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Guglielmi A, Graziano F, Bogossian EG, Turgeon AF, Taccone FS, Citerio G. Haemoglobin values, transfusion practices, and long-term outcomes in critically ill patients with traumatic brain injury: a secondary analysis of CENTER-TBI. Crit Care 2024; 28:199. [PMID: 38877571 PMCID: PMC11177426 DOI: 10.1186/s13054-024-04980-6] [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] [Received: 03/26/2024] [Accepted: 06/03/2024] [Indexed: 06/16/2024] Open
Abstract
Haemoglobin (Hb) thresholds and red blood cells (RBC) transfusion strategies in traumatic brain injury (TBI) are controversial. Our objective was to assess the association of Hb values with long-term outcomes in critically ill TBI patients. We conducted a secondary analysis of CENTER-TBI, a large multicentre, prospective, observational study of European TBI patients. All patients admitted to the Intensive Care Unit (ICU) with available haemoglobin data on admission and during the first week were included. During the first seven days, daily lowest haemoglobin values were considered either a continous variable or categorised as < 7.5 g/dL, between 7.5-9.5 and > 9.5 g/dL. Anaemia was defined as haemoglobin value < 9.5 g/dL. Transfusion practices were described as "restrictive" or "liberal" based on haemoglobin values before transfusion (e.g. < 7.5 g/dL or 7.5-9.5 g/dL). Our primary outcome was the Glasgow outcome scale extended (GOSE) at six months, defined as being unfavourable when < 5. Of 1590 included, 1231 had haemoglobin values available on admission. A mean Injury Severity Score (ISS) of 33 (SD 16), isolated TBI in 502 (40.7%) and a mean Hb value at ICU admission of 12.6 (SD 2.2) g/dL was observed. 121 (9.8%) patients had Hb < 9.5 g/dL, of whom 15 (1.2%) had Hb < 7.5 g/dL. 292 (18.4%) received at least one RBC transfusion with a median haemoglobin value before transfusion of 8.4 (IQR 7.7-8.5) g/dL. Considerable heterogeneity regarding threshold transfusion was observed among centres. In the multivariable logistic regression analysis, the increase of haemoglobin value was independently associated with the decrease in the occurrence of unfavourable neurological outcomes (OR 0.78; 95% CI 0.70-0.87). Congruous results were observed in patients with the lowest haemoglobin values within the first 7 days < 7.5 g/dL (OR 2.09; 95% CI 1.15-3.81) and those between 7.5 and 9.5 g/dL (OR 1.61; 95% CI 1.07-2.42) compared to haemoglobin values > 9.5 g/dL. Results were consistent when considering mortality at 6 months as an outcome. The increase of hemoglobin value was associated with the decrease of mortality (OR 0.88; 95% CI 0.76-1.00); haemoglobin values less than 7.5 g/dL was associated with an increase of mortality (OR 3.21; 95% CI 1.59-6.49). Anaemia was independently associated with long-term unfavourable neurological outcomes and mortality in critically ill TBI patients.Trial registration: CENTER-TBI is registered at ClinicalTrials.gov, NCT02210221, last update 2022-11-07.
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Affiliation(s)
- Angelo Guglielmi
- School of Medicine and Surgery, University of Milano - Bicocca, Milan, Italy
- University of Pavia, PhD in Experimental Medicine, Pavia, Italy
- Intensive Care Department 1, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Francesca Graziano
- Biostatistics and Clinical Epidemiology, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- Bicocca Bioinformatics Biostatistics and Bioimaging Center B4, School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Elisa Gouvêa Bogossian
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), 1070, Brussels, Belgium
| | - Alexis F Turgeon
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit (Trauma-Emergency-Critical Care Medicine), Québec City, QC, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec City, QC, Canada
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), 1070, Brussels, Belgium
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano - Bicocca, Milan, Italy.
- Neurological Intensive Care Unit, Department Neuroscience, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy.
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Younsi A, Unterberg A, Marzi I, Steudel WI, Uhl E, Lemcke J, Berg F, Woschek M, Friedrich M, Clusmann H, Hamou HA, Mauer UM, Scheer M, Meixensberger J, Lindner D, Schmieder K, Gierthmuehlen M, Hoefer C, Nienaber U, Maegele M. Development and first results of a national databank on care and treatment outcome after traumatic brain injury. Eur J Trauma Emerg Surg 2023; 49:1171-1181. [PMID: 37022377 DOI: 10.1007/s00068-023-02260-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 03/12/2023] [Indexed: 04/07/2023]
Abstract
PURPOSE In absence of comprehensive data collection on traumatic brain injury (TBI), the German Society for Neurosurgery (DGNC) and the German Society for Trauma Surgery (DGU) developed a TBI databank for German-speaking countries. METHODS From 2016 to 2020, the TBI databank DGNC/DGU was implemented as a module of the TraumaRegister (TR) DGU and tested in a 15-month pilot phase. Since its official launch in 2021, patients from the TR-DGU (intermediate or intensive care unit admission via shock room) with TBI (AIS head ≥ 1) can be enrolled. A data set of > 300 clinical, imaging, and laboratory variables, harmonized with other international TBI data collection structures is documented, and the treatment outcome is evaluated after 6- and 12 months. RESULTS For this analysis, 318 patients in the TBI databank could be included (median age 58 years; 71% men). Falls were the most common cause of injury (55%), and antithrombotic medication was frequent (28%). Severe or moderate TBI were only present in 55% of patients, while 45% suffered a mild injury. Nevertheless, intracranial pathologies were present in 95% of brain imaging with traumatic subarachnoid hemorrhages (76%) being the most common. Intracranial surgeries were performed in 42% of cases. In-hospital mortality after TBI was 21% and surviving patients could be discharged after a median hospital stay of 11 days. At the 6-and 12 months follow-up, a favorable outcome was achieved by 70% and 90% of the participating TBI patients, respectively. Compared to a European cohort of 2138 TBI patients treated in the ICU between 2014 and 2017, patients in the TBI databank were already older, frailer, fell more commonly at home. CONCLUSION Within five years, the TBI databank DGNC/DGU of the TR-DGU could be established and is since then prospectively enrolling TBI patients in German-speaking countries. With its large and harmonized data set and a 12-month follow-up, the TBI databank is a unique project in Europe, already allowing comparisons to other data collection structures and indicating a demographic change towards older and frailer TBI patients in Germany.
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Affiliation(s)
- Alexander Younsi
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg, INF 400, 69120, Heidelberg, Germany.
| | - Andreas Unterberg
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg, INF 400, 69120, Heidelberg, Germany
| | - Ingo Marzi
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum, Johann Wolfgang-Goethe-Universität, Frankfurt am Main, Germany
| | | | - Eberhard Uhl
- Neurochirurgische Klinik, Universitätsklinikum Gießen und Marburg Standort Gießen, Giessen, Germany
| | - Johannes Lemcke
- Klinik für Neurochirurgie, BG Klinikum Unfallkrankenhaus Berlin, Warener Straße 7, 12683, Berlin, Germany
| | - Florian Berg
- Klinik für Neurochirurgie, BG Klinikum Unfallkrankenhaus Berlin, Warener Straße 7, 12683, Berlin, Germany
| | - Mathias Woschek
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum, Johann Wolfgang-Goethe-Universität, Frankfurt am Main, Germany
| | - Michaela Friedrich
- Neurochirurgische Klinik, Universitätsklinikum Gießen und Marburg Standort Gießen, Giessen, Germany
| | - Hans Clusmann
- Klinik für Neurochirurgie, Uniklinik RWTH Aachen, Aachen, Germany
| | | | - Uwe Max Mauer
- Neurochirurgische Klinik, Bundeswehrkrankenhaus Ulm, Ulm, Germany
| | - Magnus Scheer
- Neurochirurgische Klinik, Bundeswehrkrankenhaus Ulm, Ulm, Germany
| | - Jürgen Meixensberger
- Klinik und Poliklinik für Neurochirurgie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Dirk Lindner
- Klinik und Poliklinik für Neurochirurgie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Kirsten Schmieder
- Universitätsklinikum Knappschaftskrankenhaus Bochum GmbH, Ruhr - Universität Bochum, In Der Schornau 23-35, 44892, Bochum, Germany
| | - Mortimer Gierthmuehlen
- Universitätsklinikum Knappschaftskrankenhaus Bochum GmbH, Ruhr - Universität Bochum, In Der Schornau 23-35, 44892, Bochum, Germany
| | - Christine Hoefer
- Akademie der Unfallchirurgie GmbH, Emil-Riedel-Straße 5, 80538, Munich, Germany
| | - Ulrike Nienaber
- Akademie der Unfallchirurgie GmbH, Emil-Riedel-Straße 5, 80538, Munich, Germany
| | - Marc Maegele
- Klinik für Orthopädie, Unfallchirurgie und Sporttraumatologie, Klinikum Köln-Merheim, Institut für Forschung in der Operativen Medizin (IFOM), Universität Witten/Herdecke, Campus Köln-Merheim, Ostmerheimerstr. 200, 51109, Cologne, Germany
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Ito H, Nakamura Y, Togami Y, Onishi S, Nakao S, Iba J, Ogura H, Oda J. Association of Extravascular Leakage on Computed Tomography Angiography with Fibrinogen Levels at Admission in Patients with Traumatic Brain Injury. Neurotrauma Rep 2022; 4:3-13. [PMID: 36636245 PMCID: PMC9811953 DOI: 10.1089/neur.2022.0054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Extravascular leakage on computed tomography (CT) angiography in patients with traumatic brain injury (TBI) is associated with hematoma expansion, functional prognosis, subsequent surgery, and death. Fresh frozen plasma (FFP) administration is often necessary to treat coagulation disorders associated with TBI. This study aimed to determine the relationship between the presence of extravascular leakage on contrast-enhanced head CT, fibrinogen level at admission, and FFP administration in patients with TBI. The medical records of patients with TBI ≥18 years of age referred to our hospital between January 2010 and December 2020 were examined retrospectively. Patients who underwent contrast-enhanced CT immediately after admission were selected, and the presence or absence of extravascular leakage, fibrinogen level at admission, and percentage of patients who required FFP administration within 24 h of admission were examined; 172 patients were included. Multi-variable linear regression analysis was performed to determine the effects of contrast extravasation on fibrinogen levels at admission and was adjusted for age, sex, systolic blood pressure, time from injury to admission, Marshall CT score, Glasgow Coma Scale score at admission, Injury Severity Score, and need for emergency surgery; the regression coefficient was -19.8. The effect of extravasation on FFP administration within 24 h of admission was analyzed using logistic regression while adjusting for age, systolic blood pressure, Marshall CT score, need for emergency surgery, and fibrinogen level at admission. The odds ratio of contrast extravasation was 7.08 after adjustment. Extravascular leakage is associated with fibrinogen levels at admission and FFP administration within 24 h of admission.
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Affiliation(s)
- Hiroshi Ito
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan.,Address correspondence to: Hiroshi Ito, PhD, Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15 Yamada-oka, Suita, Osaka 565-0871, Japan;
| | - Youhei Nakamura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yuki Togami
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Shinya Onishi
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Shunichiro Nakao
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Jiro Iba
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Jun Oda
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
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Miranda SP, Wathen C, Schuster JM, Petrov D. Letter to the Editor Regarding "Viscoelastic Hemostatic Assays and Outcomes in Traumatic Brain Injury: A Systematic Literature Review". World Neurosurg 2022; 166:291-293. [PMID: 36192854 PMCID: PMC9514967 DOI: 10.1016/j.wneu.2022.04.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 04/08/2022] [Indexed: 01/28/2023]
Affiliation(s)
- Stephen P Miranda
- Department of Neurosurgery, Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Connor Wathen
- Department of Neurosurgery, Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - James M Schuster
- Department of Neurosurgery, Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Dmitriy Petrov
- Department of Neurosurgery, Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Management of moderate to severe traumatic brain injury: an update for the intensivist. Intensive Care Med 2022; 48:649-666. [PMID: 35595999 DOI: 10.1007/s00134-022-06702-4] [Citation(s) in RCA: 47] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 04/09/2022] [Indexed: 01/04/2023]
Abstract
Traumatic brain injury (TBI) remains one of the most fatal and debilitating conditions in the world. Current clinical management in severe TBI patients is mainly concerned with reducing secondary insults and optimizing the balance between substrate delivery and consumption. Over the past decades, multimodality monitoring has become more widely available, and clinical management protocols have been published that recommend potential interventions to correct pathophysiological derangements. Even while evidence from randomized clinical trials is still lacking for many of the recommended interventions, these protocols and algorithms can be useful to define a clear standard of therapy where novel interventions can be added or be compared to. Over the past decade, more attention has been paid to holistic management, in which hemodynamic, respiratory, inflammatory or coagulation disturbances are detected and treated accordingly. Considerable variability with regards to the trajectories of recovery exists. Even while most of the recovery occurs in the first months after TBI, substantial changes may still occur in a later phase. Neuroprognostication is challenging in these patients, where a risk of self-fulfilling prophecies is a matter of concern. The present article provides a comprehensive and practical review of the current best practice in clinical management and long-term outcomes of moderate to severe TBI in adult patients admitted to the intensive care unit.
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Shammassian BH, Ronald A, Smith A, Sajatovic M, Mangat HS, Kelly ML. Viscoelastic Hemostatic Assays and Outcomes in Traumatic Brain Injury: A Systematic Literature Review. World Neurosurg 2022; 159:221-236.e4. [PMID: 34844010 DOI: 10.1016/j.wneu.2021.10.180] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 10/27/2021] [Accepted: 10/28/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Coagulopathy in traumatic brain injury (TBI) occurs frequently and is associated with poor outcomes. Conventional coagulation assays (CCA) traditionally used to diagnose coagulopathy are often not time sensitive and do not assess complete hemostatic function. Viscoelastic hemostatic assays (VHAs) including thromboelastography and rotational thromboelastography provide a useful rapid and comprehensive point-of-care alternative for identifying coagulopathy, which is of significant consequence in patients with TBI with intracranial hemorrhage. METHODS A systematic review was performed in accordance with PRISMA guidelines to identify studies comparing VHA with CCA in adult patients with TBI. The following differences in outcomes were assessed based on ability to diagnose coagulopathy: mortality, need for neurosurgical intervention, and progression of traumatic intracranial hemorrhage (tICH). RESULTS Abnormal reaction time (R time), maximum amplitude, and K value were associated with increased mortality in certain studies but not all studies. This association was reflected across studies using different statistical parameters with different outcome definitions. An abnormal R time was the only VHA parameter found to be associated with the need for neurosurgical intervention in 1 study. An abnormal R time was also the only VHA parameter associated with progression of tICH. Overall, many studies also reported abnormal CCAs, mainly activated partial thromboplastin time, to be associated with poor outcomes. CONCLUSIONS Given the heterogenous nature of the available evidence including methodology and study outcomes, the comparative difference between VHA and CCA in predicting rates of neurosurgical intervention, tICH progression, or mortality in patients with TBI remains inconclusive.
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Affiliation(s)
- Berje H Shammassian
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA; Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.
| | - Andrew Ronald
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Arvin Smith
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Martha Sajatovic
- Neurological and Behavioral Outcomes Center, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Halinder S Mangat
- Department of Neurology, Division of Neurocritical Care, University of Kansas Medical Center Kansas City, Kansas, USA
| | - Michael L Kelly
- Metrohealth Medical Center, Department of Neurological Surgery, Cleveland, Ohio, USA
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Brannon ER, Guevara MV, Pacifici NJ, Lee JK, Lewis JS, Eniola-Adefeso O. Polymeric particle-based therapies for acute inflammatory diseases. NATURE REVIEWS. MATERIALS 2022; 7:796-813. [PMID: 35874960 PMCID: PMC9295115 DOI: 10.1038/s41578-022-00458-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/09/2022] [Indexed: 05/02/2023]
Abstract
Acute inflammation is essential for initiating and coordinating the body's response to injuries and infections. However, in acute inflammatory diseases, inflammation is not resolved but propagates further, which can ultimately lead to tissue damage such as in sepsis, acute respiratory distress syndrome and deep vein thrombosis. Currently, clinical protocols are limited to systemic steroidal treatments, fluids and antibiotics that focus on eradicating inflammation rather than modulating it. Strategies based on stem cell therapeutics and selective blocking of inflammatory molecules, despite showing great promise, still lack the scalability and specificity required to treat acute inflammation. By contrast, polymeric particle systems benefit from uniform manufacturing at large scales while preserving biocompatibility and versatility, thus providing an ideal platform for immune modulation. Here, we outline design aspects of polymeric particles including material, size, shape, deformability and surface modifications, providing a strategy for optimizing the targeting of acute inflammation.
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Affiliation(s)
- Emma R. Brannon
- Department of Chemical Engineering, University of Michigan, Ann Arbor, MI USA
| | | | - Noah J. Pacifici
- Department of Biomedical Engineering, University of California, Davis, CA USA
| | - Jonathan K. Lee
- Department of Chemical Engineering, University of Michigan, Ann Arbor, MI USA
| | - Jamal S. Lewis
- Department of Biomedical Engineering, University of California, Davis, CA USA
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Early thrombocytopenia is associated with an increased risk of mortality in patients with traumatic brain injury treated in the intensive care unit: a Finnish Intensive Care Consortium study. Acta Neurochir (Wien) 2022; 164:2731-2740. [PMID: 35838800 PMCID: PMC9519714 DOI: 10.1007/s00701-022-05277-9] [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: 01/25/2022] [Accepted: 06/06/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Coagulopathy after traumatic brain injury (TBI) is associated with poor prognosis. PURPOSE To assess the prevalence and association with outcomes of early thrombocytopenia in patients with TBI treated in the intensive care unit (ICU). METHODS This is a retrospective multicenter study of adult TBI patients admitted to ICUs during 2003-2019. Thrombocytopenia was defined as a platelet count < 100 × 109/L during the first day. The association between thrombocytopenia and hospital and 12-month mortality was tested using multivariable logistic regression, adjusting for markers of injury severity. RESULTS Of 4419 patients, 530 (12%) had early thrombocytopenia. In patients with thrombocytopenia, hospital and 12-month mortality were 26% and 48%, respectively; in patients with a platelet count > 100 × 109/L, they were 9% and 22%, respectively. After adjusting for injury severity, a higher platelet count was associated with decreased odds of hospital mortality (OR 0.998 per unit, 95% CI 0.996-0.999) and 12-month mortality (OR 0.998 per unit, 95% CI 0.997-0.999) in patients with moderate-to-severe TBI. Compared to patients with a normal platelet count, patients with thrombocytopenia not receiving platelet transfusion had an increased risk of 12-month mortality (OR 2.2, 95% CI 1.6-3.0), whereas patients with thrombocytopenia receiving platelet transfusion did not (OR 1.0, 95% CI 0.6-1.7). CONCLUSION Early thrombocytopenia occurs in approximately one-tenth of patients with TBI treated in the ICU, and it is an independent risk factor for mortality in patients with moderate-to-severe TBI. Further research is necessary to determine whether this is modifiable by platelet transfusion.
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Florez-Perdomo WA, García-Ballestas E, Martinez-Perez R, Agrawal A, Deora H, Joaquim AF, Quiñones-Ossa GA, Moscote-Salazar LR. Hemoglobin levels as a transfusion criterion in moderate to severe traumatic brain injury: a systematic review and meta-analysis. Br J Neurosurg 2021; 37:1-7. [PMID: 34148446 DOI: 10.1080/02688697.2021.1940850] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 06/07/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Several factors can influence the outcome of severe head injuries including the patient's hemoglobin levels. There has often been a dilemma regarding levels of hemoglobin at which red cell blood transfusion (RCBT) should be performed. OBJECTIVE To systematically review the literature to determine the usefulness of management protocols that have hemoglobin levels <10 g/dL vs <7 g/dL as an RCBT criterion. METHODS Following the PRISMA statement, the search was constructed using terms and descriptors of the Medical Subject Heading (MeSH), combined with Boolean operators. Full text of these articles was studied, and outcome measures at 3-6 months were considered for patients who were given a RCBT at <10 g/dL or at 7 g/dL hemoglobin levels. RESULTS A total of 4 articles were found suitable for inclusion in the meta-analysis. RCBT below 7 g/dL was not associated with an increased risk of mortality as compared to RCBT using the value of less than 10 g/dL. RCBT at lower levels of hemoglobin was also not associated with a poor neurological outcome (GOS 4-5) but rather RCBT at lower levels lead to better outcomes (GOS 1-3) and the association was significant. CONCLUSION Allogenic RCBT was associated with poorer neurological outcomes, within a wide range of reported differences in the hemoglobin threshold to decide for RCBT in TBI patients. Restrictive RCBT strategy may be useful in moderate to severe TBI cases although the risk of anemia-induced cerebral injury needs further investigation regarding the risks and complications inherent to RCBT.
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Affiliation(s)
| | - Ezequiel García-Ballestas
- Latin American Council of Neurocritical Care- CLaNi, Cartagena, Colombia
- Faculty of Medicine, Centro De Investigaciones Biomédicas (CIB), University of Cartagena, Cartagena, Colombia
| | - Rafael Martinez-Perez
- Department of Neurological Surgery, University of Colorado, Aurora, CO, USA
- Institute of Neurosciences, Division of Neurosurgery, Universidad Austral de Chile, Valdivia, Chile
| | - Amit Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, India
| | - Harsh Deora
- Department of Neurosurgery, NIMHANS, Bangalore, India
| | - Andrei F Joaquim
- Department of Neurosurgery, University of Campinas (UNICAMP), São Paulo, Brazil
| | - Gabriel A Quiñones-Ossa
- Latin American Council of Neurocritical Care- CLaNi, Cartagena, Colombia
- Faculty of Medicine, University El Bosque, Bogotá, Colombia
| | - Luis Rafael Moscote-Salazar
- Latin American Council of Neurocritical Care- CLaNi, Cartagena, Colombia
- Faculty of Medicine, Centro De Investigaciones Biomédicas (CIB), University of Cartagena, Cartagena, Colombia
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Feng J, van Veen E, Yang C, Huijben JA, Lingsma HF, Gao G, Jiang J, Maas AI, Åkerlund C, Amrein K, Andelic N, Andreassen L, Anke A, Antoni A, Audibert G, Azouvi P, Azzolini ML, Bartels R, Barzó P, Beauvais R, Beer R, Bellander BM, Belli A, Benali H, Berardino M, Beretta L, Blaabjerg M, Bragge P, Brazinova A, Brinck V, Brooker J, Brorsson C, Buki A, Bullinger M, Cabeleira M, Caccioppola A, Calappi E, Calvi MR, Cameron P, Lozano GC, Carbonara M, Cavallo S, Chevallard G, Chieregato A, Citerio G, Care N, Ceyisakar I, Clusmann H, Coburn M, Coles J, Cooper JD, Correia M, Čović A, Curry N, Czeiter E, Czosnyka M, Dahyot-Fizelier C, Dark P, Dawes H, De Keyser V, Degos V, Corte FD, den Boogert H, Depreitere B, Đilvesi Đ, Dixit A, Donoghue E, Dreier J, Dulière GL, Ercole A, Esser P, Ezer E, Fabricius M, Feigin VL, Foks K, Frisvold S, Furmanov A, Gagliardo P, Galanaud, George P, Ghuysen A, Giga L, Glocker B, Golubovic J, Gomez PA, Gratz J, Gravesteijn B, Grossi F, Gruen RL, Gupta D, Haagsma JA, Haitsma I, Helbok R, Helseth E, Horton L, Hutchinson PJ, Jacobs B, Jankowski S, Jarrett M, Johnson F, Jones K, Karan M, Kolias AG, Kompanje E, Kondziella D, Koraropoulos E, Koskinen LO, Kovács N, Kowark A, Lagares A, Lanyon L, Laureys S, Lecky F, Department E, Ledoux D, Lefering R, Legrand V, Lejeune A, Levi L, Lightfoot R, Castaño-León AM, Maegele M, Majdan M, Manara A, Manley G, Martino C, Maréchal H, Mattern J, McMahon C, Melegh B, Menon D, Menovsky T, Mikolic A, Misset B, Muraleedharan V, Murray L, Negru A, Nelson D, Newcombe V, Nieboer D, Nyirádi J, Olubukola O, Oresic M, Ortolano F, Palotie A, Parizel PM, Payen JF, Perera N, Perlbarg V, Persona P, Peul W, Piippo-Karjalainen A, Pirinen M, Ples H, Polinder S, Pomposo I, Posti JP, Puybasset L, Radoi A, Ragauskas A, Raj R, Rambadagalla M, Rhodes J, Richardson S, Richter S, Ripatti S, Rocka S, Roe C, Roise O, Rosand J, Rosenfeld JV, Rosenlund C, Rosenthal G, Rossaint R, Rossi S, Rueckert D, Rusnák M, Sahuquillo J, Sakowitz O, Sanchez-Porras R, Sandor J, Schäfer N, Schmidt S, Schoechl H, Schoonman G, Schou RF, Schwendenwein E, Sewalt C, Skandsen T, Smielewski P, Sorinola A, Stamatakis E, Stanworth S, Stevens R, Stewart W, Steyerberg EW, Stocchetti N, Sundström N, Synnot A, Takala R, Tamás V, Tamosuitis T, Taylor MS, Ao BT, Tenovuo O, Theadom A, Thomas M, Tibboel D, Timmers M, Tolias C, Trapani T, Tudora CM, Vajkoczy P, Vallance S, Valeinis E, Vámos Z, van der Jagt M, Van der Steen G, van der Naalt J, van Dijck JT, van Essen TA, Van Hecke W, van Heugten C, Van Praag D, Vyvere TV, van Wijk RPJ, Vargiolu A, Vega E, Velt K, Verheyden J, Vespa PM, Vik A, Vilcinis R, Volovici V, von Steinbüchel N, Voormolen D, Vulekovic P, Wang KK, Wiegers E, Williams G, Wilson L, Winzeck S, Wolf S, Yang Z, Ylén P, Younsi A, Zeiler FA, Zelinkova V, Ziverte A, Zoerle T, Ma Y, Kang W, Fu S, Luan Y, Qin H, Sun Z, Guo H, Tian H, Ju S, Xu Y, Wei Q, Zhang S, Tu Y, Wang D, Zhang L, Long L, Jiang C, Yang X, Wen L, Liu K, Xu L, Liu J, Sun Z, Chen L, Jiang Y, Xu W, Gao Y, Jiang R, Guo Y, Gao L, Zeng T, Hou L, Zhao L, Zhu X, Lv S, Mou Z, Wu J, Xu Y, Dong B, Yang C, An Z, Wang X, Zhu X, Gu L, Ma C, Sun H, Li W, Huang X, Li L, Qiu B, Bao Y, Qian S, Bu X, Wang Y, Yang L, Fu X, Qian S, Zhang J, Fan S, Wang Y, Bao Y, Wang Y, Chen H, Cui G, Sun C, Guo Z, Li Y, Wang X, Zhou S, Wang X, Zhu X, Zheng G, Huang Q, Zhang Y, Feng H, Huang Y, Ren H, Hou B, Zhou C, Chen J, Hu J, Du Z, Wang S, Xiang P, Huang Y, Qu Y, Yu H, Wang R, Chen J, Chen J, Xu L, Kang P, Chen H, Wu G, Wang M, Li R, Zhang H, Li Y, Sun X, Tan X. Comparison of Care System and Treatment Approaches for Patients with Traumatic Brain Injury in China versus Europe: A CENTER-TBI Survey Study. J Neurotrauma 2020; 37:1806-1817. [PMID: 32174214 DOI: 10.1089/neu.2019.6900] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Affiliation(s)
- Junfeng Feng
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People's Republic of China
- Shanghai Institute of Head Trauma, Shanghai, People's Republic of China
| | - Ernest van Veen
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Chun Yang
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People's Republic of China
- Shanghai Institute of Head Trauma, Shanghai, People's Republic of China
| | - Jilske A. Huijben
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Hester F. Lingsma
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Guoyi Gao
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People's Republic of China
- Shanghai Institute of Head Trauma, Shanghai, People's Republic of China
| | - Jiyao Jiang
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People's Republic of China
- Shanghai Institute of Head Trauma, Shanghai, People's Republic of China
| | - Andrew I.R. Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
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Changing care pathways and between-center practice variations in intensive care for traumatic brain injury across Europe: a CENTER-TBI analysis. Intensive Care Med 2020; 46:995-1004. [PMID: 32100061 PMCID: PMC7210239 DOI: 10.1007/s00134-020-05965-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 02/09/2020] [Indexed: 10/28/2022]
Abstract
PURPOSE To describe ICU stay, selected management aspects, and outcome of Intensive Care Unit (ICU) patients with traumatic brain injury (TBI) in Europe, and to quantify variation across centers. METHODS This is a prospective observational multicenter study conducted across 18 countries in Europe and Israel. Admission characteristics, clinical data, and outcome were described at patient- and center levels. Between-center variation in the total ICU population was quantified with the median odds ratio (MOR), with correction for case-mix and random variation between centers. RESULTS A total of 2138 patients were admitted to the ICU, with median age of 49 years; 36% of which were mild TBI (Glasgow Coma Scale; GCS 13-15). Within, 72 h 636 (30%) were discharged and 128 (6%) died. Early deaths and long-stay patients (> 72 h) had more severe injuries based on the GCS and neuroimaging characteristics, compared with short-stay patients. Long-stay patients received more monitoring and were treated at higher intensity, and experienced worse 6-month outcome compared to short-stay patients. Between-center variations were prominent in the proportion of short-stay patients (MOR = 2.3, p < 0.001), use of intracranial pressure (ICP) monitoring (MOR = 2.5, p < 0.001) and aggressive treatments (MOR = 2.9, p < 0.001); and smaller in 6-month outcome (MOR = 1.2, p = 0.01). CONCLUSIONS Half of contemporary TBI patients at the ICU have mild to moderate head injury. Substantial between-center variations exist in ICU stay and treatment policies, and less so in outcome. It remains unclear whether admission of short-stay patients represents appropriate prudence or inappropriate use of clinical resources.
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12
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Huijben JA, Wiegers EJA, de Keizer NF, Maas AIR, Menon D, Ercole A, Citerio G, Lecky F, Wilson L, Cnossen MC, Polinder S, Steyerberg EW, van der Jagt M, Lingsma HF. Development of a quality indicator set to measure and improve quality of ICU care for patients with traumatic brain injury. Crit Care 2019; 23:95. [PMID: 30902117 PMCID: PMC6431034 DOI: 10.1186/s13054-019-2377-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 02/26/2019] [Indexed: 11/18/2022] Open
Abstract
Background We aimed to develop a set of quality indicators for patients with traumatic brain injury (TBI) in intensive care units (ICUs) across Europe and to explore barriers and facilitators for implementation of these quality indicators. Methods A preliminary list of 66 quality indicators was developed, based on current guidelines, existing practice variation, and clinical expertise in TBI management at the ICU. Eight TBI experts of the Advisory Committee preselected the quality indicators during a first Delphi round. A larger Europe-wide expert panel was recruited for the next two Delphi rounds. Quality indicator definitions were evaluated on four criteria: validity (better performance on the indicator reflects better processes of care and leads to better patient outcome), feasibility (data are available or easy to obtain), discriminability (variability in clinical practice), and actionability (professionals can act based on the indicator). Experts scored indicators on a 5-point Likert scale delivered by an electronic survey tool. Results The expert panel consisted of 50 experts from 18 countries across Europe, mostly intensivists (N = 24, 48%) and neurosurgeons (N = 7, 14%). Experts agreed on a final set of 42 indicators to assess quality of ICU care: 17 structure indicators, 16 process indicators, and 9 outcome indicators. Experts are motivated to implement this finally proposed set (N = 49, 98%) and indicated routine measurement in registries (N = 41, 82%), benchmarking (N = 42, 84%), and quality improvement programs (N = 41, 82%) as future steps. Administrative burden was indicated as the most important barrier for implementation of the indicator set (N = 48, 98%). Conclusions This Delphi consensus study gives insight in which quality indicators have the potential to improve quality of TBI care at European ICUs. The proposed quality indicator set is recommended to be used across Europe for registry purposes to gain insight in current ICU practices and outcomes of patients with TBI. This indicator set may become an important tool to support benchmarking and quality improvement programs for patients with TBI in the future. Electronic supplementary material The online version of this article (10.1186/s13054-019-2377-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jilske A Huijben
- Department of Public Health, Center for Medical Decision Making, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Eveline J A Wiegers
- Department of Public Health, Center for Medical Decision Making, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Nicolette F de Keizer
- Department of Medical Informatics, Amsterdam Public Health research institute, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - David Menon
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.,Neuro-Intensive Care, Department of Emergency and Intensive Care, San Gerardo Hospital, ASST, Monza, Italy
| | - Fiona Lecky
- Centre for Urgent and Emergency Care Research, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Lindsay Wilson
- Division of Psychology, University of Stirling, Stirling, UK
| | - Maryse C Cnossen
- Department of Public Health, Center for Medical Decision Making, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Suzanne Polinder
- Department of Public Health, Center for Medical Decision Making, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ewout W Steyerberg
- Department of Public Health, Center for Medical Decision Making, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Mathieu van der Jagt
- Department of Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Hester F Lingsma
- Department of Public Health, Center for Medical Decision Making, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
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Abstract
Purpose of review The aim of this review is to summarize the recent studies looking at the effects of anemia and red blood cell transfusion in critically-ill patients with traumatic brain injury (TBI), describe the transfusion practice variations observed worldwide, and outline the ongoing trials evaluating restrictive versus liberal transfusion strategies for TBI. Recent findings Anemia is common among critically-ill patients with TBI, it is also thought to exacerbate secondary brain injury, and is associated with an increased risk of poor outcome. Conversely, allogenic red blood cell transfusion carries its own risks and complications, and has been associated with worse outcomes. Globally, there are large reported differences in the hemoglobin threshold used for transfusion after TBI. Observational studies have shown differential results for improvements in cerebral oxygenation and metabolism after red blood cell transfusion in TBI. Summary Currently, there is insufficient evidence to make strong recommendations regarding which hemoglobin threshold to use as a transfusion trigger in critically-ill patients with TBI. There is also uncertainty whether the restrictive transfusion strategy used in general critical care can be extrapolated to acutely brain injured patients. Ultimately, the consequences of anemia-induced cerebral injury need to be weighed up against the risks and complications associated with red blood cell transfusion.
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Gritti P, Akeju O, Lorini FL, Lanterna A, Brembilla C, Bilotta F. Breaking the rules: is it the neurointensivists' turn? Crit Care 2018; 22:21. [PMID: 29378635 PMCID: PMC5789649 DOI: 10.1186/s13054-017-1919-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 12/05/2017] [Indexed: 12/03/2022] Open
Affiliation(s)
- Paolo Gritti
- Department of Anaesthesia and Critical Care Medicine, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Oluwaseun Akeju
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - Ferdinando Luca Lorini
- Department of Anaesthesia and Critical Care Medicine, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Andrea Lanterna
- Department of Neurosurgery, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Carlo Brembilla
- Department of Neurosurgery, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Federico Bilotta
- Department of Anaesthesia and Critical Care Medicine, “Sapienza” University, Rome, Italy
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