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Melo JRT, de Brito Tischer CM, Rodrigues FPA, Giordano JC, de Oliveira LFG, Bodra SM, de Oliveira JG, Veiga JCE. Accuracy of acute hyperglycemia as a biomarker of severe brain damage in children with traumatic brain injury. Childs Nerv Syst 2024; 40:2781-2787. [PMID: 38862794 DOI: 10.1007/s00381-024-06488-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Accepted: 06/01/2024] [Indexed: 06/13/2024]
Abstract
PURPOSE Biomarkers are substances measured at the systemic level to evaluate organic responses in certain situations, establishing diagnoses, disease staging, and prognosis. Blood glucose is a biomarker recognized as a predictor of prognosis in children victims of traumatic brain injury (TBI). The scope of this study was to identify the accuracy of blood glucose as a biomarker of severe brain injury. METHODS A retrospective analytical study was conducted through the consecutive review of medical records of children and teenage victims of TBI who underwent neurological surgery between 2016 and 2023 in a level 1 trauma center. Two groups were compared: children with Glasgow Coma Scale (GCS) score ≤ 8 and children with GCS > 8. We calculated the predictive values to define the accuracy of blood glucose as a biomarker of brain injury. RESULTS Ninety-two medical records were included for analysis. Hyperglycemia predominated in cases with GCS ≤ 8 (48% vs 3%; p < 0.0001; OR, 30; 95% CI, 5.9902-150.2448). The glycemic measurement considering the cutoff point of 200 mg/dL or 11.1 mmol/L showed a specificity of 97%, a positive predictive value of 86%, an accuracy of 84%, and a likelihood ratio for a positive test of 16. CONCLUSION Victims with GCS ≤ 8 are 16 times more likely to develop acute hyperglycemia after TBI when compared to those with GCS > 8. Blood glucose is a biomarker with an accuracy of 84% to predict severe brain injury, considering the cutoff point of 200 mg/dL or 11.1 mmol/L.
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Affiliation(s)
- José Roberto Tude Melo
- Division of Neurosurgery, Department of Surgery, School of Medical Sciences, Santa Casa of São Paulo, São Paulo, Brazil.
- Neurotrauma Research Group of the Neurosurgery Course, Department of Surgery, School of Medical Sciences, Santa Casa of São Paulo, São Paulo, Brazil.
| | - Chiara Maria de Brito Tischer
- School of Medical Sciences, Santa Casa of São Paulo, São Paulo, Brazil
- Neurotrauma Research Group of the Neurosurgery Course, Department of Surgery, School of Medical Sciences, Santa Casa of São Paulo, São Paulo, Brazil
| | - Fernanda Paiva Augusto Rodrigues
- School of Medical Sciences, Santa Casa of São Paulo, São Paulo, Brazil
- Neurotrauma Research Group of the Neurosurgery Course, Department of Surgery, School of Medical Sciences, Santa Casa of São Paulo, São Paulo, Brazil
| | - Júlia Calviello Giordano
- School of Medical Sciences, Santa Casa of São Paulo, São Paulo, Brazil
- Neurotrauma Research Group of the Neurosurgery Course, Department of Surgery, School of Medical Sciences, Santa Casa of São Paulo, São Paulo, Brazil
| | - Larissa Ferreira Gomes de Oliveira
- School of Medical Sciences, Santa Casa of São Paulo, São Paulo, Brazil
- Neurotrauma Research Group of the Neurosurgery Course, Department of Surgery, School of Medical Sciences, Santa Casa of São Paulo, São Paulo, Brazil
| | - Stephannie Monaco Bodra
- School of Medical Sciences, Santa Casa of São Paulo, São Paulo, Brazil
- Neurotrauma Research Group of the Neurosurgery Course, Department of Surgery, School of Medical Sciences, Santa Casa of São Paulo, São Paulo, Brazil
| | - Jean Gonçalves de Oliveira
- Division of Neurosurgery, Department of Surgery, School of Medical Sciences, Santa Casa of São Paulo, São Paulo, Brazil
- Neurotrauma Research Group of the Neurosurgery Course, Department of Surgery, School of Medical Sciences, Santa Casa of São Paulo, São Paulo, Brazil
| | - José Carlos Esteves Veiga
- Division of Neurosurgery, Department of Surgery, Santa Casa of São Paulo, Hospital and School of Medical Sciences, São Paulo, Brazil
- Neurotrauma Research Group of the Neurosurgery Course, Department of Surgery, School of Medical Sciences, Santa Casa of São Paulo, São Paulo, Brazil
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Bakar B, Yuksel U, Ozdemir A, Bulut IU, Ogden M. Clinical and Laboratory Markers in Determination of Treatment Modalities and Short-Term Prognosis in Patients with Traumatic Acute Subdural Hematoma: Original Study. INDIAN JOURNAL OF NEUROTRAUMA 2021. [DOI: 10.1055/s-0041-1739475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Abstract
Objective In patients with traumatic acute subdural hematoma (ASH), it has not been yet fully elucidated which patients can benefit from surgery or from clinical follow-up. This study was constructed to predict treatment modality and short-term prognosis in patients with ASH using their clinical, radiological, and biochemical laboratory findings during admission to hospital.
Methods Findings of patients with ASH determined on their CT scan between 2015 and 2018 were evaluated. Patients were grouped in terms of ASH-FOL (patients followed-up without surgery, n = 13), ASH-OP (patients treated surgically, n = 10), and ASH-INOP (patients considered as inoperable, n = 5) groups. They also were divided into “survived (n = 14)” and “nonsurvived (n = 14)” groups.
Results ASH developed as a result of fall from a height in 15 patients and traffic accidents in 13 patients. In deciding for surgery, it was determined that Glasgow coma scale (GCS) scores < 8, midline shift (MLS) level > 5 mm, MLS-hematoma thickness ratio > 0.22, leukocyte count > 12730 uL, and presence of anisocoria could be used as predictive markers. It was determined that GCS scores < 8, hematoma thickness value > 8 mm, and the presence of anisocoria could be considered as biomarkers in prediction of mortality likelihood.
Conclusion It could be suggested that GCS scores, MLS level, MLS-hematoma thickness ratio, presence of anisocoria, and leukocyte count value could help in determination of the treatment modality in patients with ASH. Additionally, GCS scores, hematoma thickness value, and presence of anisocoria could each be used as a marker in the prediction of early-stage prognosis and mortality likelihood of these patients.
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Affiliation(s)
- Bulent Bakar
- Department of Neurosurgery, Kirikkale University, Faculty of Medicine, Kirikkale, Turkey
| | - Ulas Yuksel
- Department of Neurosurgery, Kirikkale University, Faculty of Medicine, Kirikkale, Turkey
| | - Alemiddin Ozdemir
- Department of Neurosurgery, Kirikkale University, Faculty of Medicine, Kirikkale, Turkey
| | - Ibrahim Umud Bulut
- Department of Neurosurgery, Kirikkale University, Faculty of Medicine, Kirikkale, Turkey
| | - Mustafa Ogden
- Department of Neurosurgery, Kirikkale University, Faculty of Medicine, Kirikkale, Turkey
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Bussolin L, Falconi M, Leo MC, Parri N, DE Masi S, Rosati A, Cecchi C, Spacca B, Grandoni M, Bettiol A, Lucenteforte E, Lubrano R, Falsaperla R, Melosi F, Agostiniani R, Mangiantini F, Talamonti G, Calderini E, Mancino A, DE Luca M, Conti G, Petrini F. The management of pediatric severe traumatic brain injury: Italian Guidelines. Minerva Anestesiol 2021; 87:567-579. [PMID: 33432789 DOI: 10.23736/s0375-9393.20.14122-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION The aim of the work was to update the "Guidelines for the Management of Severe Traumatic Brain Injury" published in 2012, to reflect the new available evidence, and develop the Italian national guideline for the management of severe pediatric head injuries to reduce variation in practice and ensure optimal care to patients. EVIDENCE ACQUISITION MEDLINE and EMBASE were searched from January 2009 to October 2017. Inclusion criteria were English language, pediatric populations (0-18 years) or mixed populations (pediatric/adult) with available age subgroup analyses. The guideline development process was started by the Promoting Group that composed a multidisciplinary panel of experts, with the representatives of the Scientific Societies, the independent expert specialists and a representative of the Patient Associations. The panel selected the clinical questions, discussed the evidence and formulated the text of the recommendations. The documentarists of the University of Florence oversaw the bibliographic research strategy. A group of literature reviewers evaluated the selected literature and compiled the table of evidence for each clinical question. EVIDENCE SYNTHESIS The search strategies identified 4254 articles. We selected 3227 abstract (first screening) and, finally included 67 articles (second screening) to update the guideline. This Italian update includes 25 evidence-based recommendations and 5 research recommendations. CONCLUSIONS In recent years, progress has been made on the understanding of severe pediatric brain injury, as well as on that concerning all major traumatic pathology. This has led to a progressive improvement in the clinical outcome, although the quantity and quality of evidence remains particularly low.
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Affiliation(s)
- Leonardo Bussolin
- Neuroanesthesiology, Intensive Care and Trauma Center, A. Meyer University Hospital, Florence, Italy
| | - Martina Falconi
- Techical-Scientific Secretary, Pediatric Regional and Ethical Committee, A. Meyer University Hospital, Florence, Italy
| | - Maria C Leo
- Techical-Scientific Secretary, Pediatric Regional and Ethical Committee, A. Meyer University Hospital, Florence, Italy
| | - Niccolò Parri
- Emergency Department and Trauma Center, A. Meyer University Hospital, Florence, Italy -
| | - Salvatore DE Masi
- Clinical Trial Office, A. Meyer University Hospital, Florence, Italy
| | - Anna Rosati
- Neurosciences Excellence Center, A. Meyer University Hospital, Florence, Italy
| | - Costanza Cecchi
- Anestesiology and Intensive Care Unit, A. Meyer University Hospital, Florence, Italy
| | - Barbara Spacca
- Unit of Neurosurgery, A. Meyer University Hospital, Florence, Italy
| | - Manuela Grandoni
- Unit of Neurosurgery, A. Meyer University Hospital, Florence, Italy
| | | | | | - Riccardo Lubrano
- Società Italiana di Medicina Emergenza Urgenza Pediatrica (SIMEUP), Milan, Italy.,Pediatrics Unit, Pediatric Emergency Department, Neonatology and Neonatal Intensive Care, "Rodolico-San Marco" University Hospital, Catania, Italy
| | - Raffaele Falsaperla
- Società Italiana di Medicina Emergenza Urgenza Pediatrica (SIMEUP), Milan, Italy.,Pediatrics and Neonatology Unit, Department of Maternal and Urological Sciences, Sapienza University, Latina, Rome, Italy
| | - Francesca Melosi
- Anestesiology and Intensive Care Unit, A. Meyer University Hospital, Florence, Italy.,Società Italiana di Neurosonologia ed Emodinamica Cerebrale (SINSEC), Bologna, Italy
| | | | | | | | - Edoardo Calderini
- Società Italiana di Anestesia Analgesia Rianimazione e Terapia Intensiva (SIAARTI), Rome, Italy
| | - Aldo Mancino
- Società di Anestesia e Rianimazione Neonatale e Pediatrica Italiana (S.A.R.N.eP.I), Rome, Italy
| | - Marco DE Luca
- Accademia Medica ed Infermieristica di Emergenza e Terapia Intensiva Pediatrica (AMIETIP), Bologna, Italy
| | - Giorgio Conti
- Accademia Medica ed Infermieristica di Emergenza e Terapia Intensiva Pediatrica (AMIETIP), Bologna, Italy.,IRCCS A. Gemelli, Catholic University, Rome, Italy
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Chen S, Liu Z. Effect of hyperglycemia on all-cause mortality from pediatric brain injury: A systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e23307. [PMID: 33235087 PMCID: PMC7710234 DOI: 10.1097/md.0000000000023307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND This study aimed to assess the effect of hyperglycemia on all-cause mortality in pediatric patients with brain injury, based on currently available evidence. METHODS We systematically searched the PubMed, Embase, and Cochrane Library databases with the keywords "hyperglycemia", "brain injury", and "pediatrics". The retrieved records were screened by title, abstract, and full-text to include original articles assessing the effects of hyperglycemia on pediatric brain injury. The extracted data were assessed by a fixed-effects model. The risk of bias in the eligible studies was evaluated with the Newcastle-Ottawa Scale. Publication bias was visually examined with a funnel plot. Begg and Egger tests, respectively, were used to identify small-study effects. Sensitivity analysis was performed to evaluate the robustness of the original effect size. RESULTS Nine observational studies were identified from 1439 primary hits. A total of 970 pediatric patients, including 304 with hyperglycemia and brain injury, were included for meta-analysis. Hyperglycemia was strongly associated with a higher risk of all-cause mortality in pediatric patients (odds ratio = 11.60, 95% confidence interval [CI] 7.88-17.08; I = 0%). The overall quality of eligible studies was low, but the funnel plot indicated no publication bias. CONCLUSIONS Hyperglycemia is significantly associated with high all-cause mortality in pediatric patients with brain injury. However, the relationship should be confirmed by larger-scale observational studies and randomized controlled trials.
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Affiliation(s)
- Shuyun Chen
- Department of Clinical Nutrition
- Department of Neurosurgery, Shanxi Children Hospital, Taiyuan, Shanxi, China
| | - Zhaohe Liu
- Department of Clinical Nutrition
- Department of Neurosurgery, Shanxi Children Hospital, Taiyuan, Shanxi, China
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5
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Metabolic perturbations after pediatric TBI: It's not just about glucose. Exp Neurol 2019; 316:74-84. [PMID: 30951705 DOI: 10.1016/j.expneurol.2019.03.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 03/13/2019] [Accepted: 03/30/2019] [Indexed: 12/22/2022]
Abstract
Improved patient survival following pediatric traumatic brain injury (TBI) has uncovered a currently limited understanding of both the adaptive and maladaptive metabolic perturbations that occur during the acute and long-term phases of recovery. While much is known about the redundancy of metabolic pathways that provide adequate energy and substrates for normal brain growth and development, the field is only beginning to characterize perturbations in these metabolic pathways after pediatric TBI. To date, the majority of studies have focused on dysregulated oxidative glucose metabolism after injury; however, the immature brain is well-equipped to use alternative substrates to fuel energy production, growth, and development. A comprehensive understanding of metabolic changes associated with pediatric TBI cannot be limited to investigations of glucose metabolism alone. All energy substrates used by the brain should be considered in developing nutritional and pharmacological interventions for pediatric head trauma. This review summarizes post-injury changes in brain metabolism of glucose, lipids, ketone bodies, and amino acids with discussion of the therapeutic potential of altering substrate utilization to improve pediatric TBI outcomes.
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Hale AT, Pekala K, Theobald B, Kelly K, Wolf M, Wellons JC, Le T, Shannon CN. Predictors of post-discharge seizures in children with traumatic brain injury. Childs Nerv Syst 2018; 34:1361-1365. [PMID: 29564537 DOI: 10.1007/s00381-018-3779-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 03/15/2018] [Indexed: 11/29/2022]
Abstract
PURPOSE In traumatic brain injury (TBI), hyperglycemia and hypothermia are thought to be associated with poor outcomes, but have not been systematically studied in children. Thus, our aim was to evaluate whether serum glucose and temperature at admission, among other clinical variables, were associated with need for post hospital-discharge seizure medication in children diagnosed with TBI. METHODS We performed a retrospective study of 1814 children who were diagnosed with TBI at a tertiary pediatric hospital. Serum glucose levels at admission and temperature at initial presentation, 12, and 24 h were collected. Ongoing seizure activity was defined as discharge prescription of a seizure-modifying medication. RESULTS We identified 121 patients with need for continued seizure medications, and 80 patients expired. Independent predictors of prolonged seizures included serum glucose levels above 140 mg/dl (p < 0.003) and 199 mg/dl (p < 0.001), hypothermia (<35 °C), subdural hematoma (p < 0.001), midline shift (p < 0.001), and > 1% temperature change in the first 24 h (p < 0.001). Multivariate regression adjusting for GCS revealed that bilateral bleed (p = 0.008), body-temperature instability (p = 0.026), subdural hematoma (p < 0.001), and mechanism of injury (p = 0.007) were predictive of prolonged seizure activity. CONCLUSIONS In summary, we conclude that body temperature may be playing a more significant role than glycemic control in propensity for ongoing seizure activity in children sustaining TBI.
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Affiliation(s)
- Andrew T Hale
- Surgical Outcomes Center for Kids, Monroe Carrell Jr. Children's Hospital at Vanderbilt University, Nashville, TN, USA. .,Vanderbilt University School of Medicine, 2200 Pierce Avenue, 610 RRB, Nashville, TN, 37232, USA.
| | - Kelly Pekala
- Surgical Outcomes Center for Kids, Monroe Carrell Jr. Children's Hospital at Vanderbilt University, Nashville, TN, USA.,Vanderbilt University School of Medicine, 2200 Pierce Avenue, 610 RRB, Nashville, TN, 37232, USA
| | - Benjamin Theobald
- Surgical Outcomes Center for Kids, Monroe Carrell Jr. Children's Hospital at Vanderbilt University, Nashville, TN, USA.,Vanderbilt University School of Medicine, 2200 Pierce Avenue, 610 RRB, Nashville, TN, 37232, USA
| | - Katherine Kelly
- Surgical Outcomes Center for Kids, Monroe Carrell Jr. Children's Hospital at Vanderbilt University, Nashville, TN, USA
| | - Michael Wolf
- Department of Pediatrics, Monroe Carrell Jr. Children's Hospital at Vanderbilt University, Nashville, TN, USA
| | - John C Wellons
- Surgical Outcomes Center for Kids, Monroe Carrell Jr. Children's Hospital at Vanderbilt University, Nashville, TN, USA.,Department of Neurological Surgery, Division of Pediatric Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Truc Le
- Department of Pediatrics, Monroe Carrell Jr. Children's Hospital at Vanderbilt University, Nashville, TN, USA.,Department of Neurological Surgery, Division of Pediatric Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Chevis N Shannon
- Surgical Outcomes Center for Kids, Monroe Carrell Jr. Children's Hospital at Vanderbilt University, Nashville, TN, USA.,Department of Neurological Surgery, Division of Pediatric Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
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Chelly H, Bahloul M, Ammar R, Dhouib A, Mahfoudh KB, Boudawara MZ, Chakroun O, Chabchoub I, Chaari A, Bouaziz M. Clinical characteristics and prognosis of traumatic head injury following road traffic accidents admitted in ICU "analysis of 694 cases". Eur J Trauma Emerg Surg 2017; 45:245-253. [PMID: 29234838 DOI: 10.1007/s00068-017-0885-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 12/01/2017] [Indexed: 01/21/2023]
Abstract
BACKGROUND The aim of the present study is to analyze the clinical and epidemiological characteristics of Traumatic Brain Injury (TBI) following Road Traffic Accidents (RTAs). Moreover, we aim to evaluate the outcome of the TBI victims referred to our medico-surgical Intensive Care Unit (ICU), and to define predictive factors associated with poor prognosis. METHODS A retrospective study over a 4-year period (2009 to 2012) of 694 patients with head injuries, incurred during road traffic accidents, admitted to the Intensive Care Unit (ICU) of a university hospital (Sfax-Tunisia). Basic demographic, clinical, biological, and radiological data were recorded on admission and during the ICU stay. RESULTS There were 592 males (85.3%), and 102 female patients. The mean age was at 31.8 ± 17.8 years (range 1-91). The mechanism of the accident was detailed in 666 patients (96%). The majority of the victims were motorcycle riders and/or passengers (40.5%), followed by pedestrians (29.1%). Extra-cranial pathology was present in 452 patients (65%). A total of 677 patients (97.6%) required intubation, mechanical ventilation, and sedation. Mean ICU stay was 16 ± 17.4 days. A total of 187 patients (26.9%) died during their hospital stay. The GOS performed within a mean delay of 6 months after hospital discharge was as follows: 198 deaths (28.5%), 13 vegetative state (1.9%), and 349 (50.3%) good recovery and/or moderate disability. A multivariate analysis showed that the factors which correlated with a poor prognosis (mortality and severe disability) were: age > 38 years, Glasgow coma scale score < 8, subdural hematoma, and development of secondary systemic insults (respiratory, circulatory, and metabolic). CONCLUSION In Tunisia, traumatic brain injury due to RTAs is a frequent cause of ICU admission, especially among young adults, and is associated with high mortality and morbidity rates. The majority of the victims were motorcycle riders and/or passengers and pedestrians. The factors associated with a poor outcome were: age > 38 years, Glasgow Coma Scale score < 8, subdural hematoma, and development of secondary systemic insults (respiratory, circulatory, and metabolic). As a consequence, prevention is highly warranted.
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Affiliation(s)
- Hedi Chelly
- Department of Intensive Care, Habib Bourguiba University Hospital, 3029, Sfax, Tunisia
| | - Mabrouk Bahloul
- Department of Intensive Care, Habib Bourguiba University Hospital, 3029, Sfax, Tunisia.
| | - Rania Ammar
- Department of Intensive Care, Habib Bourguiba University Hospital, 3029, Sfax, Tunisia
| | - Ahmed Dhouib
- Department of Intensive Care, Habib Bourguiba University Hospital, 3029, Sfax, Tunisia
| | | | | | - Olfa Chakroun
- Departement of Emergency Medicine, Habib Bourguiba University Hospital, Sfax, Tunisia
| | - Imen Chabchoub
- Department of Pediatrics, Hedi Chaker University Hospital, Sfax, Tunisia
| | - Anis Chaari
- Department of Intensive Care, Habib Bourguiba University Hospital, 3029, Sfax, Tunisia
| | - Mounir Bouaziz
- Department of Intensive Care, Habib Bourguiba University Hospital, 3029, Sfax, Tunisia
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Abstract
Traumatic brain injury is the number one cause of death and disability among the pediatric population in the USA. The heterogeneity of the pediatric population is reflected by both the normal cerebral maturation and the age differences in the causes of TBI, which generate unique age-related pathophysiology responses and recovery profiles. This review will address the normal changes in cerebral glucose metabolism throughout developmental phases and how TBI alters glucose metabolism. Evidence has shown that TBI disrupts the biochemical processing of glucose to energy. This brings to question, "What is the optimal substrate to manage a pediatric TBI patient?" Issues related to glycemic control and alternative substrate metabolism are addressed specifically in regard to pediatric TBI. Research into pediatric glucose metabolism after TBI is limited, and understanding these age-related differences within the pediatric population have great potential to improve support for the injured younger brain.
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Figaji AA, Graham Fieggen A, Mankahla N, Enslin N, Rohlwink UK. Targeted treatment in severe traumatic brain injury in the age of precision medicine. Childs Nerv Syst 2017; 33:1651-1661. [PMID: 28808845 DOI: 10.1007/s00381-017-3562-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 07/27/2017] [Indexed: 11/28/2022]
Abstract
In recent years, much progress has been made in our understanding of traumatic brain injury (TBI). Clinical outcomes have progressively improved, but evidence-based guidelines for how we manage patients remain surprisingly weak. The problem is that the many interventions and strategies that have been investigated in randomized controlled trials have all disappointed. These include many concepts that had become standard care in TBI. And that is just for adult TBI; in children, the situation is even worse. Not only is pediatric care more difficult than adult care because physiological norms change with age, but also there is less evidence for clinical practice. In this article, we discuss the heterogeneity inherent in TBI and why so many clinical trials have failed. We submit that a key goal for the future is to appreciate important clinical differences between patients in their pathophysiology and their responses to treatment. The challenge that faces us is how to rationally apply therapies based on the specific needs of an individual patient. In doing so, we may be able to apply the principles of precision medicine approaches to the patients we treat.
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Affiliation(s)
- Anthony A Figaji
- Division of Neurosurgery and Neuroscience Institute, University of Cape Town, Cape Town, South Africa.
| | - A Graham Fieggen
- Division of Neurosurgery and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Ncedile Mankahla
- Division of Neurosurgery, University of Cape Town, Cape Town, South Africa
| | - Nico Enslin
- Division of Neurosurgery, University of Cape Town, Cape Town, South Africa
| | - Ursula K Rohlwink
- Division of Neurosurgery and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
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Lee JK, Brady KM, Deutsch N. The Anesthesiologist's Role in Treating Abusive Head Trauma. Anesth Analg 2017; 122:1971-82. [PMID: 27195639 DOI: 10.1213/ane.0000000000001298] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Abusive head trauma (AHT) is the most common cause of severe traumatic brain injury (TBI) in infants and the leading cause of child abuse-related deaths. For reasons that remain unclear, mortality rates after moderate AHT rival those of severe nonintentional TBI. The vulnerability of the developing brain to injury may be partially responsible for the poor outcomes observed after AHT. AHT is mechanistically more complex than nonintentional TBI. The acute-on-chronic nature of the trauma along with synergistic injury mechanisms that include rapid rotation of the brain, diffuse axonal injury, blunt force trauma, and hypoxia-ischemia make AHT challenging to treat. The anesthesiologist must understand the complex injury mechanisms inherent to AHT, as well as the pediatric TBI treatment guidelines, to decrease the risk of persistent neurologic disability and death. In this review, we discuss the epidemiology of AHT, differences between AHT and nonintentional TBI, the severe pediatric TBI treatment guidelines in the context of AHT, anesthetic considerations, and ethical and legal reporting requirements.
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Affiliation(s)
- Jennifer K Lee
- From the *Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology, Johns Hopkins University, Baltimore, Maryland; †Department of Pediatrics, Anesthesia, and Critical Care, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas; and ‡Departments of Anesthesiology and Pediatrics, Children's National Health System, Washington DC
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Fu YQ, Chong SL, Lee JH, Liu CJ, Fu S, Loh TF, Ng KC, Xu F. The impact of early hyperglycaemia on children with traumatic brain injury. Brain Inj 2017; 31:396-400. [PMID: 28296528 DOI: 10.1080/02699052.2016.1264629] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Hyperglycaemia is common amongst children with traumatic brain injury (TBI). We aim to investigate the association between early hyperglycaemia and poor clinical outcomes in children with moderate to severe TBI. METHODS We performed a retrospective study in a tertiary paediatric hospital between May 2012 and October 2014 of all patients with TBI who were aged <16 years with a Glasgow Coma Scale (GCS) of ≤13. The primary outcome was death. Secondary outcomes were 14 ventilation-free, 14 paediatric intensive care unit (PICU)-free and 28 hospital-free days. We defined hyperglycaemia as glucose >11.1 mmol/L (200 mg/dL). RESULTS There were 109 patients with a median age of 54 months [inter-quartile range (IQR): 17-82]. Median glucose on arrival was 6.1 mmol/L (IQR: 5.2-9.8). Median GCS in our cohort was 8 (IQR: 6-12). Multivariate logistic regression demonstrated that initial hyperglycaemia [odds ratio (OR): 15.23; 95% confidence interval (CI): 3.74-62.00; P < 0.001], and GCS <8 (OR: 13.02; 95% CI: 2.31-73.33; P = 0.004) were risk factors for mortality. Multivariate linear regression showed that initial hyperglycaemia was a risk factor for reduced ventilation-free, PICU-free and hospital-free days. CONCLUSIONS Early hyperglycaemia predicts for in-hospital mortality, reduced ventilation-free, PICU-free and hospital-free days in children with moderate to severe TBI.
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Affiliation(s)
- Yue-Qiang Fu
- a Department of Critical Care Medicine, Children's Hospital , Chongqing Medical University , Chongqing , China
| | - Shu-Ling Chong
- b Department of Children's Emergency , KK Women's and Children's Hospital , Singapore , Singapore.,c Duke-NUS Medical School , Singapore , Singapore
| | - Jan Hau Lee
- c Duke-NUS Medical School , Singapore , Singapore.,d Children's Intensive Care Unit , KK Women's and Children's Hospital , Singapore , Singapore
| | - Cheng-Jun Liu
- a Department of Critical Care Medicine, Children's Hospital , Chongqing Medical University , Chongqing , China
| | - Sheng Fu
- e Department of Paediatrics , KK Women's and Children's Hospital , Singapore , Singapore
| | - Tsee Foong Loh
- c Duke-NUS Medical School , Singapore , Singapore.,d Children's Intensive Care Unit , KK Women's and Children's Hospital , Singapore , Singapore
| | - Kee Chong Ng
- b Department of Children's Emergency , KK Women's and Children's Hospital , Singapore , Singapore.,c Duke-NUS Medical School , Singapore , Singapore
| | - Feng Xu
- a Department of Critical Care Medicine, Children's Hospital , Chongqing Medical University , Chongqing , China
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Kang X, Liu Y, Yuan T, Jiang NN, Dong YB, Wang JW, Fu GH, Liu YL, Wang WX. Early care of acute hyperglycemia benefits the outcome of traumatic brain injury in rats. Brain Res 2016; 1650:112-117. [PMID: 27577851 DOI: 10.1016/j.brainres.2016.08.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Revised: 08/25/2016] [Accepted: 08/26/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Previous animal studies showed contradictory clinical observations on whether acute hyperglycemia contributes to poor outcome in traumatic brain injury (TBI). Herein, we tried to clarify this issue. METHODS Striking with depths of 3.0-4.25mm at right occipitoparietal brain region and with depth of 3.75mm at right/left occipitoparietal or right/left frontoparietal brain region were performed, respectively. Blood glucose and insulin levels were traced every four hours from 1 to 72h after striking. HOMA2-%S and HOMA2-%β were calculated. Modified neurological severity scores (mNSS) were used to evaluate neurological deficit within 72h. RESULTS Striking with depths of 3.5-4.25mm induced increase in blood glucose lasting up to 24h after striking. The levels of blood glucose after striking with depths of 3.75-4.25mm were significantly different from that of striking with the depth of 3.0mm. Striking with depth of 3.75mm at right/left occipitoparietal region induced higher blood glucose in 24h than that at right/left frontoparietal region. Insulin concentration increased slowly during 72h after striking. Striking also induced decrease in insulin sensitivity and secretion lasting 72h. Evaluation of mNSS revealed that severe striking (beyond 3.75mm) worsened nerve function than slight striking (<3.0mm). Intervention of acute hyperglycemia could decrease the mNSS from 2 to 7 days after TBI. CONCLUSION Our results suggested that only severe TBI could induce acute hyperglycemia by itself, and early care of acute hyperglycemia could benefit the outcome of TBI patients.
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Affiliation(s)
- Xin Kang
- Neurosurgery Department, Lianyungang Oriental Hospital, 222042 Lianyungang, Jiangsu, China
| | - Yuepeng Liu
- Center for clinical research and translational medicine, Lianyungang Oriental Hospital, 222042 Lianyungang, Jiangsu, China
| | - Tao Yuan
- Neurosurgery Department, Lianyungang Oriental Hospital, 222042 Lianyungang, Jiangsu, China
| | - Na-Na Jiang
- Bengbu Medical College, 233000 Bengbu, Anhui, China
| | - Yan-Bin Dong
- Center for clinical research and translational medicine, Lianyungang Oriental Hospital, 222042 Lianyungang, Jiangsu, China
| | - Jian-Wei Wang
- Neurosurgery Department, Lianyungang Oriental Hospital, 222042 Lianyungang, Jiangsu, China
| | - Guang-Hui Fu
- Neurosurgery Department, Lianyungang Oriental Hospital, 222042 Lianyungang, Jiangsu, China
| | - Yu-Liang Liu
- Neurosurgery Department, Lianyungang Oriental Hospital, 222042 Lianyungang, Jiangsu, China
| | - Wen-Xue Wang
- Neurosurgery Department, Lianyungang Oriental Hospital, 222042 Lianyungang, Jiangsu, China.
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Prins ML, Matsumoto J. Metabolic Response of Pediatric Traumatic Brain Injury. J Child Neurol 2016; 31:28-34. [PMID: 25336427 PMCID: PMC4405388 DOI: 10.1177/0883073814549244] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 07/21/2014] [Indexed: 12/26/2022]
Abstract
Traumatic brain injury (TBI) in the pediatric brain presents unique challenges as the complex cascades of metabolic and biochemical responses to TBI are further complicated ongoing maturational changes of the developing brain. TBIs of all severities have been shown to significantly alter metabolism and hormones which impair the ability of the brain to process glucose for cellular energy. Under these conditions, the brain's primary fuel (glucose) becomes a less favorable fuel and the ability of the younger brain to revert to ketone metabolism can an advantage. This review addresses the potential of alternative substrate metabolic intervention as a logical pediatric TBI neuroprotective strategy.
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Affiliation(s)
- Mayumi L Prins
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, CA, USA Brain Injury Research Center, University of California Los Angeles, Los Angeles, CA, USA
| | - Joyce Matsumoto
- Department of Pediatrics, Division of Pediatric Neurology, University of California Los Angeles, Los Angeles, CA, USA
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Chong SL, Harjanto S, Testoni D, Ng ZM, Low CYD, Lee KP, Lee JH. Early Hyperglycemia in Pediatric Traumatic Brain Injury Predicts for Mortality, Prolonged Duration of Mechanical Ventilation, and Intensive Care Stay. Int J Endocrinol 2015; 2015:719476. [PMID: 26074963 PMCID: PMC4446478 DOI: 10.1155/2015/719476] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Revised: 04/23/2015] [Accepted: 04/30/2015] [Indexed: 12/30/2022] Open
Abstract
We aim to study the association between hyperglycemia and in-hospital outcomes among children with moderate and severe traumatic brain injury (TBI). This retrospective cohort study was conducted in a tertiary pediatric hospital between 2003 and 2013. All patients < 16 years old who presented to the Emergency Department within 24 hours of head injury with a Glasgow Coma Scale (GCS) ≤ 13 were included. Our outcomes of interest were death, 14 ventilation-free, 14 pediatric intensive care unit- (PICU-) free, and 28 hospital-free days. Hyperglycemia was defined as glucose > 200 mg/dL (11.1 mmol/L). Among the 44 patients analyzed, the median age was 8.6 years (interquartile range (IQR) 5.0-11.0). Median GCS and pediatric trauma scores were 7 (IQR 4-10) and 4 (IQR 3-6), respectively. Initial hyperglycemia was associated with death (37% in the hyperglycemia group versus 8% in the normoglycemia group, p = 0.019), reduced median PICU-free days (6 days versus 11 days, p = 0.006), and reduced median ventilation-free days (8 days versus 12 days, p = 0.008). This association was however not significant in the stratified analysis of patients with GCS ≤ 8. Conclusion. Our findings demonstrate that early hyperglycemia is associated with increased mortality, prolonged duration of mechanical ventilation, and PICU stay in children with TBI.
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Affiliation(s)
- Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore 229899
- SingHealth Duke-NUS Paediatrics Academic Clinical Programme, 100 Bukit Timah Road, Singapore 229899
| | - Sumitro Harjanto
- Duke-NUS Graduate Medical School, 8 College Road, Singapore 169857
| | - Daniela Testoni
- Division of Neonatal Medicine, Escola Paulista de Medicina-Universidade Federal de Sao Paulo, Rua Marselhesa 630, Vila Clementino, 04020-060 São Paulo, SP, Brazil
| | - Zhi Min Ng
- SingHealth Duke-NUS Paediatrics Academic Clinical Programme, 100 Bukit Timah Road, Singapore 229899
- Department of Paediatric Medicine, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore 229899
| | - Chyi Yeu David Low
- Department of Neurosurgery, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore 229899
| | - Khai Pin Lee
- Department of Emergency Medicine, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore 229899
- SingHealth Duke-NUS Paediatrics Academic Clinical Programme, 100 Bukit Timah Road, Singapore 229899
| | - Jan Hau Lee
- SingHealth Duke-NUS Paediatrics Academic Clinical Programme, 100 Bukit Timah Road, Singapore 229899
- Children's Intensive Care Unit, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore 229899
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15
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Elkon B, Cambrin JR, Hirshberg E, Bratton SL. Hyperglycemia: an independent risk factor for poor outcome in children with traumatic brain injury*. Pediatr Crit Care Med 2014; 15:623-31. [PMID: 24849146 DOI: 10.1097/pcc.0000000000000170] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE We sought 1) to describe the severity and duration of hyperglycemia among surviving and dying children after traumatic brain injury; 2) to evaluate whether persistent severe hyperglycemia (averaged blood glucose > 200 mg/dL [11 mmol/L] during the first 12 hr after injury) is independently associated with poor Glasgow Outcome Score; and 3) to evaluate different definitions and the prevalence of poor Glasgow Outcome Score to better understand measurement and potential hyperglycemia treatment evaluation. DESIGN Retrospective cohort. SETTING Level I American College of Surgery verified pediatric trauma center. PATIENTS Children admitted to intensive care with moderate-to-severe traumatic brain injury. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Time course for glucose changes was compared by survival and blood glucose groups. Twelve-hour averaged patient blood glucoses were categorized as persistent: severe hyperglycemia (> 200 mg/dL [11 mmol/L]), moderate hyperglycemia (161-200 mg/dL [9-11 mmol/L]), mild hyperglycemia (110-160 mg/dL [6-9 mmol/L]), normal glycemia (80-109 mg/dL [4-6 mmol/L]), or hypoglycemia (< 80 mg/dL [< 4 mmol/L]). Among 271 children, less than 1% had hypoglycemia and were excluded from further analysis. Seven percent had normal, 49% had mild, 24% had moderate, and 20% had severe blood glucose elevation. Among dying children (n = 44, 16%), the mean blood glucose at 20-24 hours after injury was significantly greater compared with survivors (150 vs 113 mg/dL [8 vs 6 mmol/L]) but by 29-32 hours, no longer significantly differed (112 vs 102 mg/dL [6 mmol/L]). Sixty-eight percent of children with severe blood glucose elevation had a poor outcome, whereas good outcomes at discharge occurred in 87% with mild or moderate blood glucose elevation. Severe blood glucose elevation was associated with a 3.5-fold increased adjusted odds ratio of poor outcome (95% CI, 1.2-10.3) compared with mild blood glucose elevation adjusted for injury severity and cardiorespiratory instability. CONCLUSIONS Duration of severe blood glucose elevation (blood glucose > 200 mg/dL [11 mmol/L]) was brief but remained independently associated with poor outcome.
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Affiliation(s)
- Benjamin Elkon
- 1Department of Pediatrics, University of Utah, Salt Lake City, UT. 2Department of Neurosurgery, University of Utah, Salt Lake City, UT. 3Department of Internal Medicine, University of Utah, Salt Lake City, UT
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Prins ML, Matsumoto JH. The collective therapeutic potential of cerebral ketone metabolism in traumatic brain injury. J Lipid Res 2014; 55:2450-7. [PMID: 24721741 DOI: 10.1194/jlr.r046706] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
The postinjury period of glucose metabolic depression is accompanied by adenosine triphosphate decreases, increased flux of glucose through the pentose phosphate pathway, free radical production, activation of poly-ADP ribose polymerase via DNA damage, and inhibition of glyceraldehyde dehydrogenase (a key glycolytic enzyme) via depletion of the cytosolic NAD pool. Under these post-brain injury conditions of impaired glycolytic metabolism, glucose becomes a less favorable energy substrate. Ketone bodies are the only known natural alternative substrate to glucose for cerebral energy metabolism. While it has been demonstrated that other fuels (pyruvate, lactate, and acetyl-L-carnitine) can be metabolized by the brain, ketones are the only endogenous fuel that can contribute significantly to cerebral metabolism. Preclinical studies employing both pre- and postinjury implementation of the ketogenic diet have demonstrated improved structural and functional outcome in traumatic brain injury (TBI) models, mild TBI/concussion models, and spinal cord injury. Further clinical studies are required to determine the optimal method to induce cerebral ketone metabolism in the postinjury brain, and to validate the neuroprotective benefits of ketogenic therapy in humans.
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Affiliation(s)
- Mayumi L Prins
- Department of Neurosurgery, Brain Injury Research Center University of California, Los Angeles, Los Angeles, CA
| | - Joyce H Matsumoto
- Department of Pediatrics, Division of Pediatric Neurology, University of California, Los Angeles, Los Angeles, CA
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Chen D, Bao L, Lu SQ, Xu F. Serum albumin and prealbumin predict the poor outcome of traumatic brain injury. PLoS One 2014; 9:e93167. [PMID: 24671050 PMCID: PMC3966890 DOI: 10.1371/journal.pone.0093167] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Accepted: 03/02/2014] [Indexed: 11/18/2022] Open
Abstract
Background Serum albumin and prealbumin are both negative acute-phase reactants, and usually at low levels in stress. We aim to determine their predictive values for poor outcome of traumatic brain injury (TBI). Methods A total of 326 patients of TBI were enrolled and followed-up by telephone 6 months after discharge. They were divided into a favorable group (GOS: 3 to 5) and an unfavorable group (GOS: 1 to 2). Serum albumin and prealbumin were measured from vein blood within 24 h after admission. Results Ninety one (27.9%) patients were with poor outcome (GOS: 1 to 2). The unfavorable group had lower albumin and prealbumin (P<0.001). Albumin and prealbumin were both positively correlated with GCS (r = 0.489, P<0.001; r = 0.222, P<0.001, respectively) and GOS (r = 0.518, P<0.001; r = 0.314, P<0.001, respectively). After adjustment for confounding factors, the odds ratios of albumin and prealbumin were 0.866, 95% CI: 0.829 to 0.904 and 0.990, 95% CI: 0.985 to 0.995, respectively. In subgroup of GCS≤8 (n = 101), the crude and adjusted odds ratios of serum albumin were both statistically significant (P = 0.027, P = 0.033, respectively), while prealbumin were not (P = 0.553, P = 0.576, respectively). The AUC of albumin for predicting poor outcome was 0.762, 95% CI: 0.712 to 0.807, which was significantly higher than that of prealbumin (0.664, 95% CI: 0.610 to 0.715). In analyses of all patients and subgroup of GCS≤8, the AUCs of serum albumin were both significantly higher than those of prealbumin (P = 0.001, P = 0.045, respectively). Conclusions Both serum albumin and prealbumin could predict the poor outcome of TBI, but the former is much better, especially, in patients with severe TBI.
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Affiliation(s)
- Du Chen
- Department of Emergency Medicine, the First Affiliated Hospital of Soochow University, Suzhou, China
| | - Long Bao
- Department of Emergency Medicine, the First Affiliated Hospital of Soochow University, Suzhou, China
| | - Shi-qi Lu
- Department of Emergency Medicine, the First Affiliated Hospital of Soochow University, Suzhou, China
| | - Feng Xu
- Department of Emergency Medicine, the First Affiliated Hospital of Soochow University, Suzhou, China
- * E-mail:
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18
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Muehlschlegel S, Carandang R, Ouillette C, Hall W, Anderson F, Goldberg R. Frequency and impact of intensive care unit complications on moderate-severe traumatic brain injury: early results of the Outcome Prognostication in Traumatic Brain Injury (OPTIMISM) Study. Neurocrit Care 2014; 18:318-31. [PMID: 23377884 DOI: 10.1007/s12028-013-9817-2] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Known predictors of adverse outcomes in patients with moderate-severe TBI (msTBI) explain only a relatively small proportion of patient-related outcomes. The frequency and impact of intensive care unit complications (ICU-COMPL) on msTBI-associated outcomes are poorly understood. METHODS In 213 consecutive msTBI patients admitted to a Level I Trauma Center neuro trauma ICU, twenty-eight ICU-COMPL (21 medical and 7 neurological) were prospectively collected and adjudicated by group consensus, using pre-defined criteria. We determined frequencies, and explored associations of ICU-COMPL and hospital discharge outcomes using multivariable logistic regression. RESULTS The average age of the study sample was 53 years, and the median presenting Glasgow Coma Scale and Injury Severity Scores were 5 and 27, respectively. Hyperglycemia (79%), fever (62%), systemic inflammatory response syndrome (60%), and hypotension requiring vasopressors (42%) were the four most common medical ICU-COMPL. Herniation (39%), intracranial rebleed (39%), and brain edema requiring osmotherapy (37%) were the three most common neurological ICU-COMPL. After adjusting for admission variables, duration of ventilation, and ICU length-of-stay, patients with brain edema (OR 5.8; 95% CI 2, 16.7) had a significantly increased odds for dying during hospitalization whereas patients with hospital-acquired urinary tract infection (UTI) had a decreased odds (OR 0.05; 95% CI 0.005, 0.6). Sensitivity analysis revealed that UTI occurred later, suggesting a non-causal association with survival. Brain herniation (OR 15.7; 95% CI 2.6, 95.4) was associated with an unfavorable functional status (GOS 1-3). CONCLUSION ICU-COMPL are very common after msTBI, have a considerable impact on short-term outcomes, and should be considered in the prognostication of these high risk patients. Survival associations of time-dependent complications warrant cautious interpretation.
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Affiliation(s)
- Susanne Muehlschlegel
- Division of Neurocritical Care, Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA.
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19
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Forde CT, Karri SK, Young AMH, Ogilvy CS. Predictive markers in traumatic brain injury: opportunities for a serum biosignature. Br J Neurosurg 2013; 28:8-15. [DOI: 10.3109/02688697.2013.815317] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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20
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Sambany E, Pussard E, Rajaonarivo C, Raobijaona H, Barennes H. Childhood dysglycemia: prevalence and outcome in a referral hospital. PLoS One 2013; 8:e65193. [PMID: 23741481 PMCID: PMC3669285 DOI: 10.1371/journal.pone.0065193] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2011] [Accepted: 04/26/2013] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Hypoglycemia is a defining feature of severe malaria and several other infectious diseases in children but the prevalence, significance, and prognosis of abnormal blood glucose, including hyperglycemia, have rarely been addressed in severely ill children in non-malaria endemic areas. METHODS In Madagascar, consecutive children (1 month-15 years) admitted to the pediatric ward of a referral hospital, were categorized using the integrated management of childhood illness (IMCI). Samples were taken once on admission for measuring blood glucose concentration. Glycemia levels (hypoglycemia <2.2 mmol/l; low glycemia: 2.2-4.4 mmol/l; normoglycemia >4.4-8.3 mmol/l; and hyperglycemia >8.3 mmol/l) were related to the IMCI algorithm and case fatality. Factors associated with blood glucose concentration and case fatality were analysed using univariate and multivariate analysis. RESULTS Of 420 children, 48.1% (n = 202) were severely ill; 3.1% (n = 13) had hypoglycemia; 20.0% (n = 84) low glycemia; 65.9% (n = 277) normoglycemia; and 10.9% (n = 46) hyperglycemia. In univariate analysis, hypoglycemia and hyperglycemia both showed significant increase in the risk of death, as compared to normal blood glucose (RR: 12.2, 95% CI: 6.2-23.7 and RR: 2.5, 95% CI: 1.0-6.2, respectively). Children with low glycemia had no increased risk of death (RR: 1.2, 95% CI: 0.4-3.2) despite a poorer IMCI status on admission. After logistic regression, hypoglycemia (RR: 19.4, 95% CI: 5.0-.74.7, hepatomegaly (RR: 12.2, 95% CI: 3.3-44.9) and coma (RR: 4.8, 95% CI: 1.3-17.6) were the features on admission associated with an increased risk of death. CONCLUSIONS Dysglycemia in non-neonates is associated with increased mortality. These findings underline the need for the use of rapid screening tests to initiate early treatment. Alternative treatments such as oral or sublingual administration of glucose should be developed in structures with limited resources.
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Affiliation(s)
- Emercia Sambany
- Institut Francophone pour la Médecine Tropicale, Vientiane, Lao PDR
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Alessandri B, Schwandt E, Kamada Y, Nagata M, Heimann A, Kempski O. The neuroprotective effect of lactate is not due to improved glutamate uptake after controlled cortical impact in rats. J Neurotrauma 2012; 29:2181-91. [PMID: 22888957 DOI: 10.1089/neu.2011.2067] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
For many years lactate was considered to be a waste product of glycolysis. Data are accumulating that suggest that lactate is an important energy substrate for neurons during activation. In severe traumatic brain injury (TBI) glutamate release and ischemic cerebral blood flow (CBF) are major factors for a mismatch between energy demand and supply and for neuronal cell death. Although ATP and behavior could be improved by lactate treatment after TBI, no histological correlate nor any linkage to better astrocytic glutamate uptake or CBF as possible mechanisms have been described. We subjected male rats to a controlled cortical impact (CCI; 5 m/sec, 2.5 mm). To study the effects of lactate treatment on lesion volume, glutamate release, and CBF, animals were infused with either NaCl or 100 mM lactate for up to 3 h. The role of endogenous lactate was investigated by inhibiting transport with α-cyano-4-hydroxy-cinnamic acid (4-CIN; 90 mg/kg). Lactate treatment 15 min post-CCI reduced lesion volume from 21.1±2.8 mm³ to 12.1±1.9 mm³ at day 2 after CCI. Contusion produced a significant three- to fourfold increase of glutamate in microdialysates, but there was no significant difference between treatments that began 30 min before CCI. In this experiment lesion volume was significantly reduced by lactate at day 7 post-CCI (23.7±4 to 9.3±1-2 mm³). CBF increased immediately after CCI and dropped thereafter below baseline in all animals. Lactate infusion 15 min post-CCI elevated CBF for 20 min in 7 of 10 animals, whereas 7 of 8 NaCl-treated animals showed a further CBF decline. Neuroprotection was achieved by lactate treatment following contusion injury, whereas blocking of endogenous lactate transport exerted no adverse effects. Neuroprotection was not achieved by improved glutamate uptake into astrocytes, but was supported by augmented CBF following CCI. Due to its neuroprotective property, lactate might be a beneficial pharmacological treatment for TBI patients.
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Affiliation(s)
- Beat Alessandri
- Institute for Neurosurgical Pathophysiology, University Medical Center of the Johannes Gutenberg-University of Mainz, Mainz, Germany.
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Seyed Saadat SM, Bidabadi E, Seyed Saadat SN, Mashouf M, Salamat F, Yousefzadeh S. Association of persistent hyperglycemia with outcome of severe traumatic brain injury in pediatric population. Childs Nerv Syst 2012; 28:1773-7. [PMID: 22526446 DOI: 10.1007/s00381-012-1753-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2011] [Accepted: 03/29/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE Hyperglycemia is a common secondary insult associated with an increased risk of mortality and poor outcome in traumatic brain injury (TBI), but the effect of hyperglycemia on outcomes of severe TBI in children and adolescents is less apparent. The aim of this study was to evaluate the association of hyperglycemia with mortality in pediatric patients with severe TBI. METHODS In this cross-sectional study, data of all children and adolescents with severe TBI admitted to Poursina Hospital in Rasht, including age, gender, Glasgow Coma Scale (GCS) upon admission, mortality rate, hospital length of stay, and serial blood glucose during the first three consecutive ICU days following admission, were reviewed from April 2007 to May 2011. After univariate analysis and adjustment for related covariates, logistic regression model was established to determine the association between persistent hyperglycemia and outcome. RESULTS One-hundred and twenty-two children were included with a median admission GCS of 6 (interquartile range (IQR) 5-7) and a median age of 13 years (IQR 7.75-17). Among them, 91 were boys (74.6%) and 31 were girls (26.6%); the overall mortality was 40.2% (n=49). Patients who died had a significantly greater blood glucose levels than survivors for the first 3 days of admission (P=0.003, P<0.001, P=0.001, respectively). Moreover, persistent hyperglycemia during the first 3 days of admission had an adjusted odds ratio of 11.11 for mortality (P<0.001). CONCLUSION Early hyperglycemia is associated with poor outcome, and persistent hyperglycemia is a powerful and independent predictor of mortality in children and adolescents with severe TBI.
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Alexiou GA, Sfakianos G, Prodromou N. Pediatric head trauma. J Emerg Trauma Shock 2011; 4:403-8. [PMID: 21887034 PMCID: PMC3162713 DOI: 10.4103/0974-2700.83872] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2010] [Accepted: 11/04/2010] [Indexed: 11/12/2022] Open
Abstract
Head injury in children accounts for a large number of emergency department visits and hospital admissions. Falls are the most common type of injury, followed by motor-vehicle-related accidents. In the present study, we discuss the evaluation, neuroimaging and management of children with head trauma. Furthermore, we present the specific characteristics of each type of pediatric head injury.
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Affiliation(s)
- George A Alexiou
- Department of Neurosurgery, Children's Hospital "Agia Sofia", Athens, Greece
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Bahloul M, Chaari A, Chabchoub I, Medhyoub F, Dammak H, Kallel H, Ksibi H, Haddar S, Rekik N, Chelly H, Bouaziz M. Outcome analysis and outcome predictors of traumatic head injury in childhood: Analysis of 454 observations. J Emerg Trauma Shock 2011; 4:198-206. [PMID: 21769206 PMCID: PMC3132359 DOI: 10.4103/0974-2700.82206] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2010] [Accepted: 11/29/2010] [Indexed: 12/02/2022] Open
Abstract
Aim: To determine factors associated with poor outcome in children suffering traumatic head injury (HI). Materials and Methods: A retrospective study over an 8-year period including 454 children with traumatic HI admitted in the Intensive Care Unit of a university hospital (Sfax-Tunisia). Basic demographic, clinical, biological and radiological data were recorded on admission and during the ICU stay. Prognosis was defined according Glasgow outcome scale (GOS) performed after hospital discharge by ICU and pediatric physicians. Results: There were 313 male (68.9%) and 141 female patients. Mean age (±SD) was 7.2±3.8 years, the main cause of trauma was traffic accidents (69.4%). Mean Glasgow coma scale (GCS) score was 8±3, mean injury severity score (ISS) was 26.4±8.6, mean pediatric trauma score (PTS) was 4±2 and mean pediatric risk of mortality (PRISM) was 11.1±8. The GOS performed within a mean delay of 7 months after hospital discharge was as follow: 82 deaths (18.3%), 5 vegetative states (1.1%), 15 severe disabilities (3.3%), 71 moderate disabilities (15.6%) and 281 good recoveries (61.9%). Multivariate analysis showed that factors associated with poor outcome (death, vegetative state or severe disability) were: PRISM ≥24 (P=0.03; OR: 5.75); GCS ≤8 (P=0.04; OR:2.42); Cerebral edema (P=0.03; OR:2.23); lesion type VI according to Traumatic Coma Data Bank Classification (P=0.002; OR:55.95); Hypoxemia (P=0.02; OR:2.97) and sodium level >145 mmol/l (P=0.04; OR: 4.41). Conclusions: A significant proportion of children admitted with HI were found to have moderate disability at follow-up. We think that improving prehospital care, establishing trauma centers and making efforts to prevent motor vehicle crashes should improve the prognosis of HI in children.
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Affiliation(s)
- Mabrouk Bahloul
- Department of Intensive Care, Habib Bourguiba University hospital Sfax, Tunisia
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Abstract
PURPOSE OF REVIEW The developing brain is particularly vulnerable to traumatic brain injury (TBI), leading to frequent disability or death. This article is an update of the pediatric specificities of TBI management. RECENT FINDINGS We review the evidences with regards to general management and therapeutic goals to prevent secondary injuries in pediatric TBI patients. Recent controversies in neurocritical care, such as multimodal neuromonitoring, hyperventilation, barbiturate coma, hypothermia, and decompressive surgery, are also highlighted. SUMMARY Many therapeutic modalities in pediatric TBI have a low level of evidence. Further research is needed to establish clear resuscitation goals. Universal objectives may not be suitable for all patients; intensive neuromonitoring may help in identifying individual therapeutic goals and guiding the selection of treatments.
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