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Ediga PK, Saradhi MV, Alugolu R, Maddury J. Correlation of head injury with ECG and echo changes. Surg Neurol Int 2024; 15:296. [PMID: 39246793 PMCID: PMC11380885 DOI: 10.25259/sni_559_2023] [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: 07/02/2023] [Accepted: 07/25/2024] [Indexed: 09/10/2024] Open
Abstract
Background Abnormal electrocardiogram (ECG) findings can be seen in traumatic brain injury (TBI) patients. ECG may be an inexpensive tool to identify patients at high risk for developing cardiac dysfunction after TBI. This study aimed to examine abnormal ECG findings after isolated TBI and their association with true cardiac dysfunction based on echocardiogram. Methods This prospective observational study examined the data from adult patients with isolated and non-operated TBI between 2020 and 2021. Patients aged <18 years and >65 years with and presence of extracranial injuries including orthopedic, chest, cardiac, abdominal, and pelvis, pre-existing cardiac disease, patients who have undergone cardiothoracic surgery, with inotrope drugs, acute hemorrhage, and brain death were excluded from the study. Results We examined data from 100 patients with isolated TBI who underwent ECG and echocardiographic evaluation. ECG changes among 53% of mild cases showed a heart rate of 60-100/min, and 2% of cases showed more than 100/min. Prolonged pulse rate (PR) interval was observed in 8%, 11%, and 16% of mild, moderate, and severe cases, while no changes in PR interval were observed in 65% of cases. A prolonged QRS pattern was observed in 5%, 7%, and 15% of mild, moderate, and severe cases. A normal QRS complex was observed in 71% of cases. Prolonged QTc was observed in 3%, 10%, and 15% of cases in mild, moderate, and severe cases, respectively. Conclusion Repolarization abnormalities, but not ischemic-like ECG changes, are associated with cardiac dysfunction after isolated TBI. 12-lead ECG may be an inexpensive screening tool to evaluate isolated TBI patients for cardiac dysfunction.
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Affiliation(s)
| | | | - Rajesh Alugolu
- Department of Cardiology, NIMS, Hyderabad, Telangana, India
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Zewdu M, Mersha AT, Ashagre HE, Arefayne NR, Tegegne BA. Incidence of intraoperative hypotension and its factors among adult traumatic head injury patients in comprehensive specialized hospitals, Northwest Ethiopia: a multicenter observational study. BMC Anesthesiol 2024; 24:125. [PMID: 38561657 PMCID: PMC10983668 DOI: 10.1186/s12871-024-02511-y] [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: 01/10/2024] [Accepted: 03/26/2024] [Indexed: 04/04/2024] Open
Abstract
INTRODUCTION Traumatic head injury (THI) poses a significant global public health burden, often contributing to mortality and disability. Intraoperative hypotension (IH) during emergency neurosurgery for THI can adversely affect perioperative outcomes, and understanding associated risk factors is essential for prevention. METHOD A multi-center observational study was conducted from February 10 to June 30, 2022. A simple random sampling technique was used to select the study participants. Patient data were analyzed using bivariate and multivariate logistic regression to identify significant factors associated with intraoperative hypotension (IH). Odds ratios with 95% confidence intervals were used to show the strength of association, and P value < 0.05 was considered as statistically significant. RESULT The incidence of intra-operative hypotension was 46.41% with 95%CI (39.2,53.6). The factors were duration of anesthesia ≥ 135 min with AOR: 4.25, 95% CI (1.004,17.98), severe GCS score with AOR: 7.23, 95% CI (1.098,47.67), intracranial hematoma size ≥ 15 mm with AOR: 7.69, 95% CI (1.18,50.05), and no pupillary abnormality with AOR: 0.061, 95% CI (0.005,0.732). CONCLUSION AND RECOMMENDATION: The incidence of intraoperative hypotension was considerably high. The duration of anesthesia, GCS score, hematoma size, and pupillary abnormalities were associated. The high incidence of IH underscores the need for careful preoperative neurological assessment, utilizing CT findings, vigilance for IH in patients at risk, and proactive management of IH during surgery. Further research should investigate specific mitigation strategies.
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Affiliation(s)
- Melaku Zewdu
- Department of Anesthesia, School of Medicine, College of Medicine and Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Abraham Tarekegn Mersha
- Department of Anesthesia, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Henos Enyew Ashagre
- Department of Anesthesia, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Nurhusen Riskey Arefayne
- Department of Anesthesia, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Biresaw Ayen Tegegne
- Department of Anesthesia, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
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Muangman S, Raksakietisak M, Vacharaksa K, Manomatangkul K, Chankaew E, Kotchasit C, Deepinta P, Phoowanakulchai S. A Comparison of Perioperative Complications and Outcomes in Patients Undergoing Cerebral Aneurysm Clipping Performed Ultra-Early (≤ 24 hours) versus Late (> 24 hours): A 7-Year Retrospective Study of 302 Patients. Asian J Neurosurg 2024; 19:8-13. [PMID: 38751394 PMCID: PMC11093643 DOI: 10.1055/s-0043-1769758] [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] [Indexed: 05/18/2024] Open
Abstract
Objectives The intracerebral aneurysm with subarachnoid hemorrhage (SAH) has a high morbidity and mortality rate. This study aimed to compare the incidences of perioperative complications in ultra-early surgery (within 24 hours) with those in late surgery (> 24 hours). Methods Retrospective data were reviewed for 302 patients who underwent craniotomies with aneurysm clipping between January 2014 and December 2020. Perioperative data were obtained from the medical records and reviewed by the investigators. The complications were compared between ultra-early and late operations. We were interested in major complications such as delayed ischemic neurologic deficit (DIND), intraoperative aneurysm rupture (IAR), and anesthesia-related complications. The short-term (in hospital) and long-term (1 year) outcomes in patients with or without DIND and IAR were compared. The collected data was statistically analyzed. Results Three hundred and two patients were analyzed, and 264 patients had completed follow-up. The ultra-early cases (150 patients) had a higher American Society of Anesthesiologists physical status, a lower Glasgow Coma Scale, and higher Hunt and Hess scales. The surgeons operated on more cases of the anterior cerebral artery as ultra-early operations. The incidence rates of DIND, IAR, severe hemodynamic instability, and cardiac arrest were 5.6, 8.3, 6.3, and 0.3%, respectively, which were not different between groups. However, the reintubation rate was higher in the ultra-early surgery cases (0 vs. 3.3%, p = 0.023). The DIND and IAR patients had poorer short-term (in hospital) outcomes. Conclusions There were no differences in major complications between ultra-early and late craniotomy with aneurysm clipping. However, the reintubation rate was strikingly higher in the ultra-early group. Patients with major complications had early, unfavorable outcomes.
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Affiliation(s)
- Saipin Muangman
- Department of Anesthesiology, Faculty of Medicine, Mahidol University, Siriraj Hospital, Bangkok, Thailand
| | - Manee Raksakietisak
- Department of Anesthesiology, Faculty of Medicine, Mahidol University, Siriraj Hospital, Bangkok, Thailand
| | - Kamheang Vacharaksa
- Department of Anesthesiology, Faculty of Medicine, Mahidol University, Siriraj Hospital, Bangkok, Thailand
| | - Kattiya Manomatangkul
- Department of Anesthesiology, Faculty of Medicine, Mahidol University, Siriraj Hospital, Bangkok, Thailand
| | - Ekawut Chankaew
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Mahidol University, Siriraj Hospital, Bangkok, Thailand
| | - Chayasorn Kotchasit
- Department of Anesthesiology, Faculty of Medicine, Mahidol University, Siriraj Hospital, Bangkok, Thailand
| | - Penpuk Deepinta
- Department of Anesthesiology, Faculty of Medicine, Mahidol University, Siriraj Hospital, Bangkok, Thailand
| | - Sirima Phoowanakulchai
- Department of Anesthesiology, Faculty of Medicine, Mahidol University, Siriraj Hospital, Bangkok, Thailand
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Feld SI, Hippe DS, Miljacic L, Polissar NL, Newman SF, Nair BG, Vavilala MS. A Machine Learning Approach for Predicting Real-time Risk of Intraoperative Hypotension in Traumatic Brain Injury. J Neurosurg Anesthesiol 2023; 35:215-223. [PMID: 34759236 PMCID: PMC9091057 DOI: 10.1097/ana.0000000000000819] [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: 04/12/2021] [Accepted: 10/08/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a major cause of death and disability. Episodes of hypotension are associated with worse TBI outcomes. Our aim was to model the real-time risk of intraoperative hypotension in TBI patients, compare machine learning and traditional modeling techniques, and identify key contributory features from the patient monitor and medical record for the prediction of intraoperative hypotension. METHODS The data included neurosurgical procedures in 1005 TBI patients at an academic level 1 trauma center. The clinical event was intraoperative hypotension, defined as mean arterial pressure <65 mm Hg for 5 or more consecutive minutes. Two types of models were developed: one based on preoperative patient-level predictors and one based on intraoperative predictors measured per minute. For each of these models, we took 2 approaches to predict the occurrence of a hypotensive event: a logistic regression model and a gradient boosting tree model. RESULTS The area under the receiver operating characteristic curve for the intraoperative logistic regression model was 0.80 (95% confidence interval [CI]: 0.78-0.83), and for the gradient boosting model was 0.83 (95% CI: 0.81-0.85). The area under the precision-recall curve for the intraoperative logistic regression model was 0.16 (95% CI: 0.12-0.20), and for the gradient boosting model was 0.19 (95% CI: 0.14-0.24). Model performance based on preoperative predictors was poor. Features derived from the recent trend of mean arterial pressure emerged as dominantly predictive in both intraoperative models. CONCLUSIONS This study developed a model for real-time prediction of intraoperative hypotension in TBI patients, which can use computationally efficient machine learning techniques and a streamlined feature-set derived from patient monitor data.
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Affiliation(s)
- Shara I Feld
- Anesthesiology and Pain Medicine, University of Washington
| | - Daniel S Hippe
- The Mountain-Whisper-Light: Statistics & Data Science, Seattle, WA
| | | | - Nayak L Polissar
- The Mountain-Whisper-Light: Statistics & Data Science, Seattle, WA
| | | | - Bala G Nair
- Anesthesiology and Pain Medicine, University of Washington
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Scurfield AK, Wilson MD, Gurkoff G, Martin R, Shahlaie K. Identification of Demographic and Clinical Prognostic Factors in Traumatic Intraventricular Hemorrhage. Neurocrit Care 2023; 38:149-157. [PMID: 36050537 PMCID: PMC9957945 DOI: 10.1007/s12028-022-01587-z] [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: 03/18/2022] [Accepted: 08/08/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND The presence of traumatic intraventricular hemorrhage (tIVH) following traumatic brain injury (TBI) is associated with worse neurological outcome. The mechanisms by which patients with tIVH have worse outcome are not fully understood and research is ongoing, but foundational studies that explore prognostic factors within tIVH populations are also lacking. This study aimed to further identify and characterize demographic and clinical variables within a subset of patients with TBI and tIVH that may be implicated in tIVH outcome. METHODS In this observational study, we reviewed a large prospective TBI database to determine variables present on admission that predicted neurological outcome 6 months after injury. A review of 7,129 patients revealed 211 patients with tIVH on admission and 6-month outcome data. Hypothesized risk factors were tested in univariate analyses with significant variables (p < 0.05) included in logistic and linear regression models. Following the addition of either the Rotterdam computed tomography or Glasgow Coma Scale (GCS) score, we employed a backward selection process to determine significant variables in each multivariate model. RESULTS Our study found that that hypotension (odds ratio [OR] = 0.35, 95% confidence interval [CI] = 0.13-0.94, p = 0.04) and the hemoglobin level (OR = 1.33, 95% CI = 1.09-1.63, p = 0.006) were significant predictors in the Rotterdam model, whereas only the hemoglobin level (OR = 1.29, 95% CI = 1.06-1.56, p = 0.01) was a significant predictor in the GCS model. CONCLUSIONS This study represents one of the largest investigations into prognostic factors for patients with tIVH and demonstrates that admission hemoglobin level and hypotension are associated with outcomes in this patient population. These findings add value to established prognostic scales, could inform future predictive modeling studies, and may provide potential direction in early medical management of patients with tIVH.
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Affiliation(s)
- Abby K Scurfield
- Frank H. Netter M.D. School of Medicine, Quinnipiac University, 830 Orange Street, New Haven, CT, 06511, USA
| | - Machelle D Wilson
- Division of Biostatistics, Department of Public Health Sciences, Davis Clinical and Translational Science Center, University of California, 2921 Stockton Blvd., Suite 1400, Sacramento, CA, 95817, USA
| | - Gene Gurkoff
- Department of Neurological Surgery, University of California, 4860 Y Street, Suite 3740,, 95817, Davis, Sacramento, CA, USA
| | - Ryan Martin
- Department of Neurological Surgery, University of California, 4860 Y Street, Suite 3740,, 95817, Davis, Sacramento, CA, USA
- Department of Neurology, University of California, 4860 Y Street, Suite 3740,, Davis, Sacramento, CA, USA
| | - Kiarash Shahlaie
- Department of Neurological Surgery, University of California, 4860 Y Street, Suite 3740,, 95817, Davis, Sacramento, CA, USA.
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Meyer S, Hummel R, Neulen A, Hirnet T, Thal SC. Influence of traumatic brain injury on ipsilateral and contralateral cortical perfusion in mice. Neurosci Lett 2023; 795:137047. [PMID: 36603737 DOI: 10.1016/j.neulet.2023.137047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 11/28/2022] [Accepted: 01/01/2023] [Indexed: 01/04/2023]
Abstract
Traumatic brain injury (TBI) is one of the most important causes of death in young adults. After brain injury cortical perfusion is impaired by cortical spreading depression, cerebral microvasospasm or microvascular thrombosis and contributes to secondary expansion of lesion into surrounding healthy brain tissue. The present study was designed to determine the regional cortical perfusion pattern after experimental TBI induced by controlled cortical impact (CCI) in male C57/BL6N mice. We performed a longitudinal time series analysis by Laser speckle contrast imaging (LSCI). Measurements were carried out before, immediately and 24 h after trauma. Immediately after CCI cortical perfusion in the lesion core dropped to 10 % of before injury (baseline; %BL) and to 21-24 %BL in the cortical area surrounding the core. Interestingly, cortical perfusion was also significantly reduced in the contralateral non-injured hemisphere (41-58 %BL) matching the corresponding brain region of the injured hemisphere. 24 h after CCI perfusion of the contralateral hemisphere returned to baseline level in the area corresponding to the lesion core, whereas the lateral area of the parietal cortex was hyperperfused (125 %BL). The lesion core region itself remained severely hypoperfused (18 to 26 %BL) during the observation period. TBI causes a maldistribution of both ipsi- and contralateral cerebral perfusion immediately after trauma, which persist for at least 24 h. Higher perfusion levels in the lesion core 24 h after trauma were associated with increased tissue damage, which supports the role of reperfusion injury for secondary brain damage after TBI.
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Affiliation(s)
- Simon Meyer
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstraße 1, 55131 Mainz, Germany.
| | - Regina Hummel
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstraße 1, 55131 Mainz, Germany.
| | - Axel Neulen
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University, Langenbeckstraße 1, 55131 Mainz, Germany.
| | - Tobias Hirnet
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstraße 1, 55131 Mainz, Germany.
| | - Serge C Thal
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstraße 1, 55131 Mainz, Germany; Department of Anesthesiology, HELIOS University Hospital Wuppertal, University Witten/Herdecke, Heusnerstraße 40, 42283 Wuppertal, Germany.
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Saengrung S, Kaewborisutsakul A, Tunthanathip T, Phuenpathom N, Taweesomboonyat C. Risk Factors for Intraoperative Hypotension During Decompressive Craniectomy in traumatic Brain Injury Patients. World Neurosurg 2022; 162:e652-e658. [PMID: 35358728 DOI: 10.1016/j.wneu.2022.03.102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/22/2022] [Accepted: 03/23/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Decompressive craniectomy (DC) is an important therapy for treating intracranial pressure elevation following traumatic brain injury (TBI). During this procedure, about one-third of patients become complicated with intraoperative hypotension (IH), which is associated with abruptly decreasing sympathetic activity resulting from brain decompression. This study aimed to identify factors associated with IH during DC procedures and the mortality rate in these patients. METHODS The records of adult TBI patients aged 18 years and older who underwent DC at Songklanagarind Hospital between January 2014 and January 2021 were retrospectively reviewed. Using logistic regression analysis, various factors were analyzed for their associations with IH during the DC procedures. RESULTS This study included 83 patients. The incidence of IH was 54%. Multivariate analysis showed that Glasgow Coma Scale motor response (GCS-M) 1-3 (vs. 4-6), higher preoperative heart rate (PHR), and larger amount of intraoperative blood loss were significantly associated with IH (P = 0.013, P < 0.001, and P < 0.001, respectively). Patients with GCS-M 1-3 and PHR ≥ 75 bpm had the highest chance of IH (77%), while patients with neither of these risk factors had the lowest chance (29%). The in-hospital mortality rate in the IH and non-IH groups was 44% and 26%, respectively (P = 0.138). CONCLUSIONS GCS-M 1-3, higher PHR, and larger amount of intraoperative blood loss were the risk factors associated with IH during DC procedure in TBI patients. Patients who have these risk factors should be closely monitored and the attending physician be ready to apply prompt resuscitation and treatment for IH.
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Affiliation(s)
- Suchada Saengrung
- Division of Neurosurgery, Department of Surgery, Songklanagarind Hospital, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Anukoon Kaewborisutsakul
- Division of Neurosurgery, Department of Surgery, Songklanagarind Hospital, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Thara Tunthanathip
- Division of Neurosurgery, Department of Surgery, Songklanagarind Hospital, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Nakornchai Phuenpathom
- Division of Neurosurgery, Department of Surgery, Songklanagarind Hospital, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Chin Taweesomboonyat
- Division of Neurosurgery, Department of Surgery, Songklanagarind Hospital, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand.
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Xu R, Nair SK, Materi J, Raj D, Medikonda R, Shah PP, Kannapadi NV, Wang A, Mintz D, Gottschalk A, Antonik LJ, Huang J, Bettegowda C, Lim M. Case Series in the Utility of Invasive Blood Pressure Monitoring in Microvascular Decompression. Oper Neurosurg (Hagerstown) 2022; 22:262-268. [PMID: 35315836 DOI: 10.1227/ons.0000000000000130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 11/28/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The utility of arterial lines in microvascular decompression (MVD) is not well described. OBJECTIVE To examine the safety and costs of arterial lines compared with noninvasive blood pressure (NIBP) monitoring in MVDs. METHODS We retrospectively reviewed patients undergoing MVD from 2012 to 2020. Patients were grouped by procedure date from 2012 to 2014 and 2015 to 2020, reflecting our institution's decreasing trend in arterial line placement around 2014 to 2015. Patient features, intraoperative characteristics, and postoperative complications were collected for all cases. Statistical differences were evaluated using chi-squared analyses and t-tests. RESULTS Eight hundred fifty-eight patients underwent MVDs, with 204 between 2012 and 2014 and 654 between 2015 and 2020. Over time, the frequency of arterial line placement decreased from 64.2% to 30.1%, P < .001. Arterial lines involved 11 additional minutes of preincision time, P < .001. Patients with arterial lines required both increased doses and costs of vasoactive medications intraoperatively. Patients receiving arterial lines demonstrated no significant differences in complications compared with patients with NIBP monitoring. On average, patients with arterial lines incurred $802 increased costs per case compared with NIBP monitoring. CONCLUSION NIBP monitoring in MVDs provides neurologically and hemodynamically safe outcomes compared with invasive blood pressure monitoring. For patients without significant cardiopulmonary risk factors, NIBP monitoring may be a cost-effective alternative in MVDs.
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Affiliation(s)
- Risheng Xu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sumil K Nair
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Josh Materi
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Divyaansh Raj
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ravi Medikonda
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Pavan P Shah
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nivedha V Kannapadi
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Andrew Wang
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - David Mintz
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Allan Gottschalk
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Laurie J Antonik
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Chetan Bettegowda
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michael Lim
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
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Hamila M, Hussein K, Ismail MF, Kamal A. Prevalence of Electrocardiographic Changes in Patients with Traumatic Brain Injury: A Prospective Hospital-based Study. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.8313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: Head trauma and traumatic brain injury (TBI) are major causes of death and disability worldwide. TBI is associated with a variety of electrocardiographic (ECG) changes.
AIM: We aimed to evaluate the prevalence of ECG changes in TBI.
METHODS: Participants with TBI were included in the study, while participants with chest trauma or cardiovascular diseases were excluded from the study. A consecutive sample of 50 participants (mean age 37.8 ± 14.85 years, 80% males) was selected and referred for 12 lead ECG on admission, 24 h, and 72 h after admission.
RESULTS: The prevalence of sinus bradycardia versus sinus tachycardia, short PR interval, ST segment elevation, and inverted T wave in the study population was 18% versus 38%, 26%, 2%, and 16% in ECG on admission, 5% versus 22%, 14%, 0%, and 10% in ECG 24 h after admission, 5% versus 8%, 4%, 0%, and 8% in ECG 72 h after admission, respectively. Serial ECG was significantly associated with changes in heart rate (χ² [1] = 17.337, p = 0.002) and short PR interval (χ² [1] = 9.695, p = 0.008), respectively. There was a significant association between ECG changes and brain edema (χ² [1] = 4.131, p = 0.042), intracerebral hemorrhage (χ² [1] = 4.539, p = 0.033), and subarachnoid hemorrhage groups (χ² [1] = 5.889, p = 0.015), respectively.
CONCLUSIONS: ECG changes are prevalent in non-cardiac TBI patients. The significant association of serial ECG with changes in heart rate and short PR interval and the significant association of ECG changes with brain edema, intracerebral hemorrhage, and subarachnoid hemorrhage highlights the potential role of serial ECG as a screening tool for cardiac dysfunction in patients with TBI.
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Khandelwal A, Bithal PK, Rath GP. Anesthetic considerations for extracranial injuries in patients with associated brain trauma. J Anaesthesiol Clin Pharmacol 2019; 35:302-311. [PMID: 31543576 PMCID: PMC6748016 DOI: 10.4103/joacp.joacp_278_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Patients with severe traumatic brain injury often presents with extracranial injuries, which may contribute to fatal outcome. Anesthetic management of such polytrauma patients is extremely challenging that includes prioritizing the organ system to be dealt first, reducing on-going injury, and preventing secondary injuries. Neuroprotective and neurorescue measures should be instituted simultaneously during extracranial surgeries. Selection of anesthetic drugs that minimally interferes with cerebral dynamics, maintenance of hemodynamics and cerebral perfusion pressure, optimal utilization of multimodal monitoring techniques, and aggressive rehabilitation approach are the key factors for improving overall patient outcome.
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Affiliation(s)
- Ankur Khandelwal
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Parmod Kumar Bithal
- Department of Anesthesia and OR Administration, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Girija Prasad Rath
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
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Abstract
We provide a synopsis of innovative research, recurring themes, and novel experimental findings pertinent to the care of neurosurgical patients and critically ill patients with neurological diseases. We cover the following broad topics: general neurosurgery, spine surgery, stroke, traumatic brain injury, monitoring, and anesthetic neurotoxicity.
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Intraoperative Secondary Insults During Orthopedic Surgery in Traumatic Brain Injury. J Neurosurg Anesthesiol 2018; 29:228-235. [PMID: 26954768 DOI: 10.1097/ana.0000000000000292] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Secondary insults worsen outcomes after traumatic brain injury (TBI). However, data on intraoperative secondary insults are sparse. The primary aim of this study was to examine the prevalence of intraoperative secondary insults during orthopedic surgery after moderate-severe TBI. We also examined the impact of intraoperative secondary insults on postoperative head computed tomographic scan, intracranial pressure (ICP), and escalation of care within 24 hours of surgery. MATERIALS AND METHODS We reviewed medical records of TBI patients 18 years and above with Glasgow Coma Scale score <13 who underwent single orthopedic surgery within 2 weeks of TBI. Secondary insults examined were: systemic hypotension (systolic blood pressure<90 mm Hg), intracranial hypertension (ICP>20 mm Hg), cerebral hypotension (cerebral perfusion pressure<50 mm Hg), hypercarbia (end-tidal CO2>40 mm Hg), hypocarbia (end-tidal CO2<30 mm Hg in absence of intracranial hypertension), hyperglycemia (glucose>200 mg/dL), hypoglycemia (glucose<60 mg/dL), and hyperthermia (temperature >38°C). RESULTS A total of 78 patients (41 [18 to 81] y, 68% male) met the inclusion criteria. The most common intraoperative secondary insults were systemic hypotension (60%), intracranial hypertension and cerebral hypotension (50% and 45%, respectively, in patients with ICP monitoring), hypercarbia (32%), and hypocarbia (29%). Intraoperative secondary insults were associated with worsening of head computed tomography, postoperative decrease of Glasgow Coma Scale score by ≥2, and escalation of care. After Bonferroni correction, association between cerebral hypotension and postoperative escalation of care remained significant (P<0.001). CONCLUSIONS Intraoperative secondary insults were common during orthopedic surgery in patients with TBI and were associated with postoperative escalation of care. Strategies to minimize intraoperative secondary insults are needed.
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Kamiutsuri K, Tominaga N, Kobayashi S. Preoperative elevated FDP may predict severe intraoperative hypotension after dural opening during decompressive craniectomy of traumatic brain injury. JA Clin Rep 2018; 4:8. [PMID: 29457118 PMCID: PMC5804671 DOI: 10.1186/s40981-018-0146-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 01/04/2018] [Indexed: 01/30/2023] Open
Abstract
Purpose Coagulation disorder and intraoperative hypotension are representative complications of traumatic brain injury which cause worse perioperative outcome. The aim of this study was to survey the relation of coagulation disorder and intraoperative hypotension (IH) during decompressive craniectomy. Method Patients who underwent emergency decompressive craniectomy due to traumatic brain injury were retrospectively surveyed. The relation between preoperative coagulation date and intraoperative hypotension (systolic blood pressure < 60 mmHg after dural opening) was analyzed. Results Of 41 patients screened, 12 patients (27.9%) developed IH. Fibrinogen degradation products (314 vs 64.4 μg/mL; p = 0.01) were significantly higher in the IH group. In contrast, fibrinogen (181 vs 239 mg/dL; p = 0.01) was significantly lower in the IH group. Reduction rate of sBRP before and after dural opening (%) was higher in IH group than in non-IH group (49.1 vs 27.6%: p = 0.001). Conclusions Preoperative elevated FDP may predict IH after dural opening during traumatic decompressive craniectomy.
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Affiliation(s)
- Kei Kamiutsuri
- Department of Anesthesiology, Rinku General Medical Center, Izumisano, Japan.
| | - Naoki Tominaga
- Department of Cardiovascular Internal Medicine, Shin Komonji Hospital, Kitakyushu, Japan
| | - Shunji Kobayashi
- Department of Anesthesiology, Rinku General Medical Center, Izumisano, Japan
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Perioperative Management of Adult Patients with Severe Head Injury. Anesthesiology 2018. [DOI: 10.1007/978-3-319-74766-8_62] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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15
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Sheffy N, Bentov I, Mills B, Nair BG, Rooke GA, Vavilala MS. Perioperative hypotension and discharge outcomes in non-critically injured trauma patients, a single centre retrospective cohort study. Injury 2017; 48:1956-1963. [PMID: 28733043 DOI: 10.1016/j.injury.2017.06.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 06/20/2017] [Accepted: 06/22/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND There is a lack of information on the effect of age on perioperative care and outcomes after minor trauma in the elderly. We examined the association between perioperative hypotension and discharge outcome among non-critically injured adult patients. METHODS We conducted a retrospective study of non-critically ill patients (ISS <9 or discharged within less than 24h) who received anaesthesia care for surgery and Recovery Room care at a level-1 trauma centre between 5/1/2012 and 11/30/2013. Perioperative hypotension was defined as systolic blood pressure (SBP) <90mmHg (traditional measure) for all patients, and SBP <110mmHg (strict measure) for patients ≥65years. Poor outcome was defined as death or discharge to skilled nursing facility/hospice. RESULTS 1744 patients with mean ISS 4.4 across age groups were included; 169 (10%) were ≥65years. Among patients≥65years, intraoperative hypotension occurred in >75% (131/169, traditional measure) and in >95% (162/169, strict measure); recovery room hypotension occurred in 2% (4/169) and 29% (49/169), respectively. Mean age-adjusted anaesthetic agent concentration (MAC) was similar across age groups. Opioid use decreased from 9.3 (SD 5.7) mg/h morphine equivalents in patients <55years to 6.2 (SD 4.0) mg/h in patients over 85 years. Adjusted for gender, ASA score, anaesthesia duration, morphine equivalent/hr, fluid balance, MAC and surgery type, and using traditional definition, older patients were more likely than patients <55 to experience perioperative hypotension: aRR 1.21, 95% CI 1.11-1.30 for 55-64 and aRR 1.19, 95% CI 1.07-1.32 for ages 65-74. Perioperative hypotension was associated with poor discharge outcome (aRR 1.55; 95% CI 1.04-2.31 and aRR 1.87; 95% CI 1.17-2.98, respectively). CONCLUSION Despite age related reduction in doses of volatile anaesthetic and opioids administered during anaesthesia care, and regardless of hypotension definition used, non-critically injured patients undergoing surgery experience a large perioperative hypotension burden. This burden is higher for patients 55-74 years and older and is a risk factor for poor discharge outcomes, independent of age and ASA status.
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Affiliation(s)
- Nadav Sheffy
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States; Department of Anesthesiology, Rabin Medical Center, Petah Tikva, Israel(2).
| | - Itay Bentov
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Brianna Mills
- Harborview Injury Prevention and Research Center, Seattle, WA, United States; Department of Epidemiology, University of Washington, Seattle, WA, United States; Center for Studies in Demography and Ecology, University of Washington, Seattle, WA, United States
| | - Bala G Nair
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States; Harborview Injury Prevention and Research Center, Seattle, WA, United States
| | - G Alec Rooke
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Monica S Vavilala
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States; Harborview Injury Prevention and Research Center, Seattle, WA, United States
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Vavilala MS, Ferrari LR, Herring SA. Perioperative Care of the Concussed Patient. Anesth Analg 2017; 125:1053-1055. [DOI: 10.1213/ane.0000000000002080] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Algarra NN, Sharma D. Perioperative Management of Traumatic Brain Injury. CURRENT ANESTHESIOLOGY REPORTS 2016. [DOI: 10.1007/s40140-016-0170-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
PURPOSE OF REVIEW In this review, we present an update on the relationship between anesthesia and intraoperative hemodynamic complications, early postanesthesia recovery, postoperative pain and postoperative nausea and vomiting after craniotomy. We also review latest advances in education and research in neuroanesthesia for brain surgery. RECENT FINDINGS Insights from clinical reports published from January 2012 to April 2013 on anesthesia for craniotomy will be summarized. Recent findings address the need for a tight intraoperative hemodynamic monitoring - that should include aggressive prevention of arterial hypotension and cardiac arrhythmias - and a careful management of fluids and electrolytes balance. Data on the relationship between anesthesia (selection of anesthetics used intraoperatively) and early recovery demonstrate a limited benefit when ultra-short acting drugs (as remifentanil vs fentanyl) are used. Evidence on postoperative pain and postoperative nausea and vomiting contribute to define how to better prevent and treat these complications. Latest guidelines on training and research in neuroanesthesia define unique end points in this subspecialty. SUMMARY Neuroanesthesia for craniotomy should be aimed to ensure intraoperative loss of consciousness (unless awake craniotomy is the selected anesthesiological approach), pain control and an uneventful postoperative recovery, but should also be addressed to manipulate physiological variables including cerebral blood flow and to obtain optimal surgical exposure.
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Moscote-Salazar LR, M. Rubiano A, Alvis-Miranda HR, Calderon-Miranda W, Alcala-Cerra G, Blancas Rivera MA, Agrawal A. Severe Cranioencephalic Trauma: Prehospital Care, Surgical Management and Multimodal Monitoring. Bull Emerg Trauma 2016; 4:8-23. [PMID: 27162922 PMCID: PMC4779465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2015] [Revised: 11/04/2015] [Accepted: 11/13/2015] [Indexed: 06/05/2023] Open
Abstract
Traumatic brain injury is a leading cause of death in developed countries. It is estimated that only in the United States about 100,000 people die annually in parallel among the survivors there is a significant number of people with disabilities with significant costs for the health system. It has been determined that after moderate and severe traumatic injury, brain parenchyma is affected by more than 55% of cases. Head trauma management is critical is the emergency services worldwide. We present a review of the literature regarding the prehospital care, surgical management and intensive care monitoring of the patients with severe cranioecephalic trauma.
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Affiliation(s)
| | | | | | | | | | | | - Amit Agrawal
- Department of Neurosurgery, MM Institute of Medical Sciences & Research, Maharishi Markandeshwar University, Mullana- Ambala, 133-207, Haryana, India
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Krishnamoorthy V, Prathep S, Sharma D, Gibbons E, Vavilala MS. Association between electrocardiographic findings and cardiac dysfunction in adult isolated traumatic brain injury. Indian J Crit Care Med 2014; 18:570-4. [PMID: 25249741 PMCID: PMC4166872 DOI: 10.4103/0972-5229.140144] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Introduction: Abnormal electrocardiographic (ECG) findings can be seen in traumatic brain injury (TBI) patients. ECG may be an inexpensive tool to identify patients at high risk for developing cardiac dysfunction after TBI. The aim of this study was to examine abnormal ECG findings after isolated TBI and their association with true cardiac dysfunction, based on echocardiogram. Methods: Data from adult patients with isolated TBI between 2003 and 2010 was retrospectively examined. Inclusion criteria included the presence of a 12-lead ECG within 24 h of admission and a formal echocardiographic examination within 72 h of admission after TBI. Patients with preexisting cardiac disease were excluded. Baseline clinical characteristics, 12-lead ECG, and echocardiogram report were abstracted. Logistic regression was used to identify the relationship of specific ECG abnormalities with cardiac dysfunction. Results: We examined data from 59 patients with isolated TBI who underwent 12-lead ECG and echocardiographic evaluation. In this cohort, 13 (22%) patients had tachycardia (heart rate >100 bpm), 25 (42.4%) patients had a prolonged QTc, and 6 (10.2%) patients had morphologic end-repolarization abnormalities (MERA), with each having an association with abnormal echocardiographic findings: Odds ratios (and 95% confidence intervals) were 4.14 (1.02-17.05), 9.0 (1.74-46.65), and 5.63 (1.96-32.94), respectively. Ischemic-like ECG changes were not associated with echocardiographic abnormalities. Conclusions: Repolarization abnormalities (prolonged QTc and MERA), but not ischemic-like ECG changes, are associated with cardiac dysfunction after isolated TBI. 12-lead ECG may be an inexpensive screening tool to evaluate isolated TBI patients for cardiac dysfunction prior to more expensive or invasive studies.
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Affiliation(s)
- Vijay Krishnamoorthy
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Sumidtra Prathep
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Deepak Sharma
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA ; Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Edward Gibbons
- Department of Cardiology, University of Washington, Seattle, WA, USA
| | - Monica S Vavilala
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA ; Department of Neurological Surgery, University of Washington, Seattle, WA, USA ; Department of Pediatrics, University of Washington, Seattle, WA, USA ; Department of Radiology, University of Washington, Seattle, WA, USA
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Fujita Y, Algarra NN, Vavilala MS, Prathep S, Prapruettham S, Sharma D. Intraoperative secondary insults during extracranial surgery in children with traumatic brain injury. Childs Nerv Syst 2014; 30:1201-8. [PMID: 24429505 DOI: 10.1007/s00381-014-2353-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2013] [Accepted: 01/02/2014] [Indexed: 11/28/2022]
Abstract
PURPOSE Data on intraoperative secondary insults in pediatric traumatic brain injury (TBI) are limited. METHODS We examined intraoperative secondary insults during extracranial surgery in children with moderate-severe TBI and polytrauma and their association with postoperative head computed tomography (CT) scans, intracranial pressure (ICP), and therapeutic intensity level (TIL) scores 24 h after surgery. After IRB approval, we reviewed the records of children <18 years with a Glasgow Coma Scale score <13 who underwent extracranial surgery within 72 h of TBI. Definitions of secondary insults were as follows: systemic hypotension (SBP <70 + 2 × age or 90 mmHg), cerebral hypotension (cerebral perfusion pressure <40 mmHg), intracranial hypertension (ICP >20 mmHg), hypoxia (oxygen saturation <90 %), hypercarbia (end-tidal CO2 >45 mmHg), hypocarbia (end-tidal CO2 <30 mmHg without hypotension and in the absence of intracranial hypertension), hyperglycemia (blood glucose >200 mg/dL), hyperthermia (temperature >38 °C), and hypothermia (temperature <35 °C). RESULTS Data from 50 surgeries in 42 patients (median age 15.5 years, 25 males) revealed systemic hypotension during 78 %, hypocarbia during 46 %, and hypercarbia during 25 % surgeries. Intracranial hypertension occurred in 64 % and cerebral hypotension in 18 % surgeries with ICP monitoring (11/50). Hyperglycemia occurred during 17 % of the 29 surgeries with glucose monitoring. Cerebral hypotension and hypoxia were associated with postoperative intracranial hypertension (p = 0.02 and 0.03, respectively). We did not observe an association between intraoperative secondary insults and postoperative worsening of head CT scan or TIL score. CONCLUSIONS Intraoperative secondary insults were common during extracranial surgery in pediatric TBI. Intraoperative cerebral hypotension and hypoxia were associated with postoperative intracranial hypertension. Strategies to prevent secondary insults during extracranial surgery in TBI are needed.
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Affiliation(s)
- Yasuki Fujita
- Departments of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
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Tobin JM, Dutton RP, Pittet JF, Sharma D. Hypotensive resuscitation in a head-injured multi-trauma patient. J Crit Care 2014; 29:313.e1-5. [DOI: 10.1016/j.jcrc.2013.11.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2013] [Revised: 11/14/2013] [Accepted: 11/19/2013] [Indexed: 01/24/2023]
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Nair BG, Horibe M, Newman SF, Wu WY, Peterson GN, Schwid HA. Anesthesia Information Management System-Based Near Real-Time Decision Support to Manage Intraoperative Hypotension and Hypertension. Anesth Analg 2014; 118:206-14. [DOI: 10.1213/ane.0000000000000027] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Myocardial dysfunction in acute traumatic brain injury relieved by surgical decompression. Case Rep Anesthesiol 2013; 2013:482596. [PMID: 23862078 PMCID: PMC3687721 DOI: 10.1155/2013/482596] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Accepted: 05/07/2013] [Indexed: 11/28/2022] Open
Abstract
Traumatic brain injury (TBI) is a major public health issue and is a leading cause of death in North America. After a primary TBI, secondary brain insults can predispose patients to a worse outcome. One of the earliest secondary insults encountered during the perioperative period is hypotension, which has been directly linked to both mortality and poor disposition after TBI. Despite this, it has been shown that hypotension commonly occurs during surgery for TBI. We present a case of intraoperative hypotension during surgery for TBI, where the use of transthoracic echocardiography had significant diagnostic and therapeutic implications for the management of our patient. We then discuss the issue of cardiac dysfunction after brain injury and the implications that echocardiography may have in the management of this vulnerable patient population.
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Abstract
This article presents an overview of the management of traumatic brain injury (TBI) as relevant to the practicing anesthesiologist. Key concepts surrounding the pathophysiology and anesthetic principles are used to describe potential ways to reduce secondary insults and improve outcomes after TBI.
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