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Kaye C, Rhodes J, Austin P, Casey M, Gould R, Sira J, Treweek S, MacLennan G. Assessment of depth of sedation using Bispectral Index™ monitoring in patients with severe traumatic brain injury in UK intensive care units. BJA OPEN 2024; 10:100287. [PMID: 38868457 PMCID: PMC11166701 DOI: 10.1016/j.bjao.2024.100287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 04/29/2024] [Indexed: 06/14/2024]
Abstract
Introduction Severe traumatic brain injury affects ∼4500 per year across the UK. Most patients undergo a period of sedation to prevent secondary brain injury, however the optimal sedation target is unclear. This study aimed to assess the relationship between the electroencephalogram (EEG)-based Bispectral Index™ (BIS™) value and the clinical sedation score, along with other clinical outcomes. Methods Patients with severe traumatic brain injury in four UK ICUs were recruited to have blinded BIS data collected for a 24-h period while sedated on the ICU. Drug, physiological, and outcome data were recorded from the ICU record. Sedation management was at the discretion of the ICU clinical team. Results Twenty-six participants were recruited to the study. The mean BIS was 38 (inter-quartile range 29-44) and there was poor correlation between BIS and sedation score as a group (correlation coefficient 0.17, 95% confidence interval 0.08-0.26), however the spread in BIS values increased with decreasing sedation score. There was no statistically significant relationship between BIS and intracranial pressure, vasopressor use, osmotherapy use, or need for an additional sedative. Conclusion This study supports previous work showing that BIS decreases with decreasing sedation score. However, the variation in BIS values increased with deeper levels of clinical sedation. Patients may not be benefiting from the full potential of sedation in traumatic brain injury and further studies of sedation titrated to an EEG-based parameter are needed. Clinical trial registration NCT03575169.
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Affiliation(s)
- Callum Kaye
- NHS Grampian, Aberdeen, UK
- University of Aberdeen, Aberdeen, UK
| | - Jonathan Rhodes
- NHS Lothian, Edinburgh, UK
- University of Edinburgh, Edinburgh, UK
| | | | | | | | - James Sira
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
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2
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Foreman B, Kapinos G, Wainwright MS, Ngwenya LB, O'Phelan KH, LaRovere KL, Kirschen MP, Appavu B, Lazaridis C, Alkhachroum A, Maciel CB, Amorim E, Chang JJ, Gilmore EJ, Rosenthal ES, Park S. Practice Standards for the Use of Multimodality Neuromonitoring: A Delphi Consensus Process. Crit Care Med 2023; 51:1740-1753. [PMID: 37607072 PMCID: PMC11036878 DOI: 10.1097/ccm.0000000000006016] [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] [Indexed: 08/24/2023]
Abstract
OBJECTIVES To address areas in which there is no consensus for the technologies, effort, and training necessary to integrate and interpret information from multimodality neuromonitoring (MNM). DESIGN A three-round Delphi consensus process. SETTING Electronic surveys and virtual meeting. SUBJECTS Participants with broad MNM expertise from adult and pediatric intensive care backgrounds. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Two rounds of surveys were completed followed by a virtual meeting to resolve areas without consensus and a final survey to conclude the Delphi process. With 35 participants consensus was achieved on 49% statements concerning MNM. Neurologic impairment and the potential for MNM to guide management were important clinical considerations. Experts reached consensus for the use of MNM-both invasive and noninvasive-for patients in coma with traumatic brain injury, aneurysmal subarachnoid hemorrhage, and intracranial hemorrhage. There was consensus that effort to integrate and interpret MNM requires time independent of daily clinical duties, along with specific skills and expertise. Consensus was reached that training and educational platforms are necessary to develop this expertise and to provide clinical correlation. CONCLUSIONS We provide expert consensus in the clinical considerations, minimum necessary technologies, implementation, and training/education to provide practice standards for the use of MNM to individualize clinical care.
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Affiliation(s)
- Brandon Foreman
- Department of Neurology & Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH
| | - Gregory Kapinos
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Mark S Wainwright
- Division of Pediatric Neurology, Seattle Children's Hospital, University of Washington, Seattle, WA
| | - Laura B Ngwenya
- Department of Neurology & Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH
- Department of Neurosurgery, University of Cincinnati, Cincinnati, OH
| | | | - Kerri L LaRovere
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Matthew P Kirschen
- Departments of Anesthesiology and Critical Care Medicine, Pediatrics and Neurology, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Brian Appavu
- Departments of Child Health and Neurology, Phoenix Children's, University of Arizona College of Medicine-Phoenix, Phoenix, AZ
| | - Christos Lazaridis
- Departments of Neurology and Neurosurgery, University of Chicago, Chicago, IL
| | | | - Carolina B Maciel
- Department of Neurology & Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
- Division of Pediatric Neurology, Seattle Children's Hospital, University of Washington, Seattle, WA
- Department of Neurosurgery, University of Cincinnati, Cincinnati, OH
- Department of Neurology, University of Miami, Miami, FL
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA
- Departments of Anesthesiology and Critical Care Medicine, Pediatrics and Neurology, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Departments of Child Health and Neurology, Phoenix Children's, University of Arizona College of Medicine-Phoenix, Phoenix, AZ
- Departments of Neurology and Neurosurgery, University of Chicago, Chicago, IL
- Departments of Neurology and Neurosurgery, University of Florida, Tampa, FL
- Department of Neurology, University of Utah, Salt Lake City, UT
- Department of Neurology, Yale University, New Haven, CT
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA
- Department of Critical Care and Georgetown University, Department of Neurology, MedStar Washington Hospital Center, Washington, DC
- Department of Neurology, Massachusetts General Hospital, Boston, MA
- Departments of Neurology and Biomedical Informatics, Columbia University, New York, NY
| | - Edilberto Amorim
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA
| | - Jason J Chang
- Department of Critical Care and Georgetown University, Department of Neurology, MedStar Washington Hospital Center, Washington, DC
| | | | - Eric S Rosenthal
- Department of Neurology, Massachusetts General Hospital, Boston, MA
| | - Soojin Park
- Departments of Neurology and Biomedical Informatics, Columbia University, New York, NY
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3
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Gomez A, Batson C, Froese L, Sainbhi AS, Zeiler FA. Utility of Transcranial Doppler in Moderate and Severe Traumatic Brain Injury: A Narrative Review of Cerebral Physiologic Metrics. J Neurotrauma 2021; 38:2206-2220. [PMID: 33554739 PMCID: PMC8328046 DOI: 10.1089/neu.2020.7523] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Since its creation in the 1980s, transcranial Doppler (TCD) has provided a method of non-invasively monitoring cerebral physiology and has become an invaluable tool in neurocritical care. In this narrative review, we examine the role TCD has in the management of the moderate and severe traumatic brain injury (TBI) patient. We examine the principles of TCD and the ways in which it has been applied to gain insight into cerebral physiology following TBI, as well as explore the clinical evidence supporting these applications. Its usefulness as a tool to non-invasively determine intracranial pressure, detect post-traumatic vasospasm, predict patient outcome, and assess the state of cerebral autoregulation are all explored.
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Affiliation(s)
- Alwyn Gomez
- Department of Surgery, University of Manitoba, Winnipeg, Canada
- Department of Anatomy and Cell Science, University of Manitoba, Winnipeg, Canada
| | - Carleen Batson
- Department of Anatomy and Cell Science, University of Manitoba, Winnipeg, Canada
| | - Logan Froese
- Department of Biomedical Engineering, University of Manitoba, Winnipeg, Canada
| | | | - Frederick Adam Zeiler
- Department of Surgery, University of Manitoba, Winnipeg, Canada
- Department of Anatomy and Cell Science, University of Manitoba, Winnipeg, Canada
- Department of Biomedical Engineering, University of Manitoba, Winnipeg, Canada
- Center on Aging, University of Manitoba, Winnipeg, Canada
- Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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4
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Iaccarino C, Lippa L, Munari M, Castioni CA, Robba C, Caricato A, Pompucci A, Signoretti S, Zona G, Rasulo FA. Management of intracranial hypertension following traumatic brain injury: a best clinical practice adoption proposal for intracranial pressure monitoring and decompressive craniectomy. Joint statements by the Traumatic Brain Injury Section of the Italian Society of Neurosurgery (SINch) and the Neuroanesthesia and Neurocritical Care Study Group of the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI). J Neurosurg Sci 2021; 65:219-238. [PMID: 34184860 DOI: 10.23736/s0390-5616.21.05383-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
No robust evidence is provided by literature regarding the management of intracranial hypertension following severe traumatic brain injury (TBI). This is mostly due to the lack of prospective randomized controlled trials (RCTs), the presence of studies containing extreme heterogeneously collected populations and controversial considerations about chosen outcome. A scientific society should provide guidelines for care management and scientific support for those areas for which evidence-based medicine has not been identified. However, RCTs in severe TBI have failed to establish intervention effectiveness, arising the need to make greater use of tools such as Consensus Conferences between experts, which have the advantage of providing recommendations based on experience, on the analysis of updated literature data and on the direct comparison of different logistic realities. The Italian scientific societies should provide guidelines following the national laws ruling the best medical practice. However, many limitations do not allow the collection of data supporting high levels of evidence for intracranial pressure (ICP) monitoring and decompressive craniectomy (DC) in patients with severe TBI. This intersociety document proposes best practice guidelines for this subsetting of patients to be adopted on a national Italian level, along with joint statements from "TBI Section" of the Italian Society of Neurosurgery (SINch) endorsed by the Neuroanesthesia and Neurocritical Care Study Group of the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI). Presented here is a recap of recommendations on management of ICP and DC supported a high level of available evidence and rate of agreement expressed by the assemblies during the more recent consensus conferences, where members of both groups have had a role of active participants and supporters. The listed recommendations have been sent to a panel of experts consisting of the 107 members of the "TBI Section" of the SINch and the 111 members of the Neuroanesthesia and Neurocritical Care Study Group of the SIAARTI. The aim of the survey was to test a preliminary evaluation of the grade of predictable future adherence of the recommendations following this intersociety proposal. The following recommendations are suggested as representing best clinical practice, nevertheless, adoption of local multidisciplinary protocols regarding thresholds of ICP values, drug therapies, hemostasis management and perioperative care of decompressed patients is strongly recommended to improve treatment efficiency, to increase the quality of data collection and to provide more powerful evidence with future studies. Thus, for this future perspective a rapid overview of the role of the multimodal neuromonitoring in the optimal severe TBI management is also provided in this document. It is reasonable to assume that the recommendations reported in this paper will in future be updated by new observations arising from future trials. They are not binding, and this document should be offered as a guidance for clinical practice through an intersociety agreement, taking in consideration the low level of evidence.
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Affiliation(s)
- Corrado Iaccarino
- Division of Neurosurgery, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena University Hospital, Modena, Italy
| | - Laura Lippa
- Department of Neurosurgery, Ospedali Riuniti di Livorno, Livorno, Italy -
| | - Marina Munari
- Department of Anesthesia and Intensive Care, Padua University Hospital, Padua, Italy
| | - Carlo A Castioni
- Department of Anesthesia and Intensive Care, IRCCS Istituto delle Scienze Neurologiche Bellaria Hospital, Bologna, Italy
| | - Chiara Robba
- Department of Anesthesia and Intensive Care, IRCCS San Martino University Hospital, Genoa, Italy
| | - Anselmo Caricato
- Department of Anesthesia and Critical Care, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Angelo Pompucci
- Department of Neurosurgery, S. Maria Goretti Hospital, Latina, Italy
| | - Stefano Signoretti
- Division of Emergency-Urgency, Unit of Neurosurgery, S. Eugenio Hospital, Rome, Italy
| | - Gianluigi Zona
- Department of Neurosurgery, IRCCS San Martino University Hospital, Genoa, Italy.,Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
| | - Frank A Rasulo
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Spedali Civili University Hospital, Brescia, Italy.,Department of Surgical and Medical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
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5
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Kanthimathinathan HK, Mehta H, Scholefield BR, Morris KP. Traumatic Brain Injury Practice Guidelines: Variability in U.K. PICUs. Pediatr Crit Care Med 2021; 22:e270-e274. [PMID: 33009356 DOI: 10.1097/pcc.0000000000002574] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Traumatic brain injury in children is a leading cause of morbidity and mortality. Lack of high-quality evidence may lead to variation in management within and between PICUs. We examined U.K. pediatric traumatic brain injury management guidelines for extent of variability. DESIGN Analysis of U.K. PICU traumatic brain injury guidelines for areas of consistency and variation among each other and against the second edition of Brain Trauma Foundation pediatric traumatic brain injury guidelines. SETTING Not applicable. SUBJECTS Not applicable. INTERVENTIONS Textual analysis of U.K. PICU guidelines. MEASUREMENTS AND MAIN RESULTS Twelve key clinical topics in three traumatic brain injury management domains were identified. We performed textual analysis of recommendations from anonymized local guidelines and compared them against each other and the Brain Trauma Foundation pediatric traumatic brain injury guidelines. Fifteen guidelines used by 16 of the 20 U.K. PICUs that manage traumatic brain injury were analyzed. Relatively better consistency was observed for intracranial pressure treatment thresholds (10/15), avoiding prophylactic hyperventilation (15/15), cerebrospinal fluid drainage (13/15), barbiturate (14/15), and decompressive craniectomy (12/15) for intracranial hypertension. There was less consistency in indications for intracranial pressure monitoring (3/15), cerebral perfusion pressure targets (2/15), target osmolarities (7/15), and hyperventilation for intracranial hypertension (2/15). Variability in choice and hierarchy of the interventions for intracranial hypertension were observed, albeit with some points of consistency. CONCLUSIONS Significant variability in pediatric traumatic brain injury management guidelines exists. Despite the heterogeneity, we have highlighted a few points of consistency within the key topic areas of pediatric traumatic brain injury management. We anticipate that this provides impetus for further work around standardization.
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Affiliation(s)
- Hari Krishnan Kanthimathinathan
- Paediatric Intensive Care Unit, Birmingham Children's Hospital, Birmingham, United Kingdom.,Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Hiren Mehta
- Paediatric Intensive Care Unit, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - Barnaby R Scholefield
- Paediatric Intensive Care Unit, Birmingham Children's Hospital, Birmingham, United Kingdom.,Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
| | - Kevin P Morris
- Paediatric Intensive Care Unit, Birmingham Children's Hospital, Birmingham, United Kingdom.,Honorary Professor in Paediatric Critical Care Medicine, University of Birmingham, Birmingham, United Kingdom
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6
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Badenes R, Hutton B, Citerio G, Robba C, Aguilar G, Alonso-Arroyo A, Taccone FS, Tornero C, Catalá-López F. Hyperosmolar therapy for acute brain injury: study protocol for an umbrella review of meta-analyses and an evidence mapping. BMJ Open 2020; 10:e033913. [PMID: 32034026 PMCID: PMC7045244 DOI: 10.1136/bmjopen-2019-033913] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 12/05/2019] [Accepted: 01/22/2020] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Acute brain injury is a challenging public health problem worldwide. Elevated intracranial pressure is a common complication after acute brain injury. Hyperosmolar therapy is one of the main therapeutic strategies for the management of intracranial hypertension. This study protocol outlines an umbrella review of meta-analyses which will investigate the benefits and harms of hyperosmolar therapy routinely used for the management of acute brain injury in the intensive care. METHODS AND ANALYSIS We will search PubMed/MEDLINE, EMBASE and the Cochrane Database of Systematic Reviews. We will include meta-analyses of primary research studies (eg, randomised controlled trials, observational studies or both) that evaluate one or more hyperosmolar solutions (including hypertonic saline and/or mannitol) for the treatment of adult patients with acute brain injury of any severity. Two researchers will independently screen all citations, full-text articles and abstract data. Potential conflicts will be resolved through discussion with a third researcher. Primary outcomes will be mortality and neurological outcomes at discharge. Secondary outcomes will include control of intracranial pressure, cerebral perfusion pressure, length of stay (in hospital an intensive care unit) and any adverse event. Quality of the included meta-analyses will be assessed using the AMSTAR-2 tool. An overall summary of methods and results will be performed using tabular and graphical approaches and will be supplemented by narrative description. We will analyse whether published meta-analyses present an outline of available evidence (eg, cited, described and discussed any previous meta-analysis). Where objectives from two or more meta-analyses overlap, we will assess the causes of any noted discrepancies between meta-analyses. ETHICS AND DISSEMINATION No ethical approval will be required. Findings from this study will be published in a peer-reviewed journal. All data will be deposited in a cross-disciplinary public repository. PROSPERO REGISTRATION NUMBER CRD42019148152.
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Affiliation(s)
- Rafael Badenes
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clinic Universitari de València, University of Valencia, Valencia, Spain
- Department of Surgery, Faculty of Medicine, University of Valencia, Valencia, Spain
- INCLIVA Health Research Institute, Valencia, Spain
| | - Brian Hutton
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Giuseppe Citerio
- Neurointensive Care, San Gerardo Hospital, ASST-Monza, Monza, Italy
- School of Medicine and Surgery, University Milano Bicocca, Milan, Italy
| | - Chiara Robba
- Department of Anesthesia and Intensive Care, IRCCS Policlinico San Martino, Genoa, Italy
| | - Gerardo Aguilar
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clinic Universitari de València, University of Valencia, Valencia, Spain
- INCLIVA Health Research Institute, Valencia, Spain
| | - Adolfo Alonso-Arroyo
- Department of History of Science and Documentation, University of Valencia, Valencia, Spain
- Information and Social and Health Research Unit (UISYS), University of Valencia and Spanish National Research Council (CSIC), Valencia, Spain
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Carlos Tornero
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clinic Universitari de València, University of Valencia, Valencia, Spain
| | - Ferrán Catalá-López
- INCLIVA Health Research Institute, Valencia, Spain
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Health Planning and Economics, National School of Public Health, Institute of Health Carlos III, Madrid, Spain
- Department of Medicine, Faculty of Medicine, University of Valencia/CIBERSAM, Valencia, Spain
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7
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Anstey JR, Taccone FS, Udy AA, Citerio G, Duranteau J, Ichai C, Badenes R, Prowle JR, Ercole A, Oddo M, Schneider AG, van der Jagt M, Wolf S, Helbok R, Nelson DW, Skrifvars MB, Harrois A, Presneill J, Cooper DJ, Bailey M, Bellomo R, Long K, Lozano A, Saxby E, Vargiolu A, Rodrigues A, Quintard H, Del Rio M, Sisson A, Allen G, Baro N, Kofler M. Early Osmotherapy in Severe Traumatic Brain Injury: An International Multicenter Study. J Neurotrauma 2020; 37:178-184. [DOI: 10.1089/neu.2019.6399] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- James R. Anstey
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Fabio S. Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Andrew A. Udy
- Intensive Care Unit, The Alfred Hospital, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, ANZIC-RC, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Giuseppe Citerio
- School of Medicine and Surgery, University Milano Bicocca–Neurointensive Care, San Gerardo Hospital, ASST-Monza, Monza, Italy
| | - Jacques Duranteau
- Department of Anesthesia and Surgical Intensive Care, CHU de Bicetre, Le Kremlin Bicêtre, Le Kremlin-Bicêtre, France
| | - Carole Ichai
- Université Côte d'Azur, Centre hospitalier Universitaire de Nice, Service de Réanimation polyvalente, Hôpital Pasteur 2, CHU de Nice, Nice, France
| | - Rafael Badenes
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clinic Universitari de Valencia, University of Valencia, Valencia, Spain
| | - John R. Prowle
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, Royal London Hospital, Whitechapel Road, London, United Kingdom
| | - Ari Ercole
- Neurosciences and Trauma Critical Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Mauro Oddo
- Department of Medical-Surgical Intensive Care Medicine, Faculty of Biology and Medicine, Centre Hospitalier Universitaire, Vaudois (CHUV), University of Lausanne, Lausanne, Switzerland
| | - Antoine G. Schneider
- Department of Medical-Surgical Intensive Care Medicine, Faculty of Biology and Medicine, Centre Hospitalier Universitaire, Vaudois (CHUV), University of Lausanne, Lausanne, Switzerland
| | - Mathieu van der Jagt
- Department of Intensive Care, Erasmus MC-University Medical Centre, Erasmus MC–University Medical Center, Rotterdam, The Netherlands
| | - Stefan Wolf
- Department of Neurosurgery, Charité Universitätsmedizin Neuro Intensive Care Unit 102i, Campus Charité Mitte (CCM), Berlin, Germany
| | - Raimund Helbok
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Department of Neurology, Neurocritical Care Unit, Innsbruck, Austria
| | - David W. Nelson
- Section for Perioperative Medicine and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - Marius B. Skrifvars
- Division of Intensive Care, Department of Anaesthesiology, Intensive Care and Pain Medicine and Department of Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Anatole Harrois
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Anesthesia and Surgical Intensive Care, CHU de Bicetre, Le Kremlin Bicêtre, Le Kremlin-Bicêtre, France
| | - Jeffrey Presneill
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - D. Jamie Cooper
- Intensive Care Unit, The Alfred Hospital, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, ANZIC-RC, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, ANZIC-RC, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Medicine and Radiology, University of Melbourne, Parkville, Victoria, Australia
| | - Rinaldo Bellomo
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, ANZIC-RC, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care, Austin Health, Melbourne, Victoria, Australia
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8
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Abstract
PURPOSE OF REVIEW The optimal management of external ventricular drains (EVD) in the setting of acute brain injury remains controversial. Therefore, we sought to determine whether there are optimal management approaches based on the current evidence. RECENT FINDINGS We identified 2 recent retrospective studies on the management of EVDs after subarachnoid hemorrhage (SAH) which showed conflicting results. A multicenter survey revealed discordance between existing evidence from randomized trials and actual practice. A prospective study in a post-traumatic brain injury (TBI) population demonstrated the benefit of EVDs but did not determine the optimal management of the EVD itself. The recent CLEAR trials have suggested that specific positioning of the EVD in the setting of intracerebral hemorrhage with intraventricular hemorrhage may be a promising approach to improve blood clearance. Evidence on the optimal management of EVDs remains limited. Additional multicenter prospective studies are critically needed to guide approaches to the management of the EVD.
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9
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Stocker RA. Intensive Care in Traumatic Brain Injury Including Multi-Modal Monitoring and Neuroprotection. Med Sci (Basel) 2019; 7:medsci7030037. [PMID: 30813644 PMCID: PMC6473302 DOI: 10.3390/medsci7030037] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 02/01/2019] [Accepted: 02/14/2019] [Indexed: 12/20/2022] Open
Abstract
Moderate to severe traumatic brain injuries (TBI) require treatment in an intensive care unit (ICU) in close collaboration of a multidisciplinary team consisting of different medical specialists such as intensivists, neurosurgeons, neurologists, as well as ICU nurses, physiotherapists, and ergo-/logotherapists. Major goals include all measurements to prevent secondary brain injury due to secondary brain insults and to optimize frame conditions for recovery and early rehabilitation. The distinction between moderate and severe is frequently done based on the Glascow Coma Scale and therefore often is just a snapshot at the early time of assessment. Due to its pathophysiological pathways, an initially as moderate classified TBI may need the same sophisticated surveillance, monitoring, and treatment as a severe form or might even progress to a severe and difficult to treat affection. As traumatic brain injury is rather a syndrome comprising a range of different affections to the brain and as, e.g., age-related comorbidities and treatments additionally may have a great impact, individual and tailored treatment approaches based on monitoring and findings in imaging and respecting pre-injury comorbidities and their therapies are warranted.
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Affiliation(s)
- Reto A Stocker
- Institute for Anesthesiology and Intensive Care Medicine, Klinik Hirslanden, CH-8032 Zurich, Switzerland.
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10
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Carteron L, Bouzat P, Oddo M. Cerebral Microdialysis Monitoring to Improve Individualized Neurointensive Care Therapy: An Update of Recent Clinical Data. Front Neurol 2017; 8:601. [PMID: 29180981 PMCID: PMC5693841 DOI: 10.3389/fneur.2017.00601] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 10/27/2017] [Indexed: 01/04/2023] Open
Abstract
Cerebral microdialysis (CMD) allows bedside semicontinuous monitoring of patient brain extracellular fluid. Clinical indications of CMD monitoring are focused on the management of secondary cerebral and systemic insults in acute brain injury (ABI) patients [mainly, traumatic brain injury (TBI), subarachnoid hemorrhage, and intracerebral hemorrhage (ICH)], specifically to tailor several routine interventions—such as optimization of cerebral perfusion pressure, blood transfusion, glycemic control and oxygen therapy—in the individual patient. Using CMD as clinical research tool has greatly contributed to identify and better understand important post-injury mechanisms—such as energy dysfunction, posttraumatic glycolysis, post-aneurysmal early brain injury, cortical spreading depressions, and subclinical seizures. Main CMD metabolites (namely, lactate/pyruvate ratio, and glucose) can be used to monitor the brain response to specific interventions, to assess the extent of injury, and to inform about prognosis. Recent consensus statements have provided guidelines and recommendations for CMD monitoring in neurocritical care. Here, we summarize recent clinical investigation conducted in ABI patients, specifically focusing on the role of CMD to guide individualized intensive care therapy and to improve our understanding of the complex disease mechanisms occurring in the immediate phase following ABI. Promising brain biomarkers will also be described.
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Affiliation(s)
- Laurent Carteron
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besançon, University of Bourgogne - Franche-Comté, Besançon, France
| | - Pierre Bouzat
- Department of Anesthesiology and Critical Care, University Hospital Grenoble, Grenoble, France
| | - Mauro Oddo
- Department of Intensive Care Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), University of Lausanne, Lausanne, Switzerland
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Stocchetti N, Carbonara M, Citerio G, Ercole A, Skrifvars MB, Smielewski P, Zoerle T, Menon DK. Severe traumatic brain injury: targeted management in the intensive care unit. Lancet Neurol 2017; 16:452-464. [PMID: 28504109 DOI: 10.1016/s1474-4422(17)30118-7] [Citation(s) in RCA: 230] [Impact Index Per Article: 32.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 03/20/2017] [Accepted: 03/27/2017] [Indexed: 12/11/2022]
Abstract
Severe traumatic brain injury (TBI) is currently managed in the intensive care unit with a combined medical-surgical approach. Treatment aims to prevent additional brain damage and to optimise conditions for brain recovery. TBI is typically considered and treated as one pathological entity, although in fact it is a syndrome comprising a range of lesions that can require different therapies and physiological goals. Owing to advances in monitoring and imaging, there is now the potential to identify specific mechanisms of brain damage and to better target treatment to individuals or subsets of patients. Targeted treatment is especially relevant for elderly people-who now represent an increasing proportion of patients with TBI-as preinjury comorbidities and their therapies demand tailored management strategies. Progress in monitoring and in understanding pathophysiological mechanisms of TBI could change current management in the intensive care unit, enabling targeted interventions that could ultimately improve outcomes.
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Affiliation(s)
- Nino Stocchetti
- Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Department of Anaesthesia and Critical Care, Neuroscience Intensive Care Unit, Milan, Italy; University of Milan, Department of Pathophysiology and Transplants, Milan, Italy.
| | - Marco Carbonara
- Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Department of Anaesthesia and Critical Care, Neuroscience Intensive Care Unit, Milan, Italy
| | - Giuseppe Citerio
- University of Milan-Bicocca, School of Medicine and Surgery, Milan, Italy; San Gerardo Hospital, Neurointensive Care, ASST, Monza, Italy
| | - Ari Ercole
- Addenbrooke's Hospital, Division of Anaesthesia, University of Cambridge, Cambridge, UK
| | - Markus B Skrifvars
- Monash University, Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Melbourne, VIC, Australia; University of Helsinki and Helsinki University Hospital, Division of Intensive Care, Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki, Finland
| | - Peter Smielewski
- University of Cambridge Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge, UK
| | - Tommaso Zoerle
- Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Department of Anaesthesia and Critical Care, Neuroscience Intensive Care Unit, Milan, Italy
| | - David K Menon
- Addenbrooke's Hospital, Division of Anaesthesia, University of Cambridge, Cambridge, UK
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Gómez PA, Castaño-León AM, Lora D, Cepeda S, Lagares A. Evolución temporal en las características de la tomografía computarizada, presión intracraneal y tratamiento quirúrgico en el traumatismo craneal grave: análisis de la base de datos de los últimos 25 años en un servicio de neurocirugía. Neurocirugia (Astur) 2017; 28:1-14. [DOI: 10.1016/j.neucir.2016.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 09/05/2016] [Accepted: 11/04/2016] [Indexed: 10/20/2022]
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Green MS, Sehgal S, Tariq R. Near-Infrared Spectroscopy: The New Must Have Tool in the Intensive Care Unit? Semin Cardiothorac Vasc Anesth 2016; 20:213-24. [PMID: 27206637 DOI: 10.1177/1089253216644346] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Standard hemodynamic monitoring such as blood pressure and pulse oximetry may only provide a crude estimation of organ perfusion in the critical care setting. Near-infrared spectroscopy (NIRS) is based on the same principle as a pulse oximeter and allows continuous noninvasive monitoring of hemoglobin oxygenation and deoxygenation and thus tissue saturation "StO2" This review aims to provide an overview of NIRS technology principles and discuss its current clinical use in the critical care setting. The study selection was performed using the PubMed database to find studies that investigated the use of NIRS in both the critical care setting and in the intensive care unit. Currently, NIRS in the critical care setting is predominantly being used for infants and neonates. A number of studies in the past decade have shown promising results for the use of NIRS in surgical/trauma intensive care units during shock management as a prognostic tool and in guiding resuscitation. It is evident that over the past 2 decades, NIRS has gone from being a laboratory fascination to an actively employed clinical tool. Even though the benefit of routine use of this technology to achieve better outcomes is still questionable, the fact that NIRS is a low-cost, noninvasive monitoring modality improves the attractiveness of the technology. However, more research may be warranted before recommending its routine use in the critical care setting.
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Affiliation(s)
- Michael Stuart Green
- Drexel University College of Medicine/Hahnemann University Hospital, Philadelphia, PA, USA
| | - Sankalp Sehgal
- Drexel University College of Medicine/Hahnemann University Hospital, Philadelphia, PA, USA
| | - Rayhan Tariq
- Drexel University College of Medicine/Hahnemann University Hospital, Philadelphia, PA, USA
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