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Liggett MR, Lashley S, Gill NP, Scholtens DM, Dawood ZS, Alam HB. Plasma therapy for traumatic brain injury: Rationale for a prospective randomized trial. Transfusion 2024; 64:1362-1371. [PMID: 38940059 DOI: 10.1111/trf.17928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 01/08/2024] [Accepted: 02/16/2024] [Indexed: 06/29/2024]
Affiliation(s)
- Marjorie R Liggett
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Sharnia Lashley
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Nathan P Gill
- Department of Preventative Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Denise M Scholtens
- Department of Preventative Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Zaiba Shafik Dawood
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Hasan B Alam
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Perlman R, Tsai K, Lo J. Trauma Anesthesiology Perioperative Management Update. Adv Anesth 2023; 41:143-162. [PMID: 38251615 DOI: 10.1016/j.aan.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
Anesthesia for patients with life-threatening injuries is an essential part of post-accident care. Unfortunately, there is variability in trauma anesthesia care and numerous nonstandardized methods of working with patients remain. Uncertainty exists as to when and how best to intubate trauma patients, the use of vasopressors, and the appropriate management of severe traumatic brain injury. Some physicians recommend prehospital rapid sequence intubation, whereas others use bag-mask ventilation at lower pressures with no cricoid pressure and early transport to a trauma center. Overall, the absence of uniformity in trauma anesthesia care underlines the need for continued study and dialogue to define best practices and optimize patient outcomes.
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Affiliation(s)
- Ryan Perlman
- Trauma Anesthesia, Department of Anaesthesia, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, North Tower, Suite 8211, Los Angeles, CA 90048, USA.
| | - Kevin Tsai
- Department of Anaesthesia, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, North Tower, Suite 8211, Los Angeles, CA 90048, USA
| | - Jessie Lo
- Trauma Education Program, Department of Anaesthesia, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, North Tower, Suite 8211, Los Angeles, CA 90048, USA
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Jin G, Ho JW, Keeney-Bonthrone TP, Pai MP, Wen B, Ober RA, Dimonte D, Chtraklin K, Joaquin TA, Latif Z, Vercruysse C, Alam HB. Prolonging the therapeutic window for valproic acid treatment in a swine model of traumatic brain injury and hemorrhagic shock. J Trauma Acute Care Surg 2023; 95:657-663. [PMID: 37314445 DOI: 10.1097/ta.0000000000004022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND It has previously been shown that administration of valproic acid (VPA) can improve outcomes if given within an hour following traumatic brain injury (TBI). This short therapeutic window (TW) limits its use in real-life situations. Based upon its pharmacokinetic data, we hypothesized that TW can be extended to 3 hours if a second dose of VPA is given 8 hours after the initial dose. METHOD Yorkshire swine (40-45 kg; n = 10) were subjected to TBI (controlled cortical impact) and 40% blood volume hemorrhage. After 2 hours of shock, they were randomized to either (1) normal saline resuscitation (control) or (2) normal saline-VPA (150 mg/kg × two doses). First dose of VPA was started 3 hours after the TBI, with a second dose 8 hours after the first dose. Neurologic severity scores (range, 0-36) were assessed daily for 14 days, and brain lesion size was measured via magnetic resonance imaging on postinjury day 3. RESULTS Hemodynamic and laboratory parameters of shock were similar in both groups. Valproic acid-treated animals had significantly less neurologic impairment on days 2 (16.3 ± 2.0 vs. 7.3 ± 2.8) and 3 (10.9 ± 3.6 vs. 2.8 ± 1.1) postinjury and returned to baseline levels 54% faster. Magnetic resonance imaging showed no differences in brain lesion size on day 3. Pharmacokinetic data confirmed neuroprotective levels of VPA in the circulation. CONCLUSION This is the first study to demonstrate that VPA can be neuroprotective even when given 3 hours after TBI. This expanded TW has significant implications for the design of the clinical trial.
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Affiliation(s)
- Guang Jin
- From the Department of Surgery (G.J., J.W.H., T.P.K.-B., K.C., T.A.J., Z.L., C.V., H.B.A.), Feinberg School of Medicine, Northwestern University, Chicago; Department of Clinical Pharmacy (M.P.P., B.W.), University of Michigan, Ann Arbor, Michigan; Center for Comparative Medicine (R.A.O.), Northwestern University, Chicago; and Electrical and Computer Engineering (D.D.), Robert R. McCormick School, Northwestern University, Evanston, Illinois
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Zheng J, Zhang C, Wu Y, Zhang C, Che Y, Zhang W, Yang Y, Zhu J, Yang L, Wang Y. Controlled Decompression Alleviates Motor Dysfunction by Regulating Microglial Polarization via the HIF-1α Signaling Pathway in Intracranial Hypertension. Mol Neurobiol 2023; 60:5607-5623. [PMID: 37328678 DOI: 10.1007/s12035-023-03416-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 05/24/2023] [Indexed: 06/18/2023]
Abstract
Decompressive craniectomy (DC) is a major form of surgery that is used to reduce intracranial hypertension (IH), the most frequent cause of death and disability following severe traumatic brain injury (sTBI) and stroke. Our previous research showed that controlled decompression (CDC) was more effective than rapid decompression (RDC) with regard to reducing the incidence of complications and improving outcomes after sTBI; however, the specific mechanisms involved have yet to be elucidated. In the present study, we investigated the effects of CDC in regulating inflammation after IH and attempted to identify the mechanisms involved. Analysis showed that CDC was more effective than RDC in alleviating motor dysfunction and neuronal death in a rat model of traumatic intracranial hypertension (TIH) created by epidural balloon pressurization. Moreover, RDC induced M1 microglia polarization and the release of pro-inflammatory cytokines. However, CDC treatment resulted in microglia primarily polarizing into the M2 phenotype and induced the significant release of anti-inflammatory cytokines. Mechanistically, the establishment of the TIH model led to the increased expression of hypoxia-inducible factor-1α (HIF-1α); CDC ameliorated cerebral hypoxia and reduced the expression of HIF-1α. In addition, 2-methoxyestradiol (2-ME2), a specific inhibitor of HIF-1α, significantly attenuated RDC-induced inflammation and improved motor function by promoting M1 to M2 phenotype transformation in microglial and enhancing the release of anti-inflammatory cytokines. However, dimethyloxaloylglycine (DMOG), an agonist of HIF-1α, abrogated the protective effects of CDC treatment by suppressing M2 microglia polarization and the release of anti-inflammatory cytokines. Collectively, our results indicated that CDC effectively alleviated IH-induced inflammation, neuronal death, and motor dysfunction by regulating HIF-1α-mediated microglial phenotype polarization. Our findings provide a better understanding of the mechanisms that underlie the protective effects of CDC and promote clinical translational research for HIF-1α in IH.
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Affiliation(s)
- Jie Zheng
- Department of Neurosurgery, The 904th Hospital of PLA, Wuxi Clinical College of Anhui Medical University, Wuxi, 214044, Jiangsu, China
| | - Chenxu Zhang
- Department of Neurosurgery, The 904th Hospital of PLA, Wuxi Clinical College of Anhui Medical University, Wuxi, 214044, Jiangsu, China
| | - Yonghui Wu
- Department of Neurosurgery, The 904th Hospital of PLA, Wuxi Clinical College of Anhui Medical University, Wuxi, 214044, Jiangsu, China
| | - Chonghui Zhang
- Department of Neurosurgery, The 904th Hospital of PLA, Wuxi Clinical College of Anhui Medical University, Wuxi, 214044, Jiangsu, China
| | - Yuanyuan Che
- Department of Neurosurgery, The 904th Hospital of PLA, Wuxi Clinical College of Anhui Medical University, Wuxi, 214044, Jiangsu, China
| | - Wang Zhang
- Department of Neurosurgery, The 904th Hospital of PLA, Wuxi Clinical College of Anhui Medical University, Wuxi, 214044, Jiangsu, China
| | - Yang Yang
- Department of Neurosurgery, The 904th Hospital of PLA, Wuxi Clinical College of Anhui Medical University, Wuxi, 214044, Jiangsu, China
| | - Jie Zhu
- Department of Neurosurgery, The 904th Hospital of PLA, Wuxi Clinical College of Anhui Medical University, Wuxi, 214044, Jiangsu, China.
| | - Likun Yang
- Department of Neurosurgery, The 904th Hospital of PLA, Wuxi Clinical College of Anhui Medical University, Wuxi, 214044, Jiangsu, China.
| | - Yuhai Wang
- Department of Neurosurgery, The 904th Hospital of PLA, Wuxi Clinical College of Anhui Medical University, Wuxi, 214044, Jiangsu, China.
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Ngatuvai M, Martinez B, Sauder M, Beeton G, Andrade R, Maka P, Smith CP, Kornblith L, Elkbuli A. Traumatic Brain Injury, Electrolyte Levels, and Associated Outcomes: A Systematic Review. J Surg Res 2023; 289:106-115. [PMID: 37087837 DOI: 10.1016/j.jss.2023.03.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 02/26/2023] [Accepted: 03/17/2023] [Indexed: 04/25/2023]
Abstract
INTRODUCTION Although it has been established that electrolyte abnormalities are a consequence of traumatic brain injury (TBI), the degree to which electrolyte imbalances impact patient outcomes has not been fully established. We aim to determine the impact of sodium, potassium, calcium, and magnesium abnormalities on outcomes in patients with TBI. METHODS Four databases were searched for studies related to the impact of electrolyte abnormalities on outcomes for TBI patients. Outcomes of interest were rates of mortality, Glasgow Outcome Scale (GOS), and intensive care unit length of stay (ICU-LOS). The search included studies published up to July 21, 2022. Articles were then screened and included if they met inclusion and exclusion criteria. RESULTS In total, fourteen studies met inclusion and exclusion criteria for analysis in this systematic review. In patients with TBI, an increased mortality rate was associated with hypernatremia, hypokalemia, and hypocalcemia in the majority of studies. Both hyponatremia and hypomagnesemia were associated with worse GOS at 6 months. Whereas, both hyponatremia and hypernatremia were associated with increased ICU-LOS. There was no evidence to suggest other electrolyte imbalances were associated with either GOS or ICU-LOS. CONCLUSIONS Hyponatremia and hypomagnesemia were associated with worse GOS. Hypernatremia was associated with increased mortality and ICU-LOS. Hypokalemia and hypocalcemia were associated with increased mortality. Given these findings, future practice guidelines should consider the effects of electrolytes' abnormalities on outcomes in TBI patients prior to establishing management strategies.
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Affiliation(s)
- Micah Ngatuvai
- NOVA Southeastern University, Kiran Patel College of Allopathic Medicine, Fort Lauderdale, Florida
| | - Brian Martinez
- NOVA Southeastern University, Kiran Patel College of Allopathic Medicine, Fort Lauderdale, Florida
| | - Matthew Sauder
- NOVA Southeastern University, Kiran Patel College of Allopathic Medicine, Fort Lauderdale, Florida
| | - George Beeton
- University of North Texas Health Science Center, Fort Worth, Texas
| | - Ryan Andrade
- A.T. Still University School of Osteopathic Medicine, Mesa, Arizona
| | - Piueti Maka
- John A. Burns School of Medicine, Honolulu, Hawaii
| | - Chadwick P Smith
- Division of Trauma and Surgical Critical Care, Department of Surgery, Orlando Regional Medical Center, Orlando, Florida; Department of Surgical Education, Orlando Regional Medical Center, Orlando, Florida
| | - Lucy Kornblith
- Division of Trauma and Surgical Critical Care, Department of Surgery, Zuckerberg Hospital and Trauma Center, San Francisco, California
| | - Adel Elkbuli
- Division of Trauma and Surgical Critical Care, Department of Surgery, Orlando Regional Medical Center, Orlando, Florida; Department of Surgical Education, Orlando Regional Medical Center, Orlando, Florida.
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van Erp IAM, Michailidou I, van Essen TA, van der Jagt M, Moojen W, Peul WC, Baas F, Fluiter K. Tackling Neuroinflammation After Traumatic Brain Injury: Complement Inhibition as a Therapy for Secondary Injury. Neurotherapeutics 2023; 20:284-303. [PMID: 36222978 PMCID: PMC10119357 DOI: 10.1007/s13311-022-01306-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2022] [Indexed: 11/30/2022] Open
Abstract
Traumatic brain injury (TBI) is a leading cause of mortality, sensorimotor morbidity, and neurocognitive disability. Neuroinflammation is one of the key drivers causing secondary brain injury after TBI. Therefore, attenuation of the inflammatory response is a potential therapeutic goal. This review summarizes the most important neuroinflammatory pathophysiology resulting from TBI and the clinical trials performed to attenuate neuroinflammation. Studies show that non-selective attenuation of the inflammatory response, in the early phase after TBI, might be detrimental and that there is a gap in the literature regarding pharmacological trials targeting specific pathways. The complement system and its crosstalk with the coagulation system play an important role in the pathophysiology of secondary brain injury after TBI. Therefore, regaining control over the complement cascades by inhibiting overshooting activation might constitute useful therapy. Activation of the complement cascade is an early component of neuroinflammation, making it a potential target to mitigate neuroinflammation in TBI. Therefore, we have described pathophysiological aspects of complement inhibition and summarized animal studies targeting the complement system in TBI. We also present the first clinical trial aimed at inhibition of complement activation in the early days after brain injury to reduce the risk of morbidity and mortality following severe TBI.
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Affiliation(s)
- Inge A M van Erp
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and HaGa Hospital, Leiden and The Hague, Albinusdreef 2, J-11-R-83, 2333 ZA, Leiden, The Netherlands.
| | - Iliana Michailidou
- Department of Clinical Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Thomas A van Essen
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and HaGa Hospital, Leiden and The Hague, Albinusdreef 2, J-11-R-83, 2333 ZA, Leiden, The Netherlands
| | - Mathieu van der Jagt
- Department of Intensive Care Adults, Erasmus MC - University Medical Center, Rotterdam, The Netherlands
| | - Wouter Moojen
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and HaGa Hospital, Leiden and The Hague, Albinusdreef 2, J-11-R-83, 2333 ZA, Leiden, The Netherlands
| | - Wilco C Peul
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and HaGa Hospital, Leiden and The Hague, Albinusdreef 2, J-11-R-83, 2333 ZA, Leiden, The Netherlands
| | - Frank Baas
- Department of Clinical Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Kees Fluiter
- Department of Clinical Genetics, Leiden University Medical Center, Leiden, The Netherlands
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Impact of Intracranial Hypertension on Outcome of Severe Traumatic Brain Injury Pediatric Patients: A 15-Year Single Center Experience. Pediatr Rep 2022; 14:352-365. [PMID: 35997419 PMCID: PMC9397046 DOI: 10.3390/pediatric14030042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 08/04/2022] [Indexed: 12/04/2022] Open
Abstract
Background: Intracranial hypertension (IC-HTN) is significantly associated with higher risk for an unfavorable outcome in pediatric trauma. Intracranial pressure (ICP) monitoring is widely becoming a standard of neurocritical care for children. Methods: The present study was designed to evaluate influences of IC-HTN on clinical outcomes of pediatric TBI patients. Demographic, injury severity, radiologic characteristics were used as possible predictors of IC-HTN or of functional outcome. Results: A total of 118 pediatric intensive care unit (PICU) patients with severe TBI (sTBI) were included. Among sTBI cases, patients with GCS < 5 had significantly higher risk for IC-HTN and for mortality. Moreover, there was a statistically significant positive correlation between IC-HTN and severity scoring systems. Kaplan−Meier analysis determined a significant difference for good recovery among patients who had no ICP elevations, compared to those who had at least one episode of IC-HTN (log-rank chi-square = 11.16, p = 0.001). A multivariable predictive logistic regression analysis distinguished the ICP-monitored patients at risk for developing IC-HTN. The model finally revealed that higher ISS and Helsinki CT score increased the odds for developing IC-HTN (p < 0.05). Conclusion: The present study highlights the importance of ICP-guided clinical practices, which may lead to increasing percentages of good recovery for children.
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Jifang W, Liping Y, Jing Z, Jie S. The effect of trauma care systems on the mortality of injured adult patients: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e22279. [PMID: 32991428 PMCID: PMC7523867 DOI: 10.1097/md.0000000000022279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 08/20/2020] [Indexed: 11/30/2022] Open
Abstract
PURPOSE The aim of this study was to have a comprehensive evaluation of the effect of trauma care systems on the mortality of injured adult patients. MATERIALS AND METHODS This protocol established in this study has been reported following the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols. Web of Science, PubMed, EMBASE, Scopus, and the Cochrane Library were searched for all clinical trials evaluating the effect of trauma care systems on the mortality of injured adult patients until July 31, 2020. We will use a combination of Medical Subject Heading and free-text terms with various synonyms to search based on the eligibility criteria. Two investigators independently reviewed the included studies and extracted relevant data. The odds ratio (OR) and 95% confidence intervals (CIs) were used as effect estimate. I-square (I) test, substantial heterogeneity, sensitivity analysis, and publication bias assessment will be performed accordingly. Stata 15.0 and Review Manger 5.3 are used for meta-analysis and systematic review. RESULTS The results will be published in a peer-reviewed journal. CONCLUSION The results of this review will be widely disseminated through peer-reviewed publications and conference presentations. This evidence may also provide a comprehensive evaluation of the effect of trauma care systems on the mortality of injured adult patients. REGISTRATION NUMBER INPLASY202080058.
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Schmidt LE, Hamblin SE, Jaynes MP, Atchison L, Beavers JR, Dennis BM. Optimization of Sedative Therapies Leads to Potential Pentobarbital Cost Avoidance in Treatment of Refractory Intracranial Hypertension. Ann Pharmacother 2020; 55:269-270. [PMID: 32723077 DOI: 10.1177/1060028020945183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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