention Field Triage Guidelines. PREHOSP EMERG CARE 2012; 16:323-8. [PMID: 22548387 PMCID: PMC4959004 DOI: 10.3109/10903127.2012.682701] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) represents a serious subset of injuries among persons in the United States, and prehospital care of these injuries can mitigate both the morbidity and the mortality in patients who suffer from these injuries. Guidelines for triage of injured patients have been set forth by the American College of Surgeons Committee on Trauma (ACS-COT) in cooperation with the Centers for Disease Control and Prevention (CDC). These guidelines include physiologic criteria, such as the Glasgow Coma Scale (GCS) score, systolic blood pressure, and respiratory rate, which should be used in determining triage of an injured patient. OBJECTIVES This study examined the numbers of visits at level I and II trauma centers by patients with a diagnosed TBI to determine the prevalence of those meeting physiologic criteria from the ACS-COT/CDC guidelines and to determine the extent of mortality among this patient population. METHODS The data for this study were taken from the 2007 National Trauma Data Bank (NTDB) National Sample Program (NSP). This data set is a nationally representative sample of visits to level I and II trauma centers across the United States and is funded by the American College of Surgeons. Estimates of demographic characteristics, physiologic measures, and death were made for this study population using both chi-square analyses and adjusted logistic regression modeling. RESULTS The analyses demonstrated that although many people who sustain a TBI and were taken to a level I or II trauma center did not meet the physiologic criteria, those who did meet the physiologic criteria had significantly higher odds of death than those who did not meet the criteria. After controlling for age, gender, race, Injury Severity Score (ISS), and length of stay in the hospital, persons who had a GCS score ≤13 were 17 times more likely to die than TBI patients who had a higher GCS score (odds ratio [OR] 17.4; 95% confidence interval [CI] 10.7-28.3). Other physiologic criteria also demonstrated significant odds of death. CONCLUSIONS These findings support the validity of the ACS-COT/CDC physiologic criteria in this population and stress the importance of prehospital triage of patients with TBI in the hopes of reducing both the morbidity and the mortality resulting from this injury.
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Affiliation(s)
- William S Pearson
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia 30341, USA.
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Impact of elevated ICP on outcome after paediatric traumatic brain injury requiring intensive care. Childs Nerv Syst 2012; 28:1069-75. [PMID: 22573139 DOI: 10.1007/s00381-012-1772-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2011] [Accepted: 04/12/2012] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Traumatic brain injury is an important cause of morbidity and mortality in children and adolescents. Moderate to severe brain injuries account for approximately 20 % of all brain injuries, and nearly 50 % of the patients experience neuropsychological sequelae due to the injury. The purposes of this study are, firstly, to describe intensive care management of children with a severe brain injury and, secondly, to study the impact of elevated intracranial pressure on outcome. METHODS A retrospective review of medical records was done. RESULTS Sixty children were admitted for intensive care during the study period. Seventy-three percent of all children received neurosurgical interventions, 26 children received an intracranial pressure-monitoring device and 14 of those had an elevated intracranial pressure (ICP) >20 mmHg requiring ICP-targeted therapies. Eighty-eight percent of all children reported cognitive impairment at follow-up. No significant correlation was found between the King's Outcome Scale for Childhood Head Injury outcome groups and whether or not the children have had a neurosurgical intervention or were treated with ICP-targeted medical therapies. CONCLUSION Children receiving rehabilitation after a brain injury during childhood make a moderate to good recovery. No significant correlation was found between outcome and whether or not the child had been treated for elevated intracranial pressure.
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150
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Gradisek P, Osredkar J, Korsic M, Kremzar B. Multiple indicators model of long-term mortality in traumatic brain injury. Brain Inj 2012; 26:1472-81. [PMID: 22721420 DOI: 10.3109/02699052.2012.694567] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To examine the prognostic ability of protein S100B, neuron-specific enolase (NSE) and glial fibrillary acid protein (GFAP) for prediction of 1-year mortality in patients with traumatic brain injury (TBI) in relation to clinical and radiological characteristics of TBI. METHODS Brain injury was quantified in 84 patients (Glasgow Coma Scale [GCS] ≤ 12) using clinical (GCS, pupils), radiological (computed tomography [CT] classification and individual CT characteristics) and biochemical (S100B, NSE and GFAP) data at admission and in the acute post-injury period. RESULTS Initial and peak S100B, NSE and GFAP concentrations were higher in non-survivors (n = 26) than in survivors (p-value range: <0.001-0.018). Cox regression showed that GFAP and S100B concentration and the temporal profile of S100B were more powerful independent predictors of mortality than baseline clinical and radiological characteristics or clinical and radiological indicators of neurological deterioration. The prognostic models containing admission variables and those available during the subsequent clinical course showed the same discrimination ability (area under receiver characteristic curve 0.92), but the model based on variables available in the acute post-injury period calibrated better (p = 0.428). CONCLUSION Mortality at 1-year post-TBI is accurately predicted by the combination of GFAP and S100B concentration and clinical and radiological characteristics at admission or in the acute post-injury period.
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Affiliation(s)
- Primoz Gradisek
- Clinical Department of Anaesthesiology and Intensive Therapy, Centre for Intensive Therapy, University Medical Centre, Ljubljana, Slovenia.
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