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Siebers NW, Steiner LA. Anesthesia for traumatic brain injury. Curr Opin Anaesthesiol 2024:00001503-990000000-00212. [PMID: 39011685 DOI: 10.1097/aco.0000000000001404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/17/2024]
Abstract
PURPOSE OF REVIEW Traumatic brain injury (TBI) presents complex clinical challenges, requiring a nuanced understanding of its pathophysiology and current management principles to improve patient outcomes. Anesthetists play a critical role in care and need to stay updated with recent evidence and trends to ensure high-quality treatment. The Brain Trauma Foundation Guidelines, last updated in 2016, have shown moderate adherence, and much of the current management relies on expert opinions. This literature review synthesizes the current evidence and provides insights into the role of anesthetists in TBI management. RECENT FINDINGS Recent literature has emphasized the importance of tailored anesthetic management principles in treating TBI, focusing on minimizing secondary brain injury during neurosurgical interventions or extracranial surgery. Emerging trends include individualized intracranial pressure approaches and multimodal neuromonitoring for comprehensive assessment of cerebral physiology. SUMMARY Anesthesia for TBI patients requires a comprehensive approach that balances anesthetic goals with the unique pathophysiological factors of brain injury. Despite recent research expanding our understanding, challenges remain in standardizing protocols and addressing individual patient response variability. Adherence to established management principles, personalized approaches, and ongoing research is crucial for improving the outcomes.
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Affiliation(s)
- Nys Willem Siebers
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
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2
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Gueret G, Lemoine S, Le Maguet P. The choice of crystalloid type in the intensive care unit is likely more complex than expected: should doubt benefit the patient? Intensive Care Med 2024; 50:1206-1207. [PMID: 38771367 DOI: 10.1007/s00134-024-07486-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2024] [Indexed: 05/22/2024]
Affiliation(s)
- Gildas Gueret
- Service d'anesthésie Réanimation, Centre Hospitalier Intercommunal de Cornouaille, Avenue Yves Thépot, 29000, Quimper, France.
| | - Sabine Lemoine
- Service Médical d'urgence, Brigade de Sapeurs-Pompiers de Paris, 1 Place Jules-Renard, 75000, Paris, France
| | - Pascale Le Maguet
- Service d'anesthésie Réanimation, Centre Hospitalier Intercommunal de Cornouaille, Avenue Yves Thépot, 29000, Quimper, France
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3
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Arabi YM, Belley-Cote E, Carsetti A, De Backer D, Donadello K, Juffermans NP, Hammond N, Laake JH, Liu D, Maitland K, Messina A, Møller MH, Poole D, Mac Sweeney R, Vincent JL, Zampieri FG, AlShamsi F. European Society of Intensive Care Medicine clinical practice guideline on fluid therapy in adult critically ill patients. Part 1: the choice of resuscitation fluids. Intensive Care Med 2024; 50:813-831. [PMID: 38771364 DOI: 10.1007/s00134-024-07369-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 02/20/2024] [Indexed: 05/22/2024]
Abstract
PURPOSE This is the first of three parts of the clinical practice guideline from the European Society of Intensive Care Medicine (ESICM) on resuscitation fluids in adult critically ill patients. This part addresses fluid choice and the other two will separately address fluid amount and fluid removal. METHODS This guideline was formulated by an international panel of clinical experts and methodologists. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology was applied to evaluate the certainty of evidence and to move from evidence to decision. RESULTS For volume expansion, the guideline provides conditional recommendations for using crystalloids rather than albumin in critically ill patients in general (moderate certainty of evidence), in patients with sepsis (moderate certainty of evidence), in patients with acute respiratory failure (very low certainty of evidence) and in patients in the perioperative period and patients at risk for bleeding (very low certainty of evidence). There is a conditional recommendation for using isotonic saline rather than albumin in patients with traumatic brain injury (very low certainty of evidence). There is a conditional recommendation for using albumin rather than crystalloids in patients with cirrhosis (very low certainty of evidence). The guideline provides conditional recommendations for using balanced crystalloids rather than isotonic saline in critically ill patients in general (low certainty of evidence), in patients with sepsis (low certainty of evidence) and in patients with kidney injury (very low certainty of evidence). There is a conditional recommendation for using isotonic saline rather than balanced crystalloids in patients with traumatic brain injury (very low certainty of evidence). There is a conditional recommendation for using isotonic crystalloids rather than small-volume hypertonic crystalloids in critically ill patients in general (very low certainty of evidence). CONCLUSIONS This guideline provides eleven recommendations to inform clinicians on resuscitation fluid choice in critically ill patients.
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Affiliation(s)
- Yaseen M Arabi
- Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, King Abdullah International Medical Research Center, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
| | - Emilie Belley-Cote
- Divisions of Cardiology and Critical Care, McMaster University, Riyadh, Saudi Arabia
| | - Andrea Carsetti
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Katia Donadello
- Department of Surgery, Dentistry, Gynaecology and Paediatrics, University of Verona, Verona, Italy
- Anaesthesia and Intensive Care B Unit, AOUI-University Hospital Integrated Trust of Verona, Verona, Italy
| | - Nicole P Juffermans
- Department of Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Naomi Hammond
- Critical Care Program, The George Institute for Global Health and UNSW, Sydney, Australia
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney, Australia
| | - Jon Henrik Laake
- Department of Anaesthesiology and Intensive Care Medicine, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Dawei Liu
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Kathryn Maitland
- Institute of Global Health and Innovation, Division of Medicine, Imperial College, London, UK
| | - Antonio Messina
- IRCCS Humanitas Research Hospital, Department of Anesthesia and Intensive Care Medicine, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, København, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Daniele Poole
- Operative Unit of Anesthesia and Intensive Care, S. Martino Hospital, Belluno, Italy
| | - Rob Mac Sweeney
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, Northern Ireland
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Brussels, Belgium
| | - Fernando G Zampieri
- Department of Critical Care Medicine, University of Alberta, Edmonton, Canada
| | - Fayez AlShamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
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LaGrone LN, Stein D, Cribari C, Kaups K, Harris C, Miller AN, Smith B, Dutton R, Bulger E, Napolitano LM. American Association for the Surgery of Trauma/American College of Surgeons Committee on Trauma: Clinical protocol for damage-control resuscitation for the adult trauma patient. J Trauma Acute Care Surg 2024; 96:510-520. [PMID: 37697470 DOI: 10.1097/ta.0000000000004088] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
ABSTRACT Damage-control resuscitation in the care of critically injured trauma patients aims to limit blood loss and prevent and treat coagulopathy by combining early definitive hemorrhage control, hypotensive resuscitation, and early and balanced use of blood products (hemostatic resuscitation) and the use of other hemostatic agents. This clinical protocol has been developed to provide evidence-based recommendations for optimal damage-control resuscitation in the care of trauma patients with hemorrhage.
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Affiliation(s)
- Lacey N LaGrone
- From the Department of Surgery (D.S.), University of Maryland, Baltimore, Maryland; Department of Surgery (L.N.L., C.C.), UCHealth, Loveland, Colorado; Department of Surgery (K.K), University of California San Francisco Fresno, San Francisco, California; Department of Surgery (C.H.), Tulane University, New Orleans, Louisiana; Orthopedic Surgery (A.N.M.), Washington University in St. Louis, St. Louis, Missouri; Department of Surgery (B.S.), University of Pennsylvania, Philadelphia, Pennsylvania; American Society of Anesthesiologists (R.D.), Anesthesia, Waco, Texas; Department of Surgery (E.B.), University of Washington, Seattle, Washington; and Department of Surgery (L.M.N.), University of Michigan, Ann Arbor, Michigan
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Poh K, Bustam A, Hasan MS, Mohd Yunos N, Cham CY, Lim FJ, Ahmad Zahedi AZ, Zambri A, Noor Azhar M. Isotonic balanced fluid versus 0.9% saline in patients with moderate to severe traumatic brain injury: A double-blinded randomised controlled trial. Am J Emerg Med 2024; 77:106-114. [PMID: 38118385 DOI: 10.1016/j.ajem.2023.11.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 11/29/2023] [Accepted: 11/29/2023] [Indexed: 12/22/2023] Open
Abstract
BACKGROUND AND IMPORTANCE Traumatic brain injury (TBI) is a global health concern with significant economic impact. Optimal fluid therapy aims to restore intravascular volume, maintain cerebral perfusion pressure and blood flow, thus preventing secondary brain injury. While 0.9% saline (NS) is commonly used, concerns about acid-base and electrolyte imbalance and development of acute kidney injury (AKI) lead to consideration of balanced fluids as an alternative. OBJECTIVES This study aimed to compare the outcomes of patients with moderate to severe TBI treated with Sterofundin (SF) versus NS. DESIGN, SETTINGS AND PARTICIPANTS A double-blinded randomised controlled trial of patients aged 18 to 65 years with TBI was conducted at the University Malaya Medical Centre from February 2017 to November 2019. INTERVENTION OR EXPOSURE Patients were randomly assigned to receive either NS or SF. The study fluids were administered for 72 h as continuous infusions or boluses. Participants, investigators, and staff were blinded to the fluid type. OUTCOMES MEASURE AND ANALYSIS The primary outcome was in-hospital mortality. Relative risk (RR) with 95% confidence interval (CI) was calculated. MAIN RESULTS A total of 70 patients were included in the analysis, with 38 in the NS group and 32 in the SF group. The in-hospital mortality rate were 3 (7.9%) in the NS group vs. 4 (12.5%) in the SF group, RR = 1.29 (95% CI, 0.64 to 2.59; p = 0.695). No patients developed AKI and required renal replacement therapy. ICP on day 3 was significantly higher in the SF group (18.60 ± 9.26) compared to 12.77 ± 3.63 in the NS group, (95% CI, -11.46 to 0.20; p = 0.037). There were no significant differences in 3-day biochemical parameters and cerebral perfusion pressure, ventilator-free days, length of ICU stay, or Glasgow Outcome Scale-Extended (GOS-E) score at 6 months. CONCLUSIONS In patients with moderate to severe TBI, the use of SF was not associated with reduced in-hospital mortality, development of AKI, or improved 6-month GOS-E when compared to NS.
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Affiliation(s)
- Khadijah Poh
- Department of Emergency Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Aida Bustam
- Department of Emergency Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Mohd Shahnaz Hasan
- Department of Anaesthesiology, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Nor'azim Mohd Yunos
- Department of Anaesthesiology, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Chun Yoong Cham
- Division of Neurosurgery, Department of Surgery, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Fang Jen Lim
- Department of Emergency Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | | | - Aliyah Zambri
- Department of Emergency Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Muhaimin Noor Azhar
- Department of Emergency Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia.
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Cavaliere F, Biancofiore G, Bignami E, DE Robertis E, Giannini A, Grasso S, McCREDIE VA, Scolletta S, Taccone FS, Terragni P. A year in review in Minerva Anestesiologica 2023: critical care. Minerva Anestesiol 2024; 90:110-118. [PMID: 38415512 DOI: 10.23736/s0375-9393.24.18017-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Affiliation(s)
- Franco Cavaliere
- IRCCS A. Gemelli University Polyclinic Foundation, Sacred Heart Catholic University, Rome, Italy -
| | - Gianni Biancofiore
- Department of Transplant Anesthesia and Critical Care, University School of Medicine, Pisa, Italy
| | - Elena Bignami
- Division of Anesthesiology, Critical Care and Pain Medicine, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Edoardo DE Robertis
- Section of Anesthesia, Analgesia and Intensive Care, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Alberto Giannini
- Unit of Pediatric Anesthesia and Intensive Care, Children's Hospital - ASST Spedali Civili di Brescia, Brescia, Italy
| | - Salvatore Grasso
- Section of Anesthesiology and Intensive Care, Department of Emergency and Organ Transplantation, Polyclinic Hospital, Aldo Moro University, Bari, Italy
| | - Victoria A McCREDIE
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada
| | - Sabino Scolletta
- Department of Emergency-Urgency and Organ Transplantation, Anesthesia and Intensive Care, University Hospital of Siena, Siena, Italy
| | - Fabio S Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Pierpaolo Terragni
- Division of Anesthesia and General Intensive Care, Department of Medical, Surgical and Experimental Sciences, University Hospital of Sassari, University of Sassari, Sassari, Italy
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Lascarrou JB, Ermel C, Cariou A, Laitio T, Kirkegaard H, Søreide E, Grejs AM, Reinikainen M, Colin G, Taccone FS, Le Gouge A, Skrifvars MB. Dysnatremia at ICU admission and functional outcome of cardiac arrest: insights from four randomised controlled trials. Crit Care 2023; 27:472. [PMID: 38041177 PMCID: PMC10693108 DOI: 10.1186/s13054-023-04715-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 10/30/2023] [Indexed: 12/03/2023] Open
Abstract
PURPOSE To evaluate the potential association between early dysnatremia and 6-month functional outcome after cardiac arrest. METHODS We pooled data from four randomised clinical trials in post-cardiac-arrest patients admitted to the ICU with coma after stable return of spontaneous circulation (ROSC). Admission natremia was categorised as normal (135-145 mmol/L), low, or high. We analysed associations between natremia category and Cerebral Performance Category (CPC) 1 or 2 at 6 months, with and without adjustment on the modified Cardiac Arrest Hospital Prognosis Score (mCAHP). RESULTS We included 1163 patients (581 from HYPERION, 352 from TTH48, 120 from COMACARE, and 110 from Xe-HYPOTHECA) with a mean age of 63 ± 13 years and a predominance of males (72.5%). A cardiac cause was identified in 63.6% of cases. Median time from collapse to ROSC was 20 [15-29] minutes. Overall, mean natremia on ICU admission was 137.5 ± 4.7 mmol/L; 211 (18.6%) and 31 (2.7%) patients had hyponatremia and hypernatremia, respectively. By univariate analysis, CPC 1 or 2 at 6 months was significantly less common in the group with hyponatremia (50/211 [24%] vs. 363/893 [41%]; P = 0.001); the mCAHP-adjusted odds ratio was 0.45 (95%CI 0.26-0.79, p = 0.005). The number of patients with hypernatremia was too small for a meaningful multivariable analysis. CONCLUSIONS Early hyponatremia was common in patients with ROSC after cardiac arrest and was associated with a poorer 6-month functional outcome. The mechanisms underlying this association remain to be elucidated in order to determine whether interventions targeting hyponatremia are worth investigating. Registration ClinicalTrial.gov, NCT01994772, November 2013, 21.
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Affiliation(s)
- Jean Baptiste Lascarrou
- Nantes Université, CHU Nantes, Movement - Interactions - Performance, MIP, UR 4334, 44000, Nantes, France.
- Médecine Intensive Reanimation, University Hospital Centre, Nantes, France.
- AfterROSC Network, Nantes, France.
- Service de Médecine Intensive Reanimation, CHU Nantes, 30 Boulevard Jean Monet, 44093, Nantes Cedex 9, France.
| | - Cyrielle Ermel
- Médecine Intensive Reanimation, University Hospital Centre, Nantes, France
| | - Alain Cariou
- AfterROSC Network, Nantes, France
- Université de Paris Cité, INSERM, Paris Cardiovascular Research Centre, Paris, France
- Médecine Intensive Reanimation, AP-HP, CHU Cochin, Paris, France
| | - Timo Laitio
- Division of Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital, University of Turku, Turku, Finland
| | - Hans Kirkegaard
- Research Centre for Emergency Medicine and Anaesthesiology and Intensive Care, Aarhus University Hospital and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Eldar Søreide
- Intensive Care Unit, Department of Anaesthesiology, Stavanger University Hospital and Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Anders M Grejs
- Department of Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Matti Reinikainen
- Department of Anaesthesiology and Intensive Care, Kuopio University Hospital, Kuopio, Finland
- University of Eastern Finland, Kuopio, Finland
| | - Gwenhael Colin
- AfterROSC Network, Nantes, France
- Médecine Intensive Reanimation, CHD Vendee, La Roche Sur Yon, France
| | - Fabio Silvio Taccone
- AfterROSC Network, Nantes, France
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | | | - Markus B Skrifvars
- Department of Emergency Care and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Bauer SR, Gellatly RM, Erstad BL. Precision fluid and vasoactive drug therapy for critically ill patients. Pharmacotherapy 2023; 43:1182-1193. [PMID: 36606689 PMCID: PMC10323046 DOI: 10.1002/phar.2763] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 10/03/2022] [Accepted: 10/30/2022] [Indexed: 01/07/2023]
Abstract
There are several clinical practice guidelines concerning the use of fluid and vasoactive drug therapies in critically ill adult patients, but the recommendations in these guidelines are often based on low-quality evidence. Further, some were compiled prior to the publication of landmark clinical trials, particularly in the comparison of balanced crystalloid and normal saline. An important consideration in the treatment of critically ill patients is the application of precision medicine to provide the most effective care to groups of patients most likely to benefit from the therapy. Although not currently widely integrated into these practice guidelines, the utility of precision medicine in critical illness is a recognized research priority for fluid and vasoactive therapy management. The purpose of this narrative review was to illustrate the evaluation and challenges of providing precision fluid and vasoactive therapies to adult critically ill patients. The review includes a discussion of important investigations published after the release of currently available clinical practice guidelines to provide insight into how recommendations and research priorities may change future guidelines and bedside care for critically ill patients.
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Affiliation(s)
- Seth R Bauer
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio, USA
| | - Rochelle M Gellatly
- Pharmacy Department, Surrey Memorial Hospital, Surrey, British Columbia, Canada
| | - Brian L Erstad
- Department of Pharmacy Practice and Science, University of Arizona, Tucson, Arizona, USA
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Kletečka J, Zatloukal J, Smékalová O, Beneš J. Year 2022 in Review - Intensive care medicine - Cardiovascular and general issues. ANESTEZIOLOGIE A INTENZIVNÍ MEDICÍNA 2022. [DOI: 10.36290/aim.2022.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
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