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Peng C, Chi L, Chen M, Peng L, Yang F, Shao L, Bo L, Jin Z. Effect of continuous hypertonic saline infusion on clinical outcomes in patients with traumatic brain injury. Neurosurg Rev 2024; 47:78. [PMID: 38340147 DOI: 10.1007/s10143-024-02316-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 02/01/2024] [Accepted: 02/06/2024] [Indexed: 02/12/2024]
Abstract
Osmotic therapy has been recognized as an important treatment option for patients with traumatic brain injury (TBI). Nevertheless, the effect of hypertonic saline (HTS) remains unknown, as findings are primarily based on a large database. This study aimed to elucidate the effect of HTS on the clinical outcomes of patients with TBI admitted to the intensive care unit (ICU). We retrospectively identified patients with moderate-to-severe TBI from two public databases: Medical Information Mart for Intensive Care (MIMIC)-IV and eICU Collaborative Research Database (eICU-CRD). A marginal structural Cox model (MSCM) was used, with time-dependent variates designed to reflect exposure over time during ICU stay. Trajectory modeling based on the intracranial pressure evolution pattern allowed for the identification of subgroups. Overall, 130 (6.65%) of 1955 eligible patients underwent HTS. MSCM indicated that the HTS significantly associated with higher infection complications (e.g., urinary tract infection (HR 1.88, 95% CI 1.26-2.81, p = 0.002)) and increased ICU LOS (HR 2.02, 95% CI 1.71-2.40, p < 0.001). A protective effect of HTS on GCS was found in subgroups with medium and low intracranial pressure. Our study revealed no significant difference in mortality between patients who underwent HTS and those who did not. Increased occurrence rates of infection and electrolyte imbalance are inevitable outcomes of continuous HTS infusion. Although the study suggests slight beneficial effects, including better neurological outcomes, these results warrant further validation.
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Affiliation(s)
- Chi Peng
- Department of Health Statistics, Naval Medical University, No. 800 Xiangyin Road, Shanghai, 200433, China
| | - Lijie Chi
- Department of Vascular and Endovascular Surgery, Hainan Hospital of PLA General Hospital, Sanya, 572000, China
| | - Mengjie Chen
- Department of Otorhinolaryngology-Head and Neck Surgery, The First Affiliated Hospital of Naval Medical University, Shanghai, 200433, China
| | - Liwei Peng
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University (Fourth Military Medical University), Xi'an, 710038, China
| | - Fan Yang
- Institute of Pathology and Southwest Cancer Center, Southwest Hospital, Third Military Medical University, (Army Medical University) and Key Laboratory of Tumor Immunopathology, Ministry of Education of China, Chongqing, China
| | - Liangjing Shao
- Department of Hematology, General Hospital Eastern Theater Command of PLA, Nanjing, 210002, China
| | - Lulong Bo
- Department of Anesthesiology, The First Affiliated Hospital of Naval Medical University, No. 168, Changhai Road, Yangpu District, Shanghai, 200433, China.
| | - Zhichao Jin
- Department of Health Statistics, Naval Medical University, No. 800 Xiangyin Road, Shanghai, 200433, China.
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Kocik VI, April MD, Rizzo JA, Dengler BA, Schauer SG. A Review of Electrolyte, Mineral, and Vitamin Changes After Traumatic Brain Injury. Mil Med 2024; 189:e101-e109. [PMID: 37192042 DOI: 10.1093/milmed/usad112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 02/27/2023] [Accepted: 03/24/2023] [Indexed: 05/18/2023] Open
Abstract
INTRODUCTION Despite the prevalence of traumatic brain injury (TBI) in both civilian and military populations, the management guidelines developed by the Joint Trauma System involve minimal recommendations for electrolyte physiology optimization during the acute phase of TBI recovery. This narrative review aims to assess the current state of the science for electrolyte and mineral derangements found after TBI. MATERIALS AND METHODS We used Google Scholar and PubMed to identify literature on electrolyte derangements caused by TBI and supplements that may mitigate secondary injuries after TBI between 1991 and 2022. RESULTS We screened 94 sources, of which 26 met all inclusion criteria. Most were retrospective studies (n = 9), followed by clinical trials (n = 7), observational studies (n = 7), and case reports (n = 2). Of those, 29% covered the use of some type of supplement to support recovery after TBI, 28% covered electrolyte or mineral derangements after TBI, 16% covered the mechanisms of secondary injury after TBI and how they are related to mineral and electrolyte derangements, 14% covered current management of TBI, and 13% covered the potential toxic effects of the supplements during TBI recovery. CONCLUSIONS Knowledge of mechanisms and subsequent derangements of electrolyte, mineral, and vitamin physiology after TBI remains incomplete. Sodium and potassium tended to be the most well-studied derangements after TBI. Overall, data involving human subjects were limited and mostly involved observational studies. The data on vitamin and mineral effects were limited, and targeted research is needed before further recommendations can be made. Data on electrolyte derangements were stronger, but interventional studies are needed to assess causation.
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Affiliation(s)
| | - Michael D April
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- 40th Forward Resuscitative Surgical Detachment, Fort Carson, CO 80902, USA
| | - Julie A Rizzo
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
| | - Bradley A Dengler
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Steven G Schauer
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78234, USA
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Kocoglu Barlas U, Ozel A, Yenice Bal M, Ozturk S. The Effect of Serum Electrolyte Levels and Infusion Treatments on the Development of Femoral Central Venous Catheter-Associated Deep Vein Thrombosis in Pediatric Intensive Care Unit. Clin Pediatr (Phila) 2023; 62:1277-1284. [PMID: 36856119 DOI: 10.1177/00099228231157956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
In this study, we aimed to determine the frequency of symptomatic central venous catheters-associated deep vein thrombosis (CVC-a DVT) among critically ill children with femoral vein implantation in our pediatric intensive care unit (PICU), and to compare the demographic factors, serum electrolyte levels, and types of the infusion treatments performed. A total of 215 patients aged 1 month to 18 years who had femoral CVC implanted between 2019 and 2021 were included in this study. The cases that were clinically symptomatic and had thrombosis diagnosed ultrasonography were accepted as CVC-a DVT (+), and the other cases were considered as CVC-a DVT (-). Of the total 215 cases, 57.2% (n = 123) were female and 42.8% (n = 92) were male. Catheters-associated deep vein thrombosis diagnosis were made in 9.8% of the cases (n = 21). The mean time to diagnose thrombosis in CVC-a DVT (+) cases was 8.33 ± 5.65 days. With regard to gender, age, blood type, intubation status, length of stay on mechanical ventilator, presence of extra hemodialysis catheter, acute and chronic disease status, number of days of PICU hospitalization, and Pediatric Risk of Mortality-3 scoring, no significant differences between CVC-a DVT (-) and CVC-a DVT (+) cases were observed (P > .05). The incidence of thrombosis in refugee cases was found to be significantly higher than in Turkish cases (P = .047; P < .05). There was no statistically significant difference between the groups in baseline, mean, and peak glucose, sodium, and magnesium values and who received magnesium, blood product, inotrope, and 3% hypertonic saline (HTS) infusion (P > .05). No effect of serum glucose, sodium, and magnesium levels on the development of CVC-a DVT was found. Magnesium, blood product, inotrope, and 3% HTS infusion treatments have not been shown to have an effect on the development of CVC-a DVT.
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Affiliation(s)
- Ulkem Kocoglu Barlas
- Pediatric Intensive Care Unit, Bagcılar Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Abdulrahman Ozel
- Department of Pediatrics, Bagcılar Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Merve Yenice Bal
- Department of Pediatrics, Bagcılar Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Samet Ozturk
- Department of Radiology, Bagcılar Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
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Marchesini N, Fernández Londoño LL, Boaro A, Kuhn I, Griswold D, Sala F, Rubiano AM. Hyperosmolar therapies for neurological deterioration in mild and moderate traumatic brain injury: A scoping review. Brain Inj 2023:1-9. [PMID: 36929819 DOI: 10.1080/02699052.2023.2191010] [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: 03/18/2023]
Abstract
OBJECTIVE To explore the available evidence on hyperosmolar therapies(HT) in mild and moderate traumatic brain injury(TBI) and to evaluate the effects on outcomes.A scoping review was conducted according to the Joanna Briggs Institute methodology. Inclusion criteria: (a)randomized controlled trials(RCTs), prospective and retrospective cohort studies and case-control studies; (b)all-ages mild and moderate TBIs; (c)HT administration; (d)functional outcomes recorded; (e)comparator group. RESULTS From 4424 records, only 3 respected the inclusion criteria. In a retrospective cohort study of adult moderate TBIs, the Glasgow Coma Scale(GCS) remained the same at 48 hours in those treated with hypertonic saline(HTS) while it worsened in the non-treated. A trend toward increased pulmonary infections and length of stay was found. In an RCT of adult severe and moderate TBIs, moderate TBIs treated with HTS showed a trend toward better secondary outcomes than standard care alone, with similar odds of adverse effects. An RCT enrolling children with mild TBI found a significant improvement in concussive pain immediately after HTS administration and after 2-3 days. No adverse events occurred. CONCLUSIONS A gap in the literature about HTs' role in mild and moderate TBI was found. Some benefits may exist with limited side effects and further studies are desirable.
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Affiliation(s)
| | | | - Alessandro Boaro
- Department of Neurosciences, Biomedicine and Movement, Section of Neurosurgery, University of Verona, Verona, Italy.,Clinical and Translational Science Institute, University of Utah, Logan, Utah, USA
| | - Isla Kuhn
- University of Cambridge Medical Library, Cambridge, UK
| | - Dylan Griswold
- NIHR Group on Neurotrauma, University of Cambridge, Cambridge, UK.,Stanford School of Medicine, Stanford, California, USA
| | - Francesco Sala
- Department of Neurosciences, Biomedicine and Movement, Section of Neurosurgery, University of Verona, Verona, Italy
| | - Andrés M Rubiano
- Neuroscience Institute, Universidad El Bosque, Bogotá, Colombia.,NIHR Group on Neurotrauma, University of Cambridge, Cambridge, UK.,Meditech Foudation, Cali, Colombia
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Lovett ME, Daniel M, Keesari R, MacDonald J, Rodriguez V, Muszynski J, Sribnick EA, O'Brien NF, Ayad O. Catheter-associated deep vein thrombosis in children with severe traumatic brain injury: A single-center experience. Pediatr Blood Cancer 2023; 70:e30044. [PMID: 36250988 DOI: 10.1002/pbc.30044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 09/08/2022] [Accepted: 09/17/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND This study was performed to describe the single-center experience of deep vein thrombosis (DVT) in children with severe traumatic brain injury (sTBI) who were mechanically ventilated with a central line, and to identify potentially modifiable risk factors. It was hypothesized that children with DVT would have a longer duration of central venous line (CVL) and a higher use of hypertonic saline (HTS) compared to those without DVT. PROCEDURE/METHODS This was a retrospective study of children (0-18 years) with sTBI, who were intubated, had a CVL, and a minimum intensive care unit (ICU) stay of 3 days. Children were analyzed by the presence or absence of DVT. HTS use was evaluated using milliliter per kilogram (ml/kg) of 3% equivalents. Univariable and multivariable logistic regression models were used to determine which factors were associated with DVT. RESULTS Seventy-seven children met inclusion criteria, 23 (29.9%) had a DVT detected in an extremity. On univariable analysis, children with DVT identified in an extremity had prolonged CVL use (14 vs. 8.5 days, p = .021) and longer duration of mechanical ventilation (15 vs. 10 days, p = .013). HTS 3% equivalent ml/kg was not different between groups. On multivariable analysis, mechanical ventilation duration was associated with DVT detection in an extremity, whereas neither CVL duration nor HTS use had an association. CONCLUSIONS There was a high incidence of extremity DVT detected in children with sTBI who received invasive mechanical ventilation and had a CVL. HTS administration was not associated with DVT detection in an extremity.
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Affiliation(s)
- Marlina E Lovett
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, The Ohio State University School of Medicine, Columbus, Ohio, USA
| | - Megan Daniel
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, The Ohio State University School of Medicine, Columbus, Ohio, USA
| | - Rohali Keesari
- Pediatric Biostatistics Core, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jennifer MacDonald
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, The Ohio State University School of Medicine, Columbus, Ohio, USA
| | - Vilmarie Rodriguez
- Department of Pediatrics, Division of Hematology and Oncology, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
| | - Jennifer Muszynski
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, The Ohio State University School of Medicine, Columbus, Ohio, USA.,Center for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Eric A Sribnick
- Center for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Surgery, Division of Neurosurgery, Nationwide Children's Hospital, The Ohio State University School of Medicine, Columbus, Ohio, USA
| | - Nicole F O'Brien
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, The Ohio State University School of Medicine, Columbus, Ohio, USA
| | - Onsy Ayad
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, The Ohio State University School of Medicine, Columbus, Ohio, USA
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Pulmonary infection in traumatic brain injury patients undergoing tracheostomy: predicators and nursing care. BMC Pulm Med 2022; 22:130. [PMID: 35392885 PMCID: PMC8988413 DOI: 10.1186/s12890-022-01928-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 03/29/2022] [Indexed: 11/30/2022] Open
Abstract
Background Pulmonary infection is common yet serious complication in patients with severe traumatic brain injury (STBI). We aimed to evaluate the predicators of pulmonary infection in STBI patients undergoing tracheostomy, to provide evidence for the clinical nursing care of STBI patients. Methods This study was a retrospective cohort design. STBI patients undergoing tracheostomy treatment from January 1, 2019 to August 31, 2021 in our hospital were included. The characteristics of pulmonary infection and no pulmonary infection patients were analyzed. Results A total 216 STBI patients undergoing tracheostomy were included, the incidence of pulmonary infection was 26.85%. Diabetes (r = 0.782), hypoproteinemia (r = 0.804), duration of coma(r = 0.672), duration of mechanical ventilation(r = 0.724) and length of hospital stay (r = 0.655), length of hospital stay post tracheostomy (r = 0.554), mortality (r = 0.598) were all correlated with pulmonary infection (all p < 0.05). Klebsiella pneumoniae (33.87%) and Staphylococcus aureus (29.03%) were the most commonly seen pathogens in the pulmonary infection of TBI patients. Logistic regression analyses indicated that diabetes (OR 2.232, 95% CI 1.215–3.904), hypoproteinemia with plasma total protein < 60 g/L (OR 1.922, 95% CI 1.083–3.031), duration of coma ≥ 22 h (OR 2.864, 95% CI 1.344–5.012), duration of mechanical ventilation ≥ 5 days (OR 3.602, 95% CI 1.297–5.626), length of hospital stay ≥ 21 days (OR 2.048, 95% CI 1.022–3.859) were the risk factors of pulmonary infection in TBI patients undergoing tracheostomy (all p < 0.05). Conclusions Further investigations on the early preventions and treatments targeted on those risk factors are needed to reduce the pulmonary infection in clinical practice.
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Acute Kidney Injury in Traumatic Brain Injury Patients: Results From the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury Study. Crit Care Med 2021; 49:112-126. [PMID: 33060506 DOI: 10.1097/ccm.0000000000004673] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVES Acute kidney injury is frequent in polytrauma patients, and it is associated with increased mortality and extended hospital length of stay. However, the specific prevalence of acute kidney injury after traumatic brain injury is less recognized. The present study aims to describe the occurrence rate, risk factors, timing, and association with outcome of acute kidney injury in a large cohort of traumatic brain injury patients. DESIGN The Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury is a multicenter, prospective observational, longitudinal, cohort study. SETTING Sixty-five ICUs across Europe. PATIENTS For the present study, we selected 4,509 traumatic brain injury patients with an ICU length of stay greater than 72 hours and with at least two serum creatinine values during the first 7 days of ICU stay. MEASUREMENTS AND MAIN RESULTS We classified acute kidney injury in three stages according to the Kidney Disease Improving Global Outcome criteria: acute kidney injury stage 1 equals to serum creatinine × 1.5-1.9 times from baseline or an increase greater than or equal to 0.3 mg/dL in 48 hours; acute kidney injury stage 2 equals to serum creatinine × 2-2.9 times baseline; acute kidney injury stage 3 equals to serum creatinine × three times baseline or greater than or equal to 4 mg/dL or need for renal replacement therapy. Standard reporting techniques were used to report incidences. A multivariable Cox regression analysis was performed to model the cause-specific hazard of acute kidney injury and its association with the long-term outcome. We included a total of 1,262 patients. The occurrence rate of acute kidney injury during the first week was as follows: acute kidney injury stage 1 equals to 8% (n = 100), acute kidney injury stage 2 equals to 1% (n = 14), and acute kidney injury stage 3 equals to 3% (n = 36). Acute kidney injury occurred early after ICU admission, with a median of 2 days (interquartile range 1-4 d). Renal history (hazard ratio = 2.48; 95% CI, 1.39-4.43; p = 0.002), insulin-dependent diabetes (hazard ratio = 2.52; 95% CI, 1.22-5.197; p = 0.012), hypernatremia (hazard ratio = 1.88; 95% CI, 1.31-2.71; p = 0.001), and osmotic therapy administration (hazard ratio = 2.08; 95% CI, 1.45-2.99; p < 0.001) were significantly associated with the risk of developing acute kidney injury. Acute kidney injury was also associated with an increased ICU length of stay and with a higher probability of 6 months unfavorable Extended Glasgow Outcome Scale and mortality. CONCLUSIONS Acute kidney injury after traumatic brain injury is an early phenomenon, affecting about one in 10 patients. Its occurrence negatively impacts mortality and neurologic outcome at 6 months. Osmotic therapy use during ICU stay could be a modifiable risk factor.
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Schwimmbeck F, Voellger B, Chappell D, Eberhart L. Hypertonic Saline Versus Mannitol for Traumatic Brain Injury: A Systematic Review and Meta-analysis With Trial Sequential Analysis. J Neurosurg Anesthesiol 2021; 33:10-20. [PMID: 31567726 DOI: 10.1097/ana.0000000000000644] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Mannitol and hypertonic saline are widely used to treat raised intracranial pressure (ICP) after traumatic brain injury (TBI), but the clinical superiority of one over the other has not been demonstrated. METHODS According to the PRISMA statement, this meta-analysis reports on randomized controlled trials investigating hypertonic saline compared with mannitol in the treatment of elevated ICP following TBI. The protocol for the literature searches (Medline, Embase, Central databases), quality assessment, endpoints (mortality, favorable outcome, brain perfusion parameters), and statistical analysis plan (including a trial sequential analysis) were prospectively specified and registered on the PROSPERO database (CRD42017057112). RESULTS A total of 12 randomized controlled trials with 464 patients were eligible for inclusion in this analysis. Although there was a nonsignificant trend in favor of hypertonic saline, there were no significant differences in mortality between the 2 treatments (relative risk [RR]: 0.69, 95% confidence interval [CI]: 0.45, 1.04; P=0.08). There were also no significant differences in favorable neurological outcome between hypertonic saline (HS) and mannitol (RR: 1.28, 95% CI: 0.86, 1.90; P=0.23). There was no difference in ICP at 30 to 60 minutes after treatment (mean difference [MD]: -0.19 mm Hg, 95% CI: -0.54, 0.17; P=0.30), whereas ICP was significantly lower after HS compared with mannitol at 90 to 120 minutes (MD: -2.33 mm Hg, 95% CI: -3.17, -1.50; P<0.00001). Cerebral perfusion pressure was higher between 30 to 60 and 90 to 120 minutes after treatment with HS compared with after treatment with mannitol (MD: 5.48 mm Hg, 95% CI: 4.84, 6.12; P<0.00001 and 9.08 mm Hg, 95% CI: 7.54, 10.62; P<0.00001, respectively). Trial sequential analysis showed that the number of cases was insufficient to produce reliable statements on long-term outcomes. CONCLUSION There are indications that HS might be superior to mannitol in the treatment of TBI-related raised ICP. However, there are insufficient data to reach a definitive conclusion, and further studies are warranted.
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Affiliation(s)
- Franz Schwimmbeck
- Department of Anaesthesiology, University Hospital of Munich (LMU), Marchioninistr, Munich
| | | | - Daniel Chappell
- Department of Anaesthesiology, University Hospital of Munich (LMU), Marchioninistr, Munich
| | - Leopold Eberhart
- Anesthesiology and Intensive Care Therapy, Philipps University Marburg, Baldingerstr, Marburg, Germany
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Rossong H, Hasen M, Ahmed B, Zeiler FA, Dhaliwal P. Hypertonic Saline for Moderate Traumatic Brain Injury: A Scoping Review of Impact on Neurological Deterioration. Neurotrauma Rep 2020; 1:253-260. [PMID: 33381773 PMCID: PMC7769038 DOI: 10.1089/neur.2020.0056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Hypertonic saline (HTS) is a commonly administered agent for intracranial pressure (ICP) control in traumatic brain injury (TBI). The literature on its use is mainly in moderate/severe TBI where invasive ICP monitoring is present. The role of HTS in patients with moderate TBI (mTBI) outside of the intensive care unit (ICU) setting remains unclear. The goal of this scoping review was to provide an overview of the available literature on HTS administration in patients with mTBI without ICP monitoring, assessing its impact on outcome and transitions in care. We performed a scoping systematic review of the literature of MEDLINE, Embase, Scopus, BIOSIS, and the Cochrane Databases from inception to July 31, 2020. We searched for those published articles documenting the administration of HTS in patients with mTBI with recorded functional outcome or transitions in hospital care. A two-step review process was conducted in accordance with methodology outlined in the Cochrane Handbook for Systematic Reviews of Interventions. There were many studies with combined moderate/severe TBI populations. However, most failed to document subgroup analysis for patients with mTBI. Our search strategy identified only one study that documented the administration of HTS in mTBI in which subgroup analysis for mTBI and outcomes were provided. This retrospective cohort study assessed patients with mTBI who did/did not receive prophylactic HTS, finding that those not receiving HTS demonstrated a deterioration in Glasgow Coma Scale (GCS) score in the first 48 h. However, the HTS group did demonstrate a trend to longer hospital stay and pneumonia. Our scoping review identified a significant gap in knowledge surrounding the use of HTS for patients with mTBI without invasive ICP monitoring. The limited identified literature suggests prophylactic administration prevents clinical deterioration, although this is based on a single study with data available for mTBI sub-analysis. Further studies on HTS in non-monitored patients with mTBI are required.
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Affiliation(s)
- Heather Rossong
- Undergraduate Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,Section of Neurosurgery, Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Mohammed Hasen
- Section of Neurosurgery, Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Bilal Ahmed
- Undergraduate Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Frederick A Zeiler
- Section of Neurosurgery, Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada.,Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.,Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada.,Centre on Aging, University of Manitoba, Winnipeg, Manitoba, Canada.,Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Perry Dhaliwal
- Section of Neurosurgery, Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
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Nederpelt CJ, El Hechi M, Parks J, Fawley J, Mendoza AE, Saillant N, King DR, Fagenholz PJ, Velmahos GC, Kaafarani HMA. The dose-dependent relationship between blood transfusions and infections after trauma: A population-based study. J Trauma Acute Care Surg 2020; 89:51-57. [PMID: 32102046 DOI: 10.1097/ta.0000000000002637] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The relationship between total transfusion volume and infection in the trauma patient remains unclear, especially at lower volumes of transfusion. We sought to quantify the cumulative, independent impact of transfusion within 24 hours of admission on the risk of infection in trauma patients. METHODS Using the Trauma Quality Improvement Program 2013 to 2016 database, we included all patients who received blood transfusions in the first 4 hours. Patients who were transferred or had incomplete/wrongly coded information on transfusion volume were excluded. Patients were divided into 20 cohorts based on the total blood product volume transfused in the first 24 hours. A composite infection variable (INF) was created, including surgical site infection, ventilator-associated pneumonia, urinary tract infection, central line associated blood stream infection, and sepsis. Univariate and stepwise multivariable logistic regression analyses were performed to study the relationship between blood transfusion and INF, controlling for demographics (e.g., age, sex), comorbidities (e.g., cirrhosis, diabetes, steroid use), severity of injury (e.g., vital signs on arrival, mechanism, Injury Severity Score), and operative and angiographic interventions. RESULTS Of 1,002,595 patients, 37,568 were included. The mean age was 42 ± 18.6 years, 74.6% were males, 68% had blunt trauma, and median Injury Severity Score was 25 [17-34]. Adjusting for all available confounders, odds of INF increased incrementally from 1.00 (reference, 0-2 units) to 1.23 (95% confidence interval, 1.11-1.37) for 4 units transfused to 4.89 (95% confidence interval, 2.72-8.80) for 40 units transfused. Each additional unit increased the odds of INF by 7.6%. CONCLUSION Transfusion of the bleeding trauma patient was associated with a dose-dependent increased risk of infectious complications. Trauma surgeons and anesthesiologists should resuscitate the trauma patient until prompt hemorrhage control while avoiding overtransfusion. LEVEL OF EVIDENCE Retrospective cohort study, Therapeutic IV.
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Affiliation(s)
- Charlie J Nederpelt
- From the Division of Trauma, Emergency Surgery and Surgical Critical Care (C.J.N., M.E.H., J.P., J.F., A.E.M., N.S., D.R.K., P.J.F., G.C.V., H.M.A.K.), Massachusetts General Hospital, Boston, Massachusetts; Department of Trauma Surgery (C.J.N.), Leiden University Medical Center, Leiden, The Netherlands; Harvard Medical School (J.P., J.F., A.E.M., N.S., D.R.K., P.J.F., G.C.V., H.M.A.K.), Cambridge; and Center for Outcomes and Patient Safety in Surgery (COMPASS) (H.M.A.K.), Massachusetts General Hospital, Boston, Massachusetts
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11
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Sun MK, Passaro AP, Latchoumane CF, Spellicy SE, Bowler M, Goeden M, Martin WJ, Holmes PV, Stice SL, Karumbaiah L. Extracellular Vesicles Mediate Neuroprotection and Functional Recovery after Traumatic Brain Injury. J Neurotrauma 2020; 37:1358-1369. [PMID: 31774030 DOI: 10.1089/neu.2019.6443] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The lack of effective therapies for moderate-to-severe traumatic brain injuries (TBIs) leaves patients with lifelong disabilities. Neural stem cells (NSCs) have demonstrated great promise for neural repair and regeneration. However, direct evidence to support their use as a cell replacement therapy for neural injuries is currently lacking. We hypothesized that NSC-derived extracellular vesicles (NSC EVs) mediate repair indirectly after TBI by enhancing neuroprotection and therapeutic efficacy of endogenous NSCs. We evaluated the short-term effects of acute intravenous injections of NSC EVs immediately following a rat TBI. Male NSC EV-treated rats demonstrated significantly reduced lesion sizes, enhanced presence of endogenous NSCs, and attenuated motor function impairments 4 weeks post-TBI, when compared with vehicle- and TBI-only male controls. Although statistically not significant, we observed a therapeutic effect of NSC EVs on brain lesion volume, nestin expression, and behavioral recovery in female subjects. Our study demonstrates the neuroprotective and functional benefits of NSC EVs for treating TBI and points to gender-dependent effects on treatment outcomes, which requires further investigation.
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Affiliation(s)
- Min Kyoung Sun
- Regenerative Bioscience Center, University of Georgia, Athens, Georgia, USA
- Interdisciplinary Neuroscience Program, University of Georgia, Athens, Georgia, USA
| | - Austin P Passaro
- Regenerative Bioscience Center, University of Georgia, Athens, Georgia, USA
- Interdisciplinary Neuroscience Program, University of Georgia, Athens, Georgia, USA
| | - Charles-Francois Latchoumane
- Regenerative Bioscience Center, University of Georgia, Athens, Georgia, USA
- Department of Animal and Dairy Science, University of Georgia, Athens, Georgia, USA
| | - Samantha E Spellicy
- Regenerative Bioscience Center, University of Georgia, Athens, Georgia, USA
- Interdisciplinary Neuroscience Program, University of Georgia, Athens, Georgia, USA
| | - Michael Bowler
- Department of Biochemistry and Molecular Biology, University of Georgia, Athens, Georgia, USA
| | - Morgan Goeden
- Department of Biochemistry and Molecular Biology, University of Georgia, Athens, Georgia, USA
| | - William J Martin
- Animal Health Research Center, College of Veterinary Medicine, University of Georgia, Athens, Georgia, USA
| | - Philip V Holmes
- Interdisciplinary Neuroscience Program, University of Georgia, Athens, Georgia, USA
- Department of Psychology, University of Georgia, Athens, Georgia, USA
| | - Steven L Stice
- Regenerative Bioscience Center, University of Georgia, Athens, Georgia, USA
- Interdisciplinary Neuroscience Program, University of Georgia, Athens, Georgia, USA
- Department of Animal and Dairy Science, University of Georgia, Athens, Georgia, USA
| | - Lohitash Karumbaiah
- Regenerative Bioscience Center, University of Georgia, Athens, Georgia, USA
- Interdisciplinary Neuroscience Program, University of Georgia, Athens, Georgia, USA
- Department of Animal and Dairy Science, University of Georgia, Athens, Georgia, USA
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Hu PJ, Pittet JF, Kerby JD, Bosarge PL, Wagener BM. Acute brain trauma, lung injury, and pneumonia: more than just altered mental status and decreased airway protection. Am J Physiol Lung Cell Mol Physiol 2017; 313:L1-L15. [PMID: 28408366 DOI: 10.1152/ajplung.00485.2016] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 03/24/2017] [Accepted: 04/07/2017] [Indexed: 01/25/2023] Open
Abstract
Traumatic brain injury (TBI) is a major cause of mortality and morbidity worldwide. Even when patients survive the initial insult, there is significant morbidity and mortality secondary to subsequent pulmonary edema, acute lung injury (ALI), and nosocomial pneumonia. Whereas the relationship between TBI and secondary pulmonary complications is recognized, little is known about the mechanistic interplay of the two phenomena. Changes in mental status secondary to acute brain injury certainly impair airway- and lung-protective mechanisms. However, clinical and translational evidence suggests that more specific neuronal and cellular mechanisms contribute to impaired systemic and lung immunity that increases the risk of TBI-mediated lung injury and infection. To better understand the cellular mechanisms of that immune impairment, we review here the current clinical data that support TBI-induced impairment of systemic and lung immunity. Furthermore, we also review the animal models that attempt to reproduce human TBI. Additionally, we examine the possible role of damage-associated molecular patterns, the chlolinergic anti-inflammatory pathway, and sex dimorphism in post-TBI ALI. In the last part of the review, we discuss current treatments and future pharmacological therapies, including fever control, tracheostomy, and corticosteroids, aimed to prevent and treat pulmonary edema, ALI, and nosocomial pneumonia after TBI.
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Affiliation(s)
- Parker J Hu
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jean-Francois Pittet
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama.,Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama; and.,Department of Cell, Developmental, and Integrative Biology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jeffrey D Kerby
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Patrick L Bosarge
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Brant M Wagener
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama; and
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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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de Oliveira MF, Pinto FCG. Hypertonic saline: a brief overview of hemodynamic response and anti-inflammatory properties in head injury. Neural Regen Res 2015; 10:1938-9. [PMID: 26889177 PMCID: PMC4730813 DOI: 10.4103/1673-5374.169620] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | - Fernando Campos Gomes Pinto
- Division of Functional Neurosurgery of the Institute of Psychiatry, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
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