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Avoiding brain hypoxia in severe traumatic brain injury in settings with limited resources - A pathophysiological guide. J Crit Care 2023; 75:154260. [PMID: 36773368 DOI: 10.1016/j.jcrc.2023.154260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 12/17/2022] [Accepted: 01/22/2023] [Indexed: 02/11/2023]
Abstract
Cerebral oxygenation represents the balance between oxygen delivery, consumption and utilization by the brain, and therefore reflects the adequacy of cerebral perfusion. Different factors can influence the amount of oxygen to the brain including arterial blood pressure, hemoglobin levels, systemic oxygenation, and transfer of oxygen from blood to the cerebral microcirculation. A mismatch between cerebral oxygen supply and demand results in cerebral hypoxia/ischemia, and is associated with secondary brain damage and worsened outcome after acute brain injury. Therefore, monitoring and prompt treatment of cerebral oxygenation compromise is warranted in both neuro and general intensive care unit populations. Several tools have been proposed for the assessment of cerebral oxygenation, including non-invasive/invasive or indirect/direct methods, including Jugular Venous Oxygen Saturation (SjO2), Partial Brain Tissue Oxygen Tension (PtiO2), Near infrared spectroscopy (NIRS), Transcranial Doppler, electroencephalography and Computed Tomography. In this manuscript, we aim to review the pathophysiology of cerebral oxygenation, describe monitoring technics, and generate recommendations for avoiding brain hypoxia in settings with low availability of resources for direct brain oxygen monitoring.
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Godoy DA, Murillo-Cabezas F, Suarez JI, Badenes R, Pelosi P, Robba C. "THE MANTLE" bundle for minimizing cerebral hypoxia in severe traumatic brain injury. Crit Care 2023; 27:13. [PMID: 36635711 PMCID: PMC9835224 DOI: 10.1186/s13054-022-04242-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 11/12/2022] [Indexed: 01/13/2023] Open
Abstract
To ensure neuronal survival after severe traumatic brain injury, oxygen supply is essential. Cerebral tissue oxygenation represents the balance between oxygen supply and consumption, largely reflecting the adequacy of cerebral perfusion. Multiple physiological parameters determine the oxygen delivered to the brain, including blood pressure, hemoglobin level, systemic oxygenation, microcirculation and many factors are involved in the delivery of oxygen to its final recipient, through the respiratory chain. Brain tissue hypoxia occurs when the supply of oxygen is not adequate or when for some reasons it cannot be used at the cellular level. The causes of hypoxia are variable and can be analyzed pathophysiologically following "the oxygen route." The current trend is precision medicine, individualized and therapeutically directed to the pathophysiology of specific brain damage; however, this requires the availability of multimodal monitoring. For this purpose, we developed the acronym "THE MANTLE," a bundle of therapeutical interventions, which covers and protects the brain, optimizing the components of the oxygen transport system from ambient air to the mitochondria.
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Affiliation(s)
- Daniel Agustin Godoy
- Departamento Medicina Critica. Unidad de Cuidados Neurointensivos, Sanatorio Pasteur, Catamarca, Argentina
| | | | - Jose Ignacio Suarez
- grid.21107.350000 0001 2171 9311Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, USA
| | - Rafael Badenes
- grid.411308.fAnesthesiology and Surgical-Trauma Intensive Care, University Clinic Hospital, Valencia, Spain ,grid.5338.d0000 0001 2173 938XDepartment of Surgery, University of Valencia, Valencia, Spain ,INCLIVA Research Medical Institute, Valencia, Spain
| | - Paolo Pelosi
- grid.410345.70000 0004 1756 7871Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy ,grid.5606.50000 0001 2151 3065Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Chiara Robba
- grid.410345.70000 0004 1756 7871Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy ,grid.5606.50000 0001 2151 3065Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
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Zhao JL, Song J, Yuan Q, Bao YF, Sun YR, Li ZQ, Xi CH, Yao HJ, Wang MH, Wu G, Du ZY, Hu J, Yu J. Characteristics and therapeutic profile of TBI patients who underwent bilateral decompressive craniectomy: experience with 151 cases. Scand J Trauma Resusc Emerg Med 2022; 30:59. [PMCID: PMC9670501 DOI: 10.1186/s13049-022-01046-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 11/08/2022] [Indexed: 11/18/2022] Open
Abstract
Background Decompressive craniectomy (DC) and intracranial pressure (ICP) monitoring are common approaches to reduce the death rate of Traumatic brain injury (TBI) patients, but the outcomes of these patients are unfavorable, particularly those who receive bilateral DC. The authors discuss their experience using ICP and other potential methods to improve the outcomes of TBI patients who receive bilateral DC. Methods Data from TBI patients receiving bilateral DC from Jan. 2008 to Jan. 2022 were collected via a retrospective chart review. Included patients who received unplanned contralateral DC after initial surgery were identified as unplanned secondary surgery (USS) patients. Patients’ demographics and baseline medical status; pre-, intra-, and postoperative events; and follow-up visit outcome data were analyzed. Results A total of 151 TBI patients were included. Patients who underwent USS experienced more severe outcomes as assessed using the 3-month modified Rankin Scale score (P = 0.024). In bilateral DC TBI patients, USS were associated with worsen outcomes, moreover, ICP monitoring was able to lower their death rate and was associated with a lower USS incidence. In USS patients, ICP monitoring was not associated with improved outcomes but was able to lower their mortality rate (2/19, 10.5%, vs. 10/25, 40.0%; P = 0.042). Conclusion The avoidance of USS may be associated with improved outcomes of TBI patients who underwent bilateral DC. ICP monitoring was a potential approach to lower USS rate in TBI patients, but its specific benefits were uncertain. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-022-01046-w.
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Affiliation(s)
- Jian-Lan Zhao
- grid.8547.e0000 0001 0125 2443Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai Clinical Medical Center of Neurosurgery, Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040 China
| | - Jie Song
- grid.8547.e0000 0001 0125 2443Department of Neurosurgery and Neurocritical Care, Huashan Hospital, Fudan University, Shanghai, 200040 China
| | - Qiang Yuan
- grid.8547.e0000 0001 0125 2443Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai Clinical Medical Center of Neurosurgery, Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040 China
| | - Yi-Feng Bao
- grid.8547.e0000 0001 0125 2443Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai Clinical Medical Center of Neurosurgery, Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040 China
| | - Yi-Rui Sun
- grid.8547.e0000 0001 0125 2443Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai Clinical Medical Center of Neurosurgery, Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040 China
| | - Zhi-Qi Li
- grid.8547.e0000 0001 0125 2443Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai Clinical Medical Center of Neurosurgery, Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040 China
| | - Cai-Hua Xi
- grid.8547.e0000 0001 0125 2443Department of Neurosurgery and Neurocritical Care, Huashan Hospital, Fudan University, Shanghai, 200040 China
| | - Hai-Jun Yao
- grid.8547.e0000 0001 0125 2443Department of Neurosurgery and Neurocritical Care, Huashan Hospital, Fudan University, Shanghai, 200040 China
| | - Mei-Hua Wang
- grid.8547.e0000 0001 0125 2443Department of Neurosurgery and Neurocritical Care, Huashan Hospital, Fudan University, Shanghai, 200040 China
| | - Gang Wu
- grid.8547.e0000 0001 0125 2443Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai Clinical Medical Center of Neurosurgery, Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040 China
| | - Zhuo-Ying Du
- grid.8547.e0000 0001 0125 2443Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai Clinical Medical Center of Neurosurgery, Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040 China
| | - Jin Hu
- grid.8547.e0000 0001 0125 2443Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai Clinical Medical Center of Neurosurgery, Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040 China ,grid.8547.e0000 0001 0125 2443Department of Neurosurgery and Neurocritical Care, Huashan Hospital, Fudan University, Shanghai, 200040 China
| | - Jian Yu
- grid.8547.e0000 0001 0125 2443Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai Clinical Medical Center of Neurosurgery, Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040 China
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Egea-Guerrero JJ, García-Sáez I, Quintana-Díaz M. Trigger transfusion in severe traumatic brain injury. Med Intensiva 2021; 46:157-160. [PMID: 34952791 DOI: 10.1016/j.medine.2021.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/08/2021] [Accepted: 03/21/2021] [Indexed: 11/28/2022]
Affiliation(s)
- J J Egea-Guerrero
- Unidad de Gestión Clínica de Medicina Intensiva, Hospital Universitario Virgen del Rocío, Sevilla, IBIS/CSIC/Universidad de Sevilla, Sevilla, Spain.
| | - I García-Sáez
- Servicio de Medicina Intensiva, Hospital Universitario de Donostia, San Sebastián, Guipúzcoa, Spain
| | - M Quintana-Díaz
- Servicio de Medicina Intensiva, Hospital Universitario de La Paz, Idipaz, Madrid, Spain
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Zhong W, Ji Z, Sun C. A Review of Monitoring Methods for Cerebral Blood Oxygen Saturation. Healthcare (Basel) 2021; 9:healthcare9091104. [PMID: 34574878 PMCID: PMC8466732 DOI: 10.3390/healthcare9091104] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/13/2021] [Accepted: 07/31/2021] [Indexed: 01/02/2023] Open
Abstract
In recent years, cerebral blood oxygen saturation has become a key indicator during the perioperative period. Cerebral blood oxygen saturation monitoring is conducive to the early diagnosis and treatment of cerebral ischemia and hypoxia. The present study discusses the three most extensively used clinical methods for cerebral blood oxygen saturation monitoring from different aspects: working principles, relevant parameters, current situations of research, commonly used equipment, and relative advantages of different methods. Furthermore, through comprehensive comparisons of the methods, we find that near-infrared spectroscopy (NIRS) technology has significant potentials and broad applications prospects in terms of cerebral oxygen saturation monitoring. Despite the current NIRS technology, the only bedside non-invasive cerebral oxygen saturation monitoring technology, still has many defects, it is more in line with the future development trend in the field of medical and health, and will become the main method gradually.
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Affiliation(s)
- Wentao Zhong
- College of Bioengineering, Chongqing University, Chongqing 400044, China; (W.Z.); (C.S.)
| | - Zhong Ji
- College of Bioengineering, Chongqing University, Chongqing 400044, China; (W.Z.); (C.S.)
- Key Laboratory of Biorheological Science and Technology, Chongqing University, Ministry of Education, Chongqing 400044, China
- Correspondence:
| | - Changlong Sun
- College of Bioengineering, Chongqing University, Chongqing 400044, China; (W.Z.); (C.S.)
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Egea-Guerrero JJ, García-Sáez I, Quintana-Díaz M. Trigger transfusion in severe traumatic brain injury. Med Intensiva 2021; 46:S0210-5691(21)00071-1. [PMID: 33962806 DOI: 10.1016/j.medin.2021.03.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/08/2021] [Accepted: 03/21/2021] [Indexed: 11/17/2022]
Affiliation(s)
- J J Egea-Guerrero
- Unidad de Gestión Clínica de Medicina Intensiva, Hospital Universitario Virgen del Rocío, Sevilla. IBIS/CSIC/Universidad de Sevilla, Sevilla, España.
| | - I García-Sáez
- Servicio de Medicina Intensiva, Hospital Universitario de Donostia, San Sebastián, Guipúzcoa, España
| | - M Quintana-Díaz
- Servicio deMedicina Intensiva, Hospital Universitario de La Paz. Idipaz, Madrid, España
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