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Léger M, Frasca D, Roquilly A, Seguin P, Cinotti R, Dahyot-Fizelier C, Asehnoune K, Le Borgne F, Gaillard T, Foucher Y, Lasocki S. Early use of barbiturates is associated with increased mortality in traumatic brain injury patients from a propensity score-based analysis of a prospective cohort. PLoS One 2022; 17:e0268013. [PMID: 35507627 PMCID: PMC9067881 DOI: 10.1371/journal.pone.0268013] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 04/20/2022] [Indexed: 01/29/2023] Open
Abstract
Barbiturates are proposed as a second/third line treatment for intracranial hypertension in traumatic brain injury (TBI) patients, but the literature remains uncertain regarding their benefit/risk balance. We aimed to evaluate the impact of barbiturates therapy in TBI patients with early intracranial hypertension on the intensive care unit (ICU) survival, the occurrence of ventilator-associated pneumonia (VAP), and the patient’s functional status at three months. We used the French AtlanREA prospective cohort of trauma patients. Using a propensity score-based methodology (inverse probability of treatment weighting), we compared patients having received barbiturates within the first 24 hours of admission (barbiturates group) and those who did not (control group). We used cause-specific Cox models for ICU survival and risk of VAP, and logistic regression for the 3-month Glasgow Outcome Scale (GOS) evaluation. Among the 1396 patients with severe trauma, 383 had intracranial hypertension on admission and were analyzed. Among them, 96 (25.1%) received barbiturates. The early use of barbiturates was significantly associated with increased ICU mortality (HR = 1.85, 95%CI 1.03–3.33). However, barbiturates treatment was not significantly associated with VAP (HR = 1.02, 95%CI 0.75–1.41) or 3-month GOS (OR = 1.67, 95%CI 0.84–3.33). Regarding the absence of relevant clinical trials, our results suggest that each early prescription of barbiturates requires a careful assessment of the benefit/risk ratio.
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Affiliation(s)
- Maxime Léger
- Département d’Anesthésie Réanimation, Centre Hospitalier Universitaire d’Angers, Angers, France
- INSERM UMR 1246—SPHERE, Nantes University, Tours University, Nantes, France
- * E-mail:
| | - Denis Frasca
- INSERM UMR 1246—SPHERE, Nantes University, Tours University, Nantes, France
- Département d’Anesthésie Réanimation, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
| | - Antoine Roquilly
- Département d’Anesthésie Réanimation, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Philippe Seguin
- Département d’Anesthésie Réanimation, Centre Hospitalier Universitaire de Rennes, Rennes, France
| | - Raphaël Cinotti
- Département d’Anesthésie Réanimation, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Claire Dahyot-Fizelier
- Département d’Anesthésie Réanimation, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
| | - Karim Asehnoune
- Département d’Anesthésie Réanimation, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Florent Le Borgne
- INSERM UMR 1246—SPHERE, Nantes University, Tours University, Nantes, France
- IDBC-A2COM, Pacé, France
| | - Thomas Gaillard
- Département d’Anesthésie Réanimation, Centre Hospitalier Universitaire d’Angers, Angers, France
| | - Yohann Foucher
- INSERM UMR 1246—SPHERE, Nantes University, Tours University, Nantes, France
- Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Sigismond Lasocki
- Département d’Anesthésie Réanimation, Centre Hospitalier Universitaire d’Angers, Angers, France
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Takahashi CE, Virmani D, Chung DY, Ong C, Cervantes-Arslanian AM. Blunt and Penetrating Severe Traumatic Brain Injury. Neurol Clin 2021; 39:443-469. [PMID: 33896528 DOI: 10.1016/j.ncl.2021.02.009] [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: 12/09/2022]
Abstract
Severe traumatic brain injury is a common problem. Current practices focus on the importance of early resuscitation, transfer to high-volume centers, and provider expertise across multiple specialties. In the emergency department, patients should receive urgent intracranial imaging and consideration for tranexamic acid. Close observation in the intensive care unit environment helps identify problems, such as seizure, intracranial pressure crisis, and injury progression. In addition to traditional neurologic examination, patients benefit from use of intracranial monitors. Monitors gather physiologic data on intracranial and cerebral perfusion pressures to help guide therapy. Brain tissue oxygenation monitoring and cerebromicrodialysis show promise in studies.
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Affiliation(s)
- Courtney E Takahashi
- Department of Neurology, Boston Medical Center, 72 East Concord Street, Collamore, C-3, Boston, MA 02118, USA.
| | - Deepti Virmani
- Department of Neurology, Boston University School of Medicine and Boston Medical Center, 72 East Concord Street, Collamore, C-3, Boston, MA 02118, USA
| | - David Y Chung
- Department of Neurology, Boston University School of Medicine and Boston Medical Center, 72 East Concord Street, Collamore, C-3, Boston, MA 02118, USA; Division of Neurocritical Care, Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA; Neurovascular Research Unit, Department of Radiology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Charlene Ong
- Department of Neurology, Boston University School of Medicine and Boston Medical Center, 72 East Concord Street, Collamore, C-3, Boston, MA 02118, USA
| | - Anna M Cervantes-Arslanian
- Boston University School of Medicine and Boston Medical Center, 72 East Concord Street, Collamore, C-3, Boston, MA 02118, USA
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Alotaibi NM, Wang JZ, Pasarikovski CR, Guha D, Al-Mufti F, Mamdani M, Saposnik G, Schweizer TA, Macdonald RL. Management of raised intracranial pressure in aneurysmal subarachnoid hemorrhage: time for a consensus? Neurosurg Focus 2018; 43:E13. [PMID: 29088956 DOI: 10.3171/2017.7.focus17426] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Elevated intracranial pressure (ICP) is a well-recognized phenomenon in aneurysmal subarachnoid hemorrhage (aSAH) that has been demonstrated to lead to poor outcomes. Despite significant advances in clinical research into aSAH, there are no consensus guidelines devoted specifically to the management of elevated ICP in the setting of aSAH. To treat high ICP in aSAH, most centers extrapolate their treatment algorithms from studies and published guidelines for traumatic brain injury. Herein, the authors review the current management strategies for treating raised ICP within the aSAH population, emphasize key differences from the traumatic brain injury population, and highlight potential directions for future research in this controversial topic.
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Affiliation(s)
- Naif M Alotaibi
- Institute of Medical Science, Faculty of Medicine, University of Toronto, and.,Department of Neurosurgery, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Justin Z Wang
- Division of Neurosurgery, Department of Surgery, St Michael's Hospital, University of Toronto, Ontario, Canada
| | - Christopher R Pasarikovski
- Division of Neurosurgery, Department of Surgery, St Michael's Hospital, University of Toronto, Ontario, Canada
| | - Daipayan Guha
- Institute of Medical Science, Faculty of Medicine, University of Toronto, and.,Division of Neurosurgery, Department of Surgery, St Michael's Hospital, University of Toronto, Ontario, Canada
| | - Fawaz Al-Mufti
- Department of Neurology and Critical Care, Robert Wood Johnson University Hospital, New Brunswick, New Jersey; and
| | - Muhammad Mamdani
- Li Ka Shing Centre for Healthcare Analytics Research and Training, Institute for Clinical Evaluative Sciences
| | - Gustavo Saposnik
- Neuroscience Research Program, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael's Hospital; and.,Stroke Outcomes and Decision Neuroscience Research Unit, St. Michael's Hospital, University of Toronto, Ontario, Canada
| | - Tom A Schweizer
- Institute of Medical Science, Faculty of Medicine, University of Toronto, and.,Division of Neurosurgery, Department of Surgery, St Michael's Hospital, University of Toronto, Ontario, Canada.,Neuroscience Research Program, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael's Hospital; and
| | - R Loch Macdonald
- Institute of Medical Science, Faculty of Medicine, University of Toronto, and.,Division of Neurosurgery, Department of Surgery, St Michael's Hospital, University of Toronto, Ontario, Canada.,Neuroscience Research Program, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael's Hospital; and
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Abstract
OBJECTIVE Acute intracranial hemorrhage and intraventricular hemorrhage are devastating disorders. The goal of this review is to familiarize clinicians with recent information pertaining to the acute care of intracranial hemorrhage and intraventricular hemorrhage. DATA SOURCES PubMed search and review of the relevant medical literature. SUMMARY The management of intracranial hemorrhage and intraventricular hemorrhage is complex. Effective treatment should include strategies designed to reduce hematoma expansion and limit the medical consequences of intracranial hemorrhage and intraventricular hemorrhage. At present, there are a number of new approaches to treatment that may reduce mortality and improve clinical outcomes. Clinicians should recognize that patients with large hematomas may make a substantial recovery. CONCLUSIONS Patients with intracranial hemorrhage and intraventricular hemorrhage should be cared for in an intensive care unit. New therapies designed to stabilize hematoma growth and reduce hematoma burden may improve outcomes.
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Affiliation(s)
- Paul Nyquist
- Neurology/Anesthesiology Critical Care Medicine/ Neurosurgery, Johns Hopkins School of Medicine, Baltimore Maryland, USA.
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5
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Bell D, Adams JP. The Secondary Management of Traumatic Brain Injury. Neurocrit Care 2010. [DOI: 10.1007/978-1-84882-070-8_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Spontaneous intracerebral hemorrhage (ICH) has the highest mortality of all cerebrovascular events. Thirty-day mortality approaches 50%, and only 20% of survivors achieve meaningful functional recovery at 6 months. Many clinicians believe that effective therapies are lacking; however, this is changing because of new data on the pathophysiology and treatment of ICH, particularly research establishing the role of medical therapies to promote hematoma stabilization. This article provides updates to a recent publication discussing basic principles of ICH management, including initial stabilization, the prevention of hematoma growth, treatment of complications, and identification of the underlying etiology. Minimally invasive surgery (MIS) to reduce clot size is also discussed, with the goal of preserving neurologic function through reduction in parenchymal damage from edema formation.
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Kim YI, Park SW, Nam TK, Park YS, Min BK, Hwang SN. The effect of barbiturate coma therapy for the patients with severe intracranial hypertension: a 10-year experience. J Korean Neurosurg Soc 2008; 44:141-5. [PMID: 19096664 DOI: 10.3340/jkns.2008.44.3.141] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2008] [Accepted: 08/18/2008] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Barbiturate coma therapy (BCT) has been known to be an useful method to control increased intracranial pressure (IICP) refractory to medical and surgical treatments. We have used BCT for patients with severe IICP during the past 10 years, and analyzed our results with review of literatures. METHODS We analyzed 92 semicomatose or comatose patients with Glasgow coma scale (GCS) of 7 or less with severe IICP due to cerebral edema secondary to parenchymal damages irrespective of their causes. Forty patients who had received BCT with ICP monitoring from January 1997 to December 2006 were included in BCT group, and fifty-two patients who had been managed without BCT from January 1991 to December 1995 were divided into control group. We compared outcomes with Glasgow outcome scale (GOS) and survival rate between the two groups. RESULTS Good outcome (GOS=4 and 5) rates at 3-month after insult were 27.5% and 5.8% in BCT and control group, respectively (p<0.01). One-year survival rates were 35.9% and 12.5% in BCT and control group, respectively (p<0.01). In BCT group, the mean age of good outcome patients (37.1 +/- 14.9) was significantly lower than that of poor outcome patients (48.1 +/- 13.5) (p<0.05). CONCLUSION With our 10-year experience, we suggest that BCT is an effective treatment method for severe IICP patients for better survival and GOS, especially for younger patients.
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Affiliation(s)
- Young-Il Kim
- Department of Neurological Surgery, Chung-Ang University Yongsan Hospital, Seoul, Korea
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Naval NS, Nyquist PA, Carhuapoma JR. Management of spontaneous intracerebral hemorrhage. Neurol Clin 2008; 26:373-84, vii. [PMID: 18514818 DOI: 10.1016/j.ncl.2008.03.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Spontaneous intracerebral hemorrhage (ICH) has the highest mortality of all cerebrovascular events. Thirty-day mortality approaches 50%, and only 20% of survivors achieve meaningful functional recovery at 6 months. Many clinicians believe that effective therapies are lacking; however, this is changing because of new data on the pathophysiology and treatment of ICH, particularly research establishing the role of medical therapies to promote hematoma stabilization. This article provides updates to a recent publication discussing basic principles of ICH management, including initial stabilization, the prevention of hematoma growth, treatment of complications, and identification of the underlying etiology. Minimally invasive surgery (MIS) to reduce clot size is also discussed, with the goal of preserving neurologic function through reduction in parenchymal damage from edema formation.
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Affiliation(s)
- Neeraj S Naval
- Department of Neurology, Division of Neurosciences Critical Care, Johns Hopkins Medical Institutions, Baltimore, MD 21287, USA
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Bouchard PM, Frenette AJ, Williamson DR, Perreault MM. Thiopental-associated dyskalemia in severe head trauma. THE JOURNAL OF TRAUMA 2008; 64:838-842. [PMID: 18332833 DOI: 10.1097/ta.0b013e3180341f65] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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Naval NS, Nyquist PA, Carhuapoma JR. Advances in the management of spontaneous intracerebral hemorrhage. Crit Care Clin 2007; 22:607-17; abstract vii-viii. [PMID: 17239746 DOI: 10.1016/j.ccc.2006.11.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Spontaneous intracerebral hemorrhage (ICH) is associated with the highest mortality of all cerebrovascular events, and most survivors never regain functional independence. Many clinicians believe that effective therapies are lacking for patients who have ICH; however, this perception is changing in light of new data on the pathophysiology and treatment of this disorder, in particular, research establishing the role of medical therapies to promote hematoma stabilization. This article discusses the basic principles of management of ICH, including initial stabilization, the prevention of hematoma growth, treatment of complications, and identification of the underlying etiology. In addition, minimally invasive surgery to reduce clot size is discussed, with the goal of preserving neurologic function through reduction in parenchymal damage from edema formation.
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Affiliation(s)
- Neeraj S Naval
- Department of Neurology, Division of Neurosciences Critical Care, Johns Hopkins Medical Institutions, Baltimore, MD 21287, USA
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Abstract
OBJECTIVE To review the current understanding of the medical management of severe brain injury. DATA SOURCE The MEDLINE database, bibliographies of selected articles, and current English-language texts on the subject. STUDY SELECTION Studies related to management of intracranial hypertension, traumatic brain injury, and brain edema. DATA EXTRACTION All studies relevant to the subject under consideration were considered, with a focus on clinical studies in adults. DATA SYNTHESIS Basic rules of resuscitation must apply, including adequate ventilation, appropriate fluid administration, and cardiovascular support. The control of intracranial pressure can be considered in three steps. The first step should be initial slight hyperventilation with a target PaCO2 of 35 mm Hg and cerebrospinal fluid drainage for intracranial pressure of >15-20 mm Hg. The second step should be mannitol or hypertonic saline and hyperventilation to target PaCO2 of 28-35 mm Hg. The third step should be barbiturate coma or decompressive craniectomy. Additional management issues, including seizure prophylaxis, sedation, nutritional support, use of hypothermia, and corticosteroids, are also discussed. CONCLUSIONS Brain injury is frequently associated with the development of brain edema and the development of intracranial hypertension. However, with a coordinated, stepwise, and aggressive approach to management, focusing on control of intracranial pressure without adversely affecting cerebral perfusion pressure, outcomes can be good.
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Affiliation(s)
- Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Free University of Brussels, Belgium
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