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Büyükkaragöz B, Bakkaloğlu SA. Serum osmolality and hyperosmolar states. Pediatr Nephrol 2023; 38:1013-1025. [PMID: 35779183 DOI: 10.1007/s00467-022-05668-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 05/26/2022] [Accepted: 06/14/2022] [Indexed: 11/26/2022]
Abstract
Serum osmolality is the sum of the osmolalities of every single dissolved particle in the blood such as sodium and associated anions, potassium, glucose, and urea. Under normal conditions, serum sodium concentration is the major determinant of serum osmolality. Effective blood osmolality, so-called blood tonicity, is created by the endogenous (e.g., sodium and glucose) and exogenous (e.g., mannitol) solutes that are capable of creating an osmotic gradient across the membranes. In case of change in effective blood osmolality, water shifts from the compartment with low osmolality into the compartment with high osmolarity in order to restore serum osmolality. The difference between measured osmolality and calculated osmolarity forms the osmolal gap. An increase in serum osmolal gap can stem from the presence of solutes that are not included in the osmolarity calculation, such as hypertonic treatments or toxic alcoholic ingestions. In clinical practice, determination of serum osmolality and osmolal gap is important in the diagnosis of disorders related to sodium, glucose and water balance, kidney diseases, and small molecule poisonings. As blood hypertonicity exerts its main effects on the brain cells, neurologic symptoms varying from mild neurologic signs and symptoms to life-threatening outcomes such as convulsions or even death may occur. Therefore, hypertonic states should be promptly diagnosed and cautiously managed. In this review, the causes and treatment strategies of hyperosmolar conditions including hypernatremia, diabetic ketoacidosis, hyperglycemic hyperosmolar syndrome, hypertonic treatments, or intoxications are discussed in detail to increase awareness of this important topic with significant clinical consequences.
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Affiliation(s)
- Bahar Büyükkaragöz
- Department of Pediatric Nephrology, Gazi University, 06560, Besevler, Ankara, Turkey.
| | - Sevcan A Bakkaloğlu
- Department of Pediatric Nephrology, Gazi University, 06560, Besevler, Ankara, Turkey
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2
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Volume replacement is associated with a diminished osmolar effect of mannitol in patients with acute brain injury. J Stroke Cerebrovasc Dis 2022; 31:106867. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 10/24/2022] [Accepted: 10/26/2022] [Indexed: 11/05/2022] Open
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Susanto M, Riantri I. The Optimal Dose and Concentration of Hypertonic Saline in Traumatic Brain Injury - A Systematic Review. Medeni Med J 2022; 37:203-211. [PMID: 35735001 PMCID: PMC9234368 DOI: 10.4274/mmj.galenos.2022.75725] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Management of increased intracranial pressure in traumatic brain injury remains challenging in neurosurgical emergencies. The mainstay of medical management for increased intracranial pressure is hyperosmolar therapy with mannitol or hypertonic saline. Mannitol has been the “gold standard” osmotic agent for almost a century. Given its wide usage, there has been a dilemma of concern because of its adverse effects. Over the past few decades, hypertonic saline has become an increasingly better alternative. To date, there is no consensus on the optimal therapeutic dose and concentration of hypertonic saline for treating increased intracranial pressure. This systematic review aimed to compare the efficacy of hypertonic saline and mannitol in the management of traumatic brain injury and investigate the optimal dose and concentration of hypertonic saline for the treatment. Extensive research was conducted on PubMed, DOAJ, and Cochrane databases. Studies published within the last 20 years were included. Research articles in the form of meta-analyses, clinical trials, and randomized controlled trials were preferred. Those with ambiguous remarks, irrelevant correlations to the main issue, or a focus on other disorders were excluded. Nineteen studies were included in the systematic review. Eleven studies have stated that hypertonic saline and mannitol were equally efficacious, whereas eight studies have reported that hypertonic saline was superior. Moreover, 3% hypertonic saline was the main concentration most discussed in research. Improvements in increased intracranial pressure, cerebral perfusion pressure, survival rate, brain relaxation, and systemic hemodynamics were observed. Hypertonic saline is worthy of consideration as an excellent alternative to mannitol. This study suggests 3% hypertonic saline as the optimal concentration, with the therapeutic dose from 1.4 to 2.5 mL/kg, given as a bolus.
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Blomqvist KJ, Skogster MOB, Kurkela MJ, Rosenholm MP, Ahlström FHG, Airavaara MT, Backman JT, Rauhala PV, Kalso EA, Lilius TO. Systemic hypertonic saline enhances glymphatic spinal cord delivery of lumbar intrathecal morphine. J Control Release 2022; 344:214-224. [PMID: 35301056 DOI: 10.1016/j.jconrel.2022.03.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 03/09/2022] [Accepted: 03/10/2022] [Indexed: 12/13/2022]
Abstract
The blood-brain barrier significantly limits effective drug delivery to central nervous system (CNS) targets. The recently characterized glymphatic system offers a perivascular highway for intrathecally (i.t.) administered drugs to reach deep brain structures. Although periarterial cerebrospinal fluid (CSF) influx and concomitant brain drug delivery can be enhanced by pharmacological or hyperosmotic interventions, their effects on drug delivery to the spinal cord, an important target for many drugs, have not been addressed. Hence, we studied in rats whether enhancement of periarterial flow by systemic hypertonic solution might be utilized to enhance spinal delivery and efficacy of i.t. morphine. We also studied whether the hyperosmolar intervention affects brain or cerebrospinal fluid drug concentrations after systemic administration. Periarterial CSF influx was enhanced by intraperitoneal injection of hypertonic saline (HTS, 5.8%, 20 ml/kg, 40 mOsm/kg). The antinociceptive effects of morphine were characterized, using tail flick, hot plate and paw pressure tests. Drug concentrations in serum, tissue and microdialysis samples were determined by liquid chromatography-tandem mass spectrometry. Compared with isotonic solution, HTS increased concentrations of spinal i.t. administered morphine by 240% at the administration level (T13-L1) at 60 min and increased the antinociceptive effect of morphine in tail flick, hot plate, and paw pressure tests. HTS also independently increased hot plate and paw pressure latencies but had no effect in the tail flick test. HTS transiently increased the penetration of intravenous morphine into the lateral ventricle, but not into the hippocampus. In conclusion, acute systemic hyperosmolality is a promising intervention for enhanced spinal delivery of i.t. administered morphine. The relevance of this intervention should be expanded to other i.t. drugs and brought to clinical trials.
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Affiliation(s)
- Kim J Blomqvist
- Department of Pharmacology, Faculty of Medicine, University of Helsinki, Helsinki, Finland; Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland.
| | - Moritz O B Skogster
- Department of Pharmacology, Faculty of Medicine, University of Helsinki, Helsinki, Finland; Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Mika J Kurkela
- Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland; Department of Clinical Pharmacology, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Marko P Rosenholm
- Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland; Center for Translational Neuromedicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Fredrik H G Ahlström
- Department of Pharmacology, Faculty of Medicine, University of Helsinki, Helsinki, Finland; Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Mikko T Airavaara
- Faculty of Pharmacy and Neuroscience Center, University of Helsinki, Helsinki, Finland
| | - Janne T Backman
- Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland; Department of Clinical Pharmacology, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Pekka V Rauhala
- Department of Pharmacology, Faculty of Medicine, University of Helsinki, Helsinki, Finland; Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Eija A Kalso
- Department of Pharmacology, Faculty of Medicine, University of Helsinki, Helsinki, Finland; Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and University of Helsinki, Finland; SleepWell Research Programme, Faculty of Medicine, University of Helsinki, Finland
| | - Tuomas O Lilius
- Department of Pharmacology, Faculty of Medicine, University of Helsinki, Helsinki, Finland; Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland; Center for Translational Neuromedicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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5
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Soares MS, Andrade AFD, Brasil S, DE-Lima-Oliveira M, Belon AR, Bor-Seng-Shu E, Nogueira RDC, Godoy DA, Paiva WS. Evaluation of cerebral hemodynamics by transcranial Doppler ultrasonography and its correlation with intracranial pressure in an animal model of intracranial hypertension. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:344-352. [PMID: 35195225 DOI: 10.1590/0004-282x-anp-2020-0591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 04/30/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Transcranial Doppler has been tested in the evaluation of cerebral hemodynamics as a non-invasive assessment of intracranial pressure (ICP), but there is controversy in the literature about its actual benefit and usefulness in this situation. OBJECTIVE To investigate cerebral blood flow assessed by Doppler technique and correlate with the variations of the ICP in the acute phase of intracranial hypertension in an animal model. METHODS An experimental animal model of intracranial hypertension was used. The experiment consisted of two groups of animals in which intracranial balloons were implanted and inflated with 4 mL (A) and 7 mL (B) for controlled simulation of different volumes of hematoma. The values of ICP and Doppler parameters (systolic [FVs], diastolic [FVd], and mean [FVm] cerebral blood flow velocities and pulsatility index [PI]) were collected during the entire procedure (before and during hematoma simulations and venous hypertonic saline infusion intervention). Comparisons between Doppler parameters and ICP monitoring were performed. RESULTS Twenty pigs were studied, 10 in group A and 10 in group B. A significant correlation between PI and ICP was obtained, especially shortly after abrupt elevation of ICP. There was no correlation between ICP and FVs, FVd or FVm separately. There was also no significant change in ICP after intravenous infusion of hypertonic saline solution. CONCLUSIONS These results demonstrate the potential of PI as a parameter for the evaluation of patients with suspected ICP elevation.
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Affiliation(s)
- Matheus Schmidt Soares
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil
| | | | - Sérgio Brasil
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil
| | - Marcelo DE-Lima-Oliveira
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil
| | - Alessandro Rodrigo Belon
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil
| | - Edson Bor-Seng-Shu
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil
| | | | - Daniel Agustin Godoy
- Hospital Carlos G. Malbrán, Sanatorio Pasteur, Unidad de Cuidados Intensivos, Catamarca, Argentina
| | - Wellingson Silva Paiva
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil
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Lin JJ, Kuo HC, Hsia SH, Lin YJ, Wang HS, Hsu MH, Chiang MC, Chan OW, Lee EP, Lin KL. The Utility of a Point-of-Care Transcranial Doppler Ultrasound Management Algorithm on Outcomes in Pediatric Asphyxial Out-of-Hospital Cardiac Arrest – An Exploratory Investigation. Front Med (Lausanne) 2022; 8:690405. [PMID: 35155456 PMCID: PMC8832099 DOI: 10.3389/fmed.2021.690405] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 12/31/2021] [Indexed: 11/13/2022] Open
Abstract
Background Transcranial Doppler ultrasound is a sensitive, real time tool used for monitoring cerebral blood flow; it could provide additional information for cerebral perfusion in cerebral resuscitation during post cardiac arrest care. The aim of the current study was to evaluate the utility of a point-of-care transcranial Doppler ultrasound management algorithm on outcomes in pediatric asphyxial out-of-hospital cardiac arrest. Methods This retrospective cohort study was conducted in two tertiary pediatric intensive care units between January 2013 and June 2018. All children between 1 month and 18 years of age with asphyxial out-of-hospital cardiac arrest and a history of at least 3 min of chest compressions, who were treated with therapeutic hypothermia and survived for 12 h or more after the return of circulation were eligible for inclusion. Results Twenty-one patients met the eligibility criteria for the study. Sixteen (76.2%) of the 21 children were male, and the mean age was 2.8 ± 4.1 years. Seven (33.3%) of the children had underlying disorders. The overall 1-month survival rate was 52.4%. Twelve (57.1%) of the children received point-of-care transcranial Doppler ultrasound. The 1-month survival rate was significantly higher (p = 0.03) in the point-of-care transcranial Doppler ultrasound group (9/12, 75%) than in the non-point-of-care transcranial Doppler ultrasound group (2/9, 22.2%). Conclusions Point-of-care transcranial Doppler ultrasound group was associated with a significantly better 1-month survival rate compared with no point-of-care transcranial Doppler ultrasound group in pediatric asphyxial out-of-hospital cardiac arrest.
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Affiliation(s)
- Jainn-Jim Lin
- Division of Pediatric Critical Care and Pediatric Neurocritical Care Center, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
- Graduate Institute of Clinical Medical Sciences, Chang Gung University, College of Medicine, Taoyuan, Taiwan
- Division of Pediatric Neurology, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
- Department of Respiratory Therapy, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Hsuan-Chang Kuo
- Division of Cardiology, Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Division of Critical Care, Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Shao-Hsuan Hsia
- Division of Pediatric Critical Care and Pediatric Neurocritical Care Center, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ying-Jui Lin
- Division of Cardiology, Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Division of Critical Care, Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Huei-Shyong Wang
- Division of Pediatric Neurology, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Mei-Hsin Hsu
- Division of Critical Care, Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Division of Neurology, Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Ming-Chou Chiang
- Graduate Institute of Clinical Medical Sciences, Chang Gung University, College of Medicine, Taoyuan, Taiwan
- Department of Respiratory Therapy, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
- Division of Neonatology, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Oi-Wa Chan
- Division of Pediatric Critical Care and Pediatric Neurocritical Care Center, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - En-Pei Lee
- Division of Pediatric Critical Care and Pediatric Neurocritical Care Center, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Kuang-Lin Lin
- Division of Pediatric Neurology, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
- *Correspondence: Kuang-Lin Lin
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A Quasi-Physiological Microfluidic Blood-Brain Barrier Model for Brain Permeability Studies. Pharmaceutics 2021; 13:pharmaceutics13091474. [PMID: 34575550 PMCID: PMC8468926 DOI: 10.3390/pharmaceutics13091474] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 09/11/2021] [Accepted: 09/13/2021] [Indexed: 01/25/2023] Open
Abstract
Microfluidics-based organ-on-a-chip technology allows for developing a new class of in-vitro blood-brain barrier (BBB) models that recapitulate many hemodynamic and architectural features of the brain microvasculature not attainable with conventional two-dimensional platforms. Herein, we describe and validate a novel microfluidic BBB model that closely mimics the one in situ. Induced pluripotent stem cell (iPSC)-derived brain microvascular endothelial cells (BMECs) were juxtaposed with primary human pericytes and astrocytes in a co-culture to enable BBB-specific characteristics, such as low paracellular permeability, efflux activity, and osmotic responses. The permeability coefficients of [13C12] sucrose and [13C6] mannitol were assessed using a highly sensitive LC-MS/MS procedure. The resulting BBB displayed continuous tight-junction patterns, low permeability to mannitol and sucrose, and quasi-physiological responses to hyperosmolar opening and p-glycoprotein inhibitor treatment, as demonstrated by decreased BBB integrity and increased permeability of rhodamine 123, respectively. Astrocytes and pericytes on the abluminal side of the vascular channel provided the environmental cues necessary to form a tight barrier and extend the model’s long-term viability for time-course studies. In conclusion, our novel multi-culture microfluidic platform showcased the ability to replicate a quasi-physiological brain microvascular, thus enabling the development of a highly predictive and translationally relevant BBB model.
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Mohney N, Alkhatib O, Koch S, O'Phelan K, Merenda A. What is the Role of Hyperosmolar Therapy in Hemispheric Stroke Patients? Neurocrit Care 2021; 32:609-619. [PMID: 31342452 DOI: 10.1007/s12028-019-00782-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The role of hyperosmolar therapy (HT) in large hemispheric ischemic or hemorrhagic strokes remains a controversial issue. Past and current stroke guidelines state that it represents a reasonable therapeutic measure for patients with either neurological deterioration or intracranial pressure (ICP) elevations documented by ICP monitoring. However, the lack of evidence for a clear effect of this therapy on radiological tissue shifts and clinical outcomes produces uncertainty with respect to the appropriateness of its implementation and duration in the context of radiological mass effect without clinical correlates of neurological decline or documented elevated ICP. In addition, limited data suggest a theoretical potential for harm from the prophylactic and protracted use of HT in the setting of large hemispheric lesions. HT exerts effects on parenchymal volume, cerebral blood volume and cerebral perfusion pressure which may ameliorate global ICP elevation and cerebral blood flow; nevertheless, it also holds theoretical potential for aggravating tissue shifts promoted by significant interhemispheric ICP gradients that may arise in the setting of a large unilateral supratentorial mass lesion. The purpose of this article is to review the literature in order to shed light on the effects of HT on brain tissue shifts and clinical outcome in the context of large hemispheric strokes, as well as elucidate when HT should be initiated and when it should be avoided.
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Affiliation(s)
- Nathan Mohney
- Department of Neurology, University of Miami Health System, 1120 NW 14th Street, Miami, FL, 33136, USA
- Department of Neurosurgery, University of Miami Health System, 1120 NW 14th Street, Miami, FL, 33136, USA
| | - Omar Alkhatib
- Department of Neurology, University of Miami Health System, 1120 NW 14th Street, Miami, FL, 33136, USA
- Department of Neurosurgery, University of Miami Health System, 1120 NW 14th Street, Miami, FL, 33136, USA
| | - Sebastian Koch
- Department of Neurology, University of Miami Health System, 1120 NW 14th Street, Miami, FL, 33136, USA
- Department of Neurosurgery, University of Miami Health System, 1120 NW 14th Street, Miami, FL, 33136, USA
| | - Kristine O'Phelan
- Department of Neurology, University of Miami Health System, 1120 NW 14th Street, Miami, FL, 33136, USA
- Department of Neurosurgery, University of Miami Health System, 1120 NW 14th Street, Miami, FL, 33136, USA
| | - Amedeo Merenda
- Department of Neurology, University of Miami Health System, 1120 NW 14th Street, Miami, FL, 33136, USA.
- Department of Neurosurgery, University of Miami Health System, 1120 NW 14th Street, Miami, FL, 33136, USA.
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9
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Wang T, Kleiven S, Li X. Designing electrode configuration of electroosmosis based edema treatment as a complement to hyperosmotic therapy. Acta Neurochir (Wien) 2021; 163:2603-2614. [PMID: 34291383 PMCID: PMC8357759 DOI: 10.1007/s00701-021-04938-5] [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: 05/05/2021] [Accepted: 07/11/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Hyperosmotic therapy is a mainstay treatment for cerebral edema. Although often effective, its disadvantages include mainly acting on the normal brain region with limited effectiveness in eliminating excess fluid in the edema region. This study investigates how to configure our previously proposed novel electroosmosis based edema treatment as a complement to hyperosmotic therapy. METHODS Three electrode configurations are designed to drive the excess fluid out of the edema region, including 2-electrode, 3-electrode, and 5-electrode designs. The focality and directionality of the induced electroosmotic flow (EOF) are then investigated using the same patient-specific head model with localized edema. RESULTS The 5-electrode design shows improved EOF focality with reduced effect on the normal brain region than the other two designs. Importantly, this design also achieves better directionality driving excess edema tissue fluid to a larger region of surrounding normal brain where hyperosmotic therapy functions better. Thus, the 5-electrode design is suggested to treat edema more efficiently via a synergic effect: the excess fluid is first driven out from the edema to surrounding normal brain via EOF, where it can then be treated with hyperosmotic therapy. Meanwhile, the 5-electrode design drives 2.22 mL excess fluid from the edema region in an hour comparable to the other designs, indicating a similar efficiency of EOF. CONCLUSIONS The results show that the promise of our previously proposed novel electroosmosis based edema treatment can be designed to achieve better focality and directionality towards a complement to hyperosmotic therapy.
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Affiliation(s)
- Teng Wang
- Division of Neuronic Engineering, Department of Biomedical Engineering and Health Systems, KTH Royal Institute of Technology, Hälsovägen 11C, SE-141 52, Huddinge, Sweden.
| | - Svein Kleiven
- Division of Neuronic Engineering, Department of Biomedical Engineering and Health Systems, KTH Royal Institute of Technology, Hälsovägen 11C, SE-141 52, Huddinge, Sweden
| | - Xiaogai Li
- Division of Neuronic Engineering, Department of Biomedical Engineering and Health Systems, KTH Royal Institute of Technology, Hälsovägen 11C, SE-141 52, Huddinge, Sweden
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10
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Rakhit S, Nordness MF, Lombardo SR, Cook M, Smith L, Patel MB. Management and Challenges of Severe Traumatic Brain Injury. Semin Respir Crit Care Med 2020; 42:127-144. [PMID: 32916746 DOI: 10.1055/s-0040-1716493] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Traumatic brain injury (TBI) is the leading cause of death and disability in trauma patients, and can be classified into mild, moderate, and severe by the Glasgow coma scale (GCS). Prehospital, initial emergency department, and subsequent intensive care unit (ICU) management of severe TBI should focus on avoiding secondary brain injury from hypotension and hypoxia, with appropriate reversal of anticoagulation and surgical evacuation of mass lesions as indicated. Utilizing principles based on the Monro-Kellie doctrine and cerebral perfusion pressure (CPP), a surrogate for cerebral blood flow (CBF) should be maintained by optimizing mean arterial pressure (MAP), through fluids and vasopressors, and/or decreasing intracranial pressure (ICP), through bedside maneuvers, sedation, hyperosmolar therapy, cerebrospinal fluid (CSF) drainage, and, in refractory cases, barbiturate coma or decompressive craniectomy (DC). While controversial, direct ICP monitoring, in conjunction with clinical examination and imaging as indicated, should help guide severe TBI therapy, although new modalities, such as brain tissue oxygen (PbtO2) monitoring, show great promise in providing strategies to optimize CBF. Optimization of the acute care of severe TBI should include recognition and treatment of paroxysmal sympathetic hyperactivity (PSH), early seizure prophylaxis, venous thromboembolism (VTE) prophylaxis, and nutrition optimization. Despite this, severe TBI remains a devastating injury and palliative care principles should be applied early. To better affect the challenging long-term outcomes of severe TBI, more and continued high quality research is required.
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Affiliation(s)
- Shayan Rakhit
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mina F Nordness
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sarah R Lombardo
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Madison Cook
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Meharry Medical College, Nashville, Tennessee
| | - Laney Smith
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Washington and Lee University, Lexington, Virginia
| | - Mayur B Patel
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Neurosurgery and Hearing and Speech Sciences, Vanderbilt Brain Institute, Vanderbilt University Medical Center, Nashville, Tennessee.,Surgical Service, Nashville VA Medical Center, Tennessee Valley Healthcare System, US Department of Veterans Affairs, Nashville, Tennessee.,Geriatric Research, Education, and Clinical Center Service, Nashville VA Medical Center, Tennessee Valley Healthcare System, US Department of Veterans Affairs, Nashville, Tennessee
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11
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Nguyen T, Pope K, Capobianco P, Cao-Pham M, Hassan S, Kole MJ, O'Connell C, Wessell A, Strong J, Tran QK. Sedation Patterns and Hyperosmolar Therapy in Emergency Departments were Associated with Blood Pressure Variability and Outcomes in Patients with Spontaneous Intracranial Hemorrhage. J Emerg Trauma Shock 2020; 13:151-160. [PMID: 33013096 PMCID: PMC7472811 DOI: 10.4103/jets.jets_76_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 11/02/2019] [Accepted: 11/21/2019] [Indexed: 11/04/2022] Open
Abstract
Background Spontaneous intracranial hemorrhage (sICH) is associated with high mortality. Little information exists to guide initial resuscitation in the emergency department (ED) setting. However, blood pressure variability (BPV) and mechanical ventilation (MV) are known risk factors for poor outcome in sICH. Objectives The objective was to examine the associations between BPV and MV in ED (EDMV) and between two ED interventions - post-MV sedation and hyperosmolar therapy for elevated intracranial pressure - and BPV in the ED and in-hospital mortality. Methods We retrospectively studied adults with sICH and external ventricular drainage who were transferred to a quaternary academic medical center from other hospitals between January 2011 and September 2015. We used multivariable linear and logistic regressions to measure associations between clinical factors, BPV, and outcomes. Results We analyzed ED records from 259 patients. There were 143 (55%) EDMV patients who had more severe clinical factors and significantly higher values of all BPV indices than NoEDMV patients. Two clinical factors and none of the severity scores (i.e., Hunt and Hess, World Federation of Neurological Surgeons Grades, ICH score) correlated with BPV. Hyperosmolarity therapy without fluid resuscitation positively correlated with all BPV indices, whereas propofol infusion plus a narcotic negatively correlated with one of them. Two BPV indices, i.e., successive variation of blood pressure (BPSV) and absolute difference in blood pressure between ED triage and departure (BPDepart - Triage), were significantly associated with increased mortality rate. Conclusion Patients receiving MV had significantly higher BPV, perhaps related to disease severity. Good ED sedation, hyperosmolar therapy, and fluid resuscitation were associated with less BPV and lower likelihood of death.
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Affiliation(s)
- Tina Nguyen
- Department of Emergency Medicine, University of Maryland School of Medicine, College Park, MD, USA
| | - Kanisha Pope
- Department of Emergency Medicine, University of Maryland School of Medicine, College Park, MD, USA
| | - Paul Capobianco
- Research Associate Program in Emergency Medicine and Critical Care, University of Maryland, School of Medicine, College Park, MD, USA
| | - Mimi Cao-Pham
- Research Associate Program in Emergency Medicine and Critical Care, University of Maryland, School of Medicine, College Park, MD, USA
| | - Soha Hassan
- Department of Statistics, University of Maryland at College Park, College Park, MD, USA
| | - Matthew J Kole
- Department of Neurosurgery, University of Maryland School of Medicine, College Park, MD, USA
| | - Claire O'Connell
- Department of Emergency Medicine, University of Maryland School of Medicine, College Park, MD, USA
| | - Aaron Wessell
- Department of Neurosurgery, University of Maryland School of Medicine, College Park, MD, USA
| | - Jonathan Strong
- Department of Emergency Medicine, University of Maryland School of Medicine, College Park, MD, USA
| | - Quincy K Tran
- Department of Emergency Medicine, University of Maryland School of Medicine, College Park, MD, USA.,R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, College Park, MD, USA
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12
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Zusman BE, Kochanek PM, Jha RM. Cerebral Edema in Traumatic Brain Injury: a Historical Framework for Current Therapy. Curr Treat Options Neurol 2020; 22:9. [PMID: 34177248 PMCID: PMC8223756 DOI: 10.1007/s11940-020-0614-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE OF REVIEW The purposes of this narrative review are to (1) summarize a contemporary view of cerebral edema pathophysiology, (2) present a synopsis of current management strategies in the context of their historical roots (many of which date back multiple centuries), and (3) discuss contributions of key molecular pathways to overlapping edema endophenotypes. This may facilitate identification of important therapeutic targets. RECENT FINDINGS Cerebral edema and resultant intracranial hypertension are major contributors to morbidity and mortality following traumatic brain injury. Although Starling forces are physical drivers of edema based on differences in intravascular vs extracellular hydrostatic and oncotic pressures, the molecular pathophysiology underlying cerebral edema is complex and remains incompletely understood. Current management protocols are guided by intracranial pressure measurements, an imperfect proxy for cerebral edema. These include decompressive craniectomy, external ventricular drainage, hyperosmolar therapy, hypothermia, and sedation. Results of contemporary clinical trials assessing these treatments are summarized, with an emphasis on the gap between intermediate measures of edema and meaningful clinical outcomes. This is followed by a brief statement summarizing the most recent guidelines from the Brain Trauma Foundation (4th edition). While many molecular mechanisms and networks contributing to cerebral edema after TBI are still being elucidated, we highlight some promising molecular mechanism-based targets based on recent research including SUR1-TRPM4, NKCC1, AQP4, and AVP1. SUMMARY This review outlines the origins of our understanding of cerebral edema, chronicles the history behind many current treatment approaches, and discusses promising molecular mechanism-based targeted treatments.
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Affiliation(s)
- Benjamin E. Zusman
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Institute for Clinical Research Education, University of Pittsburgh, Pittsburgh, PA, USA
- Clinical and Translational Science Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Patrick M. Kochanek
- Clinical and Translational Science Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- UPMC Children’s Hospital of Pittsburgh, UPMC, Pittsburgh, PA, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, John G. Rangos Research Center, Pittsburgh, PA, USA
| | - Ruchira M. Jha
- Clinical and Translational Science Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, John G. Rangos Research Center, Pittsburgh, PA, USA
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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13
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Erndt-Marino J, Yeisley DJ, Chen H, Levin M, Kaplan DL, Hahn MS. Interferon-Gamma Stimulated Murine Macrophages In Vitro: Impact of Ionic Composition and Osmolarity and Therapeutic Implications. Bioelectricity 2020; 2:48-58. [PMID: 32292895 PMCID: PMC7107958 DOI: 10.1089/bioe.2019.0032] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background: Injections of osmolytes are promising immunomodulatory treatments for medical benefit, although the rationale and underlying mechanisms are often lacking. The goals of the present study were twofold: (1) to clarify the anti-inflammatory role of the potassium ion and (2) to begin to decouple the effects that ionic strength, ionic species, and osmolarity have on macrophage biology. Materials and Methods: RAW 264.7 murine macrophages were encapsulated in three-dimensional, poly(ethylene glycol) diacrylate hydrogels and activated with interferon-gamma to yield M(IFN). Gene and protein profiles were made of M(IFN) exposed to different hyperosmolar treatments (80 mM potassium gluconate, 80 mM sodium gluconate, and 160 mM sucrose). Results: Relative to M(IFN), all hyperosmolar treatments suppressed expression of pro-inflammatory markers (nitric oxide synthase-2 [NOS-2], tumor necrosis factor-alpha, monocyte chemoattractant protein-1 [MCP-1]) and increased messenger RNA (mRNA) expression of the pleiotropic and angiogenic markers interleukin-6 (IL-6) and vascular endothelial growth factor-A (VEGF), respectively. Ionic osmolytes also demonstrated a greater level of change compared to the nonionic treatments, with mRNA levels of IL-6 the most significantly affected. M(IFN) exposed to K+ exhibited the lowest levels of NOS-2 and MCP-1, and this ion limited IL-6 release induced by osmolarity. Conclusion: Cumulatively, these data suggest that osmolyte composition, ionic strength, and osmolarity are all parameters that can influence therapeutic outcomes. Future work is necessary to further decouple and mechanistically understand the influence that these biophysical parameters have on cell biology, including their impact on other macrophage functions, intracellular osmolyte composition, and cellular and organellular membrane potentials.
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Affiliation(s)
- Joshua Erndt-Marino
- Department of Biomedical Engineering, Rensselaer Polytechnic Institute, Troy, New York
- Department of Biomedical Engineering, Tufts University, Medford, Massachusetts
- Department of Biology, Allen Discovery Center at Tufts University, Tufts University, Medford, Massachusetts
| | - Daniel J. Yeisley
- Department of Biomedical Engineering, Rensselaer Polytechnic Institute, Troy, New York
| | - Hongyu Chen
- Department of Biomedical Engineering, Rensselaer Polytechnic Institute, Troy, New York
| | - Michael Levin
- Department of Biology, Allen Discovery Center at Tufts University, Tufts University, Medford, Massachusetts
| | - David L. Kaplan
- Department of Biomedical Engineering, Tufts University, Medford, Massachusetts
- Department of Biology, Allen Discovery Center at Tufts University, Tufts University, Medford, Massachusetts
| | - Mariah S. Hahn
- Department of Biomedical Engineering, Rensselaer Polytechnic Institute, Troy, New York
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Changa AR, Czeisler BM, Lord AS. Management of Elevated Intracranial Pressure: a Review. Curr Neurol Neurosci Rep 2019; 19:99. [DOI: 10.1007/s11910-019-1010-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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15
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Halstead MR, Geocadin RG. The Medical Management of Cerebral Edema: Past, Present, and Future Therapies. Neurotherapeutics 2019; 16:1133-1148. [PMID: 31512062 PMCID: PMC6985348 DOI: 10.1007/s13311-019-00779-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Cerebral edema is commonly associated with cerebral pathology, and the clinical manifestation is largely related to the underlying lesioned tissue. Brain edema usually amplifies the dysfunction of the lesioned tissue and the burden of cerebral edema correlates with increased morbidity and mortality across diseases. Our modern-day approach to the medical management of cerebral edema has largely revolved around, an increasingly artificial distinction between cytotoxic and vasogenic cerebral edema. These nontargeted interventions such as hyperosmolar agents and sedation have been the mainstay in clinical practice and offer noneloquent solutions to a dire problem. Our current understanding of the underlying molecular mechanisms driving cerebral edema is becoming much more advanced, with differences being identified across diseases and populations. As our understanding of the underlying molecular mechanisms in neuronal injury continues to expand, so too is the list of targeted therapies in the pipeline. Here we present a brief review of the molecular mechanisms driving cerebral edema and a current overview of our understanding of the molecular targets being investigated.
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Affiliation(s)
- Michael R Halstead
- Neurosciences Critical Care Division, Departments of Neurology, Anesthesiology-Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, 21287, USA.
| | - Romergryko G Geocadin
- Neurosciences Critical Care Division, Departments of Neurology, Anesthesiology-Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, 21287, USA
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16
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Ma P, Zha S, Shen X, Zhao Y, Li L, Yang L, Lei M, Liu W. NFAT5 mediates hypertonic stress-induced atherosclerosis via activating NLRP3 inflammasome in endothelium. Cell Commun Signal 2019; 17:102. [PMID: 31429763 PMCID: PMC6701070 DOI: 10.1186/s12964-019-0406-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 07/28/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND How high-salt intake leads to the occurrence of many cardiovascular diseases such as atherosclerosis is a fundamental question in pathology. Here we postulated that high-salt-induced NFAT5 controls the inflammasome activation by directly regulating NLRP3, which mediates the expression of inflammatory- and adhesion-related genes in vascular endothelium, resulting in the formation of atherosclerosis. METHODS Atherosclerosis-prone apolipoprotein E-deficient (ApoE-/-) mice which accumulate cholesterol ester-enriched particles in the blood due to poor lipoprotein clearance capacity were used as the atherosclerosis model in vivo. Cultured endothelial cells (ECs) and monocytes under high-salt condition were used to explore the atheroprone role of the activation of NFAT5-NLRP3 inflammasome in vascular endothelium in vitro. Bioinformatic analysis and chromatin immunoprecipitation assay were used to identify the DNA binding sites of NFAT5 on promoters of NLRP3 and IL-1β. RESULTS We first observe that high-salt intake promotes atherosclerosis formation in the aortas of ApoE-/- mice, through inducing the expression of NFAT5, NLRP3, and IL-1β in endothelium. Overexpression of NFAT5 activates NLRP3-inflammasome and increases the secretion of IL-1β in ECs partly via ROS. Chromatin immunoprecipitation assay demonstrates that NFAT5 directly binds to the promoter regions of NLRP3 and IL-1β in endothelial cells subjected to the high-salt environment. CONCLUSIONS Our study identifies NFAT5 as a new and essential transcription factor that is required for the early activation of NLRP3-inflammasome-mediated endothelium innate immunity, contributing to the formation of atherosclerosis under hypertonic stress induction.
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Affiliation(s)
- Pingping Ma
- Key Laboratory of Biorheological Science and Technology, Ministry of Education, Bioengineering College, Chongqing University, Chongqing, 400044, China
| | - Shenfang Zha
- Key Laboratory of Biorheological Science and Technology, Ministry of Education, Bioengineering College, Chongqing University, Chongqing, 400044, China
| | - Xinkun Shen
- Key Laboratory of Biorheological Science and Technology, Ministry of Education, Bioengineering College, Chongqing University, Chongqing, 400044, China
| | - Yulan Zhao
- Key Laboratory of Biorheological Science and Technology, Ministry of Education, Bioengineering College, Chongqing University, Chongqing, 400044, China
| | - Li Li
- Key Laboratory of Biorheological Science and Technology, Ministry of Education, Bioengineering College, Chongqing University, Chongqing, 400044, China
| | - Li Yang
- Key Laboratory of Biorheological Science and Technology, Ministry of Education, Bioengineering College, Chongqing University, Chongqing, 400044, China
| | - Mingxing Lei
- Integrative Stem Cell Center, China Medical University Hospital, China Medical University, Taichung, 40402, Taiwan. .,Institute of New Drug Development, College of Biopharmaceutical and Food Sciences, China Medical University, Taichung, 40402, Taiwan.
| | - Wanqian Liu
- Key Laboratory of Biorheological Science and Technology, Ministry of Education, Bioengineering College, Chongqing University, Chongqing, 400044, China.
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17
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Sekarningrum PA, Wati DK, Suwarba IGNM, Hartawan INB, Mahalini DS, Suparyatha IBG. Early mannitol administration improves clinical outcomes of pediatric patients with brain edema. MEDICAL JOURNAL OF INDONESIA 2018. [DOI: 10.13181/mji.v27i4.2377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Background: Mannitol 20% is used to treat patients with decreased consciousness and as the first line of treatment to reduce intracranial pressure (ICP). However, its application in pediatric patients is still based on minimal evidence. This study was performed to determine the predictive factors of clinical outcomes in pediatric patients with brain edema in the pediatric intensive care unit (PICU).Methods: This prospective cohort study was conducted in the PICU, Sanglah Hospital Denpasar, Bali, Indonesia. The subjects were chosen by consecutive sampling from July 2016 to July 2017. The primary outcome variable was the patient’s clinical outcome. A chi-square test was used to evaluate the association between the timing of mannitol administration and the patient’s clinical outcome. Multivariate analysis was performed on all variables with p≤0.25.Results: Forty-one patients were included in the study, 65% of them were male, 65% had good nutritional status, 90% had non-traumatic brain injury, and 73% had confirmed intracranial infection. The risk of sequelae or death for patients in a coma was 1.8 times greater than that of non-comatose patients (p=0.018; CI 95% 1.119–3.047). Based on the timing of mannitol administration from the onset of decreased consciousness, the risk of sequelae or death in patients who received mannitol after 24 hours was 2.1 times higher than that in patients who received mannitol within 24 hours (p=0.006; CI 95% 1.167–3.779). Based on multivariate analysis, only two variables were associated with the patient’s clinical outcome: pediatric Glasgow coma scale (PGCS) ≤3 (p=0.03) and timing of mannitol administration >24 hours (p=0.01).Conclusion: Early administration (<24 hours) of mannitol and high PGCS are related to favorable outcomes in patients with brain edema in the PICU.
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18
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Jha RM, Kochanek PM. A Precision Medicine Approach to Cerebral Edema and Intracranial Hypertension after Severe Traumatic Brain Injury: Quo Vadis? Curr Neurol Neurosci Rep 2018; 18:105. [PMID: 30406315 DOI: 10.1007/s11910-018-0912-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW Standard clinical protocols for treating cerebral edema and intracranial hypertension after severe TBI have remained remarkably similar over decades. Cerebral edema and intracranial hypertension are treated interchangeably when in fact intracranial pressure (ICP) is a proxy for cerebral edema but also other processes such as extent of mass lesions, hydrocephalus, or cerebral blood volume. A complex interplay of multiple molecular mechanisms results in cerebral edema after severe TBI, and these are not measured or targeted by current clinically available tools. Addressing these underpinnings may be key to preventing or treating cerebral edema and improving outcome after severe TBI. RECENT FINDINGS This review begins by outlining basic principles underlying the relationship between edema and ICP including the Monro-Kellie doctrine and concepts of intracranial compliance/elastance. There is a subsequent brief discussion of current guidelines for ICP monitoring/management. We then focus most of the review on an evolving precision medicine approach towards cerebral edema and intracranial hypertension after TBI. Personalization of invasive neuromonitoring parameters including ICP waveform analysis, pulse amplitude, pressure reactivity, and longitudinal trajectories are presented. This is followed by a discussion of cerebral edema subtypes (continuum of ionic/cytotoxic/vasogenic edema and progressive secondary hemorrhage). Mechanisms of potential molecular contributors to cerebral edema after TBI are reviewed. For each target, we present findings from preclinical models, and evaluate their clinical utility as biomarkers and therapeutic targets for cerebral edema reduction. This selection represents promising candidates with evidence from different research groups, overlap/inter-relatedness with other pathways, and clinical/translational potential. We outline an evolving precision medicine and translational approach towards cerebral edema and intracranial hypertension after severe TBI.
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Affiliation(s)
- Ruchira M Jha
- Department of Critical Care Medicine, Room 646A, Scaife Hall, 3550 Terrace Street, Pittsburgh, 15261, PA, USA.
- Safar Center for Resuscitation Research John G. Rangos Research Center, 6th Floor; 4401 Penn Avenue, Pittsburgh, PA, 15224, USA.
- Department of Neurology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
- Department of Neurological Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
- Clinical and Translational Science Institute, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Patrick M Kochanek
- Department of Critical Care Medicine, Room 646A, Scaife Hall, 3550 Terrace Street, Pittsburgh, 15261, PA, USA
- Safar Center for Resuscitation Research John G. Rangos Research Center, 6th Floor; 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
- Clinical and Translational Science Institute, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Anesthesiology, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- UPMC Children's Hospital of Pittsburgh John G. Rangos Research Center, 6th Floor 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
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Human iPSC-derived blood-brain barrier microvessels: validation of barrier function and endothelial cell behavior. Biomaterials 2018; 190-191:24-37. [PMID: 30391800 DOI: 10.1016/j.biomaterials.2018.10.023] [Citation(s) in RCA: 123] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 10/16/2018] [Accepted: 10/19/2018] [Indexed: 12/19/2022]
Abstract
Microvessels of the blood-brain barrier (BBB) regulate transport into the brain. The highly specialized brain microvascular endothelial cells, a major component of the BBB, express tight junctions and efflux transporters which regulate paracellular and transcellular permeability. However, most existing models of BBB microvessels fail to exhibit physiological barrier function. Here, using (iPSC)-derived human brain microvascular endothelial cells (dhBMECs) within templated type I collagen channels we mimic the cylindrical geometry, cell-extracellular matrix interactions, and shear flow typical of human brain post-capillary venules. We characterize the structure and barrier function in comparison to non-brain-specific microvessels, and show that dhBMEC microvessels recapitulate physiologically low solute permeability and quiescent endothelial cell behavior. Transcellular permeability is increased two-fold using a clinically relevant dose of a p-glycoprotein inhibitor tariquidar, while paracellular permeability is increased using a bolus dose of hyperosmolar agent mannitol. Lastly, we show that our human BBB microvessels are responsive to inflammatory cytokines via upregulation of surface adhesion molecules and increased leukocyte adhesion, but no changes in permeability. Human iPSC-derived blood-brain barrier microvessels support quantitative analysis of barrier function and endothelial cell dynamics in quiescence and in response to biologically- and clinically-relevant perturbations.
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20
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Serena K, Piva JP, Andreolio C, Carvalho PRA, Rocha TSD. Accidental strangulation in children by the automatic closing of a car window. Rev Bras Ter Intensiva 2018; 30:112-115. [PMID: 29742212 PMCID: PMC5885238 DOI: 10.5935/0103-507x.20180017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 04/13/2017] [Indexed: 11/21/2022] Open
Abstract
Among the main causes of death in our country are car accidents, drowning and
accidental burns. Strangulation is a potentially fatal injury and an important
cause of homicide and suicide among adults and adolescents. In children, its
occurrence is usually accidental. However, in recent years, several cases of
accidental strangulation in children around the world have been reported. A
2-year-old male patient was strangled in a car window. The patient was admitted
to the pediatric intensive care unit with a Glasgow Coma Scale score of 8 and
presented with progressive worsening of respiratory dysfunction and torpor. The
patient also presented acute respiratory distress syndrome, acute pulmonary
edema and shock. He was managed with protective mechanical ventilation,
vasoactive drugs and antibiotic therapy. He was discharged from the intensive
care unit without neurological or pulmonary sequelae. After 12 days of
hospitalization, he was discharged from the hospital, and his state was very
good. The incidence of automobile window strangulation is rare but of high
morbidity and mortality due to the resulting choking mechanism. Fortunately,
newer cars have devices that stop the automatic closing of the windows if
resistance is encountered. However, considering the severity of complications
strangulated patients experience, the intensive neuro-ventilatory and
hemodynamic management of the pathologies involved is important to reduce
morbidity and mortality, as is the need to implement new campaigns for the
education of parents and caregivers of children, aiming to avoid easily
preventable accidents and to optimize safety mechanisms in cars with electric
windows.
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Affiliation(s)
- Kailene Serena
- Unidade de Terapia Intensiva Pediátrica, Hospital das Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Jefferson Pedro Piva
- Unidade de Terapia Intensiva Pediátrica, Hospital das Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Cinara Andreolio
- Unidade de Terapia Intensiva Pediátrica, Hospital das Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | | | - Tais Sica da Rocha
- Pediatria, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
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Rossi S, Picetti E, Zoerle T, Carbonara M, Zanier ER, Stocchetti N. Fluid Management in Acute Brain Injury. Curr Neurol Neurosci Rep 2018; 18:74. [PMID: 30206730 DOI: 10.1007/s11910-018-0885-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
PURPOSE OF THE REVIEW The aims of fluid management in acute brain injury are to preserve or restore physiology and guarantee appropriate tissue perfusion, avoiding potential iatrogenic effects. We reviewed the literature, focusing on the clinical implications of the selected papers. Our purposes were to summarize the principles regulating the distribution of water between the intracellular, interstitial, and plasma compartments in the normal and the injured brain, and to clarify how these principles could guide fluid administration, with special reference to intracranial pressure control. RECENT FINDINGS Although a considerable amount of research has been published on this topic and in general on fluid management in acute illness, the quality of the evidence tends to vary. Intravascular volume management should aim for euvolemia. There is evidence of harm with aggressive administration of fluid aimed at achieving hypervolemia in cases of subarachnoid hemorrhage. Isotonic crystalloids should be the preferred agents for volume replacement, while colloids, glucose-containing hypotonic solutions, and other hypotonic solutions or albumin should be avoided. Osmotherapy seems to be effective in intracranial hypertension management; however, there is no clear evidence regarding the superiority of hypertonic saline over mannitol. Fluid therapy plays an important role in the management of acute brain injury patients. However, fluids are a double-edged weapon because of the potential risk of hyper-hydration, hypo- or hyper-osmolar conditions, which may unfavorably affect the clinical course and the outcome.
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Affiliation(s)
- Sandra Rossi
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43100, Parma, Italy.
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43100, Parma, Italy
| | - Tommaso Zoerle
- Neuro ICU, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marco Carbonara
- Neuro ICU, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Elisa R Zanier
- Department of Neuroscience, Laboratory of Acute Brain Injury and Therapeutic Strategies, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Nino Stocchetti
- Neuro ICU, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Physiopathology and Transplantation, Milan University, Milan, Italy
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Godoy DA, Lubillo S, Rabinstein AA. Pathophysiology and Management of Intracranial Hypertension and Tissular Brain Hypoxia After Severe Traumatic Brain Injury: An Integrative Approach. Neurosurg Clin N Am 2018; 29:195-212. [PMID: 29502711 DOI: 10.1016/j.nec.2017.12.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Monitoring intracranial pressure in comatose patients with severe traumatic brain injury (TBI) is considered necessary by most experts. Acute intracranial hypertension (IHT), when severe and sustained, is a life-threatening complication that demands emergency treatment. Yet, secondary anoxic-ischemic injury after brain trauma can occur in the absence of IHT. In such cases, adding other monitoring modalities can alert clinicians when the patient is in a state of energy failure. This article reviews the mechanisms, diagnosis, and treatment of IHT and brain hypoxia after TBI, emphasizing the need to develop a physiologically integrative approach to the management of these complex situations.
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Affiliation(s)
- Daniel Agustín Godoy
- Intensive Care Unit, San Juan Bautista Hospital, Catamarca, Argentina; Neurointensive Care Unit, Sanatorio Pasteur, Catamarca, Argentina.
| | - Santiago Lubillo
- Intensive Care Unit, Hospital Universitario NS de Candelaria, Tenerife, Spain
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Dunham CM, Malik RJ, Huang GS, Kohli CM, Brocker BP, Ugokwe KT. Hypertonic saline administration and complex traumatic brain injury outcomes: a retrospective study. INTERNATIONAL JOURNAL OF BURNS AND TRAUMA 2018; 8:40-53. [PMID: 30042863 PMCID: PMC6055080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 06/12/2018] [Indexed: 06/08/2023]
Abstract
Although hypertonic saline (HTS) decreases intracranial pressure (ICP) with traumatic brain injury (TBI), its effects on survival and post-discharge neurologic function are less certain. We assessed the impact of HTS administration on TBI outcomes and hypothesized that favorable outcomes would be associated with larger amounts of 3% saline. This is a retrospective study of consecutive-patients with the following criteria: blunt trauma, age 18-70 years, intracranial hemorrhage, Glasgow Coma Scale score (GCS) 3-12, and mechanical ventilation ≥ 5 days. The need for craniotomy or craniectomy denoted surgical decompression patients. Amounts of HTS were during the first-5 trauma center days. Traits for the 112 patients during 2012-2016 were as follows: GCS, 6.8 ± 3.2; subdural hematoma, 71.4%; cerebral contusion, 31.3%, ICP device, 47.3%; surgical decompression, 51.8%; ventilator days, 14.8 ± 6.7; trauma center mortality, 13.4%; and no commands at 3 months 35.5%. In surgically decompressed patients, trauma center mortality was greater with ≤ 8.0 mEq/kg sodium (38.9%) than with > 8.0 mEq/kg (7.5%; P = 0.0037). In surgically decompressed patients, following commands at 3 months was greater with ≥ 1400 mEq sodium (76.9%) than with < 1400 mEq (50.0%; P = 0.0489). For trauma center surviving non-decompression patients with no ICP device, those following commands at 3 months received more sodium (513 ± 784 mEq) than individuals not following commands (82 ± 144 mEq; P = 0.0142). For patients with a GCS 5-8, following commands at 3 months was greater with ≥ 1350 mEq sodium (92.3%) than with < 1350 mEq (60.0%; P = 0.0214). In patients with subdural hematoma or cerebral contusion, following commands at 3 months was greater with ≥ 1400 mEq sodium (84.2%) than with < 1400 mEq (61.8%; P = 0.0333). Patients with ICP > 20 mmHg for ≤ 10 hours (mean hours 2.0) received more sodium (16.5 ± 11.5 mEq/kg) when compared to ICP elevation for ≥ 11 hours (mean hours 34) (9.4 ± 6.3 mEq/kg; P = 0.0139). These observations demonstrate that hypertonic saline administration in patients with complex traumatic brain injury is associated with 1) mitigation of intracranial hypertension, 2) trauma center survival, and 3) following commands at 3 months post-injury.
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Affiliation(s)
- C Michael Dunham
- Trauma, Critical Care, General Surgery Services, St. Elizabeth Youngstown Hospital, Level I Trauma Center1044 Belmont Ave., Youngstown, OH 44501, USA
| | - Rema J Malik
- Department of Surgery, St. Elizabeth Youngstown Hospital, Level I Trauma Center1044 Belmont Ave., Youngstown, OH 44501, USA
| | - Gregory S Huang
- Trauma, Critical Care, General Surgery Services, St. Elizabeth Youngstown Hospital, Level I Trauma Center1044 Belmont Ave., Youngstown, OH 44501, USA
| | - Chander M Kohli
- Department of Neurosurgery, St. Elizabeth Youngstown Hospital, Level I Trauma Center1044 Belmont Ave., Youngstown, OH 44501, USA
| | - Brian P Brocker
- Department of Neurosurgery, St. Elizabeth Youngstown Hospital, Level I Trauma Center1044 Belmont Ave., Youngstown, OH 44501, USA
| | - Kene T Ugokwe
- Department of Neurosurgery, St. Elizabeth Youngstown Hospital, Level I Trauma Center1044 Belmont Ave., Youngstown, OH 44501, USA
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Tsaousi G, Stazi E, Cinicola M, Bilotta F. Cardiac output changes after osmotic therapy in neurosurgical and neurocritical care patients: a systematic review of the clinical literature. Br J Clin Pharmacol 2018; 84:636-648. [PMID: 29247499 DOI: 10.1111/bcp.13492] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 11/20/2017] [Accepted: 12/11/2017] [Indexed: 01/20/2023] Open
Abstract
AIM Osmotherapy constitutes a first-line intervention for intracranial hypertension management. However, hyperosmolar solutes exert various systematic effects, among which their impact on systemic haemodynamics is poorly clarified. This review aims to appraise the clinical evidence of the effect of mannitol and hypertonic saline (HTS) on cardiac performance in neurosurgical and neurocritical care patients. METHOD A database search was conducted to identify randomized clinical trials and observational studies reporting HTS or mannitol use in acute brain injury setting. The primary end-points were alterations of cardiac output (CO) and other haemodynamic variables, while the impact of osmotic agents on intracranial pressure, brain relaxation, plasma osmolality, electrolyte levels and urinary output constituted secondary outcomes. RESULTS Eight studies, enrolling 182 patients in total, were included. HTS exerted a more profound cardiac output augmentation than mannitol, but no distinct difference between groups occurred. Central venous pressure, stroke volume and stroke volume variation were favourably affected by both osmotic agents, whilst the reported changes in blood pressure were inconclusive. HTS infusion yielded a larger intracranial pressure reduction than mannitol but had an equivalent effect on brain relaxation. Mannitol presented a more potent diuretic effect than HTS. Effect on serum osmolality was alike in both osmotic agents, but contrary to HTS-promoted hypernatraemia, mannitol use induced transient hyponatraemia. CONCLUSIONS Mannitol or HTS administration seems to induce an enhancement of cardiac performance; being more prominent after HTS infusion. This effect combined with mannitol-induced enhancement of diuresis and HTS-promoted increase of plasma sodium concentration could partially explain the effects of osmotherapy on cerebral haemodynamics.
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Affiliation(s)
- Georgia Tsaousi
- Department of Anesthesiology and ICU, Faculty of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Elisabetta Stazi
- Department of Anesthesiology, University of Rome "La Sapienza", Rome, Italy
| | - Marco Cinicola
- Department of Anesthesiology, University of Rome "La Sapienza", Rome, Italy
| | - Federico Bilotta
- Department of Anesthesiology, University of Rome "La Sapienza", Rome, Italy
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Godoy DA, Videtta W, Di Napoli M. Practical Approach to Posttraumatic Intracranial Hypertension According to Pathophysiologic Reasoning. Neurol Clin 2017; 35:613-640. [DOI: 10.1016/j.ncl.2017.06.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Abstract
Traumatic brain injury (TBI) continues to be a major public health problem. Proposed treatments have not withstood testing in clinical trials because of failure to account for different types of TBI and other weaknesses in trial design. Management goals continue to be prevention and prompt treatment of secondary insults (hypotension, hypoxia, and other physiologic derangements). This goal is best accomplished by careful attention to airway, breathing, circulation, and basic principles of intensive care unit management. Attempts to intervene prophylactically to prevent intracranial hypertension or other complications have not been beneficial and may even have deleterious effects.
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Affiliation(s)
- Wittstatt Alexandra Whitaker-Lea
- Department of Neurosurgery, Virginia Commonwealth University, 417 North 11th Street, 6th Floor, PO Box 980631, Richmond, VA 23298-0631, USA
| | - Alex B Valadka
- Department of Neurosurgery, Virginia Commonwealth University, 417 North 11th Street, 6th Floor, PO Box 980631, Richmond, VA 23298-0631, USA.
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Dienel GA, Rothman DL, Nordström CH. Microdialysate concentration changes do not provide sufficient information to evaluate metabolic effects of lactate supplementation in brain-injured patients. J Cereb Blood Flow Metab 2016; 36:1844-1864. [PMID: 27604313 PMCID: PMC5094313 DOI: 10.1177/0271678x16666552] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 08/03/2016] [Indexed: 12/31/2022]
Abstract
Cerebral microdialysis is a widely used clinical tool for monitoring extracellular concentrations of selected metabolites after brain injury and to guide neurocritical care. Extracellular glucose levels and lactate/pyruvate ratios have high diagnostic value because they can detect hypoglycemia and deficits in oxidative metabolism, respectively. In addition, patterns of metabolite concentrations can distinguish between ischemia and mitochondrial dysfunction, and are helpful to choose and evaluate therapy. Increased intracranial pressure can be life-threatening after brain injury, and hypertonic solutions are commonly used for pressure reduction. Recent reports have advocated use of hypertonic sodium lactate, based on claims that it is glucose sparing and provides an oxidative fuel for injured brain. However, changes in extracellular concentrations in microdialysate are not evidence that a rise in extracellular glucose level is beneficial or that lactate is metabolized and improves neuroenergetics. The increase in glucose concentration may reflect inhibition of glycolysis, glycogenolysis, and pentose phosphate shunt pathway fluxes by lactate flooding in patients with mitochondrial dysfunction. In such cases, lactate will not be metabolizable and lactate flooding may be harmful. More rigorous approaches are required to evaluate metabolic and physiological effects of administration of hypertonic sodium lactate to brain-injured patients.
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Affiliation(s)
- Gerald A Dienel
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, AR, USA, and Department of Cell Biology and Physiology, University of New Mexico, Albuquerque, NM, USA
| | - Douglas L Rothman
- Department of Radiology and Biomedical Imaging, Magnetic Resonance Research Center, Yale University School of Medicine, New Haven, CT, USA
| | - Carl-Henrik Nordström
- Department of Neurosurgery, Lund University Hospital, Lund, Sweden, and Department of Neurosurgery, Odense University Hospital, Odense, Denmark
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The effect of continuous hypertonic saline infusion and hypernatremia on mortality in patients with severe traumatic brain injury: a retrospective cohort study. Can J Anaesth 2016; 63:664-73. [PMID: 27030131 DOI: 10.1007/s12630-016-0633-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 10/30/2015] [Accepted: 03/14/2016] [Indexed: 10/22/2022] Open
Abstract
PURPOSE Hypertonic saline (HTS) is used to control intracranial pressure (ICP) in patients with traumatic brain injury (TBI); however, in prior studies, the resultant hypernatremia has been associated with increased mortality. We aimed to study the effect of HTS on ICP and mortality in patients with severe TBI. METHODS We performed a retrospective cohort study of 231 patients with severe TBI (Glasgow Coma Scale [GCS] ≤ 8) admitted to two neurotrauma units from 2006-2012. We recorded daily HTS, ICP, and serum sodium (Na) concentration. We used Cox proportional regression modelling for hospital mortality and incorporated the following time-dependent variables: use of HTS, hypernatremia, and desmopressin administration. RESULTS The mean [standard deviation (SD)] age of patients was 34 (17) and the median (interquartile range [IQR]) GCS was 6 [3-8]. Hypertonic saline was administered as a continuous infusion in 124 of 231 (54%) patients over 788 of 2,968 (27%) patient-days. Hypernatremia (Na > 145 mmol·L(-1)) developed in 151 of 231 (65%) patients over 717 of 2,968 (24%) patients-days. In patients who developed hypernatremia, the median [IQR] Na was 146 [142-147] mmol·L(-1). Overall hospital mortality was 26% (59 of 231 patients). After adjusting for baseline covariates, neither HTS (hazard ratio [HR], 1.07; 95% confidence interval [CI], 0.56 to 2.05; P = 0.84) nor hypernatremia (HR, 1.31; 95% CI, 0.68 to 2.55; P = 0.42) was associated with hospital mortality. There was no effect modification by either HTS or hypernatremia on each another. Patients who received HTS observed a significant decrease in ICP during their ICU stay compared with those who did not receive HTS (4 mmHg; 95% CI, 2 to 6; P < 0.001 vs 2 mmHg; 95% CI, -1 to 5; P = 0.14). CONCLUSIONS Hypertonic saline and hypernatremia are not associated with hospital mortality in patients with severe TBI.
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Langlois PL, Bourguignon MJ, Manzanares W. L’hyponatrémie chez le patient cérébrolésé en soins intensifs : étiologie et prise en charge. MEDECINE INTENSIVE REANIMATION 2016. [DOI: 10.1007/s13546-016-1187-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Conti B, Villacin MK, Simmons JW. Trauma Anesthesia for Traumatic Brain Injury. CURRENT ANESTHESIOLOGY REPORTS 2016. [DOI: 10.1007/s40140-016-0141-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
OPINION STATEMENT Cerebral edema (i.e., "brain swelling") is a common complication following intracerebral hemorrhage (ICH) and is associated with worse clinical outcomes. Perihematomal edema (PHE) accumulates during the first 72 h after hemorrhage, and during this period, patients are at risk of clinical deterioration due to the resulting tissue shifts and brain herniation. First-line medical therapies for patients symptomatic of PHE include osmotic agents, such as mannitol in low- or high-dose bolus form, or boluses of hypertonic saline (HTS) at varied concentrations with or without subsequent continuous infusion. Decompressive craniectomy may be required for symptomatic edema refractory to osmotherapy. Other strategies that reduce PHE such as hypothermia and minimally invasive surgery have shown promise in pilot studies and are currently being evaluated in larger clinical trials. Ongoing basic, translational, and clinical research seek to better elucidate the pathophysiology of PHE to identify novel strategies to prevent edema formation as a next major advance in the treatment of ICH.
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Garnacho-Montero J, Fernández-Mondéjar E, Ferrer-Roca R, Herrera-Gutiérrez M, Lorente J, Ruiz-Santana S, Artigas A. Cristaloides y coloides en la reanimación del paciente crítico. Med Intensiva 2015; 39:303-15. [DOI: 10.1016/j.medin.2014.12.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Revised: 12/14/2014] [Accepted: 12/18/2014] [Indexed: 12/22/2022]
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Stetefeld HR, Dohmen C. [Acute care of patients with bacterial meningitis]. Med Klin Intensivmed Notfmed 2015; 111:215-23. [PMID: 25876743 DOI: 10.1007/s00063-015-0021-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Revised: 02/17/2015] [Accepted: 02/27/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Bacterial meningitis is a life-threatening emergency that is still associated with high mortality and poor outcome. OBJECTIVE The purpose of this article is to provide a review of clinical presentation, diagnostic procedure, therapy, and prognosis in bacterial meningitis. Prognostic factors which could be influenced positively are identified and a focused procedure in the emergency setting and for the treatment of complications are provided. MATERIAL AND METHODS This work is based on a literature search (PubMed, guidelines) and personal experience (standard operating procedures, SOP). RESULTS Despite improved health care, bacterial meningitis is still associated with high mortality and poor neurological outcome, which has remained largely unaltered during recent decades. Diagnosis and, more importantly, effective therapy of bacterial meningitis are often delayed, having an immediate negative influence on clinical outcome. Neurological and nonneurological complications often necessitate intensive care and may occur rapidly or in the further course of the disease. CONCLUSION Immediate initiation of effective therapy is crucial to positively influence mortality and neurological outcome. Antibiotics should be administered within 30 min after admission. To achieve this, a focused and well-organized procedure in the emergency setting is necessary. Because of intra- and extracranial complications, patients need to be treated on intensive care units including neurological expertise and interdisciplinary support.
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Affiliation(s)
- H R Stetefeld
- Abteilung für Neurologie, Universitätsklinikum Köln, Kerpener Str. 62, 50924, Köln, Deutschland.
| | - C Dohmen
- Abteilung für Neurologie, Universitätsklinikum Köln, Kerpener Str. 62, 50924, Köln, Deutschland
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Manzanares W, Aramendi I, Langlois PL, Biestro A. Hyponatremia in the neurocritical care patient: An approach based on current evidence. Med Intensiva 2015; 39:234-43. [PMID: 25593019 DOI: 10.1016/j.medin.2014.11.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Revised: 11/06/2014] [Accepted: 11/11/2014] [Indexed: 01/20/2023]
Abstract
In the neurocritical care setting, hyponatremia is the commonest electrolyte disorder, which is associated with significant morbimortality. Cerebral salt wasting and syndrome of inappropriate antidiuretic hormone have been classically described as the 2 most frequent entities responsible of hyponatremia in neurocritical care patients. Nevertheless, to distinguish between both syndromes is usually difficult and useless as volume status is difficult to be determined, underlying pathophysiological mechanisms are still not fully understood, fluid restriction is usually contraindicated in these patients, and the first option in the therapeutic strategy is always the same: 3% hypertonic saline solution. Therefore, we definitively agree with the current concept of "cerebral salt wasting", which means that whatever is the etiology of hyponatremia, initially in neurocritical care patients the treatment will be the same: hypertonic saline solution.
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Affiliation(s)
- W Manzanares
- Cátedra de Medicina Intensiva, Centro de Tratamiento Intensivo, Hospital de Clínicas, Facultad de Medicina, Universidad de la República (UdeLaR), Montevideo, Uruguay.
| | - I Aramendi
- Cátedra de Medicina Intensiva, Centro de Tratamiento Intensivo, Hospital de Clínicas, Facultad de Medicina, Universidad de la República (UdeLaR), Montevideo, Uruguay
| | - P L Langlois
- Hôpital Fleurimont, Centre Hospitalier Universitaire de Sherbrooke, Département d'Anesthésie-Réanimation, Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Québec, Canadá
| | - A Biestro
- Cátedra de Medicina Intensiva, Centro de Tratamiento Intensivo, Hospital de Clínicas, Facultad de Medicina, Universidad de la República (UdeLaR), Montevideo, Uruguay
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35
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Dias C, Silva MJ, Pereira E, Silva S, Cerejo A, Smielewski P, Rocha AP, Gaio AR, Paiva JA, Czosnyka M. Post-traumatic multimodal brain monitoring: response to hypertonic saline. J Neurotrauma 2014; 31:1872-80. [PMID: 24915462 DOI: 10.1089/neu.2014.3376] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Emerging evidence suggests that hypertonic saline (HTS) is efficient in decreasing intracranial pressure (ICP). However there is no consensus about its interaction with brain hemodynamics and oxygenation. In this study, we investigated brain response to HTS bolus with multimodal monitoring after severe traumatic brain injury (TBI). We included 18 consecutive TBI patients during 10 days after neurocritical care unit admission. Continuous brain monitoring applied included ICP, tissue oxygenation (PtO2) and cerebral blood flow (CBF). Cerebral perfusion pressure (CPP), cerebrovascular resistance (CVR), and reactivity indices related to pressure (PRx) and flow (CBFx) were calculated. ICM+software was used to collect and analyze monitoring data. Eleven of 18 (61%) patients developed 99 episodes of intracranial hypertension (IHT) greater than 20 mm Hg that were managed with 20% HTS bolus. Analysis over time was performed with linear mixed-effects regression modelling. After HTS bolus, ICP and CPP improved over time (p<0.001) following a quadratic model. From baseline to 120 min, ICP had a mean decrease of 6.2 mm Hg and CPP a mean increase of 3.1 mmHg. Mean increase in CBF was 7.8 mL/min/100 g (p<0.001) and mean decrease in CVR reached 0.4 mm Hg*min*100 g/mL (p=0.01). Both changes preceded pressures improvement. PtO2 exhibited a marginal increase and no significant models for time behaviour could be fitted. PRx and CBFx were best described by a linear decreasing model showing autoregulation recover after HTS (p=0.01 and p=0.04 respectively). During evaluation, CO2 remained constant and sodium level did not exhibit significant variation. In conclusion, management of IHT with 20% HTS significantly improves cerebral hemodynamics and cerebrovascular reactivity with recovery of CBF appearing before rise in CPP and decrease in ICP. In spite of cerebral hemodynamic improvement, no significant changes in brain oxygenation were identified.
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Affiliation(s)
- Celeste Dias
- 1 Department of Intensive Care, University Hospital Sao Joao , Porto, Portugal
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Fletcher JJ, Kade AM, Sheehan KM, Wilson TJ. A case-cohort study with propensity score matching to evaluate the effects of mannitol on venous thromboembolism. J Clin Neurosci 2014; 21:1323-8. [DOI: 10.1016/j.jocn.2013.12.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 12/28/2013] [Indexed: 11/28/2022]
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Moruzzi N, Del Sole M, Fato R, Gerdes JM, Berggren PO, Bergamini C, Brismar K. Short and prolonged exposure to hyperglycaemia in human fibroblasts and endothelial cells: metabolic and osmotic effects. Int J Biochem Cell Biol 2014; 53:66-76. [PMID: 24814290 DOI: 10.1016/j.biocel.2014.04.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Revised: 04/25/2014] [Accepted: 04/29/2014] [Indexed: 11/25/2022]
Abstract
High blood glucose levels are the main feature of diabetes. However, the underlying mechanism linking high glucose concentration to diabetic complications is still not fully elucidated, particularly with regard to human physiology. Excess of glucose is likely to trigger a metabolic response depending on the cell features, activating deleterious pathways involved in the complications of diabetes. In this study, we aim to elucidate how acute and prolonged hyperglycaemia alters the biology and metabolism in human fibroblasts and endothelial cells. We found that hyperglycaemia triggers a metabolic switch from oxidative phosphorylation to glycolysis that is maintained over prolonged time. Moreover, osmotic pressure is a major factor in the early metabolic response, decreasing both mitochondrial transmembrane potential and cellular proliferation. After prolonged exposure to hyperglycaemia we observed decreased mitochondrial steady-state and uncoupled respiration, together with a reduced ATP/ADP ratio. At the same time, we could not detect major changes in mitochondrial transmembrane potential and reactive oxygen species. We suggest that the physiological and metabolic alterations observed in healthy human primary fibroblasts and endothelial cells are an adaptive response to hyperglycaemia. The severity of metabolic and bioenergetics impairment associated with diabetic complications may occur after longer glucose exposure or due to interactions with cell types more sensitive to hyperglycaemia.
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Affiliation(s)
- Noah Moruzzi
- The Rolf Luft Research Center, Department of Endocrinology, Metabolism and Diabetes, Karolinska University/Hospital, 17176 Stockholm, Sweden.
| | - Marianna Del Sole
- The Rolf Luft Research Center, Department of Endocrinology, Metabolism and Diabetes, Karolinska University/Hospital, 17176 Stockholm, Sweden
| | - Romana Fato
- Department of Pharmacology and Biotechnology (FaBiT), University of Bologna, 40126 Bologna, Italy
| | - Jantje M Gerdes
- The Rolf Luft Research Center, Department of Endocrinology, Metabolism and Diabetes, Karolinska University/Hospital, 17176 Stockholm, Sweden; Institute for Diabetes and Regeneration Research, Helmholtz Zentrum München, Parkring 11, 85748 Garching, Germany
| | - Per-Olof Berggren
- The Rolf Luft Research Center, Department of Endocrinology, Metabolism and Diabetes, Karolinska University/Hospital, 17176 Stockholm, Sweden
| | - Christian Bergamini
- Department of Pharmacology and Biotechnology (FaBiT), University of Bologna, 40126 Bologna, Italy
| | - Kerstin Brismar
- The Rolf Luft Research Center, Department of Endocrinology, Metabolism and Diabetes, Karolinska University/Hospital, 17176 Stockholm, Sweden
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Secretion of von Willebrand factor by endothelial cells links sodium to hypercoagulability and thrombosis. Proc Natl Acad Sci U S A 2014; 111:6485-90. [PMID: 24733925 DOI: 10.1073/pnas.1404809111] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Hypercoagulability increases risk of thrombi that cause cardiovascular events. Here we identify plasma sodium concentration as a factor that modulates blood coagulability by affecting the production of von Willebrand factor (vWF), a key initiator of the clotting cascade. We find that elevation of salt over a range from the lower end of what is normal in blood to the level of severe hypernatremia reversibly increases vWF mRNA in endothelial cells in culture and the rate of vWF secretion from them. The high NaCl increases expression of tonicity-regulated transcription factor NFAT5 and its binding to promoter of vWF gene, suggesting involvement of hypertonic signaling in vWF up-regulation. To elevate NaCl in vivo, we modeled mild dehydration, subjecting mice to water restriction (WR) by feeding them with gel food containing 30% water. Such WR elevates blood sodium from 145.1 ± 0.5 to 150.2 ± 1.3 mmol/L and activates hypertonic signaling, evidenced from increased expression of NFAT5 in tissues. WR increases vWF mRNA in liver and lung and raises vWF protein in blood. Immunostaining of liver revealed increased production of vWF protein by endothelium and increased number of microthrombi inside capillaries. WR also increases blood level of D-dimer, indicative of ongoing coagulation and thrombolysis. Multivariate regression analysis of clinical data from the Atherosclerosis Risk in Communities Study demonstrated that serum sodium significantly contributes to prediction of plasma vWF and risk of stroke. The results indicate that elevation of extracellular sodium within the physiological range raises vWF sufficiently to increase coagulability and risk of thrombosis.
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Hultström M. Neurohormonal interactions on the renal oxygen delivery and consumption in haemorrhagic shock-induced acute kidney injury. Acta Physiol (Oxf) 2013; 209:11-25. [PMID: 23837642 DOI: 10.1111/apha.12147] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Revised: 07/02/2013] [Accepted: 07/04/2013] [Indexed: 12/14/2022]
Abstract
Haemorrhagic shock is a common cause of acute kidney injury (AKI), which is a major risk factor for developing chronic kidney disease. The mechanism is superficially straightforward. An arterial pressure below the kidney's autoregulatory region leads to a direct reduction in filtration pressure and perfusion, which in turn cause renal failure with reduced glomerular filtration rate and AKI because of hypoxia. However, the kidney's situation is further worsened by the hormonal and neural reactions to reduced perfusion pressure. There are three major systems working to maintain arterial pressure in shock: sympathetic signalling, the renin-angiotensin system and vasopressin. These work to retain electrolytes and water and to increase peripheral resistance and cardiac output. In the kidney, the increased electrolyte reabsorption consumes oxygen. At the same time, at the signalling level seen in shock, all of these hormones reduce renal perfusion and thereby oxygen delivery. This creates an exaggerated hypoxic situation that is liable to worsen the AKI. The present review will examine this mechanistic background and identify a number of areas that require further studies. At this time, the ideal treatment of haemorrhagic shock appears to be slow fluid resuscitation, possibly with hyperosmolar sodium, low chloride and no artificial colloids. From the standpoint of the kidney, renin-angiotensin system inhibitors appear fruitful for further study.
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Affiliation(s)
- M Hultström
- Unit for Integrative Physiology, Department of Medical Cellbiology, Uppsala University, Uppsala, Sweden; Anaesthesiology and Intensive Care, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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