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Velarde-Ruiz Velasco JA, Crespo J, Montaño-Loza A, Aldana-Ledesma JM, Cano-Contreras AD, Cerda-Reyes E, Fernández Pérez NJ, Castro-Narro GE, García-Jiménez ES, Lira-Vera JE, López-Méndez YI, Meza-Cardona J, Moreno-Alcántar R, Pérez-Escobar J, Pérez-Hernández JL, Tapia-Calderón DK, Higuera-de-la-Tijera F. Position paper on perioperative management and surgical risk in the patient with cirrhosis. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2024; 89:418-441. [PMID: 39003101 DOI: 10.1016/j.rgmxen.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 05/02/2024] [Indexed: 07/15/2024]
Abstract
INTRODUCTION Management of the patient with cirrhosis of the liver that requires surgical treatment has been relatively unexplored. In Mexico, there is currently no formal stance or expert recommendations to guide clinical decision-making in this context. AIMS The present position paper reviews the existing evidence on risks, prognoses, precautions, special care, and specific management or procedures for patients with cirrhosis that require surgical interventions or invasive procedures. Our aim is to provide recommendations by an expert panel, based on the best published evidence, and consequently ensure timely, quality, efficient, and low-risk care for this specific group of patients. RESULTS Twenty-seven recommendations were developed that address preoperative considerations, intraoperative settings, and postoperative follow-up and care. CONCLUSIONS The assessment and care of patients with cirrhosis that require major surgical or invasive procedures should be overseen by a multidisciplinary team that includes the anesthesiologist, hepatologist, gastroenterologist, and clinical nutritionist. With respect to decompensated patients, a nephrology specialist may be required, given that kidney function is also a parameter involved in the prognosis of these patients.
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Affiliation(s)
- J A Velarde-Ruiz Velasco
- Servicio de Gastroenterología, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
| | - J Crespo
- Servicio de Aparato Digestivo, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - A Montaño-Loza
- División de Gastroenterología y Hepatología, Hospital de la Universidad de Alberta, Alberta, Canada
| | - J M Aldana-Ledesma
- Servicio de Gastroenterología, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
| | - A D Cano-Contreras
- Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, Veracruz, Mexico
| | | | | | - G E Castro-Narro
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - E S García-Jiménez
- Servicio de Gastroenterología, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
| | - J E Lira-Vera
- Servicio de Gastroenterología y Hepatología, Hospital Central «Dr. Ignacio Morones Prieto», San Luis Potosí, San Luis Potosí, Mexico
| | - Y I López-Méndez
- Departamento de Gastroenterología, Medica Sur, Mexico City, Mexico
| | - J Meza-Cardona
- Departamento de Gastroenterología, Hospital Español, Mexico City, Mexico
| | - R Moreno-Alcántar
- Departamento de Gastroenterología, Hospital de Especialidades «Dr. Bernando Sepúlveda», UMAE Centro Médico Nacional Siglo XXI, IMSS, Mexico City, Mexico
| | - J Pérez-Escobar
- Servicio de Gastroenterología y Unidad de Trasplante Hepático, Hospital Juárez de México, Mexico City, Mexico
| | - J L Pérez-Hernández
- Servicio de Gastroenterología y Hepatología, Hospital General de México «Dr. Eduardo Liceaga», Mexico City, Mexico
| | - D K Tapia-Calderón
- Servicio de Gastroenterología, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
| | - F Higuera-de-la-Tijera
- Servicio de Gastroenterología y Hepatología, Hospital General de México «Dr. Eduardo Liceaga», Mexico City, Mexico.
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Liu SY, Kelly-Hedrick M, Temkin N, Barber J, Komisarow J, Hatfield J, Ohnuma T, Manley G, Treggiari MM, Colton K, Vavilala MS, Grandhi R, Laskowitz DT, Mathew JP, Hernandez A, James ML, Raghunathan K, Goldstein B, Krishnamoorthy V. Association of Early Dexmedetomidine Utilization With Clinical and Functional Outcomes Following Moderate-Severe Traumatic Brain Injury: A Transforming Clinical Research and Knowledge in Traumatic Brain Injury Study. Crit Care Med 2024; 52:607-617. [PMID: 37966330 PMCID: PMC10939970 DOI: 10.1097/ccm.0000000000006106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
OBJECTIVE To examine early sedation patterns, as well as the association of dexmedetomidine exposure, with clinical and functional outcomes among mechanically ventilated patients with moderate-severe traumatic brain injury (msTBI). DESIGN Retrospective cohort study with prospectively collected data. SETTING Eighteen Level-1 Trauma Centers, United States. PATIENTS Adult (age > 17) patients with msTBI (as defined by Glasgow Coma Scale < 13) who required mechanical ventilation from the Transforming Clinical Research and Knowledge in TBI (TRACK-TBI) study. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Using propensity-weighted models, we examined the association of early dexmedetomidine exposure (within the first 5 d of ICU admission) with the primary outcome of 6-month Glasgow Outcomes Scale Extended (GOS-E) and the following secondary outcomes: length of hospital stay, hospital mortality, 6-month Disability Rating Scale (DRS), and 6-month mortality. The study population included 352 subjects who required mechanical ventilation within 24 hours of admission. The initial sedative medication was propofol for 240 patients (68%), midazolam for 59 patients (17%), ketamine for 6 patients (2%), dexmedetomidine for 3 patients (1%), and 43 patients (12%) never received continuous sedation. Early dexmedetomidine was administered in 77 of the patients (22%), usually as a second-line agent. Compared with unexposed patients, early dexmedetomidine exposure was not associated with better 6-month GOS-E (weighted odds ratio [OR] = 1.48; 95% CI, 0.98-2.25). Early dexmedetomidine exposure was associated with lower DRS (weighted OR = -3.04; 95% CI, -5.88 to -0.21). In patients requiring ICP monitoring within the first 24 hours of admission, early dexmedetomidine exposure was associated with higher 6-month GOS-E score (OR 2.17; 95% CI, 1.24-3.80), lower DRS score (adjusted mean difference, -5.81; 95% CI, -9.38 to 2.25), and reduced length of hospital stay (hazard ratio = 1.50; 95% CI, 1.02-2.20). CONCLUSION Variation exists in early sedation choice among mechanically ventilated patients with msTBI. Early dexmedetomidine exposure was not associated with improved 6-month functional outcomes in the entire population, although may have clinical benefit in patients with indications for ICP monitoring.
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Affiliation(s)
- Sunny Yang Liu
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Duke University School of Medicine, Durham, NC
| | - Margot Kelly-Hedrick
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Duke University School of Medicine, Durham, NC
| | - Nancy Temkin
- Department of Biostatistics, University of Washington. Seattle, WA
- Department of Neurosurgery, University of Washington. Seattle, WA
| | - Jason Barber
- Department of Neurosurgery, University of Washington. Seattle, WA
| | | | - Jordan Hatfield
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Duke University School of Medicine, Durham, NC
| | - Tetsu Ohnuma
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Department of Anesthesiology, Duke University. Durham, NC
| | - Geoffrey Manley
- Brain and Spinal Injury Center, University of California, San Francisco, San Francisco, CA
| | - Miriam M. Treggiari
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Department of Anesthesiology, Duke University. Durham, NC
| | | | - Monica S. Vavilala
- Department of Anesthesiology and Pain Medicine, University of Washington. Seattle, WA
| | - Ramesh Grandhi
- Department of Neurosurgery, University of Utah, Salt Lake City, UT
| | - Daniel T. Laskowitz
- Department of Neurosurgery, Duke University. Durham, NC
- Department of Anesthesiology, Duke University. Durham, NC
- Department Neurology, Duke University. Durham, NC
| | | | | | - Michael L. James
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Department of Anesthesiology, Duke University. Durham, NC
- Department Neurology, Duke University. Durham, NC
| | - Karthik Raghunathan
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Department of Anesthesiology, Duke University. Durham, NC
- Department of Population Health Sciences, Duke University. Durham, NC
| | - Ben Goldstein
- Departments of Biostatistics and Bioinformatics, Duke University. Durham, NC
| | - Vijay Krishnamoorthy
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Department of Anesthesiology, Duke University. Durham, NC
- Department of Population Health Sciences, Duke University. Durham, NC
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Dietvorst S, Vervekken A, Depreitere B. Developing a porcine model of severe traumatic brain injury induced by high amplitude rotational acceleration. BRAIN & SPINE 2023; 4:102728. [PMID: 38510621 PMCID: PMC10951692 DOI: 10.1016/j.bas.2023.102728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 11/29/2023] [Accepted: 12/08/2023] [Indexed: 03/22/2024]
Abstract
Introduction It is unclear which pathophysiological processes initiate and drive dynamic cerebrovascular autoregulation (CA) impairment as seen in traumatic brain injury (TBI). This is not solely attributable to raised intracranial pressure (ICP), but also results from local tissue damage. Research question In order to investigate CA disturbing processes, a porcine model is needed that mimics severe TBI as seen in humans. This model requires high amplitude rotational acceleration. Material and methods A customized device was built to produce a rotational impulse with high amplitude and short pulse duration. Following preparatory tests on cadaver piglets, six piglets of six weeks old were sedated, ventilated and subjected to rotational impulses of different magnitudes. The impulse was immediately followed by installment of invasive monitoring of ICP, PbO₂, Laser Doppler Flowmetry and arterial blood pressure. TBI was further characterized by magnetic resonance brain imaging. Results The current setup enabled to reach sagittal head rotational maximal acceleration magnitudes up to 30 krad/s2. Half of the animals had an increase in ICP, measured shortly after the impulse. It has proved impossible so far to produce a sustained rise in ICP as seen in human severe TBI. MRI showed no anatomical abnormalities which would confirm severe TBI. Discussion and conclusion The challenge to build a porcine model in which severe TBI with ICP raise and MRI changes as seen in humans can be reliably reproduced is still ongoing. It might be that higher peak rotational accelerations are needed.
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Affiliation(s)
- Sofie Dietvorst
- Department of Neurosurgery, University Hospitals, Leuven, Belgium
- Research Group Experimental Neurosurgery and Neuroanatomy, KULeuven, Belgium
| | - Aline Vervekken
- Research Group Experimental Neurosurgery and Neuroanatomy, KULeuven, Belgium
| | - Bart Depreitere
- Department of Neurosurgery, University Hospitals, Leuven, Belgium
- Research Group Experimental Neurosurgery and Neuroanatomy, KULeuven, Belgium
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Gedeno K, Neme D, Jemal B, Aweke Z, Achule A, Geremu K, Bekele Uddo T. Evidence-based management of adult traumatic brain injury with raised intracranial pressure in intensive critical care unit at resource-limited settings: a literature review. Ann Med Surg (Lond) 2023; 85:5983-6000. [PMID: 38098558 PMCID: PMC10718354 DOI: 10.1097/ms9.0000000000001291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 09/02/2023] [Indexed: 12/17/2023] Open
Abstract
Background In underdeveloped countries, there is a greater incidence of mortality and morbidity arising from trauma, with traumatic brain injury (TBI) accounting for 50% of all trauma-related deaths. The occurrence of elevated intracranial pressure (ICP), which is a common pathophysiological phenomenon in cases of TBI, acts as a contributing factor to unfavorable outcomes. The aim of this systematic review is to analyze the existing literature regarding the management of adult TBI with raised ICP in an intensive critical care unit, despite limited resources. Methods This systematic review was performed in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis protocol. Search engines such as PubMed, the Cochrane database, and Google Scholar were utilized to locate high-level evidence that would facilitate the formation of sound conclusions. Result A total of 11 715 articles were identified and individually assessed to determine their eligibility for inclusion or exclusion based on predetermined criteria and outcome variables. The methodological quality of each study was evaluated using recommended criteria. Ultimately, the review consisted of 51 articles. Conclusion Physical examination results and noninvasive assessments of the optic nerve sheath diameter (ONSD) via sonography are positively associated with elevated ICP, and are employed as diagnostic and monitoring tools for elevated ICP in resource-limited settings. Management of elevated ICP necessitates an algorithmic approach that utilizes prophylactic measures and acute intervention treatments to mitigate the risk of secondary brain injury.
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Affiliation(s)
- Kanbiro Gedeno
- Department of Anesthesia, College of Medicine and Health Science, Arba Minch University, Arba Minch
| | | | | | - Zemedu Aweke
- Department of Anesthesia
- School of Clinical Science, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Astemamagn Achule
- Department of Anesthesia, College of Medicine and Health Science, Arba Minch University, Arba Minch
| | - Kuchulo Geremu
- Department of Anesthesia, College of Medicine and Health Science, Arba Minch University, Arba Minch
| | - Tesfanew Bekele Uddo
- Department of Surgery, College of Medicine and Health Science, Dilla University, Dilla, Ethiopia
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Jeffcote T, Weir T, Anstey J, Mcnamara R, Bellomo R, Udy A. The Impact of Sedative Choice on Intracranial and Systemic Physiology in Moderate to Severe Traumatic Brain Injury: A Scoping Review. J Neurosurg Anesthesiol 2023; 35:265-273. [PMID: 35142704 DOI: 10.1097/ana.0000000000000836] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 01/06/2022] [Indexed: 11/27/2022]
Abstract
Although sedative use is near-ubiquitous in the acute management of moderate to severe traumatic brain injury (m-sTBI), the evidence base for these agents is undefined. This review summarizes the evidence for analgosedative agent use in the intensive care unit management of m-sTBI. Clinical studies of sedative and analgosedative agents currently utilized in adult m-sTBI management (propofol, ketamine, benzodiazepines, opioids, and alpha-2 agonists) were identified and assessed for relevance and methodological quality. The primary outcome was the effect of the analgosedative agent on intracranial pressure (ICP). Secondary outcomes included intracranial hemodynamic and metabolic parameters, systemic hemodynamic parameters, measures of therapeutic intensity, and clinical outcomes. Of 594 articles identified, 61 met methodological review criteria, and 40 were included in the qualitative summary; of these, 33 were prospective studies, 18 were randomized controlled trials, and 8 were blinded. There was consistent evidence for the efficacy of sedative agents in the management of m-sTBI and raised ICP, but the overall quality of the evidence was poor, consisting of small studies (median sample size, 23.5) of variable methodological quality. Propofol and midazolam achieve the goals of sedation without notable differences in efficacy or safety, although high-dose propofol may disrupt cerebral autoregulation. Dexmedetomidine and propofol/ dexmedetomidine combination may cause clinically significant hypotension. Dexmedetomidine was effective to achieve a target sedation score. De novo opioid boluses were associated with increased ICP and reduced cerebral perfusion pressure. Ketamine bolus and infusions were not associated with increased ICP and may reduce the incidence of cortical spreading depolarization events. In conclusion, there is a paucity of high-quality evidence to inform the optimal use of analgosedative agents in the management of m-sTBI, inferring significant scope for further research.
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Affiliation(s)
- Toby Jeffcote
- Department of Intensive Care Medicine, The Alfred Hospital
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Prahran, Vic
| | - Timothy Weir
- Department of Intensive Care Medicine, The Alfred Hospital
| | - James Anstey
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne
| | - Robert Mcnamara
- Department of Intensive Care, Royal Perth Hospital, Perth, WA, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care Medicine, The Austin Hospital
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne
- Department of Critical Care, University of Melbourne, Parkville
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Prahran, Vic
| | - Andrew Udy
- Department of Intensive Care Medicine, The Alfred Hospital
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Prahran, Vic
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Kurni M, Kaloria N, Hazarika A, Jain K, Gupta SK, Walia R. Comparison of Midazolam and Propofol Infusion to Suppress Stress Response in Patients With Severe TBII: A Prospective, Randomized Controlled Trial. Korean J Neurotrauma 2023; 19:70-81. [PMID: 37051035 PMCID: PMC10083446 DOI: 10.13004/kjnt.2023.19.e4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 11/21/2022] [Accepted: 11/22/2022] [Indexed: 03/05/2023] Open
Abstract
Objective The stress response following traumatic brain injury (TBI) is a preventable cause of secondary brain injury. This can be prevented using sedation in the intensive care unit (ICU). To date, the choice of sedative agent for preventing stress response is not well-studied in literature. Methods This prospective randomized controlled trial included 60 patients with severe TBI admitted to ICU. The patients were randomized into 2 study groups according to the choice of sedation: propofol (group I) and midazolam infusion (group II). The serum cortisol was measured as the primary outcome at admission to ICU and 48 hours following sedation infusion. The baseline Glasgow coma scale, hemodynamic, optic nerve sheath diameter (ONSD), and computed tomography scan findings were noted at admission. Glasgow outcome scale (GOS) was measured as a neurological outcome at discharge from ICU. Results There was a statistically significant reduction in serum cortisol level in both the study groups (Δ cortisol, p-value=134.91 (50.5,208.2), 0.00 and 118.8 (42.6,160.4), 0.00, in group I and II, respectively). Serum cortisol levels were comparable among both groups at baseline and 48 hours. Similarly, there was a statistically significant difference in ONSD in both groups, but there was no difference in ONSD value between the groups at 48 hours. The GOS was also similar in both groups at discharge from ICU. Conclusion The study demonstrated a similar reduction in serum cortisol levels following 48 hours of propofol or midazolam infusion in patients with severe TBI.
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Affiliation(s)
- Mallikarjun Kurni
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Narender Kaloria
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Amarjyoti Hazarika
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Kajal Jain
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sunil Kumar Gupta
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Rama Walia
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Russo G, Harrois A, Anstey J, Van Der Jagt M, Taccone F, Udy A, Citerio G, Duranteau J, Ichai C, Badenes R, Prowle J, Ercole A, Oddo M, Schneider A, Wolf S, Helbok R, Nelson D, Cooper J. Early sedation in traumatic brain injury: a multicentre international observational study. CRIT CARE RESUSC 2022; 24:319-329. [PMID: 38047010 PMCID: PMC10692594 DOI: 10.51893/2022.4.oa2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
Objectives: We aimed to investigate the use of sedation in patients with severe traumatic brain injury (TBI), focusing on the choice of sedative agent, dose, duration, and their association with clinical outcomes. Design: Multinational, multicentre, retrospective observational study. Settings: 14 trauma centres in Europe, Australia and the United Kingdom. Participants: A total of 262 adult patients with severe TBI and intracranial pressure monitoring. Main outcome measures: We described how sedative agents were used in this population. The primary outcome was 60-day mortality according to the use of different sedative agents. Secondary outcomes included intensive care unit and hospital length of stay, and the Extended Glasgow Outcome Scale at hospital discharge. Results: Propofol and midazolam were the most commonly used sedatives. Propofol was more common than midazolam as first line therapy (35.4% v 25.6% respectively). Patients treated with propofol had similar Acute Physiology and Chronic Health Evaluation (APACHE) II and International Mission for Prognosis and Analysis of Clinical Trials in Traumatic Brain Injury (IMPACT) scores to patients treated with midazolam, but lower Injury Severity Score (ISS) (median, 26 [IQR, 22-38] v 34 [IQR, 26-44]; P = 0.001). The use of propofol was more common in heavier patients, and midazolam use was strongly associated with opioid co-administration (OR, 12.9; 95% CI, 3.47-47.95; P < 0.001). Sixty-day mortality and hospital mortality were predicted by a higher IMPACT score (P < 0.001) and a higher ISS (P < 0.001), but, after adjustment, were not related to the choice of sedative agent. Conclusions: Propofol was used more often than midazolam, and large doses were common for both sedatives. The first choice was highly variable, was affected by injury severity, and was not independently associated with 60-day mortality.
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Affiliation(s)
- Giovanni Russo
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Anatole Harrois
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Anesthesia and Surgical Intensive Care, CHU de Bicetre, Le Kr emlin Bicêtre, France
| | - James Anstey
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Mathieu Van Der Jagt
- Department of Intensive Care for Adults, Erasmus MC-University Medical Center, Rotterdam, The Netherlands
| | - Fabio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Andrew Udy
- Intensive Care Unit, Alfred Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Giuseppe Citerio
- School of Medicine and Surgery, University Milano Bicocca-Neurointensive Care, San Gerar do Hospital, ASST-Monza, Monza, Italy
| | - Jacques Duranteau
- Department of Anesthesia and Surgical Intensive Care, CHU de Bicetre, Le Kr emlin Bicêtre, France
| | - Carole Ichai
- Université Côte d’Azur, Center Hospitalier Universitaire de Nice, Service de Réanimation polyvalente, Hôpital Pasteur 2, Nice, France
| | - Rafael Badenes
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clinic Universitari de Valencia, University of Valencia, Valencia, Spain
| | - John Prowle
- Adult Critical Care Unit, Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Ari Ercole
- Neurosciences and Trauma Critical Care Unit, Cambridge University Hospitals NHS Foundation T rust, Cambridge, United Kingdom
| | - Mauro Oddo
- Department of Medical-Surgical Intensive Care Medicine, Faculty of Biology and Medicine, Center Hospitalier Universitaire, Vaudois (CHUV), University of Lausanne, Lausanne, Switzerland
| | - Antoine Schneider
- Department of Medical-Surgical Intensive Care Medicine, Faculty of Biology and Medicine, Center Hospitalier Universitaire, Vaudois (CHUV), University of Lausanne, Lausanne, Switzerland
| | - Stefan Wolf
- Department of Neur osurgery, Charité Universitätsmedizin Neuro Intensive Care Unit 102i, Berlin, Germany
| | - Raimund Helbok
- Department of Neur ology, Neurocritical Care Unit, Medical University of Innsbruck, Innsbruck, Austria
| | - David Nelson
- Section for Perioperative Medicine and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - Jamie Cooper
- Intensive Care Unit, Alfred Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - For the TBI Collaborative Investigators
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Anesthesia and Surgical Intensive Care, CHU de Bicetre, Le Kr emlin Bicêtre, France
- Department of Intensive Care for Adults, Erasmus MC-University Medical Center, Rotterdam, The Netherlands
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
- Intensive Care Unit, Alfred Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- School of Medicine and Surgery, University Milano Bicocca-Neurointensive Care, San Gerar do Hospital, ASST-Monza, Monza, Italy
- Université Côte d’Azur, Center Hospitalier Universitaire de Nice, Service de Réanimation polyvalente, Hôpital Pasteur 2, Nice, France
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clinic Universitari de Valencia, University of Valencia, Valencia, Spain
- Adult Critical Care Unit, Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
- Neurosciences and Trauma Critical Care Unit, Cambridge University Hospitals NHS Foundation T rust, Cambridge, United Kingdom
- Department of Medical-Surgical Intensive Care Medicine, Faculty of Biology and Medicine, Center Hospitalier Universitaire, Vaudois (CHUV), University of Lausanne, Lausanne, Switzerland
- Department of Neur osurgery, Charité Universitätsmedizin Neuro Intensive Care Unit 102i, Berlin, Germany
- Department of Neur ology, Neurocritical Care Unit, Medical University of Innsbruck, Innsbruck, Austria
- Section for Perioperative Medicine and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
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Sebastiani A, Bender S, Schäfer MKE, Thal SC. Posttraumatic midazolam administration does not influence brain damage after experimental traumatic brain injury. BMC Anesthesiol 2022; 22:60. [PMID: 35246037 PMCID: PMC8896377 DOI: 10.1186/s12871-022-01592-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 02/09/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The benzodiazepine midazolam is a γ-aminobutyric acid (GABA)-A receptor agonist frequently used for sedation or stress control in patients suffering from traumatic brain injury (TBI). However, experimental studies on benzodiazepines have reported divergent results, raising concerns about its widespread use in patients. Some studies indicate that benzodiazepine-mediated potentiation of GABAergic neurotransmission is detrimental in brain-injured animals. However, other experimental investigations demonstrate neuroprotective effects, especially in pretreatment paradigms. This study investigated whether single-bolus midazolam administration influences secondary brain damage post-TBI. METHODS Two different midazolam dosages (0.5 and 5 mg/kg BW), a combination of midazolam and its competitive antagonist flumazenil, or vehicle solution (NaCl 0.9%) was injected intravenously to mice 24 h after experimental TBI induced by controlled cortical impact. Mice were evaluated for neurological and motor deficits using a 15-point neuroscore and the rotarod test. Histopathological brain damage and mRNA expression of inflammatory marker genes were analyzed using quantitative polymerase chain reaction three days after insult. RESULTS Histological brain damage was not affected by posttraumatic midazolam administration. Midazolam impaired functional recovery, and this effect could not be counteracted by administering the midazolam antagonist flumazenil. An increase in IL-1β mRNA levels due to postinjury application of midazolam was reversible by flumazenil administration. However, other inflammatory parameters were not affected. CONCLUSIONS This study merely reports minor effects of a postinjury midazolam application. Further studies focusing on a time-dependent analysis of posttraumatic benzodiazepine administration are required.
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Affiliation(s)
- Anne Sebastiani
- Department of Anesthesiology, HELIOS University Hospital Wuppertal, University of Witten/Herdecke, Heusnerstrasse 40, 42283, Wuppertal, Germany.,Department of Anesthesiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Simone Bender
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Michael K E Schäfer
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Serge C Thal
- Department of Anesthesiology, HELIOS University Hospital Wuppertal, University of Witten/Herdecke, Heusnerstrasse 40, 42283, Wuppertal, Germany. .,Department of Anesthesiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany.
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Kayambankadzanja RK, Samwel R, Baker T. Pragmatic sedation strategies to prevent secondary brain injury in low‐resource settings. Anaesthesia 2022; 77 Suppl 1:43-48. [DOI: 10.1111/anae.15621] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2021] [Indexed: 01/22/2023]
Affiliation(s)
- R. K. Kayambankadzanja
- School of Public Health Kamuzu University of Health Science Blantyre Malawi
- Department of Anaesthesia and Intensive Care Queen Elizabeth Central Hospital Blantyre Malawi
| | - R. Samwel
- Department of Anaesthesia and Intensive Care Bugando Medical Centre Mwanza Tanzania
| | - T. Baker
- Muhimbili University of Health and Allied Sciences Dar es Salaam Tanzania
- Department of Clinical Research London School of Hygiene and Tropical Medicine London UK
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Firdaus R, Theresia S, Austin R, Tiara R. Propofol effects in rodent models of traumatic brain injury: a systematic review. ASIAN BIOMED 2021; 15:253-265. [PMID: 37551361 PMCID: PMC10321222 DOI: 10.2478/abm-2021-0032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background Traumatic brain injury (TBI) causes high mortality and disability worldwide. Animal models have been developed to explore the complex processes in TBI. Propofol is used to manage head injuries during surgical intervention and mechanical ventilation in patients with TBI. Many studies have investigated the neuroprotective effect of propofol on TBI. However, other studies have shown neurotoxic effects. Objectives To review systematically the literature regarding the neuroprotective and neurotoxic effects of propofol in rodent models of TBI. Methods Data from rodents as models of TBI with propofol as one of the intervention agents, and/or comparing the neuroprotective effects of propofol with the other substances in rodent models of TBI, were obtained from PubMed, EBSCO Host, and ProQuest databases. The PRISMA 2020 statement recommendations were followed and research questions were developed based on PICOS guidelines. Data was extracted from the literature using a standardized Cochrane method. Results We analyzed data from 12 articles on physiological changes of experimental animals before and after trauma, the effects of propofol administration, and the observed neurotoxic effects. The effects of propofol administration were observed in terms of changes in traumatic lesion volume, the release of antioxidants and inflammatory factors, and the neurological function of rodent models of TBI. Conclusion Propofol has neuroprotective and neurotoxic effects via several mechanisms, and various doses have been used in research to determine its effects. The timing of administration, the dose administered, and the duration of administration contribute to determine the effect of propofol in rodent models of TBI. However, the doses that produce neuroprotective and neurotoxic effects are not yet clear and further research is needed to determine them.
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Affiliation(s)
- Riyadh Firdaus
- Department of Anesthesiology and Intensive Therapy, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo Hospital, Jakarta10430, Indonesia
| | - Sandy Theresia
- Department of Anesthesiology and Intensive Therapy, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo Hospital, Jakarta10430, Indonesia
| | - Ryan Austin
- Department of Anesthesiology and Intensive Therapy, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo Hospital, Jakarta10430, Indonesia
| | - Rani Tiara
- Department of Anesthesiology and Intensive Therapy, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo Hospital, Jakarta10430, Indonesia
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Marini CP, McNelis J, Petrone P. Multimodality Monitoring and Goal-Directed Therapy for the Treatment of Patients with Severe Traumatic Brain Injury: A Review for the General and Trauma Surgeon. Curr Probl Surg 2021; 59:101070. [DOI: 10.1016/j.cpsurg.2021.101070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 10/04/2021] [Indexed: 11/28/2022]
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12
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Marini CP, McNelis J, Petrone P. In Brief. Curr Probl Surg 2021. [DOI: 10.1016/j.cpsurg.2021.101071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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13
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Sedatives in neurocritical care: an update on pharmacological agents and modes of sedation. Curr Opin Crit Care 2020; 25:97-104. [PMID: 30672819 DOI: 10.1097/mcc.0000000000000592] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW In this article, the specific and general indications for sedatives in the neurocritical care unit are discussed, together with an overview on current insights in sedative protocols for these patients. In addition, physiological effects of sedative agents on the central nervous system are reviewed. RECENT FINDINGS In the general ICU population, a large body of evidence supports light protocolized sedation over indiscriminate deep sedation. Unfortunately, in patients with severe acute brain injury, the evidence from randomized controlled trials is scarce to nonexistent, and practice is supported by expert opinion, physiological studies and observational or small interventional trials. The different sedatives each have different beneficial effects and side-effects. SUMMARY Extrapolating the findings from studies in the general ICU population suggests to reserve deep continuous sedation in the neuro-ICU for specific indications. Although an improved understanding of cerebral physiological changes in patients with brain injury may be helpful to guide individualized sedation, we still lack the evidence base to make broad recommendations for specific patient groups.
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Gao J, Wei L, Xu G, Ren C, Zhang Z, Liu Y. Effects of dexmedetomidine vs sufentanil during percutaneous tracheostomy for traumatic brain injury patients: A prospective randomized controlled trial. Medicine (Baltimore) 2019; 98:e17012. [PMID: 31464960 PMCID: PMC6736089 DOI: 10.1097/md.0000000000017012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Percutaneous tracheostomy, almost associated with cough reflex and hemodynamic fluctuations, is a common procedure for traumatic brain injury (TBI) patients, especially those in neurosurgery intensive care units (NICUs). However, there are currently a lack of effective preventive measures to reduce the risk of secondary brain injury. The aim of this study was to compare the effect of dexmedetomidine (DEX) vs sufentanil during percutaneous tracheostomy in TBI patients. METHODS The 196 TBI patients who underwent percutaneous tracheostomy were randomized divided into 3 groups: group D1 (n = 62, DEX infusion at 0.5 μg·kg for 10 minutes, then adjusted to 0.2-0.7 μg·kg·hour), group D2 (n = 68, DEX infusion at 1 μg·kg for 10 minutes, then adjusted to 0.2-0.7 μg·kg·hour), and group S (n = 66, sufentanil infusion 0.3 μg·kg for 10 minutes, then adjusted to 0.2-0.4 μg·kg·hour). The bispectral index (BIS) of all patients was maintained at 50 to 70 during surgery. Anesthesia onset time, hemodynamic variables, total cumulative dose of DEX/sufentanil, total doses of rescue propofol and fentanyl, time to first dose of rescue propofol and fentanyl, number of intraoperative patient movements and cough reflexes, adverse events, and surgeon satisfaction score were recorded. RESULTS Anesthesia onset time was significantly lower in group D2 than in both other groups (14.35 ± 3.23 vs 12.42 ± 2.12 vs 13.88 ± 3.51 minutes in groups D1, D2, and S, respectively; P < .001). Both heart rate and mean arterial pressure during percutaneous tracheostomy were more stable in group D2. Total doses of rescue propofol and fentanyl were significantly lower in group D2 than in group D1 (P < .001). The time to first dose of rescue propofol and fentanyl were significantly longer in group D2 than in both other groups (P < .001). The number of patient movements and cough reflexes during percutaneous tracheostomy were lower in group D2 than in both other groups (P < .001). The overall incidences of tachycardia and hypertension (which required higher doses of esmolol and urapidil, respectively) were also lower in group D2 than in both other groups (P < .05). Three patients in group S had respiratory depression compared to X in the D1 group and X in the D2 group. The surgeon satisfaction score was significantly higher in group D2 than in both other groups (P < .05). CONCLUSIONS During percutaneous tracheostomy, compared with sufentanil, DEX (1 μg·kg for 10 minutes, then adjusted to 0.2-0.7 μg·kg·hour) can provide the desired attenuation of the hemodynamic response without increased adverse events. Consequently, DEX could be used safely and effectively during percutaneous tracheostomy in TBI patients.
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15
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Kim S, Mortera M, Hu X, Krishnan S, Hoffecker L, Herrold A, Terhorst L, King L, Machtinger J, Zumsteg JM, Negm A, Heyn P. Overview of pharmacological interventions after traumatic brain injuries: impact on selected outcomes. Brain Inj 2019; 33:442-455. [DOI: 10.1080/02699052.2019.1565896] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Sonya Kim
- Department of Neurology and Department of Rehabilitation Medicine, NYU School of Medicine, New York, USA
| | - Marianne Mortera
- NYU Steinhardt, Department of Occupational Therapy, New York University, New York, USA
| | - Xiaolei Hu
- Department of Community Medicine and Rehabilitation, Umeå University, Sweden
| | - Shilpa Krishnan
- Department of Rehabilitation Medicine, Division of Physical Therapy, Emory University, Atlanta, Georgia, USA
| | - Lilian Hoffecker
- Health Sciences Library, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Amy Herrold
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr., VA Hospital, Hines, Illinois, USA
| | - Lauren Terhorst
- Department of Occupational Therapy, School of Health and Rehabilitation Services, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Laurie King
- Neurology, Oregon Health & Science University, Portland, Oregon, USA
| | - Joseph Machtinger
- Department of Neurology, Division of Multiple Sclerosis, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jennifer M. Zumsteg
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Ahmed Negm
- School of Rehabilitation Sciences, McMaster University, Hamilton, Ontario, USA
| | - Patricia Heyn
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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George S, Mathew J. Midazolam is effective in controlling intracranial pressure in severe traumatic brain injury. CHRISMED JOURNAL OF HEALTH AND RESEARCH 2019. [DOI: 10.4103/cjhr.cjhr_111_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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17
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Synnot A, Bragge P, Lunny C, Menon D, Clavisi O, Pattuwage L, Volovici V, Mondello S, Cnossen MC, Donoghue E, Gruen RL, Maas A. The currency, completeness and quality of systematic reviews of acute management of moderate to severe traumatic brain injury: A comprehensive evidence map. PLoS One 2018; 13:e0198676. [PMID: 29927963 PMCID: PMC6013193 DOI: 10.1371/journal.pone.0198676] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 05/23/2018] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE To appraise the currency, completeness and quality of evidence from systematic reviews (SRs) of acute management of moderate to severe traumatic brain injury (TBI). METHODS We conducted comprehensive searches to March 2016 for published, English-language SRs and RCTs of acute management of moderate to severe TBI. Systematic reviews and RCTs were grouped under 12 broad intervention categories. For each review, we mapped the included and non-included RCTs, noting the reasons why RCTs were omitted. An SR was judged as 'current' when it included the most recently published RCT we found on their topic, and 'complete' when it included every RCT we found that met its inclusion criteria, taking account of when the review was conducted. Quality was assessed using the AMSTAR checklist (trichotomised into low, moderate and high quality). FINDINGS We included 85 SRs and 213 RCTs examining the effectiveness of treatments for acute management of moderate to severe TBI. The most frequently reviewed interventions were hypothermia (n = 17, 14.2%), hypertonic saline and/or mannitol (n = 9, 7.5%) and surgery (n = 8, 6.7%). Of the 80 single-intervention SRs, approximately half (n = 44, 55%) were judged as current and two-thirds (n = 52, 65.0%) as complete. When considering only the most recently published review on each intervention (n = 25), currency increased to 72.0% (n = 18). Less than half of the 85 SRs were judged as high quality (n = 38, 44.7%), and nearly 20% were low quality (n = 16, 18.8%). Only 16 (20.0%) of the single-intervention reviews (and none of the five multi-intervention reviews) were judged as current, complete and high-quality. These included reviews of red blood cell transfusion, hypothermia, management guided by intracranial pressure, pharmacological agents (various) and prehospital intubation. Over three-quarters (n = 167, 78.4%) of the 213 RCTs were included in one or more SR. Of the remainder, 17 (8.0%) RCTs post-dated or were out of scope of existing SRs, and 29 (13.6%) were on interventions that have not been assessed in SRs. CONCLUSION A substantial number of SRs in acute management of moderate to severe TBI lack currency, completeness and quality. We have identified both potential evidence gaps and also substantial research waste. Novel review methods, such as Living Systematic Reviews, may ameliorate these shortcomings and enhance utility and reliability of the evidence underpinning clinical care.
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Affiliation(s)
- Anneliese Synnot
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- National Trauma Research Institute, The Alfred, Monash University, Melbourne, Victoria, Australia
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Cochrane Consumers and Communication, School of Psychology and Public Health, La Trobe University, Melbourne, Victoria, Australia
| | - Peter Bragge
- BehaviourWorks Australia, Monash Sustainable Development Institute, Monash University, Melbourne, Victoria, Australia
| | - Carole Lunny
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - David Menon
- Division of Anaesthesia, University of Cambridge; Neurosciences Critical Care Unit, Addenbrooke’s Hospital; Queens’ College, Cambridge, United Kingdom
| | - Ornella Clavisi
- National Trauma Research Institute, The Alfred, Monash University, Melbourne, Victoria, Australia
- MOVE: Muscle, Bone and Joint Health Ltd, Melbourne, Victoria, Australia
| | - Loyal Pattuwage
- National Trauma Research Institute, The Alfred, Monash University, Melbourne, Victoria, Australia
- Monash Centre for Occupational and Environmental Health (MonCOEH), Monash University, Melbourne, Victoria, Australia
| | - Victor Volovici
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Neurosurgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Stefania Mondello
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Maryse C. Cnossen
- Center for Medical Decision Making, Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Emma Donoghue
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Russell L. Gruen
- Nanyang Technical University, Singapore
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Andrew Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
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Burry L, Dryden L, Rose L, Williamson DR, Adhikari NKJ, Turgeon AF, Golan E, Dewhurst N, Fergusson DA, Hutton B, Mehta S. Sedation for moderate-to-severe traumatic brain injury in adults: a network meta-analysis. Hippokratia 2017. [DOI: 10.1002/14651858.cd012639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Lisa Burry
- Mount Sinai Hospital, Leslie Dan Faculty of Pharmacy, University of Toronto; Department of Pharmacy; 600 University Avenue, Room 18-377 Toronto ON Canada M5G 1X5
| | - Lindsay Dryden
- University of Toronto; Leslie Dan Faculty of Pharmacy; 144 College Street Toronto ON Canada M5S 3M2
| | - Louise Rose
- University of Toronto; Lawrence S. Bloomberg Faculty of Nursing; 155 College St Toronto ON Canada M5T 1P8
| | - David R Williamson
- Université de Montréal / Höpital du Sacré-Coeur de Montréal; Faculty of Pharmacy / Department of Pharmacy; 5400 Gouin W Montreal QC Canada H4J 1C5
| | - Neill KJ Adhikari
- University of Toronto; Interdepartmental Division of Critical Care; 2057 Bayview Avenue Toronto ON Canada M4N 3M5
| | - Alexis F Turgeon
- CHU de Québec - Université Laval, Université Laval; Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, and Population Health and Optimal Health Practices Research Unit (Trauma - Emergency - Critical Care Medicine), CHU de Québec - Université Laval Research Center; 1401, 18eme rue Quebec City QC Canada G1J 1Z4
| | - Eyal Golan
- University Health Network; Department of Medicine; 399 Bathurst Street, 2MCL-411J Toronto ON Canada M5S-2T8
| | - Norman Dewhurst
- St. Michaels Hospital; Department of Pharmacy; 30 Bond Street Toronto ON Canada M5B 1W8
| | - Dean A Fergusson
- Ottawa Hospital Research Institute; Clinical Epidemiology Program; 501 Smyth Road Ottawa ON Canada K1H 8L6
| | - Brian Hutton
- Ottawa Hospital Research Institute; Knowledge Synthesis Group; 501 Smyth Road Ottawa ON Canada K1H 8L6
| | - Sangeeta Mehta
- Mount Sinai Hospital, University of Toronto; Interdepartmental Division of Critical Care Medicine; 600 University Ave, Rm 1504 Toronto ON Canada M5G 1X5
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Abstract
Although urgent surgical hematoma evacuation is necessary for most patients with subdural hematoma (SDH), well-orchestrated, evidenced-based, multidisciplinary, postoperative critical care is essential to achieve the best possible outcome. Acute SDH complicates approximately 11% of mild to moderate traumatic brain injuries (TBIs) that require hospitalization, and approximately 20% of severe TBIs. Acute SDH usually is related to a clear traumatic event, but in some cases can occur spontaneously. Management of SDH in the setting of TBI typically conforms to the Advanced Trauma Life Support protocol with airway taking priority, and management breathing and circulation occurring in parallel rather than sequence.
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Affiliation(s)
- Fawaz Al-Mufti
- Endovascular Surgical Neuroradiology Program, Rutgers University-New Jersey Medical School, Newark, NJ, USA
| | - Stephan A Mayer
- Department of Neurology, Henry Ford Health System, 2799 W Grand Boulevard, Detroit, MI 48202, USA.
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Abstract
Traumatic brain injury (TBI) represents a wide spectrum of disease and disease severity. Because the primary brain injury occurs before the patient enters the health care system, medical interventions seek principally to prevent secondary injury. Anesthesia teams that provide care for patients with TBI both in and out of the operating room should be aware of the specific therapies and needs of this unique and complex patient population.
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Pharmacological interventions in traumatic brain injury: Can we rely on systematic reviews for evidence? Injury 2016; 47:516-24. [PMID: 26589595 DOI: 10.1016/j.injury.2015.10.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 10/04/2015] [Accepted: 10/06/2015] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Providing current, reliable and evidence based information for clinicians and researchers in a synthesised and summarised way can be challenging particularly in the area of traumatic brain injury where a vast number of reviews exists. These reviews vary in their methodological quality and are scattered across varying sources. In this paper, we present an overview of systematic reviews that evaluate the pharmacological interventions in traumatic brain injury (TBI). By doing this, we aim to evaluate the existing evidence for improved outcomes in TBI with pharmacological interventions, and to identify gaps in the literature to inform future research. METHODS We searched the Neurotrauma Evidence Map on systematic reviews relating to pharmacological interventions for managing TBI in acute phase. Two reviewers independently screened search results and appraised each systematic review using the validated AMSTAR tool and extracted data from the review. RESULTS A total of 288 systematic reviews relating to TBI were available on the Neurotrauma Evidence Map at the time of this study. We identified 19 systematic reviews on pharmacological management for acute TBI with publications dates ranging from 1998 to 2014. The studies were of varying methodological quality, with a mean AMSTAR score of 7.78 (range 2-11]. CONCLUSION The evidence from high quality systematic reviews show that there is currently insufficient evidence for the use of magnesium, monoaminergic and dopamine agonists, progesterone, aminosteroids, excitatory amino acid inhibitors, haemostatic and antifibrinolytic drugs in TBI. Anti-convulsants are only effective in reducing early seizures with no significant difference between phenytoin and leviteracetam. There is no difference between propofol and midazolam for sedation in TBI patients and ketamine may not cause increased ICP. Overviews of systematic review provide informative and powerful summaries of evidence based research.
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Yu Y, Jian MY, Wang YZ, Han RQ. Propofol ameliorates calpain-induced collapsin response mediator protein-2 proteolysis in traumatic brain injury in rats. Chin Med J (Engl) 2015; 128:919-27. [PMID: 25836613 PMCID: PMC4834009 DOI: 10.4103/0366-6999.154298] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Collapsin response mediator protein-2 (CRMP2), a multifunctional cytosolic protein highly expressed in the brain, is degraded by calpain following traumatic brain injury (TBI), possibly inhibiting posttraumatic neurite regeneration. Lipid peroxidation (LP) is involved in triggering postinjury CRMP2 proteolysis. We examined the hypothesis that propofol could attenuate LP, calpain-induced CRMP2 degradation, and brain injury after TBI. METHODS A unilateral moderate controlled cortical impact injury was induced in adult male Sprague-Dawley rats. The animals were randomly divided into seven groups: Sham control group, TBI group, TBI + propofol groups (including propofol 1 h, 2 h, and 4 h groups), TBI + U83836E group and TBI + fat emulsion group. The LP inhibitor U83836E was used as a control to identify that antioxidation partially accounts for the potential neuroprotective effects of propofol. The solvent of propofol, fat emulsion, was used as the vehicle control. Ipsilateral cortex tissues were harvested at 24 h post-TBI. Immunofluorescent staining, Western blot analysis, and terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling were used to evaluate LP, calpain activity, CRMP2 proteolysis and programmed cell death. The data were statistically analyzed using one-way analysis of variance and a paired t-test. RESULTS Propofol and U83836E significantly ameliorated the CRMP2 proteolysis. In addition, both propofol and U83836E significantly decreased the ratio of 145-kDa αII-spectrin breakdown products to intact 270-kDa spectrin, the 4-hydroxynonenal expression and programmed cell death in the pericontusional cortex at 24 h after TBI. There was no difference between the TBI group and the fat emulsion group. CONCLUSIONS These results demonstrate that propofol postconditioning alleviates calpain-mediated CRMP2 proteolysis and provides neuroprotective effects following moderate TBI potentially by counteracting LP and reducing calpain activation.
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Affiliation(s)
| | | | | | - Ru-Quan Han
- Department of Anesthesiology, Beijing Tian Tan Hospital, Capital Medical University, Beijing 100050, China
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Abstract
More than one-half million patients are hospitalized annually for traumatic brain injury (TBI). One-quarter demonstrate sleep-disordered breathing, up to 50% experience insomnia, and half have hypersomnia. Sleep disturbances after TBI may result from injury to sleep-regulating brain tissue, nonspecific neurohormonal responses to systemic injury, ICU environmental interference, and medication side effects. A diagnosis of sleep disturbances requires a high index of suspicion and appropriate testing. Treatment starts with a focus on making the ICU environment conducive to normal sleep. Treating sleep-disordered breathing likely has outcome benefits in TBI. The use of sleep promoting sedative-hypnotics and anxiolytics should be judicious.
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Abstract
OPINION STATEMENT Pediatric severe traumatic brain injury continues to be a major cause of disability and death. Rapid initial airway and hemodynamic stabilization is critical, followed by the need for immediate recognition of intracranial pathology that requires neurosurgical intervention. Intracranial hypertension and cerebral hypoperfusion have been recognized as major insults after trauma and management should be directed at preventing both. Sedation with opioids, moderate hyperventilation to arterial carbon dioxide level of 35-40 mmHg, hyperosmolar therapy with 3 % saline or mannitol, normothermia, and cerebrospinal fluid drainage continue to be the cornerstones of initial management of intracranial hypertension (intracranial pressure >20 mmHg). Refractory intracranial hypertension is treated with high-dose barbiturate therapy to achieve medical burst suppression on electroencephalography and decompressive craniectomy. In addition, those children require antiepileptic medications for seizure prophylaxis, adequate nutritional management, and early physical therapy and rehabilitation referrals. Most of the evidence for care of children with brain injury comes from center-specific practice and experience rather than objective data. This lack of evidence provides the ground for ongoing research; nevertheless, outcomes after traumatic brain injury continue to show improvement.
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Affiliation(s)
- Haifa Mtaweh
- Department of Critical Care Medicine, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada,
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Lu HL, Ying PH, Li WJ. Effects of propofol with midazolam verus lidocaine during gastroscopy in elderly patients. Shijie Huaren Xiaohua Zazhi 2014; 22:1201-1206. [DOI: 10.11569/wcjd.v22.i9.1201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the effects of propofol with midazolam versus lidocaine during endoscopy in elderly patients.
METHODS: Ninety-seven ASA-Ⅱ class patients were used as an experimental group. They were treated with propofol with midazolam for painless gastroscopy between July 2008 and July 2013 at our hospital. Eighty-two ASA-Ⅱ level patients who used traditional lidocaine gel pulp in painless gastroscopy were used as a control group. Age, weight, baseline blood pressure between two groups had no significant differences (P > 0.05 for all). Professional medical personnel recorded the changes in blood pressure, heart rate, oxygen saturation and adverse reactions in the examination process.
RESULTS: After the painless gastroscopy procedure, blood pressure and heart rate in the experimental group were significantly lower than those in the control group (blood pressure: 90.2 mmHg ± 2.5 mmHg vs 131.2 mmHg ± 3.4 mmHg; heart rate: 70.2 ± 1.5 vs 85.0 ± 6.4, P < 0.05). During the examination process, blood pressure and heart rate dropped initially and then rose to a stable level in the experimental group, while in the control group, blood pressure and heart rate initially increased and then decreased to a stable level. The differences were statistically significant (P < 0.05) within the two groups. Oxygen saturation between groups and within groups showed no significant differences (P > 0.05). Compared with the control group, adverse reactions in the experimental group were significantly reduced (χ2 = 12.991, 142.482, 55.838, 179.000, P < 0.05). Times to wake up from anesthesia and drug elimination were relatively short in the experimental group (1.51 s ± 0.17 s, 8.21 s ± 2.32 s).
CONCLUSION: Propofol combined with midazolam in painless gastroscopy can effectively reduce the risk of cardiovascular diseases in patients and is associated with shorter times to wake up and drug elimination.
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