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Valentim W, Bertani R, Brasil S. A Narrative Review on Financial Challenges and Health Care Costs Associated with Traumatic Brain Injury in the United States. World Neurosurg 2024; 187:82-92. [PMID: 38583561 DOI: 10.1016/j.wneu.2024.03.175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Accepted: 03/30/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a highly prevalent and potentially severe medical condition. Challenges regarding TBI management are related to accurate diagnostics, defining its severity, and establishing prompt interventions to affect outcomes. Among the health care components in the TBI handling strategy is intracranial pressure (ICP) monitoring, which is fundamental to therapy decisions. However, ICP monitoring is an Achilles tendon, imposing a significant financial burden on health care systems, particularly in middle and low-income communities. This article arises from the understanding from the authors that there is insufficient scientific evidence about the potential economic impacts from the use of noninvasive technologies in the monitoring of TBI. Based on personal experience, as well as from reading other, clinically focused studies, the thesis is that the use of such technologies could greatly affect the health care system and this article seeks to address this lack of literature, show ways in which such systems could be evaluated, and show estimations of possible results from these investigations. OBJECTIVE This review primarily investigates the economic burden of TBI and whether new technologies are suitable to reduce its health care costs without compromising the quality of care, according to the levels of evidence available. The objective is to stimulate more research and attention in the area. METHODS For this narrative review, a PubMed search was conducted for articles discussing TBI health care costs, as well as monitoring technologies (tomography, magnetic resonance imaging, optic nerve sheath diameter, transcranial Doppler, pupillometry, and noninvasive ICP waveform) and their application in managing TBI. Strategies were first evaluated from a medical noninferiority perspective before calculating the average savings of each selected strategy. All applicable studies were analyzed for quality using the Consolidated Health Economic Evaluation Reporting Standards 2022 Statement117 and this article was written to conform as much as possible with it. RESULTS The review included 109 references and showed a consistent potential in noninvasive technologies to reduce costs and maintain or improve the quality of care. CONCLUSIONS TBI prevalence has increased with a disproportionate health care burden in the last decades. Noninvasive monitoring techniques seem to be effective in reducing TBI health care costs, with few limitations, especially the need for more supporting scientific evidence. The undeniable clinical and financial potential of these techniques is compelling to further investigate their role in TBI management, as well as the creation of more comprehensive monitoring models to the understanding of complex phenomena occurring in the injured brain.
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Affiliation(s)
- Wander Valentim
- Faculty of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil.
| | - Raphael Bertani
- Neurosurgery Division, Department of Neurology, São Paulo University School of Medicine, São Paulo, Brazil
| | - Sergio Brasil
- Neurosurgery Division, Department of Neurology, São Paulo University School of Medicine, São Paulo, Brazil
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Taran S, Stevens RD, Perrot B, McCredie VA, Cinotti R, Asehnoune K, Pelosi P, Robba C. Incidence and Outcomes of Acute Respiratory Distress Syndrome in Brain-Injured Patients Receiving Invasive Ventilation: A Secondary Analysis of the ENIO Study. J Intensive Care Med 2024; 39:136-145. [PMID: 37563968 PMCID: PMC10771027 DOI: 10.1177/08850666231194532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
Background: Acute respiratory distress syndrome (ARDS) is an important pulmonary complication in brain-injured patients receiving invasive mechanical ventilation (IMV). We aimed to evaluate the incidence and association between ARDS and clinical outcomes in patients with different forms of acute brain injury requiring IMV in the intensive care unit (ICU). Methods: This was a preplanned secondary analysis of a prospective, multicenter, international cohort study (NCT03400904). We included brain-injured patients receiving IMV for ≥ 24 h. ARDS was the main exposure of interest and was identified during index ICU admission using the Berlin definition. We examined the incidence and adjusted association of ARDS with ICU mortality, ICU length of stay, duration of IMV, and extubation failure. Outcomes were evaluated using mixed-effect logistic regression and cause-specific Cox proportional hazards models. Results: 1492 patients from 67 hospitals and 16 countries were included in the analysis, of whom 137 individuals developed ARDS (9.2% of overall cohort). Across countries, the median ARDS incidence was 5.1% (interquartile range [IQR] 0-10; range 0-27.3). ARDS was associated with increased ICU mortality (adjusted odds ratio (OR) 2.66; 95% confidence interval [CI], 1.29-5.48), longer ICU length of stay (adjusted hazard ratio [HR] 0.59; 95% CI, 0.48-0.73), and longer duration of IMV (adjusted HR 0.54; 95% CI, 0.44-0.67). The association between ARDS and extubation failure approached statistical significance (adjusted HR 1.48; 95% CI 0.99-2.21). Higher ARDS severity was associated with incrementally longer ICU length of stay and longer cumulative duration of IMV. Findings remained robust in a sensitivity analysis evaluating the magnitude of unmeasured confounding. Conclusions: In this cohort of acutely brain-injured patients, the incidence of ARDS was similar to that reported in other mixed cohorts of critically ill patients. Development of ARDS was associated with worse outcomes.
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Affiliation(s)
- Shaurya Taran
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert D. Stevens
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Biomedical Engineering, Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Bastien Perrot
- UMR 1246 MethodS in Patient-centered outcomes and HEalth REsearch, SPHERE, Nantes Université, Tours Université, Nantes, France
| | - Victoria A. McCredie
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Raphael Cinotti
- UMR 1246 MethodS in Patient-centered outcomes and HEalth REsearch, SPHERE, Nantes Université, Tours Université, Nantes, France
- Department of Anaesthesia and Critical Care, CHU Nantes, Nantes Université, Hôtel-Dieu, Nantes, France
| | - Karim Asehnoune
- Department of Anaesthesia and Critical Care, CHU Nantes, Nantes Université, Hôtel-Dieu, Nantes, France
| | - Paolo Pelosi
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Chiara Robba
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
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Taran S, Hamad DM, von Düring S, Malhotra AK, Veroniki AA, McCredie VA, Singh JM, Hansen B, Englesakis M, Adhikari NKJ. Factors associated with acute respiratory distress syndrome in brain-injured patients: A systematic review and meta-analysis. J Crit Care 2023; 77:154341. [PMID: 37235919 DOI: 10.1016/j.jcrc.2023.154341] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 03/29/2023] [Accepted: 05/14/2023] [Indexed: 05/28/2023]
Abstract
PURPOSE Acute respiratory distress syndrome (ARDS) is common in patients with acute brain injury admitted to the ICU. We aimed to identify factors associated with ARDS in this population. METHODS We searched MEDLINE, Embase, Cochrane Central, Scopus, and Web of Science from inception to January 14, 2022. Three reviewers independently screened articles and selected English-language studies reporting risk factors for ARDS in brain-injured adult patients. Data were extracted on ARDS incidence, adjusted and unadjusted risk factors, and clinical outcomes. Risk of bias was reported using the Quality in Prognostic Studies tool. Certainty of evidence was assessed using GRADE. RESULTS We selected 23 studies involving 6,961,284 patients with acute brain injury. The pooled cumulative incidence of ARDS after brain injury was 17.0% (95%CI 10.7-25.8). In adjusted analysis, factors associated with ARDS included sepsis (odds ratio (OR) 4.38, 95%CI 2.37-8.10; high certainty), history of hypertension (OR 3.11, 95%CI 2.31-4.19; high certainty), pneumonia (OR 2.69, 95%CI 2.35-3.10; high certainty), acute kidney injury (OR 1.44, 95%CI 1.30-1.59; moderate certainty), admission hypoxemia (OR 1.67, 95%CI 1.29-2.17; moderate certainty), male sex (OR 1.30, 95%CI 1.06-1.58; moderate certainty), and chronic obstructive pulmonary disease (OR 1.27, 95%CI 1.13-1.44; moderate certainty). Development of ARDS was independently associated with increased odds of in-hospital mortality (OR 3.12, 95% CI 1.39-7.00). CONCLUSIONS Multiple risk factors are associated with ARDS in brain-injured patients. These findings could be used to develop prognostic models for ARDS or as prognostic enrichment strategies for patient enrolment in future clinical trials.
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Affiliation(s)
- Shaurya Taran
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Neurology, Massachusetts General Hospital, Harvard University, Boston, MA, USA.
| | - Doulia M Hamad
- Department of Surgery, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, ON, Canada
| | - Stephan von Düring
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Intensive Care Division, Geneva University Hospitals (HUG) and Faculty of Medicine, University of Geneva, Switzerland
| | - Armaan K Malhotra
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Areti Angeliki Veroniki
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada; Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Victoria A McCredie
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Jeffrey M Singh
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Bettina Hansen
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada; Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, ON, Canada; Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands
| | - Marina Englesakis
- Library and Health Information Services, University Health Network, Toronto, ON, Canada
| | - Neill K J Adhikari
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
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The mechanical power in neurocritical care patients: is it useful? J Clin Monit Comput 2022; 36:1581-1583. [PMID: 35849210 DOI: 10.1007/s10877-022-00885-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 05/30/2022] [Indexed: 10/17/2022]
Abstract
Patients with acute brain injury have been excluded in the majority of the randomized clinical trials which evaluated a lung protective strategy in patients with acute respiratory failure. It remains unclear if low tidal volume, higher PEEP levels and recruitment maneuvers by increasing both the intracranial and intrathoracic pressure and by leading to a permissible hypercapnia could furthermore deteriorate the acute brain injury and the final outcome. Mechanical power has been associated with the outcome in ARDS patients without brain injury. Jiang et al. demonstrated in neurocritical patients that non-survivors had a higher mechanical power compared to survivors. Mechanical power was associated with an increase in intensive care mortality risk and also to an enhanced risk of hospital mortality, prolonged intensive care length of stay and fewer ventilatory free days; in addition, the mechanical power could better predict mortality compared to the Glasgow Coma Scale.
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Prevalence and Outcome of Acute Respiratory Distress Syndrome in Traumatic Brain Injury: A Systematic Review and Meta-Analysis. Lung 2021; 199:603-610. [PMID: 34779897 PMCID: PMC8590970 DOI: 10.1007/s00408-021-00491-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 10/26/2021] [Indexed: 11/01/2022]
Abstract
OBJECTIVES Acute respiratory distress syndrome (ARDS) in patients with traumatic brain injury (TBI) is associated with increased mortality. Information on the prevalence of ARDS and its neurological outcome after TBI is sparse. We aimed to systematically review the prevalence, risk factors, and outcome of ARDS in TBI population. DATA SOURCES PubMed and four other databases (Embase, Cochrane Library, Web of Science Core Collection, and Scopus) from inception to July 6, 2020. STUDY SELECTION Randomized controlled trials (RCTs) and observational studies in patients older than 18 years old. DATA EXTRACTION Two independent reviewers extracted the data. Study quality was assessed by the Cochrane Risk of Bias tool for RCTs, the Newcastle-Ottawa Scale for cohort and case-control studies. Good neurological outcome was defined as Glasgow Outcome Scale ≥ 4. Random-effects meta-analyses were conducted to estimate pooled outcome prevalence and their 95% confidence intervals (CI). DATA SYNTHESIS We included 20 studies (n = 2830) with median age of 44 years (interquartile range [IQR] = 35-47, 64% male) and 79% (n = 2237) suffered severe TBI. In meta-analysis, 19% patients (95% CI = 0.13-0.27, I2 = 93%) had ARDS after TBI. The median time from TBI to ARDS was 3 days (IQR = 2-5). Overall survival at discharge for the TBI cohort was 70% (95% CI = 0.64-0.75; I2 = 85%) and good neurological outcome at any time was achieved in 31% of TBI patients (95% CI = 0.23-0.40; I2 = 88%). TBI cohort without ARDS had higher survival (67% vs. 57%, p = 0.01) and good neurological outcomes (34% vs. 23%, p = 0.02) compared to those with ARDS. We did not find any specific risk factors for developing ARDS. CONCLUSION In this meta-analysis, approximately one in five patients had ARDS shortly after TBI with the median time of 3 days. The presence of ARDS was associated with worse neurological outcome and mortality in TBI. Further research on prevention and intervention strategy of TBI-associated ARDS is warranted.
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Parker BM, Menaker J, Berry CD, Tesoreiero RB, O'Connor JV, Stein DM, Scalea TM. Single Center Experience With Veno-Venous Extracorporeal Membrane Oxygenation in Patients With Traumatic Brain Injury. Am Surg 2020; 87:949-953. [PMID: 33295187 DOI: 10.1177/0003134820956360] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
METHODS We retrospectively reviewed TBI patients ≥ 18 years of age treated with VV-ECMO. The primary outcome was survival to discharge. Secondary outcomes included progression of intracranial hemorrhage, bleeding complications, and episodes of oxygenator thrombosis requiring exchange. Medians and interquartile ranges were reported where appropriate. RESULTS 13 TBI patients received VV-ECMO support during the study period. The median age was 28 years (Interquartile range (IQR) 25-37.5) and 85% were men. Median admission Glasgow coma scale was 5 (IQR 3-13.5). Median injury severity score (ISS) was 48 (IQR 33.5-66). Median pre-ECMO PaO2:FiO2 ratio was 58 (IQR 47-74.5). Five (38.4%) patients survived to discharge. Six patients (46%) received systemic A/C while on ECMO. No patient had worsening of intracranial hemorrhage on computed tomography imaging. There were two bleeding complications in patients on A/C, neither was related to TBI. Four patients required an oxygenator change; 2 in patients on A/C. CONCLUSION VV-ECMO appears safe with TBI. We have demonstrated that A/C can be withheld without increased complications. Traumatic brain injury should not be considered an absolute contraindication to the use of VV-ECMO for severe respiratory failure and should be decided on a case by case basis. Additional research is needed to confirm these preliminary findings.
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Affiliation(s)
- Brandon M Parker
- Department of Surgery, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Jay Menaker
- Department of Surgery, School of Medicine, University of Maryland Baltimore, MD, USA
| | - Cherisse D Berry
- Department of Surgery, School of Medicine, New York University, New York, NY, USA
| | | | - James V O'Connor
- Department of Surgery, School of Medicine, University of Maryland Baltimore, MD, USA
| | - Deborah M Stein
- Department of Surgery, Univeristy of California, San Francisco, CA, USA
| | - Thomas M Scalea
- Department of Surgery, School of Medicine, University of Maryland Baltimore, MD, USA
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Komisarow JM, Chen F, Vavilala MS, Laskowitz D, James ML, Krishnamoorthy V. Epidemiology and Outcomes of Acute Respiratory Distress Syndrome Following Isolated Severe Traumatic Brain Injury. J Intensive Care Med 2020; 37:68-74. [PMID: 33191844 DOI: 10.1177/0885066620972001] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patients with traumatic brain injury (TBI) are at risk for extra-cranial complications, such as the acute respiratory distress syndrome (ARDS). We conducted an analysis of risk factors, mortality, and healthcare utilization associated with ARDS following isolated severe TBI. The National Trauma Data Bank (NTDB) dataset files from 2007-2014 were used to identify adult patients who suffered isolated [other body region-specific Abbreviated Injury Scale (AIS) < 3] severe TBI [admission total Glasgow Coma Scale (GCS) from 3 to 8 and head region-specific AIS >3]. In-hospital mortality was compared between patients who developed ARDS and those who did not. Utilization of healthcare resources (ICU length of stay, hospital length of stay, duration of mechanical ventilation, and frequency of tracheostomy and gastrostomy tube placement) was also examined. This retrospective cohort study included 38,213 patients with an overall ARDS occurrence of 7.5%. Younger age, admission tachycardia, pre-existing vascular and respiratory diseases, and pneumonia were associated with the development of ARDS. Compared to patients without ARDS, patients that developed ARDS experienced increased in-hospital mortality (OR 1.13, 95% CI 1.01-1.26), length of stay (p = <0.001), duration of mechanical ventilation (p = < 0.001), and placement of tracheostomy (OR 2.70, 95% CI 2.34-3.13) and gastrostomy (OR 2.42, 95% CI 2.06-2.84). After isolated severe TBI, ARDS is associated with increased mortality and healthcare utilization. Future studies should focus on both prevention and management strategies specific to TBI-associated ARDS.
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Affiliation(s)
| | - Fangyu Chen
- School of Medicine, 12277Duke University, Durham, NC, USA
| | - Monica S Vavilala
- Department of Anesthesiology, 7284University of Washington, Seattle, WA, USA
| | | | - Michael L James
- Department of Neurology, 12277Duke University, Durham, NC, USA.,Department of Anesthesiology, 12277Duke University, Durham, NC, USA
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Shao XF, Li B, Shen J, Wang QF, Chen SS, Jiang XC, Qiang D. Ghrelin alleviates traumatic brain injury-induced acute lung injury through pyroptosis/NF-κB pathway. Int Immunopharmacol 2020; 79:106175. [PMID: 31918060 DOI: 10.1016/j.intimp.2019.106175] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 12/22/2019] [Accepted: 12/30/2019] [Indexed: 12/18/2022]
Abstract
Acute lung injury (ALI) is one of the severe complications in patients with traumatic brain injury (TBI), contributing to the high mortality. Ghrelin has protective effects against various inflammatory diseases, but the effects of Ghrelin on TBI-induced ALI and its mechanisms remain unknown. In this study, Ghrelin administration was performed on the mice with TBI, then histological change in cortex and lung tissues, lung vascular permeability and macrophage number in bronchoalveolar lavage fluid (BALF) were examined, respectively. Simultaneously, the alterations of proinflammatory factors and pyroptosis-related proteins in lung tissues were detected. As a result, TBI-induced ALI was ameliorated after Ghrelin treatment, which was demonstrated by improved histology, reduced lung vascular permeability, and peripheral macrophage number. Furthermore, Ghrelin decreased the mRNA levels of proinflammatory factors (IL-1β, IL-6, TNF-α and IL-18), the protein levels of pyroptosis-related proteins (NLRP3, Caspase1-P20, HMGB1 and Gasdermin D), and the phosphorylation levels of NF-κB in lung tissues. These results showed that Ghrelin attenuating TBI-induced ALI might be via ameliorating inflammasome-induced pyroptosis by blocking NF-κB signal, which are important for the prevention and treatment of TBI-induced ALI.
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Affiliation(s)
- Xue-Fei Shao
- Department of Neurosurgery, Yi Ji Shan Hospital of Wannan Medical College, Wuhu, China.
| | - Bo Li
- Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Jun Shen
- Department of Neurosurgery, Yi Ji Shan Hospital of Wannan Medical College, Wuhu, China
| | - Qi-Fu Wang
- Department of Neurosurgery, Yi Ji Shan Hospital of Wannan Medical College, Wuhu, China
| | - San-Song Chen
- Department of Neurosurgery, Yi Ji Shan Hospital of Wannan Medical College, Wuhu, China
| | - Xiao-Chun Jiang
- Department of Neurosurgery, Yi Ji Shan Hospital of Wannan Medical College, Wuhu, China
| | - Di Qiang
- Department of Dermatology and STD, Yi-Ji Shan Hospital of Wannan Medical College, Wuhu, China.
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Medar SS, Villacres S, Kaushik S, Eisenberg R, Stone ME. Pediatric Acute Respiratory Distress Syndrome (PARDS) in Children With Pulmonary Contusion. J Intensive Care Med 2019; 36:107-114. [PMID: 31711367 DOI: 10.1177/0885066619887666] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE There is paucity of data about prevalence of pediatric acute respiratory distress syndrome (PARDS) in children with pulmonary contusion (PC). We intend to evaluate PC in children with chest trauma and the association between PC and PARDS. DESIGN Retrospective review of Institutional Trauma Registry for patients with trauma. SETTING Level 1 trauma center. PATIENTS Age 18 years and younger with a diagnosis of PC. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of the 1916 children with trauma, 50 (2.6%) had PC. Patients with PC and PARDS had lower Glasgow Coma Scale (GCS) score (7 [3-15] vs 15 [15-15], P = .0003), higher Injury Severity Scale (ISS) score (29 [22-34] vs 19 [14-22], P = .004), lower oxygen saturations (96 [93-99] days vs 99 [98-100] days, P = .0009), higher FiO2 (1 [1-1] vs 0.21 [0.21-0.40], P < .0001), lower oxygen saturation/FiO2 (S/F) ratios (97 [90-99] vs 457 [280-471], P < .0001), need for invasive mechanical ventilation (IMV; 86% vs 23%, P < .0001), and mortality (28% vs 0%, P = .006) compared to those without PARDS. Forty-two percent (21/50) of patients needed IMV, of these 61% (13/21) had PARDS. Patients who needed IMV had significantly lower GCS score (8 [3-11] vs 15 [15-15], P < .0001), higher ISS score (27 [22-34] vs 18 [14-22], P = .002), longer length of stay (LOS; 7.5 [4-14] days vs 3.3 [2-5] days, P = .003), longer hospital LOS (18 [7.0-25] vs 5 [4-11], P = .008), higher PARDS rate (62% vs 7%, P < .0001), and lower S/F ratios (99 [94-190] vs 461 [353-471], P < .0001) compared to those who did not require IMV. Lower GCS score was independently associated with both PARDS and need for IMV. CONCLUSIONS Pediatric ARDS in children with PC is independently associated with lower GCS score, and its presence significantly increased morbidity and mortality. Further larger studies are needed to explore association of lower GCS and higher injury score in children with PARDS and PC.
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Affiliation(s)
- Shivanand S Medar
- Division of Pediatric Critical Care Medicine and Pediatric Cardiology, 37292Children's Hospital at Montefiore, Bronx, NY, USA
- Albert Einstein College of Medicine, Bronx, NY, USA
- Jacobi Medical Center, Bronx, NY, USA
| | - Sindy Villacres
- Division of Pediatric Critical Care Medicine, 25104Neumors Children's Hospital, Orlando, FL, USA
| | - Shubhi Kaushik
- Division of Pediatric Critical Care Medicine and Pediatric Cardiology, 37292Children's Hospital at Montefiore, Bronx, NY, USA
- Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Melvin E Stone
- Albert Einstein College of Medicine, Bronx, NY, USA
- Jacobi Medical Center, Bronx, NY, USA
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van Dijck JTJM, Dijkman MD, Ophuis RH, de Ruiter GCW, Peul WC, Polinder S. In-hospital costs after severe traumatic brain injury: A systematic review and quality assessment. PLoS One 2019; 14:e0216743. [PMID: 31071199 PMCID: PMC6508680 DOI: 10.1371/journal.pone.0216743] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 04/28/2019] [Indexed: 12/19/2022] Open
Abstract
Background The in-hospital treatment of patients with traumatic brain injury (TBI) is considered to be expensive, especially in patients with severe TBI (s-TBI). To improve future treatment decision-making, resource allocation and research initiatives, this study reviewed the in-hospital costs for patients with s-TBI and the quality of study methodology. Methods A systematic search was performed using the following databases: PubMed, MEDLINE, Embase, Web of Science, Cochrane library, CENTRAL, Emcare, PsychINFO, Academic Search Premier and Google Scholar. Articles published before August 2018 reporting in-hospital acute care costs for patients with s-TBI were included. Quality was assessed by using a 19-item checklist based on the CHEERS statement. Results Twenty-five out of 2372 articles were included. In-hospital costs per patient were generally high and ranged from $2,130 to $401,808. Variation between study results was primarily caused by methodological heterogeneity and variable patient and treatment characteristics. The quality assessment showed variable study quality with a mean total score of 71% (range 48% - 96%). Especially items concerning cost data scored poorly (49%) because data source, cost calculation methodology and outcome reporting were regularly unmentioned or inadequately reported. Conclusions Healthcare consumption and in-hospital costs for patients with s-TBI were high and varied widely between studies. Costs were primarily driven by the length of stay and surgical intervention and increased with higher TBI severity. However, drawing firm conclusions on the actual in-hospital costs of patients sustaining s-TBI was complicated due to variation and inadequate quality of the included studies. Future economic evaluations should focus on the long-term cost-effectiveness of treatment strategies and use guideline recommendations and common data elements to improve study quality.
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Affiliation(s)
- Jeroen T. J. M. van Dijck
- Department of Neurosurgery, Neurosurgical Center Holland, Leiden University Medical Center, Leiden, The Netherlands
- Department of Neurosurgery, Neurosurgical Center Holland, Haaglanden Medical Center, The Hague, The Netherlands
- Department of Neurosurgery, Neurosurgical Center Holland, Haga Teaching Hospital, The Hague, The Netherlands
- * E-mail:
| | - Mark D. Dijkman
- Department of Neurosurgery, Neurosurgical Center Holland, Leiden University Medical Center, Leiden, The Netherlands
- Department of Neurosurgery, Neurosurgical Center Holland, Haaglanden Medical Center, The Hague, The Netherlands
- Department of Neurosurgery, Neurosurgical Center Holland, Haga Teaching Hospital, The Hague, The Netherlands
| | - Robbin H. Ophuis
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Godard C. W. de Ruiter
- Department of Neurosurgery, Neurosurgical Center Holland, Leiden University Medical Center, Leiden, The Netherlands
- Department of Neurosurgery, Neurosurgical Center Holland, Haaglanden Medical Center, The Hague, The Netherlands
- Department of Neurosurgery, Neurosurgical Center Holland, Haga Teaching Hospital, The Hague, The Netherlands
| | - Wilco C. Peul
- Department of Neurosurgery, Neurosurgical Center Holland, Leiden University Medical Center, Leiden, The Netherlands
- Department of Neurosurgery, Neurosurgical Center Holland, Haaglanden Medical Center, The Hague, The Netherlands
- Department of Neurosurgery, Neurosurgical Center Holland, Haga Teaching Hospital, The Hague, The Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
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Incidence, risk factors, and mortality associated with acute respiratory distress syndrome in combat casualty care. J Trauma Acute Care Surg 2017; 81:S150-S156. [PMID: 27768663 DOI: 10.1097/ta.0000000000001183] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The overall incidence and mortality of acute respiratory distress syndrome (ARDS) in civilian trauma settings have decreased over the past four decades; however, the epidemiology and impact of ARDS on modern combat casualty care are unknown. We sought to determine the incidence, risk factors, resource utilization, and mortality associated with ARDS in current combat casualty care. METHODS This was a retrospective review of mechanically ventilated US combat casualties within the Department of Defense Trauma Registry (formerly the Joint Theater Trauma Registry) during Operation Iraqi Freedom/Enduring Freedom (October 2001 to August 2008) for ARDS development, resource utilization, and mortality. RESULTS Of 18,329 US Department of Defense Trauma Registry encounters, 4,679 (25.5%) required mechanical ventilation; ARDS was identified in 156 encounters (3.3%). On multivariate logistic regression, ARDS was independently associated with female sex (odds ratio [OR], 2.62; 95% confidence interval [CI], 1.21-5.71; p = 0.02), higher military-specific Injury Severity Score (Mil ISS) (OR, 4.18; 95% CI, 2.61-6.71; p < 0.001 for Mil ISS ≥25 vs. <15), hypotension (admission systolic blood pressure <90 vs. ≥90 mm Hg; OR, 1.76; 95% CI, 1.07-2.88; p = 0.03), and tachycardia (admission heart rate ≥90 vs. <90 beats per minute; OR, 1.53; 95% CI, 1.06-2.22; p = 0.02). Explosion injury was not associated with increased risk of ARDS. Critical care resource utilization was significantly higher in ARDS patients as was all-cause hospital mortality (ARDS vs. no ARDS, 12.8% vs. 5.9%; p = 0.002). After adjustment for age, sex, injury severity, injury mechanism, Mil ISS, hypotension, tachycardia, and admission Glasgow Coma Scale score, ARDS remained an independent risk factor for death (OR, 1.99; 95% CI, 1.12-3.52; p = 0.02). CONCLUSIONS In this large cohort of modern combat casualties, ARDS risk factors included female sex, higher injury severity, hypotension, and tachycardia, but not explosion injury. Patients with ARDS also required more medical resources and were at greater risk of death compared with patients without ARDS. Thus, ARDS remains a significant complication in current combat casualty care. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III.
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Abstract
Neuropulmonology refers to the complex interconnection between the central nervous system and the respiratory system. Neurologic injury includes traumatic brain injury, hemorrhage, stroke, and seizures, and in each there are far-reaching effects that can result in pulmonary dysfunction. Systemic changes can induce impairment of pulmonary function due to changes in the core structure and function of the lung. The conditions and disorders that often occur in these patients include aspiration pneumonia, neurogenic pulmonary edema, and acute respiratory distress syndrome, but also several abnormal respiratory patterns and sleep-disordered breathing. Lung infections, pulmonary edema - neurogenic or cardiogenic - and pulmonary embolus all are a serious barrier to recovery and can have significant effects on outcomes such as hospital course, prognosis, and mortality. This review presents the spectrum of pulmonary abnormalities seen in neurocritical care.
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Hendrickson CM, Howard BM, Kornblith LZ, Conroy AS, Nelson MF, Zhuo H, Liu KD, Manley GT, Matthay MA, Calfee CS, Cohen MJ. The acute respiratory distress syndrome following isolated severe traumatic brain injury. J Trauma Acute Care Surg 2016; 80:989-97. [PMID: 26881489 PMCID: PMC5851280 DOI: 10.1097/ta.0000000000000982] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Acute respiratory distress syndrome (ARDS) is common after traumatic brain injury (TBI) and is associated with worse neurologic outcomes and longer hospitalization. However, the incidence and associated causes of ARDS in isolated TBI have not been well studied. METHODS We performed a subgroup analysis of 210 consecutive patients with isolated severe TBI enrolled in a prospective observational cohort at a Level 1 trauma center between 2005 and 2014. Subjects required endotracheal intubation and had isolated severe TBI defined by a head Abbreviated Injury Scale (AIS) score of 3 or greater and AIS score lower than 3 in all other categories. ARDS within the first 8 days of admission was rigorously adjudicated using Berlin criteria. Regression analyses were used to test the association between predictors of interest and ARDS. RESULTS The incidence of ARDS in the first 8 days after severe isolated TBI was 30%. Patients who developed ARDS were administered more crystalloids (4.3 L vs. 3.5 L, p = 0.005) and blood products in the first 12 hours of admission. Patients with ARDS had significantly worse clinical outcomes measured at 28 days, including longer median intensive care unit and hospital stays (4 days vs. 13 days, p < 0.001, and 7.5 days vs. 14.5 days, p < 0.001, respectively). In unadjusted logistic regression analyses, the odds of developing ARDS were significantly associated with head AIS score (odds ratio [OR], 1.8; p = 0.018), male sex (OR, 2.9; p = 0.012), and early transfusion of platelets (OR, 2.8; p = 0.003). These associations were similar in a multivariate logistic regression model. CONCLUSION In the era of balanced hemostatic resuscitation practices, severity of head injury, male sex, early crystalloids, and early transfusion of platelets are associated with a higher risk of ARDS after severe isolated TBI. Early transfusion of platelets after severe TBI may be a modifiable risk factor for ARDS, and these findings invite further investigation into causal mechanisms driving this observed association. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III.
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Affiliation(s)
- Carolyn M Hendrickson
- From the Division of Pulmonary and Critical Care Medicine (C.M.H., H.Z., C.S.C, M.A.M.) and Division of Nephrology and Critical Care Medicine (K.D.L.), Departments of Medicine and Anesthesia, University of California San Francisco; and Department of Surgery (B.M.H., L.Z.K., A.S.C., M.F.N., M.J.C.) and Department of Neurological Surgery (G.T.M.), University of California San Francisco and San Francisco General Hospital; San Francisco, California
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Aisiku IP, Yamal JM, Doshi P, Rubin ML, Benoit JS, Hannay HJ, Tilley BC, Gopinath S, Robertson CS. The incidence of ARDS and associated mortality in severe TBI using the Berlin definition. J Trauma Acute Care Surg 2016; 80:308-12. [PMID: 26491799 PMCID: PMC4731296 DOI: 10.1097/ta.0000000000000903] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The incidence of adult respiratory distress syndrome (ARDS) in severe traumatic brain injury (TBI) is poorly reported. Recently, a new definition for ARDS was proposed, the Berlin definition. The percentage of patients represented by TBI in the Berlin criteria study is limited. This study describes the incidence and associated mortality of ARDS in TBI patients. METHODS The study was an analysis of the safety of erythropoietin administration and transfusion threshold on the incidence of ARDS in severe TBI patients. Three reviewers independently assessed all patients enrolled in the study for acute lung injury/ARDS using the Berlin and the American-European Consensus Conference (AECC) definitions. A Cox proportional hazards model was used to assess the relationship between ARDS and mortality and 6-month Glasgow Outcome Scale (GOS) score. RESULTS Two hundred patients were enrolled in the study. Of the patients, 21% (41 of 200) and 26% (52 of 200) developed ARDS using the AECC and Berlin definitions, respectively, with a median time of 3 days (interquartile range, 3) after injury. ARDS by either definition was associated with increased mortality (p = 0.04) but not with differences in functional outcome as measured by the GOS score at 6 months. Adjusted analysis using the Berlin criteria showed an increased mortality associated with ADS (p = 0.01). CONCLUSION Severe TBI is associated with an incidence of ARDS ranging from 20% to 25%. The incidence is comparable between the Berlin and AECC definitions. ARDS is associated with increased mortality in severe TBI patients, but further studies are needed to validate these findings. LEVEL OF EVIDENCE Epidemiologic study, level II.
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Affiliation(s)
- Imo P. Aisiku
- Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115
| | - Jose-Miguel Yamal
- Division of Biostatistics, University of Texas School of Public Health
| | - Pratik Doshi
- Assistant Professor, Department of Emergency Medicine and Internal Medicine, University of Texas Health Science Center at Houston
| | - M. Laura Rubin
- Division of Biostatistics, University of Texas School of Public Health
| | - Julia S. Benoit
- Department of Basic Vision Sciences, College of Optometry Texas Institute for Measurement Evaluation and Statistics, University of Houston
| | | | - Barbara C. Tilley
- Division of Biostatistics, University of Texas School of Public Health
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Schreiter D, Carvalho NC, Katscher S, Mende L, Reske AP, Spieth PM, Carvalho AR, Beda A, Lachmann B, Amato MBP, Wrigge H, Reske AW. Experimental blunt chest trauma--cardiorespiratory effects of different mechanical ventilation strategies with high positive end-expiratory pressure: a randomized controlled study. BMC Anesthesiol 2016; 16:3. [PMID: 26757894 PMCID: PMC4709895 DOI: 10.1186/s12871-015-0166-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 12/09/2015] [Indexed: 02/01/2023] Open
Abstract
Background Uncertainty persists regarding the optimal ventilatory strategy in trauma patients developing acute respiratory distress syndrome (ARDS). This work aims to assess the effects of two mechanical ventilation strategies with high positive end-expiratory pressure (PEEP) in experimental ARDS following blunt chest trauma. Methods Twenty-six juvenile pigs were anesthetized, tracheotomized and mechanically ventilated. A contusion was applied to the right chest using a bolt-shot device. Ninety minutes after contusion, animals were randomized to two different ventilation modes, applied for 24 h: Twelve pigs received conventional pressure-controlled ventilation with moderately low tidal volumes (VT, 8 ml/kg) and empirically chosen high external PEEP (16cmH2O) and are referred to as the HP-CMV-group. The other group (n = 14) underwent high-frequency inverse-ratio pressure-controlled ventilation (HFPPV) involving respiratory rate of 65breaths · min−1, inspiratory-to-expiratory-ratio 2:1, development of intrinsic PEEP and recruitment maneuvers, compatible with the rationale of the Open Lung Concept. Hemodynamics, gas exchange and respiratory mechanics were monitored during 24 h. Computed tomography and histology were analyzed in subgroups. Results Comparing changes which occurred from randomization (90 min after chest trauma) over the 24-h treatment period, groups differed statistically significantly (all P values for group effect <0.001, General Linear Model analysis) for the following parameters (values are mean ± SD for randomization vs. 24-h): PaO2 (100 % O2) (HFPPV 186 ± 82 vs. 450 ± 59 mmHg; HP-CMV 249 ± 73 vs. 243 ± 81 mmHg), venous admixture (HFPPV 34 ± 9.8 vs. 11.2 ± 3.7 %; HP-CMV 33.9 ± 10.5 vs. 21.8 ± 7.2 %), PaCO2 (HFPPV 46.9 ± 6.8 vs. 33.1 ± 2.4 mmHg; HP-CMV 46.3 ± 11.9 vs. 59.7 ± 18.3 mmHg) and normally aerated lung mass (HFPPV 42.8 ± 11.8 vs. 74.6 ± 10.0 %; HP-CMV 40.7 ± 8.6 vs. 53.4 ± 11.6 %). Improvements occurring after recruitment in the HFPPV-group persisted throughout the study. Peak airway pressure and VT did not differ significantly. HFPPV animals had lower atelectasis and inflammation scores in gravity-dependent lung areas. Conclusions In this model of ARDS following unilateral blunt chest trauma, HFPPV ventilation improved respiratory function and fulfilled relevant ventilation endpoints for trauma patients, i.e. restoration of oxygenation and lung aeration while avoiding hypercapnia and respiratory acidosis.
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Affiliation(s)
- Dierk Schreiter
- Helios Park Clinic, Department of Intensive Care Medicine, Leipzig, Germany.
| | - Nadja C Carvalho
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Liebigstr. 20, D-04103, Leipzig, Germany. .,Department of Electronic Engineering, Federal University of Minas Gerais, Belo Horizonte, Brazil.
| | - Sebastian Katscher
- Sana Kliniken Leipziger Land, Department of Orthopedic, Trauma and Hand Surgery, Borna, Germany.
| | - Ludger Mende
- Intensive Care Unit, Sana Kliniken Leipziger Land, Borna, Germany.
| | - Alexander P Reske
- Anesthesiology and Intensive Care Medicine, Fachkrankenhaus Coswig, Coswig, Sachsen, Germany.
| | - Peter M Spieth
- Pulmonary Engineering Group, Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Dresden, Germany.
| | - Alysson R Carvalho
- Carlos Chagas Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.
| | - Alessandro Beda
- Department of Electronic Engineering, Federal University of Minas Gerais, Belo Horizonte, Brazil.
| | - Burkhard Lachmann
- Department of Anesthesiology and Intensive Care Medicine, Charité, Berlin Medical University, Berlin, Germany.
| | - Marcelo B P Amato
- Cardio-Pulmonary Department, Pulmonary Division, Hospital das Clínicas, University of São Paulo, São Paulo, Brazil.
| | - Hermann Wrigge
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Liebigstr. 20, D-04103, Leipzig, Germany.
| | - Andreas W Reske
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Liebigstr. 20, D-04103, Leipzig, Germany.
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Karnatovskaia LV, Lee AS, Festic E, Kramer CL, Freeman WD. Effect of prolonged therapeutic hypothermia on intracranial pressure, organ function, and hospital outcomes among patients with aneurysmal subarachnoid hemorrhage. Neurocrit Care 2015; 21:451-61. [PMID: 24865270 DOI: 10.1007/s12028-014-9989-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Global cerebral edema (GCE) with subsequent refractory intracranial hypertension complicates some cases of aneurysmal subarachnoid hemorrhage (aSAH), and typically is associated with poorer outcome. Treatment options for refractory intracranial pressure (ICP) cases are limited to decompressive hemicraniectomy (DHC) and targeted temperature management (TTM) with induced hypothermia (32-34 °C). No outcomes comparison between patients treated with either or both forms of refractory ICP therapy exists, and data on the effect of prolonged hypothermia on ICP and organ function among patients with aSAH are limited. METHODS This is a retrospective study of aSAH patients who underwent DHC and/or prolonged hypothermia (greater than 48 h) for refractory ICP (i.e., ICP >20 mmHg after osmotherapy) in the intensive care unit of a single, tertiary-care academic center. RESULTS Nineteen individuals with aSAH underwent TTM with or without DHC; sixteen patients underwent DHC alone. The patients in TTM group were younger (median age 44 years) than the DHC without TTM population (median age 60 years). TTM was started on median day 2 with a median duration of 7 days. There were no significant group differences in survival to discharge (59 % vs. 69 %) or in the mean modified Rankin score on follow-up (3.6 vs. 3.7), despite the TTM group having longer hospital length of stay (24 vs. 19 days, p = 0.03), longer duration of mechanical ventilation (20 vs. 9 days, p = 0.04), a higher cumulative fluid balance (12.8 vs. 5.1 L, p = 0.01), and higher APACHEII scores. The median maximal ICP decreased from 23.5 to 21 mmHg within 24 h of hypothermia initiation. There were no significant differences in other markers of end-organ function (respiratory, hematologic, renal, liver, and cardiac), infection rate, or adverse events between groups. CONCLUSIONS Use of prolonged TTM among aSAH patients with GCE and refractory ICP elevations is associated with a longer duration of mechanical ventilation but is not different in terms of neurological outcomes measured by modified Rankin score or organ function outcomes compared to patients who received DHC alone.
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Affiliation(s)
- Lioudmila V Karnatovskaia
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, 4500 San Pablo Rd, Davis Building E-7A, Jacksonville, FL, 32224, USA,
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dos Reis HFC, Almeida MLO, da Silva MF, Moreira JO, Rocha MDS. Association between the rapid shallow breathing index and extubation success in patients with traumatic brain injury. Rev Bras Ter Intensiva 2015; 25:212-7. [PMID: 24213084 PMCID: PMC4031850 DOI: 10.5935/0103-507x.20130037] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2013] [Accepted: 09/05/2013] [Indexed: 11/20/2022] Open
Abstract
Objective To investigate the association between the rapid shallow breathing index and
successful extubation in patients with traumatic brain injury. Methods This study was a prospective study conducted in patients with traumatic brain
injury of both genders who underwent mechanical ventilation for at least two days
and who passed a spontaneous breathing trial. The minute volume and respiratory
rate were measured using a ventilometer, and the data were used to calculate the
rapid shallow breathing index (respiratory rate/tidal volume). The dependent
variable was the extubation outcome: reintubation after up to 48 hours (extubation
failure) or not (extubation success). The independent variable was the rapid
shallow breathing index measured after a successful spontaneous breathing trial.
Results The sample comprised 119 individuals, including 111 (93.3%) males. The average age
of the sample was 35.0±12.9 years old. The average duration of mechanical
ventilation was 8.1±3.6 days. A total of 104 (87.4%) participants achieved
successful extubation. No association was found between the rapid shallow
breathing index and extubation success. Conclusion The rapid shallow breathing index was not associated with successful extubation in
patients with traumatic brain injury.
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Rincon F, Maltenfort M, Dey S, Ghosh S, Vibbert M, Urtecho J, Jallo J, Ratliff JK, McBride JW, Bell R. The prevalence and impact of mortality of the acute respiratory distress syndrome on admissions of patients with ischemic stroke in the United States. J Intensive Care Med 2013; 29:357-64. [PMID: 23753254 DOI: 10.1177/0885066613491919] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
PURPOSE To determine the epidemiology of the acute respiratory distress syndrome (ARDS) and impact on in-hospital mortality in admissions of patients with acute ischemic stroke (AIS) in the United States. METHODS Retrospective cohort study of admissions with a diagnosis of AIS and ARDS from 1994 to 2008 identified through the Nationwide Inpatient Sample. RESULTS During the 15-year study period, we found 55 58 091 admissions of patients with AIS. The prevalence of ARDS in admissions of patients with AIS increased from 3% in 1994 to 4% in 2008 (P < .001). The ARDS was more common among younger men, nonwhites, and associated with history of congestive heart failure, hypertension, chronic obstructive pulmonary disease, renal failure, chronic liver disease, systemic tissue plasminogen activator, craniotomy, angioplasty or stent, sepsis, and multiorgan failures. Mortality due to AIS and ARDS decreased from 8% in 1994 to 6% in 2008 (P < .001) and 55% in 1994 to 45% in 2008 (P < .001), respectively. The ARDS in AIS increased in-hospital mortality (odds ratio, 14; 95% confidence interval, 13.5-14.3). A significantly higher length of stay was seen in admissions of patients with AIS having ARDS. CONCLUSION Our analysis demonstrates that ARDS is rare after AIS. Despite an overall significant reduction in mortality after AIS, ARDS carries a higher risk of death in this patient population.
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Affiliation(s)
- Fred Rincon
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Saugat Dey
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Sayantani Ghosh
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Matthew Vibbert
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Jaqueline Urtecho
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Jack Jallo
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - John K Ratliff
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - John William McBride
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA Division of Critical Care and Neurotrauma, Thomas Jefferson University, Philadelphia, PA, USA Division of Cerebrovascular Diseases, Thomas Jefferson University, Philadelphia, PA, USA
| | - Rodney Bell
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA Division of Critical Care and Neurotrauma, Thomas Jefferson University, Philadelphia, PA, USA Division of Cerebrovascular Diseases, Thomas Jefferson University, Philadelphia, PA, USA
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Rincon F, Ghosh S, Dey S, Maltenfort M, Vibbert M, Urtecho J, McBride W, Moussouttas M, Bell R, Ratliff JK, Jallo J. Impact of acute lung injury and acute respiratory distress syndrome after traumatic brain injury in the United States. Neurosurgery 2013; 71:795-803. [PMID: 22855028 DOI: 10.1227/neu.0b013e3182672ae5] [Citation(s) in RCA: 103] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Traumatic brain injury (TBI) is a major cause of disability, morbidity, and mortality. The effect of the acute respiratory distress syndrome and acute lung injury (ARDS/ALI) on in-hospital mortality after TBI remains controversial. OBJECTIVE To determine the epidemiology of ARDS/ALI, the prevalence of risk factors, and impact on in-hospital mortality after TBI in the United States. METHODS Retrospective cohort study of admissions of adult patients>18 years with a diagnosis of TBI and ARDS/ALI from 1988 to 2008 identified through the Nationwide Inpatient Sample. RESULTS During the 20-year study period, the prevalence of ARDS/ALI increased from 2% (95% confidence interval [CI], 2.1%-2.4%) in 1988 to 22% (95% CI, 21%-22%) in 2008 (P<.001). ARDS/ALI was more common in younger age; males; white race; later year of admission; in conjunction with comorbidities such as congestive heart failure, hypertension, chronic obstructive pulmonary disease, chronic renal and liver failure, sepsis, multiorgan dysfunction; and nonrural, medium/large hospitals, located in the Midwest, South, and West continental US location. Mortality after TBI decreased from 13% (95% CI, 12%-14%) in 1988 to 9% (95% CI, 9%-10%) in 2008 (P<.001). ARDS/ALI-related mortality after TBI decreased from 33% (95% CI, 33%-34%) in 1988 to 28% (95% CI, 28%-29%) in 2008 (P<.001). Predictors of in-hospital mortality after TBI were older age, male sex, white race, cancer, chronic kidney disease, hypertension, chronic liver disease, congestive heart failure, ARDS/ALI, and organ dysfunctions. CONCLUSION Our analysis demonstrates that ARDS/ALI is common after TBI. Despite an overall reduction of in-hospital mortality, ARDS/ALI carries a higher risk of in-hospital death after TBI.
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Affiliation(s)
- Fred Rincon
- Department of Neurology, Division of Critical Care, Thomas Jefferson University, Jefferson College of Medicine, Philadelphia, Pennsylvania 19107, USA.
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Bakowitz M, Bruns B, McCunn M. Acute lung injury and the acute respiratory distress syndrome in the injured patient. Scand J Trauma Resusc Emerg Med 2012; 20:54. [PMID: 22883052 PMCID: PMC3518173 DOI: 10.1186/1757-7241-20-54] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Accepted: 06/11/2012] [Indexed: 12/27/2022] Open
Abstract
Acute lung injury and acute respiratory distress syndrome are clinical entities of multi-factorial origin frequently seen in traumatically injured patients requiring intensive care. We performed an unsystematic search using PubMed and the Cochrane Database of Systematic Reviews up to January 2012. The purpose of this article is to review recent evidence for the pathophysiology and the management of acute lung injury/acute respiratory distress syndrome in the critically injured patient. Lung protective ventilation remains the most beneficial therapy. Future trials should compare intervention groups to controls receiving lung protective ventilation, and focus on relevant outcome measures such as duration of mechanical ventilation, length of intensive care unit stay, and mortality.
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Affiliation(s)
- Magdalena Bakowitz
- Department of Anesthesiology & Critical Care, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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Mascia L. Acute lung injury in patients with severe brain injury: a double hit model. Neurocrit Care 2011. [PMID: 19548120 DOI: 10.1007/s12028-009-9242-8].] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2022]
Abstract
The presence of pulmonary dysfunction after brain injury is well recognized. Acute lung injury (ALI) occurs in 20% of patients with isolated brain injury and is associated with a poor outcome. The "blast injury" theory, which proposes combined "hydrostatic" and "high permeability" mechanisms for the formation of neurogenic pulmonary edema, has been challenged recently by the observation that a systemic inflammatory response may play an integral role in the development of pulmonary dysfunction associated with brain injury. As a result of the primary cerebral injury, a systemic inflammatory reaction occurs, which induces an alteration in blood-brain barrier permeability and infiltration of activated neutrophils into the lung. This preclinical injury makes the lungs more susceptible to the mechanical stress of an injurious ventilatory strategy. Tight CO2 control is a therapeutic priority in patients with acute brain injury, but the use of high tidal volume ventilation may contribute to the development of ALI. Establishment of a therapeutic regimen that allows the combination of protective ventilation with the prevention of hypercapnia is, therefore, required. Moreover, in patients with brain injury, hypoxemia represents a secondary insult associated with a poor outcome. Optimal oxygenation may be achieved by using an adequate FiO2 and by application of positive end-expiratory pressure (PEEP). PEEP may, however, affect the cerebral circulation by hemodynamic and CO2-mediated mechanisms and the effects of PEEP on cerebral hemodynamics should be monitored in these patients and used to titrate its application.
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Affiliation(s)
- Luciana Mascia
- Dipartimento di Anestesiologia e Rianimazione, Università di Torino, Ospedale S. Giovanni Battista, Corso Dogliotti 14, 10126 Torino, Italy.
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Acute lung injury in patients with traumatic injuries: utility of a panel of biomarkers for diagnosis and pathogenesis. ACTA ACUST UNITED AC 2010; 68:1121-7. [PMID: 20038857 DOI: 10.1097/ta.0b013e3181c40728] [Citation(s) in RCA: 114] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The diagnosis of acute lung injury (ALI) is based on a consensus clinical definition. Despite the simplicity of this definition, ALI remains underdiagnosed and undertreated. Severe trauma is a well-described cause of ALI that represents a relatively homogeneous subset of patients with ALI. The aims of this study were to develop a panel of plasma biomarkers to facilitate diagnosis of trauma-induced ALI and to enhance our understanding of the pathogenesis of human ALI. METHODS A retrospective nested case control of 192 patients admitted to the trauma intensive care unit at a university hospital between 2002 and 2006. We compared 107 patients with ALI to 85 patients without ALI. Plasma was collected within 72 hours of intensive care unit admission. Twenty-one plasma biomarkers were measured in duplicate in each plasma sample. RESULTS Patients with ALI had higher severity of illness scores, more days of mechanical ventilation, longer hospital stays, and higher mortality versus controls. Seven biomarkers (receptor for advanced glycation end products, procollagen peptide III, brain natriuretic peptide, angiopoietin-2, interleukin-10, tumor necrosis factor alpha, and interleukin-8) had a high diagnostic accuracy as reflected by the area under the receiver operating characteristic curve of 0.86 (95% confidence interval, 0.82-0.92) in differentiating ALI from controls. CONCLUSIONS A model using seven plasma biomarkers had a high diagnostic accuracy in differentiating patients with trauma-induced ALI from trauma patients without ALI. In addition, use of a panel of biomarkers provides insight into the likely importance of alveolar epithelial injury in the pathogenesis of early ALI.
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Abstract
Damage control orthopaedics (DCO) is a staged approach for the management of multiply injured patients. It is ideal for trauma patients presenting in an unstable or extremis physiological state. It focuses on the rapid resuscitation of these patients by providing temporary stabilisation of fractures while at the same time reducing the biological load of surgery. Early findings support its usefulness in controlling the lethal triad of hypothermia, acidosis and coagulopathy. Furthermore, recent evidence indicates that it regulates the evolving systemic inflammatory response, reducing the detrimental complications of adult respiratory distress syndrome, multiple organ dysfunction and subsequent mortality. Although DCO has been proven a useful surgical strategy for efficiently managing patients with multiple trauma, further work is required to establish fully its indications, results and cost implications.
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Affiliation(s)
- Peter V Giannoudis
- Academic Dept of Trauma & Orthopaedics, Leeds General Infirmary, Leeds, UK.
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Acute lung injury in patients with severe brain injury: a double hit model. Neurocrit Care 2009. [PMID: 19548120 DOI: 10.1007/s12028-009-9242-8]] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The presence of pulmonary dysfunction after brain injury is well recognized. Acute lung injury (ALI) occurs in 20% of patients with isolated brain injury and is associated with a poor outcome. The "blast injury" theory, which proposes combined "hydrostatic" and "high permeability" mechanisms for the formation of neurogenic pulmonary edema, has been challenged recently by the observation that a systemic inflammatory response may play an integral role in the development of pulmonary dysfunction associated with brain injury. As a result of the primary cerebral injury, a systemic inflammatory reaction occurs, which induces an alteration in blood-brain barrier permeability and infiltration of activated neutrophils into the lung. This preclinical injury makes the lungs more susceptible to the mechanical stress of an injurious ventilatory strategy. Tight CO2 control is a therapeutic priority in patients with acute brain injury, but the use of high tidal volume ventilation may contribute to the development of ALI. Establishment of a therapeutic regimen that allows the combination of protective ventilation with the prevention of hypercapnia is, therefore, required. Moreover, in patients with brain injury, hypoxemia represents a secondary insult associated with a poor outcome. Optimal oxygenation may be achieved by using an adequate FiO2 and by application of positive end-expiratory pressure (PEEP). PEEP may, however, affect the cerebral circulation by hemodynamic and CO2-mediated mechanisms and the effects of PEEP on cerebral hemodynamics should be monitored in these patients and used to titrate its application.
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