Positioning of patients with severe traumatic brain injury: research-based practice

Critical ICP thresholds in relation to outcome: Is 22 mmHg really the answer?

PURPOSE

Intensive care for patients with traumatic brain injury (TBI) aims, among other tasks, at avoiding high intracranial pressure (ICP), which is perceived to worsen motor and cognitive deficits and increase mortality. International recommendations for threshold values for ICP were increased from 20 to 22 mmHg in 2016 following the findings in a study by Sorrentino et al., which were based on an observational study of patients with TBI of averaged ICP values. We aimed to reproduce their approach and validate the findings in a separate cohort.

METHODS

Three hundred thirty-one patients with TBI were included and categorised according to survival/death and favourable/unfavourable outcome at 6 months (based on Glasgow Outcome Score-Extended of 6-8 and 1-5, respectively). Repeated chi-square tests of survival and death (or favourable and unfavourable outcome) vs. high and low ICP were conducted with discrimination between high and low ICP sets at increasing values (integers) between 10 and 35 mmHg, using the average ICP for the entire monitoring period. The ICP limit returning the highest chi-square score was assumed to be the threshold with best discriminative ability. This approach was repeated after stratification by sex, age, and initial Glasgow Coma Score (GCS).

RESULTS

An ICP limit of 18 mmHg was found for both mortality and unfavourable outcome for the entire cohort. The female and the low GCS subgroups both had threshold values of 18 mmHg; for all other subgroups, the threshold varied between 16 and 30 mmHg. According to a multiple logistic regression analysis, age, initial GCS, and average ICP are independently associated with mortality and outcome.

CONCLUSIONS

Using identical methods and closely comparable cohorts, the critical thresholds for ICP found in the study by Sorrentino et al. could not be reproduced.

Intensive care management of traumatic brain injury: How can mnemonics help?

Traumatic brain injury (TBI) is considered to be a "silent global epidemic" and is the leading cause of death in young males in developed countries, major cause of disability, morbidity, and mortality worldwide. The classification of TBI severity was performed using the Glasgow coma scale (GCS) into mild (GCS = 15-13), moderate (GCS = 12-9), and severe (GCS = 8-3). Despite developments in modern intensive care, improvements in resuscitation and vital organ support, the management of critically ill patients with traumatic brain injury presents a challenge to all members of the critical care team. Since severe head injury is often associated with poor functional outcomes due to secondary brain insults, the benefits of intensive treatment and care may not become apparent until months or years later during rehabilitation after injury. Due to the complexity and specificity of TBI, implementation of an easy-to-remember mnemonic can significantly help anesthesiologists and clinicians in conducting intensive therapy. Mnemonic GOST CAP was implementing to help with treatment of patients with primary craniocerebral trauma and prevention of secondary brain injury. GOST CAP acronym emphasizes the significance of glycemic control in neurotrauma, maintaining haemoglobin levels, oxygen support, sodium concentration, temperature maintenance, pain and agitation control, arterial blood pressure control in maintaining cerebral perfusion pressure, and partial pressure of CO2 control. The aim of this paper is to display acronyms that address the most important steps in treating patients with TBI.

Indomethacin for intracranial hypertension secondary to severe traumatic brain injury in adults

BACKGROUND

Among people who have suffered a traumatic brain injury, increased intracranial pressure continues to be a major cause of early death; it is estimated that about 11 people per 100 with traumatic brain injury die. Indomethacin (also known as indometacin) is a powerful cerebral vasoconstrictor that can reduce intracranial pressure and, ultimately, restore cerebral perfusion and oxygenation. Thus, indomethacin may improve the recovery of a person with traumatic brain injury.

OBJECTIVES

To assess the effects of indomethacin for adults with severe traumatic brain injury.

SEARCH METHODS

We ran the searches from inception to 23 August 2019. We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 8) in the Cochrane Library, Ovid MEDLINE, Ovid Embase, CINAHL Plus (EBSCO), four other databases, and clinical trials registries. We also screened reference lists and conference abstracts, and contacted experts in the field.

SELECTION CRITERIA

Our search criteria included randomised controlled trials (RCTs) that compared indomethacin with any control in adults presenting with severe traumatic brain injury associated with elevated intracranial pressure, with no previous decompressive surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently decided on the selection of the studies. We followed standard Cochrane methods.

MAIN RESULTS

We identified no eligible studies for this review, either completed or ongoing.

AUTHORS' CONCLUSIONS

We found no studies, either completed or ongoing, that assessed the effects of indomethacin in controlling intracranial hypertension secondary to severe traumatic brain injury. Thus, we cannot draw any conclusions about the effects of indomethacin on intracranial pressure, mortality rates, quality of life, disability or adverse effects. This absence of evidence should not be interpreted as evidence of no effect for indomethacin in controlling intracranial hypertension secondary to severe traumatic brain injury. It means that we have not identified eligible research for this review.

[Effects of body positioning in patients with non-traumatic intracranial hemorrhages]

The article presents an analysis of different methods of positioning patients with acute cerebral pathology. Changing of 'head-of-the bed' position is a routine and simple method of correction of intracranial hypertension. For the majority of patients with cerebral damage, regardless of the etiological factor, 15-30° 'head - of - the bed' position is preferable. However, in some cases head-of-bed manipulation can lead to the irreversible ischemic damage due to the reduction in systemic and perfusion pressure and cerebral blood flow. Thus, the selection of the optimal body position in different types of acute cerebral pathology remains a debated issue.

Elevation of the head during intensive care management in people with severe traumatic brain injury

BACKGROUND

Traumatic brain injury (TBI) is a major public health problem and a fundamental cause of morbidity and mortality worldwide. The burden of TBI disproportionately affects low- and middle-income countries. Intracranial hypertension is the most frequent cause of death and disability in brain-injured people. Special interventions in the intensive care unit are required to minimise factors contributing to secondary brain injury after trauma. Therapeutic positioning of the head (different degrees of head-of-bed elevation (HBE)) has been proposed as a low cost and simple way of preventing secondary brain injury in these people. The aim of this review is to evaluate the evidence related to the clinical effects of different backrest positions of the head on important clinical outcomes or, if unavailable, relevant surrogate outcomes.

OBJECTIVES

To assess the clinical and physiological effects of HBE during intensive care management in people with severe TBI.

SEARCH METHODS

We searched the following electronic databases from their inception up to March 2017: Cochrane Injuries' Specialised Register, CENTRAL, MEDLINE, Embase, three other databases and two clinical trials registers. The Cochrane Injuries' Information Specialist ran the searches.

SELECTION CRITERIA

We selected all randomised controlled trials (RCTs) involving people with TBI who underwent different HBE or backrest positions. Studies may have had a parallel or cross-over design. We included adults and children over two years of age with severe TBI (Glasgow Coma Scale (GCS) less than 9). We excluded studies performed in children of less than two years of age because of their unfused skulls. We included any therapeutic HBE including supine (flat) or different degrees of head elevation with or without knee gatch or reverse Trendelenburg applied during the acute management of the TBI.

DATA COLLECTION AND ANALYSIS

Two review authors independently checked all titles and abstracts, excluding references that clearly didn't meet all selection criteria, and extracted data from selected studies on to a data extraction form specifically designed for this review. There were no cases of multiple reporting. Each review author independently evaluated risk of bias through assessing sequence generation, allocation concealment, blinding, incomplete outcome data, selective outcome reporting, and other sources of bias.

MAIN RESULTS

We included three small studies with a cross-over design, involving a total of 20 participants (11 adults and 9 children), in this review. Our primary outcome was mortality, and there was one death by the time of follow-up 28 days after hospital admission. The trials did not measure the clinical secondary outcomes of quality of life, GCS, and disability. The included studies provided information only for the secondary outcomes intracranial pressure (ICP), cerebral perfusion pressure (CPP), and adverse effects.We were unable to pool the results as the data were either presented in different formats or no numerical data were provided. We included narrative interpretations of the available data.The overall risk of bias of the studies was unclear due to poor reporting of the methods. There was marked inconsistency across studies for the outcome of ICP and small sample sizes or wide confidence intervals for all outcomes. We therefore rated the quality of the evidence as very low for all outcomes and have not included the results of individual studies here. We do not have enough evidence to draw conclusions about the effect of HBE during intensive care management of people with TBI.

AUTHORS' CONCLUSIONS

The lack of consistency among studies, scarcity of data and the absence of evidence to show a correlation between physiological measurements such as ICP, CCP and clinical outcomes, mean that we are uncertain about the effects of HBE during intensive care management in people with severe TBI.Well-designed and larger trials that measure long-term clinical outcomes are needed to understand how and when different backrest positions can affect the management of severe TBI.

The effect of positional changes on oxygenation in patients with head injury in the intensive care unit

Background:

Following head injury, cardiopulmonary functions are impaired and this disturbs the oxygenation transport pathway. Expanding cardiopulmonary physical therapy to encompass the oxygen transport system as a whole has implication for treatment as well as assessment and treatment outcome. Therefore, the aim of the study is to assess the oxygenation level in head injury patients with relation to body positioning in the intensive care unit (ICU).

Methodology:

Thirty consecutive patients with head injury with hemodynamically stable were included from the surgical ICU, ages ranging from 15 to 50 years. Noninvasive vital parameters (oxygen saturation [SpO₂], pulse rate [PR], respiratory rate [RR], and blood pressure [BP]) were observed and recorded in different body positions at regular intervals of 5 min for 15 min in each position.

Results:

There was increment in SpO₂ value in all positions from 0 min to end of 15 min in supine (98.63 ± 0.36–98.73 ± 0.30), right-side lying (98.77 ± 0.30–98.93 ± 0.20), left-side lying (98.73 ± 0.29–99.03 ± 0.24), and recline sitting (30°–70°) (99.03 ± 0.24–99.50 ± 0.22). However, there was statistically significant increment in recline sitting (30°–70°) compared to other positions (P = 0.036) while other parameters (PR, RR, and BP) were getting stabilized at lower values at end of 15 min in every positions tested.

Conclusion:

We conclude that upright position bring about significant increase in arterial SpO₂ compared to any other positions. Other vital parameters were seen to stabilize at lower values at the end of 15 min in every position tested.

S2e guideline: positioning and early mobilisation in prophylaxis or therapy of pulmonary disorders : Revision 2015: S2e guideline of the German Society of Anaesthesiology and Intensive Care Medicine (DGAI)

The German Society of Anesthesiology and Intensive Care Medicine (DGAI) commissioneda revision of the S2 guidelines on "positioning therapy for prophylaxis or therapy of pulmonary function disorders" from 2008. Because of the increasing clinical and scientificrelevance the guidelines were extended to include the issue of "early mobilization"and the following main topics are therefore included: use of positioning therapy and earlymobilization for prophylaxis and therapy of pulmonary function disorders, undesired effects and complications of positioning therapy and early mobilization as well as practical aspects of the use of positioning therapy and early mobilization. These guidelines are the result of a systematic literature search and the subsequent critical evaluation of the evidence with scientific methods. The methodological approach for the process of development of the guidelines followed the requirements of evidence-based medicine, as defined as the standard by the Association of the Scientific Medical Societies in Germany. Recently published articles after 2005 were examined with respect to positioning therapy and the recently accepted aspect of early mobilization incorporates all literature published up to June 2014.

The Use of Aesthetic Knowledge in the Management of Brain Injury Patients

A patient's recovery from a brain injury (BI) is unpredictable and requires flexible nursing strategies for each stage of recovery. Empirical knowledge provides a framework for delivering nursing care based on scientific principles. Aesthetic knowledge, including intuition, provides a further opportunity to know and understand BI patients and their responses as they progress along the trajectory of recovery. Incorporating both empirical and aesthetic knowledge into the nursing plan of care for this population affords on opportunity for nurses to help patients and their families negotiate the course of recovery with greater success.

Therapeutic positioning of the multiply-injured trauma patient in ICU

Critically-ill patients who have sustained multiple traumatic injuries have complex, and often conflicting, physiological needs. These have profound implications on the way in which nursing staff approach the physical positioning of these patients to minimize the risks of further physiological injury and damage, maintain homeostasis and promote optimum recovery. This article reviews and discusses the evidence base underpinning therapeutic positioning of the multiply-injured trauma patient within the intensive-care unit (ICU), focusing on patients with a known or suspected unstable spinal injury, pelvic injury, traumatic brain injury, chest injury, or multiple limb fractures. Included are guidelines on the therapeutic positioning of the multiply-injured trauma patient within the ICU, based on the current available evidence and also drawn from practical experience within the author's own place of work. There is also a brief discussion of how such guidelines may be introduced into clinical practice.

Traumatic brain injury: an integrated clinical case presentation and literature review part II: the continuum of care

The following paper continues the presentation of a case scenario outlining the assessment, interventions and outcome of a person who sustained multiple trauma with a focus on traumatic brain injury (TBI). Part I explored assessment and initial management of the patient from pre-hospital care through to the emergency department and operating theatre. Part II describes the intensive care period as an integral component of the continuum of care. Key issues in the case are presented sequentially with relevant theory integrated and applied to the clinical case throughout the discussion with a focus on the complex physiological, psychological, and spiritual needs of the patient and their family.

A mobility protocol for critically ill adults

Although the complications of immobility are well-described in the literature, critically ill patients are often subjected to prolonged periods of bed rest. Nurses, by virtue of their expertise in preventing iatrogenic complications, are in an ideal position to prevent the adverse outcomes associated with immobility. This article describes how nurses can use a mobility protocol to increase the activity of critically ill patients in a timely manner that may prevent the infirmity and suffering that is caused by unnecessarily long periods of bed rest.

Subjective assessment of backrest elevation: magnitude of error

BACKGROUND

Backrest elevation, defined as the angle of the backrest height above the horizontal position, is a common nursing intervention that is often used by subjective visual estimation in critically ill patients.

OBJECTIVES

The aim of the study was to describe the magnitude of error during the subjective assessment of backrest elevation.

METHODS

This prospective study was conducted in a sample of 160 subjects: 97 registered nurses, 48 undergraduate nursing students, and 15 nursing assistants. Data were collected by recording the degrees of backrest elevation identified by the subjects through an individual random presentation of the selected study angles of 20 degrees, 30 degrees, 35 degrees, 40 degrees, and 45 degrees. A measurement instrument was developed for determination of the angles.

RESULTS

Of the 800 investigated angles, 14.9% were estimated accurately, 61.6% were overestimated, and 23.5% were underestimated, with an error average of 8 degrees (+/-13.5 degrees). It was determined that the larger the angle estimated, the greater the average error. A statically significant difference (P <or= .001) was found between the actual degree of backrest elevation and the estimated backrest elevation for 20 degrees, 40 degrees, and 45 degrees with the exception of 30 degrees and 35 degrees, which had similar averages of error. Years of critical care experience did not significantly influence the magnitude of error.

CONCLUSION

The results indicate that the subjective assessment of backrest angle may result in errors that may potentially compromise the patient's condition and supports the need for a more objective method for determining backrest angle.

Cerebrovascular Dynamics With Head-of-Bed Elevation in Patients With Mild or Moderate Vasospasm After Aneurysmal Subarachnoid Hemorrhage

• Background In patients with aneurysmal subarachnoid hemorrhage, elevation of the head of the bed during vasospasm has been limited in an attempt to minimize vasospasm or its sequelae or both. Consequently, some patients have remained on bed rest for weeks.

• Objectives To determine how elevations of the head of the bed of 20° and 45° affect cerebrovascular dynamics in adult patients with mild or moderate vasospasm after aneurysmal subarachnoid hemorrhage and to describe the response of mild or moderate vasospasm to head-of-bed elevations of 20° and 45° with respect to variables such as grade of subarachnoid hemorrhage and degree of vasospasm.

• Methods A within-patient repeated-measures design was used. The head of the bed was positioned in the sequence of 0°-20°-45°-0° in 20 patients with mild or moderate vasospasm between days 3 and 14 after aneurysmal subarachnoid hemorrhage. Continuous transcranial Doppler recordings were obtained for 2 to 5 minutes after allowing approximately 2 minutes for stabilization in each position.

• ResultsNo patterns or trends indicated that having the head of the bed elevated increases vasospasm. As a group, there were no significant differences within patients at the different positions of the head of the bed. Utilizing repeated-measures analysis of variance, P values ranged from .34 to .97, well beyond .05. No neurological deterioration occurred.

• Conclusions In general, elevation of the head of the bed did not cause harmful changes in cerebral blood flow related to vasospasm.

Activity in the chronically critically ill

Although therapeutic activity prevents functional decline and reduces mortality, little is known about typical levels of activity among intensive care unit (ICU) patients. This report of a preliminary study describes typical therapeutic activity and compares the use of two measures of activity in a small sample of chronically critically ill adults. Type, frequency, and duration of therapeutic activity were measured simultaneously with direct observation and actigraphy. The only consistent activity documented was turning (frequency: 3 turns/8 hours; duration: mean average of 11 minutes). Analysis demonstrated acceptable agreement between the two measures of activity for both frequency and duration of therapeutic but not for type of activity. Congruence between measures for duration of activity was also supported. This study provides information for investigators and practitioners who are interested in measuring or implementing therapeutic activity in selected critically ill adults.

Does oxygen deficit to the cerebral blood flow caused by subdural hematoma and/or increased intracranial pressure affect the variations in auditory evoked potentials in white New Zealand rabbits?

The experiment entails surgically placing two subarachnoid bolts and a subdural balloon through the skull of white New Zealand rabbits. One bolt is used to raise the intracranial pressure (ICP) by continuously infusing lactated Ringer's solution (LRS) into the subarachnoid space to maintain the desired level of ICPs, and the second bolt is to monitor the ICP. A subdural balloon is inflated with a known volume of LRS to simulate a subdural hematoma condition. Using various levels of ICP and/or different sizes of balloons, auditory evoked potentials (AEPs) were recorded from a rabbit. The results indicate that a major correlation of changes in AEP peak latencies is due to mechanical forces of a mass (inflated balloon simulating a hematoma) on the brain matter rather than increased ICP. The AEP peak latencies are relatively insensitive to an increase in ICP without the simulated intracranial hematoma. This study provides evidence that oxygen deficit to the cerebral blood flow caused by deformation of certain parts of the brain could be identified using AEPs.

Acute care management of severe traumatic brain injuries

Preservation or restoration of optimal neurologic function following traumatic brain injury (TBI) requires timely and aggressive therapeutic interventions. Effective diagnostic tools, together with an armamentarium of treatment modalities, have augmented the treatment strategies utilized today. In addition, the Guidelinesfor the Management of Severe Head Injury have established a standardized approach for the TBI patient. This article will provide current information regarding the resuscitation priorities, appropriate interventions, and pharmacological agents used in the treatment required by the complex nature of TBI. Also, a review of the occurrences associated with TBI will be discussed.